ObjectiveTo provide a detailed description of characteristics at hospital admission and clinical outcomes at 30-day and 6-month follow-up in patients hospitalised with coronary artery disease (CAD) in a poor South-East Asian setting.DesignProspective observational cohort study.SettingFrom February 2013 to December 2014, in Makassar Cardiac Center, Indonesia.Participants477 patients with CAD (acute coronary syndrome and stable CAD).Outcome measuresAll-cause mortality and major adverse cardiovascular events (MACE).ResultsOut of 477 patients with CAD, the proportion of young age (<60 years) was 53.9% and 72.7% were male. At admission, 44.2% of patients were diagnosed with ST-segment elevation myocardial infarction (STEMI), 38.6% with diagnosis or signs of heart failure and 75.1% had previous hypertension. Out of 211 patients with STEMI, only 4.7% had been treated with primary percutaneous coronary intervention (PCI) and 6.2% received thrombolysis. The time lapse from symptom onset to hospital admission was 26.8 (IQR 10.0–48.0) hours, and 19.1% of all patients had undergone either PCI or coronary artery bypass graft. The survival rate at 6 months was 78.9%. The rates of all-cause mortality at 30 days and 6 months were 13.4% and 7.3%, respectively; the rate of composite MACE at 30 days was 26.2% and 18.0% at 6 months.ConclusionsPatients with CAD from a poor South-East Asian setting present themselves with predominantly unstable conditions of premature CAD. These patients show relatively severe illness, have significant time delay from symptom onset to admission or intervention, and most do not receive the guidelines-recommended treatment. Awareness of symptoms, prompt initial management of acute CVD, well-established infrastructures and resources both in primary and secondary hospital for CVD should be improved to reduce the high rates of 30-day and 6-month mortality and adverse outcomes in this population.
The benefit of antagonizing the effect of the renin angiotensin aldosterone system (RAAS), notably by the use of angiotensin-converting enzyme inhibitor (ACEi) and angiotensin II type 1 receptor blocker (ARB) for coronary artery disease (CAD), has been demonstrated in multiple studies, which may be attributed to their ability to inhibit the deleterious effect of RAAS to the cardiovascular system. It is well known that angiotensin II (Ang II) plays a vital role in atheromatous plaque formation and progression through multiple pathways, including inflammatory and arterial remodeling aspects. Significant coronary atheromatous plaque regression has been previously demonstrated in various studies using statin agents. Similar results have been reported in different studies using angiotensin inhibitor agents, notably ARB agents. Analysis from various trials utilizing ARB showed a significant plaque regression using olmesartan and telmisartan as evaluated by IVUS studies. In contrary, the use of ACEi did not demonstrated significant plaque regression, which may be attributed to the heavy plaque calcification in respective studies. On this review, we aim to present the basic mechanism on the role of RAAS in plaque modulation and its arterial remodeling aspect, which is then integrated with the clinical evidence based on the available intravascular ultrasonography (IVUS) studies on coronary arteries.
Pendahuluan: Berbagai studi sebelumnya yang melihat outcome pada pasien PJK multivessel stabil baik yang menjalani CABG, PCI, maupun yang hanya mendapat terapi obat tidak mempertimbangkan gambaran EKG yang mungkin berpengaruh pada outcome. Studi ini bertujuan untuk melihat outcome jangka pendek pasien PJK multivessel stabil kandidat untuk operasi CABG dengan gambaran EKG normal. Metode: Studi Kohort. Outcome primer yang dinilai berupa angina berulang, kejadian SKA, stroke dan kematian karena berbagai sebab dalam 6 bulan. Data dianalisis menggunakan SPPSS versi 16. Data dinyatakan signifikan jika nilai p<0.05. Hasil: Didapatkan 79 pasien (69 pria dan 10 wanita) dikelompokkan pada kelompok yang menjalani CABG(n=13), PCI (n=12), maupun terapi obat (n=54). Kejadian bebas SKA dalam 6 bulan pada kelompok CABG sebanyak 100%, kelompok PCI sebanyak 75%, dan kelompok terapi obat sebanyak 85.1%. Dalam ikutan selama 6 bulan, kejadian bebas angina pada kelompok CABG sebanyak 87.4%, kelompok PCI sebanyak 67% dan kelompk terapi obat sebanyak 42.9% (p=0.015 & OR=7.413). Kesimpulan: Terapi obat untuk PJK multivessel berhubungan dengan kejadian SKA yang lebih rendah dibandingkan PCI dalam 6 bulan. CABG lebih superior dibandingkan terapi obat dalam menghilangkan gejala angina. Ketiga strategi terapi berhubungan dengan tingkat kematian yang rendah dalam 6 bulan.
Worldwide, ischemic heart disease is the most common cause of death and its frequency is increasing. ST-segment elevation myocardial infarction or STEMIis as form of ischemic heart disease with the highest mortality rate. Based on ESC (European Society of Cardiology) guideline 2017 for STEMI management, reperfusion therapywhich is primary PCI strategy is recommended over fibrinolysis within induced timeframes, but if timely primary PCI cannot be performed after STEMI diagnosis, fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications. In fibrinolytic therapy, oral aspirin should be given, and Clopidogrel is indicated as an addition to aspirin. Although Clopidogrel is a recommended P2Y12receptor inhibitorin fibrinolytic therapy,PERKI guideline 2018 in ACS management also mention thatswitching to Ticagrelor can be considered in patients whowillundergo PCI treatmentafter fibrinolytic. In PLATO study, patients who have acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke. However, patients who received fibrinolytic therapy within 24 hours before randomization were excluded. WhileinSET-FAST study, Ticagrelor provides more prompt and potent platelet inhibition compared with Clopidogrel in patients undergoing PCI within 24 hours of receiving fibrinolysis for STEMI. TREAT study was conducted to evaluate the safety of ticagrelor in STEMI patients receiving fibrinolytic therapy within 24 hours.TREAT study concluded, at 30 days observation, in patients younger than 75 years with STEMI, delayed administration of Ticagrelor after fibrinolytic therapy was noninferior to Clopidogrel for TIMI major bleeding. Based on the result from PLATO study and preliminary TREAT study result on 30 days, the use of Ticagrelor within 24 hours after fibrinolytic therapy can be considered with comparable safety profile to Clopidogrel. Keywords: STEMI, fibrinolysis, ticagrelor
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