Joanna Dutheil

C-reactive protein improves risk prediction in patients with acute coronary syndromes

AIMS Elevated C-reactive protein level is a risk marker in patients with acute coronary syndromes (ACSs), but current risk score systems do not consider this factor. We studied the incremental predictive value of adding C-reactive protein to the Global Registry of Acute Coronary Events (GRACE) risk score. METHODS AND RESULTS Characteristics, treatments and 30-day mortality were recorded for 1408/1901 consecutive ACS patients. Changes in global model fit, discrimination, calibration, and reclassification were evaluated upon addition of C-reactive protein to the GRACE risk score. High-C-reactive protein patients (C-reactive protein >22 mg/L, 4th quartile of C-reactive protein) were older, had more comorbidities and worse haemodynamic conditions, received less recommended treatment, and had a four-fold higher 30 day mortality. Multivariable analysis demonstrated high-C-reactive protein as an important and independent predictor of mortality. Addition of high-C-reactive protein in the GRACE model modestly improved global fit, discriminatory capacity (c-statistic from 0.795 to 0.823), and calibration. Patients were divided into four groups according to GRACE risk score prediction: <1, 1 to <5, 5 to <10, and >or=10%. The model with high-C-reactive protein allowed adequate reclassification in 12.2%. CONCLUSION Elevated C-reactive protein level is a modest but independent predictive factor of 30-day mortality in ACS patients, even after adjustment for co-morbidities, haemodynamic conditions, and treatment. Combined with the GRACE risk score, C-reactive protein information improves risk classification.

Routine use of fondaparinux in acute coronary syndromes: A 2-year multicenter experience

BACKGROUND Fondaparinux has recently been approved in patients with acute coronary syndromes. The primary aim of this study was to describe the changes in use of anticoagulants between January 2006 and December 2007. The secondary aim was to compare 30-day mortality and rate of a combined end point (30-day death or major bleeding) according to the initial and final anticoagulant agent used. METHODS The rates of use of unfractionated heparin (UFH), enoxaparin, and fondaparinux were compared by periods of 1 month in a multicenter registry. The initial anticoagulant (first used at admission), the final anticoagulant (last used during hospitalization), and switches in anticoagulation were recorded. Temporal trends in monthly use of each anticoagulant were assessed; 30-day mortality rates and the combined end point were compared according to initial and final anticoagulant. RESULTS Among 2,874 patients included, the first anticoagulant used was UFH in 26%, enoxaparin in 59%, and fondaparinux in 15%. Respective figures for final anticoagulant were 17%, 56%, and 27%. Although 3 centers did not use fondaparinux (community centers with catheterization laboratory), the overall rate of use of fondaparinux, as initial and final anticoagulant, increased at the expense of the use of enoxaparin. We observed a growing proportion of patients with a switch from UFH to either enoxaparin or fondaparinux, ranging from 5% at the beginning to 25% at the end of the study. Patients treated with UFH were older, had more comorbidities, were at higher risk, and received fewer guidelines-recommended treatments. In patients submitted to angioplasty and treated with fondaparinux, a bolus of 60 IU/kg of UFH was added. After adjustment, 30-day mortality and combined end point rates were higher in patients treated with UFH. Irrespective of the type of acute coronary syndromes, patients treated with enoxaparin or fondaparinux had similar outcomes. CONCLUSIONS Between 2006 and 2007, the use of fondaparinux in patients with acute coronary syndromes increased considerably, either because it was used instead of enoxaparin or because of a switch from UFH. Adjusted mortality in patients treated with fondaparinux was lower than with UFH and similar to enoxaparin.

001 Thromboaspiration before primary PCI in STEMI patients reduces infarct size, but not microvascular obstruction: a magnetic resonance imaging study

Background Thromboaspiration (TA) during primary percutaneous intervention (PCI) is effective in opening infarct related artery (IRA) in patients (pts) with ST elevation acute myocardial infarction (STEMI), leading to better reperfusion and outcome. Microvascular obstruction (MVO) after successful IRA revascularization is associated with greater myocardial damage, left ventricular (LV) impairment and higher mortality. We evaluated relationships between (i) TA and MVO 5 days after STEMI; (ii) TA and infarct size at 5 days and 6 months; (iii) TA and LV remodelling at 6 months. Methods 51 pts aged <75, with first STEMI and totally occluded IRA, referred for primary PCI within 12 hours of onset of symptoms were enrolled. All pts underwent TA before stenting. Pts were categorized according to positive or negative TA. MVO, infarct size and remodelling were assessed by contrast-enhanced cardiac magnetic resonance imaging (MRI) at 3T performed 5 days and 6 months after STEMI. Infarct size was measured by assessing global myocardial extent of hyperenhancement on delayed contrast-enhanced MRI. MVO was defined as subendocardial areas of hypoenhanced signal surrounded by hyperenhanced myocardial tissue and expressed as % of total myocardium. Results See table. Conclusion Positive TA during primary PCI was associated with infarct size reduction at 5 days and 6 months follow-up in STEMI pts with TIMI 0 flow IRA. Although this phenomenon led to positive LV remodelling, it was not associated with a reduction in MVO. Negative TA (N = 34) Positive TA (N = 17) p TIMI III flow post PCI (%) 91% (31/34) 94% (16/17) 0.86 MVO at 5 days (%) 7.1 ± 5.7 6.8 ± 4.9 0.85 Infarct size at 5 days (%) 20.6 ± 8.1 9.9 ± 7.2 <10-5 Infarct size at 6 months (%) 16.4 ± 9.9 7.2 ± 8.1 .0007 LVSVI at 6 months (ml/m2) 27.5 ± 9.3 36.4 ± 12.2 0.01 LVSVI = left ventricular stroke volume index Full-size table Table options View in workspace Download as CSV

010 Anemia for Risk Assessment of Patients With Acute Coronary Syndromes

Background In patients admitted with acute coronary syndromes (ACS), those with anemia are at higher risk. However, current risk score systems do not take into account the presence of anemia. Methods The impact of anemia on mortality was studied, and its incremental predictive value was evaluated. Demographic, clinical, and biologic characteristics at admission, as well as treatments and mortality, were recorded for 1,410 consecutive patients with acute coronary syndromes. The incremental value of adding anemia information to risk score evaluation was determined using changes in the appropriateness of Cox models when anemia was added. Results Anemia was detected in 381 patients (27%). They were older, had more co-morbidities, had higher Global Registry of Acute Coronary Events (GRACE) risk scores, received fewer guideline-recommended treatments, and, as a result, had 4-fold higher mortality. When included in a prediction model based on the GRACE risk score, anemia remained an independent predictor of mortality. The addition of anemia improved both the discriminatory capacity and calibration of the models. According to the GRACE risk score, the population was divided into 4 groups of different risk levels of or =10%. The addition of anemia to the model made it possible to reclassify 9%, 43%, 47%, and 23% of patients into the different risk categories, respectively. Conclusion Our data confirmed that anemia was an independent predictive factor of mortality and had incremental predictive value to the GRACE score system for early clinical outcomes.