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The management of atrial fibrillation (AF), the most common sustained arrhythmia, impacts healthcare resource utilization (HCRU). This study aims to estimate global resource use in AF patients, using the GARFIELD-AF registry. A prospective cohort study was conducted to characterize HCRU in AF patients enrolled in sequential cohorts from 2012 to 2016 in 35 countries. Components of HCRU studied were hospital admissions, outpatient care visits, and diagnostic and interventional procedures occurring during follow-up. AF-related HCRU was reported as the percentage of patients demonstrating at least one event and was quantified as rate-per-patient-per-year (PPPY) over time. A total of 49,574 patients was analyzed, having an overall median follow-up of 719 days. Almost all patients (99.5%) had at least one outpatient care visit, while hospital admissions were the second most frequent medical contact, with similar proportions in North America (37.5%) and Europe (37.2%), and slightly higher in the other GARFIELD-AF countries (42.0%; namely Australia, Egypt, and South Africa). Asia and Latin America showed lower percentages of hospitalizations, outpatient care visits, and diagnostic and interventional procedures. Analyses of GARFIELD-AF highlighted the vast AF-related HCRU, underlying significant geographical differences in the type, quantity, and frequency of AF-related HCRU. These differences were likely attributable to health service availability and differing models of care. [ABSTRACT FROM AUTHOR]

Objective: To investigate reasons for and impact of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) at very low thromboembolic risk.Methods: Individuals with CHA2DS2-VASc score 0 (men) or 1 (women) from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) were studied. Baseline characteristics according to OAC use were evaluated by logistic regression analysis. Non-haemorrhagic stroke or systemic embolism, major bleeding, cardiovascular and all-cause mortality were compared.Results: From 2224 low CHA2DS2-VASc patients in GARFIELD-AF, 44% received OAC. In an adjusted model, increasing age up to 65 years (OR (95% CI)=1.31 (1.19 to 1.44)) and persistent AF (OR (95% CI)=3.25 (2.44 to 4.34)) or permanent AF (OR (95% CI)=2.29 (1.59 to 3.30)) versus paroxysmal/unclassified AF were associated with OAC use. Concomitant antiplatelet therapy (OR (95% CI)=0.21 (0.17 to 0.27)) was inversely associated. Crude incidence rates per 100 person-years over 2 years in patients on OAC versus not on OAC were 0.32 (95% CI 0.14 to 0.71) vs 0.30 (95% CI 0.14 to 0.63) for non-haemorrhagic stroke or systemic embolism, 0.21 (95% CI 0.08 to 0.57) vs 0.17 (95% CI 0.06 to 0.46) for major bleeding, 0.26 (95% CI 0.11 to 0.64) vs 0.26 (95% CI 0.12 to 0.57) for cardiovascular mortality and 0.74 (95% CI 0.44 to 1.25) vs 0.99 (95% CI 0.66 to 1.49) for all-cause mortality.Conclusions: In contrast to guideline recommendations, almost half of real-world patients with AF at a very low thromboembolic risk according to the CHA2DS2-VASc score receive OAC. Persistent or permanent AF and increasing age up to 65 years are associated with OAC use, while concomitant antiplatelet therapy shows an inverse association. Regardless whether patients received OAC therapy, few thromboembolic and bleeding events occur, highlighting the low risk of this population. [ABSTRACT FROM AUTHOR]

For the management of ST-segment elevation acute myocardial infarction (STEMI), international guidelines recommend primary percutaneous coronary intervention with adjunctive antithrombotic therapy, the management of complications, and secondary prevention measures. Delivery of care has, however, lagged behind establishing the evidence for effectiveness. Approximately a quarter of all patients with STEMI still fail to receive reperfusion therapy. Additionally, for most patients delays substantially exceed guideline recommendations and secondary prevention is incomplete. What can be done? First, cardiologists need to take the lead in improving systems of care, with the integration of prehospital care within 'heart attack networks' involving intervention centers, nonintervention hospitals, primary care, and paramedic ambulance care. Several examples show that such systems are feasible. 'Door-to-balloon' initiatives can improve care in the final interventional hospital, but only make a modest contribution to total patient delay. Second, high-risk patients, including the elderly and those with cardiac complications like heart failure, should be targeted for more-aggressive interventional and pharmacologic therapy; the opposite situation currently exists in clinical practice (the treatment--risk paradox). Third, greater emphasis on quality improvement, collaboration among health professionals, and achieving high-quality care for all is required from funding bodies, regulatory agencies and professional societies. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation is associated with increased risks of death, stroke/systemic embolism, and bleeding (incurred by antithrombotic therapy), which may occur early after diagnosis.Methods: We assessed the risk of early events (death, stroke/systemic embolism, and major bleeding) over 12 months and their relation to the time after diagnosis of atrial fibrillation in 52 014 patients prospectively enrolled in the GARFIELD-AF registry (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) between March 2010 and August 2016.Results: Over 12 months, 2140 patients died (mortality rate, 4.3; 95% CI, 4.2-4.5 per 100 person-years), of whom 288 (13.5%) died in the first month (6.8; 95% CI, 6.1-7.6). Over 12 months, 657 patients had a stroke/systemic embolism (1.3; 95% CI, 1.2-1.4) and 411 had a major bleeding (0.8; 95% CI, 0.8-0.9). During the first month, the rates (per 100 person-years) of stroke/systemic embolism and major bleed were 2.3 (95% CI, 1.9-2.8) and 1.5 (95% CI, 1.2-1.9), respectively. The elevated 1-month mortality rate was mostly attributable to cardiovascular mortality (3.5; 95% CI, 3.0-4.1), in particular, heart failure, sudden death, and acute coronary syndromes (1.0 [95% CI, 0.8-1.4], 0.6 [95% CI, 0.4-0.8], and 0.5 [95% CI, 0.3-0.8], respectively). Age, heart failure, prior stroke, history of cirrhosis, vascular disease, moderate-to-severe kidney disease, diabetes mellitus, and living in North or Latin America were independent predictors of a higher risk of early death, whereas anticoagulation and living in Europe or Asia were independent predictors of a lower risk of early death. A predictive model developed for the 1-month risk of death had a C-statistic of 0.81 (95% CI, 0.78-0.83).Conclusions: The increased hazard of early events, in particular, cardiovascular mortality, in newly diagnosed atrial fibrillation points to the importance of comprehensive care for such patients and should alert clinicians to detect warning signs of possible early mortality.Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01090362. [ABSTRACT FROM AUTHOR]

Regulatory authorities interpret the results of randomized controlled trials according to published principles. The European Medicines Agency (EMA) is planning a revision of the 2000 and 2003 guidance documents on clinical investigation of new medicinal products for the treatment of acute coronary syndrome (ACS) to achieve consistency with current knowledge in the field. This manuscript summarizes the key output from a collaborative workshop, organized by the Cardiovascular Round Table and the European Affairs Committee of the European Society of Cardiology, involving clinicians, academic researchers, trialists, European and US regulators, and pharmaceutical industry researchers. Specific questions in four key areas were selected as priorities for changes in regulatory guidance: patient selection, endpoints, methodologic issues and issues related to the research for novel agents. Patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) should be studied separately for therapies aimed at the specific pathophysiology of either condition, particularly for treatment of the acute phase, but can be studied together for other treatments, especially long-term therapy. Unstable angina patients should be excluded from acute phase ACS trials. In general, cardiovascular death and reinfarction are recommended for primary efficacy endpoints; other endpoints may be considered if specifically relevant for the therapy under study. New agents or interventions should be tested against a background of evidence-based therapy with expanded follow-up for safety assessment. In conclusion, new guidance documents for randomized controlled trials in ACS should consider changes regarding patient and endpoint selection and definitions, and trial designs. Specific requirements for the evaluation of novel pharmacological therapies need further clarification.

Aims: The management of anticoagulation therapy in patients with atrial fibrillation (AF) and cancer is challenging due to increased thrombotic and bleeding risks. We sought to determine the safety and efficacy of rivaroxaban in patients with AF and a history of cancer., Methods and Results: ROCKET AF randomized 14 264 patients with AF to rivaroxaban or warfarin with a median follow-up of 1.9 years. Cox regression models were used to assess the association between cancer history and clinical outcomes, and the relative treatment effect of rivaroxaban vs. warfarin in these patients. A total of 640 patients enrolled in ROCKET AF had a history of cancer, with the most common types being prostate (28.6%), colorectal (16.1%), and breast (14.7%) cancer. Patients with a history of cancer were older, more frequently male, more likely to have prior vitamin K antagonist (VKA) use and had higher rates of overall bleeding [hazard ratio (HR) 1.30, 95% confidence interval (CI) 1.16-1.47; P < 0.0001] and non-cardiovascular death (HR 1.47, 95% CI 1.04-2.07; P = 0.031) compared with those with no cancer history. There were no significant associations between cancer history and stroke, venous thromboembolism, or myocardial infarction. The relative efficacy of rivaroxaban vs. warfarin for prevention of stroke/systemic embolism was similar in those with and without a history of cancer (interaction P-value = 0.21)., Conclusion: In ROCKET AF, a history of cancer was associated with a higher risk of bleeding and non-cardiovascular death, but not ischaemic events. The relative efficacy and safety of rivaroxaban compared with warfarin were not significantly different in patients with and without a history of cancer. The results of this study are exploratory and should be taken in context of the study population, which may not be generalizable to those with advanced malignancy. Further investigation is needed to understand optimal anticoagulation strategies in patients with AF and cancer.Clinical trial registration: ClinicalTrials.gov: NCT00403767., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Background: In the ROCKET AF (Rivaroxaban-Once-daily, oral, direct Factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) trial, marked regional differences in control of warfarin anticoagulation, measured as the average individual patient time in the therapeutic range (iTTR) of the international normalized ratio (INR), were associated with longer inter-INR test intervals. The standard Rosendaal approach can produce biased low estimates of TTR after an appropriate dose change if the follow-up INR test interval is prolonged. We explored the effect of alternative calculations of TTR that more immediately account for dose changes on regional differences in mean iTTR in the ROCKET AF trial., Methods and Results: We used an INR imputation method that accounts for dose change. We compared group mean iTTR values between our dose change-based method with the standard Rosendaal method and determined that the differences between approaches depended on the balance of dose changes that produced in-range INRs ("corrections") versus INRs that were out of range in the opposite direction ("overshoots"). In ROCKET AF, the overall mean iTTR of 55.2% (Rosendaal) increased up to 3.1% by using the dose change-based approach, depending on assumptions. However, large inter-regional differences in anticoagulation control persisted., Conclusions: TTR, the standard measure of control of warfarin anticoagulation, depends on imputing daily INR values for the vast majority of follow-up days. Our TTR calculation method may better reflect the impact of warfarin dose changes than the Rosendaal approach. In the ROCKET AF trial, this dose change-based approach led to a modest increase in overall mean iTTR but did not materially affect the large inter-regional differences previously reported., Clinical Trial Registration: URL: ClinicalTrials.gov. Unique identifier: NCT00403767., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Time in therapeutic range (TTR) is a standard quality measure of the use of warfarin. We assessed the relative effects of rivaroxaban versus warfarin at the level of trial center TTR (cTTR) since such analysis preserves randomized comparisons., Methods and Results: TTR was calculated using the Rosendaal method, without exclusion of international normalized ratio (INR) values performed during warfarin initiation. Measurements during warfarin interruptions >7 days were excluded. INRs were performed via standardized finger-stick point-of-care devices at least every 4 weeks. The primary efficacy endpoint (stroke or non-central nervous system embolism) was examined by quartiles of cTTR and by cTTR as a continuous function. Centers with the highest cTTRs by quartile had lower-risk patients as reflected by lower CHADS2 scores (P<0.0001) and a lower prevalence of prior stroke or transient ischemic attack (P<0.0001). Sites with higher cTTR were predominantly from North America and Western Europe. The treatment effect of rivaroxaban versus warfarin on the primary endpoint was consistent across a wide range of cTTRs (P value for interaction=0.71). The hazard of major and non-major clinically relevant bleeding increased with cTTR (P for interaction=0.001), however, the estimated reduction by rivaroxaban compared with warfarin in the hazard of intracranial hemorrhage was preserved across a wide range of threshold cTTR values., Conclusions: The treatment effect of rivaroxaban compared with warfarin for the prevention of stroke and systemic embolism is consistent regardless of cTTR.

The European Society of Cardiology (ESC) Congress in 2013 met in Amsterdam (The Netherlands) as an innovative and interactive congress involving more than 30,000 participants. There were 10,490 abstract submissions and a total of 227 hotline, basic science hotline and trial update submissions. Participants were involved from more than 150 countries. To make the congress manageable for participants, related topics were grouped together in ‘villages’ and a smart electronic application allowed the participants to guide their way through the congress and choose the sessions of interest. The innovative new program was initiated by the ESC Congress Programme Committee and the Congress Chair (Keith AA Fox, Chair 2012–2014) has responsibility for the design and delivery of the scientific program. The spotlight of the congress was ‘the heart interacting with systemic organs’, chosen because of the importance of cardiovascular disease conditions crossing conventional boundaries. In all 572 abstracts, the work involved an interaction between the heart and another organ, such as the brain, lungs, kidney, vasculature or inflammation system. In addition, innovative new approaches linked basic science and clinical science and the new ‘hubs of the congress’ allowed excellent interaction and exchange of ideas.

Aims: Large inequalities in the use of primary percutaneous interventions (PPCI) for ST-elevation myocardial infarction (STEMI) are evident. In order to understand how we can help to implement best practice for STEMI patients, we investigated the variation in PPCI utilisation in 120 regions in 10 EU countries and the association with economic, organisational and demographic characteristics., Methods and Results: We performed an ecological study using mixed effects regression models in the following 10 countries: Austria, Belgium, Denmark, England and Wales, Germany, Italy, Portugal, Spain, Sweden, and Northern Ireland. The main finding was the annual number of PPCI per million inhabitants from 2003 through 2008. Overall, the annual increase in PPCI utilisation was 1.15 (95% CI: 1.12, 1.19) per million per year. Regional-level rates varied from 0.74 (95% CI: 0.42, 1.30) to 1.90 (95 % CI: 1.01, 3.55) per million per year. At a regional level, significant positive associations with PPCI utilisation were the number of physicians per 100,000 inhabitants; the number of nurses and midwives per 100,000 inhabitants; and the proportion of the region's population aged 50 to <70 years. At a country level, significant positive associations with utilisation were the year of STEMI treatment, population density per km2; number of general hospital beds per 100,000 inhabitants; and the number of physicians per 100,000 inhabitants., Conclusions: Between 2003 and 2008, PPCI utilisation increased significantly in the ten European countries studied, but there was a great variation within country regions. Regional variation in PPCI rates were associated with both demographic and supply factors, revealing substantial opportunities to improve PPCI utilisation across Europe at national and regional levels.

Background: Vitamin K antagonist (VKA) therapy remains the most common method of stroke prevention in patients with atrial fibrillation. Time in therapeutic range (TTR) is a widely cited measure of the quality of VKA therapy. We sought to identify factors associated with TTR in a large, international clinical trial., Methods and Results: TTR (international normalized ratio [INR] 2.0 to 3.0) was determined using standard linear interpolation in patients randomized to warfarin in the ROCKET AF trial. Factors associated with TTR at the individual patient level (i-TTR) were determined via multivariable linear regression. Among 6983 patients taking warfarin, recruited from 45 countries grouped into 7 regions, the mean i-TTR was 55.2% (SD 21.3%) and the median i-TTR was 57.9% (interquartile range 43.0% to 70.6%). The mean time with INR <2 was 29.1% and the mean time with an INR >3 was 15.7%. While multiple clinical features were associated with i-TTR, dominant determinants were previous warfarin use (mean i-TTR of 61.1% for warfarin-experienced versus 47.4% in VKA-naïve patients) and geographic region where patients were managed (mean i-TTR varied from 64.1% to 35.9%). These effects persisted in multivariable analysis. Regions with the lowest i-TTRs had INR distributions shifted toward lower INR values and had longer inter-INR test intervals., Conclusions: Independent of patient clinical features, the regional location of medical care is a dominant determinant of variation in i-TTR in global studies of warfarin. Regional differences in mean i-TTR are heavily influenced by subtherapeutic INR values and are associated with reduced frequency of INR testing., Clinical Trial Registration: URL: ClinicalTrials.gov. Unique identifier: NCT00403767.

Advances in technique and adjunctive medication have improved outcome of ST-segment elevation myocardial infarction (STEMI) patients. However, the timely delivery and administration of reperfusion strategies to all eligible patients remain challenging. Currently, up to one-third of eligible STEMI patients in industrialized countries worldwide receive no specific reperfusion treatment, a problem that is rectified by the development and implementation of STEMI networks, as also recommended by the latest European Society of Cardiology and American College of Cardiology/American Heart Association guidelines. Indeed, over the last 5 years, published figures demonstrate that STEMI networks increase the percentage of patients treated by any reperfusion strategy, and the percentage of patients receiving treatment within the recommended time frames has also improved, thereby reducing in-hospital and long-term mortality to very low levels. This manuscript demonstrates how STEMI networks can be adapted to local needs and circumstances against pre-existing barriers and despite the heterogeneity in local situations, patient's characteristics, treatment delays, and distances for transfer. Modern and efficacious networks must be prepared to offer both primary percutaneous coronary intervention and thrombolytic therapy, preferably prehospital, as long as primary percutaneous coronary intervention cannot be guaranteed to all individuals within the recommended timeline., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Aims: The rate and type of reperfusion, as well as time delays to reperfusion are directly associated with mortality and are established as performance measures (PMs) in the treatment of ST elevation myocardial infarction (STEMI). To date, little information exists about PMs for reperfusion in clinical practice in Europe and their temporal changes., Methods and Results: Using the Euro Heart Survey ACS-III data set (2 years of inclusions between 2006 and 2008, 138 centres in 21 countries), we selected patients with STEMI eligible for reperfusion therapy. Recorded variables corresponded to the CARDS data set. The rate and type of reperfusion, as well as door to needle and door to artery times were assessed and compared between periods. Timely reperfusion was defined as a door to needle time < 30 min, or a door to artery time < 90 min. We assessed changes in PMs for reperfusion over the 2 years of recruitment. Among 19 205 patients included in the registry, 7655 had STEMI, and 6481 were admitted within the first 12 h and eligible for reperfusion. The rate of patients who underwent reperfusion increased from 77.2 to 81.3%, with an increase in the use of primary percutaneous coronary intervention (P-PCI). The door to needle and door to artery times decreased significantly during the study period, from 20 to 15 min (P = 0.0011) and from 60 to 45 min (P < 0.0001) respectively. As a result, the number of eligible patients receiving reperfusion therapy in a timely manner increased from 53.1 to 63.5% (P < 0.0001). In parallel, over the 2-year period, in-hospital mortality decreased from 8.1 to 6.6% (P = 0.047)., Conclusion: In centres participating in the Euro Heart Survey ACS III, PMs for reperfusion in STEMI improved significantly between 2006 and 2008, with greater use of PCI. Similarly, the rate of patients reperfused in a timely manner also increased, with a significant reduction in door to needle and door to artery times.

Background: A limited number of studies have examined the age and sex differences, and potentially changing trends, in cardiac medication and procedure use in patients hospitalized with an acute coronary syndrome (ACS)., Methods: Using data from a large multinational study, we examined the age and sex differences, and changing trends (1999-2007) therein, in the hospital use of evidence-based therapies in patients hospitalized with an ACS using data from the Global Registry of Acute Coronary Events (n=50 096)., Results: After adjustment for several variables, in comparison with men below 65 years, patients in other age-sex strata had a significantly lower odds of receiving aspirin [odds ratios (ORs) for men 65-74, 75-84, and >or=85 years, women <65, 65-74, 75-84, and >or=85 years were 0.86, 0.84, 0.72, 0.80, 0.86, 0.68 and 0.46, respectively], angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ORs, 1.08, 1.01, 0,71, 0.83, 0.90, 0.89, and 0.63), beta blockers (ORs, 0.66, 0.52, 0.53, 0.67, 0.54, 0.53, and 0.52), statins (ORs, 0.72, 0.49, 0.29, 0.82, 0.68, 0.44, and 0.22), and undergoing coronary artery bypass graft surgery or a percutaneous coronary intervention (ORs, 0.79, 0.53, 0.21, 0.64, 0.57, 0.38, and 0.13) during their acute hospitalization. Age and sex differences in the receipt of these therapies remained relatively unchanged during the period under study., Conclusion: Although there were increasing trends in the use of evidence-based medications and cardiac procedures over time, important gaps in the utilization of effective cardiac treatment modalities persist in elderly patients and younger women.

Aims: Differences in cardiovascular risk factors across Europe provide an opportunity to examine the impact of adiposity on the frequency of diabetes and cardiovascular disease (CVD)., Methods and Results: The International Day for Evaluation of Abdominal obesity (IDEA) study evaluated the prevalence of abdominal obesity, elevated body mass index (BMI), and other cardiometabolic risk factors among primary care patients. Abdominal obesity predicted increased diabetes risk, despite socio-economic, demographic, and risk factor differences. Cardiovascular disease was at least two-fold more frequent in Eastern Europe vs. Northwest Europe (P < 0.0001) and 2.5-fold more vs. Southern Europe (P < 0.0001). Waist circumference (WC) predicted increased (P < 0.0001) age- and BMI-adjusted risks of CVD and diabetes. In women, odds ratios (95% confidence intervals) for CVD per 1 SD increase in WC were: Northwest Europe 1.28 (1.18-1.40); Southern Europe 1.26 (1.16-1.37); and Eastern Europe 1.10 (1.03-1.18). Values for diabetes were 1.72 (1.58-1.88), 1.45 (1.35-1.56), and 1.59 (1.46-1.73), with similar findings in men., Conclusion: Abdominal obesity impacted similarly on the frequency of diabetes across Europe, despite regional differences in cardiovascular risk factors and CVD rates. Increasing abdominal obesity may offset future declines in CVD, even where CVD rates are lower.

Purpose: To identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and to assess the relation of these measures with mortality., Methods: The study sample consisted of 20 140 patients with acute coronary syndromes from the international GRACE registry. Multivariable logistic regression modeling was used to determine predictors of quality performance. Quality indicators were use of aspirin and beta-blockers within 24 hours and at hospital discharge, use of angiotensin-converting enzyme (ACE) inhibitors at discharge, and in-hospital mortality., Results: Use of medications in eligible patients at discharge ranged from 73% for ACE inhibitors to 93% for aspirin. High-risk features (eg, heart failure, older age) were related to failure to use aspirin and beta-blockers. Being at a teaching hospital and care by a cardiologist were associated with better use of aspirin and beta-blockers. Coronary artery bypass surgery was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval: 11% to 42%) lower relative mortality., Conclusion: Identification of factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies, provides an opportunity to focus quality improvement interventions. The association of lower hospital mortality with better use of selected medical treatments supports their measurement to improve quality of care.

Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non-ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.

The long-term use of aspirin (ASA) reduces the risk of subsequent acute coronary syndromes in patients with coronary artery disease (CAD). It is less clear whether ASA therapy benefits patients who develop an acute coronary syndrome despite its use. Baseline characteristics, type of acute coronary syndrome, and in-hospital events were compared on the basis of previous use of ASA in 11,388 patients with and without a history of CAD presenting to 94 multinational hospitals. A total of 73.0% of patients with a history of CAD (n = 4,974) were previously on long-term ASA therapy compared with 19.4% of patients without a history of CAD (n = 6,414). After multivariate regression analysis controlling for various potentially confounding factors, patients with a history of CAD who were previously taking ASA were significantly less likely to present with ST-segment elevation myocardial infarction (MI) (adjusted odds ratio [OR] 0.52, 95% confidence intervals [CI] 0.44 to 0.61) or die during hospitalization (OR 0.69, 95% CI 0.50 to 0.95) in comparison to patients who were not taking ASA. Patients without a history of CAD and who were previously taking ASA also had a lower risk of developing ST-segment elevation MI (OR 0.35, 95% CI 0.30 to 0.40) and a trend toward a decreased hospital death rate (OR 0.77, 95% CI 0.55 to 1.07). These results demonstrate that patients with a history of CAD who present with an acute coronary syndrome despite prior ASA use have less severe clinical presentation, fewer hospital complications, and lower in-hospital death rates than patients not previously taking ASA.