BackgroundElderly represents a subgroup of high-risk ACS patients due to their advanced age and other comorbidities. Unfortunately, they are also often under-represented in many studies and clinical trials. Furthermore, cardiologists commonly find difficulties in the choice of the antiplatelet treatment and even on whether invasive revascularization should be used. In this study, the management of elderly ACS patients regarding antiplatelet therapy and revascularization procedures will be analyzed.Methods1717 ACS patients were consecutively included in this study from 3 tertiary Hospitals in the Southeast of Spain. Of them, 529 (30.8%) were ≥ 75 years. They were mainly male (60.7%) with a mean age of 81.4±4.7 years. Clinical characteristics, treatment received (antiaplatelet therapy, revascularization) and outcome were analyzed.ResultsRegression analysis showed that being ≥ 75 years is independently associated with neither performing catheterization (79.6% vs 97.1%), nor revascularization (51.8% vs 72.5%), being the medical conservative treatment the election in these elderly patients (40.6% vs 18.9%) (p < 0.001 for all). Furthermore, ticagrelor prescription were significantly decreased in older patients (11.5% vs 19.6%; p < 0.001). Regarding patients outcome after one-year of follow-up, being ≥ 75 years was associated with death, major adverse cardiac events (MACE) and major bleeding (all of them p < 0.001). Importantly, nor performing catheterization was independently associated with MACE and death in Cox multivariate analysis in elderly patients.ConclusionsElderly patients with ACS are undertreated both invasively and pharmacologically, and this fact might be associated with the observed worse outcomes.
Background: Prasugrel and ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with acute coronary syndrome (ACS). However, the long-term prognosis and different clinical characteristics related to the type of antiplatelet prescription in current clinical practice ACS patients have not been analysed in depth. The objective of this study was to analyse the clinical profile of ACS and the efficacy and safety of novel oral P2Y 12 inhibitors in current clinical practice patients discharged after ACS. Methods:We collected data from the ACHILLES registry, and an observational, prospective and multicentre registry of patients discharged after ACS. We analysed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1 year of follow-up, ischaemic and major bleeding events were analysed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted.Results: Of 1717 consecutive patients, 1294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. Novel oral P2Y 12 inhibitors were indicated in 47%. Patients treated with clopidogrel were elderly (69.1 ± 13.4 vs 60.4 ± 11.5 years; P < .001) and had a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE scores were higher in the clopidogrel than in novel oral P2Y 12 inhibitors group (P < .001). After 1 year of follow-up, 64 (5.0%/year) patients had a new myocardial infarction, 127 (10.0%/year) had a major adverse cardiovascular event (MACE) and 78 (6.1%/year) died. Patients treated with clopidogrel had a The authors confirm that the Principal Investigator for this paper is J.M.R.-N. All patients included in the ACHILLES registry, 1717 patients, provided individual signed informed consent and an external independent audit of the registry data (independent clinical research organization) was performed evaluating the correct inclusion of the patients, data analysed, compliance with the ethical principles and the presence of all signed informed consent of the patients included.
Introduction and aimsPatients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are often managed conservatively. Clinical practice guidelines recommend treating these patients with the same pharmacological drugs as those who receive invasive treatment. We analyze the use of new antiplatelet drugs (NADs) and other recommended treatments in people discharged following an NSTE-ACS according to the treatment strategy used, comparing the medium-term prognosis between groups.MethodsProspective observational multicenter registry study in 1717 patients discharged from hospital following an ACS; 1143 patients had experienced an NSTE-ACS. We analyzed groups receiving the following treatment: No cardiac catheterization (NO CATH): n = 134; 11.7%; Cardiac catheterization without revascularization (CATH-NO REVASC): n = 256; 22.4%; percutaneous coronary intervention (PCI): n = 629; 55.0%; and coronary artery bypass graft (CABG): n = 124; 10.8%. We assessed major adverse cardiovascular events (MACE), all-cause mortality, and hemorrhagic complications at one year.ResultsNO CATH was the oldest, had the most comorbidities, and was at the highest risk for ischemic and hemorrhagic events. Few patients who were not revascularized with PCI received NADs (NO CATH: 3.7%; CATH-NO REVASC: 10.6%; PCI: 43.2%; CABG: 3.2%; p<0.001). Non-revascularized patients also received fewer beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and statins (p<0.001). At one year, MACE incidence in NO CATH group was three times that of the other groups (30.1%, p<0.001), and all-cause mortality was also much higher (26.3%, p<0.001). There were no significant differences in hemorrhagic events. Belonging to NO CATH group was an independent predictor for MACE at one year in the multivariate analysis (HR 2.72, 95% CI 1.29–5.73; p = 0.008).ConclusionsDespite current invasive management of NSTE-ACS, patients not receiving catheterization are at very high risk for under treatment with recommended drugs, including NADs. Their medium-term prognosis is poor, with high mortality. Patients treated with PCI receive better pharmacological management, with high use of NADs.
Background Prasugrel and Ticagrelor have demonstrated higher efficacy than clopidogrel in their main clinical trials for patients with Acute Coronary Syndrome (ACS). However, the long-term prognosis and different clinical characteristics related with the type of antiplatelet prescription in current clinical practice ACS patients have not been analyzed in depth. Purpose The objective of this study was to analyze the clinical profile of ACS and the efficacy and safety of new antiplatelet drugs (NAD) in current clinical practice patients discharged after an ACS. Methods We collected data from ACHILLES registry, and observational, prospective and multicenter registry of patients discharged after an ACS. We analyzed baseline characteristics, clinical profile and therapy during ACS admission and compared with the different treatments at discharge. After 1 year of follow-up, ischaemic and major bleeding events were analyzed. Multivariate Cox regression analysis and Kaplan Meier curves were also plotted. Results Of 1,717 consecutive patients, 1,294 (75.4%) were discharged with a P2Y12 inhibitor without oral anticoagulation. NAD was indicated in 47%. Patients treated with clopidogrel were elderly (69.1±13.4 vs. 60.4±11.5 years; p<0.001) and with a higher prevalence of cardiovascular risk factors. GRACE and CRUSADE score were higher in the clopidogrel than in NAD group (p<0.001). After 1 year of follow-up, 64 (5.0%/year) patients had a new myocardial infarction, 127 (10.0%/year) had a MACE and 78 (6.1%/year) patients died. Patients treated with clopidogrel had significantly higher annual rate of cardiovascular mortality, MACE and all cause-mortality (all of them p<0.001) without differences in major bleeding (p=0.587) compared with NAD therapy. After multivariate adjustment for the main clinical variables related with adverse prognosis in ACS patients, the discharge with NAD was independently associated with lower risk of all-cause mortality [HR 0.49, 95% CI (0.24–0.99); p=0.043] and lower risk of MACE [HR 0.65, 95% CI (0.43–0.99); p=0.049]. Event Free Survival according NAD Use Conclusions In this prospective, observational and current clinical practice ACS registry, the use of NAD was associated with a reduction of adverse events compared with clopidogrel in patients with ACS. NAD prescription at discharge was independently associated with lower all-cause mortality and MACE without differences in bleeding events. However, clopidogrel remained the most common P2Y12 inhibitor employed for ACS, especially in older and high risk population.
Background:The prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) is poor. Balloon pulmonary angioplasty (BPA) has a potential to overcome this problem. However, even though hemodynamics may significantly be improved with BPA, exercise tolerance is not always ameliorated correspondingly. Purpose: The objective of this study was to investigate if any laboratory parameters can predict exercise tolerance by examining the correlation between RV function and exercise tolerance after BPA, using right heart catheterization (RHC) and echocardiography. Methods: We studied consecutive 68 patients with CTEPH. Assessments of RV hemodynamics and function were performed before, after, and 6 months after BPA. RV hemodynamic parameters including mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), cardiac output, were measured by RHC. RV function was assessed by conventional echocardiographic parameters such as RV diameter, tricuspid annular plain systolic excursion, RV S', RV index of myocardial performance, and RV fractional area change. Furthermore, the twodimensional speckle-tracking echocardiography as well as the three-dimensional transthoracic echocardiography (3D-TTE) were used to investigate RV strain and RV volumetric parameters including RV ejection fraction and RV end diastolic volume and systolic volume. Exercise capacity was assessed by 6-minute walk distance (6MWD) before and 6 months after BPA. Results: Hemodynamic parameters such as mPAP, PVR, and cardiac index were significantly improved immediately after BPA, and the effects of BPA were maintained at follow up after 6 months. Among all cases, PVR was normalized after 6 months in 53 cases (78%). RV free wall longitudinal strain at 6 months after BPA (RVFS_6M) was inversely correlated with 6MWD (r=0.33, p=0.02) in these 53 cases, implicating that RV dysfunction after BPA was associated with exercise tolerance regardless of RV afterload. Therefore, we investigated the RV parameters before BPA that correlated with RVFS_6M. Three-dimensional RV ejection fraction (r=0.35, p=0.01) and RV free wall longitudinal strain before BPA (RVFS_pre) (r=0.43, p=0.01) were significantly correlated with RVFS_6M. Receiver operating characteristic analysis revealed that the smaller RVFS_pre (<-15.9%) was the strongest predictor for normalization of RVFS_6M (area under the curve 0.71, p=0.02) among RV parameters. Conclusions: Although RV afterload affects the RV function, RV myocardial injury may remain and be associated with persistent RV dysfunction and impaired exercise tolerance even after successful BPA therapy. Thus the assessment of RV function would be useful for the management of CTEPH. Background: The optimal duration of dual antiplatelet therapy (DAPT) following drug eluting stent (DES) implantation is unclear. Since most evidence yielded from randomized trials, it is inconclusive and challenged by patient heterogeneity, massive drug discontinuations, and incomplete follow-up, National uniformed database may offer an advantage. Objec...
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