Temporal trends in clinical characteristics of patients without known cardiovascular disease with a first episode of myocardial infarction

Nomogram for Predicting in-Hospital Severe Complications in Patients with Acute Myocardial Infarction Admitted in Emergency Department

Background

There is lack of predictive models for the risk of severe complications during hospitalization in patients with acute myocardial infarction (AMI). In this study, we aimed to create a nomogram to forecast the likelihood of in-hospital severe complications in AMI.

Methods

From August 2020 to January 2023, 1024 patients with AMI including the modeling group (n=717) and the validation group (n=307) admitted in Changsha Central Hospital's emergency department. Conduct logistic regression analysis, both univariate and multivariate, on the pertinent patient data from the modeling cohort at admission, identify independent risk factors, create a nomogram to forecast the likelihood of severe complications in patients with AMI, and assess the accuracy of the graph's predictions in the validation cohort.

Results

Age, heart rate, mean arterial pressure, diabetes, hypertension, triglycerides and white blood cells were seven independent risk factors for serious complications in AMI patients. Based on these seven variables, the nomogram model was constructed. The nomogram has high predictive accuracy (AUC=0.793 for the modeling group and AUC=0.732 for the validation group). The calibration curve demonstrates strong consistency between the anticipated and observed values of the nomogram in the modeling and validation cohorts. Moreover, the DCA curve results show that the model has a wide threshold range (0.01-0.73) and has good practicality in clinical practice.

Conclusion

This study developed and validated an intuitive nomogram to assist clinicians in evaluating the probability of severe complications in AMI patients using readily available clinical data and laboratory parameters.

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

BACKGROUND

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

AIM

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

METHOD

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

PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

Leveraging Clinical Digitized Data to Understand Temporal Characteristics and Outcomes of Acute Myocardial Infarctions at a Tertiary Care Medical Centre in Pakistan from 1988–2018 – Methods and Results

Background and Objective:

Few data exist on trends in acute myocardial infarction (AMI) patterns spanning recent epidemiological shifts in low middle-income countries (LMICs). To understand temporal disease patterns of AMI characteristics and outcomes between 1988–2018, we used digitized legacy clinical data at a large tertiary care centre in Pakistan.

Methods:

We reviewed digital health information capture systems maintained across the Aga Khan University Hospital and obtained structured elements to create a master dataset. We included index admissions of patients >18 years that were discharged between January 1, 1988, and December 31, 2018, with a primary discharge diagnosis of AMI (using ICD-9 diagnoses). The outcome evaluated was in-hospital mortality.

Clinical characteristics derived from the electronic database were validated against chart review in a random sample of cases (k 0.53–1.00).

Results:

The final population consisted of 14,601 patients of which 30.6% (n = 4,470) were female, 52.4% (n = 7,651) had ST elevation MI and 47.6% (n = 6,950) had non-ST elevation MI. The median (IQR) age at presentation was 61 (52–70) years. Overall unadjusted in-hospital mortality was 10.3%. Across the time period, increasing trends were noted for the following characteristics: age, proportion of women, prevalence of hypertension, diabetes, proportion with NSTEMI (all p_trend < 0.001). In-hospital mortality rates declined significantly between 1988–1997 and 2008–2018 (13.8% to 9.2%, p < 0.001).

Conclusions:

The patterns of AMI have changed over the last three decades with a concomitant decline in in-hospital mortality at a tertiary care centre in Pakistan. Clinical digitized data presents a unique opportunity for gaining insights into disease patterns in LMICs.

Temporal trends in cardiovascular risk factors' prevalence in patients with myocardial infarction

INTRODUCTION AND OBJECTIVES

Little is known about changes in cardiovascular risk factors (CVRF) profile over time in patients presenting with acute myocardial infarction (AMI).

METHODS

We assessed changes in age and CVRF profile in consecutive AMI patients enrolled in the Swiss nationwide AMIS Plus registry between 1 January 1997 and 31 December 2018.

RESULTS

A total of 57 995 AMI patients were included in the analysis. Mean age at presentation was 71.5 ± 11.3 years for women and 63.9 ± 12.8 years for men and did not change over time. Overall, the mean (standard deviation) number of CVRF increased from 1.76 (1.07) in 1997/98 to 2.26 (1.10) in 2017/18 in men (P_trend  < .001), while the corresponding rates in females were 1.83 (1.11) and 2.24 (1.08) (P_trend  < .001). In terms of active smoking, no significant trend was detected for males, while there was a significant increase in females (P < .001). As a result, the gap in smoking rates between men and women presenting with AMI decreased from 19.9% (45.3% vs 25.4%) in 1997/98 to 7.9% (41.2% vs 33.3%) in 2017/18. Reassuring was the stability in terms of diabetes prevalence for both genders. Obesity was more prevalent over time in men, while the prevalence of hypertension and dyslipidemia increased in both genders.

CONCLUSION

Among patients with AMI in Switzerland over two decades, age at presentation remained stable, while the mean number of CVRF increased in both men and women. Striking was the increase in the prevalence of smoking in women, leading to a reduction of the gender gap over time.

Hypertension and patients with acute coronary syndrome: Putting blood pressure levels into perspective

Arterial hypertension is a well-established cardiovascular risk factor, and blood pressure (BP) control has largely improved the prognosis of hypertensive patients. A number of studies have assessed the role of BP levels in the prognosis of patients with acute coronary syndromes. Pathophysiologic links of hypertension to acute myocardial infarction (MI) include endothelial dysfunction, autonomic nervous system dysregulation, impaired vasoreactivity, and a genetic substrate. A history of hypertension is highly prevalent among patients presenting with MI, and some, but not all, studies have associated it with a worse prognosis. Some data support that low levels of admission and in-hospital BP may indicate an increased risk for subsequent events. Risk scores used in patients with MI have, therefore, included BP levels and a history of hypertension in their variables. Of note, good long-term BP control, ideally initiated prior to discharge, should be pursued in order to improve secondary prevention.

Statin Utilization Patterns and Outcomes for Patients with Acute Coronary Syndrome During and Following Inpatient Admissions

PURPOSE

High-intensity statins (HIS) are recommended by current treatment guidelines for patients with clinical atherosclerotic cardiovascular disease and should be administered soon after an acute coronary syndrome (ACS) event and maintained thereafter. However, adherence to guidelines remains adequate. Statin utilization patterns during index hospitalization and the first year after ACS event, and the association between statin utilization and post-discharge clinical and economic outcomes, are described.

METHODS

Retrospective, observational study of US adults from the MarketScan Research Databases (2002-2014) with ≥ 1 inpatient admission for ACS and no evidence of previous ACS event < 12 months prior to index.

RESULTS

In total, 7802 patients met inclusion criteria. The most common index hospitalization primary diagnosis was myocardial infarction (94.6%). In the 3-month period before ACS admission, 3.4 and 14.9% of patients received HIS or low-to-moderate intensity statin, versus 13.2 and 30.7% during index hospitalization, and 16.4 and 45.1% in the year of follow-up. Of 1336 patients with a statin prescription filled on/after discharge, 53.2% filled prescriptions within 15 days of discharge and 14.9% delayed for > 91 days. The most common post-index hospital admissions for cardiovascular events were due to recurrent ACS (incidence rate = 115.2), heart failure (110.0), and revascularization (76.4). During follow-up, 2355 patients (30.2%) had all-cause inpatient admissions and 1136 (14.6%) had cardiovascular-specific admissions; mean all-cause medical and healthcare costs were $2456 and $2870, respectively, per patient per month.

CONCLUSIONS

Statin dosing and utilization of HIS remains lower than recommended in current treatment guidelines, leaving patients at considerable risk of subsequent cardiovascular events.

Trends of Cardiovascular Risk Factors in Patients With Acute Myocardial Infarction: Soroka Acute Myocardial Infarction II (SAMI II) Project

CONCLUSIONS

The last decade, patients with AMI became older with increased burden of CVRFs. Framingham risk score increased among patients with NSTEMI and decreased in patients with STEMI. These trends impact on risk stratification and secondary prevention programs.

An alarming trend: Change in the risk profile of patients with ST elevation myocardial infarction over the last two decades

BACKGROUND

Coronary artery disease (CAD) is the leading cause of mortality around the world. We sought to study changes in the risk profile of patients presenting with ST elevation myocardial infarction (STEMI).

METHODS

We retrospectively studied all patients presenting with STEMI to our center between 1995 and 2014. Patients were divided into four quartiles, 5years each. Baseline risk factors and comorbidities were recorded. Sub-analysis was done for patients with established CAD and their household incomes.

RESULTS

A total of 3913 patients (67.9% males) were included; 42.5% presented with anterior STEMI and 57.5% inferior STEMI. Ages were 64±12, 62±13, 61±13 and 60±13 in the four quartiles respectively. Obesity prevalence was 31, 37, 38 and 40% and diabetes mellitus prevalence was 24, 25, 24 and 31%, while hypertension was 55, 67, 70 and 77%, respectively, p<0.01 for all. Smoking prevalence was 28, 32, 42 and 46, p<0.01. When subgroup analysis was done for patients with history of CAD, prevalence of smoking, obesity, diabetes and hypertension significantly increased across the four quartiles. When patients were divided to four groups based on household income (poor, low middle, middle and high income), prevalence of diabetes, hypertension, smoking and obesity were significantly higher in patients with low income.

CONCLUSION

Despite better understanding of cardiovascular risk factors and more focus on preventive cardiology, patients presenting with STEMI over the past 20years are getting younger and more obese, with more prevalence of smoking, hypertension, and diabetes mellitus. This trend is greater in the lower income population.

Changing Trends of Atherosclerotic Risk Factors Among Patients With Acute Myocardial Infarction and Acute Ischemic Stroke

We aimed to evaluate the secular trends in demographics, risk factors, and clinical characteristics of patients presenting with acute myocardial infarction (AMI) or acute ischemic stroke (AIS), using a large nationally representative data set of in-hospital admissions. We used the 2003 to 2013 Nationwide Inpatient Sample. All admissions with primary diagnosis of AMI or AIS were included. Across 2003 to 2013, a total of 1,360,660 patients with AMI and 937,425 patients with AIS were included in the study. We noted a progressive reduction in the mean age of patients presenting with AMI and AIS (p trend <0.001 for all groups), implying that the burden of young patients with these acute syndromes is progressively increasing. In addition, there was a progressive increase in the proportion of patients who are uninsured among patients presenting with AMI and AIS. Furthermore, despite a progressively younger age at presentation, there was an observed increase in the prevalence of atherosclerotic risk factors including hypertension, hyperlipidemia, diabetes, smoking, and obesity among patients presenting with AMI or AIS during 2003 to 2013. Significant disparities were noted in the prevalence of risk factors among various demographic and geographical cohorts. Low socioeconomic status as well as uninsured patients had a significantly higher prevalence of preventable risk factors like smoking and obesity as compared to the high socioeconomic status and insured patients, respectively. In conclusion, there have been significant changes in the risk factor profile of patients presenting with AMI and AIS over the last decade.

Trends in prevalence, incidence and mortality of diagnosed and silent coronary heart disease in Quebec

INTRODUCTION

Of all cardiovascular causes of mortality, coronary heart disease (CHD) remains the leading cause of death. Our objectives were to establish trends in the prevalence and incidence of CHD in the province of Quebec, and to determine the proportion of CHD mortality that had no previous CHD diagnosis.

METHODS

Trends in prevalence, incidence and mortality were examined with a population-based study using the Quebec Integrated Chronic Disease Surveillance System, which links several health administrative databases. Data are presented using two case definitions for Quebecers aged 20 years and over: 1) a validated definition, and 2) CHD causes of death codes added to estimate the proportion of deaths that occurred without any previous CHD diagnosis as a proxy for sudden cardiac death (SCD).

RESULTS

In 2012/2013, the crude prevalence of CHD was 9.4% with the first definition (593 000 people). Between 2000/2001 and 2012/2013, the age-standardized prevalence increased by 14%, although it has been decreasing slightly since 2009/2010. Age-standardized incidence and mortality rates decreased by 46% and 26% respectively, and represented a crude rate of 6.9 per 1000 and 5.2% in 2012/2013. The proportion identified only by CHD mortality, our SCD proxy, was only significant for the incident cases (0.38 per 1000 in 2009/2010) and declined over the study period.

CONCLUSION

The prevalence of CHD has tended to decrease in recent years, and incidence and mortality have been declining in Quebec. Most CHD mortality occurs in previously diagnosed patients and only a small proportion of incident cases were not previously identified.

Diagnosis of takotsubo cardiomyopathy is increasing over time in patients presenting as ST-elevation myocardial infarction

Background

Takotsubo cardiomyopathy often presents with the clinical signs of ST-elevation myocardial infarction (STEMI). The increase in scientific publications addressing this relatively rare condition may result in higher awareness and diagnosis of takotsubo cardiomyopathy.

Aim

To assess the observed prevalence per year of takotsubo cardiomyopathy in a large registry of patients with STEMI, during a 12-year inclusion period.

Method

All patients presenting with STEMI at a large regional cardiology clinic were entered into a database (n = 8,413, mean age 63 ± 13 years). Takotsubo cardiomyopathy was diagnosed in 42 patients (0.5 %). Years of evaluation were defined as ‘early years’ (January 2002 to December 2007; n = 4350) and ‘later years’ (January 2008 to December 2013). Multivariable analyses were performed to adjust for differences in demographical and clinical variables.

Results

In later years, the age of STEMI patients was slightly higher (64 ± 13 vs. 63 ± 13 years, p < 0.001), with more patients with clinical symptoms of shock (10 vs. 7 %, p < 0.001) or a history of percutaneous coronary intervention or hypertension (10 vs. 8 %, p = 0.001 and 37 vs. 34 %, p < 0.001). Smoking and a positive family history were less often observed during later years (39 vs. 46 %, p < 0.001 and 37 vs. 42 % p < 0.001). Patients with takotsubo cardiomyopathy were more often female (81 vs. 27 %, p = 0.001). Takotsubo cardiomyopathy was more often diagnosed in the later period (0.7 vs. 0.3 %, OR 2.4, 95 % CI 1.2–4.6, p = 0.009). The higher prevalence of takotsubo cardiomyopathy in recent years remained significant after adjustment for differences in patient characteristics (OR 2.1, 95 % CI 1.1–4.3).

Conclusion

Takotsubo cardiomyopathy is currently more often diagnosed in patients with STEMI compared with in earlier years. This is probably due to the increased scientific and clinical awareness among doctors, but the prevalence is still low.

Prognostic significance of whole blood viscosity estimated by de Simone’s formula in ST-elevation myocardial infarction

Background: We assessed the predictive value of estimated whole blood viscosity (WBV) in-hospital and long-term cardiovascular outcomes in patients with ST-elevation myocardial infarction (STEMI). Materials & methods: One thousand eight hundred and thirty-five STEMI patients were followed up for median 34.6 months. WBV was calculated consistent with the de Simone’s formula. Results: In-hospital and long-term major adverse cardiovascular events (MACE) demonstrated an incremental trend in ascending order of WBV tertiles at low and high shear rate. Kaplan–Meier analysis showed a higher occurrence of long-term MACE in third WBV tertiles compared with other tertiles. Conclusion: WBV seems to be a feasible prognostic indicator of short- and long-term cardiovascular adverse events in patients with STEMI. As an easily available parameter, WBV may be utilized in identifying high-risk patients for subsequent MACE.