Invasive versus conservative strategy in consecutive patients aged 80 years or older with non-ST-segment elevation myocardial infarction: a retrospective study in China

Objective To investigate whether the very elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) will benefit from an invasive strategy versus a conservative strategy. Methods 190 consecutive patients aged 80 years or older with NSTEMI were included in the retrospective study from September 2014 to August 2017, of which 69 patients received conservative strategy and 121 patients received invasive strategy. The primary outcome was death. Multivariate Cox regression models were used to assess the statistical association between strategies and mortality. The survival probability was further analyzed. Results The primary outcome occurred in 17.4% patients in the invasive group and in 42.0% patients in the conservative group (P = 0.0002). The readmission rate in the invasive group (14.9%) was higher than that in the conservative group (7.2%). Creatinine level (OR = 1.01, 95% CI: 0.10–1.03, P = 0.05) and use of diuretic (OR = 3.65, 95% CI: 1.56–8.53, P = 0.003) were independent influential factors for invasive strategy. HRs for multivariate Cox regression models were 3.45 (95% CI: 1.77–6.75, P = 0.0003), 3.02 (95% CI: 1.52–6.01, P = 0.0017), 2.93 (95% CI: 1. 46–5.86, P = 0.0024) and 2.47 (95% CI: 1.20–5.07, P = 0.0137). Compared with the patients received invasive strategy, the conservative group had remarkably reduced survival probability with time since treatment (P < 0.001). Conclusions An invasive strategy is superior to a conservative strategy in reducing mortality of patients aged 80 years or older with NSTEMI. Our results suggest that an invasive strategy is more suitable for the very elderly patients with NSTEMI in China.

Effects of omeprazole or pantoprazole on platelet function in non-ST-segment elevation acute coronary syndrome patients receiving clopidogrel

Background: This study evaluated the effect of omeprazole or pantoprazole on platelet reactivity in non-STsegment elevation acute coronary syndrome(NSTE-ACS) patients receiving clopidogrel.Methods: Consecutive patients with NSTE-ACS(n =620) from general hospital of Shenyang Military Command were randomized to the omeprazole or pantoprazole(20mg/d) group(1:1), and received routine dual antiplatelet treatment. Patients' reversion rate of adenosine diphosphate-induced platelet aggregation(ADP-PA) was assessed at baseline, 12 to 24 h after administration of medication, and after 72 h of percutaneous coronary intervention(PCI). The primary endpoint of the study was platelet reactivity assessed with ADP-PA at 30 days after PCI. Adverse events(AEs) were recorded for 30-day and 180-day follow-up periods.Results: There were no significant differences between both the groups in platelet response to clopidogrel at 12–24h after drug administration(54.09%±18.90% vs. 51.62%±19.85%, P=0.12), 72 h after PCI(52.15%±19.45% vs. 49.66%±20.05%, P=0.18), and 30 days after PCI(50.44%±14.54% vs. 48.52%±15.08%, P=0.17). The rate of AEs did not differ significantly between groups during the 30-day(15.2% vs. 14.8%, P=0.91) and 180-day(16.5% vs. 14.5%, P=0.50) follow-up periods after PCI.Conclusion: The addition of omeprazole or pantoprazole to clopidogrel did not restrict the effect of platelet aggregation by reducing the conversion of clopidogrel. Compared with clopidogrel alone, pantoprazole-clopidogrel and omeprazoleclopidogrel combinations did not increase the incidence of adverse clinical events during 30-day and 180-day follow-up periods after PCI.

Effect of Shenmai injection combined with antiplatelet drugs on the plaque property and inflammatory response in patients with non-ST-segment elevation ACS

Objective: To investigate the effect of Shenmai injection combined with antiplatelet drugs on the plaque property and inflammatory response in patients with non-ST-segment elevation ACS. Methods: A total of 142 patients with non-ST-segment elevation ACS who were treated in the hospital between June 2015 and September 2017 were divided into control group (n=71) and Shenmai injection group (n=71) by random number table method. Control group received antiplatelet drugs based on routine treatment, and Shenmai injection group received Shenmai injection combined with antiplatelet drugs on the basis of routine treatment. The differences in serum contents of plaque property-related indexes and inflammatory factors were compared between the two groups before and after treatment. Results: Before treatment, there was no significant difference in serum contents of metabolism indexes, lipid indexes, cell adhesion molecules and inflammatory factors between the two groups. After 1 week of treatment, serum metabolism indexes Hcy and UA contents of Shenmai injection group were lower than those of control group;serum lipid indexes ox-LDL and Lp-PLA2 contents were lower than those of control group;serum adhesion molecules sVCAM-1 and sICAM-1 contents were lower than those of control group;serum inflammatory factors IL-1β, IL-6, IL-17 and IL-23 contents were lower than those of control group. Conclusion: Adjuvant Shenmai injection therapy can further stabilize the plaques and inhibit the systemic inflammatory response in patients with non-ST-segment elevation ACS.

Distribution of gene polymorphisms associated with aspirin antiplatelet in the Han NSTEMI population

Objective:To analyze the genotype and allele distribution characteristics of GPⅢa PLA2(rs5918),PEAR1(rs12041331),and PTGS1(rs10306114)genes related to the antiplatelet pharmacological effects of aspirin,providing reference for individualized treatment of Chinese Han NSTEMI patients.Methods:A total of 107 Han patients with NSTEMI in Beijing Luhe Hospital affiliated to Capital Medical University from January 2016 to December 2022 were selected as the research subjects.The genotypes of GPⅢa PLA2(rs5918),PEAR1(rs12041331)and PTGS1(rs10306114)were detected by fluorescence staining in situ hybridization.The frequency distribution and allele distribution of genotype were analyzed.The results were analyzed whether there were statistical differences in the distribution of related alleles between the Han NSTEMI population and some populations in the 1000 Genomes database.Results:In the Han NSTEMI population,the genotype frequencies of GPⅢa PLA2(rs5918)locus were TT 97.20%,TC 2.80%and CC 0%,the allele frequencies were T 98.60%and C 1.40%.The genotype frequencies of PEAR1(rs12041331)locus were GG 42.06%,GA 44.86%and AA 13.08%,the allele frequencies were G 64.49%and A 35.51%.The genotypes at the PTGS1(rs10306114)locus were all AA(100%),no AG or GG genotype was found.Conclusion:In the NSTEMI population of Han nationality,the mutation at GPⅢa PLA2(rs5918)site related to aspirin antiplatelet pharmacology is rare,and there is no mutation at PTGS1(rs10306114)site.Wild homozygotes are dominant in these two gene loci,while mutations in PEAR1(rs12041331)are more common.Some of the findings in this study are similar to those in previous reports or other populations included in the relevant database;however,some results differ from previous reports or other populations。

丹参酮ⅡA磺酸钠注射液对非ST段抬高心肌梗死患者血浆组织型纤溶酶原激活物抑制物的影响

目的观察非ST段抬高心肌梗死患者血浆组织型纤溶酶原激活物抑制物(PAI-1)的变化和丹参酮ⅡA磺酸钠注射液对其的影响。方法将非ST段抬高心肌梗死患者136例随机分为治疗组72例和对照组64例。2组均予西药常规治疗,治疗组另加用丹参酮ⅡA磺酸钠注射液治疗。2组均14d为1个疗程。2组分别于治疗前、治疗后14d测定血浆PAI-1浓度,并观察其严重心律失常、心绞痛、心力衰竭的发生情况。结果治疗后2组PAI-1水平均下降(P<0.05),但治疗组下降更明显(P<0.05)。治疗组严重心律失常、心绞痛、心力衰竭的发生率均显著低于对照组,差异均有统计学意义(P<0.05)。结论丹参酮ⅡA磺酸钠注射液辅治非ST段抬高心肌梗死疗效确切,并能降低其严重心律失常、心绞痛、心力衰竭的发生率。

Relationship between serum vasoactive factors and plaque morphology in patients with non-ST-segment elevated acute coronary syndrome

Background Vasoactive factors have been reported to correlate with vulnerable plaque and acute coronary syndrome （ACS）. This study aimed to investigate the relationship between vasoactive factors and plaque morphology in patients suffering from non-ST-segment elevated ACS. Methods From April 2007 to April 2009, 124 consecutive patients suffering from non-ST-segment elevated ACS who had received coronary angiography （CAG） and intravascular ultrasound （IVUS） in the People＇s Liberation Army General Hospital and Beijing Anzhen Hospital were enrolled in this study. Three serum vasoactive factors, plasma soluble vascular endothelial growth factor receptor-1 （sFIt-1）, placental growth factor （PLGF） and interleukin-18 （IL-18）, were measured by enzyme-linked-immunosorbent serologic assay of the patients. The levels of vasoactive factors were compared between vulnerable plaque group and stable plaque group, and between unstable angina pectoris （UAP） group and non-ST-segment elevation acute myocardial infarction （NSTE-AMI） group. The relationship between the plaque morphology and levels of vasoactive factors was analyzed. Results The levels of vasoactive factors were similar between the UAP group （69 patients） and NSTE-AMI group （55 patients）. The levels of sFIt-1 and PLGF in the vulnerable plaque group were significantly higher than those in the stable plaque group. The level of IL-18 was correlated positively with plaque morphology. Multivariate Logistic regression analysis showed that the level of PLGF was an independent risk factor for vulnerable plaque （OR=2.115, 95%Cl 1.415-5.758, P=0.018）. Using the ROC curve, PLGF was a significant factor for the diagnosis of vulnerable plaque （the diagnostic point was 26.3 ng/L, the proportion of square area under the ROC curve was 0.799, 95%C/0.758-0.839, P 〈0.001 ; the sensitivity of PLGF under the ROC curve was 86%, and the specificity 63%）. Conclusion Both IL-18 and PLGF are biomarkers for vulnerable plaques and helpful to predict vulnerable plaque.

Long-term Prognosis of Patients with Acute non-ST-segment Elevation Myocardial Infarction undergoing Different Treatment Strategies

Background： In cardiology, it is controversial whether different therapy strategies influence prognosis after acute coronary syndrome. We examined and compared the long-term outcomes of invasive and conservative strategies in patients with non-ST-segment elevation myocardial infarction （NSTEMI） and characterized the patients selected for an invasive approach. Methods： A total of 976 patients with acute NSTEMI were collected from December 2006 to October 2012 in the First Affiliated Hospital of Dalian Medical University Hospital. They are divided into conservative strategy （586 patients） and invasive strategy （390 patients） group. Unified tbllow-up questionnaire was performed by telephone contact （cut-off date was November, 2013）. The long-term clinical events were analyzed and related to the different treatment strategies. Results： The median follow-up time was 29 months. Mortality was 28.7% （n = 168） in the conservative group and 2.1% （n = 8） in the invasive management at long-term clinical follow-up. The secondary endpoint （the composite endpoint） was 59.0% （n = 346） in the conservative group and 30.3% （n = 118） in the invasive management. Multivariate analysis showed that patients in the conservative group had higher all-cause mortality rates than those who had the invasive management （adjusted risk ratio [RR] = 7.795; 95% confidence interval [CI]： 3.796 16.006, P 〈 0.001）, and the similar result was also seen in tile secondary endpoint （adjusted RR ： 2.102; 95% （7： 1.694-2.610, P 〈 0.001 ）. In the subgroup analysis according to each Thrombolysis in Myocardial Infarction risk score （TRS）, log-rank analysis showed lower mortality and secondary endpoint rates in the invasive group with the intermediate and high-risk patients （TRS 3-7）. Conclusions： An invasive strategy could improve long-term outcomes for NSTEMI patients, especially for intermediate and high-risk ones （TRS 3- 7）.

The association between admission systolic blood pressure and 1-year mortality in patients with non-ST-segment elevation acute coronary syndrome

Background In patients with acute coronary syndrome（ACS）, lower admission systolic blood pressure（SBP）levels infer a worse prognosis. However, the predictive potential of admission SBP on 1-year mortality has not fully elucidated in patients with non-ST-segment elevation ACS（NSTEACS）. Methods We enrolled 1325 patients to investigate the association between admission SBP in patients hospitalized for NSTEACS. We analyzed the association between admission SBP and 1-year mortality. Admission SBP was categorized as low（〈110 mm Hg）, normal（110-140 mm Hg）, high（141-160 mm Hg）, and very high（〉160 mm Hg）. Results Compared with patients with normal admission SBP, those with low SBP had a significantly increased hazard ratios（HRs） for 1-year mortality of 3.03（P〈0.05）, while patients with high and very high admission SBP had no significantly increased HRs for 1-year mortality. Conclusion Low admission SBP, but not elevated admission SBP, is a strong independent predictor of 1-year mortality in patients with NSTEACS.

Comparison Between Upstream Tirofiban and Downstream Tirofiban in Patients With Non-ST-segment Elevation Acute Coronary Syndromes at High-risk Undergoing Percutaneous Coronary Interventions:Efficacy and Safety

Objectives To compare the efficacy and safety of upstream tirofiban with downstream tirofiban in patients with non- ST-segment elevation acute coronary syndromes （NSTE-ACS） at high-risk undergoing percutaneous coronary intervention （PCI）. Methods Two hundred and four patients with NSTE-ACS at high-risk undergoing PCI were randomized to upstream （4 -6 hours before coronary angiography） tirofiban or downstream （with the guidewire crossing the lesion） tirofiban. We evaluated myocardial damage after PCI by qualitatively analyzing cardiac troponin I （cTnI） and MB isoenzyme of creatine kinase （CK-MB）. Platelet aggregation inhibition and thrombolysis in myocardial infarction （TIMI） flow grade were assessed. The incidences of major adverse cardiac events （MACE） at 24-hour, 90-day and 180-day after PCI were followed up. The incidences of bleeding complications and thrombocytopenia during tirofiban administration were recorded. Results There were 102 patients with NSTE-ACS randomly assigned to upstream group and downstream group respectively. The peak serum levels of cTnI within 48 hours after PCI were significantly lower with upstream tirofiban than downstream tirofiban （0.34 vs 0. 61 ; P 〈 0.05 ）. Post-procedural cTnI elevation within 48 hours was significantly less frequent among patients who received upstream tirofiban than downstream tirofiban （63 % vs 82%, P 〈 0. 05 ）. The peak serum levels of CK-MB as well as post-procedural CK-MB elevation within 48 hours after PCI were not significantly different between the two groups （ 15 vs 18 and 38% vs 43% ; respectively; P 〉 0. 05 ）. ECG changes and the inhibition of platelet aggregation between two groups were similar （ P 〉 0.05 ）. Although the inci- dences of MACE at 90-day and 180-day after PCI were not statistically different, they were consistently lower with upstream tirofiban （3 % vs 6% and 6% vs 16% ; P 〉 0.05 ）. The incidences of bleeding complications and thrombocyto- penia were similar in the two groups （ 11% vs 9% ; P 〉 0.05 ）. Conclusions Among patients with NSTE-ACS at high-risk undergoing PCI, upstream tirofiban is associated with attenuated myocardial damage without increasing complications. （ S Chin J Cardiol 2009; 10（4） ： 179 -185）

Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndromeaTitle and subTitle Breakaaaaaaaa randomized controlled trial

Abstract Objectives The authors sought to describe the association between post-procedural bleeding and long-term recurrent bleeding, major adverse cardiac events （MACE）, and mortality among older patients undergoing per-cutaneous coronary intervention （PCI）.

Effect of Danlou Tablet(丹蒌片) on Peri-procedural Myocardial Injury among Patients undergoing Percutaneous Coronary Intervention for Non-ST Elevation Acute Coronary Syndrome:A Study Protocol of A Multicenter,Randomized,Controlled Trial

Background： It has been shown that administration of statins reduced the risk of peri-procedural myocardial damage. However, it remains unclear whether Chinese medicine Danlou Tablet （~）~）, similar to statins, may protect patients undergoing percutaneous coronary intervention （PCI） from peri-procedural myocardial damage. Objective： To demonstrate the hypothesis whether treatment with Danlou Tablet would improve clinical outcome in patients undergoing selective PCI with non-ST elevation acute coronary syndrome （NSTE-ACS） in China. Methods： Approximately 220 patients with unstable angina or non-ST-segment elevation myocardial infarction undergoing PCI will be enrolled and randomized to Danlou Tablet treatment （4.5 g/day for 2 days before intervention, with a further 4.5 g/day for 90 days thereafter） or placebo. All patients will not receive Danlou Tablet before procedure. The primary end point is to evaluate the incidence of cardiac death, myocardial infarction or unplanned re-hospitalization and revascularization after 30 days in patients undergoing selective PCI treated with Danlou Tablet compared with placebo. Secondary endpoints include the incidence of peri-procedural myocardial injury, 3-month clinical outcomes, the quality of life and Chinese medicine syndromes assessment. Conclusion： This study protocol will provide important evidence of Danlou Tablet treatment on the peri-procedural myocardial injury in patients with NSTE-ACS undergoing selective PCI, which may support a strategy of routine Danlou Tablet therapy to improve the clinical outcomes.

Prognostic value of combination of ST-segment elevation in lead aVR and positive cTnI in patients with non-ST- segment elevation acute coronary syndrome

Background Non-ST-segment elevation acute coronary syndrome （NSTE-ACS） is an acute heart disease caused by incomplete occlusion of related coronary arteries with unstable atherosclerotic plaques. Lead aVR ST- segment elevation and cTnI positive are closely correlated to the prognosis of NSTE-ACS patients. However, there are few studies applying the two predictors to early risk stratification in NSTE-ACS patients. Method Two hundred and five cases of NSTE-ACS patients followed up for 6 months after discharge were reviewed. All patients were divided into four groups： Group A-cTnI negative combined with aVR-non-ST-segment elevation group （100 cases） ; Group B-cTnI negative combined with aVR-ST-segment elevation group （31 cases） ; Group C-cTnI positive combined with aVR-non-ST-segment elevation group （43 cases） ; Group D-cTnI positive combined with aVR-ST-segment elevation group （31 cases）. There was no significant difference in gender, age, old myocardial infarction, previous PCI history, hypertension, and diabetes between aVR-ST elevation group and no aVR-ST elevation group. The morbidity of left main or three-vessel coronary artery disease as well as adverse cardiovascular events in the four groups were observed and analyzed. Results （i） The morbidity of left main or three-vessel coronary artery disease was highest in Group D （87.1%） , and was markedly higher in Group B （41.9%） than that in Group A （7%） or Group C （9.3%） ; （ii） The incidence of adverse cardiovascular events was highest in Group D （77.4%）, and was much higher in B （35.5%） as compared with that tin Group A （1%） or group C （7%）. Conclusion Electrocardiographic lead aVR ST-segment elevation combined with cTnI positive has an important clinical value in predicting the prognosis of the patients with NSTE-ACS.

Latest Advancement of Non ST-segment Elevation Acute Coronary Syndrome

Further understanding of the pathphophisyology, advance of the diagnosis instrument and renovation of the risk delamination standard can offer better therapy evidence for the non-ST-segment elevation acute coronary syndrome(NSTE-ACS). Drugs, such as trigeminy antiplatelet drug, prasugrel, fondaparinux and bivalirudin, have brought great clinical effect to the high risk patients. Since the result of the ICTUS test announced and the drug eluting balloon developed, we have reached the newest recognition of how to select a chance for intervention and how to prevent and cure the restenosis of in-stent.