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The risk of ischemic events gradually decreases after acute coronary syndrome (ACS), reaching a stable level after 1 month, while the risk of bleeding remains steady during the whole period of dual antiplatelet treatment (DAPT). Several de-escalation strategies of antiplatelet treatment aiming to enhance safety of DAPT without depriving it of its efficacy have been evaluated so far. We hypothesized that reduction of the ticagrelor maintenance dose 1 month after ACS and its continuation until 12 months after ACS may improve adherence to antiplatelet treatment due to better tolerability compared with the standard dose of ticagrelor. Moreover, improved safety of treatment and preserved anti-ischemic benefit may also be expected with additional acetylsalicylic acid (ASA) withdrawal. To evaluate these hypotheses, we designed the Evaluating Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome - a randomized clinical trial (ELECTRA-SIRIO 2), to assess the influence of ticagrelor dose reduction with or without continuation of ASA versus DAPT with standard dose ticagrelor in reducing clinically relevant bleeding and maintaining anti-ischemic efficacy in ACS patients. The study was designed as a phase III, randomized, multicenter, double-blind, investigator-initiated clinical study with a 12-month follow-up (ClinicalTrials.gov Identifier: NCT04718025; EudraCT number: 2020-005130-15).

The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the Dual Antiplatelet Therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in post-acute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic therapy (DATT) appear after a longer time from ACS (more than 2 years) and/or from cessation of DAPT (more than 1 year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.

Background: The Global Registry of Acute Coronary Events (GRACE) study produced a scale for risk stratification in acute coronary syndromes (ACSs). Pregnancy-associated plasma protein A (PAPP-A) serum concentration was implicated as a marker of unstable atherosclerotic plaques., Objectives: We hypothesized that the measurement of the concentration of PAPP-A on admission may improve the stratification of cardiovascular risk in suspected ACS patients., Material and Methods: We studied 70 patients with chest pain suggesting ACS diagnosis on admission. Serum cardiac biomarkers and PAPP-A were measured on top of the standard biochemical panel, and the GRACE risk score was calculated. A 12-month follow-up was completed to major adverse cardiac events (MACE): death, myocardial infarction (MI), need for percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG), unplanned cardiovascular hospitalization., Results: In hospital/6-month GRACE, low risk was found in 35 patients (50%)/37 patients (53%), intermediate risk in 23 patients (33%)/21 patients (30%) and high risk in 12 patients (17%)/12 patients (17%). Mean PAPP-A was 39.64 mlU/L (standard deviation - SD 24.2), and median PAPP-A values for in hospital/6-month GRACE were 21.49 mlU/L (quartile 1st; 3rd - 13.41; 32.65) and 22.61 mlU/L (14.03; 34.1) for low risk patients, 51.76 mlU/L (35.18; 59.99) and 51.76 mlU/L (28.9; 62.1) for intermediate risk patients, and 68.82 mlU/L (58.54; 83.76) for high risk patients. The PAAP-A concentration with specific cut-off points had 66.7% positive predictive value (PPV) and 95.5% negative predictive value (NPV) for death, 33.3% PPV and 80.6% NPV for MI, 71.4% PPV and 57.1% NPV for any event. Intermediate and high in hospital/6-months GRACE had 14.3%/15.2% PPV and 100%/100% NPV for death, 34.3%/33.3% PPV and 94.3%/91.9% NPV for MI, 74.3%/72.7% PPV and 65.7%/62.2% NPV for any event., Conclusions: The PAPP-A serum concentration represents a promising prognostic biomarker with significantly improved PPV. The GRACE score is superior to stratification based on PAPP-A with regard to combined cut-off point for 1-year mortality.

Introduction: MicroRNA (miRNAs) are noncoding RNAs involved in the regulation of gene expression. Certain miRNAs, especially miRNA-21 (miR-21), may be involved in lipid metabolism., Objectives: The aim of the study was to evaluate the association between plasma free circulating miR-21 levels and lipid fractions: total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides (TG), as well as their atherogenic profile expressed as the ratio of individual lipid fractions (TC:LDL-C, TC:non-HDL-C, TG:HDL-C, and HDL-C:LDL-C) in patients with acute coronary syndromes without persistent ST -segment elevation (NSTE ACS)., Patients and Methods: The study group consisted of 34 patients diagnosed with NSTE ACS on admission to the emergency department. Plasma miRNA levels were determined by real-time polymerase chain reaction and the ΔΔCt method. Serum lipid fractions were assessed after a minimum of 12-hour fasting during the first day of hospitalization., Results: MiR-21 levels showed a significant inverse correlation with TC (r = -0.5; P = 0.002), LDLC (r = -0.5; P = 0.001), and non-HDL-C (r = -0.6; P <0.001) levels. Moreover, they were inversely correlated with TC:HDL-Cratio (r = -0.6; P <0.001), LDL-C:HDL-Cratio (r = -0.6; P <0.001), TG:HDL-Cratio (r = -0.4; P = 0.037), and TC:non-HDLratio (r = 0.6; P <0.001). In a multivariate analysis, miR-21 levels (β = -0.41; P = 0.018) and the need for revascularization (β = 0.35; P = 0.027) were independent predictors of non-HDL-C levels., Conclusions: Free circulating miR-21 levels inversely correlate with TC, LDL-C, and non-HDL-C and are an independent predictor of non-HDL-C levels in patients with NSTE ACS. Thus, the overexpression of miR-21 is associated with a less atherogenic lipid profile.

Background: Recent guidelines recommended by ESC, ACC, AHA, and WHF concerning biomarkers of myocardial necrosis also apply to the work of clinical laboratories. Methodological modification for tests used in determining cardiac biomarkers reduced the time of the analytical procedure to 9 min (STAT version of the tests). We decided to determine and compare analytical quality of the tests in standard and STAT versions for determining serum level: troponin T, MB isoenzyme of creatine kinase, and myoglobin, as well as to verify whether the TnThs STAT test meets the following requirements: CV<10% at the level close to diagnostic, equal to the 99th percentile of reference population, and turnaround time<60 min., Material/methods: We evaluated real precision and accuracy for both standard and STAT versions of tests as well as the correlation of results of physiological and pathological levels. Additionally, observations of turnaround time were made., Results: Calculated values of total errors did not exceed the recommended acceptable total error (<20%). Comparable precision of the 2 measurement methods (CV=3.07%) was obtained. A strong correlation (R>0.99) between both variants of tests for all the parameters was confirmed. Thanks to the application of new reagent kit, the percentage of results with turnaround time<60 min increased from 40% to 75% (n=115; p=0.000008)., Conclusions: The new generation of STAT cardiac biomarkers has high analytical quality and meets international precision requirements. It guarantees high analytical and clinical reliability of results. Use of the STAT version of biomarkers contributes to a significant decrease in turnaround time and allows obtaining a good result of an analysis.

Introduction: The endothelium and sympathetic nervous system play an important role in the pathogenesis of acute coronary syndrome (ACS)., Objectives: The aim of our study was to evaluate correlations between noninvasive markers of the endothelial function and the sympathetic nervous system in patients with a recent ACS., Patients and Methods: The study included 52 patients who experienced an ACS within the previous 3 to 6 months. Endothelial function was expressed as the reactive hyperemia index (RHI), and the activity of the sympathetic nervous system--as latency and amplitude of sympathetic skin response (SSR) potentials from the 4 limbs. Linear and partial correlations between the RHI and SSR were calculated., Results: There were significant correlations between the RHI and the latency of the SSR in the upper limbs (r = 0.34, P = 0.02 for the right limb; and r = 0.34, P = 0.01 for the left limb). After eliminating the effects of age, sex, weight, and glomerular filtration rate, the partial correlation between the RHI and the latency of the SSR in the upper limbs remained statistically significant (r = 0.41, P = 0.004 for the right limb, and r = 0.42, P = 0.004 for the left limb). There was no correlation between the RHI and latency of the SSR during the stimulation of the lower limbs., Conclusions: Our study confirmed the correlations between the sympathetic autonomic nervous system and endothelium in patients with ACS. The correlation of the RHI with the latency of the SSR was observed only in the upper limbs.

We present a case of a 51 year-old, premenopausal, non-smoker for many years woman with severe, two-coronary artery disease in the form of acute coronary syndrome (ACS), and severe hypercholesterolaemia as the predominant risk factor. The first clinical diagnosis of familial hypercholesterolaemia has been established at the time of diagnosis of ACS. Satisfactory effect of pharmacological treatment is achieved by a complex lipid-lowering therapy.

Background: The pocket echocardiograph (PE) with color Doppler imaging belongs to a new class of diagnostic tools, the feasibility and accuracy of which is not well established. The aim of this study was to assess the feasibility and diagnostic value of transthoracic echocardiography (TTE) performed with the use of PE by a cardiology resident (2nd year of training) and by an experienced cardiologist., Methods: The study population comprised 220 consecutive patients (142 men, mean age 63 ± 8 years), 110 of whom were admitted to our intensive cardiac care unit (ICU) and 110 patients referred for TTE from the outpatient clinic. All patients had PE TTE performed by a resident (60 ICU patients, 60 outpatients) or a cardiologist (50 ICU patients, 50 outpatients). Within 24 h of PE TTE, all subjects had a standard TTE (sTTE) performed by an experienced echocardiographer., Results: 96% of patients had echocardiographic measurements completed by both PE TTE and sTTE. The dimensions measured with PE TTE by the resident and the cardiologist showed good to excellent correlation with sTTE (r = 0.64-0.96, P < 0.001). The agreement in detection of various pathologies between PE TTE performed by the resident and sTTE examinations was moderate to very good, whereas it was good to excellent if PE TTE was performed by the experienced cardiologist., Conclusion: The diagnostic accuracy of the PE in basic assessment of cardiac morphology and function as compared to standard echocardiography is moderate to very good for a cardiology resident and good to excellent for an experienced cardiologist. (Echocardiography 2012;29:1-6)., (© 2011, Wiley Periodicals, Inc.)

Total occlusion of the left main coronary artery is a rare finding at coronary angiography. When present, patients most often have extensive collateral circulation from the right coronary artery. The mainstay of treatment is surgical with coronary artery bypass grafting. We present a case of a 78 year-old woman admitted to our department with two days history of nonspecific, abdominal pain. Her coronarography revealed chronic total occlusion of left main with concomitant critical, proximal right coronary artery stenosis.

Anticoagulants are the cornerstone of current acute coronary syndrome (ACS) therapy; however, anticoagulation regimens that aggressively reduce ischemic events are almost uniformly associated with more bleeding. REG1, an anticoagulation system, consists of RB006 (pegnivacogin), an RNA oligonucleotide factor IXa inhibitor, and RB007 (anivamersen), its complementary controlling agent. Phase I and IIa studies defined predictable relationships between doses of RB006, RB007, and degree of antifactor IX activity. The efficacy and safety of REG1 for the treatment of patients with ACS managed invasively and the safety of reversing RB006 with RB007 after cardiac catheterization are unknown. Randomized, partially-blinded, multicenter, active-controlled, dose-ranging study assessing the safety, efficacy, and pharmacodynamics of the REG1 anticoagulation system compared to unfractionated heparin or low molecular heparin in subjects with acute coronary syndrome (RADAR) is designed to assess both the efficacy of the anticoagulant RB006 and the safety of a range of levels of RB006 reversal with RB007. The objectives of RADAR are (1) to determine the safety of a range of levels of RB006 reversal with RB007 after catheterization, (2) to confirm whether a dose of 1 mg/kg RB006 results in near-complete inhibition of factor IXa in patients with ACS, and (3) to assess the efficacy of RB006 as an anticoagulant in patients with ACS undergoing percutaneous coronary intervention., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Myocardial infarction (MI) with its complications is one of the most serious challenges in contemporary cardiology. Among biochemical markers of myocardial necrosis, heart-type specific fatty acid binding protein (h-FABP) showed excellent sensitivity and specificity for the early diagnosis of an acute MI. The h-FABP is released rapidly (after 30 min) from the cardiomiocyte to the circulation in response to myocardial injury and may be useful for rapid confirmation or exclusion of MI. In recent years, glycogen phosphorylase BB (GP-BB) also emerged as a promising early specific marker of myocardial necrosis. Rapid, qualitative "point of care" tests (POCT) detecting h-FABP (Cardio Detect med) and GP-BB (Diacordon) have recently become available., Aim: To evaluate and compare qualitative POCTs detecting h-FABP and GP-BB in patients with an acute coronary syndrome (ACS)., Methods: We studied 52 patients with a strong suspicion of ACS with persistent ST-segment elevation and chest pain lasting less than 6 hours. The ultimate diagnosis of ST-segment elevation MI (STEMI) was confirmed in case of a second (6 h after admission) positive quantitative result of a cardiac troponin T (cTnT) test. On admission, POCTs to detect both h-FABP and GP-BB were performed. The study population was divided into two groups, with chest pain lasting 〈 3 h (n = 20) or 4-6 h (n = 32). All patients underwent coronary angiography and angioplasty if indicated. The sensitivity of the analysed biomarkers of myocardial necrosis was calculated., Results: The sensitivity of h-FABP (84%) was superior in comparison to the other biomarkers, GP-BB and cTnT, which had sensitivity of 64% and 50%, respectively. Comparison of typical parameters of the diagnostic value of a test (sensitivity, predictive values and accuracy) in both time periods demonstrated that h-FABP was superior to GP-BB. In particular, sensitivity and accuracy of h-FABP was excellent in the group of patients with chest pain lasting 〈 3 h, with sensitivity of 79% for h-FABP and only 47% for GP-BB. Sensitivity and accuracy of cTnT were significantly lower (32% and 35%, respectively)., Conclusions: The h-FABP seems to be an excellent early biomarker of cardiac necrosis in the group of patients with chest pain lasting 〈 3 h. The GP-BB can be also used as a biomarker of myocardic necrosis, but its sensitivity in the early phase of MI is limited.

Background: Myocardial infarction (MI) is one of the most serious challenges of contemporary cardiology. Among biochemical markers, heart-type specific fatty acid binding protein (h-FABP) has a high potential as a marker for the early diagnosis of acute MI. The h-FABP is released early to the bloodstream and may be useful for both rapid confirmation and exclusion of infarction. As opposed to patients with ST segment elevation MI (STEMI), patients with unstable angina (UA)/non-ST segment elevation MI (NSTEMI) present a heterogeneous group in which the confirmation of MI often meets diagnostic difficulties. A rapid, qualitative immunoenzymatic 'point of care' type test, revealing h-FABP in blood, has recently been made available (CardioDetect med)., Aim: To evaluate diagnostic value of early measurements of h-FABP and other markers of necrosis (cTnT, CK-MB, CK-MB mass) in a group of 100 patients with an acute coronary syndrome (ACS) without persistent ST segment elevation (NSTE ACS)., Methods: We studied 100 consecutive patients (34 women, 66 men; mean age 61.6 years) with strong suspicion of NSTE ACS and chest pain lasting <24 h before admission. During admission and after 3 and 6 hours patients had measured a panel of conventional biomarkers as well as quantitative measurements of h-FABP (on admission and 3 hours later) using CardioDetect med. The ultimate diagnosis of infarction (NSTEMI) was confirmed in case of a second (6 h after admission) positive quantitative result of cardiac troponin. Non-ST segment elevation MI was finally diagnosed in 56 patients., Results: The comparison of diagnostic utility of all analysed biomarkers of necrosis revealed that h-FABP was superior to other parameters, when measured on admission, and was characterised by 94.7% sensitivity, 100% specificity, 100% positive predictive value, 93.4% negative predictive value and 97% accuracy. Other biomarkers had on admission lower sensitivity - 70.1% for CK-MB mass, 66.7% for CK-MB, 64.9% for cTnT, whereas their specificity was 97.6% for CK-MB mass, 93% for CK-MB and 100% for cTnT., Conclusions: Qualitative h-FABP test (CardioDetect med) showed excellent sensitivity, higher than measurements of CK-MB mass, CK-MB, and cTnT on hospital admission, and high specificity in the patient group with NSTE ACS. The h-FABP seems to be an excellent biochemical cardiac marker for diagnosing NSTEMI, especially in its early phase, allowing exclusion of myocardial necrosis.

At this year's Congress of the American College of Cardiology, which took place on 24-27 March 2012 in a spacious exhibition center, McCormick Place in Chicago (United States), the results of recently completed clinical trials were presented. This article presents selected recent and noteworthy research presented during the scientific sessions Late Breaking Clinical Trials. Attention should be paid to miscellaneous topics of the presented papers - from the prevention of cardiovascular diseases, advances in pharmacotherapy, through innovations in the treatment of acute coronary syndromes, the procedure in acute pulmonary embolism to advanced cardiac surgery. Among these studies were: INFUSE-AMI, TRA 2P-TIMI 50, CORONARY, STAMPEDE, MOPETT, EINSTEIN-PE, FOCUS-CCTRN, HOST-ASSURE, IMMEDIATE. [ABSTRACT FROM AUTHOR]

Background and objectives: Some experimental studies demonstrated adverse modulation of atherothrombosis by interleukin-1beta (IL-1b). To assess the relationship between the five most common variants of three polymorphisms of the IL1b gene cluster and the complexity of coronary atherosclerosis expressed in Gensini Score (GS), and the age of onset of the first acute coronary syndrome (ACS), we assessed the patients (pts) hospitalized due to ACS in this aspect. Materials and Methods: 250 individuals were included. The single nucleotide polymorphisms of IL1b gene: transition T/C at -31 position, C/T at -511, and those of IL1 receptor antagonist gene (IL1RN)—variable number of tandem repeats allele 1, 2, 3, or 4—were determined by PCR. GS was calculated from the coronary angiogram performed at the index ACS. The impact of the presence of T or C and allele 1 to 4 at the investigated loci on the mean GS, GS greater than 40, mean age of onset of ACS, and the fraction of pts over 60 years of age at ACS were compared between the five most common genotype variants. Results: The five most common variants were present in 203 pts (81.2%). Patients with pair 22 in ILRN had the lowest rate and those with pair 12 had the highest rate of ACS before 60 years of age (29.4 vs. 67.8%; p = 0.004). GS > 40 entailed an eight-fold increase of risk, as observed when pts with one T allele at locus -31 were compared with carriers of 2 or no T allele at this locus: OR 8.73 [CI95 4.26–70.99] p = 0.04. Conclusion: Interleukin-1 beta is subject to frequent genetic variability and our results show a potential relationship of this polymorphism with the extent of coronary atherosclerosis and age at the first ACS. [ABSTRACT FROM AUTHOR]