Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States

Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Acute Coronary Syndrome: A Modern Cinderella?

PURPOSE

Atherosclerotic cardiovascular disease remains a prominent global cause of mortality, with coronary artery disease representing its most prevalent manifestation. Recently, a novel class of antidiabetic medication, namely sodium-glucose cotransporter-2 (SGLT2) inhibitors, has been reported to have remarkable cardiorenal advantages for individuals with type 2 diabetes mellitus (DM), and they may reduce cardiorenal risk even in individuals without pre-existing DM. Currently, there is no evidence regarding the safety and efficacy of these drugs in acute coronary syndrome (ACS), regardless of diabetes status. This review aims to comprehensively present the available preclinical and clinical evidence regarding the potential role of SGLT2 inhibitors in the context of ACS, as adjuncts to standard-of-care treatment for this patient population, while also discussing potential short- and long-term cardiovascular benefits.

METHODS

A literature search was performed through MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and Scopus until February 26, 2024. Eligible were preclinical and clinical studies, comprising randomized controlled trials (RCTs), real-world studies, and meta-analyses.

FINDINGS

Evidence from preclinical models indicates that the use of SGLT2 inhibitors is associated with a blunted ischemia-reperfusion injury and decreased myocardial infarct size, particularly after prior treatment. Although RCTs and real-world data hint at a potential benefit in acute ischemic settings, showing improvements in left ventricular systolic and diastolic function, decongestion, and various cardiometabolic parameters such as glycemia,body weight, and blood pressure, the recently published DAPA-MI (Dapagliflozin in Myocardial Infarction without Diabetes or Heart Failure) trial did not establish a clear advantage regarding surrogate cardiovascular end points of interest. SGLT2 inhibitors appear to provide a benefit in reducing contrast-induced acute kidney injury events in patients with ACS undergoing percutaneous coronary intervention. However, data on other safety concerns, such as treatment discontinuation because of hypotension, hypovolemia, or ketoacidosis, are currently limited.

IMPLICATIONS

Despite the well-established cardiovascular benefits observed in the general population with type 2 DM and, more recently, in other patient groups irrespective of diabetes status, existing evidence does not support the use of SGLT2 inhibitors in the context of ACS. Definitive answers to this intriguing research question, which could potentially expand the therapeutic indications of this novel drug class, require large-scale, well-designed RCTs.

Catheter-Based Radiofrequency Renal Denervation in the United States: A Cost-Effectiveness Analysis Based on Contemporary Evidence

Background

Catheter-based radiofrequency renal denervation (RF RDN) has recently been approved as an adjunctive treatment for hypertensive patients without adequate blood pressure control. This study assessed the cost-effectiveness of RF RDN in the United States based on contemporary clinical evidence.

Methods

A decision-analytic Markov model projected costs, quality-adjusted life years (QALY), and clinical events for an active cohort treated with RF RDN and a control cohort treated with standard-of-care (defined as 1, 2, or 3 antihypertensive medications). Cohort demographics and therapy effect were derived from the SPYRAL HTN-ON MED study demonstrating an absolute 9.9 mm Hg reduction in office systolic blood pressure and 4.9 mm Hg reduction compared with sham control. Clinical event risk reduction from blood pressure lowering was based on a meta-regression of 47 hypertension trials. The incremental cost-effectiveness ratio was evaluated against willingness-to-pay thresholds of $50,000 per QALY (high value) and $150,000 per QALY (intermediate value). Extensive scenario and sensitivity analyses were conducted to assess robustness of the findings.

Results

RF RDN yielded a significant risk reduction in clinical events (0.80 for stroke, 0.88 for myocardial infarction, and 0.85 for cardiovascular death over 10 years). Over lifetime, RF RDN added 0.34 QALY at an additional cost of $11,275, leading to an incremental cost-effectiveness ratio of $32,732 per QALY. The cost-effectiveness of RF RDN was robust across a broad range of scenarios and sensitivity analyses.

Conclusions

Based on a lifetime projection, catheter-based RF RDN is a cost-effective, high-value intervention for hypertensive patients with uncontrolled hypertension.

Prevalence and management of depressive symptoms in coronary heart disease patients and relationship with cardiovascular prognosis: a prospective cohort study

AIMS

Depressive symptoms are comorbid with coronary heart disease (CHD). There is a controversial debate about whether screening and intervention for depressive symptoms could improve cardiovascular prognosis. This study characterizes the prevalence, characteristics, cardiovascular prognosis and management need of depressive symptoms among CHD patients.

METHODS

CHD patients were recruited between November 18, 2020 and November 26, 2021. Depressive symptoms were evaluated with the Patient Health Questionnaire (PHQ-9). During the 12-month follow-up, cardiovascular disease (CVD) was the endpoint. Time-to-event data were estimated by Kaplan-Meier curves and Cox models.

RESULTS

Of 582 patients (25% women), 21.0% had mild depressive symptoms, and 7.5% had moderate-to-severe depressive symptoms during hospitalization. Mild and moderate-to-severe depressive symptoms were risk factor-adjusted predictors of the primary composite endpoints (adjusted HR = 2.20; 95%CI 1.19-4.03, and adjusted HR = 2.70; 95%CI 1.23-5.59, respectively). Platelet count and low-density lipoprotein were higher in mild depressive symptoms compared to no depressive symptoms.

CONCLUSION

Depressive symptoms are prevalent in CHD patients. Mild and moderate-to-severe depressive symptoms are associated with higher risk of further CVD in CHD patients. Platelet function and behavioral mechanisms may contribute to this association.

TRIAL REGISTRATION

This research was registered at https://www.chictr.org.cn . Full data of first registration is 11/09/2020. The registration number is ChiCTR2000038139.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study

BACKGROUND

Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care.

OBJECTIVE

To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations.

DESIGN

Retrospective cohort study.

SETTING

Medicare.

PARTICIPANTS

Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019.

MEASUREMENTS

Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes.

RESULTS

The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF.

LIMITATION

Generalizability to other payers.

CONCLUSION

Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Adherence to Cardiac Rehabilitation in Patients with Acute Myocardial Infarction After PCI: A Scoping Review

Purpose

Cardiac rehabilitation (CR) is a multidisciplinary intervention program aimed at enhancing the physical, psychological, and social functioning of patients with cardiovascular disease. Although CR is cost-effective and reduces mortality and readmission rates, and many patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) do not adhere to CR. This review aimed to synthesize the evidence on adherence to CR in patients with AMI after PCI (AMI-PCI).

Patients and Methods

The review was conducted using the methodology proposed by the Joanna Briggs Institute (JBI) to guide reviews and reporting using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extended for Scoping Reviews (PRISMA-ScR). We searched PubMed, Web of Science, CINAHL, Embase, Ovid, and Scopus databases, and two reviewers independently screened the abstracts and full texts of eligible studies against the inclusion and exclusion criteria. Disagreements were resolved in consultation with a third reviewer.

Results

A total of 10 studies were included in the analysis. The results demonstrated that CR reduces the incidence of complications and improves the quality of life of patients with AMI-PCI. However, the CR adherence rate was low, and the factors affecting it are complex and varied, including age, sex, and employment status. Furthermore, interventions to improve adherence in patients with AMI-PCI mainly combined the internet-based interventions, including videoconferencing tele-training, with wearable device monitoring and intelligent management platform follow-up. All these interventions have shown promising results compared with routine care.

Conclusion

Adherence to CR in patients with AMI-PCI is generally low, and CR adherence is affected by many factors; however, relevant research designs are rare and simple. Healthcare professionals should pay more attention to adherence to CR in this population and use a variety of interventions to improve it.

Long-term exposure to air pollution, greenness and temperature and survival after a nonfatal myocardial infarction

BACKGROUND

Little is known about the impact of environmental exposures on mortality risk after a myocardial infarction (MI).

OBJECTIVE

The goal of this study was to evaluate associations of long-term temperature, air pollution and greenness exposures with mortality among survivors of an MI.

METHODS

We used data from the US-based Nurses' Health Study to construct an open cohort of survivors of a nonfatal MI 1990-2017. Participants entered the cohort when they had a nonfatal MI, and were followed until death, loss to follow-up, end of follow-up, or they reached 80 years old, whichever came earliest. We assessed residential 12-month moving average fine particulate matter (PM2.5) and nitrogen dioxide (NO2), satellite-based annual average greenness (in a circular 1230 m buffer), summer average temperature and winter average temperature. We used Cox proportional hazard models adjusted for potential confounders to assess hazard ratios (HR and 95% confidence intervals). We also assessed potential effect modification.

RESULTS

Among 2262 survivors of a nonfatal MI, we observed 892 deaths during 19,216 person years of follow-up. In single-exposure models, we observed a HR (95%CI) of 1.20 (1.04, 1.37) per 10 ppb NO2 increase and suggestive positive associations were observed for PM2.5, lower greenness, warmer summer average temperature and colder winter average temperature. In multi-exposure models, associations of summer and winter average temperature remained stable, while associations of NO2, PM2.5 and greenness attenuated. The strength of some associations was modified by other exposures. For example, associations of greenness (HR = 0.88 (0.78, 0.98) per 0.1) were more pronounced for participants in areas with a lower winter average temperature.

CONCLUSION

We observed associations of air pollution, greenness and temperature with mortality among MI survivors. Some associations were confounded or modified by other exposures, indicating that it is important to explore the combined impact of environmental exposures.

Trends in Mortality After Incident Hospitalization for Heart Failure Among Medicare Beneficiaries

Importance

Despite advances in treatment and care quality for patients hospitalized with heart failure (HF), minimal improvement in mortality has been observed after HF hospitalization since 2010.

Objective

To evaluate trends in mortality rates across specific intervals after hospitalization.

Design, Setting, and Participants

This cohort study evaluated a random sample of Medicare fee-for-service beneficiaries with incident HF hospitalization from January 1, 2008, to December 31, 2018. Data were analyzed from February 2023 to May 2024.

Main Outcomes and Measures

Unadjusted mortality rates were calculated by dividing the number of all-cause deaths by the number of patients with incident HF hospitalization for the following periods: in-hospital, 30 days (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Annual unadjusted and risk-adjusted mortality ratios were calculated (using logistic regression to account for differences in patient characteristics), defined as observed mortality divided by expected mortality based on 2008 rates.

Results

A total of 1 256 041 patients (mean [SD] age, 83.0 [7.6] years; 56.0% female; 86.0% White) were hospitalized with incident HF. There was a substantial decrease in the mortality ratio for the in-hospital period (unadjusted ratio, 0.77; 95% CI, 0.67-0.77; risk-adjusted ratio, 0.74; 95% CI, 0.71-0.76). For subsequent periods, mortality ratios increased through 2013 and then decreased through 2018, resulting in no reductions in unadjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.94; 95% CI, 0.82-1.06; short-term mortality ratio, 1.02; 95% CI, 0.87-1.17; intermediate-term mortality ratio, 0.99; 95% CI, 0.79-1.19; and long-term mortality ratio, 0.96; 95% CI, 0.76-1.16) and small reductions in risk-adjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.88; 95% CI, 0.86-0.90; short-term mortality ratio, 0.94; 95% CI, 0.94-0.95; intermediate-term mortality ratio, 0.94; 95% CI, 0.92-0.95; and long-term mortality ratio, 0.95; 95% CI, 0.93-0.96).

Conclusions and Relevance

In this study of Medicare fee-for-service beneficiaries, there was a substantial decrease in in-hospital mortality for patients hospitalized with incident HF from 2008 to 2018, but little to no reduction in mortality for subsequent periods up to 3 years after hospitalization. These results suggest opportunities to improve longitudinal outpatient care for patients with HF after hospital discharge.

A decade of firearm injuries: Have we improved?

BACKGROUND

Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020.

METHODS

Patients 18 years and older with firearm injuries from 2011 to 2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020.

RESULTS

A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011 to 2019 ( p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often Level I centers, with higher historic trauma volumes and percentages of firearm injuries ( p < 0.001). Unadjusted mortality decreased by 0.9% from 2011 to 2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared with 2011 (SMR of 0.950 in 2020; 95% confidence interval, 0.916-0.986).

CONCLUSION

Firearm injuries pose an increasing burden to trauma systems, with Level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Sex Differences in Process-of-Care and In-Hospital Prognosis Among Elderly Patients Hospitalized With Acute Myocardial Infarction

BACKGROUND

Limited studies have demonstrated sex differences in the clinical outcomes and quality of care among elderly patients hospitalized with acute myocardial infarction (AMI).

Methods and Results

Using nationwide cardiovascular registry data collected in Japan between 2012 and 2019, we enrolled patients aged ≥45 years. The 30-day and all in-hospital mortality rates, as well as process-of-care measures, were assessed, and mixed-effects logistic regression analysis was performed. A total 254,608 patients were included and stratified into 3 age groups: middle-aged, old and oldest old. The 30-day mortality rates for females and males were as follows: 3.0% vs. 2.7%, with an adjusted odds ratio (OR) of 1.17 (95% confidence interval (CI): 1.01-1.36, P=0.030) in middle-aged patients; 7.2% vs. 5.8%, with an OR of 1.14 (95% CI: 1.09-1.21, P<0.001) in old patients; and 19.6% vs. 15.5% with an OR of 1.17 (95% CI: 1.09-1.26, P<0.001) in the oldest old patients. Moreover, significantly higher numbers of female AMI patients across all age groups died in hospital, as well as having fewer invasive procedures and cardiovascular prescriptions, compared with their male counterparts.

CONCLUSIONS

This nationwide cohort study revealed that female middle-aged and elderly patients experienced suboptimal quality of care and poorer in-hospital outcomes following AMI, compared with their male counterparts, highlighting the need for more effective management in consideration of sex-specific factors.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Cardiac arrest and post-discharge mortality in patients with myocardial infarction: A large-scale nationwide registry analysis

Background

Cardiac arrest is a serious complication of acute myocardial infarction. The implementation of contemporary approaches to acute myocardial infarction management, including urgent revascularization procedures, has led to significant improvements in short-term outcomes. However, the extent of post-discharge mortality in patients experiencing cardiac arrest during acute myocardial infarction remains uncertain. This study aimed to determine the post-discharge outcomes of patients with cardiac arrest.

Methods

We analysed data from the J-PCI OUTCOME registry, a Japanese prospectively planed, observational, multicentre, national registry of percutaneous coronary intervention involving consecutive patients from 172 institutions who underwent percutaneous coronary intervention and were discharged. Patients who underwent percutaneous coronary intervention for acute myocardial infarction between January 2017 and December 2018 and survived for 30 days were included. Mortality in patients with and without cardiac arrest from 30 days to 1 year after percutaneous coronary intervention for acute myocardial infarction was compared.

Results

Of the 26,909 patients who survived for 30 days after percutaneous coronary intervention for acute myocardial infarction, 1,567 (5.8%) had cardiac arrest at the onset of acute myocardial infarction. Patients with cardiac arrest were younger and more likely to be males than patients without cardiac arrest. The 1-year all-cause mortality was significantly higher in patients with cardiac arrest than in those without (11.9% vs. 2.8%, p < 0.001) for all age groups. Multivariable analysis showed that cardiac arrest was an independent predictor of all-cause long-term mortality (hazard ratio: 2.94; 95% confidence interval: 2.29-3.76).

Conclusions

Patients with acute myocardial infarction and concomitant cardiac arrest have a worse prognosis for up to 1 year after percutaneous coronary intervention than patients without cardiac arrest.

Polypill Strategy in Secondary Cardiovascular Prevention

PURPOSE OF REVIEW

The polypill strategy, originally developed to improve medication adherence, has demonstrated efficacy in improving baseline systolic blood pressures and cholesterol levels in multiple clinical trials. However, the long-term clinical impact of improved major cardiovascular events (MACE) outcomes by the polypill remains uncertain.

RECENT FINDINGS

Recent trials with long-term follow-up, which included minority groups and people with low socioeconomic status, have shown non-inferiority with no difference in adverse effects rates for the secondary prevention of MACE. Although the polypill strategy was initially introduced to improve adherence to guideline-directed medical therapy (GDMT) for cardiovascular complications, the strategy has surpassed standard medical treatment for secondary prevention of MACE outcomes. Studies also showed improved medication compliance in underserved populations.

Microvascular Obstruction in Patients With Anterior STEMI Treated With Supersaturated Oxygen

Background

Supersaturated oxygen (SSO2) delivered into the left anterior descending coronary artery after percutaneous coronary intervention (PCI) for anterior ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size, but its effects on microvascular obstruction (MVO) are unknown. The aim of this study was to compare MVO in patients with anterior STEMI treated with SSO2 after successful primary PCI from 2 studies (the optimized SSO2 pilot and IC-HOT) with similar patients from 7 randomized trials who underwent primary PCI without SSO2 treatment.

Methods

A total of 874 patients with anterior STEMI who underwent MVO assessment using cardiac magnetic resonance imaging within 10 days after primary PCI were included, of whom 90 patients (10.3%) were treated with SSO2. The primary end point was the extent of MVO as a continuous measure in a weighted multivariable model. The secondary end point was the presence of MVO.

Results

SSO2 therapy was independently associated with a lower extent of MVO compared with no SSO2 therapy (coefficient, -1.35; 95% CI, -2.58 to -0.11; P = .03). SSO2 therapy was also associated with a borderline lower risk of any MVO (adjusted odds ratio, 0.56; 95% CI, 0.31-1.00; P = .051).

Conclusions

In the present individual patient data pooled analysis from 9 studies, SSO2 therapy was associated with less MVO after successful primary PCI for anterior STEMI.

Platelet Function and Maturity and Related microRNA Expression in Whole Blood in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

 Reduced effect of antiplatelet therapy has been reported in patients with ST-segment elevation myocardial infarction (STEMI). MicroRNAs (miRs) may influence platelet function and maturity, and subsequently the effect of antiplatelet therapy.

OBJECTIVES

 We aimed to explore the association between miR expression and platelet function and maturity in patients with acute STEMI and healthy individuals.

METHODS

 We performed an observational study of STEMI patients admitted directly to primary percutaneous coronary intervention. Patients were treated with antiplatelet therapy according to guidelines. Within 24 hours after admission, blood samples were obtained to measure: the expression of 10 candidate miRs, platelet function markers using advanced flow cytometry, platelet aggregation, serum thromboxane B2, and platelet maturity markers. Furthermore, blood samples from healthy individuals were obtained to determine the normal variation.

RESULTS

 In total, 61 STEMI patients and 50 healthy individuals were included. STEMI patients had higher expression of miR-21-5p, miR-26b-5p, and miR-223-3p and lower expression of miR-150-5p, miR423-5p, and miR-1180-3p than healthy individuals. In STEMI patients, the expression of miR-26b-5p showed the most consistent association with platelet function (all p-values <0.05, Spearman's rho ranging from 0.27 to 0.41), while the expression of miR-150-5p and miR-223-3p showed negative associations with platelet function. No association between miR expression and platelet maturity markers was observed.

CONCLUSION

 In patients with STEMI, the expression of six miRs was significantly different from healthy individuals. The expression of miR-26b-5p may affect platelet function in acute STEMI patients and potentially influence the effect of antiplatelet therapy.

Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative

BACKGROUND

Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries.

METHODS

We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality.

RESULTS

Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI.

CONCLUSIONS

We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.

Effect of sodium-glucose cotransporter-2 inhibitors on myocardial infarction incidence: A systematic review and meta-analysis of randomized controlled trials and cohort studies

AIM

To assess whether sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce myocardial infarction (MI) incidence in patients with or without type 2 diabetes.

METHODS

PubMed, Embase, Web of Science, the Cochrane library, and https://ClinicalTrials.gov were searched up to 7 May 2022. Randomized controlled trials (RCTs) and cohort studies reporting the effects of SGLT2 inhibitor treatment on MI incidence were included. Relative risks (RRs) with a 95% confidence interval (CI) for MI incidence were extracted and pooled. Subgroup analysis and meta-regression were performed to explore the heterogeneity.

RESULTS

This meta-analysis included 54 RCTs and 32 cohort studies, with data from six SGLT2 inhibitors and 3 394 423 individuals. In the overall analysis, SGLT2 inhibitors significantly reduced MI incidence in RCTs (RR 0.9, 95% CI 0.84-0.96) and cohort studies (RR 0.89, 95% CI 0.83-0.94). In RCTs, the results of the subgroup analysis revealed no significant alterations in outcomes based on different SGLT2 inhibitor types, control drug types, cardiovascular disease (CVD) status and sources of outcome extraction (p for interaction >0.05). In cohort studies, the presence or absence of CVD led to similar effects of SGLT2 inhibitors on decreasing MI incidence (p for interaction = 0.179). However, variations in results were observed based on the type of control group in cohort studies (p for interaction = 0.036). Meta-regression results did not reveal an association between baseline cardiovascular risk factors, follow-up length, or MI incidence.

CONCLUSIONS

In both RCTs and cohort studies, SGLT2 inhibitors reduced MI incidence. The cardioprotective effects of SGLT2 inhibitors were observed in patients with and without a history of CVD.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The Relationship Between Residential Mobility and Mortality Following Acute Myocardial Infarction

BACKGROUND

The extent to which residential mobility is associated with declining health among disease-specific populations, such as survivors of acute myocardial infarction (AMI), remains unknown.

METHODS

This prospective cohort study consisted of 3377 patients followed from index AMI (December 1, 1999 to March 30, 2003) to death or the last available follow-up date (March 30, 2020) in Ontario, Canada. Each residential postal code move from a patient's sentinel AMI event was tracked. Time-varying Cox proportional hazards examined the associated impact of each residential postal code move on mortality after adjusting for age, sex, baseline socioeconomic, psychosocial factors, changes in neighbourhood income level from each residential move, preexisting cardiovascular and noncardiovascular illnesses, and rural residence. All models evaluated death and long-term care institutionalisation as competing risks to distinguish mortality from other end-of-life destination outcomes among community-dwelling populations.

RESULTS

The study sample included 3369 patients with 1828 (54.3%) having at least 1 residential move throughout the study; 86.5% of patients either died in the community or moved from a community dwelling into a long-term care facility as an end-of-life destination. When adjusted for baseline factors and changing neighbourhood socioeconomic status over time, each residential move was associated with a 12% higher rate of death (adjusted hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.05-1.19; P < 0.001) and a 26% higher rate of long-term care end-of-life institutionalisation (adjusted HR 1.26, 95% CI 1.14-1.58; P < 0.001).

CONCLUSIONS

Residential mobility was associated with higher mortality after AMI. Further research is needed to better evaluate intermediary causal pathways that may explain why residential mobility is associated with end-of-life outcomes.

Sex differences in trends and outcomes of acute myocardial infarction with mechanical complications in the United States

BACKGROUND

Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited.

METHODS

We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation.

RESULTS

Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079-1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12-2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345-0.690; p < 0.001).

CONCLUSION

Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment.

Recent advances in the diagnosis and management of acute myocardial infarction

With the discovery of new biomarkers for the early detection of acute myocardial infarction (AMI), advancements in valid medication, and percutaneous coronary intervention (PCI), the overall prognosis of AMI has improved remarkably. Nevertheless, challenges remain which require more difficult work to overcome. Novel diagnostic and therapeutic techniques include new AMI biomarkers, hypothermia therapy, supersaturated oxygen (SSO 2 ) therapy, targeted anti-inflammatory therapy, targeted angiogenesis therapy, and stem cell therapy. With these novel methods, we believe that the infarction size after AMI will decrease, and myocardial injury-associated ventricular remodeling may be avoided. This review focuses on novel advances in the diagnosis and management of AMI.

Disease trajectories following myocardial infarction: insights from process mining of 145 million hospitalisation episodes

BACKGROUND

Knowledge of post-myocardial infarction (MI) disease risk to date is limited-yet the number of survivors of MI has increased dramatically in recent decades. We investigated temporally ordered sequences of all conditions following MI in nationwide electronic health record data through the application of process mining.

METHODS

We conducted a national retrospective cohort study of all hospitalisations (145,670,448 episodes; 34,083,204 individuals) admitted to NHS hospitals in England (1st January 2008-31st January 2017, final follow-up 27th March 2017). Through process mining, we identified trajectories of all major disease diagnoses following MI and compared their relative risk (RR) and all-cause mortality hazard ratios (HR) to a risk-set matched non-MI control cohort using Cox proportional hazards and flexible parametric survival models.

FINDINGS

Among a total of 375,669 MI patients (130,758 females; 34.8%) and 1,878,345 matched non-MI patients (653,790 females; 34.8%), we identified 28,799 unique disease trajectories. The accrual of multiple circulatory diagnoses was more common amongst MI patients (RR 4.32, 95% CI 3.96-4.72) and conferred an increased risk of death (HR 1.32, 1.13-1.53) compared with matched controls. Trajectories featuring neuro-psychiatric diagnoses (including anxiety and depression) following circulatory disorders were markedly more common and had increased mortality post MI (HR ranging from 1.11 to 1.73) compared with non-MI individuals.

INTERPRETATION

These results provide an opportunity for early intervention targets for survivors of MI-such as increased focus on the psychological and behavioural pathways-to mitigate ongoing adverse disease trajectories, multimorbidity, and premature mortality.

FUNDING

British Heart Foundation; Alan Turing Institute.

Incidence and Predictors of Acute Limb Ischemia in Patients With Acute Myocardial Infarction-Insight from National Readmission Database

Acute limb ischemia (ALI) has been a rare complication of acute myocardial infarction (AMI), however, with the increasing use of mechanical circulatory devices it is seen more frequently. The incidence and predictors of ALI in patients with AMI in contemporary clinical practice are unknown. A retrospective review of patients with index hospitalization for AMI in the Nationwide Readmission Database from 2016 to 2019 was done. We evaluated the annual incidence of ALI and its impact on outcomes. We used multivariate logistic regression analysis to determine predictors of ALI. In 1,283,586 patients with AMI, 3,971 patients (0.31%) had ALI and 365 (0.03%) had limb amputation. The 3 major predictors of ALI were peripheral artery disease (odds ratio [OR] 11.91, 95% confidence interval [CI]: 10.78 to 13.51), intravascular microaxial left ventricular assist device (OR 4.39, 95% CI 3.86 to 5.00), and veno-arterial extracorporeal membrane oxygenation (OR 4.37, 95% CI 3.19 to 6.01). Intra-aortic balloon pump had a substantially lower predictive ability (OR 1.81, 95% CI 1.63 to 2.0, p <0.0001) than other forms of mechanical circulatory support. The mortality rate in patients with ALI was significantly higher than those without ALI (19.49% vs 4.85%, p <0.0001). Patients who developed ALI had higher rates of amputation (1.59% vs 0.02%, p <0.0001). This observational nationwide study showed that ALI is an important complication in patients with AMI and is more frequently seen in patients who have peripheral artery disease, and require a left ventricular assist device or venoarterial extracorporeal membrane oxygenation. This complication was also associated with significantly higher in-hospital mortality.

Prognostic Significance of Nucleated RBCs in Predicting Mortality Among ST-Elevation Myocardial Infarction Patients Admitted to the ICU

Background The nucleated red blood cells (NRBCs) are a readily available hematological parameter with potential for risk stratification for mortality. Therefore, our objective was to assess the predictive significance of NRBCs for ICU mortality among ST-elevation myocardial infarction (STEMI) patients admitted to an ICU. Additionally, we aimed to compare the predictive capacity of NRBCs with that of the acute physiology and chronic health evaluation (APACHE) II score and the sequential organ failure assessment (SOFA) score. Methodology This descriptive cross-sectional study was conducted in the ICU of the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan, from the 1st of February to the 30th of June, 2023. We included adult patients (≥18 years) diagnosed with STEMI who were subsequently admitted to the ICU. NRBCs were assessed in all patients over up to five days at 24-hour intervals, and the highest NRBC levels were used for the final analysis. Furthermore, the APACHE II score and the SOFA score were also documented. Patients were monitored throughout their ICU stay, and any adverse events or complications, such as re-intubation, bleeding necessitating transfusion, requirement for renal replacement therapy, arrhythmias, re-infarction, and mortality, were recorded. Results This study included 151 patients, of whom 97 (64.2%) were male, with an average age of 61.1 ± 10.7 years. Patients with positive NRBCs had higher mean SOFA scores (7.4 ± 2.9 vs. 5.4 ± 2.6; p < 0.001) and APACHE II scores (14.6 ± 6.3 vs. 12.6 ± 5.5; p = 0.037) compared to those with negative NRBCs. The culprit vessel showed greater mean stenosis (%) in patients with positive NRBCs (98.8 ± 3.0% vs. 96.8 ± 5.7%; p = 0.004). Post-procedure thrombolysis in myocardial infarction (TIMI) flow grade III was lower in patients with positive NRBCs (77.8% vs. 91.8% for positive vs. negative NRBCs, respectively). Moreover, patients with positive NRBCs experienced significantly higher mortality rates (63% vs. 8.2%; p < 0.001), a higher occurrence of arrhythmias (35.2% vs. 19.6%; p = 0.034), and an increased requirement for vasopressors/inotropic support (96.3% vs. 71.1%; p < 0.001) compared to those with negative NRBCs. NRBCs demonstrated superior discriminatory ability compared to the SOFA and APACHE II scores, with an area under the curve of 0.818 (95% CI: 0.738-0.899) for NRBCs, 0.774 (95% CI: 0.692-0.857) for SOFA, and 0.707 (95% CI: 0.613-0.801) for APACHE II. Positive NRBCs exhibited a sensitivity of 81.0% and a specificity of 81.7% in predicting ICU mortality. Conclusion In conclusion, positive NRBCs emerge as a robust and reliable prognostic indicator, strongly associated with an elevated risk of ICU mortality in STEMI patients. Moreover, the predictive power of positive NRBCs surpasses that of both SOFA and APACHE II scoring systems.

Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study

Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.

Trends in Short-, Intermediate-, and Long-Term Mortality Following Hospitalization for Myocardial Infarction Among Medicare Beneficiaries, 2008 to 2018

Background Advances in technology and care quality have transformed the care of acute myocardial infarction (AMI), but little is known about trends in mortality rates across separate time periods after hospitalization. Methods and Results We identified all Medicare fee-for-service beneficiaries hospitalized with incident AMI from 2008 to 2018. We calculated unadjusted mortality rates by dividing the number of all-cause deaths by the number of patients with incident AMI for the following time periods: acute (in hospital), post acute (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Using logistic regression to account for differences in patient characteristics, we calculated annual risk standardized mortality ratios defined as observed over expected mortality based on 2008 rates. Among 768 084 patients with incident AMI (mean age 81 years, 48% male, 87% White), declines in observed-to-expected mortality ratios were observed for each time period: acute (0.68 [95% CI, 0.66-0.71]), postacute (0.72 [95% CI, 0.71-0.75]), short term (0.77 [95% CI, 0.75-0.78]), intermediate term (0.79 [95% CI, 0.77-0.81]), and long term (0.77 [95% CI, 0.75-0.79]). Declines were observed both for patients with and without ST-segment-elevation AMI. Conclusions For patients with incident AMI, there have been improvements in mortality rates across periods spanning the hospital stay through 3 years after discharge, reflecting advances in AMI care from hospitalization through long-term outpatient follow-up.

Persistent mortality and heart failure burden of anterior ST-segment elevation myocardial infarction following primary percutaneous coronary intervention: real-world evidence from the US Medicare Data Set

OBJECTIVES

We sought to compare the temporal trends in the incidence of death and rehospitalisation for congestive heart failure (CHF) following anterior ST-elevation myocardial infarction (STEMI) in a Medicare cohort of beneficiaries treated with primary percutaneous coronary intervention (PCI) in 2005 (n=1479) with those treated in 2016 through quarter (Q) 2 of 2017 (n=22 432).

DESIGN

This retrospective analysis examined outcomes using both descriptive and regression analysis to control for differences in patient clinical characteristics over time.

PRIMARY OUTCOME MEASURES

The primary outcomes are 1 year and 2 year rates of mortality and re-hospitalisation for CHF.

RESULTS

The 1 year mortality rate was numerically higher in the 2016 cohort at 10.3% (95% CI 9.9 to 10.7) versus 8.9% (CI 7.4 to 10.3; p=0.068). The 2 year mortality rate was significantly higher in the 2016 cohort at 14.5% (CI 13.9 to 15.1) versus 11.4% (CI 9.2 to 13.6; p<0.01). The 1 year rehospitalisation for CHF was lower in the 2016 cohort at 10.6% (CI 10.0 to 11.2) versus 16.7% (CI 14.0 to 19.4; p<0.001), but the 2 year rate was not significantly different at 19.3% (CI 17.7 to 20.9) versus 20.7% (CI 16.4 to 24.9; p=0.55). After adjustment for covariates with two models, the 1 year mortality increased by 2.3% (CI 0.8 to 3.7; p<0.01) and 4.1% (CI 2.6 to 5.6; p<0.001) in the 2016 cohort. The 2 year adjusted mortality also increased by 4.2% (CI 2.0 to 6.4; p<0.001) and 6.5% (CI 4.2 to 8.7; p<0.001) in the 2016 cohort. The risk adjusted trends for rehospitalisation for CHF were similar to the unadjusted findings.

CONCLUSIONS

Despite prior improvements in STEMI outcomes in the reperfusion era related to the broad adoption of timely PCI, there is a persistent high mortality and CHF burden in Medicare beneficiaries with anterior STEMI. New strategies that address reperfusion injury and enhance myocardial salvage are needed.

Recurrent myocardial infarction and emergency department visits: a retrospective study on the Stockholm Area Chest Pain Cohort

BACKGROUND

Patients who experience acute myocardial infarction (AMI) are at risk of recurrent AMI. Contemporary data on recurrent AMI and its association with return emergency department (ED) visits for chest pain are needed.

METHODS

This Swedish retrospective cohort study linked patient-level data from six participating hospitals to four national registers to construct the Stockholm Area Chest Pain Cohort (SACPC). The AMI cohort included SACPC participants visiting the ED for chest pain diagnosed with AMI and discharged alive (first primary diagnosis of AMI during the study period not necessarily the patient's first AMI). The rate and timing of recurrent AMI events, return ED visits for chest pain and all-cause mortality were determined during the year following index AMI discharge.

RESULTS

Among 1 37 706 patients presenting to the ED with chest pain as principal complaint from 2011 to 2016, 5.5% (7579/137 706) were hospitalised with AMI. In total, 98.5% (7467/7579) of patients were discharged alive. In the year following index AMI discharge, 5.8% (432/7467) of AMI patients experienced ≥1 recurrent AMI event. Return ED visits for chest pain occurred in 27.0% (2017/7467) of index AMI survivors. During a return ED visit, recurrent AMI was diagnosed in 13.6% (274/2017) of patients. One-year all-cause mortality was 3.1% in the AMI cohort and 11.6% in the recurrent AMI cohort.

CONCLUSIONS

In this AMI population, 3 in 10 AMI survivors returned to the ED for chest pain in the year following AMI discharge. Furthermore, over 10% of patients with return ED visits were diagnosed with recurrent AMI during that visit. This study confirms the high residual ischaemic risk and associated mortality among AMI survivors.

An In-Depth Prospective Comprehensive View on Myocardial Infarction (MI) in Young Adults

Due to major advancements in myocardial infarction (MI) prevention and effective medical treatment, the death rate and incidence of MI have dropped considerably. We know that their risk factors and prognosis may differ; therefore, increasing primary and secondary prevention activities among young people is crucial. Multiple studies have found that MI is the deadliest form of coronary heart disease (CHD). As a result, we made an effort to illuminate MI in young people in our review of the literature. We found that young people, particularly women, are developing MI. Smoking is a key risk factor that should be targeted in an effort to minimize youth MI rates. It is thus important to create superior methods for measuring risk in young people, which may combine both standard and nonconventional risk factors, such as genetic rate scores and coronary artery calcium testing. Henceforth, addressing modifiable risk factors at a younger age has the greatest impact.

Incidence of Mid-Term Prognostic Events in Patients With Acute Coronary Syndrome During the Late 2010s in 2 Tertiary Hospitals in a Rural Area of Japan - A Temporal Comparison

Background: Data on the incidence of mid-term prognostic events in patients who developed acute coronary syndrome (ACS) in the late 2010s are scarce. Methods and Results: We retrospectively included and collected data for 889 patients with ACS (ST-elevation myocardial infarction [STEMI]/non-ST-elevation ACS [NSTE-ACS]) discharged alive from 2 tertiary hospitals in Izumo City, in rural Japan, between August 2009 and July 2018. Patients were divided into 3 time groups (T1: August 2009-July 2012; T2: August 2012-July 2015; T3: August 2015-July 2018). The cumulative incidence of major adverse cardiovascular events (MACE; comprising all-cause death, recurrent ACS, and stroke), major bleeding, and heart failure hospitalization within 2 years of discharge was compared among the 3 groups. The incidence of freedom from MACE was significantly higher in the T3 group than in the T1 and T2 groups (93 [95% confidence interval {CI} 90-96%] vs. 86% [95% CI 83-90] and 89% [95% CI 90-96], respectively; P=0.03). There was a tendency for a higher incidence of STEMI among patients in T3 (P=0.057). The incidence of NSTE-ACS was comparable among the 3 groups (P=0.31), as was the incidence of major bleeding and hospitalization for heart failure. Conclusions: The incidence of mid-term MACE in patients who developed ACS during the late 2010 s (2015-2018) was lower than that in prior periods (2009-2015).

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries

Importance

Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries.

Objective

To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries.

Design, Setting, and Participants

Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data.

Exposures

Being in the top and bottom quintile of income within and across countries.

Main Outcomes and Measures

Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates.

Results

We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients.

Conclusions and Relevance

High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

A risk model for decline in health status after acute myocardial infarction among older adults

BACKGROUND

Health status is increasingly recognized as an important patient-centered outcome after acute myocardial infarction (AMI). Yet drivers of decline in health status after AMI remain largely unknown in older adults. We sought to develop and validate a predictive risk model for health status decline among older adult survivors of AMI.

METHODS

Using data from a prospective cohort study conducted from 2013 to 2017 of 3041 patients age ≥75 years hospitalized with acute myocardial infarction at 94 U.S. hospitals, we examined a broad array of demographic, clinical, functional, and psychosocial variables for their association with health status decline, defined as a decrease of ≥5 points in the Short Form-12 (SF-12) physical component score from hospitalization to 6 months post-discharge. Model selection was performed in logistic regression models of 20 imputed datasets to yield a parsimonious risk prediction model. Model discrimination and calibration were evaluated using c-statistics and calibration plots, respectively.

RESULTS

Of the 2571 participants included in the main analyses, 30% of patients experienced health status decline from hospitalization to 6 months post-discharge. The risk model contained 14 factors, 10 associated with higher risk of health status decline (age, pre-existing AMI, pre-existing cancer, pre-existing COPD, pre-existing diabetes, history of falls, presenting Killip class, acute kidney injury, baseline health status, and mobility impairment) and four associated with lower risk of health status decline (male sex, higher hemoglobin, receipt of revascularization, and arrhythmia during hospitalization). The model displayed good discrimination (c-statistic = 0.74 in validation cohort) and calibration (p > 0.05) in both development and validation cohorts.

CONCLUSIONS

We used split sampling to develop and validate a risk model for health status decline in older adults after hospitalization for AMI and identified several risk factors that may be modifiable to mitigate the threat of this important patient-centered outcome. External validation of this risk model is warranted.

Success Rates in Psychiatry

This Viewpoint examines the scarcity of psychiatric success rate trend data and discusses what can be done about it.

Early Changes in Acute Myocardial Infarction in Pigs: Achieving Early Detection with Wearable Devices

We examined the changes in variables that could be recorded on wearable devices during the early stages of acute myocardial infarction (AMI) in an animal model. Early diagnosis of AMI is important for prognosis; however, delayed diagnosis is common because of patient hesitation and lack of timely evaluations. Wearable devices are becoming increasingly sophisticated in the ability to track indicators. In this study, we retrospectively reviewed the changes in four variables during AMI in a pig model to assess their ability to help predict AMI onset. AMI was created in 33 pigs by 90-min balloon occlusion of the left anterior descending artery. Blood pressure, EKG, and lactate and cardiac troponin I levels were recorded during the occlusion period. Blood pressure declined significantly within 15 min after balloon inflation (mean arterial pressure, from 61 ± 8 to 50 ± 8 mmHg) and remained at this low level. Within 5 min of balloon inflation, the EKG showed ST-elevation in precordial leads V1–V3. Blood lactate levels increased gradually after occlusion and peaked at 60 min (from 1.48 to 2.53 mmol/L). The continuous transdermal troponin sensor demonstrated a gradual increase in troponin levels over time. Our data suggest that significant changes in key indicators (blood pressure, EKG leads V1–V3, and lactate and troponin levels) occurred at the onset of AMI. Monitoring of these variables could be used to develop an algorithm and alert patients early at the onset of AMI with the help of a wearable device.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

No "July Effect" in the management and outcomes of acute myocardial infarction: An 18-year United States national study

BACKGROUND

There has been conflicting reports on the effect of new trainees on clinical outcomes at teaching hospitals in the first training month (July in the United States of America). We sought to assess this "July effect" in a contemporary acute myocardial infarction (AMI) population.

METHODS

Adult (>18 years) AMI hospitalizations in May and July in urban teaching and urban nonteaching hospitals in the United States were identified from the HCUP-NIS database (2000-2017). In-hospital mortality was compared between May and July admissions. A difference-in-difference analysis comparing a change in outcome from May to July in teaching hospitals to a change in outcome from May to July in nonteaching hospitals was also performed.

RESULTS

A total of 1,312,006 AMI hospitalizations from urban teaching (n = 710,593; 54.2%) or nonteaching (n = 601,413; 45.8%) hospitals in the months of May and July were evaluated. May admissions in teaching hospitals, had greater comorbidity, higher rates of acute multiorgan failure (10.6% vs. 10.2%, p < 0.001) and lower rates of cardiac arrest when compared to July admissions. July AMI admissions had lower in-hospital mortality compared to May (5.6% vs. 5.8%; adjusted odds ratio 0.94 [95% confidence interval 0.92-0.97]; p < 0.001) in teaching hospitals. Using the difference-in-difference model, there was no evidence of a July effect for in-hospital mortality (p = 0.19).

CONCLUSIONS

There was no July effect for in-hospital mortality in this contemporary AMI population.

CSF2RB overexpression promotes the protective effects of mesenchymal stromal cells against ischemic heart injury

Aims: The invasive intramyocardial injection of mesenchymal stromal cells (MSCs) allows for limited repeat injections and shows poor therapeutic efficacy against ischemic heart failure. Intravenous injection is an alternative method because this route allows for repeated, noninvasive, and easy delivery. However, the lack of targeting of MSCs hinders the ability of these cells to accumulate in the ischemic area after intravenous injections. We investigated whether and how the overexpression of colony-stimulating factor 2 receptor beta subunit (CSF2RB) may regulate the cardiac homing of MSCs and their cardioprotective effects against ischemic heart failure. Methods and Results: Adult mice were subjected to myocardial ischemia/reperfusion (MI/R) or sham operations. We observed significantly higher CSF2 protein expression and secretion by the ischemic heart from 1 day to 2 weeks after MI/R. Mouse adipose tissue-derived MSCs (ADSCs) were infected with adenovirus harboring CSF2RB or control adenovirus. Enhanced green fluorescent protein (EGFP)-labeled ADSCs were intravenously injected into MI/R mice every three days for a total of 7 times. Compared with ADSCs infected with control adenovirus, intravenously delivered ADSCs overexpressing CSF2RB exhibited markedly increased cardiac homing. Histological analysis revealed that CSF2RB overexpression significantly enhanced the ADSC-mediated proangiogenic, antiapoptotic, and antifibrotic effects. More importantly, ADSCs overexpressing CSF2RB significantly increased the left ventricular ejection fraction and cardiac contractility/relaxation in MI/R mice. In vitro experiments demonstrated that CSF2RB overexpression increases the migratory capacity and reduces the hypoxia/reoxygenation-induced apoptosis of ADSCs. We identified STAT5 phosphorylation as the key mechanism underlying the effects of CSF2RB on promoting ADSC migration and inhibiting ADSC apoptosis. RNA sequencing followed by cause-effect analysis revealed that CSF2RB overexpression increases the expression of the ubiquitin ligase RNF4. Coimmunoprecipitation and coimmunostaining experiments showed that RNF4 binds to phosphorylated STAT5. RNF4 knockdown reduced STAT5 phosphorylation as well as the antiapoptotic and promigratory actions of ADSCs overexpressing CSF2RB. Conclusions: We demonstrate for the first time that CSF2RB overexpression optimizes the efficacy of intravenously delivered MSCs in the treatment of ischemic heart injury by increasing the response of the MSCs to a CSF2 gradient and CSF2RB-dependent STAT5/RNF4 activation.

The Golden Grapes of Wrath - Staphylococcus aureus Bacteremia: A Clinical Review

Staphylococcus aureus bacteremia is common and associated with fatality rates approximating 25%. We provide a brief overview of S. aureus bacteremia from a clinical and microbiological lens and review the relevant evidence and literature gaps in its management. Using a case-based approach, evidence and clinical judgement are meshed to highlight and justify the 5 core interventions that ought to be performed for all cases of S. aureus bacteremia: 1) appropriate anti-staphylococcal therapy, 2) screening echocardiography, 3) assessment for metastatic phenomena and source control, 4) decision on duration of antimicrobial therapy, and 5) Infectious Diseases consultation.

Hypothetical interventions on emergency ambulance and prehospital acetylsalicylic acid administration in myocardial infarction patients presenting without chest pain

BACKGROUND

Myocardial infarction (MI) patients presenting without chest pain are a diagnostic challenge. They receive suboptimal prehospital management and have high mortality. To elucidate potential benefits of improved management, we analysed expected outcome among non-chest pain MI patients if hypothetically they (1) received emergency ambulances/acetylsalicylic acid (ASA) as often as observed for chest pain patients, and (2) all received emergency ambulance/ASA.

METHODS

We sampled calls to emergency and non-emergency medical services for patients hospitalized with MI within 24 h and categorized calls as chest pain/non-chest pain. Outcomes were 30-day mortality and a 1-year combined outcome of re-infarction, heart failure admission, and mortality. Targeted minimum loss-based estimation was used for all statistical analyses.

RESULTS

Among 5418 calls regarding MI patients, 24% (1309) were recorded with non-chest pain. In total, 90% (3689/4109) of chest pain and 40% (525/1309) of non-chest pain patients received an emergency ambulance, and 73% (2668/3632) and 37% (192/518) of chest pain and non-chest pain patients received prehospital ASA. Providing ambulances to all non-chest pain patients was not associated with improved survival. Prehospital administration of ASA to all emergency ambulance transports of non-chest pain MI patients was expected to reduce 30-day mortality by 5.3% (CI 95%: [1.7%;9%]) from 12.8% to 7.4%. No significant reduction was found for the 1-year combined outcome (2.6% CI 95% [- 2.9%;8.1%]). In comparison, the observed 30-day mortality was 3% among ambulance-transported chest pain MI patients.

CONCLUSIONS

Our study found large differences in the prehospital management of MI patients with and without chest pain. Improved prehospital ASA administration to non-chest pain MI patients could possibly reduce 30-day mortality, but long-term effects appear limited. Non-chest pain MI patients are difficult to identify prehospital and possible unintended effects of ASA might outweigh the potential benefits of improving the prehospital management. Future research should investigate ways to improve the prehospital recognition of MI in the absence of chest pain.

Comparative analysis of four established risk scores for prediction of in-hospital mortality in patients undergoing primary percutaneous coronary intervention

OBJECTIVE

This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country.

METHODS

Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality.

RESULTS

We included 977 patients, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (optimal cutoff: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (optimal cutoff: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (optimal cutoff: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (optimal cutoff: ≥1.66, sensitivity: 71.4%, specificity: 73.5%).

CONCLUSION

In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients.

Generating Practice-Based Evidence in the Use of Guideline-Recommended Combination Therapy for Secondary Prevention of Acute Myocardial Infarction

Background: Clinical guidelines recommend beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, and statins for the secondary prevention of acute myocardial infarction (AMI). It is not clear whether variation in real-world practice reflects poor quality-of-care or a balance of outcome tradeoffs across patients. Methods: The study cohort included Medicare fee-for-service beneficiaries hospitalized 2007-2008 for AMI. Treatment within 30-days post-discharge was grouped into one of eight possible combinations for the three drug classes. Outcomes included one-year overall survival, one-year cardiovascular-event-free survival, and 90-day adverse events. Treatment effects were estimated using an Instrumental Variables (IV) approach with instruments based on measures of local-area practice style. Pre-specified data elements were abstracted from hospital medical records for a stratified, random sample to create "unmeasured confounders" (per claims data) and assess model assumptions. Results: Each drug combination was observed in the final sample (N = 124,695), with 35.7% having all three, and 13.5% having none. Higher rates of guideline-recommended treatment were associated with both better survival and more adverse events. Unmeasured confounders were not associated with instrumental variable values. Conclusions: The results from this study suggest that providers consider both treatment benefits and harms in patients with AMIs. The investigation of estimator assumptions support the validity of the estimates.

Interaction Between Race and Income on Cardiac Outcomes After Percutaneous Coronary Intervention

Background

Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post–percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship.

Methods and Results

Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All‐cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10‐year follow‐up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self‐identified as Black Americans, and 20 649 (86.7%) self‐identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long‐term outpatient cardiology follow‐up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all‐cause mortality (18.0% versus 15.2%; P <0.001) and major adverse cardiac event (37.3% versus 34.6%; P <0.001) were greater among Black Americans and with lower income (both P <0.001); race, income, and their interaction were not significant predictors in multivariable models. At 10‐year follow‐up, increasing income was associated with improved outcomes only in White Americans but not Black Americans. In multivariable models for major adverse cardiac event, income (hazard ratio [HR], 0.97 [95% CI, 0.96–0.98]; P =0.005), Black race (HR, 1.77 [95% CI, 1.58–1.96]; P =0.006), and their interaction (HR, 0.98 [95% CI, 0.97–0.99]; P =0.003) were significant predictors. Similar findings were observed for cardiac death.

Conclusions

Early 3‐year post–percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10‐year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States

BACKGROUND

The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States.

METHODS

Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model.

RESULTS

Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003).

CONCLUSIONS

The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

The Impact of Type of Acute Myocardial Infarction on Cardiac Patient Self-efficacy After Hospitalization

BACKGROUND

Self-efficacy is an important psychological construct associated with patient adherence with healthy lifestyle choices. Few studies have focused on the impacts of the type of acute myocardial infarction (AMI), non-ST-elevation myocardial infarction (STEMI) and STEMI, and the different treatment modalities of AMI on changes in cardiac self-efficacy after hospitalization.

OBJECTIVE

This study examined the changes in cardiac self-efficacy based on the type of AMI and aimed to investigate the impact of different treatment modalities on changes in cardiac self-efficacy among post-AMI patients during hospitalization and at the 3- and 6-month follow-ups subsequent to hospitalization.

METHODS

A repeated-measures design was used with a convenient sample of 210 patients diagnosed with first AMI. Patients completed the Cardiac Self-efficacy Questionnaire at the 3 time points. The study was implemented in 3 major hospitals in Jordan. Patients did not have access to cardiac rehabilitation.

RESULTS

There was a statistically significant impact of AMI type on changes in cardiac self-efficacy measured between T1 and T2, between T2 and T3, and subsequently between T1 and T3. Nevertheless, there was no statistically significant impact of treatment modalities of AMI on changes in cardiac self-efficacy measured at the 3 time points.

CONCLUSIONS

Assessment of self-efficacy for post-AMI patients is recommended. Moreover, post-non-STEMI patients need more attention when implementing an intervention to enhance self-efficacy after hospitalization. Health decision makers have to consider establishing cardiac rehabilitation to improve self-efficacy in Jordan. Further research is needed to confirm the study results and to investigate other contributing factors that could influence self-efficacy after hospitalization.

Differences in incident and recurrent myocardial infarction among White and Black individuals aged 35 to 84: Findings from the ARIC community surveillance study

BACKGROUND

No previous study has examined racial differences in recurrent acute myocardial infarction (AMI) in a community population. We aimed to examine racial differences in recurrent AMI risk, along with first AMI risk in a community population.

METHODS

The community surveillance of the Atherosclerosis Risk in Communities Study (2005-2014) included 470,000 people 35 to 84 years old in 4 U.S. communities. Hospitalizations for recurrent and first AMI were identified from ICD-9-CM discharge codes. Poisson regression models were used to compare recurrent and first AMI risk ratios between Black and White residents.

RESULTS

Recurrent and first AMI risk per 1,000 persons were 8.8 (95% CI, 8.3-9.2) and 20.7 (95% CI, 20.0-21.4) in Black men, 6.8 (95% CI, 6.5-7.0) and 14.1 (95% CI, 13.8-14.5) in White men, 5.3 (95% CI, 5.0-5.7) and 16.2 (95% CI, 15.6-16.8) in Black women, and 3.1 (95% CI, 3.0-3.3) and 8.8 (95% CI, 8.6-9.0) in White women, respectively. The age-adjusted risk ratios (RR) of recurrent AMI were higher in Black men vs White men (RR, 1.58 95% CI, 1.30-1.92) and Black women vs White women (RR, 2.09 95% CI, 1.64-2.66). The corresponding RRs were slightly lower for first AMI: Black men vs White men, RR, 1.49 (95% CI, 1.30-1.71) and Black women vs White women, RR, 1.65 (95% CI, 1.42-1.92) CONCLUSIONS: Large disparities exist by race for recurrent AMI risk in the community. The magnitude of disparities is stronger for recurrent events than for first events, and particularly among women.

Risk of death associated with incident heart failure in patients with known or suspected chronic coronary syndrome

AIMS

Traditional adverse events in chronic coronary syndrome (CCS) include atherothrombotic events but usually exclude heart failure (HF). Data are scarce about how new-onset HF modifies mortality risk. We aimed to determine the incidence of HF and compare its long-term mortality risk with myocardial infarction (MI) and stroke in patients with known or suspected CCS.

METHODS

We prospectively evaluated 5811 consecutive HF-free patients submitted to vasodilator stress cardiac magnetic resonance (CMR) for known or suspected CCS. Ischaemic burden and left ventricular ejection fraction were assessed by CMR. HF included outpatient diagnosis or acute HF hospitalization. The mortality risk for the incident events and their cross-comparisons were evaluated using a Markov illness-death model with transition-specific survival models.

RESULTS

The mean age was 55 ± 11 years, and 38.9% were female. At a median follow-up of 5.44 (IQR = 2.53-8.55) years, 591 deaths were registered (1.79 per 100 P-Y). The rates of new-onset HF were higher compared with MI and stroke [1.02, 0.62, and 0.51, respectively (P < 0.05)]. The adjusted association between new-onset HF, MI, and stroke, and subsequent mortality was time dependent. The risk increased almost linearly for HF and became significant by the third year. By Year 10, the mortality risk attributable to new-onset HF was more than 2.5-fold (HR: 2.68, 95% CI = 1.74-4.12). For MI, there was a significant increase in mortality risk up to the second year, followed by a monotonic decrease. For stroke, the mortality risk increased for the entire follow-up but became significant by the third year. A cross-comparison among incident endpoints HF outnumbers risk for those with MI by the sixth year (HR_year6.3 : 1.88, 95% CI = 1.03-3.43). There was no difference in mortality risk between incident HF and stroke.

CONCLUSIONS

In patients with CCS, long-term rates of incident HF were higher than MI and stroke. Patients with new-onset HF showed a higher risk of long-term mortality.