Telomere length prognostic for 50 to 75 year-old men with ACS

28 jan 2014—For men aged 50 to 75 years with acute coronary syndrome, short telomeres are independently associated with worse prognosis, according to a study published in the Feb. 1 issue of The American Journal of Cardiology.

Jose-Angel Perez-Rivera, M.D., from the University Hospital of Salamanca in Spain, and colleagues assessed the prognostic value of telomere length, measured by quantitative polymerase chain reaction in peripheral blood leukocytes of 203 men admitted with acute coronary syndrome. The men were classified into two groups according to age: 50 to 75 years, and older than 75 years. Patients underwent more than 600 days of clinical follow-up and a prognostic combined event was defined.

The researchers found that for men aged 50 to 75 years, those with short telomeres had significantly worse prognosis (P < 0.05), but this association was not seen for men aged older than 75 years (P = 0.91). For men aged 50 to 75 years, Cox analysis confirmed short telomeres as an independent prognostic risk factor.

"In conclusion, telomere length is a good predictor of cardiovascular prognosis in men admitted for acute coronary syndrome, but this relation depends on the chronological age of the population studied," the authors write.

More information: Abstract 

Study examines sex differences in presentation of acute coronary syndrome

A higher proportion of women than men 55 years and younger did not have chest pain in acute coronary syndromes (ACS, such as heart attacks or unstable angina), although chest pain was the most common symptom for both sexes, according to a study published by JAMA Internal Medicine.

17 sept 2013--Chest pain is a classic symptom that often triggers diagnostic testing for ACS, however, as many as 35 percent of patients with ACS do not report chest pain at presentation. They are more likely to be misdiagnosed in the emergency department and have a higher risk of death compared to patients who report chest pain, according to the study background.

Nadia A. Khan, M.D., M.Sc., of the University of British Columbia, Vancouver, Canada, and colleagues evaluated sex differences in how younger patients with ACS presented for medical care. The study included 1,015 patients (30 percent women) who were 55 and younger, hospitalized for ACS and enrolled in a study of gender, sex and cardiovascular disease. The median (midpoint) age of the patients was 49 years.

According to the results, chest pain was a presentation symptom in about 80 percent of both sexes, but a higher proportion of women than men present without it (19 percent vs. 13.7 percent). Young women without chest pain also had fewer symptoms in general compared to women with chest pain (average number of symptoms, 3.5 vs. 5.8) with similar findings in men (2.2 vs. 4.7 symptoms). The most common non-chest pain symptoms in both sexes were weakness, feeling hot, shortness of breath, cold sweat and pain in the left arm or shoulder. Women without chest pain, however, had more symptoms than men without chest pain, the results also indicate.

The study notes patients without chest pain did not differ from those with chest pain in ACS type, troponin level elevation (heart muscle protein in the blood) or coronary stenosis (narrowing).

"The most significant findings in this study were that chest pain was the most predominant symptom of ACS in both men and women 55 years or younger, regardless of ACS type. Women had a higher likelihood of presenting without chest pain than men. Most women and men who presented without chest pain, however, reported at least one other non-chest pain symptom, such as shortness of breath or weakness," the study notes.

The authors write that the reasons for the sex difference in ACS symptom presentation were not clear.

"Our findings indicate that chest pain is the predominant symptom that should direct diagnostic evaluation for ACS and be used for public health message for young women and men similar to older patients. However, health care providers should still maintain a high degree of suspicion for ACS in young patients, particularly women, given that 1 in 5 women with diagnosed ACS do not report with chest pain," the study concludes.

In an editorial, Akintunde O. Akinkuolie, M.B.B.S., M.P.H., and Samia Mora, M.D., M.H.S., of Brigham and Women's Hospital, Boston, write: "In this study, chest pain was the most common symptom and was highly prevalent in both men and women (86.3 percent vs. 81 percent, respectively)."

"In general, women in this study were more likely than men to report non-chest pain symptoms such as weakness, flushing, back pain, right arm/shoulder pain, nausea, vomiting, headache and neck or throat pain. However, the authors were unable to identify a consistent pattern of symptoms for ACS presentation with or without chest pain in either women or men," they continue.

"Meanwhile, it is prudent for public health messages to target both men and women regarding ACS symptom presentation with or without chest pain so as to encourage earlier and more widespread access to appropriate and lifesaving care," the authors conclude.

More information: JAMA Intern Med. Published online September 16, 2013. DOI: 10.1001/jamainternmed.2013.10149
JAMA Intern Med. Published online September 16, 2013. DOI: 10.1001/jamainternmed.2013.8075

Provided by The JAMA Network Journals

Admission Glucose in ACS Linked to Adverse Events

Higher fasting glucose linked to in-hospital mortality risk in acute coronary syndrome patients

18 aug 2009-- Elevated fasting glucose upon admission for acute coronary syndrome is associated with in-hospital and six-month adverse events, according to research published Aug. 15 in the American Journal of Cardiology.

Louis Kolman, M.D., of the University of Michigan Health System in Ann Arbor, and colleagues analyzed data from 1,541 patients admitted with a diagnosis of acute coronary syndrome whose fasting glucose level upon admission was available.

The researchers found that fasting glucose of 100 mg/dL or higher was associated with increased in-hospital mortality compared with subjects whose glucose was below 100 mg/dL. Those whose fasting glucose was 126 or more and who had no known history of diabetes had a higher risk of in-hospital adverse events (odds ratio, 3.37). The fasting glucose level was associated with an increased six-month mortality risk among non-diabetics (odds ratio, 3.03 for a glucose level of 100 to 125 mg/dL and 2.81 for 126 mg/dL or higher) but not diabetics.

"In the present study of patients with acute coronary syndrome, we observed that an elevated fasting admission glucose level was associated with adverse events both in-hospital and at the six-month follow-up point. Furthermore, the risk of adverse events associated with the fasting glucose level at admission was often greatest for non-diabetic patients with acute coronary syndrome," the authors conclude.

The study was partially supported by a grant from Sanofi-Aventis.

Abstract
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Many Heart Patients Stop Taking Their Medications

Nearly a third of heart patients drop some of their meds within three months after hospital discharge

20 july 2009-- Nearly a third of patients prescribed evidence-based medicine after hospitalization for acute coronary syndrome discontinue one or more of their medications within three months, according to a study in the July 15 issue of the American Journal of Cardiology.

Chiara Melloni, M.D., of Duke University Medical Center in Durham, N.C., and colleagues conducted post-discharge telephone interviews with patients who had been hospitalized with acute coronary syndrome during 2006 and 2007, to determine if they had continued on prescribed medications. The medications were ascertained from hospital records and included several classes of evidence-based medicine: aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering drugs. The researchers asked patients who had stopped a medication whether it was done with their physician's knowledge or on their own.

By three months after discharge, the researchers found that 28.2 percent of patients had stopped taking one or more of the prescribed medications, with 61.5 percent of those categorized as self-discontinuations. The leading factors associated with self-discontinuation were lack of pharmacy coinsurance, discomfort with an increasing number of medications, failure to use a reminder tool (such as a pillbox), lower education, and dialysis.

"In conclusion, one-third of patients with acute coronary syndrome discontinue greater than or equal to one of their prescribed evidence-based medicines within three months of hospital discharge, and most of this discontinuation is without provider involvement. Patient education, better prescription drug coverage, and reminder strategies may improve use of evidence-based medicines at three months after discharge from acute coronary syndrome admission," the authors write.

The study was funded by Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals partnership and by Merck Schering-Plough Pharmaceutical.

Abstract
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Using PPIs with Clopidogrel Associated with Adverse Outcomes After ACS

04 mar 2009--After acute coronary syndrome, use of a proton pump inhibitor (PPI) alongside clopidogrel is associated with more frequent rehospitalization or mortality compared with clopidogrel alone, according to an observational study in JAMA.

Veterans Affairs researchers examined outcomes in some 8200 patients prescribed clopidogrel at discharge after ACS. Nearly two thirds of the patients also received a PPI either at discharge or during a median 1.5-year follow-up. The primary endpoint, a combination of rehospitalization for ACS or death from any cause, occurred more often among those taking clopidogrel with a PPI than among those taking clopidogrel alone.

The authors note that previous studies have shown that PPIs attenuate clopidogrel's antiplatelet effects.

In Journal Watch Cardiology, JoAnne Foody concludes: "Although [the current] results bear the limitations of all observational studies ... clinicians should consider this potential interaction when they weigh the pros and cons of prescribing a PPI with clopidogrel for ACS patients."

LINK(S):

JAMA article (Free)

AHA: Early Start for Statins Urged


ORLANDO, Nov. 11 -- Doctors here urged their colleagues to prescribe statins to patients with acute coronary syndrome at the earliest possible time -- even before they leave the hospital -- to provide the most benefit in forestalling coronary events.
In an industry-sponsored symposium held in conjunction with the American Heart Association meeting, doctors cited a series of clinical trials that illustrated benefits for early treatment with statins.
Using data from the PROVE IT -- TIMI 22 trial [NEJM, 2004], Christopher Cannon, M.D., of Harvard and Brigham and Women's Hospital, showed that patients achieved benefit from treatment with atorvastatin (Lipitor) almost from the start of the trial that compared atorvastatin to pravastatin (Pravachol).
"Even in the first 30 days of treatment, the curves between the drugs began to separate," Dr. Cannon said. "There is a clinical benefit of early initiation of high-dose statins after acute coronary syndrome."
Among the advantages of early treatment with high-dose statins, he said, is the reduction in C-reactive protein, a marker of cardiac risk.
Perhaps, suggested Giuseppi Patti, M.D., of Campus Bio-Medico University of Rome, treatment with statins should begin when the patient is undergoing percutaneous coronary intervention.
In the ARMYDA (Atorvastatin for the Reduction of Myocardial Damage During Angioplasty) trial, patients who were given statins within a week after being randomized and before undergoing angioplasty had a 5% rate of myocardial infarction compared with 18% among patients who were on placebo (P=0.0025).
Providing statins to patients who suffer heart attacks should begin within 24 hours of hospitalization, according to AHA/ACC guidelines, said Sidney Smith, M.D., of the University of North Carolina at Chapel Hill.
He said the chance is that 77% of patients started on statins in the hospital will still be on medication 6 months later compared with 25% of patients who are prescribed statins after discharge.
Valentin Fuster, M.D., of Mount Sinai Medical Center in New York, proposed that new advances in imaging technology may help guide decisions on treatment.
"A critical issue for the clinician and for society," said Dr. Fuster, "is the following: Can imaging technology detect subclinical cardiovascular disease and, as a result, foster earlier management to promote health at lower cost?"

Elevated Troponin Levels May Be a Marker for Increased Mortality in ACS

October 10, 2007 (Seattle) — Patients with acute coronary syndrome presenting to the emergency department with transient elevation in the ST segment of their electrocardiogram (ECG) who also have elevated troponin levels may be at increased risk for death. The finding suggests that such patients should be treated more aggressively.
Researchers presented the study here at the American College of Emergency Physicians (ACEP) 38th Annual Scientific Assembly.
ECG changes can suggest either acute injury to the heart (elevated ST segment) or ischemia (normal ST segment). However, some patients present with transient ST-segment elevation (tSTE), and there is no consensus for how aggressively these patients should be treated. Using data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA guidelines (CRUSADE) initiative, researchers examined the troponin levels of patients with tSTE in hopes of further stratifying this subgroup of patients.
The CRUSADE initiative included 205,000 patients at more than 500 US sites between 2001 and 2007. Patients had ECG abnormalities suggesting acute coronary syndrome or abnormal serum markers indicating myocardial necrosis. Of 189,000 patients enrolled at the time of this analysis, the researchers found that 11,979 patients had tSTE and had undergone troponin testing. Several factors were associated with tSTE (with "transient" defined as lasting < 10 minutes), including male sex (P < .001) and family history of coronary artery disease (P = .012). Factors associated with reduced likelihood of tSTE included renal insufficiency, hypertension, and history of congestive heart failure (P < .001 for each).
Of the 11,979 patients with tSTE, 8272 (69%) had elevated troponin levels; 3707 patients (31%) had negative troponin markers. The researchers compared patients in the 2 categories and found that patients with tSTE and elevated troponin levels had a 41% increased risk for death during their hospital stay (4.6% vs 2.2%; adjusted odds ratio, 1.41; 95% confidence interval, 1.04 - 1.91;P = .028) compared with patients with tSTE and normal troponin levels.
"Our conclusion was that if a patient with tSTE has abnormal troponin levels, they are in a higher risk group and should be evaluated for more aggressive therapy," said Lee Garvey, MD, medical director of the chest pain evaluation center at the Carolinas Medical Center, Charlotte, North Carolina.
"[The study] identifies a group of patients with a 40% increased risk for acute mortality. Once again, it's a demonstration that troponin is the most important biomarker for acute coronary syndrome," said W. Frank Peacock, MD, director of research for the Cleveland Clinic, Ohio, who attended the conference.
The study was internally funded. Dr. Garvey has disclosed no relevant financial relationships.
American College of Emergency Physicians 38th Annual Scientific Assembly: Abstract 22. Presented October 8, 2007.

ASNC: SPECT Scan Can Identify ACS Patients Hours after Symptoms End

SAN DIEGO, Sept. 12 -- SPECT imaging of fatty acid metabolism can detect or rule out suspected acute coronary syndrome (ACS) with good accuracy, even hours after symptoms have resolved, investigators reported here.
Imaging with iodinated BMIPP achieved a sensitivity of 85% and negative predictive value of 91% in a multi-center evaluation, James Udelson, M.D., of Tufts University in Boston reported at the American Society of Nuclear Cardiology meeting.
Among patients with troponin-positive MI, the imaging technique had 100% sensitivity, he said.
"BMIPP imaging demonstrated sensitivity and negative predictive value for ACS similar to that reported for rest myocardial perfusion imaging," said Dr. Udelson. "However, these data were seen even though BMIPP imaging was performed up to 30 hours after cessation of symptoms."
For evaluation of patients with suspected ACS, molecular imaging of fatty acid metabolism with 123I-BMIPP (β-methyl-P-[123I]-iodophenyl-pentadecanoic acid) offers the advantage of "ischemic memory"-the ability to identify "the imprint of ischemia" hours after symptoms subside, Dr. Udelson said. The technique also minimizes radiation exposure and might eliminate the need for pharmacologic or exercise stress testing, he noted.
Investigators at nine sites in the United States performed BMIPP imaging during initial emergency department evaluation of patients with suspected ACS. All patients were stratified into low, intermediate, and high risk on the basis of gender-specific criteria that included ECG findings, initial troponin levels, and medical history.
BMIPP SPECT imaging was performed within 30 hours of symptom cessation, following rest injection of the contrast material, said Dr. Udelson. BMIPP dose ranged from 2.5 to 5.4 mCi, and SPECT imaging began about 10 minutes following injection. No attenuation or scatter correction was employed.
As indicated by clinical findings, patients had coronary angiography and revascularization. Patients who did not have angiography had SPECT myocardial perfusion imaging for final diagnosis. Telephone follow-up at 30 days assessed safety and clinical events.
An abnormality on SPECT was defined as 3% of left ventricular extent. Investigators used risk-stratified criteria for quantitative analysis of BMIPP defects. For patients with a high likelihood of ACS, a defect was defined as two standard deviations, 2.5 for intermediate risk, and three for low-risk patients.
"The quantitative threshold was varied based on the likelihood of ACS, such that if it was a low-likelihood patient, the defect had to be more severe to be called abnormal," said Dr. Udelson.
A total of 97 patients had complete data: 49 at low risk, 20 at intermediate risk, and 28 at high risk. Adjudicated final diagnoses showed that a total of 26 patients had diagnoses of ACS: three low-risk patients, four intermediate-risk patients, and 19 high-risk patients. SPECT-BMIPP imaging was performed an average of 14 hours after symptom cessation, Dr. Udelson noted.
Performance characteristics of BMIPP imaging for detecting ACS included 85% sensitivity, 59% specificity, 91% negative predictive value, and 43% positive predictive value.
Additionally, the SPECT assessment of fatty acid metabolism correctly identified all patients who had positive cardiac troponin tests, consistent with myocardial infarction.
Comparing SPECT results in ACS-positive and negative patients, Dr. Udelson said the median defect size in patients with ACS was 16.6% of the left ventricle versus 1% in ACS-negative patients (P<0.0001).
Even when SPECT results were falsely positive, median abnormality size differed significantly from patients with true-positive scans (6% versus 28.6%, P=0.005).
No patient discontinued the study because of adverse events. The lone serious adverse event was deemed unrelated to the study drug.
In conclusion, Dr. Udelson said, "The ability to image prolonged post-ischemic abnormalities in fatty acid metabolism, allowing imaging long after symptoms subside, is unique in this setting. These data support the performance of larger pivotal trials, which are now ongoing, in this patient population."
Dr. Udelson said all investigators in the trial received support from Molecular Insight Pharmaceuticals, which funded the study. Additionally, Dr. Udelson and another investigator are consultants for MIP, and the principal investigators included MIP employees. Primary source: American Society of Nuclear CardiologySource reference: Udelson JE et al. "Phase 2B study of the safety and efficacy of [123I]-BMIPP for identification of ischemic myocardium using SPECT in adults admitted to the ED for evaluation of an acute coronary syndrome." American Society of Nuclear Cardiology 2007. Abstract LB-04.

ACC: Evidence Suggests Many Pathways for Thrombin Control in Acute Coronary Syndrome

NEW ORLEANS, March 30 -- When patients are being evaluated for antithrombin therapy in association with percutaneous coronary interventions, doctors have multiple choices that make it possible to tailor therapy, said a Cleveland Clinic investigator.
These choices include heparin, low molecular weight heparin, glycoprotein IIb/IIIa inhibitors, bivalirudin, and fondaparinux said A. Michael Lincoff, M.D, who is vice chairman for cardiovascular research at the clinic.
He discussed differing management strategies for antithrombin therapy at an industry symposium, held in conjunction with the American College of Cardiology meeting here.
"Acute coronary syndrome management is complicated because we don't have one-size-fits-all antithrombotic pathway because patients and conditions are different," said Dr. Lincoff, who served as moderator at the symposium, which was sponsored by the Medicines Company.
The foundation for treatment of patients with acute coronary syndromes is aspirin and on top of that is clopidogrel (Plavix), but even with aspirin and clopidogrel, which are considered relatively simple therapies, dose titration should be carefully monitored, Dr. Lincoff said.
Beyond aspirin and clopidogrel, doctors have to determine whether they should use glycoprotein IIb/IIIa inhibitors either upfront or during the procedure. Then, he said, comes the difficult choice--heparin or low molecular weight heparin or bivalirudin or fondaparinux?