Marta Afonso Nogueira

ProACS risk score: An early and simple score for risk stratification of patients with acute coronary syndromes

INTRODUCTION There are barriers to proper implementation of risk stratification scores in patients with acute coronary syndromes (ACS), including their complexity. Our objective was to develop a simple score for risk stratification of all-cause in-hospital mortality in a population of patients with ACS. METHODS The score was developed from a nationwide ACS registry. The development and internal validation cohorts were obtained from the first 31829 patients, randomly separated (60% and 40%, respectively). The external validation cohort consisted of the last 8586 patients included in the registry. This cohort is significantly different from the other cohorts in terms of baseline characteristics, treatment and mortality. Multivariate logistic regression analysis was used to select four variables with the highest predictive potential. A score was allocated to each parameter based on the regression coefficient of each variable in the logistic regression model: 1 point for systolic blood pressure ≤116 mmHg, Killip class 2 or 3, and ST-segment elevation; 2 points for age ≥72 years; and 3 points for Killip class 4. RESULTS The new score had good discriminative ability in the development cohort (area under the curve [AUC] 0.796), and it was similar in the internal validation cohort (AUC 0.785, p=0.333). In the external validation cohort, there was also excellent discriminative ability (AUC 0.815), with an adequate fit. CONCLUSIONS The ProACS risk score enables easy and simple risk stratification of patients with ACS for in-hospital mortality that can be used at the first medical contact, with excellent predictive ability in a contemporary population.

Role of intra-aortic balloon pump counterpulsation in the treatment of acute myocardial infarction complicated by cardiogenic shock: Evidence from the Portuguese nationwide registry.

Background: In previous guidelines, intra-aortic balloon pump (IABP) use was strongly recommended in the treatment of cardiogenic shock in the context of acute myocardial infarction. The recent IABP-SHOCK II trial demonstrated no benefit in short- and medium-term mortality with the use of IABP. It was our objective to evaluate in a real life nationwide population of patients with acute myocardial infarction the impact of IABP in short- and medium-term mortality. Methods: We included patients admitted with acute myocardial infarction in Killip class IV in the first 24 hours, all submitted to urgent coronary angiography. Our study objective was the occurrence of hospital and six-month all-cause mortality. Results: From the 33,300 patients included in the registry, 4.2% presented with Killip class IV in the first 24 hours and 646 (43.6%) were submitted to urgent coronary angiography. IABP was implanted in 19.8% of these patients. The IABP group was younger, had higher admission heart rate, more multivessel disease and more left main disease. There were 260 hospital deaths (40.2%), similar between groups (46.1% vs. 38.8%, p=0.132). IABP use was associated with a deleterious effect in patients with previous MI and beneficial effect in patients with mechanical complications. IABP use had a neutral effect on mortality (hazard ratio 1.14, 95% confidence interval 0.84–1.56). This was further confirmed in a propensity score matching analysis. Conclusions: In a real life population of patients with acute myocardial infarction, the use of IABP for the treatment of cardiogenic shock was associated with a neutral effect.

Validação externa do score de risco ProACS para estratificação de risco de doentes com síndrome coronária aguda

INTRODUCTION The ProACS risk score is an early and simple risk stratification score developed for all-cause in-hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short- and long-term follow-up. METHODS Consecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST-segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C-ACS) risk scores for each patient. RESULTS A total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST-segment elevation myocardial infarction. All-cause in-hospital mortality was 5.7% and 10.3% at one-year follow-up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C-ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short- and long-term follow-up (p<0.001 for all comparisons). CONCLUSIONS The ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score.

Risk factor paradox in the occurrence of cardiac arrest in acute coronary syndrome patients

Objective To compare patients without previously diagnosed cardiovascular risk factors) and patients with one or more risk factors admitted with acute coronary syndrome. Methods This was a retrospective analysis of patients admitted with first episode of acute coronary syndrome without previous heart disease, who were included in a national acute coronary syndrome registry. The patients were divided according to the number of risk factors, as follows: 0 risk factor (G0), 1 or 2 risk factors (G1 - 2) and 3 or more risk factors (G ≥ 3). Comparative analysis was performed between the three groups, and independent predictors of cardiac arrest and death were studied. Results A total of 5,518 patients were studied, of which 72.2% were male and the mean age was 64 ± 14 years. G0 had a greater incidence of ST-segment elevation myocardial infarction, with the left anterior descending artery being the most frequently involved vessel, and a lower prevalence of multivessel disease. Even though G0 had a lower Killip class (96% in Killip I; p < 0.001) and higher ejection fraction (G0 56 ± 10% versus G1 - 2 and G ≥ 3 53 ± 12%; p = 0.024) on admission, there was a significant higher incidence of cardiac arrest. Multivariate analysis identified the absence of risk factors as an independent predictor of cardiac arrest (OR 2.78; p = 0.019). Hospital mortality was slightly higher in G0, although this difference was not significant. By Cox regression analysis, the number of risk factors was found not to be associated with mortality. Predictors of death at 1 year follow up included age (OR 1.05; p < 0.001), ST-segment elevation myocardial infarction (OR 1.94; p = 0.003) and ejection fraction < 50% (OR 2.34; p < 0.001). Conclusion Even though the group without risk factors was composed of younger patients with fewer comorbidities, better left ventricular function and less extensive coronary disease, the absence of risk factors was an independent predictor of cardiac arrest.

Percutaneous closure of a large ascending aortic pseudoaneurysm

Pseudoaneurysm of the ascending aorta is a rare complication, usually after thoracic surgery or trauma. Since surgical repair is associated with very high morbidity and mortality, percutaneous closure has been described as an alternative. In this regard, we present a case in which a symptomatic large pseudoaneurysm of the ascending aorta was treated percutaneously due to the high surgical risk. Despite the technical difficulties, this procedure had a good final result followed by clinical success.

Percutaneous closure of a giant left ventricular wall pseudoaneurysm: Anterograde approach with a double snare technique

Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction, cardiac surgery, trauma or infection. Since surgical repair is associated with high morbidity and mortality, percutaneous closure has been described as an alternative. In this regard, we present a case in which a symptomatic large left ventricular pseudoaneurysm was treated by percutaneous closure due to the patients high surgical risk, using a double snare technique. Despite the technical difficulties, this procedure had a good final result followed by clinical success, confirming that this procedure is an effective alternative to surgery in high-risk patients.

Low diagnostic yield of invasive coronary angiography: is the noninvasive stress testing guilty? Data from a cohort of 2600 patients

Purpose: Many patients referred for invasive coronary angiography (ICA) following clinical assessment complemented with noninvasive stress testing (NIST) do not have obstructive coronary artery disease (OCAD). We aimed to determine the predictors of OCAD and the incremental value of NIST. Methods: We analyzed a cohort of patients referred for ICA for stable CAD diagnosis in a single tertiary-care center (2006-2011). Traditional and nontraditional CAD risk factors, modified Framingham risk score (FRS), symptoms, left ventricle function (LVF), NIST and ICA results were assessed. OCAD: luminal narrowing ≥70% (≥50% for left main artery). OCAD predictors were determined by uni and multivariate analysis. To assess the incremental predictive value of each factor, a stepwise logistic regression analysis was performed, starting with (1) FRS and progressively adding (2) nontraditional risk factors, (3) symptoms, (4) pretest (NIST) probability of CAD, (5) LVF and (6) NIST result. The discriminatory power at each step was evaluated by the area under the ROC curve (AUC). Results: 2600 patients included: 65.2±9.9 years, 59% male, mean 10-year Framingham risk 18%, 10% depressed LVF, 81% positive NIST (treadmill exercise ECG/SPECT). Only 49% had OCAD. Factors independently associated with OCAD: class 3 (CCS) angina (OR 5.3, 95% CI 3.1-8.9), typical angina (OR 3.2, 95% CI 2.6-4.1), male gender (OR 2.9, 95% CI 2.4-3.7), depressed LVF (OR 2.9, 95% CI 1.9-4.3) and high FRS (OR 1.2, 95% CI 1.1-1.2), (all p<0.05). Stepwise analysis shown in the Figure. ![Figure][1] Conclusions: The diagnostic yield of ICA was low. The single most important predictor of OCAD was severe angina, while NIST did not increase the discriminatory power over the clinical judgment. Better strategies are needed to avoid unnecessary referrals to ICA. [1]: pending:yes