Acute Coronary Syndrome

Abstract: Risk stratification and management of patients with chest pain continues to be challenging despite considerable efforts made in the last decades by many clinicians and researchers. The throutful evaluation necessitates that the physicians have a high index of suspicion for acute coronary syndrome (ACS) and always keep in mind the myriad of often subtle and atypical presentations of ischemic heart disease, especially in certain patient populations such as the elderly ones. In this article we aim to review and discuss the available evidence on the value of clinical presentation in patients with a suspected ACS, with special emphasis on history, characteristics of chest pain, associated symptoms, atypical presentations, precipitating and relieving factors, drugs, clinical rules and significance of clinical Gestalt.

Risk stratification then should be performed using the criteria in Table 1. 1 Alternatively, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument can be used. 26 This is a computerized decision-making program that is built into the ECG machine. Use of this instrument in an emergency department resulted in no change in appropriate admis- sion of patients who had acute coronary syn- drome. The benefit of its use was a significant reduction in hospital admissions of patients who did not have acute coronary syndrome. 26 However, a subsequent study 27 suggested that this benefit is not seen unless physicians have been trained in the use of the instrument.

Abstract: The aim of this review is to summarize the incidence, prevalence, trend in mortality, and general prognosis of coronary heart disease (CHD) and a related condition, acute coronary syndrome (ACS). Although CHD mortality has gradually declined over the last decades in western countries, this condition still causes about one-third of all deaths in people older than 35 years. This evidence, along with the fact that mortality from CHD is expected to continue increasing in developing countries, illustrates the need for implementing effective primary prevention approaches worldwide and identifying risk groups and areas for possible improvement.

Correspondence to: Prof. Gian Luca Salvagno, MD, PhD. Sezione di Biochimica Clinica, Dipartimento di Neuroscienze, Biomedicina e Movimento, Università degli Studi di Verona, Ospedale Policlinico G.B. Rossi, Piazzale Scuro, 10, 37134, Verona, Italy. Email: gianluca.salvagno@univr.it. Abstract: The acute coronary syndrome (ACS) is a leading cause of death around the globe. Beside a still high mortality rate, additional complications of ACS include arrhythmias, left ventricular mural thrombus, cardiac fibrosis, heart failure (HF), cardiogenic shock, mitral valve dysfunction, aneurysms, up to cardiac rupture. Despite many prognostic tools have been developed over the past decades, efforts are still ongoing to identify reliable and predictive biomarkers, which may help predict the prognosis of these patients and especially the risk of HF. Recent evidence suggests that the value of a discrete number of biomarkers of myocardial fibrosis, namely the soluble form of suppression of tumorigenicity 2 (sST2) and galectin-3 (GAL-3), may be predictive of HF and death in patients with ACS. Interestingly, the already promising predictive value of these biomarkers when measured alone was shown to be consistently magnified when combined with other and well-established cardiac biomarkers such natriuretic peptides and cardiac troponins. This article is hence aimed to review the current knowledge about cardiac biomarkers of fibrosis and adverse remodeling.

Page 3 of 26 One of the most difficult and one of the most important differential diagnoses which confront physicians in the outpatient setting is the distinguishing between chronic stable angina and the acute coronary syndrome. The former is a relatively benign condition which can be safely and successfully treated in the outpatient setting. The latter is a potentially fatal condition which requires immediate intervention to decrease the mortality risk of the patient.

Key Words: myocardial infarction 䡲 troponin 䡲 troponin degradation 䡲 diagnostics T he criteria for diagnosing acute coronary syndrome and myocardial infarction (AMI) changed in the year 2000 with the endorsement of the American College of Cardiology/ European Society of Cardiology guidelines, which designated cardiac troponin (cTn) as the biochemical marker of choice. 1

4. Conclusion Acute coronary syndrome patients who have Polycythemia were significantly younger. Those Polycythemia ACS patients in Yemen have higher risk factors for CAD, especial- ly hyperlipidaemia and history of CAD, contrary to ACS patients with normal levels of hemoglobin. ACS patients with normal levels of hemoglobin had significantly better global left ventricular function, as indicated by greater median left ventricular ejection fraction, than what Polycythemia ACS patients had. Quantitatively, there is progression of coronary artery disease with a decrease in LVEF. The Polycythemia ACS patients in Yemen were associated with more coronary artery occlusions. The Polycythemia ACS patients have significantly an angiographic infarct-related lesion in the right coronary or left circumflex artery (CX) than the ACS patients with normal levels of hemoglobin.

CA 90095, USA Tel +1 310 794 1757 email ppham@mednet.ucla.edu Abstract: The advent of potent antiplatelet and antithrombotic agents over the past decade has resulted in significant improvement in reducing ischemic events in acute coronary syndrome (ACS). However, the use of antiplatelet and antithrombotic combination therapy, often in the settings of percutaneous coronary intervention (PCI), has led to an increase in the risk of bleed- ing. In patients with non-ST elevation myocardial infarction treated with antithrombotic agents, bleeding has been reported to occur in 0.4%–10% of patients, whereas in patients undergoing PCI, periprocedural bleeding occurs in 2.2%–14% of cases. Until recently, bleeding was con- sidered an intrinsic risk of antithrombotic therapy, and efforts to reduce bleeding have received little attention. There have been increasing data demonstrating that bleeding is associated with adverse outcomes, including myocardial infarction, stroke, and death. Therefore, it is imperative to optimize patient outcomes by adopting pharmacological and nonpharmacological strategies to minimize bleeding while maximizing treatment efficacy. In this paper, we present a review of the bleeding classifications used in large-scale clinical trials in patients with ACS and those undergoing PCI treated with antiplatelets and antithrombotic agents, adverse outcomes, particu- larly mortality associated with bleeding complications, and suggested predictive risk factors.

DECLARATION I, Dr.A.MEENAKSHI, solemnly declare that dissertation titled “PREVALENCE OF METABOLIC SYNDROME IN PATIENTS WITH ACUTE CORONARY SYNDROME” is a bonafide work done by me at Government Stanley Medical College and Hospital during May 2008 to May 2010 under the guidance and supervision of my unit chief Prof.DR.K.H.NOORUL AMEEN Professor of MEDICINE Government Stanley Medical College and Hospital, CHENNAI.

The analysis of other risk factors like gender, waist circumference and waist hip ratio due to limitation of data collection in stipulated time was not done. Waist hip ratio was not collected for the reason that most of the cases came with complication of acute coronary syndrome. These measurements were not collected at time of discharge in the cases who got successfully treated and discharged, as the admission waist and hip ratio differed from the discharge ones, due to loss of free fluid due to administration of diuretics in the patients who presented with volume overload and patient had some amount of weight loss during hospital stay due to diseases state and also due to low fat, low calorie diet.

Sex Differences and Symptoms of Acute Coronary Syndrome Background: The purpose of this study was to examine symptoms of acute coronary syndrom (ACS) with resect to sex differences. Methods: This comparative cross-sectional study was performed on patients older than 20 years with ACS who were hospitalized at cardiac wards. Sampling was performed through stratified sampling on the basis of sex. Five hundred male and female patients met all eligiblity criteria.

Protease activated receptor-1 (PAR-1) is a primary receptor for thrombin on platelets and is also present on vascular endothelium and smooth muscle cells. Vorapaxar, a novel oral PAR-1 antagonist that inhibits thrombin induced platelet activation. 13 In non-ST- segment elevation acute coronary syndrome patients undergoing CABG, vorapaxar was associated with a significant reduction in ischemic events and no significant increase in major CABG-related bleeding. 14 Intravenous glycoprotein IIb/IIIa receptor antagonist GPIIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban) block platelet aggregation by inhibiting fibrinogen binding to a conformationally activated form of the GPIIb/IIIa receptor on two adjacent platelets. 4 Glycoprotein IIb/IIIa inhibitors have been shown to increase spontaneous reperfusion in STEMI patients and high risk non-ST elevation patients, particularly if they are undergoing percutaneous coronary intervention. 8 Recent studies suggest that intracoronary bolus administration of these agents rather than the traditional intravenous route may provide greater benefit as measured by infarct size and extent of microvascular perfusion and obstruction, especially in high-risk patients. 15 Potential mechanisms include higher local platelet glycoprotein IIb/IIIa receptor occupancy and better post-PCI microvascular perfusion. 16 Glycoprotein IIb/IIIa inhibitor therapy provide protection against acute stent thrombosis and prevent recurrent MI in high risk non-ST segment ACS. 17

Discussion: Several review articles suggest that the use of bivalirudin alone is associated with lower rates of major bleeding when compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitor in patients with acute coronary syndrome with invasive strategy planned. These beneficial effects span through the age ranges. Therefore, it is a good option for elderly patients. Decreased bleeding complications lead to better clinical outcomes in the elderly after percutaneous coronary intervention. It also leads to decreased length of stay in the hospital.

The overall satisfaction of inpatients with acute coronary syndrome in Bulgaria is associated with the type of hospi- tal, the number of family members living together and the severity of the disease at admission. According to these findings, the efforts by hospital managers to improve quality of care should target specific patient groups, for example women, patients living in small families and patients with less severe conditions at admission who showed to be less satisfied with their inpatient stay in gen- eral. In addition, the information obtained from the study could be used at decision-making level for implementing new strategies for structural changes in the Bulgarian inpa- tient health care system. To achieve a higher level of patient satisfaction, efforts to provide information and education, to improve coordination of care and to provide better accommodation should be undertaken. High coop- eration of the patients indicates interest and willingness for changes from the patient's point of view. Bulgarian

Abstract Acute coronary syndrome (AcS) refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia. AcS is divided into ST- elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI), and unstable angina (UA). STEMI results from complete and prolonged occlusion of an epicardial coronary blood vessel and is defined based on EcG criteria. .NSTEMI usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus and/or atheromatous material. NSTEMI is defined by an elevation of cardiac biomarkers in the absence of ST elevation. The syndrome is termed UA in the absence of elevated cardiac enzymes. History, physical examination, ECG, biochemical markers, ECHO all remain important tools to make an appropriate diagnosis The management of ACS should focus on rapid diagnosis, risk stratification, and institution of therapies that restore coronary blood flow and reduce myocardial ischemia.

Thirty-nine males with acute coronary syndrome (ACS) were selected from the Hospital Regional de Osasco, SP, Brasil. The patients median age was 69 (61 - 78) and the inclusion criteria were those of American College of Cardiology and European Society of Cardiology, including chest pain and new or presumed new ECG altera- tions. Patients with history of infection or inflammation during the last 15 days, or with hepatic and renal disease were excluded from the study. A control group of 44 healthy individuals matched by age was selected to set the reference values for platelet indices.

tested apixaban versus placebo in a phase 3 trial, which showed that the addition of 5 mg of apixa- ban twice daily to antiplatelet therapy in patients after an acute coronary syndrome increased the number of major bleeding events without a sig- nificant reduction in the rate of recurrent is- chemic events. 18 Some of the differences in the findings between our study and APPRAISE-2 may be due in part to the patient populations. Specifi- cally, our study was designed to exclude patients who had a history of ischemic stroke or transient ischemic attack who were to be treated with as- pirin and a thienopyridine, a group that has not appeared to benefit from greater degrees of an- tithrombotic therapy. 19,20

Discussion Current clinical practice guidelines recommend a door-to- balloon time of ≤90 minutes for STEMI patients undergoing primary PCI. 1 Multiple studies have demonstrated increasing morbidity and mortality with treatment delay in such patients, 7 with each 30-minute delay to primary PCI having been estimated to increase the relative risk of 1-year mortality by 7.5%. 7,21 These guidelines also recommend an emergent invasive strategy ( <2 hours from hospital admis- sion) for patients with acute coronary syndrome and either hemodynamic instability or features of ongoing ischemia. 22 An early invasive strategy ( <24 hours from hospital admis- sion) for high-risk patients with GRACE (Global Registry of Acute Coronary Events) risk score >140, temporal change in troponins, dynamic ST-changes, or prior coronary revascular- ization is also recommended. 22 Although patients with an acute total occlusion of a coronary artery would likely bene fit from either primary or emergent PCI, an absence of characteristic 12-lead ECG changes or hemodynamic insta- bility can exclude them from such an approach. This is increasingly pertinent as there are an increasing number of patients with AMI presenting as non-STEMI, particularly in the elderly population with multiple comorbidities and frailty.

Summary The findings of the present study were discussed in relation to existing literature and the theoretical framework. Variables were identified that demonstrate that women predominately report chest pain as the number one symptom of ACS. Additionally, variables of significance other than chest pain were determined to be of importance in assessing women with ACS. The lack of identification and misdiagnosis of acute coronary syndrome represents the current need to educate health care professionals, patients and the public. Being aware of the signs and symptoms of ACS can assist healthcare providers in diagnosis and treatment. Several limitations in this study were discussed and related to future research. Finally, implications for nursing practice and future nursing research were discussed.

ABSTRACT Obstructive sleep apnoea (OSA) syndrome affects about 13% of the male and 7–9% of the female population. Hypoxia, oxidative stress and systemic inflammation link OSA and cardiovascular and metabolic consequences, including coronary artery disease. Current research has identified several clinical phenotypes, and the combination of breathing disturbances during sleep, systemic effects and end-organ damage might help to develop personalised therapeutic approaches. It is unclear whether OSA is a risk factor for acute coronary syndrome (ACS) and might affect its outcome. On the one hand, OSA in patients with ACS may worsen prognosis; on the other hand, OSA-related hypoxaemia could favour the development of coronary collaterals, thereby exerting a protective effect. It is unknown whether positive airway pressure treatment may influence adverse events and consequences of ACS. In non-sleepy patients with OSA and stable coronary artery disease, randomised controlled trials failed to show that continuous positive airway pressure (CPAP) treatment protected against cardiovascular events. Conversely, uncontrolled studies suggested positive effects of CPAP treatment in such patients. Fewer data are available in subjects with ACS and OSA, and results of randomised controlled studies on the effects of CPAP are expected shortly. Meanwhile, the search for reliable markers of risk continues. Recent studies suggest that daytime sleepiness may indicate a more severe OSA phenotype with regard to cardiovascular risk. Finally, some studies suggest sex-related differences. The picture is still incomplete, and the potential role of OSA in patients with ACS awaits confirmation, as well as clear definition of subgroups with different degrees of risk.