Relationship between left ventricular ejection fraction and mortality after myocardial infarction complicated by heart failure or left ventricular dysfunction

Left Ventricular Function, Congestion, and Effect of Empagliflozin on Heart Failure Risk After Myocardial Infarction

BACKGROUND

Empagliflozin reduces the risk of heart failure (HF) hospitalizations but not all-cause mortality when started within 14 days of acute myocardial infarction (AMI).

OBJECTIVES

This study sought to evaluate the association of left ventricular ejection fraction (LVEF), congestion, or both, with outcomes and the impact of empagliflozin in reducing HF risk post-AMI.

METHODS

In the EMPACT-MI (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction) trial, patients were randomized within 14 days of an AMI complicated by either newly reduced LVEF<45%, congestion, or both, to empagliflozin (10 mg daily) or placebo and were followed up for a median of 17.9 months.

RESULTS

Among 6,522 patients, the mean baseline LVEF was 41 ± 9%; 2,648 patients (40.6%) presented with LVEF <45% alone, 1,483 (22.7%) presented with congestion alone, and 2,181 (33.4%) presented with both. Among patients in the placebo arm of the trial, multivariable adjusted risk for each 10-point reduction in LVEF included all-cause death or HF hospitalization (HR: 1.49; 95% CI: 1.31-1.69; P < 0.0001), first HF hospitalization (HR: 1.64; 95% CI: 1.37-1.96; P < 0.0001), and total HF hospitalizations (rate ratio [RR]: 1.89; 95% CI: 1.51-2.36; P < 0.0001). The presence of congestion was also associated with a significantly higher risk for each of these outcomes (HR: 1.52, 1.94, and RR: 2.03, respectively). Empagliflozin reduced the risk for first (HR: 0.77; 95% CI: 0.60-0.98) and total (RR: 0.67; 95% CI: 0.50-0.89) HF hospitalizations, irrespective of LVEF or congestion, or both. The safety profile of empagliflozin was consistent across baseline LVEF and irrespective of congestion status.

CONCLUSIONS

In patients with AMI, the severity of left ventricular dysfunction and the presence of congestion was associated with worse outcomes. Empagliflozin reduced first and total HF hospitalizations across the range of LVEF with and without congestion. (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction [EMPACT-MI]; NCT04509674).

Sudden cardiac death in long-term follow-up in patients treated with primary percutaneous coronary intervention

Objective. Most studies analyzing predictors of sudden cardiac death (SCD) after acute myocardial infarction included only high-risk patients or index reperfusion had not been performed in all patients. The aim of our study was to analyze the incidence of SCD and determine the predictors of SCD occurrence during 6-year follow-up of unselected patients with ST-elevation myocardial infarction (STEMI), treated with primary percutaneous coronary intervention (pPCI). Method. we analysed 3114 STEMI patients included included in the University Clinical Center of Serbia STEMI Register. Patients presenting with cardiogenic schock were excluded. Echocardiographic examination was performed before hospital discharge. Results. During 6-year follow-up, lethal outcome was registered in 297 (9.5%) patients, of whom 95 (31.9%) had SCD. The highest incidence of SCD was recorded in the first year of follow-up, when SCD was registered in 25 patients, which is 26.3% of the total number of patients who had had SCD, i.e. 0.8% of the patients analyzed. The independent predictors for the occurrence of SCD during 6-year follow-up were EF < 45% (HR 3.07, 95% 1.87-5.02), post-procedural TIMI flow <3 (HR 2.59, 95%CI 1.37-5.14), reduced baseline kidney function (HR 1.87, 95%CI 1.12-2.93) and Killip class >1 at admission (HR 1.69, 95%CI 1.23-2.97). Conclusion. There is a low incidence of SCD in unselected STEMI patients treated with primary PCI. Predictors of SCD occurence during long-term follow-up in analyzed patients are clinical variables that are easily recorded during index hospitalization and include: EF ≤45%, post-procedural flow TIMI < 3, Killip class >1, and reduced baseline kidney function.

Role of Heart Rate Variability in the Association between Myocardial Infarction Severity and Post-Myocardial Infarction Distress

OBJECTIVE

Myocardial infarction (MI) results in mental health consequences, including depression and post-traumatic stress disorder (PTSD). The risk and protective factors of such mental consequences are not fully understood. This study examined the relation between MI severity and future mental health consequences and the moderating role of vagal nerve activity.

METHODS

In a reanalysis of data from the Myocardial Infarction-Stress Prevention Intervention (MI-SPRINT) study, 154 post-MI patients participated. MI severity was measured by the Killip Scale and by troponin levels. Depression and PTSD symptoms were assessed with valid questionnaires, both at 3 and 12 months. Vagal nerve activity was indexed by the heart rate variability (HRV) parameter of the root-mean square of successive R-R differences (RMSSD). Following multivariate analyses, the association between MI severity and distress was examined in patients with low and high HRV (RMSSD = 30 ms).

RESULTS

In the full sample, the Killip index predicted post-MI distress only at 3 months, while troponin predicted distress at 3- and 12-months post-MI. However, HRV moderated the effects of the Killip classification; Killip significantly predicted symptoms of depression and PTSD at 3- and 12-months post-MI, but only in patients with low HRV. Such moderation was absent for troponin.

CONCLUSION

MI severity (Killip classification) predicted post-MI depression and PTSD symptoms, but only in patients with low HRV, suggesting that the vagal nerve is a partial protective (moderating) factor in the relation between Killip score and post-MI distress.

Evaluation of a Structuralized Sick-Leave Programme Compared with usual Care Sick-Leave Management for Patients after an Acute Myocardial Infarction

OBJECTIVE

To compare a structuralized sick-leave programme with usual care sick-leave management in patients after an acute myocardial infarction. We hypothesize that a structured sick-leave programme will yield a faster return to work without negatively affecting quality of life.

METHODS

Patients admitted to Oslo University Hospital due to an acute myocardial infarction were included in the study. Patients were randomized into an intervention group or a conventional care group. Patients randomized to the intervention group were provided with a standard programme with full-time sick leave for 2 weeks after discharge and then encouraged to return to work. The sick leave of the conventional group was mainly managed by their general practitioner.

RESULTS

A total of 143 patients were included in the study. The conventional care group had a mean of 20.4 days absent from work, while that of the intervention group was significantly lower, with a mean of 17.2 days (p < 0.001) absent. There was no significant change in quality of life between the groups.

CONCLUSION

These findings strengthen the case for structuralized follow-up of patients with acute myocardial infarction, as this will have positive economic consequences for the patient and society as a whole, without making quality of life worse. Further investigation, with a larger study population, is warranted to determine the extent of health benefits conferred by early return to work.

Establishment and validation of a clinical nomogram model based on serum YKL-40 to predict major adverse cardiovascular events during hospitalization in patients with acute ST-segment elevation myocardial infarction

Objective

This study aimed to investigate the predictive value of a clinical nomogram model based on serum YKL-40 for major adverse cardiovascular events (MACE) during hospitalization in patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods

In this study, 295 STEMI patients from October 2020 to March 2023 in the Second People's Hospital of Hefei were randomly divided into a training group (n = 206) and a validation group (n = 89). Machine learning random forest model was used to select important variables and multivariate logistic regression was included to analyze the influencing factors of in-hospital MACE in STEMI patients; a nomogram model was constructed and the discrimination, calibration, and clinical effectiveness of the model were verified.

Results

According to the results of random forest and multivariate analysis, we identified serum YKL-40, albumin, blood glucose, hemoglobin, LVEF, and uric acid as independent predictors of in-hospital MACE in STEMI patients. Using the above parameters to establish a nomogram, the model C-index was 0.843 (95% CI: 0.79-0.897) in the training group; the model C-index was 0.863 (95% CI: 0.789-0.936) in the validation group, with good predictive power; the AUC (0.843) in the training group was greater than the TIMI risk score (0.648), p < 0.05; and the AUC (0.863) in the validation group was greater than the TIMI risk score (0.795). The calibration curve showed good predictive values and observed values of the nomogram; the DCA results showed that the graph had a high clinical application value.

Conclusion

In conclusion, we constructed and validated a nomogram based on serum YKL-40 to predict the risk of in-hospital MACE in STEMI patients. This model can provide a scientific reference for predicting the occurrence of in-hospital MACE and improving the prognosis of STEMI patients.

Association between the number of Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria and clinical outcomes in patients with acute coronary syndrome

BACKGROUND

Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been used to identify high-risk patients undergoing percutaneous coronary intervention (PCI) in current clinical practice. This study aimed to evaluate the association between the number of ARC-HBR criteria and clinical outcomes in patients with acute coronary syndrome (ACS) after an emergent PCI.

METHODS

We assessed 338 consecutive patients with ACS who underwent successful emergent PCI between January 2017 and December 2020. The ARC-HBR score was calculated by assigning 1 point to each major criterion and 0.5 points to each minor criterion. The patients were classified into low (ARC-HBR score<1), intermediate (1≤ARC-HBR score<2), and high (ARC-HBR score≥2) bleeding risk groups. We investigated the association between the ARC-HBR score and major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke. We also compared the diagnostic ability of the ARC-HBR score and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) risk score.

RESULTS

The mean age of the patients was 67.6±12.4years, and 78.4% were men. During the median follow-up of 864 (557-1309) days, 70 patients developed MACEs. Kaplan-Meier curves showed that the cumulative incidence of MACE was significantly higher as the ARC-HBR score increased in a stepwise manner (log-rank p<0.001). There were no significant differences in the area under the receiver operating characteristic curve (AUC) for predicting MACE within two years after an emergent PCI between the ARC-HBR and CADILLAC risk scores (AUC: 0.763 vs. 0.777).

CONCLUSIONS

ARC-HBR score was independently associated with an increased risk of MACE in patients with ACS after an emergent PCI. Moreover, it had a similar diagnostic ability for predicting MACE within two years compared to the CADILLAC risk score.

The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older

BACKGROUND

We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older.

METHODS

This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome.

RESULTS

Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups.

CONCLUSIONS

In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.

Construction and evaluation of nomogram model for individualized prediction of risk of major adverse cardiovascular events during hospitalization after percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction

Background

Emergency percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) helps to reduce the occurrence of major adverse cardiovascular events (MACEs) such as death, cardiogenic shock, and malignant arrhythmia, but in-hospital MACEs may still occur after emergency PCI, and their mortality is significantly increased once they occur. The aim of this study was to investigate the risk factors associated with MACE during hospitalization after PCI in STEMI patients, construct a nomogram prediction model and evaluate its effectiveness.

Methods

A retrospective analysis of 466 STEMI patients admitted to our hospital from January 2018 to June 2022. According to the occurrence of MACE during hospitalization, they were divided into MACE group (n = 127) and non-MACE group (n = 339), and the clinical data of the two groups were compared; least absolute shrinkage and selection operator (LASSO) regression was used to screen out the predictors with non-zero coefficients, and multivariate Logistic regression was used to analyze STEMI Independent risk factors for in-hospital MACE in patients after emergency PCI; a nomogram model for predicting the risk of in-hospital MACE in STEMI patients after PCI was constructed based on predictive factors, and the C-index was used to evaluate the predictive performance of the prediction model; the Bootstrap method was used to repeat sampling 1,000 Internal validation was carried out for the second time, the Hosmer-Lemeshow test was used to evaluate the model fit, and the calibration curve was drawn to evaluate the calibration degree of the model. Receiver operating characteristic (ROC) curves were drawn to evaluate the efficacy of the nomogram model and thrombolysis in myocardial infarction (TIMI) score in predicting in-hospital MACE in STEMI patients after acute PCI.

Results

The results of LASSO regression showed that systolic blood pressure, diastolic blood pressure, Killip grade II-IV, urea nitrogen and left ventricular ejection fraction (LVEF), IABP, NT-ProBNP were important predictors with non-zero coefficients, and multivariate logistic regression analysis was performed to analyze that Killip grade II-IV, urea nitrogen, LVEF, and NT-ProBNP were independent factors for in-hospital MACE after PCI in STEMI patients; a nomogram model for predicting the risk of in-hospital MACE after PCI in STEMI patients was constructed with the above independent predictors, with a C-index of 0.826 (95% CI: 0.785-0.868) having a good predictive power; the results of H-L goodness of fit test showed χ² = 1.3328, P = 0.25, the model calibration curve was close to the ideal model, and the internal validation C-index was 0.818; clinical decision analysis also showed that the nomogram model had a good clinical efficacy, especially when the threshold probability was 0.1-0.99, the nomogram model could bring clinical net benefits to patients. The nomogram model predicted a greater AUC (0.826) than the TIMI score (0.696) for in-hospital MACE after PCI in STEMI patients.

Conclusion

Urea nitrogen, Killip class II-IV, LVEF, and NT-ProBNP are independent factors for in-hospital MACE after PCI in STEMI patients, and nomogram models constructed based on the above factors have high predictive efficacy and feasibility.

Comparison of the modified Singapore myocardial infarction registry risk score with GRACE 2.0 in predicting 1-year acute myocardial infarction outcomes

Risk stratification plays a key role in identifying acute myocardial infarction (AMI) patients at higher risk of mortality. However, current AMI risk scores such as the Global Registry of Acute Coronary Events (GRACE) score were derived from predominantly Caucasian populations and may not be applicable to Asian populations. We previously developed an AMI risk score from the national-level Singapore Myocardial Infarction Registry (SMIR) confined to ST-segment elevation myocardial infarction (STEMI) patients and did not include non-STEMI (NSTEMI) patients. Here, we derived a modified SMIR risk score for both STEMI and NSTEMI patients and compared its performance to the GRACE 2.0 score for predicting 1-year all-cause mortality in our multi-ethnic population. The most significant predictor of 1-year all-cause mortality in our population using the GRACE 2.0 score was cardiopulmonary resuscitation on admission (adjusted hazards ratio [HR] 6.50), while the most significant predictor using the SMIR score was age 80–89 years (adjusted HR 7.78). Although the variables used in the GRACE 2.0 score and SMIR score were not exactly the same, the c-statistics for 1-year all-cause mortality were similar between the two scores (GRACE 2.0 0.841 and SMIR 0.865). In conclusion, we have shown that in a multi-ethnic Asian AMI population undergoing PCI, the SMIR score performed as well as the GRACE 2.0 score.

Association between baseline smoking status and clinical outcomes following myocardial infarction

Background

Whether the effect of smoking on clinical outcomes following an acute myocardial infarction (AMI) is beneficial or detrimental remains inconclusive. We invesetigated the effect of smoking on the clinical outcomes in patients following an AMI.

Methods

Among 13,104 patients between November 2011 and June 2015 from a nationwide Korean AMI registry, a total of 10,193 participants were extracted then classified into two groups according to their smoking habit: (1) smoking group (n = 6,261) and (2) non-smoking group (n = 3,932). The participants who smoked were further subclassified according to their smoking intensity quantified by pack years (PYs): (1) <20 PYs (n = 1,695); (2) 20–40 PYs (n = 3,018); and (3) ≥40 PYs (n = 2,048). Each group was compared to each other according to treatment outcomes. The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs), which is a composite of all-cause mortality, non-fatal MI (NFMI), any revascularization, cerebrovascular accident, rehospitalization, and stent thrombosis. Secondary outcomes included the individual components of MACCEs. The Cox proportional hazard regression method was used to evaluate associations between baseline smoking and clinical outcomes following an AMI. Two propensity score weighting methods were performed to adjust for confounders, including propensity score matching and inverse probability of treatment weighting.

Results

While the incidence of all clinical outcomes, except for stent thrombosis, was lower in the smoking group than in the non-smoking group in the unadjusted data, the covariates-adjusted data showed statistical attenuation of these differences but a higher all-cause mortality in the smoking group. For smokers, the incidence of MACCEs, all-cause mortality, cardiac and non-cardiac death, and rehospitalization was significantly different between the groups, with the highest rates of MACCE, all-cause mortality, non-cardiac death, and rehospitalization in the group with the highest smoking intensity. These differences were statistically attenuated in the covariates-adjusted data, except for MACCEs, all-cause mortality, and non-cardiac death, which had the highest incidence in the group with ≥40 PYs.

Conclusion

Smoking had no beneficial effect on the clinical outcomes following an AMI. Moreover, for those who smoked, clinical outcomes tended to deteriorate as smoking intensity increased.

The role of cardiac magnetic resonance imaging in defining the prognosis of patients with acute <i>ST</i>-segment elevation myocardial infarction. Part 2. Assessment of the disease prognosis

Currently the incidence of congestive heart failure after ST-segment elevation myocardial infarction (STEMI) tends to increase. Reperfusion therapy is still the only effective method to reduce an infarct size. Therefore, there is a high unmet need of novel cardioprotective treatments that would improve outcomes in such patients. Recent advances in cardiovascular magnetic resonance (CMR) methods enabled the identification of certain new infarct characteristics associated with the development of heart failure and sudden cardiac death. These characteristics can help identify new groups of high risk patients and used as a targets for novel cardioprotective treatments. This part of the review summarizes novel CMR-based characteristics of myocardial infarction and their role in the prognostic stratification of STEMI patients.

Mid-Term Mortality in Older Anemic Patients with Type 2 Myocardial Infarction: Does Blood Transfusion sImprove Prognosis?

(1) Anemia often predisposes older patients to type 2 myocardial infarction (T2MI). However, the management of this frequent association remains uncertain. We aimed to evaluate the impact of red blood cell transfusion during the acute phase of T2MI in older anemic inpatients. (2) Methods and results: We performed a retrospective study using a French regional database. One hundred and seventy-eight patients aged 65 years or older, presenting with a T2MI and anemia, were selected. Patients were split into two groups: one that received a red blood cell transfusion (≥1 red blood cell unit) and one that did not. A propensity score was built to adjust for potential confounders, and the association between transfusion and 30-day mortality was evaluated with an inverse propensity score weighted Cox model. Transfusion was not associated with 30-day all-cause mortality (propensity score weighted hazard ratio (HR) 1.59 (0.55-4.56), p = 0.38). However, 1-year all-cause mortality was significantly higher in the transfusion group (propensity score weighted HR 2.47 (1.22-4.97), p = 0.011). (3) Conclusion: Our findings in older adults with anemia suggest that blood transfusion in the acute phase of T2MI could not be associated with improved short-term prognosis. Prospective studies are urgently needed to assess the impact of transfusion on longer-term prognosis.

The Effects of Curcumin Plus Piperine Supplementation in Patients with Acute Myocardial Infarction: A Randomized, Double-Blind, and Placebo-Controlled Trial

BACKGROUND

Acute myocardial infarction (AMI) is a leading cause of death and disability worldwide. Previous investigations have demonstrated that curcumin has a cardioprotective effect and may improve myocardial injury. So this study was performed to assess whether supplementation with curcumin could diminish myocardial injury following AMI.

METHODS

To conduct this randomized, double-blinded, and placebo-controlled clinical trial, seventy-two patients with acute myocardial infarction, aged 18-75 years, were enrolled and randomly divided into the active intervention and control groups. The active intervention group (n = 38) received curcumin capsules with piperine supplement (500 mg/day, 95% curcuminoids) for 8 weeks, whereas the control group (n = 34) received a placebo capsule. At the baseline and end of the study, ejection fraction was assessed, and blood samples were taken from all patients to measure the levels of cardiac troponin I(cTnI), lipid profile, FBG, HbA1C, liver enzymes, renal function parameters, and electrolytes.

RESULTS

In this trial, curcumin supplementation significantly reduced the levels of HbA1C (-0.3 ± 2.2 vs. +1.1 ± 1.3, P = 0.002), LDL (-10.3 ± 20.7 vs. +0.2 ± 22.5, P = 0.039), ALT (-10.2 ± 28.5 vs. +7.3 ± 39.2, P = 0.029), and ALP (+6.4 ± 39.5 vs. +38.0 ± 69.0, P = 0.018) compared to the placebo group. Moreover, the serum concentration of HDL significantly improved in comparison with the placebo group (+4.5 ± 8.9 vs. -1.6 ± 7.7, P = 0.002). However, no substantial difference was perceived between the groups regarding the ejection fraction and serum levels of cTnI, FBG, renal function parameters, and electrolytes.

CONCLUSION

Our results indicated that daily intake of 500 mg of curcumin capsules with piperine supplement for 8 weeks modified lipid profile, liver enzymes, and glycemic status, but did not have any effect on ejection fraction and serum concentration of cardiac troponin I, renal function parameters, and electrolytes in acute myocardial infarction patients.

Relationship between in-hospital event rates and high bleeding risk score in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

Academic Research Consortium for High Bleeding Risk (ARC-HBR) was defined as a criterion for predicting the risk of bleeding in patients who undergo percutaneous coronary intervention (PCI). Major bleeding is related to in-hospital mortality. However, few studies examining the HBR criteria in patients with acute myocardial infarction (AMI) have been reported. We analyzed the relationship between HBR criteria in AMI patients and in-hospital events. This study was a single-center retrospective study that included 781 patients who underwent PCI for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) from January 2010 to December 2018. Patients were classified into the HBR group (n = 309, 39.6%) and non-HBR group (n = 472, 60.4%) and investigated. The primary endpoint was the incidence of in-hospital mortality, major bleeding, recurrent MI, and stroke. As a secondary endpoint, a multivariate analysis of cases of in-hospital death was performed to identify predictors of in-hospital mortality. As the primary outcome, the rate of all events in the HBR group was significantly higher than that in the non-HBR group (29.1% vs. 11.2%, p < 0.001). Among the individual events, the rates of major bleeding (11.3% vs. 3.8%, p < 0.001) and in-hospital mortality (16.2% vs. 4.2%, p < 0.001) were significantly higher in the HBR group. Regarding the secondary outcome, the overall in-hospital mortality rate was 9.0%. The multivariate analysis revealed that ejection fraction < 40%, HBR, Killip 4, and left main trunk lesion were significant predictors of in-hospital mortality. In conclusion, the HBR criteria were associated with in-hospital events in AMI patients who underwent primary PCI.

Cardioprotection by SGLT2 Inhibitors-Does It All Come Down to Na+?

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are emerging as a new treatment strategy for heart failure with reduced ejection fraction (HFrEF) and—depending on the wistfully awaited results of two clinical trials (DELIVER and EMPEROR-Preserved)—may be the first drug class to improve cardiovascular outcomes in patients suffering from heart failure with preserved ejection fraction (HFpEF). Proposed mechanisms of action of this class of drugs are diverse and include metabolic and hemodynamic effects as well as effects on inflammation, neurohumoral activation, and intracellular ion homeostasis. In this review we focus on the growing body of evidence for SGLT2i-mediated effects on cardiac intracellular Na⁺ as an upstream mechanism. Therefore, we will first give a short overview of physiological cardiomyocyte Na⁺ handling and its deterioration in heart failure. On this basis we discuss the salutary effects of SGLT2i on Na⁺ homeostasis by influencing NHE1 activity, late I_Na as well as CaMKII activity. Finally, we highlight the potential relevance of these effects for systolic and diastolic dysfunction as well as arrhythmogenesis.

Global Left Ventricular Myocardial Work Efficiency and Long-Term Prognosis in Patients After ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction in patients with ST-segment-elevation myocardial infarction. However, LV global longitudinal strain does not take into consideration the effect of afterload. Novel speckle-tracking echocardiographic indices of myocardial work integrate blood pressure measurements (afterload) with LV global longitudinal strain. The present study aimed to investigate the prognostic value of global LV myocardial work efficiency (GLVMWE; reflecting LV performance) obtained from pressure-strain loops with echocardiography in patients with ST-segment-elevation myocardial infarction.

METHODS

A total of 507 ST-segment-elevation myocardial infarction patients (mean age, 61±11 years; 76% men) were retrospectively analyzed. LV ejection fraction and GLVMWE were measured by transthoracic echocardiography within 48 hours of admission. GLVMWE was defined as the ratio of constructive work divided by the sum of constructive and wasted work in all LV segments and expressed as a percentage. Spline curve analysis was used to define the association between reduced GLVMWE and all-cause death.

RESULTS

After a median follow-up of 80 months (interquartile range, 67-97 months), 40 (8%) patients died. Patients with reduced GLVMWE (<86%) showed higher cumulative rates of all-cause mortality (17.5% versus 4.7%; log-rank P<0.001) in comparison with patients with preserved GLVMWE (≥86%). Reduced GLVMWE (<86%) showed an independent association with all-cause mortality (hazard ratio, 3.167 [95% CI, 1.679-5.972]; P<0.001).

CONCLUSIONS

Reduced GLVMWE (<86%) measured by transthoracic echocardiography within 48 hours of admission in ST-segment-elevation myocardial infarction patients is associated with worse long-term survival.

Augmented Oscillations in QT Interval Duration Predict Mortality Post Myocardial Infarction Independent of Heart Rate

Objective

This study seeks to decompose QT variability (QTV) into physiological sources and assess their role for risk stratification in patients post myocardial infarction (MI). We hypothesize that the magnitude of QTV that cannot be explained by heart rate or respiration carries important prognostic information.

Background

Elevated beat-to-beat QTV is predictive of cardiac mortality, but the underlying mechanisms, and hence its interpretation, remain opaque.

Methods

We decomposed the QTV of 895 patients post MI into contributions by heart rate, respiration, and unexplained sources.

Results

Cox proportional hazard analysis demonstrates that augmented oscillations in QTV and their level of dissociation from heart rate are associated with a higher 5-year mortality rate (18.4% vs. 4.7%, p < 0.0001). In patients with left ventricular ejection fraction (LVEF) > 35%, a higher QTV risk score was associated with a significantly higher 5-year mortality rate (16% vs. 4%, p < 0.0001). In patients with a GRACE score ≥ 120, a higher QTV risk score was associated with a significantly higher 5-year mortality (25% vs. 11%, p < 0.001).

Conclusion

Augmented oscillations in QTV and discordance from heart rate, possibly indicative of excessive sympathetic outflow to the ventricular myocardium, predict high risk in patients post MI independent from established risk markers.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT00196274.

Rhythm Control in Heart Failure Patients with Atrial Fibrillation

AF and heart failure (HF) commonly coexist. Left atrial ablation is an effective treatment to maintain sinus rhythm (SR) in patients with AF. Recent evidence suggests that the use of ablation for AF in patients with HF is associated with an improved left ventricular ejection fraction and lower death and HF hospitalisation rates. We performed a systematic search of world literature to analyse the association in more detail and to assess the utility of AF ablation as a non-pharmacological tool in the treatment of patients with concomitant HF.

Temporal changes in left ventricular ejection fraction and their prognostic impacts in patients with Stage B heart failure

BACKGROUND

We have recently demonstrated that left ventricular ejection fraction (LVEF) dynamically changes over time with prognostic impacts in Stage C/D patients, namely, those who have a current or past history of heart failure (HF). However, it is unknown whether this is also the case in asymptomatic Stage B patients, namely, those who have a risk of HF, but do not have a history of HF.

METHODS

In our CHART-2 Study (N = 10,219), we enrolled 4005 Stage B patients and divided them into 3 groups by LVEF; preserved EF (pEF, LVEF ≥50%, N = 3526), mid-range EF (mrEF, LVEF 41-49%, N = 302), and reduced EF (rEF, LVEF ≤40%, N = 177). We examined the prognostic impacts of LVEF transitions among the 3 groups in comparison with 4477 patients with Stage C/D HF.

RESULTS

Stage B were characterized by less severe clinical status and better prognosis compared with Stage C/D. Stage B in mrEF and rEF at baseline dynamically transitioned to other groups at 1-year, whereas those in pEF unchanged; at 1-year, mrEF transitioned to pEF/rEF by 50/16%, and rEF transitioned to pEF/mrEF by 25/31%, respectively, whereas pEF transitioned to mrEF/rEF by only 3.6/0.7%, respectively, which were consistent with findings in findings with Stage C/D. Although LVEF decrease was directly associated with all-cause mortality in both the Stage B and Stage C/D with pEF, factors related to LVEF changes were different between the 2 groups.

CONCLUSIONS

In Stage B, LVEF dynamically changes with prognostic impacts as in Stage C/D, whereas different determination factors may be involved in the 2 stages.

CLINICAL TRIAL REGISTRATION

Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 (NCT00418041).

Left ventricular ejection fraction and adjudicated, cause-specific hospitalizations after myocardial infarction complicated by heart failure or left ventricular dysfunction

BACKGROUND

Reduced left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) increases risk of cardiovascular (CV) hospitalizations, but evidence regarding its association with non-CV outcome is scarce. We investigated the association between LVEF and adjudicated cause-specific hospitalizations following MI complicated with low LVEF or overt heart failure (HF).

METHODS

In an individual patient data meta-analysis of 19,740 patients from 3 large randomized trials, Fine and Gray competing risk modeling was performed to study the association between LVEF and hospitalization types.

RESULTS

The most common cause of hospitalization was non-CV (n = 2,368 for HF, n = 1,554 for MI, and n = 3,703 for non-CV). All types of hospitalizations significantly increased with decreasing LVEF. The absolute risk increase associated with LVEF ≪25% (vs LVEF ≫35%) was 15.5% (95% CI 13.4-17.5) for HF, 4.7% (95% CI 3.0-6.4) for MI, and 10.4% (95% CI 8.0-12.8) for non-CV hospitalization. On a relative scale, after adjusting for confounders, each 5-point decrease in LVEF was associated with an increased risk of HF (hazard ratio [HR] 1.15, 95% CI 1.12-1.18), MI (HR 1.06, 95% CI 1.03-1.10), and non-CV hospitalization (HR 1.03, 95% CI 1.01-1.05).

CONCLUSIONS

In a high-risk population with complicated acute MI, the absolute risk increase in non-CV hospitalizations associated with LVEF ≪25% was two thirds of the absolute risk increase in HF hospitalizations and twice the absolute risk increase in MI hospitalizations. LVEF was an independent predictor of all types of hospitalization and appears as an integrative marker of sicker patient status.

Determinants and prognostic value of cardiac magnetic resonance imaging-derived infarct characteristics in non-ST-elevation myocardial infarction

Aims

The prognostic significance of cardiac magnetic resonance (CMR)-derived infarct characteristics has been demonstrated in ST-elevation myocardial infarction (STEMI) cohorts but is undefined in non-ST-elevation myocardial infarction (NSTEMI) patients. We aimed to investigate determinants and the long-term prognostic impact of CMR imaging-derived infarct characteristics in patients with NSTEMI.

Methods and results

Infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction were assessed using CMR imaging in 284 NSTEMI patients undergoing percutaneous coronary intervention (PCI) in three centres. CMR imaging was performed 3 [interquartile range (IQR) 2–4] days after admission. The primary clinical endpoint was defined as major adverse cardiac events during median follow-up of 4.4 (IQR 3.6–4.9) years. Median IS was 7.2% (IQR 2.2–13.7) of left ventricular (LV) myocardial mass (%LV) and MSI was 65.7 (IQR 39.3–84.9). Age (P ≤ 0.003), heart rate (P ≤ 0.02), the number of diseased coronary arteries (P ≤ 0.01), and Thrombolysis In Myocardial Infarction (TIMI) flow grade before PCI (P &lt; 0.001) were independent predictors of IS and MSI. The primary endpoint occurred in 64 (22.5%) patients. CMR-derived infarct characteristics had no additional prognostic value beyond LV ejection fraction in multivariable analysis.

Conclusion

In this prospective, multicentre NSTEMI cohort reperfused by PCI, age, heart rate, the number of diseased coronary arteries, and TIMI flow grade before PCI were independent predictors of IS and MSI assessed by CMR. However, in contrast to STEMI patients there was no additional long-term prognostic value of CMR-derived infarct characteristics over and above LV ejection fraction.

Clinicaltrials.gov

NCT03516578.

Mid-term outcomes after percutaneous interventions in coronary bifurcations

BACKGROUND

The optimal treatment of patients undergoing percutaneous coronary interventions (PCI) for lesions located at coronary bifurcations is still debated.

METHODS

Data on 5036 consecutive patients who underwent PCI on coronary bifurcation at 17 major coronary intervention centers between January 2012 and December 2014 were collected.

RESULTS

Follow-up at a median 18 months (IQR 11-28) was available for 4506 patients (89%). Major Adverse Cardiac Events (MACE) occurred in 395 patients (8.8%): cardiac death in 152 (3.4%), myocardial infarction, excluding periprocedural, in 156 (3.5%) and stent thrombosis in 110 cases (2.4%). At multivariable Cox regression, left ventricular ejection fraction ≤30% (P < 0.001), bail-out stenting (beyond a planned strategy of either single or double stenting) (P < 0.001), admission for an acute coronary syndrome (P < 0.001), age >66 years (P < 0.001), multivessel disease (P < 0.001) and diabetes (P < 0.001) were independently associated with MACE. Sensitivity analysis identified premature discontinuation of dual antiplatelet therapy (DAPT) (P < 0.001) and side branch (SB) lesion length ≥9 mm (P < 0.05) as additional independent predictors of MACE.

CONCLUSIONS

Beyond traditional risk factors, multivessel disease, the length of the SB lesion, "bail-out" stenting and premature DAPT discontinuation are independent predictors of mid-term MACE after PCI of coronary bifurcations. This highlights the importance of a carefully planned PCI strategy and adequate therapy adherence to improve the clinical outcomes in these patients.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01967615.