2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Background: The clinical benefits of cytochrome P450 (CYP) 2C19 genotype-guided antiplatelet therapy in Asians remain unclear. In this study, we aimed to investigate the clinical outcomes of pharmacogenomic antiplatelet therapy in Chinese patients.Methods: Patients with acute coronary syndrome planning to undergo percutaneous coronary intervention were eligible for this study and were randomly divided into a genotype-guided treatment (GT) group and routine treatment (RT) group, with a ratio of 2:1. Patients in the GT group underwent CYP2C19 genotyping (*2 and *3 alleles), and the results were considered in selecting P2Y12 receptor inhibitors. Patients in the RT group were treated with P2Y12 receptor inhibitors according to their clinical characteristics. The primary endpoint was a composite of major adverse cardiovascular or cerebrovascular events (MACCE). The secondary endpoint was significant bleeding events.Results: Finally, 301 patients were enrolled; 75.1% were men and the mean age was 59.7 ± 9.8 years. In total, 281 patients completed the follow-up procedure. The primary endpoint occurred in 16 patients, 6 patients in the GT group and 10 in the RT group. The GT group showed lower MACCE rates than the RT group (6/189 vs. 10/92, 3.2 vs. 10.9%, hazard ratio: 0.281, 95% confidence interval: 0.102–0.773, P = 0.009). There was no statistically difference in significant bleeding events between the GT and RT groups (4.2 vs. 3.3%, hazard ratio: 1.315, 95% confidence interval: 0.349–4.956, P = 0.685).Conclusion: Personalized antiplatelet therapy that is based on CYP2C19 genotypes could decrease MACCE within a 12-month period in Chinese patients with acute coronary syndrome undergoing percutaneous coronary intervention.Clinical Trial Registration:http://www.chictr.org.cn, identifier: ChiCTR2000034352.

Section: Discussionmentioning

confidence: 99%

Personalized Antiplatelet Therapy Based on CYP2C19 Genotypes in Chinese ACS Patients Undergoing PCI: A Randomized Controlled Trial

Shi

Zhang

et al. 2021

“…Even in the early stage of acute MI, every hour of early diagnosis and timely treatment could increase the survival rate by about 15% ( 2 , 3 ). Specific markers of myocardial injury, such as cardiac troponin T (cTnT) ( 4 ) and typical changes on an electrocardiogram (ECG) ( 5 ) take the top priority for MI diagnosis in recent clinical guidelines ( 6 ). However, such diagnostic strategy still faces a lot of challenges.…”

Section: Introductionmentioning

confidence: 99%

Development and Validation of a Random Forest Diagnostic Model of Acute Myocardial Infarction Based on Ferroptosis-Related Genes in Circulating Endothelial Cells

Chen

Shi

2021

The high incidence and mortality of acute myocardial infarction (MI) drastically threaten human life and health. In the past few decades, the rise of reperfusion therapy has significantly reduced the mortality rate, but the MI diagnosis is still by means of the identification of myocardial injury markers without highly specific biomarkers of microcirculation disorders. Ferroptosis is a novel reported type of programmed cell death, which plays an important role in cancer development. Maintaining iron homeostasis in cells is essential for heart function, and its role in the pathological process of ischemic organ damages remains unclear. Being quickly detected through blood tests, circulating endothelial cells (CECs) have the potential for early judgment of early microcirculation disorders. In order to explore the role of ferroptosis-related genes in the early diagnosis of acute MI, we relied on two data sets from the GEO database to first detect eight ferroptosis-related genes differentially expressed in CECs between the MI and healthy groups in this study. After comparing different supervised learning algorithms, we constructed a random forest diagnosis model for acute MI based on these ferroptosis-related genes with a compelling diagnostic performance in both the validation (AUC = 0.8550) and test set (AUC = 0.7308), respectively. These results suggest that the ferroptosis-related genes might play an important role in the early stage of MI and have the potential as specific diagnostic biomarkers for MI.

“…Recent International guidelines have placed importance on the use of CMR in patients with unexplained acute myocardial injury and normal coronary angiography; however, the costs and benefits of adapting this approach remain poorly explored ( 10 , 11 ).…”

Section: Discussionmentioning

confidence: 99%

“…Due to the expectation that MI is the most frequent and/or important etiology of unexplained acute myocardial injury, guidance from the European Society of Cardiology (ESC) and American Heart Association (AHA) have historically focused on therapies for acute coronary syndromes in management following “MINOCA” presentations. In recognition of etiological heterogeneity of this acute presentation, recent guidelines focus on the role of improved diagnostic algorithms as key to improving patient outcomes ( 9 – 11 ). Within these algorithms is a consensus of opinion that CMR has a key role in the detection of the cause of the cardiac injury.…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, while CMR's diagnostic role is supported by single center studies and meta-analyses (Class 1, Level of evidence B), there are no convincing economic evaluations of CMR in this setting ( 11 ). We aimed to model the financial impact of implementing CMR in the diagnostic pathway for assessing patients with unexplained acute myocardial injury and culprit-free coronary angiography.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

A Cost Analysis of Cardiac Magnetic Resonance Imaging in the Diagnostic Pathway of Patients Presenting With Unexplained Acute Myocardial Injury and Culprit-Free Coronary Angiography

Murphy

Jones

Friebel

et al. 2021

Aims: To determine financial implications of implementing cardiac magnetic resonance imaging (CMR) in the diagnostic pathway of a population with unexplained acute myocardial injury and normal coronary angiography.Methods and Results: We performed a focused cost-benefit analysis using a hypothetical population of 2,000 patients with unexplained acute myocardial injury and normal coronary angiography divided into two groups to receive either standard or CMR guided management over a 10-year period. As healthcare practice and costs considerably vary geographically and over time, an algorithm with 15 key variables was developed to permit user-defined calculations of cost-benefit and other analyses. Using current UK costs, routine use of CMR increases healthcare spending by 14% per patient in the first year. After 7 years, CMR guided practice is cost neutral, reducing cost by 3% per patient 10 years following presentation. In addition, CMR -guided therapy results in 7 fewer myocardial infarctions and 14 fewer major bleeding events per 1,000 patients over a 10-year period. The three most sensitive variables were, in decreasing order, the cost of CMR, the cost of ticagrelor and the percentage of the population with MI requiring DAPT.Conclusion: Routine use of CMR in patients with unexplained acute myocardial injury and normal coronary angiography is associated with cost reductions in the medium to long term. The initial higher cost of CMR is offset over time and delivers a more personalized and higher quality of care.