|Year : 2020 | Volume
| Issue : 4 | Page : 83-88
Acute Clinical and Procedural Outcome of Rajaie Cardiovascular Medical and Research Center Acute Coronary Syndrome Registry
Mohammad Javad Alemzade-Ansari1, Feridoun Nouhi2, Majid Maleki1, Majid Kiavar2, Hossein Ali Basiri2, Ehsan Khalilipur2, Mohammad Mehdi Peighambari2, Ata Firouzi2, Bahram Mohebbi1, Parham Sadeghipour2, Mohsen Madaani2, Ali Zahedmehr2, Farshad Shakerian2, Reza Kiani2, Zahra Hosseini2, Alireza Rashidinejad2, Hooman Bakhshandeh3
1 Cardiovascular Intervention Research Center, Iran University of Medical Sciences; Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
2 Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Research Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
|Date of Submission||23-Jul-2020|
|Date of Decision||18-Sep-2020|
|Date of Acceptance||08-Oct-2020|
|Date of Web Publication||24-Dec-2020|
Dr. Ehsan Khalilipur
Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Introduction: Most fatal presentation of coronary artery disease (CAD) has been related to acute coronary syndrome (ACS), and we as a referral center in the country decide to launch a registry of patients with ACS to monitor the way they are managed and the way they are treated. Materials and Methods: Rajaie Cardiovascular, Medical and Research Center ACS registry (RHC-ACS registry) launched on December 2015 with enrolling all ACS patients referred or presented to the center. All patients' demographic variables, presenting symptoms, known risk factors, past medical history, past CAD records, serial ischemic electrocardiogram (ECG) changes, presenting echocardiographic data (such as left ventricular ejection fraction [LVEF], valvular abnormality, and mechanical complication of myocardial infarction [MI]), laboratory assessment (biochemistry, complete blood count, cardiac markers, and inflammatory indicators), and their angiographic and angioplasty data were recorded. Results: Recordings showed in the RHC-ACS registry, most patients were men (73.2%), with mean age of 59.16 ± 11.64 years, hypertension were the most known cardiac risk factor. Most patients were non-ST elevation MI patients (43.2%), 32.8% were in premature CAD group, and typical retrosternal chest pain were complained in 83.5% of our registry population. Most patients had no new ECG changes (51.7%) and from whom with new ECG changes, anterior territory ECG changes were the most common pattern (28.2%). LVEF was reported 30% or less in 171 (16.6%) of patients. Angiographic findings revealed femoral access was most common access (63.9%), most involved vessel was left anterior descending with 49.3% of the patients, percutaneous coronary intervention was performed in 48% of patients with drug-eluting stent implantation in 99.3% of these patients, dissection was the most angiographic-related complication in our registry (1%), and in-hospital death was reported in six patients (0.5%). Conclusion: RHC-ACS registry as a real-world middle-east running ACS registry would help cardiologists justify their revascularization strategy in ACS patients and would have a promising impact in future multi-center studies.
Keywords: Acute coronary syndrome, coronary artery disease, registry
|How to cite this article:|
Alemzade-Ansari MJ, Nouhi F, Maleki M, Kiavar M, Basiri HA, Khalilipur E, Peighambari MM, Firouzi A, Mohebbi B, Sadeghipour P, Madaani M, Zahedmehr A, Shakerian F, Kiani R, Hosseini Z, Rashidinejad A, Bakhshandeh H. Acute Clinical and Procedural Outcome of Rajaie Cardiovascular Medical and Research Center Acute Coronary Syndrome Registry. Res Cardiovasc Med 2020;9:83-8
|How to cite this URL:|
Alemzade-Ansari MJ, Nouhi F, Maleki M, Kiavar M, Basiri HA, Khalilipur E, Peighambari MM, Firouzi A, Mohebbi B, Sadeghipour P, Madaani M, Zahedmehr A, Shakerian F, Kiani R, Hosseini Z, Rashidinejad A, Bakhshandeh H. Acute Clinical and Procedural Outcome of Rajaie Cardiovascular Medical and Research Center Acute Coronary Syndrome Registry. Res Cardiovasc Med [serial online] 2020 [cited 2021 Jun 14];9:83-8. Available from: https://www.rcvmonline.com/text.asp?2020/9/4/83/304782
| Introduction|| |
Coronary artery disease (CAD) has been the leading cause of death in the last decades worldwide. Most fatal presentation of CAD has been related to acute coronary syndrome (ACS) which comprises of three known categories: ST elevation myocardial infarction (STEMI), non-STEMI, and unstable angina (UA)., STEMI is defined as myocardial ischemia presenting with chest pain or its equivalent accompanying with ST elevation or new left bundle branch block on electrocardiogram (ECG) and cardiac biomarker rise which seeks sharp reperfusion strategy. In non-STEMI patients developed other ECG changes than STEMI, and they also have biomarker change. In UA patents, there no biomarker elevation with ECG changes as non-STEMI. In the last years, many guidelines have been developed to improve ACS patients fate, their management, and their following cardiovascular care, but still in many areas of the world, it is not feasible to perform best reperfusion strategy as the gold standard of ACS patients care to save more lives and lessen future comorbidities.,, The position of the Middle East nations in this sense is especially alarming, as they will face the greatest increase in the absolute burden of CVD in the world according to the WHO's prediction.
Although randomized controlled trials are considered the best way to answer these obstacles, they are costly and time-consuming, limited by restricted sample size and sometimes impossible to be designed for a specific clinical scenario. Clinical registries are a committed and targeted way of data collection, intended to find a solution for a specific clinical inquiry., In the process of guideline development, some real-world information for ACS patients comes from many broad registries with demographic data, therapies, and outcomes of patients in developed countries, although little is known about ACS patients in developing countries.,,
The Rajaie Cardiovascular Medical and Research Center (RHC) is a tertiary cardiovascular center which is considered the country's largest cardiovascular hospital with over 1000 ACS presenting and referral patients each year and is therefore a dedicated ground for determining the efficiency of the treatment in these patients. In order to monitor our local acute and long-term procedural results to mitigate unintentional complications and preventable pitfalls during ACS management, we decided to launch in-hospital registry (RHC-ACS registry) parallel to our total percutaneous coronary intervention (PCI) registry (RHC-PCI registry). The present report is intended to introduce the RHC-ACS registry, its directions, objectives, and acute outcomes during the 1st year of its launch.
| Materials and Methods|| |
RHC-ACS registry first launched on May 2015. It is a prospective registry and its primary objectives were to monitor all patients presented with ACS as defined previously in a timely fashion in order to assess their demographic, clinical characteristics and study their guideline directed reperfusion strategy and declare their major adverse cardiovascular events and its complications during index hospitalization. All presented or referred patients were included based on the [Table 1] inclusion criteria.
Final diagnosis was approved by interventional cardiologists before beginning of the revascularization. The process of gathering data and fulfilling forms was carefully done by cardiology residents and interventional cardiology fellows and supervised by the attending.
Patients demographic and clinical data were obtained as following variables: Age, gender, body mass index, presenting illness with typical or atypical chest pain, dyspnea and its New York Heart Association functional assessment, past history of CAD, PCI or CABG, known cardiac risk factors, comorbidities as chronic kidney disease, chronic obstructive pulmonary disease, and past history of venous thromboembolism and stroke.
When patients were categorized in each three main categories of ACS, their presenting physical assessment was reported with following features: Presenting blood pressure, respiratory rate, O2 saturation, ECG in three consecutive orders (0, 10 min, and 30 min), baseline echocardiography performed by emergency department cardiologist, and blood sampling for cardiac biomarkers and other mandatory laboratory data.
Meanwhile, patients were prepared for their revascularization strategy, and their angiographic data, angioplasty procedure, and its complication were all reported by interventional cardiology fellows. During index hospitalization, other endpoints of our study such as any unintentional complication after angioplasty needed temporary pace maker, intra-aortic balloon pulsation (IABP) or emergent surgery, and in-hospital death were reported.
At the time of discharge, all patients were treated as guideline directed medical therapy based on the latest published guidelines., All patients were advised and monitored to be followed up next month in our center follow-up clinics and if patients were appropriate candidate for cardiac rehabilitation, it was started in the next following weeks. To analyze normal distribution, the Kolmogorov–Smirnov test has been applied. The continuous variables are expressed as mean ± standard deviation and were compared using the Student's t-test between the study groups. The categorical variables were compared using a Chi-square test or the Fisher exact test, and are presented with percentages as absolute frequencies. Acute outcome of the registry was defined as in-hospital death, stroke, postprocedural myocardial infarction (MI) and hospitalization needed more than a week due to procedural or surgical complications, drug-eluting stent implantation, IABP usage and successful revascularization, and PCi-related complications. For all analyses, the Statistical Package SPSS V.26.0 for Windows (IBM corp, Armonk, N.Y., USA) was used. P < 0.05 was considered meaningful. All steps of our registry were accepted by Medical Ethic Committee of Iran University of Medical Sciences.
| Results|| |
From December 2015 to the end of 2016, a total 1024 patients with ACS were admitted in RHC. Patients demographic and clinical presentation is summarized in [Table 2]. Most patients were in non-STEMI group (442 [43.2%]) followed by STEMI patients (328 [32.1%]). The rest of patients were UA patients or referral patients with neglected MI or patients who were administered fibrinolytic in another center (254 [24.8%]).
CAD was detected in 790 patients (77.2%), and the rest (22.8%) were categorized in MI with nonobstructive coronary arteries patients. Hypertension (HTN) was reported the most common risk factor (48.3%) and more than a third of patients were current or past cigarette smoker. Most previous medical problem was past MI which was reported in 156 (15.3%) patients.
ECG findings of our registry patients are summarized in [Table 3]. Most patients were in sinus rhythm, and most patients had no new ischemic ECG changes (51.7%) and in patients with ischemic changes, anterior territory changes were the most common pattern (28.2%).
In patients' presentation, all patients underwent transthoracic echocardiography and mean left ventricular ejection fraction (LVEF) of patients were 43.75% ± 10.33%. Valvular abnormality more than mild degree was reported in 113 (11.1%) patients, and mechanical complications such as ventricular septal rupture or severe mitral regurgitation were detected in 30 patients (2.9%). In 171 (16.6%) patients' presentation, LVEF was reported 30% or less.
Patients' laboratory evaluation is summarized in [Table 4]. Most patients had a positive hsTrop (68.3%) in their serial sampling and in 239 patients (23.3%), serum low-density lipoprotein level were more than 100 mg/dl. In our registry, laboratory measurement of neutrophil-lymphocyte ratio and platelet lymphocyte ratio were both reported in the upper limit of normal range.
Forty patients were administered fibrinolytic before attending our center (3.9%) whom most were treated with streptokinase (25 [62.5%]). Summary of registry outcome and angiographic findings is summarized in [Table 5].
|Table 5: Angiographic findings and acute outcome of Rajaie Cardiovascular Medical and Research Center-acute coronary syndrome registry|
Click here to view
Femoral access was most preferred access site by our interventional cardiologists (63.9%) and most patients as predicted were right coronary dominant (83.8%). Most involved vessel was left anterior descending (LAD) (49.3%) followed by diagonal artery (25.4%). PCI was performed in 492 (48.3%) of patients, ten patients were transferred to the operating room for emergent CABG (1.0%) and in 522 patients (50.2%) medical management was chosen. In patients who underwent PCI, preferred access site was also femoral (69.1%). Most reported complication after angioplasty was coronary dissection in five patients (1.0%) and in-hospital death was recorded in six patients (0.5%).
| Discussion|| |
RHC-ACS registry is an ACS registry in a tertiary referral teaching center with over 100 residents and 20 interventional fellows. We started the registry from December 2015 and all patients presented with all ACS categories are enrolled in the registry. In this article, we tried to present our patients' characteristics, referral pattern, decision making trend, angiographic and acute outcomes of the registry in its 1st year of launch. From three decades ago, registries have been a tremendous beneficial tool to monitor every society behavior in case of a specific demanding cardiovascular problem.,, There is no debate, ACS still plays a crucial role in cardiovascular tableland and researchers efforts have been focused on diminishing its death toll in the last decades.,,
As we monitored other ongoing registries of ACS all around the world, we observed in a Thai registry of patients presenting with ACS, 22% of patients were <55 years of age and most patients had dyslipidemia as their most common cardiac risk factor with death mostly reported in patients more than 55 years of age. In another registry held in India, the mean age of patients were 60 years and most death happened in STEMI group with and in-hospital mortality was quite high (8.2%) with most PCI undergoing in STEMI group.
In another registry which assessed ACS patients in Malaysia, the mean age of patients was 59 years, and 30-day mortality rate was 11% in STEMI group with lower mortality among patients with UA. In RECORD registry with enrolling ACS registry in European Society of Cardiology community, in-hospital mortality was 16.7% with average duration of admission of 13.9 days in STEMI patients with lower mortality and hospitalization in NSEMI and UA patients.
In SNAPSHOT ACS registry from New Zealand and Australia, the mean age of patients was 67 years with women accounting for 40% of population, STEMI reported in 33% of patients, in-hospital mortality of 4.5%. In Z-ACS registry in Zurich, the mean age of patients in registry is 63 years, HTN was most common risk factor (53.8%), IABP usage in 10.1% of all patients, LAD was most culprit artery for symptoms (44.8%), 55.8% of patients presented with STEMI and in-hospital mortality 5.7% in STEMI patients.
As it is obvious from all registries running all over the planet, every society plans to monitor their ACS patients to modify their pattern of treatment, their medications in acute and chronic phase of management and omit pitfalls which would change the course of patients' hospitalization., Finally, we also are in the middle of patients 3-year follow-up to depict our longer term results to justify our revascularization plan based on the latest milestone trials.
| Conclusion|| |
As it has been declared, every society needs its own registry to evaluate its management efficacy, and no doubt better ACS management is a milestone target in diminishing cardiovascular disease burden, and it has been our goal to launch a registry to have a remarkable leap forward to monitor our critical patients' condition and comprehend what is happening in our health-care system.
This study was approved by ethical committee of Iran university of medical sciences.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
De Backer GG. The global burden of coronary heart disease. Medicographia 2009;31:343.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al
. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
Wessler JD, Stant J, Duru S, Rabbani L, Kirtane AJ. Updates to the ACCF/AHA and ESC STEMI and NSTEMI guidelines: Putting guidelines into clinical practice. Am J Cardiol 2015;115:23A-8A.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al
. Fourth universal definition of myocardial infarction. J Am Coll Cardiol 2018;72:2231-64.
Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: A comprehensive review of contemporary management options. J Am Coll Cardiol 2007;50:917-29.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Bulpitt CJ. The advantages and disadvantages of randomised controlled trials. In: Randomised Controlled Clinical Trials. Boston, MA: Springer; 1996.
Braunwald E. The rise of cardiovascular medicine. Eur Heart J 2012;33:838-45, 845a.
Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, et al
. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23:1190-201.
Fox KA, Goodman SG, Klein W, Brieger D, Steg PG, Dabbous O, et al
. Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2002;23:1177-89.
Gibson CM. NRMI and current treatment patterns for ST-elevation myocardial infarction. Am Heart J 2004;148:S29-33.
Basiri HA, Khalilipur E, Sarreshtehdari A, Alemzadeh-Ansari MJ, Mohebbi B, Hosseini Z, et al
. Rajaie Cardiovascular Medical and Research CenterPercutaneous Coronary Intervention Registry: A real-world registry on coronary interventions in a tertiary teaching cardiovascular center. Res Cardiovasc Med 2020;9:47-51. [Full text]
Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al
. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Europ Heart J 2020;41:111-88.
Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al
. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e139-228.
Acet H, Ertaş F, Bilik MZ, Akıl MA, Özyurtlu F, Aydın M, et al
. The relationship between neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and thrombolysis in myocardial infarction risk score in patients with ST elevation acute myocardial infarction before primary coronary intervention. Postepy Kardiol Interwencyjnej 2015;11:126-35.
Emond M, Mock MB, Davis KB, Fisher LD, Holmes DR Jr., Chaitman BR, et al
. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation 1994;90:2645-57.
Kelsey SF, James M, Holubkov AL, Holubkov R, Cowley MJ, Detre KM. Results of percutaneous transluminal coronary angioplasty in women. 1985-1986 National Heart, Lung, and Blood Institute's Coronary Angioplasty Registry. Circulation 1993;87:720-7.
Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, van de Werf F, et al
. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: Prospective multinational observational study (GRACE). BMJ 2006;333:1091.
Ho PM, Peterson ED, Wang L, Magid DJ, Fihn SD, Larsen GC, et al
. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 2008;299:532-9.
Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al
. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001-15.
Tungsubutra W, Tresukosol D, Buddhari W, Boonsom W, Sanguanwang S, Srichaiveth B, et al
. Acute coronary syndrome in young adults: The Thai ACS Registry. J Med Assoc Thai 2007;90 Suppl 1:81-90.
Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al
. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: Results from the Kerala ACS Registry. Eur Heart J 2013;34:121-9.
Chin SP, Jeyaindran S, Azhari R, Wan Azman WA, Omar I, Robaayah Z, et al
. Acute coronary syndrome (ACS) registry-leading the charge for National Cardiovascular Disease (NCVD) Database. Med J Malaysia 2008;63 Suppl C: 29-36.
Erlikh AD, Gratsianskiĭ NA. Registry of acute coronary syndromes RECORD. Characteristics of patients and results of inhospital treatment. Kardiologiia 2009;49:4-12.
Chew DP, French J, Briffa TG, Hammett CJ, Ellis CJ, Ranasinghe I, et al
. Acute coronary syndrome care across Australia and New Zealand: The SNAPSHOT ACS study. Med J Aust 2013;199:185-91.
Ghadri JR, Jaguszewski M, Sacron A, Srikantharupan S, Pfister P, Siddique A, et al
. Current outcome of acute coronary syndromes: Data from the Zurich-acute coronary syndrome (Z-ACS) registry. Cardiovascular Med 2013;13:115-22.
Yan AT, Yan RT, Tan M, Eagle KA, Granger CB, Dabbous OH, et al
. In-hospital revascularization and one-year outcome of acute coronary syndrome patients stratified by the GRACE risk score. Am J Cardiol 2005;96:913-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]