Revascularization rates with coronary angioplasty and mortality in type 2 myocardial infarction: A meta-regression analysis

Biomarker profiles that differentiate type-1 and type 2 myocardial infarction

BACKGROUND

It is crucial to distinguish type-1 myocardial infarction (T1MI) from type-2 myocardial infarction (T2MI) at admission and during hospitalization to avoid unnecessary invasive exams and inappropriate admissions to the acute cardiac care unit.

OBJECTIVES

The purpose of the study was to define a simple profile derived from commonly used biomarkers to differentiate T1MI from T2MI.

METHODS

We prospectively enrolled in an observational study 213 iconsecutive patients with a provisional diagnosis of non-ST-elevation acute myocardial infarction (NSTEMI) admitted to the Cardiology Department. A final diagnosis of T1MI, T2MI, and non-ischemic acute myocardial injury (NAMI) was given based on clinical and instrumental findings. We assessed high-sensitivity Troponin I (hs-cTnI), Creatine Kinase MB (CK-MB), C-reactive protein (CRP), procalcitonin (PCT), N-Terminal prohormone of brain natriuretic peptide (NTproBNP).

RESULTS

A final diagnosis of T1MI was assigned to 77 patients, T2MI to 60 patients, and NAMI to 76 patients; mean age was not significantly different between groups (73 vs. 71 years), female were more prevalent in the T2MI/NAMI group (53 % vs. 34 %, p < 0.01). Hs-cTnI peak/upper limit of normal (ULN) (559 ± 770 vs. 286 ± 429; p = 0.04), hs-cTnI peak/CRP ratio (114 ± 337 vs. 83 ± 430; p < 0.001), hs-cTnI peak/PCT ratio (12,592 ± 21,467 vs. 4,609 ± 17,284; p < 0.001), and hs-cTnI peak/NTproBNP ratio (0.7 ± 1.6 vs. 0.3 ± 0.6; p < 0.01) differentiated T1MI from T2MI Hs-cTnI peak/ULN (559 ± 770 vs. 271 ± 412; p < 0.01), hs-cTnI peak/PCT ratio (12,592 ± 21,468 vs. 3,570 ± 12,469; p < 0.001), hs-cTnI peak/NTproBNP ratio (0.7 ± 1.6 vs. 0.3 ± 1.3; p < 0.001) and hs-cTnI peak/CRP (114 ± 337 vs. 48 ± 288; p < 0.001) differentiated T1MI from T2MI + NAMI. Hs-cTnI peak/PCT ratio was a predictor of T1MI, a multivariable logistic regression analysis (OR 1.03, 95 % CI 1.01-1.06, p < 0.05) with an accuracy of 0.704 (95 % CI 0.626-0.782, p < 0.001). No significant differences between T2MI and NAMI were detected.

CONCLUSIONS

Admission biomarker profile may differentiate T1MI from T2MI in patients admitted for NSTEMI.

Impact of Frailty on Outcome of Older Patients With Non-ST Elevation Acute Myocardial Infarction Who Undergo Percutaneous Coronary Intervention

Frailty status is linked with a poorer clinical outcome, and patients with frailty are often less revascularized, even with percutaneous coronary intervention (PCI). We therefore sought to assess the impact of frailty on the clinical outcome of older patients with non-ST elevation acute myocardial infarction (NSTEMI) who underwent PCI. We prospectively enrolled 141 consecutive older patients (>75 years) admitted for NSTEMI; 104 patients underwent PCI (35 with frailty, 69 without frailty), and 37 were not revascularized (22 with frailty, 15 without). Patients with frailty were older, less frequently male, more affected by dementia and severe left ventricular dysfunction, and less treated with PCI; patients treated with PCI were younger and less affected by dementia. Thirty-day mortality rates were proportionally higher, from 3% in patients without frailty treated with PCI, to 7% in patients without frailty not treated with PCI, 17% in patients with frailty treated with PCI, and 48% in patients with frailty not treated with PCI (p <0.05). Similarly, 6-month mortality rates were proportionally higher (12%, 29%, 37%, and 71%). At multivariable analysis, frail status was associated to a sixfold increased risk of mortality at 30 days; at 6 months, frail status was associated to a 3.4-fold risk of death (p <0.01), but PCI was also associated to a lower risk of mortality (odds ratio 0.2, p <0.01). In an observational study in older patients with NSTEMI, frail status is associated to a poorer outcome, whereas PCI is associated to a better long-term outcome. A careful selection of patient suitable for revascularization by PCI may be useful in improving outcomes of older patients with frailty with NSTEMI.

Time-Dependent Risk for Recurrence in Survivors of Major Adverse Cardiovascular Events

INTRODUCTION

The prevalence of the population with a history of an occlusive cardiovascular event has been increasing in recent years, which means that a large number of patients will have a higher risk of presenting a fatal recurrence. The aim is to determine variables associated with time-to-recurrent cardiovascular events and analyze how changes in low-density lipoprotein cholesterol (LDL-C) levels during follow-up may be associated with this time-to-event.

MATERIALS AND METHODS

This is a prospective observational cohort study of 727 adults with a history of at least one occlusive cardiovascular event recruited at a referral hospital in northeastern Colombia. Data from a follow-up period of a maximum of 33 months (median 26 months) (one death) were used to define how clinical and sociodemographic variables impact the recurrence of major adverse cardiovascular events (MACE). Analyses were performed based on proportional hazard models and time-dependent hazard models.

RESULTS

Upon enrollment, 215 (30%) of the participants reported experiencing their most recent cardiovascular event within the preceding year. After two years, the recurrence rate was 12.38% (90/727). The risk of recurrence before two years was 3.9% (95% CI 2.7-5.6). In the multiple models, the presence of severe depression gives a Hazard Ratio of 8.25 (95% CI 2.98-22.86) and LDL ≥120 md/dl Hazard Ratio of 2.12 (95% CI 1.2 -3.9). It was found that LDL >120 mg/dl maintained over time increases the chances of recurrence by 1.7% (Hazard Ratio: 1.017, 95% CI 0.008-0.025).

CONCLUSIONS

The present study allows us to identify a profile of patients who should be treated promptly in an interdisciplinary manner to avoid recurrences of coronary events.

Clinical outcomes associated with type II myocardial infarction caused by bleeding

BACKGROUND

Type ll myocardial infarction (T2MI) is caused by a mismatch between myocardial oxygen supply and demand. One subset of individuals is T2MI caused by acute hemorrhage. Traditional MI treatments including antiplatelets, anticoagulants, and revascularization can worsen bleeding. We aim to report outcomes of T2MI patients due to bleeding, stratified by treatment approach.

METHODS

The MGB Research Patient Data Registry followed by manual physician adjudication was used to identify individuals with T2MI caused by bleeding between 2009 and 2022. We defined 3 treatment groups: (1) invasively managed, (2) pharmacologic, and (3) conservatively managed Clinical parameters and outcomes for 30-day, mortality, rebleeding, and readmission were abstracted compared between the treatment groups.

RESULTS

We identified 5,712 individuals coded with acute bleeding, of which 1,017 were coded with T2MI during their admission. After manual physician adjudication, 73 individuals met the criteria for T2MI caused by bleeding. 18 patients were managed invasively, 39 received pharmacologic therapy alone, and 16 were managed conservatively. The invasively managed group experienced lower mortality (P = .021) yet higher readmission (P = .045) than the conservatively managed group. The pharmacologic group also experienced lower mortality (P= .017) yet higher readmission (P = .005) than the conservatively managed group.

CONCLUSION

Individuals with T2MI associated with acute hemorrhage are a high-risk population. Patients treated with standard procedures experienced higher readmission but lower mortality than conservatively managed patients. These results raise the possibility of testing ischemia-reduction approaches for such high-risk populations. Future clinical trials are required to validate treatment strategies for T2MI caused by bleeding.

The CHA2DS2-VASc Score Predicts New-Onset Atrial Fibrillation and Hemodynamic Complications in Patients with ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Arrhythmic and hemodynamic complications related to ST-segment elevation myocardial infarction (STEMI) represent a major clinical challenge. Several scores have been developed to predict mortality in STEMI. However, those scores almost exclusively include factors related to the acute phase of STEMI, and no score has been evaluated to date for its ability to specifically predict arrhythmic and hemodynamic complications. We, thus, aimed to assess the ability of chronic risk factors burden, as expressed by the CHA2DS2-VASc score, to predict STEMI-related arrhythmic and hemodynamic complications. Data were collected from 839 consecutive STEMI patients treated by primary percutaneous coronary interventions (pPCI). CHA2DS2-VASc and GRACE scores were calculated for all patients, and their ability to predict STEMI-related arrhythmic (i.e., new-onset atrial fibrillation (AF), ventricular tachycardia/fibrillation) and hemodynamic (i.e., cardiogenic shock, asystole) complications was assessed in univariate and multiple regression analysis. Arrhythmic and hemodynamic complications occurred in 14.8% and 10.2% of patients, respectively. Although the GRACE score outweighed the CHA2DS2-VASc score in the ability to predict STEMI-related hemodynamic complications (p < 0.0001), both scores had a similar predictive value for STEMI-related new-onset AF (p = 0.20), and both remained independent predictors of new-onset AF and of hemodynamic complications in the multiple regression analyses. A CHA2DS2-VASc score > 2 points independently predicted new-onset AF (p < 0.01) and hemodynamic complications (p = 0.04). Alongside the GRACE score, the CHA2DS2-VASc score independently predicted new-onset AF and hemodynamic complications in STEMI patients treated by pPCI. These data suggest that a combination of acute and chronic risk factors could provide additional benefit in identifying patients at risk of STEMI-related complications, who could benefit from closer follow-up and more intensive prophylactic and therapeutic strategies.

New horizons in Type 2 myocardial infarction: pathogenesis, assessment and management of an emerging geriatric disease

Type 2 myocardial infarction (MI) is characterised by a functional imbalance between myocardial oxygen supply and demand in the absence of a thrombotic process, leading to myocardial necrosis. This type of MI was relatively unknown among clinicians until the third universal definition of MI was published in 2017, differentiating Type 2 from Type 1 MI, which follows an acute atherothrombotic event. The pathogenesis, diagnostic and therapeutic aspects of Type 2 MI are described in the present review. Type 2 MI is a condition that is strongly linked to age because of vascular ageing concerning both epicardic vessels and microcirculation, age-related atherosclerosis and stress maladaptation. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extra-cardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying etiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of Type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older co-morbid patients with Type 2 MI, geriatricians and cardiologists need to work together to optimise etiological investigations, treatment and prevention of predisposing conditions and precipitating factors.

Meta-Regression Analysis of the Impact of Medical Therapy on Long-Term Mortality in Type 2 Myocardial Infarction

The first approach for Type-2 myocardial infarction (T2MI) consists of the elimination of the condition determining the oxygen supply/demand mismatch. However, the long-term impact of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors, used in the case of Type-1 myocardial infarction has been poorly investigated and remains unclear. We, therefore, sought to assess the impact of medical therapy on 1-year mortality in patients with T2MI using a meta-regression analysis. A meta-regression analysis was performed with studies involving in patients with T2MI: 1-year all-cause mortality, rates of beta blockers, statins, aspirin, and P2Y12 inhibitors use were recorded and analyzed. After careful study selection, 8 observational studies were pooled in the analysis, including 3,756 in patients. During meta-regression analysis, a borderline correlation between rates of aspirin, P2Y12 inhibitors, and statins use and 1-year mortality (p = 0.087, p = 0.05, and p = 0.067, respectively) was found; no significant correlation was found at multivariable analysis. In conclusion, in a meta-regression analysis, no significant correlation was found between rates of use of usual drug therapy indicated for Type-1 myocardial infarction (statins, aspirin, P2Y12 inhibitors, β-blockers) and 1-year mortality in T2MI patients.