Troponin-positive, MB-negative patients with non-ST-elevation myocardial infarction: An undertreated but high-risk patient group: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (NCDR ACTION-GWTG) Registry.
ABSTRACT Despite the 2000 and 2007 redefinition of myocardial infarction (MI), patients who are troponin (Tn) positive ([+]) but MB negative ([-]) may not be considered to have MI, particularly in the absence of known coronary disease (prior MI or revascularization; coronary artery disease [CAD]). How this affects treatment and outcomes has not been well described.
Direct arrival patients with non-ST elevation MI (NSTEMI) enrolled in the American College of Cardiology NCDR ACTION-GWTG Registry were included. Patients missing marker data who were Tn (-) and had CAD were excluded. Troponin (+) patients were categorized as MB (+) (n = 11,563) or MB (-) (n = 4,501). Treatments and in-hospital outcomes were compared between the 2 groups using logistic regression.
Of the 16,064 NSTEMI patients, 28% were MB (-). The MB (-) patients were older (median age 68 vs 65 years) and had more comorbidities (hypertension 71% vs 66%, diabetes 31% vs 27%, heart failure 22% vs 19%; all Ps < .01). After adjusting for baseline characteristics, MB (-) patients were significantly less likely to receive clopidogrel, antithrombins, glycoprotein IIb/IIIa antagonists, or angiography (all Ps < .001). In-hospital mortality was lower in MB (-) patients (3.8% vs 4.9%, P < .01), which remained significant after adjusting for baseline variables (odds ratio 0, 69, 95% CI 0.6-0.9, P = .002).
Patients without known CAD who have NSTEMI and are MB (-) have a higher risk profile but are less likely to receive guideline-recommended acute pharmacologic treatment than those who are MB (+). Given the relatively high mortality in this group, increased emphasis on improving quality of care in Tn (+)/MB (-) patients is warranted.
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ABSTRACT: International studies suggest almost half of all major coronary episodes annually occur in survivors of acute coronary syndrome (ACS). A greater focus on medium- and long-term ACS management and adherence to proven therapies is essential if out-of-hospital reductions in mortality and morbidity are to be optimized. A national panel of clinical and research opinion leaders in ACS care met for 2 days to set future priorities in health care delivery. Lifestyle, control of risk factors, and prescription of pharmacological therapies can improve the course of coronary heart disease (CHD) by reducing all-cause and cardiovascular mortality by 15% to 25%. All ACS patients stand to benefit from rehabilitation and systematic secondary prevention, however, underutilization and suboptimal adherence to rehabilitation and secondary prevention measures persist globally. A range of new initiatives in Australia and elsewhere indicate that time is ripe for change to improve the uptake of preventative treatments in patients after ACS. Key universal drivers of delivering best evidence practice for medium- to long-term care after ACS are economics and locality. Health-service redesign involving all stakeholders will be integral to increasing access, uptake, and adherence to lifestyle, control of risk factors, and pharmacologic therapies shown to improve cardiovascular outcomes.Clinical Therapeutics 08/2013; 35(8):1076-81. · 2.59 Impact Factor
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ABSTRACT: Myocardial infarction (MI) is a major cause of mortality and morbidity worldwide. Each year, an estimated 785,000 persons will have a new MI in the United States alone, and approximately every minute an American will succumb to one.1 In addition, MI has major psychological and legal implications for patients and the society and is an important outcome measure in research studies. The prevalence of MI provides useful data regarding the burden of coronary artery disease and offers insight into health care planning, policy, and resource allocation. The importance of accurately and reproducibly defining MI is therefore self-evident. The Third Universal Definition of Myocardial Infarction (MI) expert consensus document was published in October 2012 by the global Myocardial Infarction Task Force.2 This landmark document was cosponsored by multiple cardiovascular societies and included both updated definitions and a modified classification of MI that have important clinical, epidemiological, and research implications. We hereby present a critical overview of this important document and summarize its key recommendations.Methodist DeBakey cardiovascular journal 07/2013; 9(3):169-172.
Article: Put Disease Prevention First.[Show abstract] [Hide abstract]
ABSTRACT: Worldwide, non-communicable diseases are the dominant cause of death, with atherosclerotic cardiovascular disease (CVD) a major contributor(1). These deaths are spread across high- to low-income countries, with about one in three of all CVD deaths occurring in under 70 year-olds, amounting to an estimated six million cases annually(1). Analyses in many countries have shown that both an improvement in risk factors and advances in medical therapies have contributed to the fall in age-standardised mortality from coronary heart disease (CHD)(2). Importantly, leading a healthy lifestyle has broader implications for the prevention and management of other non-communicable diseases including cancer, diabetes and chronic respiratory diseases. Following decades of major advances in the treatment of acute CHD events it is being appreciated increasingly that evidence-based long-term management of CHD is critical to achieve optimal reductions in mortality and morbidity. Each year, approximately 50 percent of major coronary events occur in those with a hospital discharge diagnosis of CHD(3). Half of these recurrent events are fatal(3). A significant number of such CHD events will occur within the first year after hospitalization for non-fatal acute coronary syndromes(4).Circulation 07/2013; · 14.95 Impact Factor