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2013 | Buch

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New Diagnostic, Therapeutic and Organizational Strategies for Acute Coronary Syndromes Patients

herausgegeben von: Niccolò Grieco, Maurizio Marzegalli, Anna Maria Paganoni

Verlag: Springer Milan

Buchreihe : Contributions to Statistics

Enthalten in: Springer Professional "Wirtschaft+Technik" , Springer Professional "Wirtschaft" , Springer Professional "Technik"

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Über dieses Buch

This book collects several contributions, written both by statisticians and medical doctors, which focus on the identification of new diagnostic, therapeutic and organizational strategies in order to improve the occurrence of clinical outcomes for Acute Coronary Syndromes (ACS) patients. The work is structured in two different parts: the first one is focused on cooperative project mainly on statistical analysis of large clinical and administrative databases; the second one faces the development of innovative diagnostic techniques, with specific reference to genetic and proteomic, and the evolution of new imaging techniques for the early identification of patients at major risk of thrombotic, arrhythmic complications and at risk of poor revascularization.

Inhaltsverzeichnis

Frontmatter

Organizational Strategies in ACS

Frontmatter

Gender Differences in Hospitalization for Acute Myocardial Infarction in Lombardy During the Years 2000–2010

Abstract

The industrialized world is undergoing epidemiologic variations in acute coronary syndrome and the female gender is particularly involved in these changes. Our study was designed based on administrative databases of all hospital admissions in the Lombardy region during the years 2000–2010 which enabled us to obtain complete and updated information regarding the gender-related epidemiologic situation.

Women present an incidence and attack rate of acute myocardial infarction which is approximately half that of men, but this difference is influenced by age, type of infarction, and the period of time examined. The female population with acute myocardial infarction is generally 10 years older than the male population (mean age 76 vs. 66 years), and above 75 years of age the number of infarctions in women exceeds that in males, even though incidence is still higher in the male gender. ST elevation myocardial infarction is the most frequent type of infarction for both sexes, but non-ST elevation myocardial infarction is more frequent in women than in men, and unspecified myocardial infarction is similar in both sexes. Overall incidence and attack rate of acute myocardial infarction have dropped in both sexes over the last few years; this reduction is mainly supported by the decrease in ST elevation myocardial infarction in males. Non-ST elevation myocardial infarction significantly increases even threefold, in the same way for both sexes, after the introduction of troponin. Unspecified MI is similar in both genders and decreases over the years to reach very low numbers.

Even though lower in number, the incidence of acute myocardial infarction in females is not insignificant and, contrary to popular belief, must be considered a health problem in women as well as men. Diagnostic–therapeutic protocols during acute myocardial infarction must take into account the wide range of elderly women who suffer infarction and are not usually included in randomized clinical trials. Health organizations must be equipped to handle ever increasing aging populations consisting of frail patients with comorbidities and social–family problems.

Elena Corrada, Cristina Mazzali, Pietro Barbieri, Giuseppe Ferrante, Maurizio Marzegalli, Marco Mennuni, Luca Merlino, Patrizia Presbitero, Piera Angelica Merlini

Heart Diseases Registries Based on Healthcare Databases

Abstract

The present study aims to promote incidence and prevalence estimates, to evaluate potential benefits and harms of specific health policies and to evaluate adherence to best practice by quality indicators based on administrative and textual databases (DB).

Specific items include (a) definition of extraction criteria and data collection from healthcare DB, (b) data quality control and effective record linkage across DBs, (c) sensitivity analysis on incidence and prevalence estimates, (d) adherence to best practice by means of quality indicators, and (e) providing domain and linguistic knowledge for developing text mining tools and resources.

Cristina Mazzali, Barbara Severgnini, Mauro Maistrello, Pietro Barbieri, Maurizio Marzegalli

Designing and Mining a Multicenter Observational Clinical Registry Concerning Patients with Acute Coronary Syndromes

Abstract

In this work we describe design, aims, and contents of the ST-segment Elevation Myocardial Infarction (STEMI) Archive, which is a multicenter observational clinical registry planned within the Strategic Program “Exploitation, integration and study of current and future health databases in Lombardia for Acute Myocardial Infarction.” This is an observational clinical registry that collects clinical indicators, process indicators, and outcomes concerning STEMI patients admitted to any hospital of the regional district, one of the most advanced and intensive-care area in Italy. This registry is arranged to be automatically linked to the Public Health Database, the ongoing administrative datawarehouse of Regione Lombardia. Aims and perspectives of this innovative project are discussed, together with feasibility and statistical analyses which are to be performed on it, in order to monitor and evaluate the patterns of care of cardiovascular patients.

Francesca Ieva

Statistical Methods to Study the Representativeness of STEMI Archive

Abstract

Direzione Generale Sanità, Regione Lombardia, funded in January 2009 the Strategic Program “Exploitation, integration and study of current and future health databases in Lombardia for Acute Myocardial Infarction.” The aim of this project was the integration and the statistical analysis of complex clinical and administrative databases. In this context the STEMI Archive was created in collaboration with Politecnico di Milano and several hospital structures. This archive contains clinical data about patients affected by acute myocardial infarction with ST elevation (STEMI) admitted in any hospital of Regione Lombardia. In this chapter we will discuss the representativeness of the sample of patients registered in the archive compared with the overall population of STEMI patients affected by acute myocardial infarction, extracted from the administrative database of the Regione Lombardia.

Giovanni Cassarini, Francesca Ieva

Using Text Mining to Validate Diagnoses of Acute Myocardial Infarction

Abstract

We applied text mining to a database of discharge letters of patients with acute myocardial infarction for a quality of care-related task: the automatic validation of acute myocardial infarction diagnoses. The system should evaluate if the information contained in the discharge letters was consistent, by medical standards, with the letters’ coded diagnoses of acute myocardial infarction. The system was composed of a text mining tool (GATE) and a set of linguistic resources which were specifically developed from a training set of letters. It was validated on a test set of letters manually annotated by cardiologists and results were satisfactory. Further analyses can be made on the efficiency of the development of the system and on its ongoing effectiveness.

Stefano Ballerio, Dario Cerizza

New Diagnostic and Therapeutic Strategies in ACS

Frontmatter

PREDESTINATION: PRimary vEntricular fibrillation and suDden dEath during a firST myocardIal iNfArcTION: Genetic Basis

Abstract

Sudden cardiac death (SCD) is the leading cause of death in the age group 20–65 years, in the western world, with an enormous social and economic impact. The majority of the cases of ventricular fibrillation (VF) occur in patients without a preexisting structural heart disease and represent the first manifestation of coronary artery disease. In most of these cases, VF occurs in the early phase of myocardial infarction (MI) and it is then called primary VF. Although several factors have been associated in various studies with primary VF a recent meta-analysis found no evidence for risk factors other than ST elevation and time from onset of symptoms.

In the past several years, few studies have found that a family history of sudden cardiac death (SCD) is a risk factor for primary VF suggesting that this dramatic event may be favored by the genetic background. To explore this possibility we designed the ongoing PREDESTINATION Study, enrolling subjects under 75 years of age with a first MI complicated by primary VF and a control group of subjects with a first uncomplicated MI.

Data so far available confirm the association between a family history of SCD and primary VF and suggest that hypokalemia and prolonged QT interval may favor its occurrence. The genetic analysis has already provided some interesting suggestions that will need to be confirmed by the continuation of the enrolment and joint analysis with data deriving from similar patient populations.

Gaetano M. De Ferrari, Valentina De Regibus, Vincenzo Gionti, Daniela Civardi, Roberto Insolia, Matteo Pedrazzini, Davide Gentilini, Annamaria Di Blasio, Lia Crotti, Peter J. Schwartz

MicroRNAs and Tissue Response to Acute Ischemia

Abstract

MicroRNAs (miRNAs) are 21–23-nucleotide non-protein-coding RNA molecules that act as negative regulators of gene expression, modulating the stability and/or the translational efficiency of target messenger RNAs. This chapter describes miRNA regulation and function in tissue response to acute ischemia, focusing on miRNAs role in acute myocardial infarction. The role played by specific miRNAs in the regulation of apoptosis, fibrosis, regeneration, and myocardial arrhythmias is illustrated. Examples of the miRNA involvement in noncardiac ischemia are also included. The identification of specific miRNAs as key regulators of the response to ischemia has opened new clinical avenues. miRNAs may constitute excellent noninvasive disease biomarkers. Furthermore, innovative strategies targeting miRNAs, aimed at reducing the levels of pathogenic or aberrantly expressed miRNAs or to elevate the levels of miRNAs with beneficial functions, have been developed and could be applied in the treatment of ischemic diseases. The efficacy of these strategies is confirmed by two paradigmatic reports in which miRNAs have been targeted to improve cardiac function in preclinical models of myocardial infarction. Specifically, miR-210 upregulation and miR-15 inhibition can both protect against cardiac injury and rescue cardiac function after myocardial infarction.

Pasquale Fasanaro, Fabio Martelli

The Role of Cardiac Magnetic Resonance in Selecting Patients with Left Ventricular Dysfunction Undergoing Surgical Ventricular Reconstruction

Abstract

Surgical ventricular reconstruction (SVR) has gained wide acceptance over the past 10 years as a surgical treatment for ischemic heart failure. However, data from the largest randomized trial have questioned the real additional benefit of SVR in respect of coronary artery bypass grafting (CABG) alone, outlining the need to improve patient selection. To this aim, we investigated the role of cardiac magnetic resonance (CMR) in characterizing the extent of myocardial fibrosis and its prognostic value in patients affected by ischemic cardiomyopathy (ICM).

Twenty-five patients (mean age 68 ± 8 years) affected by ICM, a left ventricle ejection fraction (EF) < 40 %, and referred for CABG underwent late gadolinium enhancement (LGE)-CMR before and 6 months after surgery and were included in Group 1. Forty patients (mean age 65 ± 10 years) affected by ICM, a left ventricle EF < 40 %, and referred for CABG plus SVR underwent the same protocol and were included in Group 2. In Group 1, patients showed a high percentage of viable myocardium, a percentage of recoverable myocardium higher than 50 %, and a low percentage of hyperenhanced tissue, indicating a low degree of fibrosis. At 6 months, end-diastolic volume index (EDVI) decreased by 23 %, end-systolic volume index (ESVI) decreased by 38 %, and ejection fraction (EF) increased by 13 absolute points. Conversely, in Group 2, a lower percentage of viable tissue and a higher percentage of hyperenhanced tissue identified patients with more dilated ventricles and lower EF. At the multivariate analysis, only the percentage of scar tissue at the basal portion has been resulted to be significantly associated with an adverse outcome (P = 0.04, OR 1.26, 95 % CI 1.01–1.58) in Group 2.

In patients affected by ICM and LV dysfunction, the myocardial tissue characterization by LGE–CMR might be useful in predicting the postoperative adverse outcome after SVR.

Serenella Castelvecchio, Lorenzo Menicanti

Chronic Kidney Disease in Acute Myocardial Infarction: Clinical Relevance and Novel Potential Fields of Investigation

Abstract

In patients with acute coronary syndromes (ACS), chronic kidney disease (CKD) is highly prevalent and associated with poor short- and long-term outcomes. Management of patients with CKD presenting with ACS is more complex than in the general population because of the lack of well-designed randomized trials assessing therapeutic strategies in such patients. The almost uniform exclusion of patients with CKD from randomized studies evaluating new targeted therapies for ACS, coupled with concerns about further deterioration of renal function and therapy-related toxic effects, may explain the less frequent use of proven medical therapies in this subgroup of high-risk patients. In this chapter, we summarize the current evidence regarding the epidemiology and the clinical and prognostic relevance of CKD in ACS patients, in particular with respect to unresolved issues and uncertainties regarding recommended medical therapies and coronary revascularization strategies. Moreover, we suggest some novel promising fields of investigation in order to identify adjunctive therapeutic targets and pharmacological therapies that may favorably affect their otherwise poor prognosis.

Giancarlo Marenzi, Marina Camera, Cristina Banfi, Gualtiero Colombo, Marta Brambilla, Maura Brioschi, Elena Tremoli

Titel: New Diagnostic, Therapeutic and Organizational Strategies for Acute Coronary Syndromes Patients
herausgegeben von: Niccolò Grieco
Maurizio Marzegalli
Anna Maria Paganoni
Verlag: Springer Milan
Electronic ISBN: 978-88-470-5379-3
Print ISBN: 978-88-470-5378-6
DOI: https://doi.org/10.1007/978-88-470-5379-3