Coronary artery diseaseDisparities in Management Patterns and Outcomes of Patients With Non–ST-Elevation Acute Coronary Syndrome With and Without a History of Cerebrovascular Disease
Section snippets
Methods
The Canadian ACS I, ACS II, GRACE/GRACE2 and CANRACE registries were prospective, multicenter, observational studies of patients admitted with ACS. The full details of the registry designs have been previously published.10, 11, 12, 13 In ACS I and ACS II, patients ≥18 years old presenting to hospital with suspected cardiac ischemia of onset of <24 hours were eligible for inclusion. In GRACE/GRACE2 and CANRACE, patients ≥18 years old with a presumptive diagnosis of ACS and at least one of the
Results
Table 1 lists the baseline demographic and clinical characteristics of the patients stratified by a history of CVD. A total of 14,070 patients with NSTE-ACS were recruited from 1999 to 2008, of whom 1,377 (9.8%) had a history of CVD. Patients with CVD were older and were more likely to have pre-existing CAD, diabetes, elevated creatinine, higher Killip class, and ST-segment deviation on admission. They also presented with greater GRACE risk scores.
Table 2 lists the use of antiplatelet and
Discussion
The key findings of the present multicenter, observational study of patients with NSTE-ACS were that compared to patients without previous CVD, those with previous CVD presented with higher risk features and had worse in-hospital and 1-year outcomes. These patients were also treated more conservatively with antiplatelet and antithrombin medications and were less likely to undergo in-hospital coronary angiography. In addition, these disparities in management patterns and outcomes persisted over
Acknowledgment
We are grateful to all the study investigators, coordinators, and patients who participated in the Canadian ACS, GRACE, and CANRACE registries.
References (30)
- et al.
Evidence of a chronic systemic cause of instability of atherosclerotic plaques
Lancet
(2000) - et al.
Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women > or = 62 years of age
Am J Cardiol
(1994) - et al.
Presence of carotid and peripheral arterial disease in patients with left main disease
Am J Cardiol
(2007) - et al.
Prognostic significance of cerebrovascular disease in 11,526 chronic coronary artery disease patients
Am J Cardiol
(1998) - et al.
Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: are we doing enough?Results from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study
Am Heart J
(2003) - et al.
Impact of prior peripheral arterial disease and stroke on outcomes of acute coronary syndromes and effect of evidence-based therapies (from the Global Registry of Acute Coronary Events)
Am J Cardiol
(2007) - et al.
One-year outcome of patients after acute coronary syndromes (from the Canadian Acute Coronary Syndromes Registry)
Am J Cardiol
(2004) - et al.
Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes
Am J Cardiol
(2009) - et al.
Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study
Lancet
(2001) - et al.
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
J Am Coll Cardiol
(2007)
Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial
J Am Coll Cardiol
The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2—therapy
Can J Cardiol
5-Year outcome of an interventional strategy in non–ST-elevation acute coronary syndrome: the British Heart Foundation RITA randomised trial
Lancet
5-Year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non–ST-elevation acute coronary syndrome: a follow-up study
Lancet
Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials
J Am Coll Cardiol
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Impact of chronic kidney disease on long-term outcomes for coronary in-stent restenosis after drug-coated balloon angioplasty
2021, Journal of CardiologyCitation Excerpt :These findings may explain why patients with CKD had a higher risk of nontarget vessel-related events (any MI, cardiac death, all-cause mortality, and any repeated revascularization) compared with patients without CKD in the study. Furthermore, our study revealed that stroke history and DM were independent predictors of TVF, which have been widely reported to be potent predictors of adverse CV events for patients after PCI [23-26]. We also observed a lower rate of aspirin prescription and a lower proportion of dyslipidemia accompanied by a lower rate of statin prescription in patients with CKD than those with preserved renal function in our cohort.
Non-ST-Elevation Acute Coronary Syndrome Prognosis
2017, Encyclopedia of Cardiovascular Research and MedicineLong-term prognostic role of cerebrovascular disease and peripheral arterial disease across the spectrum of acute coronary syndromes
2016, AtherosclerosisCitation Excerpt :This is in line with published data [8] and can probably be explained by the fact that a quota of strokes had a cardioembolic origin rather than being secondary to vascular disease or that atrial fibrillation is not only a direct risk factor for embolic events but also a marker of a more extensive vascular disease. The negative prognostic value of extracardiac vascular disease at short and intermediate-term has already been well documented in stable coronary disease as well as ACS [1–10]. Likewise, long-term risk has been studied in stable coronary disease as well as in patients undergoing PCI or CABG [21]; in patients with unstable coronary disease however, it has been investigated only by a single study that was limited to patients older than 65 with NSTE-ACS [11].
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2013, International Journal of CardiologyCitation Excerpt :Meanwhile, patients with more vascular disease were more often cited as both having previously defined coronary anatomy unsuitable for and being already planned for revascularization. For patients with CVD presenting with ACS, Lee et al. found that underestimation of risk might be a deterrent from coronary angiography [7], but our data suggest that some of these patients may have also previously undergone angiography. Likely, this is partly contributed to by the inclusion of CAD as a vascular territory where some previous studies of ACS have not included it.
Dr. Yan was supported by a New Investigator Award from the Heart and Stroke Foundation of Canada, Ottawa, Ontario, Canada. The Canadian ACS registries were sponsored by the Canadian Heart Research Centre, Toronto, Ontario, Canada (a federally incorporated not-for-profit academic research organization) and Key Pharmaceuticals, Division of Schering Canada, Inc., Mississauga, Ontario, Canada. GRACE and CANRACE were sponsored by an unrestricted grant from Sanofi-Aventis Canada Inc., Laval, Quebec, Canada and Bristol-Myers Squibb Canada, Montreal, Quebec, Canada.
The industrial sponsors had no involvement in the study conception or design; collection, analysis, and interpretation of data; writing, review, or approval of the report; or the decision to submit the report for publication.