Explore the vast range of titles available.

Objective: To determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with NSTE-ACS undergoing cardiac catheterization. Methodology: We conducted a cross sectional descriptive study in 154 patients with NSTE-ACS admitted at AFIC-NIHD from 1st April to 30th September 2011. For each patient the GRACE risk score was calculated by using specific variables collected at admission. The extent and severity of coronary artery disease was evaluated on angiography for each patient. Results: A total of 154 patients were included in the study. The average age of the patients was 55.81years. Majority (75%) of the patients was male and 25% were females. The mean GRACE score was 132.85. Overall 40 patients had low, 54 had intermediate, and 60 had high GRACE risk score. Among patients with low score 28 had SVCAD, 4 patients had DVCAD and none of the patients had TVCAD. In the intermediate group 24 patients had SVCAD, 18 had DVCAD and 6 had TVCAD whereas among the high GRACE risk score 4 patients had SVCAD, 24 had DVCAD and 32 had TVCAD. Regarding the severity of coronary artery disease; among the low GRACE risk score patients; 8 had subcritical and 32 had critical CAD. In the intermediate GRACE risk score subset of patients, 6 had subcritical and 48 had critical CAD and none of the patients of high GRACE risk score had subcritical CAD and all 60 patients had critical CAD. Conclusion: GRACE risk score is a valuable noninvasive tool in predicting the extent and severity of CAD.

Objective: To determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with NSTE-ACS undergoing cardiac catheterization. Methodology: We conducted a cross sectional descriptive study in 154 patients with NSTE-ACS admitted at AFIC-NIHD from 1st April to 30th September 2011. For each patient the GRACE risk score was calculated by using specific variables collected at admission. The extent and severity of coronary artery disease was evaluated on angiography for each patient. Results: A total of 154 patients were included in the study. The average age of the patients was 55.81years. Majority (75%) of the patients was male and 25% were females. The mean GRACE score was 132.85. Overall 40 patients had low, 54 had intermediate, and 60 had high GRACE risk score. Among patients with low score 28 had SVCAD, 4 patients had DVCAD and none of the patients had TVCAD. In the intermediate group 24 patients had SVCAD, 18 had DVCAD and 6 had TVCAD whereas among the high GRACE risk score 4 patients had SVCAD, 24 had DVCAD and 32 had TVCAD. Regarding the severity of coronary artery disease; among the low GRACE risk score patients; 8 had subcritical and 32 had critical CAD. In the intermediate GRACE risk score subset of patients, 6 had subcritical and 48 had critical CAD and none of the patients of high GRACE risk score had subcritical CAD and all 60 patients had critical CAD. Conclusion: GRACE risk score is a valuable noninvasive tool in predicting the extent and severity of CAD.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction that most frequently affects younger women, making it an important cause of morbidity and mortality within these demographics. The evolution of intracoronary imaging, improved diagnosis with coronary angiography, and ongoing research efforts and attention via social media, has led to increasing recognition of this previously underdiagnosed condition. In this review, we provide a summary of the current body of knowledge, as well as focused updates on the pathogenesis of SCAD, insights on genetic susceptibility, contemporary diagnostic tools, and immediate, short‐ and long‐term management. Spontaneous Coronary Artery Dissection (SCAD) is an increasingly recognized cause of myocardial infarction that most frequently affects younger women, making it an important cause of morbidity and mortality within these demographics. The evolution of intracoronary imaging (C ‐ OCT image of IMH), improved diagnosis with coronary angiography (B ‐ Type 2 A SCAD in an obtuse marginal artery), and ongoing research efforts and attention via social media, has led to increasing recognition of this previously underdiagnosed condition (A ‐ IMH as the important pathophysiologic mechanism in SCAD). OCT, optical coherence tomography; IMH, intramural hematoma; SCAD, Spontaneous Coronary Artery Dissection.

IntroductionNon-ST-elevation myocardial infarction (NSTEMI) is part of the wider spectrum of Acute Coronary Syndrome (ACS) and is the most common type of myocardial infarction in the UK. Patients with NSTEMI can be at low, intermediate or high risk of mortality or cardiovascular events depending on their presentation and the treatment approach can be different in low or intermediate/high risk groups. The Global Registry of Acute Coronary Events (GRACE) score helps predict these events at 6-months and has been recommended by National Institute for Health and Care Excellence (NICE) to be used as a guidance when deciding conservative management for low risk patients (predicted 6-month mortality ≤3) versus invasive coronary angiography (with follow-on PCI if indicated) within 72 hours in intermediate or high risk patients (predicted 6-month mortality >3%). European Society of Cardiology (ESC) latest guidelines outline that an early invasive strategy (<24 hours) should be considered in patients with high risk features; GRACE score >15%, dynamic ST-T changes or transient ST-segment elevation on ECG.ObjectivesA quality improvement project was undertaken to assess and improve adherence to GRACE score calculation in patients with NSTEMI at Scunthorpe General Hospital and whether those in intermediate/high risk groups are getting invasive coronary angiography (ICA) within 72 hours as per the NICE guidelines with reducing ICA service at this site over the years - Non-primary PCI service every weekday in 2021 to 3 days a week in 2022 to only diagnostic angiography 3 days a week in 2023.MethodThe data was collected retrospectively from the ICA requests August onwards of each year. A total of 90 patients were included over three years. GRACE score was checked in each request and where not available, minimum score was calculated from the information on presentation. Those with >3% score were then compared in each year for the time to ICA from the time of request.ResultsGRACE score was not mentioned in any of the 90 ICA requests.The gender distribution was about 2/3rd male to 1/3rd female patients in each year.83% patients had ICA within 72 hours in 2021 and 2022 regardless of the GRACE score. This halved to 40% in 2023.18 out of 30 patients had a score >3% in the first two years and 19 in the last.89% of the intermediate/high risk patients got ICA within 72 hours in 2021 and 2022. In contrast, only 37% of the patients met this target in 2023.ConclusionThe results clearly show that GRACE score is not incorporated in ICA requests. Furthermore, reducing the service has hugely impacted the care of the patients recently where they are being transferred to a PCI centre for it.An efficient system needs to be in place and we suggest that ICA requests should have a mandatory GRACE score and other high risk features in it so that the triaging team can identify intermediate/high risk patients and prioritise transfer so that the 72 hour target is met.Abstract 80 Figure 1Abstract 80 Figure 2Conflict of InterestNo

Background The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation (non‐ST‐segment elevation myocardial infarction [NSTEMI]) has recommended immediate (<2 h) percutaneous coronary intervention (PCI) in very‐high risk patients and early (<24 h) PCI in high‐risk patients. Hypothesis To examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes. Methods All NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis. Results Out of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty‐six (14.5%) patients and 922 (85.5%) patients were defined as very high‐risk and high‐risk NSTEMI patients, respectively. Of the very high‐risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high‐risk category. Of the high‐risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities. Conclusions Despite guidelines recommendations for immediate and early PCI in very high‐risk and high‐risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high‐risk patients.

IntroductionNon-ST-segment elevation myocardial infarction (NSTEMI) results in approximately 50,000 hospital admissions in the UK every year with up to 90% undergoing invasive coronary angiograms (ICA). A non-invasive strategy using cardiovascular magnetic resonance (CMR) before ICA in suspected NSTEMI has the potential to diagnose non-ischaemic pathologies and obviate the need for ICA. Furthermore, in cases of acute myocardial infarction (MI) with multi-vessel coronary artery disease (CAD), it can identify the infarct related artery (IRA), which can help guide revascularisation strategies. This study aimed to assess the diagnostic utility of early multi-parametric CMR before ICA in suspected acute NSTEMI.MethodsWe recruited 100 consecutive patients admitted to our hospital for suspected NSTEMI (70% male, age 62±11 years) into the Oxford Acute Myocardial Infarction Study (OxAMI). They underwent CMR pre-ICA; the protocol included cine, T2-weighted imaging, T1-mapping and late gadolinium enhancement, all with full short-axis coverage of the left ventricle (LV). CMR images were interpreted by experts blinded to ICA findings. The clinicians performing the ICA and those in charge of the patients’ care were blinded to CMR findings until post-ICA.ResultsThe acute CMR protocol was successfully completed in 96% of patients at 20–48 hours post-admission and at a median of 4 [2–6] hours pre-ICA. It showed acute MI in 67%, non-ischemic pathologies in 18%, normal findings in 11%, and was uninterpretable in 4%. Patients with MI, when compared to those with non-ischaemic pathologies and normal findings, had similar frequency of ischaemic changes on ECG (48 vs 24 vs 46%; p = 0.218) but larger rise in Troponin-I levels (51(12–155) vs 19 (5–77) vs 8 (2–10) fold; p = 0.003) and lower LV ejection fraction (51±9% vs 50±12% vs 61±5%; p = 0.004) (table 1). In patients with obstructive CAD on ICA (73/100; of whom 85% received revascularisation and 15% were medically managed for MI), CMR confirmed MI in only 84% (61/73), reclassifying the diagnosis in 15% (11/73: 7 non-ischemic pathologies, 4 normal). In patients with non-obstructive coronary arteries (NOCA) (27/100), CMR reclassified the presumed diagnosis of NSTEMI in 67% (18/27: 11 non-ischemic pathologies, 7 normal), confirming MI in only 22% (6/27); i.e. true myocardial infarction with non-obstructive coronary arteries (MINOCA) (figure 1). In patients diagnosed with MI on both ICA and CMR (61/100), CMR identified a different IRA in 11% (7/61).ConclusionIn patients presenting with suspected NSTEMI, a CMR-first strategy has the potential to change management in at least 36%; by reclassifying the presumed diagnosis (29%) and offering a new IRA in CMR-confirmed MI (7%), to guide clinical decision-making, including the need for ICA and revascularisation strategies. Multi-centre randomised clinical trials are needed to test the clinical and cost-effectiveness and long-term prognostic implications of a CMR-first strategy when compared to an ICA-first strategy in patients with suspected NSTEMI.Abstract 180 Figure 1Reclassification of diagnosis by CMR in patients treated for non-obstructive coronary arteries (NOCA) (n=27) and MI (n=73) on ICA. Non-ischaemic causes include myocarditis, dilated cardiomyopathy, hypertrophic cardiomyopathy, Takotsubo cardiomyopathy and right ventricular failure. NAD = No significant abnormality detectedAbstract 180 Table 1Clinical characteristics of patients with pre-ICA CMR diagnoses of MI, non-ischaemic pathologies and no abnormalities. Average values are presented as mean±SD or median [IQR] where appropriate. Proportional data are presented as percentage for each column. P values are for comparisons amongst the three sub-groups. ICA = Invasive coronary angiogramConflict of InterestNONE

This letter provides a critical appraisal of the study by Wei et al. on clinical and electrocardiographic predictors of left circumflex artery occlusion in NSTEMI patients. While the authors identified STV5 + STV6 ≥ 2.5 mm and T‐wave imbalance as potential markers, concerns remain regarding the single‐center, retrospective design, limited sensitivity of ECG findings, and the lack of significant differences in clinical outcomes. Prior meta‐analyses suggest a higher risk in patients with occluded culprit arteries, highlighting inconsistencies with the present study. Future research should employ multicenter prospective designs and advanced diagnostic modalities, including posterior ECG leads and artificial intelligence–based analysis, to improve detection and risk stratification of culprit LCX occlusion in NSTEMI.

IntroductionThe correct choice of antiplatelet therapy is crucial for patients admitted with NSTEMI and Unstable Angina as per the European Society of Cardiology (ESC) 2023 guidelines. Following loading with aspirin, appropriate selection and timing of second antiplatelet therapy is associated with decreased mortality and enhanced patient outcomes. Prasugrel or ticagrelor are the recommended choice of second antiplatelet in these patients. Clopidogrel is known to be inferior to these agents in terms of inhibition of platelets and it should only be given if prasugrel or ticagrelor are contraindicated or in patients with high bleeding risk.The correct timing of the second antiplatelet agent is also crucial. Pre-treatment with the second antiplatelet agent at the time of diagnosis and before the coronary angiogram is not associated with any improved ischaemic outcome but it is rather associated with increased risk of bleeding.This Quality Improvement Project (QIP) aims to assess the adherence of the New Cross Hospital to these specified guidelines and implementation of interventions to improve adherence. MethodsRetrospective data collection of electronic patient records admitted between September 2023 and November 2023 with diagnosed NSTEMI and Unstable Angina for patients aged more than 18 years, planned to undergo PCI, and no contraindications to starting anti-platelet agents. Following collection and analysis of data, interventions were introduced including implementation of regular teaching to junior doctors, active involvement in data collection of the junior doctors and understanding of dual antiplatelet guidelines through posters on the ward.ResultsThe first cycle of the QIP comprised of 17 patients. The analysis of data from this cycle showed that 47%(n=8) patients were loaded with second anti-platelet agent prior to the Invasive Angiogram. It further highlighted that 41%(n=7) patients were loaded with clopidogrel instead of prasugrel or ticagrelor. Significant improvement was noted following the interventions. The succeeding cycle had a total of 18 patients.17%(n=3) of these patients were loaded prior to the invasive angiogram and these patients were loaded with clopidogrel. Hence, following intervention 83% of patients were treated as per ESC guidelines.ConclusionThe QIP highlighted initial low compliance with the ESC guidelines for second anti-platelet loading but this improved significantly. Hence, effective communication between the stakeholders, regular teaching sessions and enhanced developments will improve patient outcomes.Abstract 79 Figure 1Abstract 79 Figure 2Conflict of InterestNone

AimTo improve NSTEMI care; with a particular focus on the timing of angiography in NSTEMI and same day discharge after angiography and follow on percutaneous coronary intervention (PCI).Setting: Single site non-surgical centre in the NHS, with a national target for 75% of NSTEMI patients to have angiography within 72 hours of admission.MethodsIn August 2020 we invited a change expert to facilitate a session. Stakeholders included: Nurses- ACS/ACU/Cardiology Ward/Cath Lab/Rehab/MINAP audit/Matron; Head of Service; Site managers; Radiographers; Cardiac physiologists; Emergency Physicians; Paramedics; Cardiologists and our local pathway manager. The session focussed on heart attack care and set realistic goals. The patient pathway, current model of care and future directions were discussed, and an improvement plan was made.The goals includedImproving patient experience≥ 75% of angiography within 72 hours of admission for NSTEMIIncreased same day discharge (golden patient)Direct admission to a free bed on the Acute Cardiac Unit (ACU) for high risk NSTEMI from the community via the ambulance serviceThe key steps to achieving change wereSmart listing –cases were labelled NSTEMI or NSTEMI GP (golden patient) on the ordering system – started in April 2021Buy in from operators for a NSTEMI patient on the list each morning ahead of elective workRecovering PCI cases in the general cardiology wardNSTEMI patient information, a new leaflet given to patients by the rehab teamA half an hour biweekly meeting was held on Teams facilitated by our pathway manager. Progress was tracked, these meetings also generated ideas.ResultsThe project started in September 2020. The percentage of NSTEMI patients undergoing angiography increased steadily from a baseline of 60% to the most recent figure of 93%. In the six months following the introduction of smart listing, the same day discharge rate, or ‘Golden Index’ was 41% up from 27% in the preceding 6 months. On a base of 400 MINAP verified NSTEMI patients that is a saving of 56 hospital bed days.A patient satisfaction survey following discharge of 15 randomly selected recent patients showed an 87% understanding rate of their diagnosis and treatment.Abstract 44 Figure 1Angiography for NSTEMI patients within 72 hours of admission pre improvementAbstract 44 Figure 2Angiography for NSTEMI patients post improvementConclusionA local approach to pathway management for NSTEMI, involving stakeholders was successful in improving care, preserving income, freeing up hospital beds and will hopefully continue to deliver further benefits.Conflict of InterestNone To Declare

BackgroundWe aimed to investigate changes of incidence, outcome and related interventions of patients with acute coronary syndrome (ACS) over the past decade in Germany.MethodsData on the international statistical classification of diseases and procedural codes from the Federal Bureau of Statistics in Germany was used. This included all ACS cases in Germany in the years 2005–2015. Analyses were performed separately for the diagnoses of overall ACS, ST-elevation myocardial infarction (MI), non-ST-elevation MI and unstable angina pectoris. Procedures including coronary angiography and percutaneous coronary intervention and the endpoint in-hospital mortality were assessed.ResultsBetween 2005 and 2015 a total of 3797,546 cases of ACS were recorded. The mean age was 69 years and 36% were females. In-hospital mortality was 6.3%, 62% underwent coronary angiography and 42% received percutaneous coronary intervention. In-hospital mortality was highest for patients with ST-elevation MI (12.0%) and lowest for patients with unstable angina pectoris (0.6%). From 2005 to 2015 the incidence rates of ACS, ST-elevation MI and unstable angina pectoris decreased, while the incidence rate of non-ST-elevation MI increased. The percentages of performed coronary angiographies and percutaneous coronary interventions increased from 52 to 70% and 34 to 50%, respectively. The adjusted incidence rate of in-hospital mortality decreased from 64.9 cases per 1000 person-years to 54.8 cases.ConclusionIn a large dataset including more than 3.7 million cases, we report an increase in coronary procedures and a reduction of ACS incidence and related mortality in the past decade in Germany.