New-onset atrial fibrillation predicts malignant arrhythmias in post-myocardial infarction patients--a Cardiac Arrhythmias and RIsk Stratification after acute Myocardial infarction (CARISMA) substudy

Abnormal expression of circ_0013958 in patients with acute myocardial infarction (AMI) and its influence on prognosis

OBJECTIVE

The purpose of this study was to investigate the diagnostic value of circ_0013958 in acute myocardial infarction (AMI) patients and its influence on the prognosis of AMI patients.

METHODS

The GSE160717 dataset was downloaded from the NCBI database and differentially expressed genes were analyzed between the control group and the AMI group. The up-regulated genes included circ_0013958. The expression of circ_0013958 in both groups was further verified by RT-qPCR. The Receiver Operating Characteristic curve was used to evaluate the diagnostic value of circ_0013958 in AMI. Pearson correlation analysis was used to examine the correlation between circ_0013958 levles and biochemical indicators. Binary logistic regression was used to analyze the risk factors affecting the occurrence of AMI. Prognostic analysis was performed using COX regression analysis and the Kaplan-Meier Curve.

RESULTS

Compared to the control group, the level of circ_0013958 in AMI patients increased. Circ_0013958 can effectively distinguish AMI patients from non-AMI patients. Circ_0013958 levels were positively correlated with cTnI, LDH, CRP and TC levels. The elevated level of circ_0013958 was an independent risk factor for the occurrence of AMI. Higher circ_0013958 levels were also associated with the occurrence of major adverse cardiac events (MACEs) in AMI patients. Additionally, elevated circ_0013958 levels reduced the survival probability of AMI patients.

CONCLUSION

Circ_0013958 levels were up-regulated in AMI patients. It can be used as a diagnosis biomarker for AMI. The level of circ_0013958 was correlated with the disease severity and was an independent risk factor for the occurrence of AMI. Elevated circ_0013958 levels were associated with poor prognosis in AMI patients.

Incidentally Induced Atrial Fibrillation During Programmed Electrical Stimulation in Patients With Depressed Left Ventricular Systolic Function After an Acute Myocardial Infarction

BACKGROUND

The aim of this study was to investigate the clinical implication of incidentally induced atrial fibrillation (AF) during programmed electrical stimulation (PES) in patients with left ventricular systolic dysfunction (≤40%) after an acute myocardial infarction (MI).

METHODS

In this study, we included 231 patients from the Cardiac Arrhythmias and RIsk Stratification after Myocardial InfArction (CARISMA) study with left ventricular ejection fraction ≤40% and no prior history of AF. These patients underwent PES 6 weeks post-MI as part of the study protocol. Patients all received an implantable cardiac monitor (ICM) 3-21 days post-MI and were continuously monitored for cardiac arrhythmias for 2 years. Induction of AF was unwanted but reported if this incidentally occurred.

RESULTS

A total of 61 patients (26%) developed AF within 2 years of follow-up, in which n = 10 (29%) had incidental AF during PES at baseline. The overall risk of AF was not significantly increased in patients with incidental AF (n = 34) during PES compared to patients without incidental AF (n = 197) (HR 1.6 [0.9-3.0], p = 0.14). The risk of bradyarrhythmia (HR = 0.2 [0.0-1.2], p = 0.07), ventricular arrhythmias (HR = 0.7 [0.1-5.8], p = 0.77), and major cardiovascular events (MACE) (HR 0.5 [0.2-1.7], p = 0.28) was not significantly different in patients with versus without incidental AF.

CONCLUSIONS

Incidentally induced AF during PES in post-MI patients with reduced LVEF was not significantly associated with a higher risk of long-term atrial fibrillation, other cardiac arrhythmias, or major cardiac events.

TRIAL REGISTRATION

NCT00145119.

Association of soluble suppression of tumorigenicity 2 protein with new-onset atrial fibrillation in patients with acute ST-segment elevation myocardial infarction undergoing primary PCI

Background

Previous studies have indicated that the soluble suppression of tumorigenicity 2 protein (sST2) is associated with new-onset atrial fibrillation (NOAF) in patients diagnosed with coronary artery disease (CAD). However, the predictive value of sST2 in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been well studied.

Methods

A total of 580 patients with STEMI undergoing primary PCI were consecutively recruited between January 2021 and January 2023. These patients were then categorized into two groups: the NOAF group and the no NOAF groups based on the presence of NOAF during admission. The concentration of sST2 in blood samples was measured in all patients. The clinical data from the two groups were prospectively analyzed to investigate the predictive factors of NOAF in patients with STEMI undergoing primary PCI.

Results

A total of 41 (7.1%) patients developed NOAF. The presence of NOAF has been found to be associated with various factors, including age, diabetes mellitus, hypertension, the left atrial (LA) diameter, N-terminal pro-brain natriuretic peptide, C-reactive protein (CRP), sST2, a Killip class of ≥2, and a final TIMI flow grade of <3. After including multiple factors, it was observed that LA diameter, CRP, sST2, a Killip class of ≥2, and a final TIMI flow grade of <3 remained significant risk factors for developing NOAF. The receiver operating characteristic (ROC) curve showed the following findings: (1) when the LA diameter exceeded 38.5 mm, the sensitivity and specificity values were observed to be 67.2% and 68.2%, respectively, and the area under the ROC curve (AUC) was 0.683 [95% confidence interval (CI): 0.545-0.732; p = 0.003]; (2) when the CRP level exceeded 8.59, the sensitivity and specificity values were observed to be 68.6% and 69.2%, respectively, and the AUC was 0.713 (95% CI: 0.621-0.778; p < 0.001); and (3) when the sST2 value exceeded 53.3, the sensitivity and specificity values were 79.2% and 68.7%, respectively, and the AUC was 0.799 (95% CI: 0.675-0.865; p < 0.001).

Conclusion

sST2 has been identified as an independent predictor of NOAF in patients with STEMI undergoing PCI.

Early prediction of ventricular fibrillation using electrocardiographic characteristics in prehospital suspected ST-segment elevation myocardial infarction: a case-control study

PURPOSE

Our objective was to determine characteristics of electrocardiograms (ECG) that predict ventricular fibrillation (VF) among prehospital patients with suspected ST-segment elevation myocardial infarction (STEMI) in Québec.

METHODS

We performed a matched case-control study of prehospital adult suspected with STEMI. Patients in case group (STEMI/VF+) were matched with controls (STEMI/VF-) for age and sex and then compared for ECG characteristics, including ST-segment elevations (STE) and depressions (STD), duration of interval complexes, general characteristics, and several calculated variables. Logistic regression was used to measure the association between ECG characteristics and VF development.

RESULTS

Overall, 310 prehospital patients with suspected STEMI were included in the analysis (case group, n = 155; control group, n = 155). We confirmed that the presence of TW-pattern complex (OR 7.0, 95% CI 1.55-31.58), premature ventricular contraction (PVC) (OR 5.5, 95% CI 2.04-14.82), and STE in V2-V6 (OR 3.8, 95% CI 1.21-11.74) were electrocardiographic predictors of VF. We also observed that STD in V3-V5 (OR 6.5, 95% CI 1.42-29.39), atrial fibrillation (AF) ≥ 100 beats per minute (bpm) (OR 6.3, 95% CI 1.80-21.90), the combination of STE in V4 and V5, and STD in II, III and aVF (OR 4.8, 95% CI 1.01-22.35), and the presence of STD in ≥ 6 leads (OR 4.2, 95% CI 1.33-13.13) were also associated with VF development. Finally, simultaneous association of 2 (OR 2.3, 95% CI 1.13-4.06) and 3 (OR 11.6, 95% CI 3.22-41.66) predictors showed significant association with VF.

CONCLUSIONS

In addition to some already known predictors, we have identified several ECG findings associated with the development of VF in patients with suspected STEMI. Early identification of patients with STEMI at increased risk of VF should help EMS providers anticipate adverse events and encourage use of defibrillation pads.

Echocardiographic Measures of Left Atrial Structure and Function and the Association with Atrial Fibrillation following Acute Coronary Syndrome

INTRODUCTION

Acute coronary syndrome (ACS) is associated with an increased risk of developing atrial fibrillation (AF). This arrhythmia is associated with adverse outcomes, making it important to identify high-risk patients. The aim was to evaluate the prognostic value of measures of left atrial (LA) structure and function in AF prediction following ACS.

METHODS

Three hundred and eighty-one patients who had a percutaneous coronary intervention for ACS were included in the study. Our endpoint was new-onset AF.

RESULTS

With a median follow-up time of 5.4 [3.9-6.8] years, 56 patients (14.7%) developed AF. Patients developing AF had significantly (p ≤ 0.05) increased maximal and minimal LA volumes (LAVmax and LAVmin, respectively). LAVmax and LAVmin remained significantly increased in AF patients when indexing to either body surface area (LAVmax/BSA and LAVmin/BSA, respectively), left ventricle length in end diastole (LAVmax/LVLd and LAVmin/LVLd, respectively), or late mitral annular diastolic velocity (LAVmax/a' and LAVmin/a', respectively), while LA expansion index (LAEi), LA emptying fraction (LAEF), and peak LA longitudinal strain (PALS) were decreased. In univariable Cox regressions, all LA measures were found to be predictors of AF. After multivariable adjustment for clinical and echocardiographic parameters, all measures reflecting atrial function (LAVmin, LAVmin/BSA, LAVmin/LVLd, LAVmin/a', LAVmax/a', LAEF, LAEi, and PALS) (p ≤ 0.05) but no structural measures (LAVmax, LAVmax/BSA, and LAVmax/LVLd) remained significant independent predictors of AF.

CONCLUSION

Echocardiographic measures of LA function are independent predictors of AF following ACS. Evaluation of LA function might improve the prognostic workup, aid in risk stratification for AF, and improve selection for further examinations.

Long-term risk of new-onset arrhythmia in ST-segment elevation myocardial infarction according to revascularization status

AIMS

Emerging data show that complete revascularization (CR) reduces cardiovascular death and recurrent myocardial infarction in ST-segment elevation myocardial infarction (STEMI). However, the influence of revascularization status on development of arrhythmia in the long-term post-STEMI phase is poorly described. We hypothesized that incomplete revascularization (ICR) compared with CR in STEMI is associated with an increased long-term risk of new-onset arrhythmia.

METHODS AND RESULTS

Patients with STEMI treated with primary percutaneous coronary intervention (PPCI) at Copenhagen University Hospital, Rigshospitalet, Denmark, with CR or ICR were identified via the Eastern Danish Heart registry from 2009 to 2016. Using unique Danish administrative registries, the outcomes were assessed. The primary outcome was new-onset arrhythmia defined as a composite of atrial fibrillation/flutter (AF), sinoatrial block, advanced second- or third-degree atrioventricular block, ventricular tachycardia/fibrillation (VT), or cardiac arrest (CA), with presentation >7 days post-PPCI. Secondary outcomes were the components of the primary outcome and all-cause mortality. A total of 5103 patients (median age: 62.0 years; 76% men) were included, of whom 4009 (79%) and 1094 (21%) patients underwent CR and ICR, respectively. Compared with CR, ICR was associated with a higher risk of new-onset arrhythmia [hazard ratio (HR), 1.33; 95% confidence interval (CI), 1.07-1.66; P = 0.01], AF (HR, 1.29; 95% CI, 1.00-1.66; P = 0.05), a combined outcome of VT and CA (HR, 1.77; 95% CI, 1.10-2.84; P = 0.02) and all-cause mortality (HR, 1.27; 95% CI, 1.05-1.53; P = 0.01). All HRs adjusted.

CONCLUSION

Among patients with STEMI, ICR was associated with an increased long-term risk of new-onset arrhythmia and all-cause mortality compared with CR.

The association between systemic inflammatory response index and new-onset atrial fibrillation in patients with ST-elevated myocardial infarction treated with percutaneous coronary intervention

BACKGROUND

New-onset atrial fibrillation (NOAF) complicating with ST-elevated myocardial infarction (STEMI) patients following percutaneous coronary intervention (PCI) is associated with worse prognosis. The systemic inflammatory response index (SIRI), serves as a novel inflammatory indicator, is found to be predictive of adverse outcomes. The aim of this study is to explore the association between NOAF and SIRI.

METHODS

A retrospective data included 616 STEMI participants treated with PCI in our cardiology department had been analyzed in present investigation, of which being divided into a NOAF or sinus rhythm (SR) group based on the presence or absence of atrial fibrillation. The predictive role of SIRI for in detecting NOAF had been evaluated by the logistic regression analyses and receiver operating characteristic (ROC) curve. Additionally, long-term all-cause mortality between both groups was compared using the Kaplan-Meier test.

RESULTS

NOAF during hospitalization developed in 7.6% of PCI-treated individuals. After multivariate regression analyses, SIRI remains to be an independently predictor of NOAF (odds ratio 1.782, 95% confidence interval 1.675-1.906, P = 0.001). In the ROC curve analysis, SIRI with a cut-off value of 4.86 was calculated to predict NOAF, with 4.86, with a sensitivity of 80.85% and a specificity of 75.57%, respectively (area under the curve (AUC) = 0.826, P < 0.001). Furthermore, pairwise compassion of ROC curves displayed the superiority of SIRI in the prediction of NOAF in comparison with that of neutrophil/lymphocyte or monocyte/lymphocyte (P < 0.05). In addition, the participants in NOAF group had a significantly higher incidence of all-cause death compared to those in SR group after a median of 40-month follow-up (22.0% vs 5.8%, log-rank P < 0.001).

CONCLUSION

SIRI can independently predict NOAF in patients with STEMI after PCI, with being positively correlated to worsened outcomes.

Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy

AIMS

The Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) study was an observational trial including 312 patients with acute myocardial infarction (MI) and left ventricular ejection fraction (LVEF) <40%. Primary percutaneous intervention (pPCI) was introduced 2 years after start of the enrolment, dividing the population into two groups: pre- and post-pPCI. This substudy sought to describe the influence of the mode of revascularization on long-term risk of new-onset atrial fibrillation (AF), bradyarrhythmia, and ventricular tachycardia and the subsequent risk of relevant major cardiovascular events (MACE).

METHODS AND RESULTS

The study included the 268 patients without a history of AF. All patients received an implantable cardiac monitor (ICM) and were followed for 2 years. The choice of revascularization was made by the treating team independently of the trial and retrospectively divided into pPCI, subacute PCI, primary thrombolysis, or no revascularization. Endpoints were new-onset arrhythmia and MACE.A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received any PCI. The adjusted hazard ratio (HR) for developing any arrhythmia and the subsequently risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients (any arrhythmia, non-revascularization: HR = 1.7, P = 0.01 and thrombolysis: HR = 1.6, P = 0.05; MACE, non-revascularization: HR = 3.1, P = 0.05 and thrombolysis: HR = 3.1, P = 0.08). All HRs were adjusted for significant baseline and clinically considered covariates and stratified for calendar year.

CONCLUSION

This study is the first to demonstrate that the long-term risk of arrhythmia documented by an ICM and the subsequent risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients in a post-MI population with LVEF <40%.

Reperfused vs. nonreperfused myocardial infarction: when to use which model

There is a lack of understanding in the cardiac remodeling field regarding the use of nonreperfused myocardial infarction (MI) and reperfused MI in animal models of MI. This Perspectives summarizes the consensus of the authors regarding how to select the optimum model for your experiments and is a part of ongoing efforts to establish rigor and reproducibility in cardiac physiology research.

Efficacy of Physical Exercise on the Quality of Life, Exercise Ability, and Cardiopulmonary Fitness of Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Objective: Physical exercise is recommended to help prevent lifestyle diseases. The present study was designed to quantify the efficacy of physical exercise on the quality of life (QoL), exercise ability and cardiopulmonary fitness of patients with atrial fibrillation (AF).

Method: A comprehensive systematic literature search was performed in Medline, Embase, Cochrane Library, Web of Science and PubMed databases (from 1970 to December 1st, 2019) for randomized controlled trials (RCTs) comparing physical exercise combined with AF routine treatments to routine treatments alone. The meta-analysis was conducted following PRISMA guidelines. Our main outcomes were QoL (measured by the Short-Form 36 scale, SF-36), exercise ability (measured by the 6-min walk test, 6MWT) and cardiopulmonary fitness (measured by peak oxygen uptake and resting heart rate). Quality assessments were conducted using the Cochrane Collaboration tool.

Results: Twelve trials involving 819 patients met the criteria for analysis. The results showed that physical exercise improved the QoL by enhancing physical functioning [standardized mean difference (SMD) = 0.63, 95%CI: 0.18–1.09; p = 0.006], general health perceptions (SMD = 0.64, 95%CI: 0.35–0.93; p < 0.001) and vitality (SMD = 0.51, 95%CI: 0.31–0.71; p < 0.001); increased exercise ability by improving the 6MWT performance (SMD = 0.69, 95%CI: 0.19–1.119; p = 0.007); and enhanced peak VO₂ (SMD = 0.37, 95%CI: 0.16–0.57; p < 0.001) while reducing resting heart rate (SMD = −0.39, 95%CI: −0.65 to −0.13; p = 0.004). In addition, meta-regression analysis showed that training mode (p_{physicalfunctioning} = 0.012, p_{generalhealthperceptions} = 0.035) and training duration (p = 0.047) were the main factors of an intervention that influenced the effect size. Following sub-group analysis, we found that aerobics, Yoga and longer training durations (≥60 min) showed larger improvements.

Conclusion: In summary, our meta-analysis shows that physical exercise has a positive effect on the QoL, exercise ability and cardiopulmonary fitness in AF patients. When physicians offer exercise recommendations to AF patients, they should consider both the training mode and training duration to achieve maximum results.

Long-term prognosis of de novo atrial fibrillation during acute myocardial infarction: the impact of anti-thrombotic treatment strategies

AIMS

While the prognosis of patients presenting with de novo atrial fibrillation (AF) during the acute phase of myocardial infarction has been controversially discussed, it seems intuitive that affected individuals have an increased risk for both thrombo-embolic events and mortality. However, profound data on long-term outcome of this highly vulnerable patient population are not available in current literature. Therefore, we aimed to investigate the impact of de novo AF and associated anti-thrombotic treatment strategies on the patient outcome from a long-term perspective.

METHODS AND RESULTS

Patients presenting with acute myocardial infarction, treated at the Medical University of Vienna, were enrolled within a clinical registry and screened for the development of de novo AF. After discharge, participants were followed prospectively over a median time of 8.6 years. Primary study endpoint was defined as cardiovascular mortality. Out of 1372 enrolled individuals 149 (10.9%) developed de novo AF during the acute phase of acute myocardial infarction. After a median follow-up time of 8.6 years, a total of 418 (30.5%) died due to cardiovascular causes, including 93 (62.4%) in the de novo AF subgroup. We found that de novo AF was significantly associated with long-term cardiovascular mortality with an adjusted HR of 1.45 (95% CI 1.19-2.57; P < 0.001). While patients with de novo AF were less likely to receive a triple anti-thrombotic therapy as compared to patients with pre-existing AF at time of discharge, this therapeutic approach showed a strong and inverse association with mortality in de novo AF, with an adj. HR of 0.86 (95% CI 0.45-0.92; P = 0.012).

CONCLUSION

De novo AF was independently associated with a poor prognosis with a 67% increased risk of long-term cardiovascular mortality. Intensified anti-thrombotic treatment in this high-risk patient population might be considered.

Global research productions pertaining to atrial fibrillation from 2004 to 2018: A bibliometric analysis

BACKGROUND

We analyzed the scientific outputs of global atrial fibrillation (AF) researches, developed a model to qualitatively and quantitatively evaluate the AF research productions from 2004 to 2018.

METHODS

The data was retrieved from the Web of Science Core Collection (WOSCC) on June 15, 2019. Bibliometrics tools-CiteSpace V (Drexel university, Chaomei Chen) and VOSviewer (Leiden University, van Eck NJ) --were used for bibliometric analyzing published outputs and finding research hotspots.

RESULTS

There were a total of 21,839 research articles on AF, and the annual publication rate increased over time from 2004 to 2018. The Journal of Cardiovascular Electrophysiology published the greatest number of articles, and the leading country was the United States. The leading institution was the Mayo Clinic, and the most productive researchers were: LIP GYH, Natale A, Chen SA, DI Biase L, and Kuck KH. The keywords analysis showed that catheter ablation, risk, heart failure, stroke, and management were research hotspots.

CONCLUSION

Bibliometric analysis of the literature shows that research on AF continues to be a hot spot, and the clinical treatment of AF is an important research frontier. However, further research and collaboration are needed worldwide. Our findings aim to provide valuable information for the editors of journals that publish research on arrhythmia, and to help researchers identify new perspectives for future researches.

Value of Syntax Score II in Prediction of New-Onset Atrial Fibrillation in Patients With NSTE-ACS Undergoing Percutaneous Coronary Intervention

New-onset atrial fibrillation (NOAF) has been associated with poor outcome in patients with acute coronary syndromes (ACSs). The objective of this study was to investigate the relationship between the development of NOAF and severity of coronary artery disease using the SYNTAX score (SS) and SYNTAX score II (SSII) in patients with non-ST-segment elevation ACS (NSTE-ACS) who were treated with percutaneous coronary intervention (PCI). A total of 662 patients with NSTE-ACS were consecutively enrolled. The incidence of NOAF was 11.4% among the patients with NSTE-ACS. Mean age was significantly higher in NOAF group ( P = .011). White blood cell count, peak troponin I, high sensitivity C-reactive protein, uric acid, left atrial volume index, and ratio between early mitral inflow velocity and mitral annular early diastolic velocity were significantly higher in NOAF group (respectively, P = .024, P = .017, P = .002, P = .009, P = .025, P < .001, and P < .001). The hemoglobin, ejection fraction, and post PCI thrombolysis in myocardial infarction grade <3 were significantly lower in NOAF group ( P = 001, P = .010, P = .038). The SS and SSII were significantly higher in NOAF group (all P < .001). According to the results of multivariate logistic regression analysis, the SSII was correlated with NOAF ( P < .001) in the study groups. We demonstrated that high SSII is significantly associated with NOAF.

The value of syntax score to predict new-onset atrial fibrillation in patients with acute coronary syndrome

BACKGROUND AND AIM

New-onset atrial fibrillation (NOAF) has been associated with poor outcome in patients with acute coronary syndromes (ACS). Also, Syntax score (SS) is a scoring system that is derived from angiographic images and is associated with long-term mortality and major adverse cardiac events. In this study, we aimed to assess the relationship between SS and NOAF with known predictors of atrial fibrillation.

METHODS

In a prospective, single-center, cross-sectional study, 692 patients who were diagnosed with coronary artery disease for the first time were enrolled consecutively. NOAF was defined as atrial fibrillation, which was documented after hospital admission. SS was calculated by a computer software. Multivariable logistic regression analyzes were used to detect the relationship between variables and NOAF.

RESULTS

New-onset atrial fibrillation was detected in 82 patients (11.8%). Patients with NOAF had higher SS (22, interquartile range 18.3-25.1, vs. 12, interquartile range 7-19.5, p < 0.001). According to multivariable logistic regression analysis for NOAF, SS were independently and significantly associated (OR, 1.103; 95% confidence interval, 1.047-1.163; p < 0.001). Other independent predictors of NOAF were TIMI flow <3, C reactive protein, left ventricular ejection fraction, left atrial volume index and E/E' ratio. The optimal cut-off value for SS was 18 for the development of NOAF with 82% sensitivity and 68% specificity (area under the curve: 0.795, 95% confidence interval 0.749-0.841, p < 0.001).

CONCLUSION

Syntax score may be helpful to identify for patients who would develop atrial fibrillation in the setting of ACS.

Predictors of new-onset atrial fibrillation in elderly patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

The development of atrial fibrillation (AF) during the course of acute coronary syndrome (ACS) is related to poor prognosis. Possible predictors of new-onset AF (NOAF) have not been adequately investigated in elderly patients with ACS undergoing percutaneous coronary intervention (PCI). We aimed to identify the factors associated with NOAF in such patients.

METHODS

A total of 308 elderly patients with ACS undergoing PCI were enrolled in the study. Patients were divided into two groups: without NOAF [254 patients, 64.6% men, age: 73.5 (69.0-79.0) years] and with NOAF [54 patients, 70.4% men, age: 75.0 (68.7-81.2) years]. Clinical, angiographic, and laboratory features including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-high-density lipoprotein ratio (MHR) were compared between the groups.

RESULTS

The percentages of prior myocardial infarction (MI) (20.4 vs. 5.9%) and Killip III/ IV (24.1 vs. 7.1%), NLR [4.5 (2.6-7.2) vs. 3.2 (2.0-6.0)], and MHR [19.4 (15.7-26.5) vs. 12.9 (9.9-18.5)] were higher in patients with NOAF compared to the others (p = 0.020, < 0.001, 0.030, and < 0.001, respectively). In multivariate regression analysis, prior MI (OR 4.509, 95% CI 1.679-12.106, p = 0.003) and MHR (OR 1.102, 95% CI 1.054-1.152, p < 0.001) independently predicted NOAF. In addition, Killip III/IV was found to be an independent predictor of 6-month overall mortality (HR 2.949, 95% CI 1.218-7.136, p = 0.016).

CONCLUSIONS

Prior MI and MHR are independent predictors of NOAF in elderly patients with ACS undergoing PCI. Killip III/IV predicts 6-month overall mortality in such patients.

Monocyte to High-Density Lipoprotein Ratio Predicts Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome

Contrast-induced nephropathy (CIN) is associated with worse prognosis in patients with acute coronary syndrome (ACS). Early identification and intervention for patients with a high risk of CIN are very important to improve clinical outcomes. Inflammation plays important role in the development of CIN in the setting of ACS. The monocyte to high-density lipoprotein ratio (MHR) is a novel inflammatory marker. Bleeding is also associated with worse prognosis in such patients. We aimed to investigate whether the preprocedural MHR had a predictive role for CIN development in such patients. In addition, using the thrombolysis in myocardial infarction classification, we aimed to assess whether there was any relationship between bleeding and CIN. A total of 647 patients (496 males; age: 63.3 ± 12.7 years) with ACS who underwent percutaneous coronary intervention (PCI) were included in the study. Seventy patients (10.8%) had developed CIN. Age, diabetes mellitus, contrast volume, estimated glomerular filtration rate, and MHR were independent predictors for CIN. Preprocedural MHR may be used as a simple marker of CIN. It may help with the early identification of patients with ACS who underwent PCI who are at high risk of CIN thus allowing the planning of protective measures.

Implantable cardiac monitors in high-risk post-infarction patients with cardiac autonomic dysfunction and moderately reduced left ventricular ejection fraction: Design and rationale of the SMART-MI trial

BACKGROUND

Most deaths after myocardial infarction (MI) occur in patients with left ventricular ejection fraction (LVEF) >35%, for whom no specific prophylactic strategies exist. Deceleration capacity (DC) of heart rate and periodic repolarization dynamics (PRD) are noninvasive electrophysiological markers depending on the vagal and sympathetic tone. The combination of abnormal DC and/or PRD identifies a new high-risk group among postinfarction patients with LVEF 36%-50%. This new high-risk group has similar characteristics with respect to prognosis and patient numbers to those of the established high-risk group identified by LVEF ≤ 35%.

STUDY DESIGN

The SMART-MI trial is an investigator-initiated randomized prospective multicenter trial that tests the efficacy of implantable cardiac monitors (ICM) in this new high-risk group. The study will enroll approximately 1,600 survivors of acute MI with sinus rhythm and an LVEF of 35%-50% in 17 centers in Germany who will be tested for presence of cardiac autonomic dysfunction. Four hundred patients with either abnormal DC (≤2.5 ms) and/or PRD (≥5.75deg²) will be randomized in a 1:1 fashion to intensive follow-up via telemonitoring using an ICM device (experimental arm) or conventional follow-up (control arm). For the ICM arm, specific treatment paths have been developed according to current guidelines.

OUTCOMES

The primary end point is time to detection of predefined serious arrhythmic events during follow-up, including atrial fibrillation ≥6minutes, nonsustained ventricular tachycardia (cycle length≤320 ms; ≥40 beats), atrioventricular block ≥IIb, and sustained ventricular tachycardia/ventricular fibrillation. The median follow-up period is 18months with a minimum follow-up of 6months. The effect of remote monitoring on clinical outcomes will be tested as secondary outcome measure (ClinicalTrials.gov NCT02594488).

Global longitudinal strain predicts incident atrial fibrillation and stroke occurrence after acute myocardial infarction

Patients with acute myocardial infarction are at increased risk of developing atrial fibrillation. We aimed to evaluate whether speckle tracking echocardiography improves risk stratification for atrial fibrillation in these patients.The study comprised of 373 patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. Patients had an echocardiogram performed at a median of 2 days after their STEMI. The echocardiograms consisted of conventional measurements and myocardial strain analysis by speckle tracking from 3 apical projections. The endpoint was a composite of new-onset atrial fibrillation and ischemic stroke. At a median follow-up time of 5.5 years (interquartile range 4.9, 6.1 years), 44 patients developed the endpoint (atrial fibrillation: n = 24, ischemic stroke: n = 24, both: n = 4). Patients who reached the endpoint had significantly reduced systolic function by the left ventricular ejection fraction (LVEF) (43% vs 46%; P = 0.042) and global longitudinal strain (10.9% vs 12.6%; P = 0.004), both being univariable predictors. However, only global longitudinal strain remained a significantly independent predictor (hazard ratio 1.12, 95% confidence interval 1.00; 1.25, P = 0.042, per 1% decrease) after multivariable adjustment for baseline predictors (age, sex, diabetes, hypertension, diastolic dysfunction, and LVEF) using Cox regression. Furthermore, global longitudinal strain resulted in significantly higher c-statistics for prediction of outcome compared with LVEF <45% (0.63 vs 0.52; P = 0.026). When stratified into tertiles of global longitudinal strain, it became evident that patients in the lowest tertile mediated this signal with a 2-fold increased risk compared with the highest tertile (hazard ratio 2.10, 95% confidence interval 1.04; 4.25).Global longitudinal strain predicts atrial fibrillation after STEMI and may add valuable information which can help facilitate arrhythmia detection in these patients.

A Review of the Relationship of Atrial Fibrillation and Acute Coronary Syndrome

Atrial fibrillation (AF) is the most common arrhythmia encountered by clinicians. Clinical decision-making focuses on reducing ischemic stroke risk in AF patients; however, AF is also associated with an increased risk of acute coronary syndromes (ACS). Patients with ACS and concurrent AF are less likely to receive appropriate therapies and more likely to experience adverse outcomes than ACS patients in sinus rhythm (SR). Clinicians may be able to stratify ACS patients at increased risk of AF development based on clinical characteristics. Evidence supporting specific therapeutic options for prevention of ACS in AF patients or for prevention of AF in ACS patients is limited, however there is some evidence of differing effects among oral anticoagulant regimens in these populations. Investigations of the relationship of AF with the full spectrum of ACS are not well described and should be the focus of future research.

Should β-blockers be used in patients with heart failure and atrial fibrillation?

PURPOSE

There is overwhelming evidence that β-blockers reduce cardiovascular hospitalizations and mortality in patients with heart failure and a reduced left ventricular ejection fraction provide they are in sinus rhythm. However, a recent meta-analysis of individual patient data provides compelling evidence that β-blockers are not effective in patients with heart failure and atrial fibrillation, although neither did they increase risk. The purpose of this article is to review the evidence, seek possible explanations for this observation, and make recommendations based on the limited evidence available.

METHODS

Review and critical analysis of recent publications and meta-analyses on the use of β-blockers and other heart rate-slowing medicines in heart failure.

FINDINGS

The reasons for the lack of effect of β-blockers in patients with heart failure are uncertain. There is a substantial body of evidence to suggest that patients with heart failure and atrial fibrillation who have less stringent ventricular rate control have a better outcome. The most plausible explanation for these findings, in our view, is that β-blockers exert similar benefits through similar mechanisms regardless of intrinsic heart rhythm but that the benefits of β-blockers are neutralized in patients with atrial fibrillation due to the induction of pauses that may impair cardiac function leading to worsening heart failure or cause arrhythmias resulting in death.

IMPLICATIONS

Smaller doses of β-blockers and other rate lowering agents to achieve a resting clinic heart rate in the range of 75-89beats/min might improve outcome. Preventing pauses by pacing or pulmonary vein ablation of atrial fibrillation are strategies that should be researched.

High Killips Class as a Predictor of New-onset Atrial Fibrillation Following Acute Myocardial Infarction: Systematic Review and Meta-analysis

BACKGROUND

Recent observational studies have shown that patients with higher Killips score (>I) have higher risk of new-onset atrial fibrillation (NOAF) following acute myocardial infarction (AMI), while others drew a neutral conclusion. The ultimate predictive value of high Killips class on NOAF remained obscure.

METHODS

PubMed, Web of Science, China National Knowledge Infrastructure, and the Cochrane Controlled Trials Register Databases were searched until February 2015. Of the 3732 initially identified studies, 5 observational studies with 10,053 patients were analyzed.

RESULTS

The meta-analysis of these studies showed that higher Killips score on admission was associated with higher incidence of NOAF following AMI (odds ratio = 2.29, 95% confidence interval 1.96-2.67, P < 0.00001), while no significant differences exist among individual trials (P = 0.14 and I2 = 43%).

CONCLUSIONS

Killips class >I was associated with the higher opportunity of developing NOAF following AMI.

Short- and long-term prognosis of previous and new-onset atrial fibrillation in ST-segment elevation acute myocardial infarction

INTRODUCTION AND OBJECTIVES

The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction.

METHODS

Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models.

RESULTS

In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P<.001; 30% vs 10%; P<.001). The long-term mortality rate was 11.11/100 patient-years in patients with previous atrial fibrillation and 5.35/100 patient years in those with new-onset atrial fibrillation (both groups, P<.001). New-onset fibrillation alone (odds ratio=1.55; 95% confidence interval, 1.08-2.22) was an independent predictor of in-hospital mortality. Previous atrial fibrillation (hazard ratio=1.24; 95% confidence interval, 0.94-1.64) and new-onset atrial fibrillation (hazard ratio=0.98; 95% confidence interval, 0.80-1.21) were not independent predictors of long-term mortality.

CONCLUSIONS

New-onset atrial fibrillation during hospitalization is an independent risk factor for in-hospital mortality in acute myocardial infarction.

Usefulness of catestatin to predict malignant arrhythmia in patients with acute myocardial infarction

Catestatin (CST) displays potent vasodilatory effect and acts on lowering blood pressure in vivo. The clinical utility of CST in patients with acute myocardial infarction (AMI) has not been clearly delineated. The aim of this study was to investigate the predictive value of CST for the development of in-hospital malignant arrhythmia and other adverse cardiac events in patients with AMI. A total of 125 consecutive patients diagnosed with AMI were included. The clinical characteristics and previous history of the patients were collected. Malignant arrhythmia and other major adverse cardiac events (MACE) such as postinfarction angina pectoris or reinfarction and death were recorded during hospitalization. The levels of plasma CST, norepinephrine (NE) and amino-terminal pro-brain sodium peptides (NT-proBNP) were determined by sandwich ELISA. A multiple logistic regression model was used to predict the influence factors of malignant arrhythmia and other MACE during hospitalization of AMI patients. The results showed that the levels of plasma cystatin-C (CysC), high sensitivity C-reactive protein (hs-CRP), NE and NT-proBNP increased in a CST concentration dependent manner. The incidence of malignant arrhythmia significantly increased as the elevation of CST level (P<0.05). Age, CST and NT-proBNP were independent predictors for the MACE occurred during hospitalization. Increased blood glucose (≥6.1mmol/L) and CST were independent predictors for the complicated malignant arrhythmia of AMI patients. These data demonstrated that CST can be used as a new biological marker for prediction of malignant arrhythmia in patients with AMI.

Atrial fibrillation and microRNAs

Atrial fibrillation (AF) is the most common sustained arrhythmia, especially in the elderly, and has a significant genetic component. Recently, several independent investigators have demonstrated a functional role for small non-coding RNAs (microRNAs) in the pathophysiology of this cardiac arrhythmia. This report represents a systematic and updated appraisal of the main studies that established a mechanistic association between specific microRNAs and AF, focusing both on the regulation of electrical and structural remodeling of cardiac tissue.