Left ventricular remodeling after anterior wall acute myocardial infarction in modern clinical practice (from the REmodelage VEntriculaire [REVE] study group)

Two-Dimensional Speckle Tracking Echocardiography Predict Left Ventricular Remodeling after Acute Myocardial Infarction in Patients with Preserved Ejection Fraction

Objectives

Left ventricular remodeling after acute myocardial infarction increases cardiovascular events and mortality. But few study was done in patients with preserved ejection fraction (EF > 40%). We investigate whether the strain and strain rate by 2D speckle tracking echocardiography could predict left ventricular remodeling after acute myocardial infarction in this cohort.

Methods

The 83 patients (average age 60.7 ± 12.3 y, 75 [90.4%] male) with new-onset acute myocardial infarction receiving echocardiography immediately, and 6 months after admission were grouped by the presence or absence of left ventricular remodeling. Strain and strain rate including longitudinal, circumferential, and radial direction were calculated. The average of strain and strain rate of which segmental longitudinal strains > – 15% were defined as the injury longitudinal strain (InjLS).

Results

Left ventricular remodeling occurred in 24 of 83 patients (28.9%). In univariate logistic regression analyses, gender, peak CK-MB, log BNP, use of statin before discharge, wall motion score index, and InjLS were significantly associated with left ventricular remodeling (p < 0.05). In multivariate analysis using the forward stepwise method, gender, CK-MB, and InjLS were independent predictors. The hazard ratio for InjLS was 1.48 (p = 0.04). Receiver operating characteristic curve (ROC) analyses showed the area under the curve (AUC) of InjLS was largest (AUC = 0.75, cut-off value = –11.7%, sensitivity = 81%, specificity = 71%, p < 0.01). In ST-segment elevation myocardial infarction subgroup, InjLS was the only predictor according to ROC analysis (AUC = 0.79, p < 0.01, cut-off value = –11.4%, sensitivity = 88%, specificity = 77%) and multivariate logistic regression analysis (hazard ratio = 1.88, 95% CI: 1.22–2.88, p < 0.01).

Conclusions

InjLS was an excellent predictor for left ventricular remodeling after acute myocardial infarction in patient with preserved ejection fraction.

Prognostic Value of the Thrombolysis in Myocardial Infarction Risk Score in ST-Elevation Myocardial Infarction Patients With Left Ventricular Dysfunction (from the EPHESUS Trial)

The Thrombolysis in Myocardial Infarction (TIMI) risk score remains a robust prediction tool for short-term and midterm outcome in the patients with ST-elevation myocardial infarction (STEMI). However, the validity of this risk score in patients with STEMI with reduced left ventricular ejection fraction (LVEF) remains unclear. A total of 2,854 patients with STEMI with early coronary revascularization participating in the randomized EPHESUS (Epleronone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial were analyzed. TIMI risk score was calculated at baseline, and its predictive value was evaluated using C-indexes from Cox models. The increase in reclassification of other variables in addition to TIMI score was assessed using the net reclassification index. TIMI risk score had a poor predictive accuracy for all-cause mortality (C-index values at 30 days and 1 year ≤0.67) and recurrent myocardial infarction (MI; C-index values ≤0.60). Among TIMI score items, diabetes/hypertension/angina, heart rate >100 beats/min, and systolic blood pressure <100 mm Hg were inconsistently associated with survival, whereas none of the TIMI score items, aside from age, were significantly associated with MI recurrence. Using a constructed predictive model, lower LVEF, lower estimated glomerular filtration rate (eGFR), and previous MI were significantly associated with all-cause mortality. The predictive accuracy of this model, which included LVEF and eGFR, was fair for both 30-day and 1-year all-cause mortality (C-index values ranging from 0.71 to 0.75). In conclusion, TIMI risk score demonstrates poor discrimination in predicting mortality or recurrent MI in patients with STEMI with reduced LVEF. LVEF and eGFR are major factors that should not be ignored by predictive risk scores in this population.

Effect of left ventricular systolic dysfunction on secondary medical prevention and clinical outcome in stable coronary artery disease patients

BACKGROUND

Limited recent data are available in the literature on whether the presence of left ventricular systolic dysfunction (LVSD) affects the therapeutic management of patients with stable coronary artery disease (CAD).

AIMS

The objectives of this study were to analyse prevalence, effect on therapeutics and prognosis of LVSD in stable CAD.

METHODS

We prospectively included 4184 CAD outpatients free from any myocardial infarction or coronary revascularization for>1year. Left ventricular ejection fraction (EF) was available for 4124 (98.6%) patients. Follow-up was performed at 2years. All events were adjudicated blindly.

RESULTS

The mean EF was 57.5±10.8%, and 201 (4.9%) patients had an EF≤35%. The prescription of renin-angiotensin system inhibitors and beta-blockers was inversely related to EF, and reached>90% in patients with EF≤35%. Seventy-five (37.3%) of the patients with EF≤35% received a mineralocorticoid receptor antagonist. Eighty-five (42.3%) of the patients with EF≤35% had an implantable cardioverter defibrillator. Clinical follow-up data were obtained for 4090 patients (99.2%). Event rates were higher in patients with low EF (adjusted hazard ratio [95% confidence interval] for EF≤35%, with EF≥60% as reference: 3.93 [2.60-5.93] and 7.12 [3.85-13.18], for all-cause death and cardiovascular death, respectively).

CONCLUSIONS

In patients with stable CAD, LVSD is well taken into account by cardiologists, with extensive use of evidence-based medications and interventions. Despite this, LVSD remains a major prognostic indicator in this population.

Screening for asymptomatic coronary artery disease in patients with diabetes mellitus: A systematic review and meta-analysis of randomized trials

Background

Screening diabetic patients for the presence of asymptomatic coronary artery disease (CAD) may potentially impact therapeutic management and outcome. We performed a systematic review and meta-analysis of randomized trials addressing this question.

Methods

We searched the PubMed database for studies reporting a randomized comparison of systematic screening for CAD in diabetic patients versus no systematic screening. The screening protocols were variable with the use of exercise electrocardiogram test, or stress echocardiography, or nuclear test, or coronary computed tomography angiography.

Results

The final analysis included 5 randomized studies and 3,314 patients altogether. The screening strategy had no detectable impact on outcome with odds ratios (OR) [95 % confidence interval (CI)] of 1.00 [0.67–1.50], 0.72 [0.33–1.57], 0.71 [0.40–1.27], and 0.60 [0.23–1.52] for all-cause death, cardiovascular death, non-fatal myocardial infarction, and the composite cardiovascular death or non-fatal myocardial infarction, respectively. Protocol-related coronary procedures were relatively infrequent in screened patients: coronary angiography was performed in 8 % of the cases, percutaneous coronary intervention in 2.5 %, and coronary artery bypass surgery in 1.5 %. There was no evidence for an effect of screening on the use of statins (OR = 1.19 [0.94–1.51]), aspirin (OR = 1.02 [0.83–1.25]), or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR = 0.97 [0.79–1.19]).

Conclusion

The present analysis shows no evidence for a benefit of screening diabetic patients for the presence of asymptomatic CAD. The proportion of patients who undergo myocardial revascularization as a consequence of screening was low.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0256-9) contains supplementary material, which is available to authorized users.

Experimental induction of reparative morphogenesis and adaptive reserves in the ischemic myocardium using multipotent mesenchymal bone marrow-derived stem cells

INTRODUCTION

Current experimental research has proven the efficacy of transplantation bone marrow-derived mesenchymal stem cells (MSC) in the treatment of myocardial infarction (MI). The one of the main purposes of research was to evaluate the comparative data of the MSC transplantation with (5-azacytidine) and without commitment and to assess the post transplantation effects.

METHODS

The efficiency of intravenous cardiomyoplasty by infusion of MSC was evaluated in female Wistar-Kyoto rats with myocardial infarction model using echocardiography, morphological study, morphometry, immunohistostaining, data from in situ hybridization, and by measurement of blood serum levels of nitric oxide, endothelin-1, vascular endothelial growth factor (VEGF), and fibroblast growth factor 2 (FGF2).

RESULTS

The transplanted MSC were detected in all layers of the myocardium; MCS actively participate in the formation of blood vessels and connective tissue in the scar zone. There was no observable differentiation of male MSC into cardiomyocytes in female rats with MI. However, MSC transplantation leads to significant improvement in vascularization in the area of MI, elevation blood serum levels of nitric oxide, VEGF, and FGF2. No significant differences were identified morphologically between the two groups of animals after transplantation with unmodified MSC or commited MSC (5-azaC).

CONCLUSION

Intravenous transplantation of MSC without commitment in rats with MI improves the contractile function of the heart, the morphology of the myocardium, and should be recommended for further clinical investigation as an alternative approach to deal with heart diseases.

Postinfarct Left Ventricular Remodelling: A Prevailing Cause of Heart Failure

Heart failure is a chronic disease with high morbidity and mortality, which represents a growing challenge in medicine. A major risk factor for heart failure with reduced ejection fraction is a history of myocardial infarction. The expansion of a large infarct scar and subsequent regional ventricular dilatation can cause postinfarct remodelling, leading to significant enlargement of the left ventricular chamber. It has a negative prognostic value, because it precedes the clinical manifestations of heart failure. The characteristics of the infarcted myocardium predicting postinfarct remodelling can be studied with cardiac magnetic resonance and experimental imaging modalities such as diffusion tensor imaging can identify the changes in the architecture of myocardial fibers. This review discusses all the aspects related to postinfarct left ventricular remodelling: definition, pathogenesis, diagnosis, consequences, and available therapies, together with experimental interventions that show promising results against postinfarct remodelling and heart failure.

[Air pollution]

Short-term exposure to particulate matter (PM) air pollution is associated with an increased cardiovascular mortality. Chronic exposure to PM is also associated with cardiovascular risk. Myocardial infarction and heart failure are the most common cardiovascular events associated with PM pollution. The pathophysiological mechanisms related to PM pollution are inflammation, thrombosis, vasomotion abnormalities, progression of atherosclerosis, increased blood pressure, and cardiac remodeling. A decrease in PM exposure may be particularly beneficial in subjects with a high cardiovascular risk.

Cyclosporine before PCI in Patients with Acute Myocardial Infarction

BACKGROUND

Experimental and clinical evidence suggests that cyclosporine may attenuate reperfusion injury and reduce myocardial infarct size. We aimed to test whether cyclosporine would improve clinical outcomes and prevent adverse left ventricular remodeling.

METHODS

In a multicenter, double-blind, randomized trial, we assigned 970 patients with an acute anterior ST-segment elevation myocardial infarction (STEMI) who were undergoing percutaneous coronary intervention (PCI) within 12 hours after symptom onset and who had complete occlusion of the culprit coronary artery to receive a bolus injection of cyclosporine (administered intravenously at a dose of 2.5 mg per kilogram of body weight) or matching placebo before coronary recanalization. The primary outcome was a composite of death from any cause, worsening of heart failure during the initial hospitalization, rehospitalization for heart failure, or adverse left ventricular remodeling at 1 year. Adverse left ventricular remodeling was defined as an increase of 15% or more in the left ventricular end-diastolic volume.

RESULTS

A total of 395 patients in the cyclosporine group and 396 in the placebo group received the assigned study drug and had data that could be evaluated for the primary outcome at 1 year. The rate of the primary outcome was 59.0% in the cyclosporine group and 58.1% in the control group (odds ratio, 1.04; 95% confidence interval [CI], 0.78 to 1.39; P=0.77). Cyclosporine did not reduce the incidence of the separate clinical components of the primary outcome or other events, including recurrent infarction, unstable angina, and stroke. No significant difference in the safety profile was observed between the two treatment groups.

CONCLUSIONS

In patients with anterior STEMI who had been referred for primary PCI, intravenous cyclosporine did not result in better clinical outcomes than those with placebo and did not prevent adverse left ventricular remodeling at 1 year. (Funded by the French Ministry of Health and NeuroVive Pharmaceutical; CIRCUS ClinicalTrials.gov number, NCT01502774; EudraCT number, 2009-013713-99.).

[Potential of non-coding RNA as biomarkers in heart failure]

Heart failure is a major public health problem with an estimated prevalence of 1-2% in the adult population in developed countries. Despite some progress, the prognosis of heart failure is associated with high mortality. There is a need for prognostic markers for heart failure, such as circulating biomarkers, in order to better identify individual heart failure patients with high risk of early death, and to improve the selection of patients for invasive treatment with limited availability such as heart transplantation. Among the non coding RNA family, we investigated the potentiality of long non coding RNAs (lncRNA) as potential biomarkers in heart disease. We observed that the plasmatic levels of the lncRNA named LIPCAR may predict early mortality in patients with heart failure independently of the etiology and may improve clinical-decision making for a more personalized treatment of "high-risk" patients.

Rationale and design of the Cyclosporine to ImpRove Clinical oUtcome in ST-elevation myocardial infarction patients (the CIRCUS trial)

BACKGROUND

Both acute myocardial ischemia and reperfusion contribute to cardiomyocyte death in ST-elevation myocardial infarction (STEMI). The final infarct size is the principal determinant of subsequent clinical outcome in STEMI patients. In a proof-of-concept phase II trial, the administration of cyclosporine prior to primary percutaneous coronary intervention (PPCI) has been associated with a reduction of infarct size in STEMI patients.

METHODS

CIRCUS is an international, prospective, multicenter, randomized, double-blinded, placebo-controlled trial. The study is designed to compare the efficacy and safety of cyclosporine versus placebo, in addition to revascularization by PPCI, in patients presenting with acute anterior myocardial infarction within 12 hours of symptoms onset and initial TIMI flow ≤1 in the culprit left anterior descending coronary artery. Patients are randomized in a 1:1 fashion to 2.5 mg/kg intravenous infusion of cyclosporine or matching placebo performed in the minutes preceding PCI. The primary efficacy end point of CIRCUS is a composite of 1-year all-cause mortality, rehospitalization for heart failure or heart failure worsening during initial hospitalization, and left ventricular adverse remodeling as determined by sequential transthoracic echochardiography. Secondary outcomes will be tested using a hierarchical sequence of left ventricular (LV) ejection fraction and absolute measurements of LV volumes. The composite of death and rehospitalization for heart failure or heart failure worsening during initial hospitalization will be further assessed at three years after the initial infarction.

RESULTS

Recruitment lasted from April 2011 to February 2014. The CIRCUS trial has recruited 975 patients with acute anterior myocardial infarction. The 12-months results are expected to be available in 2015.

CONCLUSIONS

The CIRCUS trial is testing the hypothesis that cyclosporine in addition to early revascularization with PPCI compared to placebo in patients with acute anterior myocardial infarction reduces the incidence of death, heart failure and adverse LV remodeling at one-year follow-up.

Prevalence and correlates of non-optimal secondary medical prevention in patients with stable coronary artery disease

BACKGROUND

In patients with coronary artery disease (CAD), non-optimal use of evidence-based medications is associated with an increased risk of adverse outcome.

AIMS

To assess the prevalence and correlates of non-optimal secondary medical prevention in patients with stable CAD.

METHODS

We included 4184 consecutive outpatients with stable CAD. Treatment at inclusion was classified as optimal/non-optimal regarding the four major classes of secondary prevention drugs: antithrombotics; statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); and beta-blockers. For each treatment, the prescription was considered non-optimal if the drug was missing despite a class IA indication according to international guidelines. To assess the information globally, non-optimal secondary prevention was defined as at least one major treatment missing.

RESULTS

The proportions of patients with non-optimal treatment were 0.7%, 7.8%, 12.9% and 10.3% for antithrombotics, statins, ACE inhibitors/ARBs and beta-blockers, respectively. Non-optimal secondary medical prevention was observed in 16.8% of cases. By multivariable analysis, the correlates of non-optimal secondary medical prevention were long time interval since last coronary event (P<0.0001), older age (P<0.0001), diabetes mellitus (P<0.0001), hypertension (P<0.0001), no history of myocardial infarction (P=0.001), no history of coronary revascularization (P=0.013) and low glomerular filtration rate (P=0.042).

CONCLUSIONS

Although most patients with stable CAD are receiving evidence-based medications according to guidelines, there remain subgroups at higher risk of non-optimal treatment. In particular, it might be feasible to improve prevention by focusing on patients in whom a long time has elapsed since the last coronary event.

An update on primary findings and new designs in biotherapy studies for acute myocardial infarction

ABSTRACT 

Treatment of acute myocardial infarction in the future should focus not only on improving acute treatment, as it has been done over the past decades, but also on secondary prevention of left ventricular dysfunction and/or progression to heart failure by preserving left ventricular shape, avoiding left ventricular remodeling and stimulating cardiac regeneration. Biotherapies with adult stem cells and bone marrow-derived endothelial cell progenitors, combined or not with biomaterials, and new drugs are under investigation and will probably be part of routine clinical practice for patients suffering from myocardial infarction in the near future.

Intracoronary delivery of injectable bioabsorbable scaffold (IK-5001) to treat left ventricular remodeling after ST-elevation myocardial infarction: a first-in-man study

BACKGROUND

We aimed to test, for the first time, the feasibility of intracoronary delivery of an innovative, injectable bioabsorbable scaffold (IK-5001), to prevent or reverse adverse left ventricular remodeling and dysfunction in patients after ST-segment-elevation myocardial infarction.

METHODS AND RESULTS

Patients (n=27) with moderate-to-large ST-segment-elevation myocardial infarctions, after successful revascularization, were enrolled. Two milliliters of IK-5001, a solution of 1% sodium alginate plus 0.3% calcium gluconate, was administered by selective injection through the infarct-related coronary artery within 7 days after myocardial infarction. IK-5001 is assumed to permeate the infarcted tissue, cross-linking into a hydrogel and forming a bioabsorbable cardiac scaffold. Coronary angiography, 3 minutes after injection, confirmed that the injection did not impair coronary flow and myocardial perfusion. Furthermore, IK-5001 deployment was not associated with additional myocardial injury or re-elevation of cardiac biomarkers. Clinical assessments, echocardiographic studies, 12-lead electrocardiograms, 24-hour Holter monitoring, blood tests, and completion of Minnesota Living with Heart Failure Questionnaires were repeated during follow-up visits at 30, 90, and 180 days after treatment. During a 6-month follow-up, these tests confirmed favorable tolerability of the procedure, without device-related adverse events, serious arrhythmias, blood test abnormalities, or death. Serial echocardiographic studies showed preservation of left ventricular indices and left ventricular ejection fraction.

CONCLUSIONS

This first-in-man pilot study shows that intracoronary deployment of an IK-5001 scaffold is feasible and well tolerated. Our results have promoted the initiation of a multicenter, randomized controlled trial to confirm the safety and efficacy of this new approach in high-risk patients after ST-segment-elevation myocardial infarction.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01226563.

Single intracoronary injection of encapsulated antagomir-92a promotes angiogenesis and prevents adverse infarct remodeling

Background

Small and large preclinical animal models have shown that antagomir‐92a‐based therapy reduces early postischemic loss of function, but its effect on postinfarction remodeling is not known. In addition, the reported remote miR‐92a inhibition in noncardiac organs prevents the translation of nonvectorized miR‐targeted therapy to the clinical setting. We investigated whether a single intracoronary administration of antagomir‐92a encapsulated in microspheres could prevent deleterious remodeling of myocardium 1 month after acute myocardial infarction AUTHOR: Should “acute” be added before “myocardial infarction” (since abbreviation is AMI)? Also check at first mention in main text (AMI) without adverse effects.

Methods and Results

In a percutaneous pig model of reperfused AMI, a single intracoronary administration of antagomir‐92a encapsulated in specific microspheres (9 μm poly‐d,‐lactide‐co‐glycolide [PLGA]) inhibited miR‐92a in a local, selective, and sustained manner (n=3 pigs euthanized 1, 3, and 10 days after treatment; 8×, 2×, and 5×‐fold inhibition at 1, 3, and 10 days). Downregulation of miR‐92a resulted in significant vessel growth (n=27 adult minipigs randomly allocated to blind receive encapsulated antagomir‐92a, encapsulated placebo, or saline [n=8, 9, 9]; P=0.001), reduced regional wall‐motion dysfunction (P=0.03), and prevented adverse remodeling in the infarct area 1 month after injury (P=0.03). Intracoronary injection of microspheres had no significant adverse effect in downstream myocardium in healthy pigs (n=2), and fluorescein isothiocyanate albumin‐PLGA microspheres were not found in myocardium outside the left anterior descending coronary artery territory (n=4) or in other organs (n=2).

Conclusions

Early single intracoronary administration of encapsulated antagomir‐92a in an adult pig model of reperfused AMI prevents left ventricular remodeling with no local or distant adverse effects, emerging as a promising therapeutic approach to translate to patients who suffer a large AMI.

Effect of spironolactone on cardiac remodeling after acute myocardial infarction

BACKGROUND

Few studies have reported the effect of aldosterone receptor antagonist (ARA) on myocardial remodeling after acute myocardial infarction (AMI). This study was undertaken to investigate the preventive effect of ARA on myocardial remodeling after AMI.

METHODS

A total of 616 patients who had been admitted into the CCU of the First Affiliated Hospital of Harbin Medical University from January 2008 to January 2010 were studied prospectively. Only 528 patients were observed completely, including 266 of the control group and 262 of the treatment group. There was no statistical difference in age, gender, medical history, admission situation, and treatment between the two groups (P>0.05). The preventive effects of spironolactone on cardiac remodeling, left ventricular function, renal function and blood levels of potassium were evaluated by echocardiography, serum potassium and serum creatinine at one-month and one-year follow-up.

RESULTS

The echocardiography indicators such as LVESD, LVEDD, LVEF, LAD-ML and LAD-SI were significantly improved in the treatment group compared with the control group at one year (P<0.05). In the treatment group, LVESD, LVEDD, LVPWT, LVEF, LAD-ML and LAD-SI were more significantly improved at one year than one month (P<0.05, P=0.007 to LVEF), and in the control group LVEF was more significantly improved at one year than one month (P=0.0277). There were no significant differences in serum potassium and serum creatinine levels between the two groups.

CONCLUSION

On the basis of conventional treatment, the early combination of low-dose spironolactone (20 mg/d) could inhibit cardiac remodeling at late stage and prevent heart failure.

Clinical impact of Q-wave presence on electrocardiogram at presentation of patients with ST-segment elevation myocardial infarction undergoing primary coronary intervention

This study evaluated the clinical impact of Q-wave presence on ECG at presentation of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).From April 2005 to September 2009, 184 consecutive STEMI patients who underwent primary PCI within 12 hours of chest pain onset were retrospectively evaluated. Patients were grouped according to the presence (Q positive, n = 109) or absence (Q negative, n = 75) of Q waves on initial ECG at emergency room presentation. Major adverse cardiac events (MACE) and stent thrombosis (ST) were evaluated for 2 years. Risk factors for MACE and left ventricular (LV) remodeling by echocardiography were also evaluated.Baseline characteristics, including reperfusion time and infarct location, were similar between the groups. The MACE rate at 2 years was higher in the Q-positive group (32.1%) than in the Q-negative group (13.3%, P = 0.005). Independent risk factors for MACE were the presence of Q-wave (P = 0.008, Odds ratio 3.139) and no-reflow phenomenon (P = 0.016, Odds ratio, 2.819). LV remodeling was more frequent in the Q-positive group (47.9%) than in the Q-negative (24.5%, P = 0.009) group. Initial Q-wave presence (P = 0.048, Odds ratio 2.380) and anterior wall MI (P = 0.009, Odds ratio, 3.425) were independent risk factors for LV remodeling.The presence of Q waves in ECG of patients presenting with STEMI undergoing primary PCI provides an independent prognostic marker of clinical outcomes and left ventricular remodeling.

Heart 'omics' in AGEing (HOMAGE): design, research objectives and characteristics of the common database

Heart failure is common in older people and its prevalence is increasing. The Heart ‘omics’ in AGEing (HOMAGE) project aims to provide a biomarker approach that will improve the early diagnosis of heart failure. A large clinical database, based on (1) prospective population studies or (2) cross-sectional, prospective studies or randomized controlled trials (RCTs) of patients at risk for or with overt cardiovascular disease will be constructed to determine most promising ‘omics’-based biomarkers to identify the risk of developing heart failure and/or comorbidities. Population studies, patient cohorts and RCTs are eligible for inclusion in the common database, if they received ethical approval to obtain and share data and have baseline information on cardiovascular risk factors. Currently, the HOMAGE database includes 43,065 subjects, from 20 studies in eight European countries, including healthy subjects from three population studies in France, Belgium and Italy (n  =  7,124), patients with heart failure (n  =  4,312) from four cohorts in the UK, Spain and Switzerland and patients at high risk for cardiovascular disease (n  =  31,629) in 13 cohorts. It is anticipated that more partners will join the consortium and enlarge the pooled data. This large merged database will be a useful resource with which to identify candidate biomarkers that play a role in the mechanism underlying the onset and progression of heart failure.

The optimal time of B-type natriuretic peptide sampling associated with post-myocardial infarction remodelling after primary percutaneous coronary intervention

Aims

To find the optimal time to evaluate plasma B-type natriuretic peptide (BNP), which is related to post-myocardial infarction remodelling (PMIR), we measured serial plasma BNP levels according to time protocols after primary percutaneous coronary intervention (PCI).

Background

It has been established that plasma BNP levels can predict the development of PMIR in patients with ST-elevation myocardial infarction (STEMI). However, the time of plasma BNP sampling associated with PMIR is still controversial.

Methods

We analysed 42 patients who were diagnosed as PMIR on six-month follow-up echocardiography among 131 patients with STEMI. We then compared clinical variables including plasma BNP between the remodelling group and the non-remodelling group. The plasma BNP level was obtained on hospital admission (acute phase), at two to five days (early phase), three to four weeks (late phase) and at the six-month follow up (long term).

Results

Early-phase and long-term BNP levels were higher in the remodelling group. The serial plasma BNP levels, according to study protocols, showed a biphasic pattern of elevation. In multiple logistic regression analyses, early-phase BNP [odds ratio (OR): 1.013, p < 0.01] and acute-phase BNP levels (OR: 1.007, p = 0.02) were independent predictors of PMIR. However, early-phase BNP level was statistically a more powerful predictor of PMIR during follow up.

Conclusion

Consecutive BNP levels after primary PCI showed a biphasic peak elevation during follow up. Earlyphase plasma BNP level was an independent predictor of PMIR in patients with STEMI.

Umbilical-cord-blood-derived mesenchymal stem cells seeded onto fibronectin-immobilized polycaprolactone nanofiber improve cardiac function

Stem cells seeded onto biofunctional materials have greater potency for therapeutic applications. We investigated whether umbilical-cord-blood-derived mesenchymal stem cell (UCB-MSC)-seeded fibronectin (FN)-immobilized polycaprolactone (PCL) nanofibers could improve cardiac function and inhibit left ventricle (LV) remodeling in a rat model of myocardial infarction (MI). Aligned nanofibers were uniformly coated with poly(glycidyl methacrylate) by initiated chemical vapor deposition followed by covalent immobilization of FN proteins. The degree of cell elongation and adhesion efficacy were improved by FN immobilization. Furthermore, genes related to angiogenesis and mesenchymal differentiations were up-regulated in the FN-immobilized PCL nanofibers in comparison to control PCL nanofibers in vitro. 4 weeks after the transplantation in the rat MI model, the echocardiogram showed that the UCB-MSC-seeded FN-immobilized PCL nanofiber group increased LV ejection fraction and fraction shortening as compared to the non-treated control and acellular FN-immobilized PCL nanofiber groups. Histological analysis indicated that the implantation of UCB-MSCs with FN-immobilized PCL nanofibers induced a decrease in MI size and fibrosis, and an increase in scar thickness. This study indicates that FN-immobilized biofunctional PCL nanofibers could be an effective carrier for UCB-MSC transplantation for the treatment of MI.

Circulating Long Noncoding RNA, LIPCAR, Predicts Survival in Patients With Heart Failure

Rationale:

Long noncoding RNAs represent a novel class of molecules regulating gene expression. Long noncoding RNAs are present in body fluids, but their potential as biomarkers was never investigated in cardiovascular disease.

Objective:

To study the role of long noncoding RNAs as potential biomarkers in heart disease.

Methods and Results:

Global transcriptomic analyses were done in plasma RNA from patients with or without left ventricular remodeling after myocardial infarction. Regulated candidates were validated in 3 independent patient cohorts developing cardiac remodeling and heart failure (788 patients). The mitochondrial long noncoding RNA uc022bqs.1 (LIPCAR) was downregulated early after myocardial infarction but upregulated during later stages. LIPCAR levels identified patients developing cardiac remodeling and were independently to other risk markers associated with future cardiovascular deaths.

Conclusions:

LIPCAR is a novel biomarker of cardiac remodeling and predicts future death in patients with heart failure.

Prognosis of patients with stable coronary artery disease (from the CORONOR study)

There are limited data on the prognosis of patients with stable coronary artery disease (CAD) in modern clinical practice. We conducted a multicenter study enrolling 4,184 outpatients with stable CAD defined as previous myocardial infarction (>1 year ago), previous coronary revascularization (>1 year ago), and/or ≥50% coronary stenosis by angiography. Clinical follow-up was performed after 2 years. All cases of death were adjudicated and the mortality rate was compared with expected mortality of persons of the same age and gender in the same geographical area. Mean age was 66.9±11.6 years; 77.7% were men. There was a wide prescription of secondary prevention drugs: antithrombotic drugs, 99.3%; β blockers, 79.4%; statins, 92.2%; and antagonists of the angiotensin system, 81.9%. Two-year follow-up was obtained for 99.2% of the patients. There were 271 deaths (3.3/100 patient-years). The mortality rate was similar to the expected mortality in the general population (p=0.93). Most deaths were noncardiovascular (1.8/100 patient-years). Among cardiovascular deaths, the leading causes were heart failure death (0.4/100 patient-years) and sudden death (0.4/100 patient-years); in contrast, there were few deaths related to vascular causes (stroke, 0.2/100 patient-years and myocardial infarction, 0.1/100 patient-years). Age, diabetes, multivessel CAD, the absence of previous coronary revascularization, previous hospitalization for decompensated heart failure, a low ejection fraction, a low estimated glomerular filtration rate, and the absence of statin treatment were independent predictors of mortality. In conclusion, the mortality rate of patients with stable CAD in modern clinical practice is similar to that of the general population and is mostly due to noncardiovascular causes.

Does spironolactone have a dose-dependent effect on left ventricular remodeling in patients with preserved left ventricular function after an acute myocardial infarction?

AIMS

The aim of this study was to investigate the effects of spironolactone on left ventricular (LV) remodeling in patients with preserved LV function following acute myocardial infarction (AMI).

METHODS AND RESULTS

Successfully revascularized patients (n = 186) with acute ST elevation MI (STEMI) were included in the study. Patients were randomly divided into three groups, each of which was administered a different dose of spironolactone (12.5, 25 mg, or none). Echocardiography was performed within the first 3 days and at 6 months after MI. Echocardiography control was performed on 160 patients at a 6-month follow-up. The median left ventricular ejection fraction (LVEF) increased significantly in all groups, but no significant difference was observed between groups (P = 0.13). At the end of the sixth month, the myocardial performance index (MPI) had improved in each of the three groups, but no significant difference was found between groups (F = 2.00, P = 0.15). The mean LV peak systolic velocities (Sm ) increased only in the control group during the follow-up period, but there is no significant difference between groups (F = 1.79, P = 0.18). The left ventricular end-systolic volume index (LVESVI) and the left ventricular end-diastolic volume index (LVEDVI) did not change significantly compared with the basal values between groups (F = 0.05, P = 0.81 and F = 1.03, P = 0.31, respectively).

CONCLUSION

In conclusion, spironolactone dosages of up to 25 mg do not augment optimal medical treatment for LV remodeling in patients with preserved cardiac functions after AMI.

Longitudinal strain is a marker of microvascular obstruction and infarct size in patients with acute ST-segment elevation myocardial infarction

OBJECTIVES

We assessed the value of speckle tracking imaging performed early after a first ST-segment elevation myocardial infarction (STEMI) in order to predict infarct size and functional recovery at 3-month follow-up.

METHODS

44 patients with STEMI who underwent revascularization within 12 h of symptom onset were prospectively enrolled. Echocardiography was performed 3.9 ± 1.2 days after myocardial reperfusion, assessing circumferential (CGS), radial (RGS), and longitudinal global (GLS) strains. Late gadolinium-enhanced cardiac magnetic imaging (CMR), for assessing cardiac function, infarct size, and microvascular obstruction (MVO), was conducted 5.6 ± 2.5 days and 99.4 ± 4.6 days after myocardial reperfusion.

RESULTS

GLS was evaluable in 97% of the patients, while CGS and RGS could be assessed in 85%. Infarct size significantly correlated with GLS (R = 0.601, p<0.001), RGS (R = -0.405, p = 0.010), CGS (R = 0.526, p = 0.001), ejection fraction (R = -0.699, p<0.001), wall motion score index (WMSI) (R = 0.539, p = 0.001), and left atrial volume (R = 0.510, p<0.001). Baseline ejection fraction and GLS were independent predictors of 3-month infarct size. MVO mass significantly correlated with GLS (R = 0.376, p = 0.010), WMSI (R = 0.387, p = 0.011), and ejection fraction (R = -0.389, p = 0.011). In multivariate analysis, GLS was the only independent predictor of MVO mass (p = 0.015). Longitudinal strain >-6.0% within the infarcted area exhibited 96% specificity and 61% sensitivity for predicting the persistence of akinesia (≥ 3 segments) at 3-month follow-up.

CONCLUSIONS

Speckle-tracking strain imaging performed early after a STEMI is easy-to-use as a marker for persistent akinetic territories at 3 months. In addition, GLS correlated significantly with MVO and final infarct size, both parameters being relevant post-MI prognostic factors, usually obtained via CMR.

Extracellular matrix turnover biomarkers predict long-term left ventricular remodeling after myocardial infarction: insights from the REVE-2 study

BACKGROUND

Extracellular matrix turnover plays a key role in wound repair after myocardial infarction (MI). The aim of the study was to evaluate whether biomarkers of myocardial fibrosis measurements 1 month after MI may predict left ventricular (LV) remodeling.

METHODS AND RESULTS

This prospective multicenter study included 246 patients with a first anterior Q-wave MI. Echocardiographic studies were performed at hospital discharge and 12 months after MI. Brain natriuretic peptide as well as biomarkers of myocardial fibrosis (type 1 collagen telopeptide, aminoterminal propeptide of type I procollagen, aminoterminal propeptide of type III procollagen) were measured 1 month after MI in 218 patients. In multivariate analysis, aminoterminal propeptide of type III procollagen/type 1 collagen telopeptide ratio ≤1 (odds ratio [95% confidence interval], 1.86 [1.02-3.39]; P=0.043) 1 month after MI and brain natriuretic peptide >100 pg/mL (2.35 [1.28-4.31]; P=0.006) were associated with a pejorative LV remodeling, whereas LV ejection fraction at discharge (per 5% increment; 0.78 [0.65-0.94]; P=0.01) was independently associated with lower rates of detrimental LV remodeling at 12 months. Patients with high brain natriuretic peptide and aminoterminal propeptide of type III procollagen/type 1 collagen telopeptide ratio ≤1, measured 1 month after MI, had the highest risk of developing a primary composite event (cardiovascular death or hospitalization for worsening heart failure; 14 events per 216 patients; P=0.0001) during a 3-year follow-up.

CONCLUSIONS

Myocardial fibrosis turnover after MI is associated with LV remodeling. Low aminoterminal propeptide of type III procollagen/type 1 collagen telopeptide ratio (≤1) at 1 month is predictive, in addition to brain natriuretic peptide and LV ejection fraction, of detrimental LV remodeling as well as cardiovascular deaths and hospitalizations for heart failure.

Serum MMP-8: a novel indicator of left ventricular remodeling and cardiac outcome in patients after acute myocardial infarction

OBJECTIVE

Left ventricular (LV) remodeling following myocardial infarction (MI) is characterized by progressive alterations of structure and function, named LV remodeling. Although several risk factors such as infarct size have been identified, LV remodeling remains difficult to predict in clinical practice. Changes within the extracellular matrix, involving matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs), are an integral part of left ventricular (LV) remodeling after myocardial infarction (MI). We investigated the temporal profile of circulating MMPs and TIMPs and their relations with LV remodeling at 1 year and clinical outcome at 3 years in post-MI patients.

METHODS

This prospective multicentre study included 246 patients with a first anterior MI. Serial echocardiographic studies were performed at hospital discharge, 3 months, and 1 year after MI, and analysed at a core laboratory. LV remodeling was defined as the percent change in LV end-diastolic volume (EDV) from baseline to 1 year. Serum samples were obtained at hospital discharge, 1, 3, and 12 months. Multiplex technology was used for analysis of MMP-1, -2, -3, -8, -9, -13, and TIMP-1, -2, -3, -4 serum levels.

RESULTS

Baseline levels of MMP-8 and MMP-9 were positively associated with changes in LVEDV (P = 0.01 and 0.02, respectively). When adjusted for major baseline characteristics, MMP-8 levels remained an independent predictor LV remodeling (P = 0.025). By univariate analysis, there were positive relations between cardiovascular death or hospitalization for heart failure during the 3-year follow-up and the baseline levels of MMP-2 (P = 0.03), MMP-8 (P = 0.002), and MMP-9 (P = 0.03). By multivariate analysis, MMP-8 was the only MMP remaining significantly associated with clinical outcome (P = 0.02).

CONCLUSION

Baseline serum MMP-8 is a significant predictor of LV remodeling and cardiovascular outcome after MI and may help to improve risk stratification.

Circulating plasma serine208-phosphorylated troponin T levels are indicator of cardiac dysfunction

Heart failure (HF) following myocardial infarction (MI) is characterized by progressive alterations of left ventricular (LV) structure and function, named LV remodelling. Although several risk factors such as infarct size have been identified, HF remains difficult to predict in clinical practice. Recently, using phosphoproteomic technology, we found that serine(208)-phosphorylated troponin T (P-Ser(208)-TnT) decreases in LV of HF rats. Our aim was to determine the performance of P-Ser(208)-TnT as plasma biomarker of HF compared to conventional cardiac biomarkers such as B-type natriuretic peptide (BNP), cardiac troponin I (cTnI), C-reactive protein (CRP) or tissue inhibitor of metalloproteinase I (TIMP-1) measured by x-MAP technology, as well as its capacity to reflect a pharmacological improvement of HF. We observed a significant increase of BNP, TnT and cTnI levels and a significant decrease of P-Ser(208)-TnT and TIMP-1 in the plasma of 2-month-MI rats compared with control rats with no modulation of CRP level. Circulating levels of P-Ser(208)-TnT were shown to be associated with most of the echocardiographic and haemodynamic parameters of cardiac function. We verified that the decrease of P-Ser(208)-TnT was not because of an excess of phosphatase activity in plasma of HF rats. Two-month-MI rats treated with the heart rate reducing agent ivabradine had improved LV function and increased plasma levels of P-Ser(208)-TnT. Thus, circulating phosphorylated troponin T is a highly sensitive biological indicator of cardiac dysfunction and has the potentiality of a new biomarker of HF post-MI, and of a surrogate marker for the efficacy of a successful treatment of HF.

Circulating miR-133a and miR-423-5p fail as biomarkers for left ventricular remodeling after myocardial infarction

BACKGROUND

Recent studies have suggested that the microRNAs miR-133a and miR-423-5p may serve as useful biomarkers in patients with left ventricular (LV) heart failure or with LV remodeling after myocardial infarction (MI). These results were however obtained in small series of patients and control subjects were used as reference groups. Whether these microRNAs may be indicators of the degree of LV remodeling after MI is unknown.

METHODS

246 patients with a first anterior Q-wave MI were included. Serial echocardiographic studies were performed at hospital discharge, 3 months, and 1 year after MI and analyzed at a core laboratory. We investigated the temporal profile (baseline, 1, 3 and 12 months) of circulating miR-133a and miR-423-5p and their relations with cardiac biomarkers (B-type natriuretic peptide, C-reactive protein, and cardiac troponin I) and LV remodeling during the 1 year follow-up.

RESULTS

There were time-dependent changes in the levels of circulating miR-133a and miR-423-5p with significant increase of miR-133a at 12 months compared to 3 months and significant increase of miR-423-5p at 1, 3, and 12 months compared to baseline. However, miR-133a and miR-423-5p were not associated with indices of LV function and LV remodeling serially assessed during a 1 year period after an acute anterior MI, nor with B-type natriuretic peptide.

CONCLUSIONS

Circulating levels of miR-133a and miR-423-5p are not useful biomarkers of LV remodeling after MI.

Proteomic analysis of plasma of patients with left ventricular remodeling after myocardial infarction: usefulness of SELDI-TOF

SELDI-TOF and depletion of major blood proteins is one of the most promising approaches for accessing low-abundance biomarkers. The use of combinatorial peptide ligand library (CPLL) for selecting the low-abundance proteins and of liquid-phase isoelectric focusing for purifying the corresponding proteins was tested in plasma or serum from patients with myocardial infarction (MI). Here, we describe the SELDI profiling of CPLL-treated plasma to select low-abundance proteins in plasma and the strategy for purification and mass spectrometry identification. This approach shows the potential to select and identify candidate biomarkers in patients with left ventricular remodeling after MI.

Intramyocardial delivery of mesenchymal stem cell-seeded hydrogel preserves cardiac function and attenuates ventricular remodeling after myocardial infarction

Background

To improve the efficacy of bone marrow-derived mesenchymal stem cell (MSC) therapy targeted to infarcted myocardium, we investigated whether a self-setting silanized hydroxypropyl methylcellulose (Si-HPMC) hydrogel seeded with MSC (MSC+hydrogel) could preserve cardiac function and attenuate left ventricular (LV) remodeling during an 8-week follow-up study in a rat model of myocardial infarction (MI).

Methodology/Principal Finding

Si-HPMC hydrogel alone, MSC alone or MSC+hydrogel were injected into the myocardium immediately after coronary artery ligation in female Lewis rats. Animals in the MSC+hydrogel group showed an increase in cardiac function up to 28 days after MI and a mid-term prevention of cardiac function alteration at day 56. Histological analyses indicated that the injection of MSC+hydrogel induced a decrease in MI size and an increase in scar thickness and ultimately limited the transmural extent of MI. These findings show that intramyocardial injection of MSC+hydrogel induced short-term recovery of ventricular function and mid-term attenuation of remodeling after MI.

Conclusion/Significance

These beneficial effects may be related to the specific scaffolding properties of the Si-HPMC hydrogel that may provide the ability to support MSC injection and engraftment within myocardium.

Calcium-alginate hydrogel-encapsulated fibroblasts provide sustained release of vascular endothelial growth factor

Vascularization of engineered or damaged tissues is essential to maintain cell viability and proper tissue function. Revascularization of the left ventricle (LV) of the heart after myocardial infarction is particularly important, since hypoxia can give rise to chronic heart failure due to inappropriate remodeling of the LV after death of cardiomyocytes (CMs). Fibroblasts can express vascular endothelial growth factor (VEGF), which plays a major role in angiogenesis and also acts as a chemoattractant and survival factor for CMs and cardiac progenitors. In this in vitro model study, mouse NIH 3T3 fibroblasts encapsulated in 2% w/v Ca-alginate were shown to remain viable for 150 days. Semiquantitative reverse transcription-polymerase chain reaction and immunohistochemistry demonstrated that over 21 days of encapsulation, fibroblasts continued to express VEGF, while enzyme-linked immunosorbent assay showed that there was sustained release of VEGF from the Ca-alginate during this period. The scaffold degraded gradually over the 21 days, without reduction in volume. Cells released from the Ca-alginate at 7 and 21 days as a result of scaffold degradation were shown to retain viability, to adhere to fibronectin in a normal manner, and continue to express VEGF, demonstrating their potential to further contribute to maintenance of cardiac function after scaffold degradation. This model in vitro study therefore demonstrates that fibroblasts encapsulated in Ca-alginate provide sustained release of VEGF.

Decreased level of melatonin in serum predicts left ventricular remodelling after acute myocardial infarction

As experimental studies suggest that melatonin is cardioprotective after myocardial infarction (MI), this study sought to investigate the relationships between circulating levels of melatonin and left ventricular (LV) remodelling in patients after acute MI. This prospective study included 161 patients (age 61±3yr; 78% men) undergoing primary percutaneous coronary intervention who were assessed echocardiographically at hospital discharge (day 3-7) and at 12 months. LV remodelling was defined as >20% increase in LV end-diastolic volume at 12-month follow-up compared with baseline. Serum melatonin concentrations were measured at admission, during the light period. Twenty-four patients showed LV remodelling, and 137 had no evidence of LV remodelling. Patients with LV remodelling had lower levels of melatonin at study entry [9.96 (8.28-11.03) versus 16.74 (13.77-19.59) pg/mL, respectively; P <0.0001]. Multivariate analysis showed that melatonin levels (OR=2.10, CI 95% 1.547-2.870, P<0.001) were an independent predictor of LV remodelling at 12-month follow-up. Receiver operating characteristic (ROC) analysis showed an area under the curve of 0.959 (CI 95% 0.93-0.98; P<0.0001). To our knowledge, this is the first study to show the relationship between melatonin and LV remodelling during the chronic phase post-MI.

Value of C-reactive protein in predicting left ventricular remodelling in patients with a first ST-segment elevation myocardial infarction

OBJECTIVE

To assess the value of C-reactive protein (CRP) in predicting postinfarct left ventricular remodelling (LVR).

METHODS

We measured in-hospital plasma CRP concentrations in patients with a first ST-segment elevation myocardial infarction (STEMI).

RESULTS

LVR was present at 6 months in 27.8% of 198 patients. CRP concentration rose during the first 24 h, mainly in LVR group. The prevalence of LVR was higher in patients from the highest quartile of CRP concentrations at 24 h as compared to those from any other quartile (odds ratio (OR) 3.48, 95% confidence interval (95% CI) 1.76-6.88). Multivariate analysis identified CRP concentration at 24 h (OR for a 10 mg/L increase 1.29, 95% CI 1.04-1.60), B-type natriuretic peptide at discharge (OR for a 100 pg/mL increase 1.21, 95% CI 1.05-1.39), body mass index (OR for a 1 kg/m(2) increase 1.10, 95% CI 1.01-1.21), and left ventricular end-diastolic volume (OR for a 1 mL increase 0.98, 95% CI 0.96-0.99) as independent predictors of LVR. The ROC analysis revealed a limited discriminative value of CRP (area under the curve 0.61; 95% CI 0.54-0.68) in terms of LVR prediction.

CONCLUSIONS

Measurement of CRP concentration at 24 h after admission possesses a significant but modest value in predicting LVR after a first STEMI.

Prevalence and predictors of ventricular remodeling after anterior myocardial infarction in the era of modern medical therapy

BACKGROUND

The consequences of aggressive therapy following a myocardial infarction (MI) on ventricular remodeling are not well established. Thus, the objective of this study was to analyze the prevalence, clinical characteristics, and predictors of left ventricular remodeling in the era of modern medical therapy.

MATERIAL/METHODS

Clinical characteristics and echocardiographic data were analyzed in 66 consecutive patients with anterior infarction at admission and at 6-month follow-up. Ventricular remodeling was defined as an increase of 10% in ventricular end-systolic or end-diastolic diameter.

RESULTS

In our study, 58% of patients presented with ventricular remodeling. Patients with remodeling possessed higher total plasma creatine kinase (CPK), MB-fraction (CPK-MB), heart rate, heart failure, shortness of breath, and reperfusion therapy than patients without remodeling. In contrast, patients with remodeling had a smaller ejection fraction, E-Wave deceleration time (EDT), and early (E' Wave) and late (A' Wave) diastolic mitral annulus velocity (average of septal and lateral walls), but a higher E/E' than patients without remodeling. Patients with remodeling used more diuretics, digoxin, oral anticoagulants and aldosterone antagonists than patients without remodeling. In the multivariate analyses, only E' Wave was an independent predictor of ventricular remodeling. Each 1 unit increase in the E' Wave was associated with a 59% increased odds of ventricular remodeling.

CONCLUSIONS

In patients with anterior MI, despite contemporary treatment, ventricular remodeling is still a common event. In addition, diastolic function can have an important role as a predictor of remodeling in this scenario.

Impact of gender differences on myocardial salvage and post-ischaemic left ventricular remodelling after primary coronary angioplasty: new insights from cardiovascular magnetic resonance

AIMS

There is conflicting evidence on the impact of gender on reperfusion after primary coronary angioplasty (PPCI), and on left ventricular (LV) remodelling (LVR). In a cohort of patients with reperfused ST elevation myocardial infarction (STEMI), gender-related differences on myocardial reperfusion, and sex-related differences on LVR were assessed by using a comprehensive cardiac magnetic resonance (CMR) approach.

METHODS AND RESULTS

In four tertiary referral centres, 283 (238 males and 45 females) consecutive STEMI patients, treated with PPCI within 12 h from symptoms onset underwent CMR 3 ± 2 days after STEMI and at 4-month follow-up. By CMR, the area at risk, infarct size (IS), microvascular obstruction (MVO), and myocardial salvage index (MSI) were assessed. Women were older than men (P = 0.014), more hypertensive (P < 0.001) and more frequently presented with pre-infarct angina (P = 0.018). An MSI extent was significantly higher (P = 0.013), IS was significantly smaller at both time points (acute P < 0.001, follow-up P < 0.001), and the MVO extent was significantly smaller (P < 0.001) in women. At multivariate analysis, Killip class and female sex were independently associated with a higher MSI (P = 0.02, P = 0.05, respectively). A similar incidence of LVR in both sexes was observed at follow-up (P = 0.808).

CONCLUSIONS

The better reperfusion pattern observed in women by CMR in our population of reperfused STEMI suggests sex-based differences exist. No gender differences were observed with respect to incidence of LV remodelling at the follow-up mainly occurring in the subset of patients with a larger IS.

Circulating levels of soluble Fas ligand and left ventricular remodeling after acute myocardial infarction (from the REVE-2 study)

BACKGROUND

Apoptosis-related molecules may contribute to left ventricular (LV) remodeling after myocardial infarction (MI). To validate this hypothesis, we evaluated the relation between circulating plasma levels of soluble Fas ligand (sFas-L) and LV remodeling in patients post-MI.

METHODS AND RESULTS

This prospective multicenter study included 246 patients with a first anterior Q-wave MI. Serial echocardiographic studies were performed at hospital discharge and 3 and 12 months after MI; quantitative analysis was performed at a core echocardiography laboratory. Clinical follow-up was performed at 3 years post-MI. Blood samples to measure sFas-L were obtained at 1 month after MI. Median sFas-L level was 50.2 pg/mL. During the 1 year follow-up, LV remodeling was documented by a significant increase in LV volumes. LV end-diastolic and end-systolic volumes at baseline, 3 months, and 12 months after MI did not differ according to sFas-L levels; changes in LV volumes were not associated with sFas-L levels. By multivariate analysis, 2 variables were independently associated with LV remodeling: B-type natriuretic peptide (BNP) (p=0.008) and baseline ejection fraction (p=0.02). sFas-L levels were not associated with cardiovascular death or rehospitalization for heart failure at 3 years; conversely, high levels of BNP were associated with worse clinical outcome.

CONCLUSIONS

Soluble Fas-L levels are not associated with LV remodeling after MI. Further research is needed to identify apoptotic markers that may be associated with outcome post-MI.

The role of cardiac magnetic resonance imaging following acute myocardial infarction

BACKGROUND

Advances in the management of myocardial infarction have resulted in substantial reductions in morbidity and mortality.

METHODS

However, after acute treatment a number of diagnostic and prognostic questions often remain to be answered, whereby cardiac imaging plays an essential role.

RESULTS

For example, some patients will sustain early mechanical complications after infarction, while others may develop significant ventricular dysfunction. Furthermore, many individuals harbour a significant burden of residual coronary disease for which clarification of functional ischaemic status and/or viability of the suspected myocardial territory is required.

CONCLUSION

Cardiac magnetic resonance (CMR) imaging is well positioned to fulfil these requirements given its unparalleled capability in evaluating cardiac function, stress ischaemia testing and myocardial tissue characterisation. This review will focus on the utility of CMR in resolving diagnostic uncertainty, evaluating early complications following myocardial infarction, assessing inducible ischaemia, myocardial viability, ventricular remodelling and the emerging role of CMR-derived measures as endpoints in clinical trials.

KEY POINTS

Cardiac magnetic resonance (CMR) imaging identifies early complications after myocardial infarction. • Adenosine stress CMR can reliably assess co-existing disease in non-culprit arteries. • Assessment of infarct size and microvascular obstruction a robust prognostic indicator. • Assessment of myocardial viability is important to guide revascularisation decision-making.

Incidence, determinants and consequences of left atrial remodelling after a first anterior myocardial infarction

BACKGROUND

Left atrial (LA) volume is an important predictor of mortality and morbidity after myocardial infarction (MI). However, the process of LA remodelling has not been extensively investigated.

AIMS

Our purpose was to analyse the incidence, determinants and consequences of LA remodelling in a cohort of patients with a first anterior MI enrolled in the modern era of MI management.

METHODS

We used data from 246 patients with a first anterior MI who were included in a prospective study on left ventricular (LV) remodelling (REVE-2). Serial echocardiographic studies were performed before discharge and at 3 months and 1 year after MI.

RESULTS

LA volume increased from 20.5±5.9 mL/m2 at baseline to 24.6±7.4 mL/m2 at 3 months (P<0.0001 versus baseline) and 25.4±7.6 mL/m2 at 1 year (P<0.0001 versus baseline). Patients with high LA volumes at baseline had higher LV volumes, decreased LV systolic function, increased E/Ea (early transmitral velocity/mitral annular early diastolic velocity ratio) and increased B-type natriuretic peptide concentration. By multivariable analysis, the sole independent predictor of change in LA volume from baseline to 1 year was peak creatine kinase concentration (P<0.0001). Patients with higher LA volumes at baseline were at higher risk of cardiovascular death or rehospitalization for heart failure during follow-up (P=0.015).

CONCLUSIONS

Despite modern therapeutic management, LA remodelling is common during the first 3 months after anterior MI. Patients with larger infarct size are at greater risk of LA remodelling after discharge.

Insulin alone or with captopril: effects on signaling pathways (AKT and AMPK) and oxidative balance after ischemia-reperfusion in isolated hearts

Insulin and the inhibition of the renin-angiotensin system have independent benefits for ischemia-reperfusion injury, but their combination has not been tested. Our aim was to evaluate the effects of insulin+captopril on insulin/angiotensin signaling pathways and cardiac function in the isolated heart subjected to ischemia-reperfusion. Isolated hearts were perfused (Langendorff technique) with Krebs-Henseleit (KH) buffer for 25 min. Global ischemia was induced (20 min), followed by reperfusion (30 min) with KH (group KH), KH+angiotensin-I (group A), KH+angiotensin-I+captopril (group AC), KH+insulin (group I), KH+insulin+angiotensin-I (group IA), or KH+insulin+angiotensin-I+captopril (group IAC). Group A had a 24% reduction in developed pressure and an increase in end-diastolic pressure vs. baseline, effects that were reverted in groups AC, IA, and IAC. The phosphorylation of protein kinase B (AKT) was higher in groups I and IA vs. groups KH and A. The phosphorylation of AMP-activated protein kinase (AMPK) was ∼31% higher in groups I, IA, and IAC vs. groups KH, A, and AC. The tert-butyl hydroperoxide (tBOOH)-induced chemiluminescence was lower (∼2.2 times) in all groups vs. group KH and was ∼35% lower in group IA vs. group A. Superoxide dismutase content was lower in groups A, AC, and IAC vs. group KH. Catalase activity was ∼28% lower in all groups (except group IA) vs. group KH. During reperfusion of the ischemic heart, insulin activates the AKT and AMPK pathways and inhibits the deleterious effects of angiotensin-I perfusion on SOD expression and cardiac function. The addition of captopril does not potentiate these effects.

Circulating levels of hepatocyte growth factor and left ventricular remodelling after acute myocardial infarction (from the REVE-2 study)

Aim As experimental studies suggest that hepatocyte growth factor (HGF) is cardioprotective after myocardial infarction (MI), this study sought to investigate relationships between circulating levels of HGF and left ventricular (LV) remodelling in patients after acute MI.

METHODS AND RESULTS

This prospective multicentre study included 246 patients with a first anterior Q-wave MI. Serial echocardiographic studies were performed at hospital discharge and 3 and 12 months after MI; quantitative analysis was performed at a core echocardiography laboratory. Blood samples to measure HGF, brain natriuretic peptide (BNP), and C-reactive protein were obtained at discharge and at the 1, 3, and 12 month follow-up visits. Plasma HGF levels were high at baseline, decreased at 1 month, and remained stable thereafter. In the post-MI period (at 3 and 12 months), HGF levels were positively associated with LV volumes, wall motion systolic index, E/Ea, and BNP; and negatively with LV ejection fraction. High HGF levels were associated with higher C-reactive protein levels. Multivariate analysis showed that both BNP (P < 0.0001) and C-reactive protein (P < 0.0001) were independently associated with HGF levels at 3 and 12 months. Patients who died or were rehospitalized for heart failure during follow-up had higher HGF levels at 1 month (P = 0.0006), 3 months (P = 0.018), and 1 year (P = 0.006) after MI.

CONCLUSIONS

Circulating HGF levels correlate with all markers of LV remodelling after MI and are associated with rehospitalization for heart failure.