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Background The aim of this analysis was to define the risk factors associated with the problematic dose titration of unfractionated heparin (UFH) in high-risk non-ST-segment elevation acute coronary syndrome (NSTE ACS) patients. Methods and Results The study group comprised 267 patients with high-risk NSTE ACS managed with an early invasive strategy and treated with the recommended dose of UFH. The subsequent dose was adjusted after measurement of activated partial thromboplastin time (aPTT), using the nomogram. The goal for aPTT was 1.5-2.5-fold of the control value. At 6 h after starting therapy 29% of patients had a therapeutic initial aPTT value; half of them were over-anticoagulated, and 22% were undertreated. By continuing therapy, the proportion of optimally treated patients increased; after 12 h of treatment 40% of patients reached the therapeutic dose, and 58% after 24 h. Undertreatment was a problem in ≤65-year-old men. Women and older patients have a higher risk of overdose. The patients with a therapeutic dose of UFH had the lowest occurrence of major ischemic adverse events. Conclusions Expert consensus on more precise dose guidelines for UFH is needed. The dose needs to be not only weight, but also age and sex, adjusted. (Circ J 2008; 72: 1674 - 1679)

Obviously, conservative therapy would be less expensive than invasive therapy if patients were held in the conservative category and received only medical therapy along with exercise test with thallium. However, based on the TIMI 3 B outcomes, costs are similar (but not equal) even if one attempts a conservative strategy since a significant number of patients in the early conservative arm underwent angiography (64 patients) and PTCA (26 patients) or surgery (24 patients) and the number of days for rehospitalization was greater in the early conservative than in the early invasive group. I believe the TIMI 3 B study reflects the reality of clinical practice in 1995. It seems to me that either strategy is acceptable both from the medical and economic outcome standpoints. Given the model used here, I do not think that the early invasive strategy will ever be cheaper than the early conservative strategy unless all of the patients in the early conservative strategy who eventually are revascularized have CABG, and all of the patients in the early invasive strategy who are revascularized have PTCA.

Background The use of coronary catheterisation and revascularisation in unstable coronary artery disease (UCAD) varies, which could have important consequences for patients as well as for health ca ...

Source Citation Glaser R, Herrmann HC, Murphy SA, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA. 2002;288:3124-9. 12495392 (All 2003 articles ...

Comment concerning 'Cost-effectiveness of an invasive strategy in unstable coronary artery disease' - Reply

ARDIAC ISOFORMS OF TROPONIN I( CTNI) AND T (cTnT) are highly sensitive and specific markers of myocardial injury. Elevations of either of these proteins in the setting of an acute coronary syndrome (ACS) identify patients with a several-fold increased risk of death in subsequent weeks. 1 The prognostic importance of these markers likely stems from their ability to detect microscopic amounts of myocardial necrosis that result from a severe epicardial stenosis or distal embolization of friable atherothrombotic debris overlying the unstable coronary plaque. 2 As such, troponin-positive patients often have complex coronary lesion morphology with intracoronary thrombus, 3 and understandably derive particular benefit from platelet glycoprotein (Gp) IIb/IIIa inhibitors 4-6 as well as low-molecular-weight heparins. 7

Source Citation Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InSta...

Objectives The purpose of this study was to conduct a meta-analysis to examine an invasive or conservative strategy in diabetic versus nondiabetic patients. Background Diabetic patients are at increased risk of cardiovascular events after an acute coronary syndrome, yet it remains unknown whether they derive enhanced benefit from an invasive strategy. Methods Randomized trials comparing an invasive versus conservative treatment strategy were identified. The prevalence of cardiovascular events through 12 months was reported for each trial, stratified by diabetes mellitus status and randomized treatment strategy. Relative risk (RR) ratios and absolute risk reductions were combined using random-effects models. Results Data were combined across 9 trials comprising 9,904 subjects of whom 1,789 (18.1%) had diabetes mellitus. The RRs for death, nonfatal myocardial infarction (MI), or rehospitalization with an acute coronary syndrome for an invasive versus conservative strategy were similar between diabetic patients (RR: 0.87; 95% confidence interval [CI]: 0.73 to 1.03) and nondiabetic patients (RR: 0.86; 95% CI: 0.70 to 1.06; p interaction = 0.83). An invasive strategy reduced nonfatal MI in diabetic patients (RR: 0.71; 95% CI: 0.55 to 0.92), but not in nondiabetic patients (RR: 0.98; 95% CI: 0.74 to 1.29; p interaction = 0.09). The absolute risk reduction in MI with an invasive strategy was greater in diabetic than nondiabetic patients (absolute risk reduction: 3.7% vs. 0.1%; p interaction = 0.02). There were no differences in death or stroke between groups (p interactions 0.68 and 0.20, respectively). Conclusions An early invasive strategy yielded similar RR reductions in overall cardiovascular events in diabetic and nondiabetic patients. However, an invasive strategy appeared to reduce recurrent nonfatal MI to a greater extent in diabetic patients. These data support the updated guidelines that recommend an invasive strategy for patients with diabetes mellitus and non-ST-segment elevation acute coronary syndromes. (J Am Coll Cardiol 2012; 60:106-11) (C) 2012 by the American College of Cardiology Foundation

Introduction Improvement in coronary heart disease prevention and treatment, as well as availability of coronary care facilities, is important for the reduction of acute coronary syndrome (ACS) incidence. Centralized acute coronary care system is crucial to provide optimal hospitalization and management algorithm for ACS patients. Aim The aim of the current report was to assess the annual incidence of ACS and the quality of acute coronary care in Latvia. Methods The Data from The Latvian Registry of Acute Coronary Syndromes were analyzed covering the time period from 2005 to 2010. Results Since the year 2005 the annual incidence of hospitalization due to ACS decreased significantly in Latvia. The annual incidence of non-ST-elevation ACS (NSTE-ACS) decreased from 8019 to 4613 in absolute numbers based on the registry data during six years. Improvement in the use of guidelines based therapy and early invasive strategy in ACS patients was observed. Increase in primary percutaneous coronary intervention was achieved from 7.9% in 2005 to 57.0% in 2010, contributing to reduction in the proportion of STEMI patients without any reperfusion (from 45% in 2005 to 21% in 2010). Conclusions The annual incidence of hospitalized ACS, especially NSTE-ACS, decreased and guidelines based management of ACS improved from 2005 to 2010 in Latvia.

Purpose: We further explored the hypothesis of fewer cardiac deaths among Unstable Angina and Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) patients undergoing early angiography, attempting to address previous concerns on baseline risk of patients as assessed by troponin status. Methods: Only randomized controlled clinical trials reporting data on cardiac biomarkers were considered for inclusion in this meta-analysis. Routine invasive and selective invasive strategies were compared as follows: analysis 1: trials only recruiting participants with positive cardiac biomarkers (NSTEMI) versus those that recruited participants with positive and negative cardiac biomarkers as an inclusion criterion (UA/NSTEMI), regardless of stents use; analysis 2: trials selected as above, with stents deployed during procedures. The primary end-points were mortality, recurrent non fatal MI and their combination. Results: For analysis 1, a total of 8 trials (10,411 patients) were eligible for our study: 3 with NSTEMI (VINO, VANQWISH and ICTUS) and 5 with UA/NSTEMI (TIMI IIIB, MATE, FRISC II, TACTIS-TIMI 18 and RITA 3). For analysis 2, three of the eight selected trials (MATE; TIMI-3B and VANQWISH) were excluded because they were undertaken in the pre-stent era. Duration of the follow-up periods ranged from 6 to 24 months. In the period of time from randomization to the end of follow-up, the use of routine invasive strategy was associated with a significant reduction for the composite ischemic events with 21% lower odds (RR 0.79; CI, 0.70-0.90) in UA/NSTEMI. In contrast, there was no benefit of the use of such strategy (RR 1.19; CI, 1.03-1.38) in NSTEMI. The observed effects were consistent among most evaluated trials except for the case of MATE in UA/NSTEMI and VINO in NSTEMI. Regarding the period of time from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the endpoint in both UA/NSTEMI (RR 1.28; CI, 1.11-1.46) and NSTEMI (RR 1.85; CI, 1.49-2.29). Changing the methods for analysis from all randomized studies to studies that were undertaken in the post-stent era (analysis 2) did not alter the interpretation of the data. Conclusions: Contrary to expectations, a routine invasive strategy is of most benefit in trials recruiting a large number of UA patients, whereas it cannot be proven to reduce deaths or nonfatal myocardial infarction in NSTEMI patients. Potential clinical benefits from PCI do not seem to favorably affect the overall prognosis of the index myocardial infarction.

INTRODUCTION A considerable development of myocardial infarction treatment including invasive strategy and supportive pharmacotherapy ought to result in prognostic benefits for the high risk diabetic population. OBjECTIvES The aim of the present study was the evaluation of myocardial infarction treatment efficacy in diabetics from Świetokrzyskie province. PATIENTS AND mEThODS Two groups of diabetics hospitalized because myocardial infarction were compared: group 1 included 183 patients treated during the years 1992–1996, group 2 was comprised of 168 patients treated in the years 2005–2006. RESULTS Population of diabetic patients treated in the years 2005–2006 was older and presented more coronary risk factors than patients hospitalized in the years 1992–1996. A significant more frequent use of myocardial infarction reperfusion treatment in diabetic patients was demonstrated. In 1992–1996, fibrinolytic therapy was used in 18% of diabetics, while currently the reperfusion stra‑ tegy was performed in 47.2% of the study patients including fibrinolysis in 8.5% of patients, primary percutaneous coronary intervention in 38.7% of patients. In both study groups a comparably high mortality observed during the hospitalization and the 6‑month follow‑up incidence was observed. In the years 1992–1996 a significant decrease of mortality among diabetics who were treated by fibri‑ nolytic methods compared to diabetics treated by conservative methods, was observed. In the years 2005–2006 in‑hospital and long‑term mortality were significantly reduced among diabetics who had undergone invasive therapy. CONCLUSIONS A significant development of myocardial infarction treatment in diabetics, particularly in those who underwent reperfusion methods, was demonstrated. The absence of reduction in overall mortality ought to be attributed to the worse clinical characteristics of recently treated patients and lower frequency of reperfusion treatment in high risk patients.

Human blood cells may offer a minimally invasive strategy to study systemic alterations of mitochondrial function. Here we tested the reliability of a protocol designed to study mitochondrial respiratory control in human platelets (PLTs) in field studies, using high-resolution respirometry (HRR). Several factors may trigger PLT aggregation during the assay, altering the homogeneity of the cell suspension and distorting the number of cells added to the two chambers (A, B) of the Oroboros Oxygraph-2k (O2k). Thus, inter-chamber variability (∆ab) was calculated by normalizing oxygen consumption to chamber volume (JO2) or to a specific respiratory control state (flux control ratio, FCR) as a reliable parameter of experimental quality. The method’s reliability was tested by comparing the ∆ab of laboratory-performed experiments (LAB, N = 9) to those of an ultramarathon field study (three sampling time-points: before competition (PRE, N = 7), immediately after (POST, N = 10) and 24 h after competition (REC; N = 10)). Our results show that ∆ab JO2 changed PRE-POST, but also for LAB-POST and LAB-REC, while all ∆ab FCR remained unchanged. Thus, we conclude that our method is reliable for assessing PLT mitochondrial function in LAB and field studies and after systemic stress conditions.

Adverse Cardiovascular (CV) events after acute coronary syndrome (ACS) are more common in frail older patients. Left ventricular (LV) function and severity of dyspnoea in older patients (≥ 75 years) in relation to frailty status is not known. The aim of this study is to assess LV function and

Vitamin D deficiency (VDD) and frailty are common among older population. VDD has been linked to increased arterial stiffness, endothelial dysfunction, increased coronary artery calcium score and coronary artery disease. Frailty is an independent predictor of adverse cardiovascular outcomes in acute

PurposeOctogenarians with acute coronary syndrome (ACS) represent both a challenge and a dilemma to the clinicians as they frequently present with important co-morbidities. We sought to characterize octogenarian patients admitted with an ACS.MethodsA total of 1959 patients consecutively admitted with ACS were reviewed. We compared patients of 80 years or more to the others in order to characterize them beyond age. Independent predictors of six-month prognosis were determined among octogenarian patients. The end point was six-month mortality. Results: We compared the characteristics of 251 octogenarians (mean age, 84±3 years) with those of 1708 younger patients (mean age, 62±12 years). Octogenarians were more frequently women; they more often had arterial hypertension and renal insufficiency (p

We read with interest the meta-analysis published by Fox et al. ([1][1]) of long-term outcome of a routine versus selective invasive strategy in patients with non–ST-segment elevation acute coronary syndromes ([1][1]). By pooling individual data from the FRISC (Fast Revascularization During