Serum transaminase determined in the emergency room predicts outcomes in patients with acute ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention

Interrelation between hypoxic liver injury and Killip classification in ST-segment elevation myocardial infarction patients

Introduction

Hypoxic liver injury (HLI) and Killip classification are poor prognostic factors in patients with ST-segment elevation myocardial infarction (STEMI). This study investigates the interrelationship between hypoxic liver injury (HLI) and Killip classification.

Method and results

A total of 1,537 STEMI patients who underwent percutaneous coronary intervention (PCI) from 2007 to 2014 at four tertiary hospitals in the Incheon-Bucheon province were enrolled in this study. The patients were divided into four groups based on their Killip classification at presentation in the emergency room (ER). HLI was defined as a ≥2-fold increase in serum aspartate transaminase (AST). The incidence of HLI showed incremental tendency with respect to the Killip classification (19.5%, 19.4%, 34.6%, and 37.8%, respectively; p < 0.001). Left ventricular ejection fraction (LVEF) was below 45% in symptomatic, overt heart failure patients (Killip class II, III, and IV). Both initial and peak AST levels increased in accordance with Killip classification along with cardiac biomarkers. In-hospital mortality was directly related to Killip classification (2.3%, 7.3%, 16.3%, 29.2%) with statistical significance. Univariate and multivariate Cox regression analysis showed that the presence of HLI and combined Killip classification III and IV were poor prognostic factors, even after adjusting for conventional clinical risk factors. Receiver operating characteristic (ROC) analysis showed that combination of HLI and Killip classification was the most sensitive predictor of mortality (AUC 0.832, 95% CI 0.78-0.882). Kaplan-Meier curve showed that patients with HLI and Killip class (III and IV) had the lowest event-free survival regarding in-hospital mortality and major cardiovascular and cerebrovascular events.

Conclusions

The presence of HLI and Killip classification were directly related to worse prognosis in STEMI patients. Early recognition of HLI and accurate assessment of Killip classification is warranted for effective management of STEMI.

Multiplex Profiling of miR-122 for Preclinical and Clinical Evaluation of Drug-Induced Liver Injury by a Full-Scale Platform

Diagnostic and monitoring for drug-induced liver injury (DILI) predominantly rely on serum aminotransferases. However, owing to their widespread expression across multiple organs, a significant challenge emerges from the absence of reliable biomarkers for DILI diagnosis. Herein, we introduce a concept for DILI detection, circumventing the nonspecific elevation and delayed release of aminotransferases and then straightforwardly focusing on the core feature of DILI, abnormal gene expression caused by drug overdose. The developed full-scale platform integrates the properties of spherical nucleic acids with elaborately designed fluorescence in situ hybridization sequences, enabling the sensitive and specific profiling of drug-overdosed miR-122 expression alterations across molecular, cellular, organismal, and clinical scales and effectively bypassing the phenotypic features of disease. Furthermore, the diagnostic efficacies of serum and total RNA extracted from both mouse and human blood samples for DILI diagnosis were analyzed using the receiver operating characteristic curve and principal component analysis. We anticipate that this universal platform holds potential in facilitating DILI diagnosis, therapeutic evaluation, and prognosis.

Elevated liver enzymes in a German tertiary-care hospital: Distribution, diagnostic steps and diagnosis groups

BACKGROUND

The determination of liver blood tests is frequently performed in hospitalized patients, and abnormal values require further diagnostics. Yet, analyses considering the management of elevated liver enzymes are missing. Therefore, this study aimed to analyze the distribution of abnormal liver function tests and the subsequent diagnostic steps across different medical specialties.

METHODS

From our Hannover liver-injury database, we identified 63,300 cases of patients who were hospitalized between January 2008 and July 2021 with AST or ALT > 3 ULN or AP or TBI > 2 ULN at any time point during hospitalization. Of these, 29,547 cases fulfilled the inclusion criteria and were subjected to further analysis. Cases were analyzed according to the three groups: internal medicine, surgery and others. Analyses were performed regarding baseline characteristics, liver-related diagnostics and factors influencing hospital mortality.

RESULTS

Elevated liver blood tests were mainly observed in internal medicine (n=17,762, 60.1%), followed by the surgery department 34.2% (n=10,105). Notably, 40.2% (n=11,896) developed liver enzyme elevation above the cut-offs during the hospital stay. Testing for hepatitis B and C was more often performed in the surgery department compared to in internal medicine. In total, 5.6% of the cases (n=1,640) had a liver biopsy. Hyperbilirubinemia (total bilirubine ≥ 2ULN) and AST/ALT ratios >2 were associated with in-hospital mortality.

CONCLUSION

Clinicians are often faced with elevated liver enzymes. However, diagnostic steps differ between different specialties. Physicians should be aware of the increased in-hospital mortality in cases with hyperbilirubinemia or elevated AST/ALT ratios.

Anti-smoking drugs cytisine and varenicline reduce cardiac reperfusion injury in rat model of myocardial ischemia

Evidence to date indicates that activation of nicotinic acetylcholine receptors (nAChRs) can reduce cardiac injury from ischemia and subsequent reperfusion. The use of nAChR agonists in various animal models leads to a reduction in reperfusion injury. Earlier this effect was shown for the agonists of α7 nAChR subtype. In this work, we demonstrated the expression of mRNA encoding α4, α6 and β2 nAChR subunits in the left ventricle of rat heart. In a rat model of myocardial ischemia, we studied the effect of α4β2 nAChR agonists cytisine and varenicline, medicines used for the treatment of nicotine addiction, and found them to significantly reduce myocardium ischemia-reperfusion injury, varenicline manifesting a higher protection. Dihydro-β-erythroidine, antagonist of α4β2 nAChR, as well as methyllycaconitine, antagonist of α7 and α6β2-containing nAChR, prevented protective effect of varenicline. This together with the presence of α4, α6 and β2 subunit mRNA in the left ventricule of rat heart raises the possibility that the varenicline effect is mediated by α4β2 as well as by α7 and/or α6β2-containing receptors. Our results point to a new way for the use of cytisine and varenicline as cardioprotective agents.

Association of serum uric acid with prognosis in patients with myocardial infarction: an update systematic review and meta-analysis

BACKGROUND

The prognostic significance of serum uric acid (SUA) in individuals who have experienced myocardial infarction (MI) remains a subject of academic debate. Thus, the aim of this study was to examine the occurrence of immediate and long-term adverse outcomes in individuals with elevated levels of uric acid (UA) following a diagnosis of MI.

METHOD

This study conducted a literature search from PubMed, Embase, Web of Science, Medline, Cochrane Library, Emcrae, and Scopus to perform a systematic review and meta-analysis of the prognostic impact of MI with a hyper SUA to assess short-term (30-day or in-hospital) and long-term mortality, the incidence of major adverse cardiovascular events (MACE), and its adverse event rate in relation to SUA. The literature search was conducted up until April 2023. A random effects model and risk ratio (RR) were used as epidemiological indicators. For indicators with low disease rates, treatment intensity was reduced and RR was considered equivalent to odds ratio (OR). Hazard Ratio (HR), RR, and OR extracted from the data were simultaneously subjected to multivariable adjustment for confounding factors. In addition, P values for all original hypotheses were extracted and a meta-analysis was conducted. High SUA was defined as SUA levels equal to or greater than 420 μmol/L (7.0 mg/dL) for males and equal to or greater than 357 μmol/L (6.0 mg/dL) for females. The quality of the literature was evaluated using the Newcastle-Ottawa Scale (NOS).

RESULTS

This comprehensive study included a total of 41 investigations, involving a large sample size of 225,600 individuals who had experienced MI. The findings from the meta-analysis reveal that patients diagnosed with hyperuricemia have significantly increased rates of short-term mortality (RR = 2.14, 95% CI = 1.86, 2.48) and short-term incidence of MACE (RR = 1.94, 95% CI = 1.65-2.11). Furthermore, long-term adverse outcomes, including all-cause mortality (RR = 1.46, 95% CI = 1.40-1.51) and incidence of MACE (RR = 1.43, 95% CI = 1.35-1.52), were also found to be higher in this specific patient population.

CONCLUSION

Patients diagnosed with MI and elevated SUA levels exhibit a heightened incidence of MACE during their hospital stay. Furthermore, these individuals also experience elevated rates of in-hospital mortality and mortality within one year of hospitalization. However, it is important to note that further randomized controlled trials are necessary to validate and authenticate these findings.

Interaction between Acute Hepatic Injury and Early Coagulation Dysfunction on Mortality in Patients with Acute Myocardial Infarction

BACKGROUND

In acute myocardial infarction (AMI), acute hepatic injury is an independent risk factor for prognosis and is associated with complex coagulation dynamics. This study aims to determine the interaction between acute hepatic injury and coagulation dysfunction on outcomes in AMI patients.

METHODS

The Medical Information Mart for Intensive Care (MIMIC-III) database was used to identify AMI patients who underwent liver function testing within 24 h of admission. After ruling out previous hepatic injury, patients were divided into the hepatic injury group and the nonhepatic injury group based on whether the alanine transaminase (ALT) level at admission was >3 times the upper limit of normal (ULN). The primary outcome was intensive care unit (ICU) mortality.

RESULTS

Among 703 AMI patients (67.994% male, median age 65.139 years (55.757-76.859)), acute hepatic injury occurred in 15.220% (n = 107). Compared with the nonhepatic injury group, patients with hepatic injury had a higher Elixhauser comorbidity index (ECI) score (12 (6-18) vs. 7 (1-12), p < 0.001) and more severe coagulation dysfunction (85.047% vs. 68.960%, p < 0.001). In addition, acute hepatic injury was associated with increased in-hospital mortality (odds ratio (OR) = 3.906; 95% CI: 2.053-7.433; p < 0.001), ICU mortality (OR = 4.866; 95% CI: 2.489-9.514; p < 0.001), 28-day mortality (OR = 4.129; 95% CI: 2.215-7.695; p < 0.001) and 90-day mortality (OR = 3.407; 95% CI: 1.883-6.165; p < 0.001) only in patients with coagulation disorder but not with normal coagulation. Unlike patients with coagulation disorder and normal liver, patients with both coagulation disorder and acute hepatic injury had greater odds of ICU mortality (OR = 8.565; 95% CI: 3.467-21.160; p < 0.001) than those with normal coagulation.

CONCLUSIONS

The effects of acute hepatic injury on prognosis are likely to be modulated by early coagulation disorder in AMI patients.

Markedly Elevated Aspartate Aminotransferase from Non-Hepatic Causes

There have been no reports on mortality in patients with markedly elevated aspartate aminotransferase (AST) levels from non-hepatic causes to date. This study aimed to determine the etiologies of markedly elevated AST levels > 400 U/L due to non-hepatic causes and to investigate the factors associated with mortality in these cases. This retrospective study included 430 patients with AST levels > 400 U/L unrelated to liver disease at two centers between January 2010 and December 2021. Patients were classified into three groups according to etiology: skeletal muscle damage, cardiac muscle damage, and hematologic disorder. Binary logistic regression analysis was performed to evaluate the factors associated with 30-day mortality. The most common etiology for markedly elevated AST levels was skeletal muscle damage (54.2%), followed by cardiac muscle damage (39.1%) and hematologic disorder (6.7%). The 30-day mortality rates for the skeletal muscle damage, cardiac muscle damage, and hematologic disorder groups were 14.2%, 19.5%, and 65.5%, respectively. The magnitude of the peak AST level significantly correlated with 30-day mortality, with rates of 12.8%, 26.7%, and 50.0% for peak AST levels < 1000 U/L, <3000 U/L, and ≥3000 U/L, respectively. In the multivariate analysis, cardiac muscle damage (odds ratio [OR] = 2.76, 95% confidence interval [CI] = 1.31−5.80), hematologic disorder (OR = 9.47, 95% CI = 2.95−30.39), peak AST < 3000 U/L (OR = 2.94, 95% CI = 1.36−6.35), and peak AST ≥ 3000 U/L (OR = 9.61, 95% CI = 3.54−26.08) were associated with increased 30-day mortality. Our study revealed three etiologies of markedly elevated AST unrelated to liver disease and showed that etiology and peak AST level significantly affected the survival rate.

Prognostic value of De Ritis ratio in patients with acute myocardial infarction

BACKGROUND

The association between aspartate aminotransferase to alanine aminotransferase ratio (De Ritis ratio) and prognosis of patients with acute myocardial infarction (AMI) remains poorly investigated.

METHODS

This study included 3000 patients with AMI undergoing percutaneous coronary intervention. Patients were categorized in groups according to tertiles of the De Ritis ratio: tertile 1 (De Ritis ratio < 1.11; 905 patients), tertile 2 (De Ritis ratio 1.11 to 1.95; 1003 patients) and tertile 3 (De Ritis ratio > 1.95; 1002 patients). The primary endpoint was 3-year all-cause mortality.

RESULTS

At 3 years, all-cause deaths occurred in 487 patients: 119 deaths (13.2%) in patients of 1st tertile, 164 deaths (17.8%) in patients of 2nd tertile and 204 deaths (21.9%) in patients of 3rd tertile of the De Ritis ratio (adjusted hazard ratio [HR] = 1.16, 95% confidence interval [CI] 1.02 to 1.31], P = 0.023 per unit increment in the logarithmic scale of the De Ritis ratio); cardiac deaths occurred in 328 patients: 76 deaths (8.2%) in patients of 1st tertile, 110 deaths (12.0%) in patients of 2nd tertile and 142 deaths (15.4%) in patients of 3rd tertile of the De Ritis ratio (adjusted HR = 1.20 [1.04-1.40], P = 0.014 per unit increment in the logarithmic scale of De Ritis ratio). The C-statistic of the multivariable model(s) with baseline data without and with De Ritis ratio was 0.822 [0.805-0.839] and 0.823 [0.805-0.840], (P = 0.419) for all-cause mortality and 0.831[0.811-0.852] and 0.832 [0.811-0.853], P = 0.621) for cardiac mortality.

CONCLUSIONS

In patients with AMI, elevated De Ritis ratio was associated with increased risk of 3-year mortality.

Incorporation of Laboratory Test Biomarkers Into Dual Antiplatelet Therapy Score Improves Prediction of Ischemic and Bleeding Events in Post-percutaneous Coronary Intervention Patients

This study aimed to examine the performance of the dual antiplatelet therapy (DAPT) score in two retrospective cohorts of post-percutaneous coronary intervention (PCI) patients and to explore whether incorporating additional biomarkers could further improve the predictive power of the DAPT score. In a retrospective derivation cohort of 4,798 PCI patients, the validity of DAPT score for stratifying ischemic/bleeding risks was explored. Then, the association between the baseline status of 54 laboratory test biomarkers and ischemic/bleeding events was revealed while adjusting for the DAPT score. Combinations of individual laboratory test biomarkers that were significantly associated with ischemic/bleeding events were explored to identify the ones that improved discrimination of ischemic and bleeding events when incorporated into DAPT score. Finally, the impact of the combination of biomarkers with DAPT score was validated in an independent retrospective validation cohort of 1,916 PCI patients. Patients with a high DAPT score (DAPT score ≥ 2) had significantly higher risk of ischemic events and significantly lower risk of bleeding than patients with a low DAPT score (DAPT score < 2). Moreover, the addition of aspartate aminotransferase (AST) and red cell distribution width CV (RDW-CV) into the DAPT score further improved discrimination of ischemia and bleeding. Furthermore, the incremental predictive value of AST + RDW-CV maintained with measurements was updated at post-baseline time points. DAPT score successfully stratified the risks of ischemia/bleeding post PCI in the current cohorts. Incorporation of AST + RDW-CV into the DAPT score further improved prediction for both ischemic and bleeding events.

Systemic immune-inflammation index predicted the clinical outcome in patients with type-B aortic dissection undergoing thoracic endovascular repair

BACKGROUND

The systemic immune-inflammation index (SII) has been reported to have prognostic ability in various cardiovascular diseases; however, it has not been studied in type-B aortic dissection (TBAD). We aimed to explore the relation of SII with short-term and long-term outcomes in TBAD patients undergoing thoracic endovascular repair (TEVAR).

METHODS

We performed a retrospective analysis of a prospectively maintained database from 2010 to 2017. The patients were divided into two groups (high SII and low SII) as per the optimal cut-off value determined using the receiver operating characteristic curve. Multivariate logistic and Cox regression analyses were performed to analyse the relationship between the SII and the short-term and long-term outcomes.

RESULTS

A total of 805 TBAD patients who underwent TEVAR were enrolled. Twenty-six (3.2%) patients died during hospitalisation. At the end of a median follow-up duration of 48.80 mon, 70 (9.8%) patients had died. The patients were divided into the high-SII group [n = 333 (41.4%%)] and the low-SII group [n = 472 (58.6%)] as per the optimal cut-off value of 1,062. Multivariable logistic analyses showed that a high-SII score was independently associated with major adverse cardiovascular events (MACEs) in-hospital (odd ratio [OR], 1.67; 95% confidence interval [CI], 1.13-2.47; p = .01). In addition, multivariable Cox analyses showed that a high-SII score could be an independent indicator for follow-up adverse events (hazard ratio [HR], 1.70; 95% CI, 1.14-2.56, p = .01).

CONCLUSIONS

Systemic immune-inflammation index is associated with both in-hospital and long-term outcomes in patients with TBAD undergoing TEVAR. Therefore, SII may serve as valuable tool for risk stratification before intervention.

The Cardio-Hepatic Relation in STEMI

Background: Hepatic injury secondary to congestive heart failure is well described, however, only limited data exist about the possible impact of acute cardiac dysfunction on the liver. We aimed to explore the possible cardio-hepatic interaction in patients with myocardial infarction. Material and methods: A single-center retrospective cohort study of 1339 ST elevation myocardial infarction (STEMI) patients who underwent primary coronary intervention between June 2012 to June 2019. Echocardiographic examinations were performed to assess left ventricular ejection fraction (LVEF) and central venous pressure (CVP). Patients were stratified into four groups by their LVEF and CVP levels: LVEF ≥ 45%, and CVP ≤ 10 mm/Hg (n = 853), LVEF < 45% with CVP ≤ 10 mm/Hg (n = 364), EF ≥ 45%, with CVP > 10 mm/Hg (n = 61), and LVEF < 45% with CVP > 10 mm/Hg (n = 61). Patients were evaluated for baseline and peak liver enzymes including alanine transaminase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and bilirubin. Results: Greater severity of cardiac dysfunction was associated with worse elevation of liver enzymes. We found a graded increase in mean levels of maximal ALT, first and maximal ALP, and first and maximal GGT values. Using propensity score matching to estimate the impact of cardiac dysfunction on liver injury, we chose patients with the worst cardiac function parameters: (LVEF < 45% and CVP >10 mm/Hg; n = 61) and compared them to matched patients with better cardiac function (n = 45). We found a significantly higher level of maximal ALT, first and maximal ALP, and GGT values in the group with the worst cardiac function parameters (p < 0.05). Conclusions: Among patients with STEMI, the combination of decreased LVEF and venous congestion was associated with liver enzymes elevation suggesting a possible cardio-hepatic syndrome.

Clinical Implication of Hypoxic Liver Injury for Predicting Hypoxic Hepatitis and In-Hospital Mortality in ST Elevation Myocardial Infarction Patients

PURPOSE

In this study, we aimed to determine the value of hypoxic liver injury (HLI) in the emergency room (ER) for predicting hypoxic hepatitis (HH) and in-hospital mortality in ST elevation myocardial infarction (STEMI) patients.

MATERIALS AND METHODS

1537 consecutive STEMI patients were enrolled. HLI in the ER was defined as a ≥2-fold increase in serum aspartate transaminase (AST). HH was defined as a ≥20-fold increase in peak serum transaminase. Patients were divided into four groups according to HLI and HH status (group 1, no HLI or HH; group 2, HLI, but no HH; group 3, no HLI, but HH; group 4, both HLI and HH).

RESULTS

The incidences of HLI and HH in the ER were 22% and 2%, respectively. In-hospital mortality rates were 3.1%, 11.8%, 28.6%, and 47.1% for groups 1, 2, 3, and 4, respectively. Patients with HLI and/or HH had worse Killip class, higher cardiac biomarker elevations, and lower left ventricular ejection fraction. Multivariate logistic regression analysis showed that HLI in the ER was an independent predictor of HH [odds ratio 2.572, 95% confidence interval (CI) 1.166-5.675, p=0.019]. The predictive value of HLI in the ER for the development of HH during hospitalization was favorable [area under the curve (AUC) 0.737, 95% CI 0.643-0.830, sensitivity 0.548, specificity 0.805, for cut-off value AST >80]. Furthermore, in terms of in-hospital mortality, predictive values of HLI in the ER and HH during hospitalization were comparable (AUC 0.701 for HLI at ER and AUC 0.674 for HH).

CONCLUSION

Among STEMI patients, HLI in the ER is a significant predictor for the development of HH and mortality during hospitalization (INTERSTELLAR ClinicalTrials.gov number, NCT02800421).

Screening and identification of potential protein biomarkers for the early diagnosis of acute myocardial infarction

Background

Acute myocardial infarction (AMI) is the most serious type of heart disease. Clinically, there is an urgent need to discover diagnostic biomarkers for the early diagnosis of AMI.

Methods

Serum proteomic profiles in AMI patients, healthy controls, and stable angina pectoris (SAP) patients were explored and compared by iTRAQ-2DLC-MS/MS. The clinical data of AMI patients were also analyzed. Differentially expressed proteins were validated by enzyme linked immunosorbent assay (ELISA), and diagnostic models were constructed.

Results

A total of 39 differentially expressed proteins were identified in AMI patients. The results showed that the serum levels of apolipoprotein E (APOE) in AMI patients were notably higher than those in the healthy controls (P=0.0172). The serum levels of aspartate aminotransferase (AATC) in AMI patients were markedly higher than those in the healthy controls and SAP patients (P<0.0001 and P<0.0001, respectively). The serum levels of fibronectin (FINC) in SAP patients were significantly higher than those in the healthy controls and AMI patients (P=0.0043 and P=0.0044, respectively). Clinical data analysis showed a considerable difference in blood glucose levels, troponin I (TNI), and creatine kinase (CK) in AMI patients compared with SAP patients and healthy controls. A diagnostic model consisting of AATC and clinical indicators [lactate dehydrogenase (LDH) and CK] was established to distinguish between AMI patients and healthy controls, with an area under the curve (AUC) value of 0.993 sensitivity and specificity of 96.2% and 96.3%, respectively. A diagnostic model consisting of AATC and CK was established to distinguish between AMI patients and SAP patients, with an AUC value of 0.975 and a sensitivity and specificity of 85.2% and 79.30%, respectively.

Conclusions

In this study, differentially expressed proteins in AMI patients were combined with clinical indexes, LDH and CK, and two diagnostic models were constructed. This study may provide meaningful data for the early diagnosis of AMI.

The significance of transaminase ratio (AST/ALT) in acute myocardial infarction

Introduction

Fernando De Ritis described the significance of the transaminase (AST/ALT) ratio in 1957, and since then it has been commonly used to screen liver diseases. The liver is sensitive to hemodynamic changes because it receives approximately one-quarter of total cardiac output. We aimed to investigate the AST/ALT ratio changes in patients with acute myocardial infarction without any history of liver diseases in the Chinese Han population.

Material and methods

We analyzed a total of 120 patients with acute myocardial infarction admitted to the cardiology department of Zhongnan Hospital of Wuhan University between January 2019 and June 2019. AST/ALT ratio of the first blood test was calculated for all patients.

Results

The mean De Ritis ratio (AST/ALT) was higher in patients with ST-segment elevation myocardial infarction (STEMI) (3.2261 ±2.41379) than in non-ST-segment elevation myocardial infarction (NSTEMI) (2.2089 ±1.63177) patients. The difference was statistically significant (p = 0.002).

Conclusions

AST/ALT ≥ 2.0 has a strong association with total coronary occlusion. We might rely on this test to predict coronary occlusion without age difference.

Predictive value of elevated alanine aminotransferase for in-hospital mortality in patients with acute myocardial infarction

Background and aims

Liver enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are markers of hepatic dysfunction and fatty liver disease. Although ALT and AST have been suggested as risk factors for cardiovascular disease, their role as predictors of mortality after acute myocardial infarction (AMI) has not been established. The objective of this study was to investigate the predictive value of ALT and AST for mortality in patients with AMI.

Methods

We analyzed records of 712 patients with AMI and no known liver disease treated at the Department of Cardiovascular Center in the First Hospital of Jilin University. The primary outcome was all-cause in-hospital mortality. Relationships between primary outcome and various risk factors, including serum transaminase levels, were assessed using multivariate logistic regression analysis.

Results

Age (P < 0.001), hypertension (P = 0.034), prior myocardial infarction (P < 0.001), AST (P < 0.001), ALT (P < 0.001), creatinine (P = 0.007), blood urea nitrogen (P = 0.006), and troponin I (P < 0.001) differed significantly between ST-segment elevation myocardial infarction (STEMI) and non-STEMI. The following factors were associated with an increased risk of in-hospital all-cause mortality in patients with AMI: ALT ≥ 2ULN (adjusted odds ratio [AOR] 2.240 [95% confidence interval (CI), 1.331–3.771]; P = 0.002); age ≥ 65 year (AOR 4.320 [95% CI 2.687–6.947]; P < 0.001); increased fasting plasma glucose (FPG) (AOR 2.319 [95% CI 1.564–3.438]; P < 0.001); elevated D-dimer (AOR 2.117 [95% CI 1.407–3.184]; P < 0.001); elevated fibrinogen (AOR 1.601 [95% CI 1.077–2.380]; P = 0.20); and reduced estimated glomerular filtration rate (eGFR) (AOR 2.279 [95% CI 1.519–3.419]; P < 0.001).

Conclusions

Our findings demonstrated that elevated ALT was independently associated with increased in-hospital all-cause mortality in patients with AMI. Other risk factors were increased age, FPG, D-dimer, and fibrinogen and decreased eGFR.

Aspartate aminotransferase and mortality in patients with ischemic heart disease

BACKGROUND AND AIMS

Evidence on the association between aspartate aminotransferase (AST) activity and mortality of patients with ischemic heart disease (IHD) is limited. We investigated whether there is an association between AST activity and mortality in IHD patients.

METHODS AND RESULTS

The study included 6857 patients with coronary angiography-proven IHD and AST activity within the reference range. AST activity measurements were available in all patients. The primary outcome was 3-year cardiac mortality. Patients were categorized in groups according to the AST activity tertiles: a group with AST within the 1st tertile (AST < 17.0 U/L), a group with AST within the 2nd tertile (AST > 17-24.5 U/L) and a group with AST within the 3rd tertile (AST > 24.5 U/L). Cardiac death (n = 297) occurred in 109, 69 and 119 patients in the 1st to 3rd AST tertiles (Kaplan-Meier estimates of mortality: 5.3%, 3.6% and 5.9%; univariable hazard ratio [HR] = 1.75, 95% confidence interval [CI] 1.30-2.36, P < 0.001 for tertile 3 vs. 2; HR = 1.13 [0.87-1.46], P = 0.370 for tertile 3 vs. 1; and HR = 0.65 [0.48-0.87], P = 0.004 for tertile 2 vs. 1). The association between AST and cardiac mortality was U-shaped. AST values <15 U/L (HR = 1.118 [1.009-1.238]) and >23 U/L (HR = 1.029 [1.003-1.056]) were associated with higher cardiac mortality compared with the reference value (21 U/L). After adjustment, the association between AST and cardiac mortality was attenuated (P = 0.133) but remained non-linear (P = 0.047).

CONCLUSIONS

In patients with IHD, AST activity was associated with the risk of cardiac mortality with a U-shaped relationship. After adjustment, the association between AST and mortality was attenuated.

Addition of routine blood biomarkers to TIMI risk score improves predictive performance of 1-year mortality in patients with ST-segment elevation myocardial infarction

Background

Several biomarkers have been proposed as independent predictors of poor outcomes in ST-segment elevation myocardial infarction (STEMI). We investigated whether adding information obtained from routine blood tests including hypoxic liver injury (HLI), dysglycemia, anemia, and high neutrophil to lymphocyte ratio (NLR) could improve the prognostic performance of the TIMI risk score for the prediction of 1-year mortality.

Methods

A total of 1057 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) between 2007 and 2014 were retrospectively enrolled from 4-regional hospitals. HLI and dysglycemia were defined as serum transaminase > twice the normal upper limit and glucose < 90 or > 250 mg/dL, respectively. The effect of adding biomarkers to the TIMI risk score on its discriminative ability was assessed using c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

Results

The 1-year mortality rate was 7.1%. The best cutoff value of NLR for the prediction of 1-year mortality was 4.3 (sensitivity, 67%; specificity, 65%). HLI (HR 2.019; 95% CI 1.104–3.695), dysglycemia (HR 2.535; 95% CI 1.324–3.923), anemia (HR 2.071; 95% CI 1.093–3.923), and high NLR (HR 3.651; 95% CI 1.927–6.918) were independent predictors of 1-year mortality. When these 4 parameters were added to the TIMI risk score, the c-statistic significantly improved from 0.841 to 0.876 (p < 0.001), and the NRI and IDI were estimated at 0.203 (95% CI 0.130–0.275; p < 0.001) and 0.089 (95% CI 0.060–0.119; p < 0.001), respectively.

Conclusions

The addition of HLI, dysglycemia, anemia, and high NLR to the TIMI risk score may be useful for very early risk stratification in patients with STEMI receiving primary PCI.

Prognostic impact of the combination of serum transaminase and alkaline phosphatase determined in the emergency room in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Elevated serum transaminase or alkaline phosphatase (ALP) has been proposed as a novel prognosticator for ST-segment elevation myocardial infarction (STEMI). We evaluated the combined prognostic impact of elevated serum transaminases and ALP on admission in STEMI patients who underwent primary percutaneous coronary intervention (PCI).

Methods

A total of 1176 patients with STEMI undergoing primary PCI were retrospectively enrolled from the INTERSTELLAR registry. Hypoxic liver injury (HLI) was defined as serum transaminase > twice the upper limit of normal. The cut-off value of high ALP was set at the median level (73 IU/L). Patients were divided into four groups according to their serum transaminase and ALP levels. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven revascularization.

Results

Median follow-up duration was 25 months (interquartile range, 10–39 months). The rate of MACCE was highest in patients with HLI (+) and high ALP (25.9%), compared to those in the other groups (8.2% in HLI [-] and low ALP, 11.8% in HLI [-] and high ALP, and 15.0% in HLI [+] and low ALP). Each of HLI or high ALP was an independent predictor for MACCE (HR 1.807, 95% CI 1.191–2.741; HR 1.721, 95% CI 1.179–2.512, respectively). Combined HLI and high ALP was associated with the worst prognosis (HR 3.145, 95% CI 1.794–5.514).

Conclusions

Combined HLI and high ALP on admission is associated with poor clinical outcomes in patients with STEMI who have undergone primary PCI.

ALT-to-Lymphocyte Ratio as a Predictor of Long-Term Mortality in Patients with Normal Liver Function Presenting Coronary Artery Disease after Undergoing PCI: A Retrospective Cohort Study

Background

Alanine aminotransferase (ALT) is referred as liver transaminase and predominantly expressed by hepatocytes. Previous evidences showed that high levels of ALT were reversely associated with short- and long-term outcomes in patients with myocardial infarction. Besides, low lymphocyte has been demonstrated to be significantly correlated with adverse clinical outcomes in coronary artery disease (CAD). However, evidences about the relationship between ALT-to-lymphocyte ratio (ALR) and outcomes in CAD patients with normal liver function are limited. The aim of this study was to assess the relationship between ALR and clinical outcomes in patients with CAD.

Methods

This is a retrospective cohort study, and a total of 3561 patients were enrolled in Clinical Outcomes and Risk Factors of Patients with CAD after percutaneous coronary intervention (PCI), from January 2013 to December 2017. After excluding patients with liver dysfunction, we finally enrolled 2714 patients. These patients were divided into two groups according to ALR value: the lower group (ALR < 14.06, n = 1804) and the higher group (ALR ≥ 14.06, n = 910). The average follow-up time was 37.59 ± 22.24 months.

Results

We found that there were significant differences between the two groups in the incidence of all-cause mortality (ACM) (P < 0.001) and cardiac mortality (CM) (P=0.010). Kaplan–Meier survival analysis suggested that CAD patients with higher ALR tended to have an increased accumulated risk of ACM and CM (log rank P < 0.001 and P=0.006, respectively). Multivariate Cox regression analysis showed that ALR was an independent predictor of ACM (hazard ratio (HR) = 2.017 (95% confidence interval (CI): 1.289–3.158), P=0.002) and CM (HR = 1.862 (95% CI: 1.047–3.313), P=0.034). We did not find significant difference in the incidence of major adverse cardiovascular events (MACEs) and major adverse cardiovascular and cerebrovascular events (MACCEs) between the two groups after adjustments of confounders.

Conclusion

Our results indicate that ALR is an independent predictor of long-term adverse outcomes in CAD patients who underwent PCI.

Intermittent Hypoxic Conditioning Alleviates Post-Traumatic Stress Disorder-Induced Damage and Dysfunction of Rat Visceral Organs and Brain

Posttraumatic stress disorder (PTSD) causes mental and somatic diseases. Intermittent hypoxic conditioning (IHC) has cardio-, vaso-, and neuroprotective effects and alleviates experimental PTSD. IHC’s ability to alleviate harmful PTSD effects on rat heart, liver, and brain was examined. PTSD was induced by 10-day exposure to cat urine scent (PTSD rats). Some rats were then adapted to 14-day IHC (PTSD+IHC rats), while PTSD and untreated control rats were cage rested. PTSD rats had a higher anxiety index (AI, X-maze test), than control or PTSD+IHC rats. This higher AI was associated with reduced glycogen content and histological signs of metabolic and hypoxic damage and of impaired contractility. The livers of PTSD rats had reduced glycogen content. Liver and blood alanine and aspartate aminotransferase activities of PTSD rats were significantly increased. PTSD rats had increased norepinephrine concentration and decreased monoamine oxidase A activity in cerebral cortex. The PTSD-induced elevation of carbonylated proteins and lipid peroxidation products in these organs reflects oxidative stress, a known cause of organ pathology. IHC alleviated PTSD-induced metabolic and structural injury and reduced oxidative stress. Therefore, IHC is a promising preventive treatment for PTSD-related morphological and functional damage to organs, due, in part, to IHC’s reduction of oxidative stress.

Liver parameters as part of a non-invasive model for prediction of all-cause mortality after myocardial infarction

INTRODUCTION

Liver parameters are associated with cardiovascular disease risk and severity of stenosis. It is unclear whether liver parameters could predict the long-term outcome of patients after acute myocardial infarction (AMI). We performed an unbiased analysis of the predictive value of serum parameters for long-term prognosis after AMI.

MATERIAL AND METHODS

In a retrospective, observational, single-center, cohort study, 569 patients after AMI were enrolled and followed up until 6 years for major adverse cardiovascular events, including cardiac death. Patients were classified into non-survivors (n = 156) and survivors (n = 413). Demographic and laboratory data were analyzed using ensemble feature selection (EFS) and logistic regression. Correlations were performed for serum parameters.

RESULTS

Age (73; 64; p < 0.01), alanine aminotransferase (ALT; 93 U/l; 40 U/l; p < 0.01), aspartate aminotransferase (AST; 162 U/l; 66 U/l; p < 0.01), C-reactive protein (CRP; 4.7 U/l; 1.6 U/l; p < 0.01), creatinine (1.6; 1.3; p < 0.01), γ-glutamyltransferase (GGT; 71 U/l; 46 U/l; p < 0.01), urea (29.5; 20.5; p < 0.01), estimated glomerular filtration rate (eGFR; 49.6; 61.4; p < 0.01), troponin (13.3; 7.6; p < 0.01), myoglobin (639; 302; p < 0.01), and cardiovascular risk factors (hypercholesterolemia p < 0.02, family history p < 0.01, and smoking p < 0.01) differed significantly between non-survivors and survivors. Age, AST, CRP, eGFR, myoglobin, sodium, urea, creatinine, and troponin correlated significantly with death (r = -0.29; 0.14; 0.31; -0.27; 0.20; -0.13; 0.33; 0.24; 0.12). A prediction model was built including age, CRP, eGFR, myoglobin, and urea, achieving an AUROC of 77.6% to predict long-term survival after AMI.

CONCLUSIONS

Non-invasive parameters, including liver and renal markers, can predict long-term outcome of patients after AMI.

De-Ritis Ratio Improves Long-Term Risk Prediction after Acute Myocardial Infarction

Background: Recent evidence suggested levels of aspartate aminotransferase (AST), alanine transaminase (ALT), and AST/ALT ratio (De-Ritis ratio) were associated with a worse outcome after acute myocardial infarction (AMI). However, their value for predicting long-term prognosis remained unknown. Therefore, we investigated the prognostic potential of transaminases on patient outcome after AMI from a long-term perspective. Methods: Data of a large AMI registry including 1355 consecutive patients were analyzed. The Cox regression hazard analysis was used to assess the impact of transaminases and the De-Ritis ratio on long-term mortality. Results: The median De-Ritis ratio for the entire study population was 1.5 (interquartile range [IQR]: 1.0–2.6). After a median follow-up time of 8.6 years, we found that AST (crude hazard ratio (HR) of 1.19 per 1-SD [95% confidence interval (CI): 1.09–1.32; p < 0.001]) and De-Ritis ratio (crude HR of 1.31 per 1-SD [95% CI: 1.18–1.44; p < 0.001]), but not ALT (p = 0.827), were significantly associated with long-term mortality after AMI. After adjustment for confounders independently, the De-Ritis ratio remained a strong and independent predictor for long-term mortality in the multivariate model with an adjusted HR of 1.23 per 1-SD (95% CI: 1.07–1.42; p = 0.004). Moreover, the De-Ritis ratio added prognostic value beyond N-terminal pro-B-Type Natriuretic Peptide, Troponin T, and Creatine Kinase. Conclusion: The De-Ritis ratio is a strong and independent predictor for long-term mortality after AMI. As a readily available biomarker in clinical routine, it might be used to identify patients at risk for fatal cardiovascular events and help to optimize secondary prevention strategies after AMI.

Frequency and Prognostic Significance of Abnormal Liver Function Tests in Patients With Cardiogenic Shock

Cardiogenic shock (CS) is a cardiac emergency often leading to multiple organ failure and death. Assessing organ dysfunction and appropriate risk stratification are central for the optimal management of these patients. The purpose of this study was to assess the prevalence of abnormal liver function tests (LFTs), as well as early changes of LFTs and their impact on outcome in CS. We measured LFTs in 178 patients in CS from serial blood samples taken at 0 hours, 12 hours, and 24 hours. The associations of LFT abnormalities and their early changes with all-cause 90-day mortality were estimated using Fisher's exact test and Cox proportional hazards regression analysis. Baseline alanine aminotransferase (ALT) was abnormal in 58% of the patients, more frequently in nonsurvivors. Abnormalities in other LFTs analyzed (alkaline phosphatase, gamma-glutamyl transferase, and total bilirubin) were not associated with short-term mortality. An increase in ALT of >20% within 24 hours (ΔALT>+20%) was observed in 24% of patients. ΔALT>+20% was associated with a more than 2-fold increase in mortality compared with those with stable or decreasing ALT (70% and 28%, p <0.001). Multivariable regression analysis showed that ΔALT>+20% was associated with increased 90-day mortality independent of other known risk factors. In conclusion, an increase in ALT in the initial phase was seen in 1/4 of patients in CS and was independently associated with 90-day mortality. This finding suggests that serial ALT measurements should be incorporated in the clinical assessment of patients in CS.

Improved early risk stratification of patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention using a combination of serum soluble ST2 and NT-proBNP

Background

Although soluble suppression of tumorigenicity 2 (sST2) in serum is known to be associated with ischemic heart disease and heart failure, data regarding its prognostic impact in ST-segment elevation myocardial infarction (STEMI) is limited. We evaluated the prognostic impacts of serum sST2 and other serum biomarkers in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods

Consecutive all 323 patients with STEMI that underwent primary PCI were enrolled. Blood tests and samples were obtained in an emergency room. The primary endpoint was 1-year major adverse cardiovascular and cerebrovascular events (MACCEs), defined as a composite of cardiovascular death, non-fatal MI, non-fatal stroke, and ischemia-driven revascularization.

Results

Mean age was 59.1±13.1 years (men 84%). MACCE (20 cardiovascular deaths, 7 non-fatal MI, 4 non-fatal stroke, 7 ischemia-driven revascularizations) occurred in 38 patients (12%). After adjusting for confounding factors, Cox regression analysis revealed that high serum sST2 (>75.8 ng/mL mean value, adjusted hazard ratio 2.098, 95% CI 1.008–4.367, p = 0.048) and high serum NT-proBNP level (>400 pg/mL, adjusted hazard ratio 2.606, 95% CI 1.086–6.257, p = 0.032) at the time of presentation independently predicted MACCE within a year of primary PCI. Furthermore, when high serum sST2 level was combined with high serum NT-proBNP level, the hazard ratio of MACCE was highest (adjusted hazard ratio 7.93, 95% CI 2.97–20.38, p<0.001).

Conclusion

Elevated serum levels of sST2 or NT-proBNP at the time of presentation were found to predict 1-year MACCE independently and elevated serum levels of sST2 plus NT-proBNP were associated with even poorer prognosis in patients with STEMI undergoing primary PCI.

Prognostic nutritional index predicts clinical outcome in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

We aimed to investigate whether the prognostic nutritional index (PNI), a combined nutritional-inflammatory score based on serum albumin levels and lymphocyte count, was associated with mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). From September 2011 to November 2014, 309 consecutive patients with STEMI undergoing pPCI were prospectively enrolled. Patients with a combined score of albumin (g/L) + 5 × total lymphocyte count × 10⁹/L ≥ 45 or <45 were assigned a PNI score of 0 or 1, respectively. Of the 309 STEMI patients, 24 (7.74%) died in the hospital, and 15 (4.83%) died during long-term follow-up (median follow-up time, 19.5 [3–36] months). Compared to patients with a PNI of 0, patients with a PNI of 1 had significantly higher in-hospital (14.2% vs. 3.7%; P < 0.001) and long-term follow-up (21.7% vs. 6.9%, P < 0.001) mortality rates. PNI (1/0, HR, 2.414; 95% CI, 1.016 to 5.736; P = 0.046) was a significant independent predictor of mortality in patients with STEMI undergoing pPCI. Moreover, cumulative survival was significantly lower for patients with a PNI of 1 compared to patients with a PNI of 0 (78.3% vs. 93.1%, log-rank P < 0.001). PNI appears useful for the risk stratification of STEMI patients undergoing pPCI.

Prognostic Impact of Combined Dysglycemia and Hypoxic Liver Injury on Admission in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (from the INTERSTELLAR Cohort)

Dysglycemia on admission is known to predict the prognosis of ST-segment elevation myocardial infarction (STEMI). Recently, hypoxic liver injury (HLI) has been proposed as a novel prognosticator for STEMI. We evaluated the prognostic impact of combined dysglycemia and HLI at the time of presentation in patients with STEMI who underwent primary percutaneous coronary intervention. From 2007 to 2014, 1,525 consecutive patients (79% men, mean age 61 years) who underwent primary percutaneous coronary intervention for STEMI in the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort were analyzed retrospectively. Dysglycemia was defined as either hypoglycemia (serum glucose <90 mg/dl) or hyperglycemia (serum glucose >250 mg/dl). HLI was defined as more than twofold increase of any serum aminotransferases above the upper normal limit. Patients were divided into 4 groups according to their dysglycemia and HLI status on admission: group 1, normoglycemia without HLI; group 2, dysglycemia without HLI; group 3, normoglycemia with HLI; and group 4, dysglycemia with HLI. Primary end point was inhospital death and secondary end point was all-cause mortality at 12 months after the index procedure. Of the 1,525 patients, there were 87 inhospital deaths (5.7%) and 113 all-cause deaths (7.4%) at 12 months after the index procedure. Both dysglycemia and HLI on admission were independent predictors of inhospital death. Inhospital mortality rate was the highest in group 4 (32.1%), followed by groups 2 and 3. Kaplan-Meier survival analysis at 12 months showed similar trends among the 4 groups. In conclusion, combined dysglycemia and HLI on admission predicts early prognosis for STEMI.

Prognostic impact of alkaline phosphatase measured at time of presentation in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Background

Serum alkaline phosphatase (ALP) has been shown to be a prognostic factor in several subgroups of patients due to its promotion of vascular calcification. However, the prognostic impact of serum ALP level in ST-segment elevation myocardial infarction (STEMI) patients with a relatively low calcification burden has not been determined. We aimed to investigate the association of ALP level measured at time of presentation on clinical outcomes in patients with STEMI requiring primary percutaneous coronary intervention (PCI).

Methods

A total of 1178 patients with STEMI undergoing primary PCI between 2007 and 2014 were retrospectively enrolled from the INTERSTELLAR registry and classified into tertiles by ALP level (<64, 65–82, or >83 IU/L). The primary study outcome was a major adverse cardiac or cerebrovascular event (MACCE), defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven revascularization.

Results

Median follow-up duration was 25 months (interquartile range, 10–39 months). The incidence of MACCE significantly increased as ALP level increased, that is, for the <64, 65–82, and >83 IU/L tertiles incidences were 8.7%, 11.7%, and 15.7%, respectively; p for trend = 0.003). After adjustment for potential confounders, the adjusted hazard ratios for MACCE in the middle and highest tertiles were 1.69 (95% CI 1.01–2.81) and 2.46 (95% CI 1.48–4.09), respectively, as compared with the lowest ALP tertile.

Conclusions

Elevated ALP level at presentation, but within the higher limit of normal, was found to be independently associated with higher risk of MACCE after primary PCI in patients with STEMI.

Association of serum transaminases with short- and long-term outcomes in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Alanine transaminase (ALT) and aspartate aminotransferase (AST) are referred to as liver transaminases. Although used routinely in clinical practice for decades, their role as predictors of mortality has not been examined until recently. We studied the predictive value of these serum transaminases in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).

METHODS

We analyzed records of 2417 consecutive STEMI patients with no preexisting liver disease who were treated with primary PCI at the Cardiovascular Center in the First Hospital of Jilin University. The outcomes measured were all-cause mortality at the first month and at 2 years. The relationship between the baseline serum transaminase levels and primary outcome was determined.

RESULTS

We found a significant correlation between elevated liver transaminases and the Killip classification (P < 0.001 for ALT; P < 0.001 for AST), cardiac troponin I (P = 0.002 for ALT; P < 0.001 for AST), infarct-related coronary artery (P = 0.036 for ALT; P = 0.011 for AST), and pre-thrombolysis-in-myocardial-infarction (pre-TIMI) flow (P < 0.001 for ALT and AST). The serum level of ALT and AST were high along with the increasing of the grade of Killip classification. The primary infarct-related coronary artery in patients with ALT ≥95th percentage was left anterior descending artery (56%), followed by right coronary artery (36%). The OR for all-cause mortality at 2 years for participants with ALT ≥95th percentage was 5.370 (95% CI: 2.899-9.948), 7.034 (95% CI: 3.718-13.307) after adjustment for age and gender and 1.051 (95% CI: 0.302-3.652) after adjustment for all covariables. The OR for all-cause mortality at 2 years for participants with AST ≥95th percentage was 5.370 (95% CI 2.899-9.948) and 5.699 (95% CI 3.030-10.718) after adjustment for age and gender and 1.796 (95% CI: 0.588-5.481) after adjustment for all covariables. ALT (HR 1.004, 95% CI 1.001-1.006, P = 0.010) and AST (HR 0.999, 95% CI 0.998-1.000, P = 0.030) were associated with early all-cause mortality in patients with STEMI treated with PCI but not at 2 years post-procedure, unless for AST and ALT levels ≥95th percentage. Moreover, short- and long-term outcomes were significantly worse when both AST and ALT levels ≥95th percentage (P < 0.001).

CONCLUSIONS

Serum transaminases ≥95th percentage were associated with a significantly increased incidence of short- and long-term all-cause mortality.

TRIAL REGISTRATION

Registration number: ChiCTR-EPC-16008199 , 31 March 2016.

Combined biomarker testing for the prediction of left ventricular remodelling in ST-elevation myocardial infarction

Objective

The utility of different biomarkers for the prediction of left ventricular remodelling (LVR) following ST-elevation myocardial infarction (STEMI) has been evaluated in several studies. However, very few data exist on the prognostic value of combined biomarkers. The aim of this study was to comprehensively investigate the prognostic value for LVR of routinely available biomarkers measured after reperfused STEMI.

Methods

Serial measurements of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and high-sensitivity C reactive protein (hs-CRP) were performed in 123 patients with STEMI treated with primary percutaneous coronary intervention in this prospective observational study. Patients underwent cardiac MRI at 2 (1–4) and 125 (121–146) days after infarction. An increase in end-diastolic volume of ≥20% was defined as LVR.

Results

LVR occurred in 16 (13%) patients. Peak concentrations of the following biomarkers showed significant areas under the curves (AUCs) for the prediction of LVR—NT-proBNP: 0.68 (95% CI 0.59 to 0.76, p=0.03), hs-cTnT: 0.75 (95% CI 0.66 to 0.82, p<0.01), AST: 0.72 (95% CI 0.63 to 0.79, p<0.01), ALT: 0.66 (95% CI 0.57 to 0.75, p=0.03), LDH: 0.78 (95% CI 0.70 to 0.85, p<0.01) and hs-CRP: 0.63 (95% CI 0.54 to 0.72, p=0.05). The combination of all biomarkers yielded a significant increase in AUC to 0.85 (95% CI 0.77 to 0.91) (all vs NT-proBNP: p=0.02, all vs hs-cTnT: p=0.02, all vs AST: p<0.01, all vs ALT: p<0.01, all vs hs-CRP: p<0.01 and all vs LDH: p=0.04).

Conclusions

In patients with reperfused STEMI, the combined assessment of peak NT-proBNP, hs-cTnT, AST, ALT, hs-CRP and LDH provide incremental prognostic information for the prediction of LVR when compared with single-biomarker measurement.

Liver and cholestatic parameters as prognostic biomarkers of in-hospital MACE in patients with STEMI

BACKGROUND

Liver and cholestatic parameters are increased in ST-segment elevation myocardial infarction (STEMI). The aim of the present study was to evaluate the prognostic value of these parameters to predict in-hospital major adverse cardiac events (MACE) in patients after STEMI.

MATERIALS AND METHODS

Blood samples of patients with STEMI, who underwent percutaneous coronary intervention (PCI) and stent implantation, were retrospectively analysed and correlated with in-hospital events.

RESULTS

The study population consisted of 847 consecutive patients (62·4 ± 13·43 years; 73·8% male). The total in-hospital MACE rate was 9·8%, driven by death of any cause (8·4%). The Mann-Whitney U-test revealed that liver and cholestatic parameters (alanine transaminase P < 0·0001, aspartate transaminase P < 0·0001, alkaline phosphatase (AP) P < 0·0001, gamma-glutamyl transferase P = 0·0006 and total bilirubin P = 0·0023) were significantly higher in the MACE group. Further logistic regression analyses confirmed the correlation between MACE and all five laboratory markers, even after adjustment for age and heart enzymes. Logistic regression model revealed AP to be the best predictor for worth outcome (OR 1·0188; 95% CI 1·0118-1·0258; P < 0·0001).

CONCLUSION

Liver and cholestatic parameters are elevated in patients after STEMI. Increased AP is associated with in-hospital event rates.

Relation of Stature to Outcomes in Korean Patients Undergoing Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction (from the INTERSTELLAR Registry)

Although epidemiologic studies have shown the impact of height on occurrence and/or prognosis of cardiovascular diseases, the underlying mechanism is unclear. In addition, the relation in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) remains unknown. We sought to assess the influence of height on outcomes of patients with acute STEMI undergoing primary PCI and to provide a pathophysiological explanation. All 1,490 patients with STEMI undergoing primary PCI were analyzed. Major adverse cardiac and cerebrovascular events (MACCE) were defined as all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned hospitalization for heart failure (HF). Patients were divided into (1) MACCE (+) versus MACCE (-) and (2) first- to third-tertile groups according to height. MACCE (+) group was shorter than MACCE (-) group (164 ± 8 vs 166 ± 8 cm, p = 0.012). Prognostic impact of short stature was significant in older (≥70 years) male patients even after adjusting for co-morbidities (hazard ratio 0.951, 95% confidence interval 0.912 to 0.991, p = 0.017). The first-tertile group showed the worst MACCE-free survival (p = 0.035), and most cases of MACCE were HF (n, 17 [3%] vs 6 [1%] vs 2 [0%], p = 0.004). On post-PCI echocardiography, left atrial volume and early diastolic mitral velocity to early diastolic mitral annulus velocity ratio showed an inverse relation with height (p <0.001 for all) despite similar left ventricular ejection fraction. In conclusion, short stature is associated with occurrence of HF after primary PCI for STEMI, and its influence is prominent in aged male patients presumably for its correlation with diastolic dysfunction.

Prognostic Impact of Combined Contrast-Induced Acute Kidney Injury and Hypoxic Liver Injury in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: Results from INTERSTELLAR Registry

BACKGROUND

Besides contrast-induced acute kidney injury(CI-AKI), adscititious vital organ damage such as hypoxic liver injury(HLI) may affect the survival in patients with ST-elevation myocardial infarction (STEMI). We sought to evaluate the prognostic impact of CI-AKI and HLI in STEMI patients who underwent primary percutaneous coronary intervention (PCI).

METHODS

A total of 668 consecutive patients (77.2% male, mean age 61.3±13.3 years) from the INTERSTELLAR STEMI registry who underwent primary PCI were analyzed. CI-AKI was defined as an increase of ≥0.5 mg/dL in serum creatinine level or 25% relative increase, within 48h after the index procedure. HLI was defined as ≥2-fold increase in serum aspartate transaminase above the upper normal limit on admission. Patients were divided into four groups according to their CI-AKI and HLI states. Major adverse cardiovascular and cerebrovascular events (MACCE) defined as a composite of all-cause mortality, non-fatal MI, non-fatal stroke, ischemia-driven target lesion revascularization and target vessel revascularization were recorded.

RESULTS

Over a mean follow-up period of 2.2±1.6 years, 94 MACCEs occurred with an event rate of 14.1%. The rates of MACCE and all-cause mortality were 9.7% and 5.2%, respectively, in the no organ damage group; 21.3% and 21.3% in CI-AKI group; 18.5% and 14.6% in HLI group; and 57.7% and 50.0% in combined CI-AKI and HLI group. Survival probability plots of composite MACCE and all-cause mortality revealed that the combined CI-AKI and HLI group was associated with the worst prognosis (p<0.0001 for both).

CONCLUSION

Combined CI-AKI after index procedure and HLI on admission is associated with poor clinical outcomes in patients with STEMI who underwent primary PCI. (INTERSTELLAR ClinicalTrials.gov number, NCT02800421.).

Serum MiRNA panel as potential biomarkers for chronic hepatitis B with persistently normal alanine aminotransferase

BACKGROUND

Circulating miRNAs, a family of miRNAs existing in plasma and serum, have a great potential to serve as novel biomarkers in body fluids for non-invasive diagnosis and prognosis of many diseases.

METHODS

A multistage, case-control study was designed to establish a panel of serum miRNAs that could be surrogate markers for chronic hepatitis B with persistently normal alanine aminotransferase (ALT). A total of 295 CHB patients presenting persistently normal ALT levels with significant histological features (SPNALT group), 243 CHB patients presenting persistently normal ALT levels with no significant histological features (NSPNALT group), and 178 healthy controls (healthy group) were enrolled in the study. An initial screening of miRNAs was performed by Illumina sequencing using serum samples pooled from SPNALT patients and controls. Quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) assay was performed to evaluate the expression of selected miRNAs. A logistic regression model was constructed using a training cohort (n=380) and validated using a cohort (n=258). The area under the receiver operating characteristic curve (AUC) was used to evaluate diagnostic accuracy.

RESULTS

We identified 9 miRNAs (hsa-miR-885-5p, hsa-miR-122-5p, hsa-miR-10a-5p, hsa-miR-511-5p, hsa-miR-574-5p, hsa-miR-98-5p, hsa-miR-26a-5p, hsa-miR-192-5p, hsa-miR-30b-5p) and established 3 miRNA panels that provided high diagnostic accuracy for SPNALT. The AUC of miRNA panels for SPNALT vs. healthy was 0.882 (95% CI=0.839 to 0.925), for SPNALT vs. NSPNALT was 0.894 (95% CI=0.857 to 0.930), and for SPNALT vs. control was 0.860 (95% CI=0.821 to 0.899).

CONCLUSIONS

We constructed serum miRNA panels with considerable clinical value in diagnosing PNALT.

Amyotrophic Lateral Sclerosis Survival Score (ALS-SS): A simple scoring system for early prediction of patient survival

Our objectives were: (1) to identify independent prognostic factors to determine a survival score for amyotrophic lateral sclerosis (ALS) in a cohort of patients followed in the NEMO Centre (NEuroMuscular Omnicentre); (2) to replicate results in an independent cohort obtained from the Pooled Resource Open Access ALS Clinical Trial Consortium (PRO-ACT) database. Samples were collected from 428 ALS patients from the NEMO database and 2481 patients from the PRO-ACT database. Study design was a retrospective analysis with clinical and biochemical variables, using univariable and multivariable Cox models of analysis. Results showed that, in multivariable analysis, age at diagnosis, diagnostic delay, ALSFRS-R total score, Body Mass Index, aspartate aminotransferase and creatinine level were independently related to survival. These factors were recoded as categorical variables assigning a score from 5 to 15, and the sums of these scores were used to obtain the ALS-Survival Score (ALS-SS). This then allowed to identify three groups having different survival curves. The ALS-SS results were also replicated using data from the PRO-ACT database. In conclusion, considering independent prognostic factors, we were able to give an estimate of survival in our cohort of ALS patients. Whether this ALS-SS may be useful in clinical practice, and potentially in clinical trials, will have to be determined prospectively.

Prognostic significance of transaminases after acute ST-elevation myocardial infarction: insights from a cardiac magnetic resonance study

BACKGROUND

In patients with ST-elevation myocardial infarction (STEMI), the relationship between transaminases and myocardial damage detected by cardiac magnetic resonance (CMR) imaging is unknown and the prognostic value incompletely investigated.

MATERIALS AND METHODS

CMR imaging was performed in 167 STEMI patients 2.3 [1.6-3.9] days after primary percutaneous coronary intervention (PPCI). Blood samples for transaminase measurement (aspartate transaminase (AST) and alanine transaminase (ALT)) were obtained serially from day 1 to day 4 after PPCI. Patients were followed for major adverse cardiac events (MACE) for 2.7 [1.1-3.3] years.

RESULTS

Admission and peak concentrations of AST and ALT were significantly associated with ejection fraction (p < 0.001), infarct size (p < 0.001), and the presence of microvascular obstruction (p < 0.01). Peak values of both transaminases showed a stronger correlation with CMR parameters than admission values (all p < 0.05). In Kaplan-Meier analysis, a high peak AST or high peak ALT was associated with reduced MACE-free survival (both p < 0.01), whereas admission values were not (both p > 0.05). Peak AST (hazard ratio (HR): 4.93 [1.70-14.32], p = 0.003) and peak ALT (HR: 5.67 [1.94-16.56], p = 0.002) were independent predictors of MACE after adjusting for clinical risk factors.

CONCLUSIONS

Transaminases measured in the acute phase after PPCI for STEMI are associated with systolic dysfunction, more extensive myocardial necrosis and microvascular injury with subsequent prognostic information on MACE at long-term follow-up.