Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction

Characteristics and in-hospital outcomes of female patients presenting with ST-segment-elevation myocardial infarction without standard modifiable cardiovascular risk factors

BACKGROUND

Standard Modifiable Cardiovascular Risk Factors (SMuRF) such as hypertension, diabetes mellitus, hyperlipidemia, and smoking have long been established in the etiology of atherosclerotic disease. We evaluate in-hospital outcomes of female STEMI patients without these risk factors.

METHODS

The National Inpatient Sample databases (2016 to 2021) were queried to identify STEMI admissions as a principal diagnosis using ICD 10 codes. Patients with a history of coronary artery disease, myocardial infarction, coronary bypass graft, percutaneous coronary intervention, takotsubo cardiomyopathy, cocaine abuse, and spontaneous coronary dissection and males were excluded from our study population. A final study population aged >18 years was divided into cohorts of SMuRF and SMuRF-less based on the presence of ≥1 risk factor. Multivariate logistic regression model adjusting for baseline characteristics and comorbidities. The primary outcome was in-hospital mortality. The secondary outcomes are STEMI-related complications and the use of mechanical circulatory support devices.

RESULTS

200,980 patients were identified. 187,776 (93.4 %) patients were identified as having ≥1 SMuRF, and 13,205 (6.6 %) patients were SMuRF-less. Compared to SMuRF patients, SMuRF-less patients are more likely to be white (75.6 % vs. 73.1 %, p < 0.01) and older median age (69 years [IQR: 58-78] vs 67 years [IQR: 57-81], p < 0.01). In comparing co-morbidities, SMuRF-less patients were less likely to have heart failure (28.0 % vs. 23.4 %, p < 0.01), atrial fibrillation/flutter (16.1 % vs. 14.6 %, p = 0.03), chronic pulmonary disease (18.9 % vs. 9.5 %, p < 0.01), obesity (20.7 % vs. 9.2 %, p < 0.01) and aortic disease (1.1 % vs. 0.6 %, p < 0.01). They were however more likely to have dementia (6.9 % vs. 5.7 %, p < 0.01). In evaluating outcomes, SMuRF-less patients had higher in-hospital mortality (aOR 3.2 [95 % CI, 2.9-3.6]; p < 0.01), acute heart failure (aOR 1.6 [95 % CI, 1.4-1.8]; p < 0.01), acute kidney injury (aOR 1.8 [95 % CI, 1.7-2.1]; p < 0.01), and Intra-aortic balloon pump (aOR 1.7 [95 % CI, 1.5-1.9]; p < 0.01). Predictors of higher mortality in SMuRF-less patients include chronic liver disease (OR 6.8, CI 2.4-19.4, p < 0.01), and Hispanic race (OR 1.62, CI 1.1-2.5, p < 0.01). We also found that SMuRF-less patients were less likely to undergo coronary angiography (aOR 0.5 [95 % CI, 0.4-0.5]; p < 0.01) and percutaneous coronary intervention (aOR 0.7 [95 % CI, 0.6-0.8]; p < 0.01).

CONCLUSION

Female SMuRF-less patients presenting with STEMI have worse in-hospital outcomes when compared to patients with ≥1SMuRF.

In-Hospital Mortality and Treatment in Patients With Acute Coronary Syndrome With and Without Standard Modifiable Cardiovascular Risk Factors: Findings From the CCC-ACS Project

BACKGROUND

Patients with acute coronary syndrome without standard modifiable cardiovascular risk factors (SMuRFs; hypertension, smoking, dyslipidemia, diabetes) have not been well studied, with little known about their characteristics, quality of care, or outcomes. We sought to systematically analyze patients with ACS without SMuRFs, especially to evaluate the effectiveness of guideline-directed medical therapy for these patients.

METHODS AND RESULTS

In the CCC-ACS (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) project (2014-2019), we examined the presence and absence of SMuRFs and features among 89 462 patients with initial acute coronary syndrome. The main outcome was in-hospital all-cause mortality. Among eligible patients, 11.0% had none of the SMuRFs (SMuRF-less). SMuRF-less patients had higher in-hospital mortality (unadjusted hazard ratio [HR], 1.49 [95% CI, 1.19-1.87]). After adjustment for clinical characteristics and treatments, the associations between SMuRF status and in-hospital mortality persisted (adjusted HR, 1.35 [95% CI, 1.07-1.70]). Guideline-directed optimal medical therapy (receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and statins) was not associated with lower mortality (adjusted HR, 0.98 [95% CI, 0.58-1.67]) in SMuRF-less patients, unlike the association in patients with SMuRFs (adjusted HR, 0.80 [95% CI, 0.66-0.98]). Sensitivity analyses were consistent with these results.

CONCLUSIONS

SMuRF-less patients were associated with an increased risk of in-hospital mortality. Guideline-directed medical therapy was less effective in SMuRF-less patients than in patients with SMuRFs. Dedicated studies are needed to confirm the optimal therapy for SMuRF-less patients.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02306616.

Machine-learning clustering analysis identifies novel phenogroups in patients with ST-elevation acute myocardial infarction

BACKGROUND

Machine learning clustering of patients with ST-elevation acute myocardial infarction (STEMI) may provide important insights into their risk profile, management and prognosis.

METHODS

All adult discharges for STEMI in the National Inpatient Sample (October 2015 to December 2019) were included, excluding patients with prior myocardial infarction. Machine-learning clustering analysis was used to define clusters based on 21 clinical attributes of interest. Main outcomes of the study were cluster-based comparison of risk profile, in-hospital clinical outcomes and utilization of invasive management. Binomial hierarchical multivariable logistic regression with adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) was used to detect the between-cluster differences.

RESULTS

Out of overall 470,960 STEMI cases, the machine-learning analysis revealed 4 different clusters with 205,640 (cluster 0: 'behavioural risk cluster'), 146,400 (cluster 1: 'least comorbidity cluster'), 45,100 (cluster 2: 'diabetes with end-organ damage cluster') and 73,820 (cluster 3: 'cardiometabolic cluster') cases. Attributes with the highest importance for clustering were hypertension and diabetes. After multivariable adjustment, patients from 'diabetes with end-organ damage cluster' exhibited the worst mortality, MACCE and ischemic stroke (p < 0.001 for all), as well as the lowest utilization of invasive management (p < 0.001 for all), in comparison to other clusters. Patients from 'behavioural risk cluster' exhibited the best in-hospital prognosis and the highest utilization of invasive management, compared to other clusters (p < 0.001 for all).

CONCLUSIONS

Machine learning driven clustering of inpatients with STEMI reveals important population subgroups with distinct prevalence, risk profile, prognosis and management. Data driven approaches may identify high risk phenogroups and warrants further study.

Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis

BACKGROUND

Although anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database.

METHODS

All hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes.

RESULTS

Among 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07-1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68-2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577-$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001).

CONCLUSION

In MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.

Effect of Patient's Symptom Interpretation on In-Hospital Mortality in Acute Coronary Syndrome

BACKGROUND

The association between symptom interpretation and prognosis has not been investigated well among patients with acute coronary syndrome (ACS). As such, the present study evaluated the effect of heart disease awareness among patients with ACS on in-hospital mortality.

METHODS AND RESULTS

We performed a post hoc analysis of 1,979 consecutive patients with ASC with confirmed symptom interpretation on admission between 2014 and 2018, focusing on patient characteristics, recanalization time, and clinical outcomes. Upon admission, 1,264 patients interpreted their condition as cardiac disease, whereas 715 did not interpret their condition as cardiac disease. Although no significant difference was observed in door-to-balloon time between the 2 groups, onset-to-balloon time was significantly shorter among those who interpreted their condition as cardiac disease (254 vs. 345 min; P<0.001). Moreover, the hazard ratio (HR) for in-hospital mortality was significantly higher among those who did not interpret their condition as cardiac disease based on the Cox regression model adjusted for established risk factors (HR 1.73; 95% confidence interval 1.08-2.76; P=0.022).

CONCLUSIONS

This study demonstrated that prehospital symptom interpretation was significantly associated with in-hospital clinical outcomes among patients with ACS. Moreover, the observed differences in clinical prognosis were not related to door-to-balloon time, but may be related to onset-to-balloon time.

Chronic coronary syndromes without standard modifiable cardiovascular risk factors and outcomes: the CLARIFY registry

BACKGROUND AND AIMS

It has been reported that patients without standard modifiable cardiovascular (CV) risk factors (SMuRFs-diabetes, dyslipidaemia, hypertension, and smoking) presenting with first myocardial infarction (MI), especially women, have a higher in-hospital mortality than patients with risk factors, and possibly a lower long-term risk provided they survive the post-infarct period. This study aims to explore the long-term outcomes of SMuRF-less patients with stable coronary artery disease (CAD).

METHODS

CLARIFY is an observational cohort of 32 703 outpatients with stable CAD enrolled between 2009 and 2010 in 45 countries. The baseline characteristics and clinical outcomes of patients with and without SMuRFs were compared. The primary outcome was a composite of 5-year CV death or non-fatal MI. Secondary outcomes were 5-year all-cause mortality and major adverse cardiovascular events (MACE-CV death, non-fatal MI, or non-fatal stroke).

RESULTS

Among 22 132 patients with complete risk factor and outcome information, 977 (4.4%) were SMuRF-less. Age, sex, and time since CAD diagnosis were similar across groups. SMuRF-less patients had a lower 5-year rate of CV death or non-fatal MI (5.43% [95% CI 4.08-7.19] vs. 7.68% [95% CI 7.30-8.08], P = 0.012), all-cause mortality, and MACE. Similar results were found after adjustments. Clinical event rates increased steadily with the number of SMuRFs. The benefit of SMuRF-less status was particularly pronounced in women.

CONCLUSIONS

SMuRF-less patients with stable CAD have a substantial but significantly lower 5-year rate of CV death or non-fatal MI than patients with risk factors. The risk of CV outcomes increases steadily with the number of risk factors.

Incidence and Risk Factors for Arterial Thrombosis in Patients with Acute Leukemia and Lymphoid Malignancies: A Retrospective Single-Center Study

INTRODUCTION

The treatment of patients with hematological malignancies and acute arterial thrombosis (ATE) is challenging due to the risk of bleeding complications during treatment. Data on the incidence and risk factors for ATE in this group are very limited.

AIMS

We aimed to evaluate the incidence and risk factors for ATE in patients with acute leukemia (AL) and lymphoid malignancies.

MATERIAL AND METHODS

Patients with acute leukemia (AL), lymphoid malignancies, and ATE diagnosed following cancer diagnosis, who were treated and followed at the Department of Hematology, Karolinska University Hospital, 2005-2020, were candidates for inclusion in this study. Retrospective data on malignancy, ATE, and risk factors were collected.

RESULTS

No differences in either the 15-year incidence of ATE (1.4%) nor in the risk factors for cardiovascular disease (CVD) between patients with AL and lymphoid malignancies and ATE were found. ATE at diagnosis was more frequent in patients with AL and lymphoid malignancies (excluding chronic lymphatic leukemia, CLL).

CONCLUSIONS

Patients with AL and lymphoid malignancies have a similar risk of ATE when compared to each other and the general population, regardless of platelet levels. No difference could be found in the presence of CVD risk factors between patients with AL and lymphoid malignancies presenting with ATE.

Causal Inference Challenges in the Relationship Between Social Determinants and Cardiovascular Outcomes

The effects of social determinants on cardiovascular outcomes are frequently estimated in epidemiologic analyses, but the profound causal and statistical challenges of this research program are not widely discussed. Here, we carefully review definitions and measures for social determinants of cardiovascular health and then examine the various assumptions required for valid causal inference in multivariable analyses of observational data, such as what one would typically encounter in cohorts, population surveys, health care databases, and vital statistics databases. We explain the necessity of the "well-defined exposure" and show how this goal relates to the "consistency assumption" that is necessary for valid causal inference. Well-defined exposure is especially challenging for social determinants of health because they are seldom simple atomistic interventions that are easily conceptualized and measured. We then review threats to valid inference that arise from confounding, selection bias, information bias, and positivity violations. Other causal considerations are reviewed and explained, such as correct model specification, absence of immortal time, and avoidance of the "Table 2 Fallacy," and their application to social determinants of cardiovascular outcomes are discussed. Fruitful approaches, including focusing on policy interventions and the "target trial" frameworks are proposed and provide a pathway for a more efficacious research program that can more reliably improve population health. Valid causal inference in this setting is quite challenging, but-with clever design and thoughtful analysis-the important role of social factors in patterning cardiovascular outcomes can be quantified and reported.

Mortality of patients presented with acute ST-segment elevation myocardial infarction according to the status of standard modifiable cardiovascular risk factors

BACKGROUND

Standard modifiable cardiovascular risk factors (SMuRFs) remain well-established elements of assessing cardiovascular risk scores. However, there is growing evidence that patients presented without known SMuRFs at admission demonstrate worse post-myocardial outcomes. The aim of the study was to assess the influence of the SMuRF status on short- and long-term mortality rates in patients with first-time ST-segment elevation myocardial infarction (STEMI).

METHODS

This observational, cross-sectional study covered 182,726 patients admitted between 2003-2020 to the CathLabs, according to data from the Polish Registry of Acute Coronary Syndrome. Both baseline characteristics and mortality (in-hospital, 30-day, and 12-month) were examined and stratified by SMuRF status. The predictors of mortality were assessed at selected time points by multivariable analysis.

RESULTS

The majority of STEMI patients had at least one SMuRF (88.7%), however, mortality rates of SMuRF-less individuals were greater at selected time points of the follow-up (p < 0.001), and persisted at a higher level during each year of the follow-up period compared to the SMuRF group and general population. Furthermore, the SMuRFs status constituted an independent predictor of mortality at the 30-day (OR: 1.345; 95% CI: 1.142-1.585, p < 0.001) and 12-month (OR: 1.174; 95% CI: 1.054-1.308, p < 0.001) follow-ups.

CONCLUSIONS

SMuRF-less individuals presented with STEMI are at an increased risk of all-cause mortality compared to those with at least one SMuRF. Consequently, further investigations regarding the recognition and treatment of risk factors, irrespective of SMuRF status, are indicated.

Evening versus morning dosing regimen drug therapy for hypertension

BACKGROUND

Variation in blood pressure levels display circadian rhythms. Complete 24-hour blood pressure control is the primary goal of antihypertensive treatment and reducing adverse cardiovascular outcomes is the ultimate aim. This is an update of the review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of administration-time-related effects of once-daily evening versus conventional morning dosing antihypertensive drug therapy regimens on all-cause mortality, cardiovascular mortality and morbidity, total adverse events, withdrawals from treatment due to adverse effects, and reduction of systolic and diastolic blood pressure in people with primary hypertension.

SEARCH METHODS

We searched the Cochrane Hypertension Specialised Register via Cochrane Register of Studies (17 June 2022), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2022); MEDLINE, MEDLINE In-Process and MEDLINE Epub Ahead of Print (1 June 2022); Embase (1 June 2022); ClinicalTrials.gov (2 June 2022); Chinese Biomedical Literature Database (CBLD) (1978 to 2009); Chinese VIP (2009 to 7 August 2022); Chinese WANFANG DATA (2009 to 4 August 2022); China Academic Journal Network Publishing Database (CAJD) (2009 to 6 August 2022); Epistemonikos (3 September 2022) and the reference lists of relevant articles. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the administration-time-related effects of evening with morning dosing monotherapy regimens in people with primary hypertension. We excluded people with known secondary hypertension, shift workers or people with white coat hypertension.

DATA COLLECTION AND ANALYSIS

Two to four review authors independently extracted data and assessed trial quality. We resolved disagreements by discussion or with another review author. We performed data synthesis and analyses using Review Manager Web for all-cause mortality, cardiovascular mortality and morbidity, serious adverse events, overall adverse events, withdrawals due to adverse events, change in 24-hour blood pressure and change in morning blood pressure. We assessed the certainty of the evidence using GRADE. We conducted random-effects meta-analysis, fixed-effect meta-analysis, subgroup analysis and sensitivity analysis.

MAIN RESULTS

We included 27 RCTs in this updated review, of which two RCTs were excluded from the meta-analyses for lack of data and number of groups not reported. The quantitative analysis included 25 RCTs with 3016 participants with primary hypertension. RCTs used angiotensin-converting enzyme inhibitors (six trials), calcium channel blockers (nine trials), angiotensin II receptor blockers (seven trials), diuretics (two trials), α-blockers (one trial), and β-blockers (one trial). Fifteen trials were parallel designed, and 10 trials were cross-over designed. Most participants were white, and only two RCTs were conducted in Asia (China) and one in Africa (South Africa). All trials excluded people with risk factors of myocardial infarction and strokes. Most trials had high risk or unclear risk of bias in at least two of several key criteria, which was most prominent in allocation concealment (selection bias) and selective reporting (reporting bias). Meta-analysis showed significant heterogeneity across trials. No RCTs reported on cardiovascular mortality and cardiovascular morbidity. There may be little to no differences in all-cause mortality (after 26 weeks of active treatment: RR 0.49, 95% CI 0.04 to 5.42; RD 0, 95% CI -0.01 to 0.01; very low-certainty evidence), serious adverse events (after 8 to 26 weeks of active treatment: RR 1.17, 95% CI 0.53 to 2.57; RD 0, 95% CI -0.02 to 0.03; very low-certainty evidence), overall adverse events (after 6 to 26 weeks of active treatment: RR 0.89, 95% CI 0.67 to 1.20; I² = 37%; RD -0.02, 95% CI -0.07 to 0.02; I² = 38%; very low-certainty evidence) and withdrawals due to adverse events (after 6 to 26 weeks active treatment: RR 0.76, 95% CI 0.47 to 1.23; I² = 0%; RD -0.01, 95% CI -0.03 to 0; I² = 0%; very low-certainty evidence), but the evidence was very uncertain.

AUTHORS' CONCLUSIONS

Due to the very limited data and the defects of the trials' designs, this systematic review did not find adequate evidence to determine which time dosing drug therapy regimen has more beneficial effects on cardiovascular outcomes or adverse events. We have very little confidence in the evidence showing that evening dosing of antihypertensive drugs is no more or less effective than morning administration to lower 24-hour blood pressure. The conclusions should not be assumed to apply to people receiving multiple antihypertensive drug regimens.

Association Between Interleukin-6 Gene Polymorphism and Severity of Coronary Artery Disease in Patients with Diabetes

Introduction

Previous studies have identified diabetes as a risk factor for coronary heart disease. This study determined the correlation between the IL-6 gene -572 G/C polymorphism and the incidence and severity of coronary heart disease in patients with diabetes.

Methods

One hundred four patients with diabetes who were admitted to our hospital from January 2019 to December 2020 were retrospectively enrolled in the current study. These patients were divided into a diabetes only group (group A, 27 patients) and a diabetes complicated by coronary heart disease group (group B, 77 patients). Seventy patients in the latter group were further divided into low, medium, and high Syntax score groups based on coronary angiography results. A correlation analysis between IL-6, blood lipids, and the IL-6 -572 G/C gene levels was performed.

Results

The serum IL-6 level in patients with the IL-6-572G/C-GG genotype was higher than patients with the GC and CC genotypes. In patients with diabetes, the presence of the IL-6-572G/C-GG and GC genotypes was associated with a significantly increased risk of developing coronary heart disease. Patients with the IL-6-572G/C-GG genotype and diabetes were shown to have more severe coronary artery lesions compared to patients with the CC genotype. Moreover, the G allele of the IL-6-572G/C gene was linked to a higher risk of coronary heart disease and more severe coronary artery lesions in patients with diabetes compared to the C allele.

Conclusion

The IL-6-572G/C gene polymorphism is associated with the incidence and severity of coronary heart disease in patients with diabetes.

Predictors of gain in exercise capacity through cardiac rehabilitation: Sex and age matter

BACKGROUND

Cardiac rehabilitation (CR) is a cornerstone of secondary prevention that improves cardiovascular outcomes. However, the determinants of treatment success are poorly understood.

OBJECTIVES

We investigated the associations of health-related quality of life (HRQoL), sex, age, employment status and housing situation with improvement in exercise capacity throughout CR.

METHODS

We analyzed data from 392 CR outpatients (81% men and 19% women). Exercise capacity at baseline and upon completion of the program was measured with the 6-minute walk distance (6MWD). HRQoL at CR entry was assessed with the Short Form 36 Health Survey (SF-36).

RESULTS

A multivariable regression analysis revealed that both men and women showed significant improvement in exercise capacity (p < .001). Female sex (B = 18.118, 95% CI 0.341 - 36.035, p = .046) and younger age (B = -0.887, 95% CI -1.463 - -0.312, p = .003) emerged as predictors of greater improvement, while HRQoL, employment status, and housing situation were not associated with significant change in exercise capacity. The final model explained 25% of the variance in exercise capacity change (adjusted R2 = 0.25, p < .001).

CONCLUSIONS

Our results indicate that women and younger participants benefit from CR by improving their exercise capacity. Employment status, housing situation and HRQoL showed no effects on CR outcome.

Twenty-year trends in the prevalence of modifiable cardiovascular risk factors in young acute coronary syndrome patients hospitalized in Switzerland

AIMS

Modifiable cardiovascular risk factors (RFs) play a key role in the development of coronary artery disease. We evaluated 20-year trends in RF prevalence among young adults hospitalized with acute coronary syndromes (ACS) in Switzerland.

METHODS AND RESULTS

Data were analysed from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry from 2000 to 2019. Young patients were defined as those aged <50 years. Among 58 028 ACS admissions, 7073 (14.1%) were young (median 45.6 years, IQR 42.0-48.0), of which 91.6% had at least one modifiable RF and 59.0% had at least two RFs. Smoking was the most prevalent RF (71.4%), followed by dyslipidaemia (57.3%), hypertension (35.9%), obesity (21.7%), and diabetes (10.1%). Compared with older patients, young patients were more likely to be obese (21.7% vs. 17.4%, P < 0.001) and active smokers (71.4% vs. 33.9%, P < 0.001). Among young patients, between 2000 and 2019, there was a significant increase in the prevalence of hypertension from 29.0% to 51.3% and obesity from 21.2% to 27.1% (both Ptrend < 0.001) but a significant decrease in active smoking from 72.5% to 62.5% (Ptrend = 0.02). There were no significant changes in the prevalence of diabetes (Ptrend = 0.32) or dyslipidaemia (Ptrend = 0.067).

CONCLUSION

Young ACS patients in Switzerland exhibit a high prevalence of RFs and are more likely than older patients to be obese and smokers. Between 2000 and 2019, RF prevalence either increased or remained stable, except for smoking which decreased but still affected approximately two-thirds of young patients in 2019. Public health initiatives targeting RFs in young adults in Switzerland are warranted.

Characteristics, Treatment, and Mortality of Patients Hospitalized for First ST-Segment Elevation Myocardial Infarction without Standard Modifiable Risk Factors in China

Background

Little is known of the characteristics, treatment, and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) but without standard modifiable cardiovascular risk factors (SMuRFs, including smoking, hypercholesterolemia, diabetes, and hypertension) in developing countries like China. Moreover, contributors to the excess mortality of such SMuRF-less patients remain unclear.

Methods

This study was based on a nationally representative sample of patients presenting with STEMI and admitted to 162 hospitals in 31 provinces across mainland China between 2001 and 2015. We compared clinical characteristics, treatments, and mortality during hospitalization between patients with and without SMuRFs. We also investigated the possible causes of differences in mortality and quantified the contributors to excess mortality.

Results

Among 16,541 patients (aged 65 ± 13 years; 30.0% women), 19.9% were SMuRF-less. These patients were older (69 vs. 65 years), experienced more cardiogenic shock and lower blood pressure at admission, and were less likely to be admitted to the cardiac ward compared to patients with SMuRFs. Moreover, SMuRF-less patients received treatment less often, including primary percutaneous coronary intervention (17.3% vs. 28.8%, p < 0.001), dual antiplatelet therapy (59.4% vs. 77.0%, p < 0.001), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (49.9% vs. 68.1%, p < 0.001), and statins (69.9% vs. 85.1%, p < 0.001). They had higher in-hospital mortality (18.5% vs. 10.5%, p < 0.001), with 56.1% of deaths occurring within 24 hours of admission. Although the difference in mortality decreased after adjusting for patient characteristics, it remained significant and concerning (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.25-1.59). Mediation analysis found that, in patients without SMuRFs, underutilization of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins contributed to an excess mortality risk of 22.4% and 32.5%, respectively.

Conclusions

Attention and action are urgently needed for STEMI patients without SMuRFs, given their high incidence and excess in-hospital mortality. The use of timely and adequate evidence-based treatments should be strengthened.

Association of chronic neutrophil activation with risk of mortality

BACKGROUND

Levels of free myeloperoxidase (MPO), a cardiovascular risk marker, have been reported to decline with standard care. Whether such declines signify decreased risk of mortality remains unknown.

DESIGN

Cox proportional hazard models were generated using data from a retrospective cohort study of prospectively collected measures.

PARTICIPANTS

Patients (3,658) who had MPO measurements and LDL-C ≥ 90 mg/dL during 2011-2015 were selected based on a stratified random sampling on MPO risk level. Baseline MPO was either low (<470 pmol/L), moderate (470-539 pmol/L), or high (≥540 pmol/L).

MAIN OUTCOMES AND MEASURES

First occurrence of MACE (myocardial infarction, stroke, coronary revascularization, or all-cause death).

RESULTS

Mean age was 66.5 years, and 64.7% were women. During a mean 6.5-year follow-up, crude incidence per 1000 patient years was driven by death. The incidence and all-cause death was highest for patients with high MPO (21.2; 95% CI, 19.0-23.7), then moderate (14.6; 95% CI, 11.5-18.5) and low (2.3; 95% CI, 1.2-4.6) MPO. After adjusting for age, sex, and cardiovascular risk factors, risk of cardiovascular death did not differ significantly between patients with high and low MPO (HR, 1.57; 95% CI, 0.56-4.39), but patients with high MPO had greater risk of non-cardiovascular (HR, 6.15; 95% CI, 2.27-16.64) and all-cause (HR, 3.83; 95% CI, 1.88-7.78) death. During follow-up, a 100 pmol/L decrease in MPO correlated with a 5% reduction in mortality (HR, 0.95; 95% CI, 0.93-0.97) over 5 years.

CONCLUSIONS

Free circulating MPO is a strong marker of risk of mortality. Monitoring changes in MPO levels over time may provide insight into changes in physiology that mark a patient for increased risk of mortality.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Mortality of patients with ST-segment-elevation myocardial infarction without standard modifiable risk factors among patients without known coronary artery disease: Age-stratified and sex-related analysis from nationwide readmissions database 2010-2014

Objective

The proportion of ST-segment elevation myocardial infarction (STEMI) patients without standard modifiable risk factors (SMuRFs: hypertension, diabetes, hypercholesterolemia and smoking) has increased over time. The absence of SMuRFs is known to be associated with worse outcomes, but its association with age and sex is uncertain. We sought to evaluate the association between age and sex with the outcomes of post-STEMI patients without SMuRFs among patients without preexisting coronary artery disease.

Methods

Patients who underwent primary PCI for STEMI were identified from the Nationwide Readmission Database of the United States. Clinical characteristics, in-hospital, and 30-day outcomes in patients with or without SMuRFs were compared in men versus women and stratified into five age groups.

Results

Between January 2010 and November 2014, of 474,234 patients who underwent primary PCI for STEMI, 52,242 (11.0%) patients did not have SMuRFs. Patients without SMuRFs had higher in-hospital mortality rates than those with SMuRFs. Among those without SMuRFs, the in-hospital mortality rate was significantly higher in women than men (10.6% vs 7.3%, p<0.001), particularly in older age groups. The absence of SMuRFs was associated with higher 30-day readmission-related mortality rates (0.5% vs 0.3% with SMuRFs, p<0.001). Among patients without SMuRFs, women had a higher 30-day readmission-related mortality rates than men (0.6% vs 0.4%, p<0.001). After multivariable adjustment, the increased rates of in-hospital (odds ratio 1.89 (95% CI 1.72 to 2.07) and 30-day readmission-related mortality (hazard ratio 1.30 (95% CI 1.01 to 1.67)) in patients without SMuRFs remained significant.

Conclusions

STEMI patients without SMuRFs have a significantly higher risk of in-hospital and 30-day mortality than those with SMuRFs. Women and older patients without SMuRFs experienced significantly higher in-hospital and 30-day readmission-related mortality.

The Presence of Residual Vascular and Adipose Tissue Inflammation on 18F-FDG PET in Patients with Chronic Coronary Artery Disease

Purpose

We evaluated the residual vascular and adipose tissue inflammation in patients with chronic coronary artery disease (CAD) using positron emission tomography (PET).

Methods

Our study population consisted of 98 patients with known CAD and 94 control subjects who had undergone 18F-fluorodeoxyglucose (18F-FDG) PET due to non-cardiac reasons. Aortic root and vena cava superior 18F-FDG uptake were measured to obtain the aortic root target-to-background ratio (TBR). In addition, adipose tissue PET measurements were done in pericoronary, epicardial, subcutaneous, and thoracic adipose tissue. Adipose tissue TBR was calculated using the left atrium as a reference region. Data are presented as mean ± standard deviation or as median (interquartile range).

Results

The aortic root TBR was higher in CAD patients compared to control subjects, 1.68 (1.55-1.81) vs. 1.53 (1.43-1.64), p < 0.001. Subcutaneous adipose tissue uptake was elevated in CAD patients 0.30 (0.24-0.35) vs. 0.27 (0.23-0.31), p < 0.001. Metabolic activity of CAD patients and control subjects was comparable in the pericoronary (0.81 ± 0.18 vs. 0.80 ± 0.16, p = 0.59), epicardial (0.53 ± 0.21 vs. 0.51 ± 0.18, p = 0.38) and thoracic (0.31 ± 0.12 vs. 0.28 ± 0.12, p = 0.21) adipose tissue regions. Aortic root or adipose tissue 18F-FDG uptake was not associated with the common CAD risk factors, coronary calcium score, or aortic calcium score (p value > 0.05).

Conclusion

Patients with a chronic CAD had a higher aortic root and subcutaneous adipose tissue 18F-FDG uptake compared to control patients, which suggests residual inflammatory risk.

Trends in Modifiable Risk Factors Amongst First Presentation ST Elevation Myocardial Infarction Patients in a Large Longitudinal Registry

BACKGROUND

Recent studies suggest that the risk factor profile of patients presenting with ST elevation myocardial infarction (STEMI) is changing.

AIM

The aim is to determine if there has been a shift of cardiovascular risk factors to cardiometabolic causes in the first presentation STEMI population.

METHOD

We analysed data from a STEMI registry from a large tertiary referral percutaneous coronary intervention centre to determine the prevalence and trends of the modifiable risk factors of hypertension, diabetes, smoking and hypercholesterolaemia.

PARTICIPANTS

Consecutive first presentation STEMI patients between January 2006 to December 2018.

RESULTS

Among the 2,366 patients included (mean age 59, SD 12.66, 80% male) the common risk factors were hypertension (47%), hypercholesterolaemia (47%) current smoking (42%) and diabetes (27%). Over the 13 years, patients with diabetes (20% to 26%, OR 1.09 per year, CI 1.06-1.11, p<0.001) and patients with no modifiable risk factors increased (9% to 17%, OR 1.08, CI 1.04-1.11, p<0.001). Concurrently there was a fall in prevalence of hypercholesterolaemia, (47% to 37%, OR 0.94 per year, CI 0.92-0.96, p<0.001) and smoking (44% to 41%, OR 0.94, CI 0.92-0.96, p<0.001) but no significant change in rates of hypertension (53% to 49%, OR 0.99, CI 0.97-1.01, p=0.25).

CONCLUSION

The risk factor profile of first presentation STEMI has changed over time with a reduction in smoking and a concurrent rise in patients with no traditional risk factors. This suggests the mechanism of STEMI may be changing and further investigation of potential causal factors is warranted for the prevention and management of cardiovascular disease.

Risk Factors Control After an Acute Coronary Syndrome and Association with Major Adverse Cardiovascular Events: A Single Center Experience in Latin-America

INTRODUCTION

An important challenge in the secondary prevention of cardiovascular diseases is the optimization of risk factors (RFs) after hospital discharge. These have been shown to be insufficiently controlled in clinical practice.

AIM

To evaluate whether secondary prevention goals were met at our institution at 12 months after an acute coronary syndrome (ACS) index event, as well as analyzing if achieving these goals was associated with a lower incidence of major adverse cardiovascular events (MACE).

METHODS

Retrospective cohort of patients with a former diagnosis of ACS over a period of 4 years. To evaluate the proportion of patients who met RF control goals at 12 months after the index event, we used two sets of preestablished goals: stringent and lenient. During follow-up we evaluated the occurrence of MACE, defined by the following: ACS, coronary revascularization, stroke, hospitalization because of acute heart failure and cardiovascular death.

RESULTS

We included 468 patients during the study period. The mean age of the patients was 60 ± 10.76 years, 20.5% were women, and mean follow-up was 41.8 ± 22.0 months. The proportion of patients that met all secondary prevention stringent and lenient goals accounted for 5.5% and 17.2%, respectively, and 8% did not achieve any target. Overall, 9.6% presented the composite of MACE during follow-up. The number of RFs in control at 12 months was associated with a lower rate of MACE, both with stringent and lenient goals.

CONCLUSION

Achieving established goals for modifiable RFs can lower the incidence of MACE during long-term follow-up.

Outcomes of ST Segment Elevation Myocardial Infarction without Standard Modifiable Cardiovascular Risk Factors - Newer Insights from a Prospective Registry in India

Objectives

Patients with ST elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs; dyslipidaemia, hypertension, diabetes mellitus and smoking) are reported to have a worse clinical outcome compared to those with SMuRFs. However, robust prospective data and low-and middle-income country perspective are lacking. We aimed to study the patients with first STEMI and assess the influence of SMuRFs on clinical outcomes by comparing the patients with and without SMuRFs.

Methods

We included all consecutive STEMI patients without prior coronary artery disease enrolled in the Madras Medical College STEMI Registry from September 2018 to October 2019. We collected baseline clinical characteristics, revascularisation strategies and clinical outcome. We analysed suboptimal self-reported sleep duration as a 5^th extended SMuRF (eSMuRF). Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications and one-year all-cause mortality.

Results

Among 2,379 patients, 605 patients (25.4%) were SMuRF-less. More women were SMuRF-less than men (27.1% vs 22.1%; P = 0.012). SMuRF-less patients were older (57.44 ± 13.95 vs 55.68 ± 11.74; P < 0.001), more often former tobacco users (10.4% vs 5.0%; P < 0.001), with more anterior wall MI (62.6% vs 52.1%; P = 0.032). The primary outcome [in-hospital mortality (10.7% vs 11.3%; P = 0.72)] and secondary outcomes [in-hospital complications (29.1% vs 31.7%; P = 0.23) and one-year all-cause mortality (22.3% vs 22.7%; P = 0.85)] were similar in both groups. Addition of suboptimal self-reported sleep duration as a 5^th eSMuRF yielded similar results.

Conclusions

25% of first STEMI patients were SMuRF-less. Clinical outcomes of patients without SMuRFs were similar to those with SMuRFs. Suboptimal sleep duration did not account for the risk associated with the SMuRF-less status.

Cardiovascular Outcomes of ST-Elevation Myocardial Infarction (STEMI) Patients without Standard Modifiable Risk Factors (SMuRF-Less): The Intermountain Healthcare Experience

Studies primarily outside the United States have reported that SMuRF-less STEMI patients are surprisingly common (14-27%) and have a worse in-hospital/short-term prognosis. Given potential demographic and management differences over time and in the US, we aimed to identify the proportion and outcomes of SMuRF-less STEMI patients in a large US healthcare population. Patients with a first STEMI presenting to Intermountain Healthcare catheterization laboratories between 2001-2021 were included. SMuRF included a clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and smoking. Follow-up MACE were defined as death, MI, and heart failure hospitalization (HFH) by 60 days and long-term. Qualifying STEMI patients totaled 3510, 26.2% (919) with no SMuRF. SMuRF-less patients were younger, more frequently male, and had fewer comorbidities. Neither total MACE (adj HR 0.95, p = 0.72) nor death (adj HR 1.06, p = 0.69) differed by SMuRF status at 60 days. Long-term outcomes were more frequent in SMuRF patients, which remained significant for total MACE (adj HR 0.83, p = 0.02) and HFH (HR 0.36, p = 0.0005) after adjustment for baseline differences other than SMuRF. Results were consistent through subgroup and sensitivity analyses. In this moderately large US healthcare population, SMuRF-less STEMI presentation was confirmed to be common (26.2%). However, unlike earlier, mostly non-US reports, adjusted short-term outcomes were similar, and long-term outcomes were more favorable. Further studies to increase understanding, recognition, and treatment of risk factors in SMuRF-less subjects and to optimize STEMI management are indicated.

Medicine 2032: The future of cardiovascular disease prevention with machine learning and digital health technology

Machine learning (ML) refers to computational algorithms that iteratively improve their ability to recognize patterns in data. The digitization of our healthcare infrastructure is generating an abundance of data from electronic health records, imaging, wearables, and sensors that can be analyzed by ML algorithms to generate personalized risk assessments and promote guideline-directed medical management. ML's strength in generating insights from complex medical data to guide clinical decisions must be balanced with the potential to adversely affect patient privacy, safety, health equity, and clinical interpretability. This review provides a primer on key advances in ML for cardiovascular disease prevention and how they may impact clinical practice.

Effect of inclisiran on lipids in primary prevention: the ORION-11 trial

AIMS

Patients often require combination therapies to achieve LDL cholesterol (LDL-C) targets for the primary prevention of atherosclerotic cardiovascular disease. This study investigates the effect of inclisiran, a small interfering ribonucleic acid targeting hepatic proprotein convertase subtilisin/kexin type 9 production, in primary prevention patients with elevated LDL-C despite statins.

METHODS AND RESULTS

This pre-specified analysis of the placebo-controlled, randomized ORION-11 trial included 203 individuals at risk of, but without prior, cardiovascular events and LDL-C ≥2.6 mmol/L, despite maximally tolerated statins. Inclisiran 284 mg or placebo was administered on Days 1, 90, and thereafter every 6 months up to 540 days. Co-primary endpoints were percentage LDL-C change from baseline to Day 510 and time-adjusted change from baseline after Day 90 and up to Day 540. Key secondary endpoints included percentage and absolute changes in atherogenic lipoproteins. Safety was assessed over 540 days. The mean baseline (SD) LDL-C was 3.6 (1.5) mmol/L. At Day 510, the placebo-corrected LDL-C change with inclisiran was -43.7% [95% confidence interval (CI): -52.8 to -34.6] with a corresponding time-adjusted change of -41.0% (95% CI: -47.8 to -34.2); (P < 0.0001). The placebo-corrected absolute change in LDL-C at Day 510 with inclisiran was -1.5 mmol/L (95% CI: -1.8 to -1.2), with a respective time-adjusted change of -1.3 mmol/L (95% CI: -1.6 to -1.1). Inclisiran significantly lowered non-HDL cholesterol and apolipoprotein B (apoB) at Day 510 vs. placebo (P < 0.0001 for both), with a greater likelihood of attaining lipoprotein and apoB goals, and was well-tolerated except for mainly mild, treatment-emergent adverse events at the injection site.

CONCLUSION

Inclisiran was generally well-tolerated in primary prevention patients with elevated LDL-C, who derived significant reductions in atherogenic lipoprotein levels with twice-yearly maintenance dosing.

Hypoglycemia is associated with a higher risk of mortality and arrhythmias in ST-elevation myocardial infarction, irrespective of diabetes

Aims

We aimed to assess the impact of hypoglycemia in ST-elevation myocardial infarction (STEMI).

Background

Hypoglycemia increases the risk of mortality in patients with diabetes and high cardiovascular risk.

Methods

We used the National Inpatient Sample (2005–2017) database to identify adult patients with STEMI as the primary diagnosis. The secondary diagnosis was hypoglycemia. We compared cardiovascular and socio-economic outcomes between STEMI patients with and without hypoglycemia and assessed temporal trends.

Results

Hypoglycemia tends to complicate 0.17% of all cases hospitalized for STEMI. The mean age (±SD) of STEMI patients hospitalized with hypoglycemia decreased from 67 ± 15 in 2005 to 63 ± 12 in 2017 (p = 0.046). Mortality was stable with time, but the prevalence of ventricular tachycardia, ventricular fibrillation, acute renal failure, cardiogenic shock, total charges, and length of stay (LOS) increased with time (p < 0.05 for all). Compared to non-hypoglycemic patients, those who developed hypoglycemia were older and more likely to be black; only 6.7% had diabetes compared to 28.5% of STEMI patients (p = 0.001). Cardiovascular events were more likely to occur in hypoglycemia: mortality risk increased by almost 2.5-fold (adjusted OR = 2.625 [2.095–3.289]). There was a higher incidence of cardiogenic shock (adjusted OR = 1.718 [1.387–2.127]), atrial fibrillation (adjusted OR = 1.284 [1.025–1.607]), ventricular fibrillation (adjusted OR = 1.799 [1.406–2.301]), and acute renal failure (adjusted OR = 2.355 [1.902–2.917]). Patients who developed hypoglycemia were less likely to have PCI (OR = 0.596 [0.491–0.722]) but more likely to have CABG (OR = 1.792 [1.391–2.308]). They also had a longer in-hospital stay and higher charges/stay.

Conclusion

Hypoglycemia is a rare event in patients hospitalized with STEMI. However, it was found to have higher odds of mortality, arrhythmias, and other comorbidities, irrespective of diabetes.

Relationship between in-hospital mortality and creatinine/albumin in patients with ST-elevation myocardial infarction without standard modifiable risk factors

Background: Diabetes, hypertension, hyperlipidemia and smoking are associated with coronary artery disease and ST-elevation myocardial infarction (STEMI). However, patients without any classic risk factors have a higher mortality rate in the post-STEMI period. The aim of this study was to investigate the relationship between in-hospital mortality and creatinine/albumin ratio in patients with STEMI without modifiable risk factors. Materials & methods: All patients included in this study with a diagnosis of STEMI and who underwent primary percutaneous intervention between 2016 and 2020 were retrospectively analyzed. Patients were included in the standard modifiable cardiovascular risk factor (SMuRF) group if at least diabetes, hypertension, smoking or hyperlipidemia was present according to risk factors. Patients without these risk factors were considered the non-SMuRF group. Results: Creatinine/albumin ratio was found to be higher in non-SMuRF patients with mortality (p < 0.001). In multivariate logistic regression analysis, ejection fraction, hemoglobin and SMuRF were found to be inversely associated with in-hospital mortality (odds ratio [OR]: 0.48, 95% CI: 0.35-0.66, p < 0.001; OR: 0.70, 95% CI: 0.56-0.88, p = 0.002; OR: 0.57, 95% CI: 0.34-0.95, p = 0.03, respectively). Conclusion: The creatinine/albumin ratio can be used as a predictor of mortality in these patients; it can help identify high-risk patients beforehand.

Clinical Characteristics and Outcomes of Patients Presenting With Acute Myocardial Infarction Without Cardiogenic Shock

BACKGROUND

Most patients with acute myocardial infarction (AMI) present in the emergency department in a hemodynamically stable condition (i.e., non-cardiogenic shock) (AMI-NCS). However, few studies specifically focused on the clinical characteristics and outcomes of AMI-NCS patients. Temporal trends in clinical characteristics, in-hospital occurrence of in-hospital adverse outcomes, and the effect of primary percutaneous coronary intervention (PPCI) were examined.

METHODS AND RESULTS

Between April 2012 and March 2018, 176,275 AMI-NCS patients (67.7% of the total AMI population; 25.4% female; mean age 68.6±13.1 years) were identified in a nationwide Japanese administrative database. During the 6-year study period, AMI-NCS patients have been getting older and had an increasing burden of comorbidities. The rates of 30-day all-cause mortality and in-hospital complications were 2.6% and 30.5%, respectively. Thirty-day all-cause mortality did not change significantly over time, whereas in-hospital complications, especially major non-cardiac events, increased progressively. On multivariable analyses, higher age, higher Killip class, atrial fibrillation, chronic renal failure, and malignancy were independently associated with both increased 30-day mortality and in-hospital complications. PPCI was independently associated with lower mortality and in-hospital complications.

CONCLUSIONS

The clinical background of AMI-NCS patients has been becoming more complex with increasing age and the burden of comorbidities, with increased in-hospital complications. More active and appropriate application of PPCI may further decrease adverse events and improve survival of AMI-NCS patients.

Epidemiological Characteristics and Risk Factors Associated with Acute Myocardial Infarction in Somalia: A Single-Center Experience

Introduction

Acute myocardial infarction (AMI) is a clinical emergency condition that encompasses STEMI and NSTEMI that leads to significant morbidity and mortality rate.

Methods

This prospectively cohort study was obtained from adult (≥18 years) patients with definitive diagnosis of AMI based on the International Classification of Diseases (ICD; codes I21, I22) those visiting to our hospital from December 2020 to November 2021. Patients with no definite diagnosis of MI and those having with stable or unstable angina were excluded from the study. Descriptive methods including frequency of tables and bar charts for different categories were used for data analysis.

Results

Of 23,147 patients, 3526 were presented with chest pain in our emergency unit over the study period. A total of 97 patients met the inclusion criteria of AMI for this analysis. Of them, 73 (75.3%) had STEMI, and 24 (24.7%) had NSTEMI. Those with STEMI, anterior MI was common occlusion site (n=24, 32.9%) followed by inferior MI (n=15, 20.5%). The mean age of patients was 54.2±12.1 years. Of the total study subjects, 67 (69.1%) were males with no significant difference in subgroups. Most of the participants were married (n=41, 42.3%). More than half of the patients were employed (n=51, 52.6%), while most of the participants were no formal education (n-39, 44.2%). Regarding the ASCVD risk factors, history of hypertension, diabetes mellitus, previous history of coronary artery disease (CAD), and dyslipidemia were the most common comorbidities in STEMI and NSTEMI cases, 31 (41.2%), 36 (49.3%), 24 (32.9%) and 15 (20.5%) vs 14 (66.7%), 11 (45.8%), 11 (45.8%), and 6 (25%), respectively. On the initial clinical presentations, typical chest pain and palpitation were the most frequent clinical presenting symptoms in both STEMI and NSTEMI patients of our study (STEMI=80.4% vs NSTEMI=68% in each), followed by dyspnea (STEMI=72.6% vs NSTEMI=41.7%) and epigastric pain (STEMI=32.9% vs NSTEMI=29.2%). The use of aspirin, clopidogrel, and LMWH therapy within the first hours after the emergency were high and comparable in both subgroups (91.8%, vs 89.7% vs 89.7%). The majority of the patients developed heart failure (36.1%), arrhythmia (23.7%), and cardiogenic shock (18%).

Conclusion

As registered, the present study has a higher proportion of STEMI cases among the AMI participants when compared to the NSTEMI. Hypertension, diabetes, hyperlipidemia, and family history of CAD respectively were the highest prevalence risk factors of AMI.

Cardiovascular magnetic resonance characteristics and clinical outcomes of patients with ST-elevation myocardial infarction and no standard modifiable risk factors–A DANAMI-3 substudy

Introduction

A higher 30-day mortality has been observed in patients with first-presentation ST elevation myocardial infarction (STEMI) who have no standard modifiable cardiovascular risk factors (SMuRFs), i. e., diabetes, hypertension, hyperlipidemia, and current smoker. In this study, we evaluate the clinical outcomes and CMR imaging characteristics of patients with and without SMuRFs who presented with first-presentation STEMI.

Methods

Patients from the Third DANish Study of Acute Treatment of Patients With ST-Segment Elevation Myocardial Infarction (DANAMI-3) with first-presentation STEMI were classified into those with no SMuRFs vs. those with at least one SMuRF.

Results

We identified 2,046 patients; 283 (14%) SMuRFless and 1,763 (86%) had &gt;0 SMuRF. SMuRFless patients were older (66 vs. 61 years, p &lt; 0.001) with more males (84 vs. 74%, p &lt; 0.001), more likely to have left anterior descending artery (LAD) as the culprit artery (50 vs. 42%, p = 0.009), and poor pre-PCI (percutaneous coronary intervention) TIMI (thrombolysis in myocardial infarction) flow ≤1 (78 vs. 64%; p &lt; 0.001). There was no difference in all-cause mortality, non-fatal reinfarction, or hospitalization for heart failure at 30 days or at long-term follow-up. CMR imaging was performed on 726 patients. SMuRFless patients had larger acute infarct size (17 vs. 13%, p = 0.04) and a smaller myocardial salvage index (42 vs. 50%, p = 0.02). These differences were attenuated when the higher LAD predominance and/or TIMI 0-1 flow were included in the model.

Conclusion

Despite no difference in 30-day mortality, SMuRFless patients had a larger infarct size and a smaller myocardial salvage index following first-presentation STEMI. This association was mediated by a larger proportion of LAD culprits and poor TIMI flow pre-PCI.

Clinical trial registration

clinicaltrials.gov, unique identifier: NCT01435408 (DANAMI 3-iPOST and DANAMI 3-DEFER) and NCT01960933 (DANAMI 3-PRIMULTI).

Prognostic performance of multiple biomarkers in patients with acute coronary syndrome without standard cardiovascular risk factors

Background and aims

Acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs) represents a special case of ACS. Multiple biomarkers have been shown to improve risk stratification in patients with ACS. However, the utility of biomarkers for prognostic stratification in patients with ACS without SMuRFs remains uncertain. The aim of the present study was to evaluate the prognostic value of various biomarkers in patents with ACS without SMuRFs.

Methods

Data of consecutive patients with ACS without SMuRFs who underwent coronary angiography in Tianjin Chest Hospital between January 2014 and December 2017 were retrospectively collected. The primary outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of cardiovascular death, myocardial infarction and stroke. Seven candidate biomarkers analyses were analyzed using models adjusted for established risk factors.

Results

During a median 5-year follow-up, 81 of the 621 patients experienced a MACE. After adjustment for important covariates, elevated fibrinogen, D-dimer, N-terminal proB-type natriuretic peptide (NT-proBNP), and lipoprotein (a) [Lp(a)] were found to be individually associated with MACE. However, only D-dimer, NT-proBNP and Lp(a) significantly improved risk reclassification for MACE (all P < 0.05). The multimarker analysis showed that there was a clear increase in the risk of MACE with an increasing number of elevated biomarkers and a higher multimarker score. The adjusted hazard ratio- for MACE (95% confidential intervals) for patients with 4 elevated biomarkers was 6.008 (1.9650–18.367) relative to those without any elevated biomarker-. Adding- the 4 biomarkers or the multimarker score to the basic model significantly improved the C-statistic value, the net reclassification index and the integrated discrimination index (all P < 0.05).

Conclusion

Fibrinogen, D-dimer, NT-proBNP and Lp(a) provided valuable prognostic information for MACE when applied to patients with ACS without SMuRFs. The multimarker strategy, which combined multiple biomarkers reflecting different pathophysiological process with traditional risk factors improved the cardiovascular risk stratification.

Characteristics and risk factors of severe coronary artery disease in systemic lupus erythematosus: A multicenter, Chinese Rheumatism Date Center database study

AIM

Systemic lupus erythematosus (SLE) with severe coronary artery disease (CAD) is associated with increased mortality. This study aimed to assess the characteristics and risk factors of severe CAD in SLE.

METHOD

This multicenter, cross-sectional study enrolled consecutive patients with SLE included in the Chinese Rheumatism Date Center registry. Patients with severe CAD including angiography-confirmed stenosis ≥50% in the left main, ≥70% in other major coronary arteries, or myocardial infarction were classified into the CAD group. Patients without CAD were classified into the control group. Subgroups were stratified according to age (set as above and below 45 and 50 for men and women, respectively) and gender. Binary logistic regression analysis was performed to determine independent risk factors of severe CAD in SLE.

RESULTS

Forty-three patients had severe CAD from a total of 3744 patients with SLE, 30 of whom were female; 35 belonged to the older age group and 8 belonged to the younger age group. In older patients, independent risk factors included age, 5 major CAD risk factors, SLE Disease Activity Index 2000 (SLEDAI-2K), hyperuricemia, and corticosteroid exposure. In younger patients, the risk factors were 5 major CAD risk factors and positive antiphospholipid antibody (APL). Male risk factors were age and 5 major CAD risk factors, whereas female risk factors were age, 5 major CAD risk factors, SLEDAI-2K, and positive APL. Three-vessel disease was most prevalent in patients with severe CAD.

CONCLUSION

We recommend screening for severe CAD in patients with SLE with age- and gender-stratified risk factors.

Evaluation of liver transplant candidates with non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry

BACKGROUND

Recent publications reported a paradoxical finding that there was an inverse association between the number of standard modifiable risk factors (SMuRFs; smoking, hypertension, diabetes, and hyperlipidemia) and mortality in patients with myocardial infarction. However, the current evidence is only limited to those highly developed countries with advanced medical management systems.

METHODS

The China Acute Myocardial Infarction registry is a prospective observational study including patients with acute myocardial infarction from three-level hospitals across 31 administrative regions throughout mainland China. A total of 16,228 patients with first-presentation ST-elevation myocardial infarction (STEMI) admitted to hospitals from January 2013 to September 2014 were enrolled in the current analysis. Cox proportional hazard models adjusting for baseline characteristics, clinical profiles at presentation, and in-hospital treatments were used to assess the association of the number of SMuRFs with all-cause mortality at 30 days after STEMI presentation.

RESULTS

A total of 1918 (11.8%), 11,503 (70.9%), and 2807 (17.3%) patients had 0, 1-2, and 3-4 SMuRFs at presentation, respectively. Patients with fewer SMuRFs were older and more likely to be females, experienced longer pre-hospital delays, and were less likely to receive primary percutaneous coronary intervention and evidence-based medications. Compared with those without any SMuRF, patients with 1-2 SMuRFs and 3-4 SMuRFs were associated with an HR of 0.74 (95% CI, 0.63-0.87) and 0.63 (0.51-0.77) for all-cause mortality up to 30 days in the unadjusted model (P_trend < 0.0001). However, after multivariate adjustment, the number of SMuRFs was positively associated with increased mortality risk (HR for 1-2 SMuRFs, 1.15 [0.95-1.39]; HR for 3-4 SMuRFs, 1.31 [1.02-1.68]; P_trend = 0.03), and the association was only significant among patients admitted to hospitals beyond 12 h from onset (HR for 1-2 SMuRFs, 1.39 [1.03-1.87]; HR for 3-4 SMuRFs, 2.06 [1.41-3.01]) but not their counterparts (P_interaction = 0.01).

CONCLUSIONS

The increased crude mortality risk among patients without SMuRFs is explained by confounding factors related to their poor risk profiles (old age, longer pre-hospital delays, and poor clinical management). After multivariate adjustment, a higher risk-factor burden was associated with poor prognosis among patients with STEMI.

High density lipoprotein subfractions and extent of coronary atherosclerotic lesions: From the cordioprev study

BACKGROUND AND AIMS

The extent of atherosclerotic coronary heart disease (CHD) is associated with its prognosis, thus discovering potential biomarkers related to worse outcomes could prove valuable. The present work aims to investigate whether lipoprotein subfractions are associated with angiographic CHD severity.

MATERIALS AND METHODS

Patients from the CORDIOPREV study exhibiting coronary lesions in angiography were classified into two groups (single-vessel coronary disease (SVD) or multivessel coronary disease (MVD)). High-throughput nuclear magnetic resonance (NMR) spectroscopy determined lipoprotein subfractions concentration and composition.

RESULTS

SVD patients showed a higher concentration of medium and small HDL particles compared with MVD patients. For medium HDL, total lipids, phospholipids, total cholesterol, cholesteryl esters and free cholesterol reflected HDL particle concentration, whereas, for small HDL, total lipids, phospholipids, and free cholesterol mirrored lipoprotein particle concentration. Among traditional cardiovascular risk factors, age, hypertension and T2D were independently associated with angiography severity. In multivariate logistic regression models, medium and small HDL particles remained inversely associated with angiography severity (OR 0.77 (95% CI: 0.64-0.91); OR 0.78 (95% CI: 0.67-0.91), respectively) after adjusting with covariates.

CONCLUSION

In CHD patients mostly on statin treatment, angiography severity is inversely related to small and medium HDL subclasses concentration measured by NMR. These particles are also independent predictors of the presence of MVD, and its use increased the prediction of this entity over traditional risk factors.

Circulating Extracellular Vesicles Are Strongly Associated With Cardiovascular Risk Markers

Background

Extracellular vesicles (EVs) are submicron membrane-bound vesicles released from various cells, which are emerging as a potential novel biomarker in cardiovascular diseases (CVDs) due to their procoagulatory and prothrombotic properties. However, there is little information about the relationships between circulating EVs and conventional and thrombogenic risk markers of CVDs.

Objective

To investigate the relationships between circulating EVs, conventional cardiovascular risk markers and thrombogenic markers in subjects with moderate risk of CVDs.

Design

Subjects (n = 40) aged 40-70 years with moderate risk of CVDs were recruited and assessed for body mass index, blood pressure and plasma lipid profile, as well as platelet aggregation, clot formation, thrombin generation and fibrinolysis. Numbers of circulating EVs were assessed by Nanoparticle Tracking Analysis and flow cytometry. A range of assays were used to assess the procoagulatory activity of plasma and circulating EVs.

Results

Circulating EV numbers were positively associated with body mass index, blood pressure, plasma triacylglycerol concentration and overall CVD risk. Higher circulating EV numbers were also associated with increased thrombin generation and enhanced clot formation, and EVs isolated from subjects with moderate CVD risk promoted thrombin generation ex vivo. Higher numbers of endothelial-derived EVs were associated with a greater tendency for clot lysis. Plasma triacylglycerol concentration and diastolic blood pressure independently predicted circulating EV numbers, and EV numbers independently predicted aspects of thrombin generation and clot formation and 10-year CVD risk.

Conclusion

Circulating EVs were strongly associated with both conventional and thrombogenic risk markers of CVDs, and also with overall CVD risk, highlighting a potentially important role for EVs in CVDs.

Prognostic Outcomes in Acute Myocardial Infarction Patients Without Standard Modifiable Risk Factors: A Multiethnic Study of 8,680 Asian Patients

Background

An increasing proportion of patients with acute myocardial infarction (AMI) are presenting without standard modifiable risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes, and smoking, but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multiethnic Asian population.

Methods

We recruited patients presenting with AMI from 2011 to 2021 and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke, and heart failure. Kaplan-Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality.

Results

Standard modifiable risk factor-less patients, who made up 8.6% of 8,680 patients, were significantly younger with fewer comorbidities that include stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI: 1.09-1.86, p = 0.048), cardiogenic shock (RR: 1.31, 95% CI: 1.09-1.52, p = 0.015), and stroke (RR: 2.51, 95% CI: 1.67-3.34, p = 0.030) among SMuRF-less patients. A 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, patients with ST-segment elevation myocardial infarction (STEMI), and the three Asian ethnicities. All-cause mortality remains increased in the SMuRF-less group for up to 5 years.

Conclusion

There is a significant proportion of patients with AMI without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.

Comparison of Mortality Outcomes in Acute Myocardial Infarction Patients With or Without Standard Modifiable Cardiovascular Risk Factors

Background

Acute myocardial infarction (AMI) cases have decreased in part due to the advent of targeted therapies for standard modifiable cardiovascular disease risk factors (SMuRF). Recent studies have reported that ST-elevation myocardial infarction (STEMI) patients without SMuRF (termed “SMuRF-less”) may be increasing in prevalence and have worse outcomes than “SMuRF-positive” patients. As these studies have been limited to STEMI and comprised mainly Caucasian cohorts, we investigated the changes in the prevalence and mortality of both SMuRF-less STEMI and non-STEMI (NSTEMI) patients in a multiethnic Asian population.

Methods

We evaluated 23,922 STEMI and 62,631 NSTEMI patients from a national multiethnic registry. Short-term cardiovascular and all-cause mortalities in SMuRF-less patients were compared to SMuRF-positive patients.

Results

The proportions of SMuRF-less STEMI but not of NSTEMI have increased over the years. In hospitals, all-cause and cardiovascular mortality and 1-year cardiovascular mortality were significantly higher in SMuRF-less STEMI after adjustment for age, creatinine, and hemoglobin. However, this difference did not remain after adjusting for anterior infarction, cardiopulmonary resuscitation (CPR), and Killip class. There were no differences in mortality in SMuRF-less NSTEMI. In contrast to Chinese and Malay patients, SMuRF-less patients of South Asian descent had a two-fold higher risk of in-hospital all-cause mortality even after adjusting for features of increased disease severity.

Conclusion

SMuRF-less patients had an increased risk of mortality with STEMI, suggesting that there may be unidentified nonstandard risk factors predisposing SMuRF-less patients to a worse prognosis. This group of patients may benefit from more intensive secondary prevention strategies to improve clinical outcomes.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population

OBJECTIVES

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners.

METHODS

Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics.

RESULTS

Of 1196 subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients.

CONCLUSION

With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Effect of Low Body Mass Index on the Clinical Outcomes of Japanese Patients With Acute Myocardial Infarction - Results From the Prospective Japan Acute Myocardial Infarction Registry (JAMIR)

BACKGROUND

Acute myocardial infarction (AMI) patients with low body mass index (BMI) exhibit worse clinical outcomes than obese patients; however, to our knowledge, no prospective, nationwide study has assessed the effect of BMI on the clinical outcomes of AMI patients.

METHODS AND RESULTS

In this multi-center, prospective, nationwide Japanese trial, 2,373 AMI patients who underwent emergent percutaneous coronary intervention within 12 h of onset from the Japanese AMI Registry (JAMIR) were identified. Patients were divided into the following 4 groups based on their BMI at admission: Q1 group (BMI <18.5 kg/m2, n=133), Q2 group (18.5≤BMI<25.0 kg/m2, n=1,424), Q3 group (25.0≤BMI<30.0 kg/m2, n=672), and Q4 group (30.0 kg/m2≤BMI, n=144). The primary endpoint was all-cause death, and the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke. The median follow-up period was 358 days. Q1 patients were older and had lower prevalence of coronary risk factors. Q1 patients also had higher all-cause mortality and higher incidence of secondary endpoints than normal-weight or obese AMI patients. Multivariate analysis showed that low BMI (Q1 group) was an independent predictor for primary endpoint.

CONCLUSIONS

AMI patients with low BMI had fewer coronary risk factors but worse clinical outcomes than normal-weight or obese patients.

Development of a nomogram for the prediction of in-hospital mortality in patients with acute ST-elevation myocardial infarction after primary percutaneous coronary intervention: a multicentre, retrospective, observational study in Hebei province, China

OBJECTIVES

To establish a clinical prognostic nomogram for predicting in-hospital mortality after primary percutaneous coronary intervention (PCI) among patients with ST-elevation myocardial infarction (STEMI).

DESIGN

Retrospective, multicentre, observational study.

SETTING

Thirty-nine hospitals in Hebei province.

PARTICIPANTS

Patients with STEMI who underwent PCI from January 2018 to December 2019.

INTERVENTIONS

A multivariable logistic regression model was used to identify the factors associated with in-hospital mortality, and a nomogram was established using these factors. The performance of the nomogram was evaluated by the discrimination, calibration and clinical usefulness.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome was the factors associated with in-hospital mortality.

RESULTS

This study included 855 patients, among whom 223 died in hospital. Age, body mass index, systolic pressure on admission, haemoglobin, random blood glucose on admission, ejection fraction after PCI, use aspirin before admission, long lesions, thrombolysis in myocardial infarction flow grade and neutrophils/lymphocytes ratio were independently associated with in-hospital mortality (all p<0.05). In the training set, the nomogram showed a C-index of 0.947, goodness-of-fit of 0.683 and area under the receiver operating characteristic curve (AUC) of 0.947 (95% CI 0.927 to 0.967). In the testing set, the C-index was 0.891, goodness-of-fit was 0.462 and AUC was 0.891 (95% CI 0.844 to 0.939). The results indicate that the nomogram had good discrimination and good prediction accuracy and could achieve a good net benefit.

CONCLUSIONS

A nomogram to predict in-hospital mortality in patients with STEMI after PCI was developed and validated in Hebei, China and showed a satisfactory performance. Prospective studies will be necessary to confirm the performance and clinical applicability and practicality of the nomogram.

Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

INTRODUCTION

Up to 20% of patients presenting with acute coronary syndrome (ACS) have no traditional cardiovascular risk-factors (RFs). Data regarding the determinants, management, and outcomes of these patients are scarce.

OBJECTIVES

To evaluate the management, outcomes, and time-dependent changes of ACS patients without RFs.

METHODS

Evaluation of clinical characteristics, management strategies, and outcomes as well as time-dependent changes [by 3 time periods: early (2000-2006), mid (2008-2013), and late (2016-2018)] of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of ischemic heart disease, and smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (no-RF group) to those with ≥1 RFs (RF group).

RESULTS

Overall, 554/9,683 (5.7%) eligible ACS patients did not have any RFs [median age 63 (IQR 52-76) years, 25% females]. The no-RF group were older, with lower body mass index and prevalence of other cardiovascular comorbidity and chronic kidney disease compared with the RF group. The in-hospital percutaneous coronary intervention rates were lower among the no-RF vs. the RF group (55% vs. 66%, respectively p<0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge was prescribed in the no-RF group. The rate of in-hospital complications was greater in the no-RF vs. RF group (31.6% vs. 26.1%, respectively p=0.005). The rates of 30-day major adverse cardiovascular events (MACE; 17.6% vs.12.8%, respectively, p=0.002) and of 30-day and 1-year all-cause mortality (8.4% vs. 4.2%, p<0.001 and 11.4% vs. 7.7%, p=0.003 respectively) were higher among patients with no-RF vs. RF. Following propensity score matching 30-day MACE, 30-day and 1-year mortality risk remained higher in the no-RF group. The rate of 30-day MACE decreased between the early and the late study period in the no-RF group (21.5% vs. 10.5%, p=0.003, respectively).

CONCLUSIONS

ACS patients without traditional cardiovascular risk-factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse outcomes. Additional research to identify unique risk-factors and targets for interventions to improve outcomes of this group of patients is warranted.

Recent Trends in Exhaled Breath Diagnosis Using an Artificial Olfactory System

Artificial olfactory systems are needed in various fields that require real-time monitoring, such as healthcare. This review introduces cases of detection of specific volatile organic compounds (VOCs) in a patient's exhaled breath and discusses trends in disease diagnosis technology development using artificial olfactory technology that analyzes exhaled human breath. We briefly introduce algorithms that classify patterns of odors (VOC profiles) and describe artificial olfactory systems based on nanosensors. On the basis of recently published research results, we describe the development trend of artificial olfactory systems based on the pattern-recognition gas sensor array technology and the prospects of application of this technology to disease diagnostic devices. Medical technologies that enable early monitoring of health conditions and early diagnosis of diseases are crucial in modern healthcare. By regularly monitoring health status, diseases can be prevented or treated at an early stage, thus increasing the human survival rate and reducing the overall treatment costs. This review introduces several promising technical fields with the aim of developing technologies that can monitor health conditions and diagnose diseases early by analyzing exhaled human breath in real time.

Effect of Cytochrome P450 Family 2 Subfamily R Member 1 Variants on the Predisposition of Coronary Heart Disease in the Chinese Han Population

Propose: Cytochrome P450 family 2 subfamily R member 1 (CYP2R1) variations can affect the activity of 25-hydroxylase, resulting in the deficiency of 25(OH)D, which leads to an increased incidence and mortality of coronary heart disease (CHD). The purpose is to assess the influence of CYP2R1 variants on CHD risk among the Chinese Han population.

Methods: A total of 508 CHD patients and 510 healthy controls were enrolled. The MassARRAY platform completed genotyping of CYP2R1 variants. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated using logistic regression analysis.

Results: Rs6486205 (OR = 1.25, 95% CI: 1.05–1.50, p = 0.014), rs10741657 (OR = 1.29, 95% CI: 1.08–1.54, p = 0.005), and rs2060793 (OR = 1.27, 95% CI: 1.06–1.51, p = 0.009) were associated with the increased susceptibility to CHD in the whole subjects. Interestingly, the relationships between these variants and CHD risk were observed in the subjects with age >60 years, males or non-smoker. Additionally, the haplotypes A_rs10741657A_rs2060793 and G_rs10741657G_rs2060793 had the higher risk of CHD, and the combination (rs6486205 and rs10741657) was the best multi-locus model.

Conclusion: Our study suggested the contribution of CYP2R1 polymorphisms to the increased CHD predisposition in the Chinese Han population. Furthermore, the risk association was related to confounding factors for CHD, including age, sex, and smoking. These findings might help to strengthen the understanding of the CYP2R1 gene in the occurrence of CHD.

Neglected cardiovascular risk factors: Relationship of anxiety and depression with percutaneous coronary angioplasty

Introduction:

Coronary artery disease (CAD) is the leading cause of mortality in Malaysia. Psychological risk factors are associated with detrimental outcomes in CAD. Our study aimed to evaluate procedural anxiety and depression levels among subjects who underwent coronary angioplasty.

Methods:

A single-centre prospective cohort study was conducted on patients electively admitted to a tertiary hospital in Malaysia for percutaneous coronary intervention (PCI) over a half-year period. The Hospital Anxiety and Depression Scale (HADS) and the EuroQol-5 Dimension (EQ5D) Health Questionnaire were used to evaluate subjects’ psychological statuses. The EQ Visual Analogue Scale was used for the global assessment of their health.

Results:

The analysis included 65 patients with a mean age of 63 years from a predominately educated population ( n=54; 83.1%). Before the PCI procedure, female sex was found to be protective against depression, with an odds ratio (ORs) of 0.29 (95% confidence interval (CI) 0.08–1.03). A high level of education was protective against anxiety (OR=0.21; 95% CI 0.06–0.83). After the PCI, females were more likely to be depressed (OR=3.89; 95% CI 1.13–13.37), and those of Malay ethnicity were more likely to be anxious (OR=4.2; 95% CI 1.03–17.07). Using the HADS, subjects were significantly less anxious and depressed (pre-PCI: median (IQR) score=4 (7.0)); post-PCI: median (IQR) score=3 (5.0), p=0.02), measured by the HADS. Using the EQ5D, subjects had an improved mean VAS score (post-PCI: 75±14.9; pre-PCI: 68±12.6; p<0.05).

Conclusions:

PCI may predispose patients with CAD to psychological stressors. Female patients and those of Malay ethnicity are more likely to experience psychological stress. Being highly educated is protective against such stress.

Anxiety and prognosis of patients with myocardial infarction: A meta-analysis

Although anxiety is highly prevalent after myocardial infarction (MI), but the association between anxiety and MI is not well established. This study aimed to provide an updated and comprehensive evaluation of the association between anxiety and short-term and long-term prognoses in patients with MI. Anxiety is associated with poor short-term and long-term prognoses in patients with MI. We performed a systematic search in the PubMed and Cochrane databases (January 2000-October 2020). The study endpoints were complications, all-cause mortality, cardiac mortality, and/or major adverse cardiac events (MACEs). Pooled data were synthesized using Stata SE12.0 and expressed as risk ratios (RRs) and 95% confidence intervals (CIs). We included 9373 patients with MI from 16 published studies. Pooled analyses indicated a correlation between high anxiety and poor clinical outcomes (RR: 1.19, 95% CI: 1.13-1.26, p < .001), poor short-term complications (RR: 1.23, 95% CI: 1.09-1.38, p = .001), and poor long-term prognosis (RR: 1.27, 95% CI: 1.13-1.44, p < .001). Anxiety was also specifically associated with long-term mortality (RR: 1.16, 95% CI: 1.01-1.33, p = .033) and long-term MACEs (RR: 1.54, 95% CI: 1.26-1.90, p < .001). This study provided strong evidence that increased anxiety was associated with poor prognosis in patients with MI. Further analysis revealed that MI patients with anxiety had a 23% increased risk of short-term complications and a 27% increased risk of adverse long-term prognosis compared to those without anxiety.

Impaired Peripheral Microvascular Function and Risk of Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease

[Figure: see text].

Validation of the atherothrombotic risk score for secondary prevention in patients with acute myocardial infarction: the J-MINUET study

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.