Adherence to evidence-based therapies after discharge for acute coronary syndromes: an ongoing prospective, observational study.

Purpose: To determine the rates of patient adherence to key evidence-based therapies at 6 months after hospital discharge for an acute coronary syndrome.

Methods: In this nonrandomized, prospective, multinational, multicenter study, adherence to aspirin, beta-blockers, statins, or angiotensin-converting enzyme (ACE) inhibitors 6 months after discharge for myocardial infarction or unstable angina was assessed in 21,408 patients aged 18 years or older. Patients were enrolled at 104 tertiary and community hospitals representing a broad range of care facilities and practice settings (e.

Aborted myocardial infarction in patients with ST-segment elevation: insights from the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen-3 Trial Electrocardiographic Substudy.

Objectives: The investigators undertook a systematic, comprehensive analysis of the therapeutic response and clinical outcomes of reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI) in 5,470 patients from the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 trial.

Background: Prompt effective reperfusion therapy for acute STEMI may attenuate major myocardial necrosis.

Methods: We prospectively collected sequential electrocardiographs and clinical data.

One-year outcome of patients after acute coronary syndromes (from the Canadian Acute Coronary Syndromes Registry).

The objective of this study was to determine the management and outcome of less [corrected] selected patients with an acute coronary syndrome during hospitalization and up to 1 year after discharge. The Canadian Acute Coronary Syndromes Registry was a prospective observational study of patients admitted with suspected acute coronary syndromes. Data on demographic and clinical characteristics, in-hospital treatment, and outcomes were recorded.

Low-molecular-weight heparins in ischemic heart disease.

Purpose Of Review: The objective of this review was to summarize the recent developments regarding the use of low-molecular-weight heparins in the management of acute coronary syndromes.

Recent Findings: In the setting of unstable angina and non-ST-elevation myocardial infarction, enoxaparin is superior to unfractionated heparin in reducing death, myocardial infarction, and recurrent ischemia both in the short-term and to 1 year. However, this does not necessarily imply a class effect of low-molecular-weight heparins in general.

A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.

Context: Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy.

Objective: To develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS.

Design, Setting, And Patients: A multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge.

Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary Events [GRACE]).

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.

Elevated leukocyte count and adverse hospital events in patients with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events (GRACE).

Objective: To examine the association between elevated leukocyte count and hospital mortality and heart failure in patients enrolled in the multinational, observational Global Registry of Acute Coronary Events (GRACE).

Background: Elevated leukocyte count is associated with adverse hospital outcomes in patients presenting with acute myocardial infarction (AMI). The association of this prognostic factor with hospital mortality and heart failure in patients with other acute coronary syndromes (ACS) is unclear.

Global patterns of use of antithrombotic and antiplatelet therapies in patients with acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE).

Background: Many agents are available to treat acute coronary syndromes (ACS), yet limited information is available about their use from a multinational perspective. The objective of this report was to describe patterns of use of antithrombotic and antiplatelet therapies in patients with the spectrum of ACS through the use of data from the Global Registry of Acute Coronary Events (GRACE).

Methods: Data from 12,665 patients with ACS were analyzed.

Skin tissue cholesterol (SkinTc) is related to angiographically-defined cardiovascular disease.

Unlabelled: Parallel changes associated with aging found in the vasculature and skin at necropsy, have prompted small preliminary studies to assess the relation between skin tissue cholesterol (SkinTc) and cardiovascular disease. While these studies have been suggestive, no formal investigation is available to test this association. It would, therefore, be valuable to determine whether a relation between SkinTc and angiographic narrowing actually exists, the latter representing one accepted measurement of coronary atherosclerosis.

Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial.

Background: Disease management programs (DMPs) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status. Evaluations of cardiac DMPs delivered by home health nurses are required.

Methods: Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes.

Predictors of hospital mortality in the global registry of acute coronary events.

Background: Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk.

Objective: To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice.

Methods: A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001.

Does 24-hour ST-segment resolution postfibrinolysis add prognostic value to a Q wave? An ASSENT 2 electrocardiographic substudy.

Background: Both ST resolution and Q-wave development postfibrinolysis provide important prognostic insights in patients with acute myocardial infarction (MI). However, the relative contributions of these 2 factors to risk assessment have not been examined prospectively.

Methods And Results: ST resolution and Q development were evaluated 24 to 36 hours (24-36 h) postfibrinolysis in ASSENT-2: 13,100 out of 16,949 patients who had both baseline and 24-36 h electrocardiograms free of confounders (left bundle branch block, ventricular rhythm, reinfarction before 24-36 h electrocardiograms) were included in this analysis.

ST segment resolution in ASSENT 3: insights into the role of three different treatment strategies for acute myocardial infarction.

Aims: ASSENT 3 (Assessment of the Safety and Efficacy of a New Thrombolytic) demonstrated that the bolus fibrinolytic tenecteplase (TNK), combined with enoxaparin (ENOX) or abciximab (ABCX), substantially reduced ischemic complications of acute myocardial infarction as compared with unfractionated heparin (UH). We compared ST resolution in each of the three treatment regimens in order to evaluate the speed, extent and stability of ST segment resolution and its relationship to the primary composite endpoint(s) of the trial.

Methods And Results: We evaluated ST segment shift and its subsequent resolution i.

From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE).

Aims: The extent to which hospital and geographic characteristics influence the time course of uptake of evidence from key clinical trials and practice guidelines is unknown. The gap between evidence and practice is well recognized but the factors influencing this disjunction, and the extent to which such factors are modifiable, remain uncertain.

Methods And Results: Using chronological data from the GRACE registry (n=12666, July 1999 to December 2001), we test the hypothesis that hospital and geographic characteristics influence the time course of uptake of evidence-based guideline recommendations for acute coronary syndromes (ACS) with and without ST elevation.

Safety and efficacy of unfractionated heparin versus enoxaparin in patients who are obese and patients with severe renal impairment: analysis from the ESSENCE and TIMI 11B studies.

Background: The advantages of enoxaparin over unfractionated heparin (UFH) for the treatment of patients with non-ST-segment elevation acute coronary syndromes are well established. However, no data are available about the safety and efficacy in patients who are obese and patients with severe renal impairment.

Methods: A retrospective analysis of treatment effects was performed on patients who were obese and patients with severe renal impairment from the Efficacy Safety Subcutaenous Enoxaparin in Non-Q-wave Coronary Events (ESSENCE) and Thrombolysis in Myocardial Infarction (TIMI) 11B trials, in which patients were treated with enoxaparin or UFH.

The impact of gender on the treatment and outcomes of patients with early reinfarction after fibrinolysis: insights from ASSENT-2.

Aims: To assess gender differences in patients with early reinfarction after fibrinolysis for acute myocardial infarction (AMI) and the impact of these differences on treatment and outcomes.

Methods And Results: We studied 3.7% of men (n=481) and 4.

The development of Partners for Health's integrated community pathway for postmyocardial infarction patients.

Partners for Health convened an interdisciplinary team to evaluate the quality of care received by cardiac patients. The team detailed the suboptimal postacute care of patients with ischemic heart disease. To solve the quality problems, a cross-sectoral team, using an approach that is in accordance with the American Heart Association's Scientific Statement on Pathways, systematically developed and implemented an integrated community pathway for myocardial infarction patients.

Randomized evaluation of the safety and efficacy of enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes receiving the glycoprotein IIb/IIIa inhibitor eptifibatide.

Background: Current pharmacotherapeutic options for high-risk non-ST-segment elevation acute coronary syndrome patients include aspirin, clopidogrel, heparin, and platelet glycoprotein IIb/IIIa inhibition. A key issue of uncertainty is the safety and efficacy of combination glycoprotein IIb/IIIa inhibitor and low-molecular-weight heparin therapy.

Methods And Results: We randomized 746 patients with rest ischemic discomfort within 24 hours after the onset of symptoms and ST-segment deviation and/or elevation of serum cardiac markers to receive open-label enoxaparin (1 mg/kg subcutaneously twice daily) or unfractionated heparin (70-U/kg bolus; 15 U x kg(-1) x h(-1) infusion, titrated to an activated partial thromboplastin time of 1.

Preventing thrombosis: update of first-line therapy in the management of non-ST segment elevation acute coronary syndromes.

Non-ST segment elevation acute coronary syndrome (NSTE ACS) has a high rate of recurrence. Both antithrombotic and antiplatelet agents in association with coronary revascularization play an important role in the prevention of an adverse outcome. Acetylsalicylic acid, heparin and low molecular weight heparin (especially enoxaparin), and the intravenous small-molecule glycoprotein IIb/IIIa inhibitors, are of proven value.

Development and prognosis of non-Q-wave myocardial infarction in the thrombolytic era.

Background: Data on non-Q myocardial infarctions (MI) are derived primarily from prethrombolytic era studies. Previous trials demonstrated different development rates and none reported on clinical outcomes.

Methods: Our goal was to determine the incidence and prognosis of non-Q-wave MI among patients with ST-segment elevation receiving thrombolysis.

Randomized comparison of T-type versus L-type calcium-channel blockade on exercise duration in stable angina: results of the Posicor Reduction of Ischemia During Exercise (PRIDE) trial.

Background: Mibefradil is a T-type calcium-channel antagonist and arterial vasodilator with negative chronotropic effects. It is not known if T-type calcium-channel blockade is superior to L-type calcium-channel blockade in patients with stable angina pectoris.

Methods: A multicenter, randomized, double-blind trial was conducted in patients with documented coronary disease and stable angina to compare a 360 mg dose of diltiazem CD with 100 mg dose of mibefradil.

Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry).

Our primary study aim was to examine extent of, and factors associated with, delay in seeking medical care in a large multinational registry of patients with acute myocardial infarction (AMI) and unstable angina pectoris. A secondary goal was to examine the relation between duration of prehospital delay and receipt and timing of coronary reperfusion strategies. Investigators from 14 countries are participating in the Global Registry of Acute Coronary Events (GRACE) project.

Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE).

Background: The benefits of reperfusion therapy for patients with acute coronary syndromes have been established, but there is much variation in the type of reperfusion given and decisions about which patients are eligible. This study assessed current practices in relation to reperfusion therapy of ST-segment-elevation myocardial infarction from data collected in the multinational, prospective Global Registry of Acute Coronary Events.

Methods: 94 hospitals in 14 countries are recruiting patients for the registry.