Clinical profile of acute myocardial infarction in elderly patients

Shortness of breath as a diagnostic factor for acute coronary syndrome in male and female callers to out-of-hours primary care

OBJECTIVE

Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting.

METHODS

A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases.

RESULTS

Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men.

CONCLUSIONS

Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases.

Relationship Between Number of Cardiac Rehabilitation Exercise Training Sessions, Muscle Mass, and Cardiorespiratory Fitness in Rural Elderly Patients with Coronary Artery Disease

Purpose

This study aimed to compare the effects of a cardiac rehabilitation (CR) exercise program on skeletal muscle index (SMI) and cardiorespiratory fitness (CRF) in patients aged ≥65 years.

Patients and Methods

From January 2012 to December 2021, patients living in rural regions aged ≥65 who underwent percutaneous coronary intervention for acute myocardial infarction (AMI) and at least one CR exercise session were enrolled. We retrospectively reviewed the medical records of the patients who underwent an exercise tolerance test (ETT) at initial and 3-month follow-ups. A total of 36 patients were enrolled who underwent a mean of 6.56 exercise sessions and were divided into groups based on the number of center-based CR (CBCR) sessions: 14 in Group A (≥7 sessions) and 22 in Group B (<7 sessions). In CBCR session, we comprehensively counseled them about their nutrition, smoking cessation et al. Both groups underwent an ETT after 12 weeks. The outcomes were CRF parameters examined by a cardiorespiratory exercise test and the SMI examined by bioimpedance analysis (BIA).

Results

The number of exercise sessions was significantly correlated with the rate of SMI change. Group A showed significant increases in metabolic equivalent of task (MET), maximal oxygen uptake (VO2max), and SMI after 3 months. There were significant differences in the rates of change in MET, VO2max, and SMI between the two groups.

Conclusion

CRF significantly improved in Group A in a short period. Further studies are required to increase long-term CBCR adherence in elderly patients with AMI in rural regions.

Primary Percutaneous Coronary Intervention in the Left Main ST-Elevation Myocardial Infarction and Cardiogenic Shock on Octogenarian Patient with Single Remaining Vessel

The left main coronary artery (LMCA) ST-elevation myocardial infarction has been associated with significant morbidity and mortality. Older age and cardiogenic shock are independent predictors for in-hospital mortality. Here, we report a case of an 89-year-old Javanese man with a history of smoking presented with total LMCA occlusion complicated by cardiogenic shock in an octogenarian that was saved by stenting in thrombolysis in myocardial Infarction Flow III right coronary artery.

Effect of seasonality in hospitalizations and deaths from acute myocardial infarction in southern Brazil from 2009 to 2018

INTRODUCTION

Acute myocardial infarction (AMI) is one of the main causes of morbidity and mortality in Brazil and worldwide. Seasonality and climate change seem to be associated with hospitalization for AMI.

OBJECTIVE

to analyze the effect that seasonality and temperature have on the number of hospitalizations and deaths due to AMI, stratified by gender and age group, from 2009 to 2018 in a region of southern Brazil.

METHODS

An Ecological study, composed of cases of hospitalizations and deaths by AMI in the Association of Municipalities of the Laguna Region (AMUREL), SC, Brazil. Data on AMI were collected by the Department of Informatics of the Unified Health System (DATASUS) and data on average monthly temperature (degrees Celsius) of the Laguna region (SC, Brazil) were provided by the National Institute of Meteorology (INMET). The data analysis was performed through linear regression and ANOVA test with Tukey post-hoc.

RESULTS

2947 hospitalizations were analyzed. The monthly average hospitalization per AMI was 24.6±8.1 cases (7.0±2.2/100,000 inhabitants) with a lethality of 14.4±6.8%. The results showed that there is no difference in AMI hospitalization between the months of the year, but showed a significant negative correlation between temperature and AMI hospitalizations (r=-0.219; P=0.022; β=-0.165). It was also shown that men and elderly had more cases of AMI hospitalization, but women and elderly had more lethality. When the lethality rate was analyzed during the study period, there was a significant negative correlation, indicating the reduction of AMI deaths with time.

CONCLUSION

There was an association between temperature reduction and AMI hospitalization, where each 6°C reduction in temperature was related to an increase of 1 hospitalization per AMI/100,000 inhabitants. It is hoped that the results may assist in the formulation of public environmental policies for the prevention of risk factors for AMI.

Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention

Objective

To evaluate causes and impact of delay in the door-to-balloon (D2B) time for patients undergoing primary percutaneous coronary intervention (PPCI).

Subjects and methods

From January 2009 to December 2012, 1268 patients (86% male, mean age of 58 ± 12 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: Non-delay defined as D2B time ≤ 90 mins and delay group defined as D2B time > 90 mins. Data were collected retrospectively on baseline clinical characteristics, mode of presentation, angiographic findings, therapeutic modality and inhospital outcome.

Results

202 patients had delay in D2B time. There were more female patients in the delay group. They were older and tend to self-present to hospital. They were less likely to be smokers and have a higher prevalence of prior MI. The incidence of posterior MI was higher in the delay group. They also had a higher incidence of triple vessel disease.

The 3 most common reasons for D2B delay was delay in the emergency department (39%), atypical clinical presentation (37.6%) and unstable medical condition requiring stabilisation/computed tomographic imaging (26.7%). The inhospital mortality was numerically higher in the delay group (7.4% versus 4.8%, p = 0.12).

Conclusions

Delay in D2B occurred in 16% of our patients undergoing PPCI. Several key factors for delay were identified and warrant further intervention.

Plasma Metabolic Profile Determination in Young ST-segment Elevation Myocardial Infarction Patients with Ischemia and Reperfusion: Ultra-performance Liquid Chromatography and Mass Spectrometry for Pathway Analysis

Background:

This study was to establish a disease differentiation model for ST-segment elevation myocardial infarction (STEMI) youth patients experiencing ischemia and reperfusion via ultra-performance liquid chromatography and mass spectrometry (UPLC/MS) platform, which searches for closely related characteristic metabolites and metabolic pathways to evaluate their predictive value in the prognosis after discharge.

Methods:

Forty-seven consecutive STEMI patients (23 patients under 45 years of age, referred to here as “youth,” and 24 “elderly” patients) and 48 healthy control group members (24 youth, 24 elderly) were registered prospectively. The youth patients were required to provide a second blood draw during a follow-up visit one year after morbidity (n = 22, one lost). Characteristic metabolites and relative metabolic pathways were screened via UPLC/MS platform base on the Kyoto encyclopedia of genes and genomes (KEGG) and Human Metabolome Database. Receiver operating characteristic (ROC) curves were drawn to evaluate the predictive value of characteristic metabolites in the prognosis after discharge.

Results:

We successfully established an orthogonal partial least squares discriminated analysis model (R₂X = 71.2%, R₂Y = 79.6%, and Q₂ = 55.9%) and screened out 24 ions; the sphingolipid metabolism pathway showed the most drastic change. The ROC curve analysis showed that ceramide [Cer(d18:0/16:0), Cer(t18:0/12:0)] and sphinganine in the sphingolipid pathway have high sensitivity and specificity on the prognosis related to major adverse cardiovascular events after youth patients were discharged. The area under curve (AUC) was 0.671, 0.750, and 0.711, respectively. A follow-up validation one year after morbidity showed corresponding AUC of 0.778, 0.833, and 0.806.

Conclusions:

By analyzing the plasma metabolism of myocardial infarction patients, we successfully established a model that can distinguish two different factors simultaneously: pathological conditions and age. Sphingolipid metabolism is the top most altered pathway in young STEMI patients and as such may represent a valuable prognostic factor and potential therapeutic target.

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

BACKGROUND

The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.

AIM

To investigate whether using the rule adds to the GP's clinical judgement.

DESIGN AND SETTING

A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.

METHOD

Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP's clinical judgement aided by the MHS. Their accuracy was compared with the GPs' unaided clinical judgement.

RESULTS

Sensitivity and specificity of the GPs' unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = -2.4 to 19.6) and the specificity was similar (difference -0.4%, 95% CI = -5.3 to 4.5); the sensitivity of the triage was similar (difference -1.5%, 95% CI = -9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = -6.9 to 23.0 and 5.8%, 95% CI = -1.6 to 13.2, respectively).

CONCLUSION

Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction

Objective

To evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI).

Methods

From January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age ≥ 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course.

Results

The elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher.

Conclusions

Our registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.

How to Utilize Coronary Computed Tomography Angiography in the Treatment of Coronary Artery Disease

Coronary computed tomography angiography (CCTA) has high negative predictive power for detecting coronary artery disease. However CCTA is limited by moderate positive predictive power in the detection of myocardial ischemia. This is not unexpected because the diameter of a stenosis is a poor indicator of myocardial ischemia and discrepancy between the severity of stenosis and noninvasive tests is not uncommon. The value of stenosis for predicting future development of acute coronary syndrome represented by plaque rupture has been questioned. CCTA identifies the characteristics of high-risk plaque including positive remodeling, low density plaque and spotty or micro-calcification. Also, additional evaluation of myocardial ischemia using computational flow dynamics, and luminal attenuation gradient are expected to increase both diagnostic performance for hemodynamically significant stenosis and the predictive power for future cardiovascular risk. Technical advances in CCTA would enable evaluation of both coronary artery stenosis and myocardial ischemia simultaneously with high predictive performance, and would improve vastly the clinical value of CCTA.

Clinical Characteristics and Outcomes of Acute ST-Segment Elevation Myocardial Infarction in Younger Korean Adults

Background and Objectives

This study aims to investigate the clinical features, angiographic findings, and outcomes of younger Korean ST-segment elevation myocardial infarction (STEMI) patients.

Subjects and Methods

We analyzed major adverse cardiac events (MACE) in the Korea Acute Myocardial Infarction Registry from November 2005 to October 2010. The registered patients were divided into two groups; young age group (<65 years) and old age group (≥65 years).

Results

The young age group included 5281 patients (age, 53±7.8 years), and the old age group included 4896 patients (age, 74.3±6.5 years). Male gender, smoking, family history, dyslipidemia, and metabolic syndrome were more frequently observed in the young age group than in the old age group (89.5% vs. 59.3%, p<0.001; 77.3% vs. 47.2%, p<0.001; 11% vs. 4.6%, p<0.001; 11.2% vs. 7.7%, p<0.001; 67.6% vs. 62.9%, p<0.001). Most of the young Korean adults with STEMI complained of typical chest pain (89.8%), and they had a shorter symptom-to-door time (12±53.2 hours vs. 17.3±132 hours, p=0.010). The young age group showed a favorable prognosis, which was represented by the MACE, compared with the old age group at one month (1.8% vs. 2.8%, p=0.028), six months (6.8% vs. 8.2%, p<0.001), and twelve months (10.1% vs. 11.9%, p=0.025). However, there was no significant difference in the adjusted MACE rate at one month {hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.60-1.51, p=0.828} and twelve months (HR 0.86, 95% CI 0.68-1.10, p=0.233).

Conclusion

Younger Korean adults with STEMI have clinical outcomes similar to old aged patients, and therefore, they should be treated intensively like the elderly patients.

When you hear hoofbeats, think of horses but do not forget the zebras

We report a case of a 68-year-old man who was admitted to the department of cardiology with increasing abdominal and chest pain during the day. The prehospital ECG showed clear ST segment elevation in inferior leads. The patient was routed directly to the catheterisation laboratory with acute myocardial infarction as a tentative diagnosis. The coronary angiography showed an occluded right coronary artery that was reopened with a plain old balloon angioplasty procedure. After the procedure, the patient was expected to feel better, but the abdominal pain worsened. The following bedside ultrasound examination was quite surprising.

Age-related deficit accumulation and the risk of late-life dementia

Introduction

Many age-related health problems have been associated with dementia, leading to the hypothesis that late-life dementia may be determined less by specific risk factors, and more by the operation of multiple health deficits in the aggregate. Our study addressed (a) how the predictive value of dementia risk varies by the number of deficits considered and (b) how traditional (for example. vascular risks) and nontraditional risk factors (for example, foot problems, nasal congestion) compare in their predictive effects.

Methods

Older adults in the Canadian Study of Health and Aging who were cognitively healthy at baseline were analyzed (men, 2,902; women, 4,337). Over a 10-year period, 44.8% of men and 33.4% of women died; 7.4% of men and 9.1% of women without baseline cognitive impairment developed dementia. Self-rated health problems, including, but not restricted to, dementia risk factors, were coded as deficit present/absent. Different numbers of randomly selected variables were used to calculate various iterations of the index (that is, the proportion of deficits present in an individual. Risks for 10-year mortality and dementia outcomes were evaluated separately for men and women by using logistic regression, adjusted for age. The prediction accuracy was evaluated by using C-statistics.

Results

Age-adjusted odds ratios per additional deficit were 1.22 (95% confidence interval (CI), 1.18 to 1.26) in men and 1.14 (1.11 to 1.16) in women in relation to death, and 1.18 (1.12 to 1.25) in men and 1.08 (1.04 to 1.11) in women in relation to dementia. The predictive value increased with the number (n) of deficits considered, regardless of whether they were known dementia risks, and stabilized at n > 25. The all-factor index best predicted dementia (C-statistics, 0.67 ± 0.03).

Conclusions

The variety of items associated with dementias suggests that some part of the risk might relate more to aberrant repair processes, than to specifically toxic results. The epidemiology of late-life illness might best consider overall health status.

Genetic polymorphisms, Biochemical Factors, and Conventional Risk Factors in Young and Elderly North Indian Patients With Acute Myocardial Infarction

This study compared genetic polymorphisms (factor V Leiden [FVL] 1691G/A, factor VII [FVII] 10976G/A, FVII HVR4, platelet membrane glycoproteins GP1BA 1018C/T, GP1BA VNTR, integrin ITGB3 1565T/C, ITGA2 807C/T and methylenetetrahydrofolate reductase [MTHFR] 677C/T), biochemical (fibrinogen and homocysteine), and conventional risk factors in 184 young and 166 elderly north Indian patients with acute myocardial infarction (AMI). Univariate analysis revealed higher prevalence of hypertension and obesity in elderly patients while smoking, alcohol intake, and low socioeconomic status in young patients (P < .001). Although mean fibrinogen predominated (P = .01) in elderly patients, mean homocysteine was higher (P < .001) among young patients. Prevalence of hyperhomocysteinemia was greater in young than in elderly patients (odds ratio: 2.8, 95% confidence interval: 1.8-4.4, P < .001); however, genetic polymorphisms were equally prevalent in young and elderly patients. Multiple logistic regression analysis showed smoking (P < .001), alcohol intake (P = .046), and hyperhomocysteinemia (P = .001) to be associated with AMI in the young patients while hypertension (P = .006) in elderly patients. To conclude, smoking, alcohol intake, and elevated homocysteine are the risk factors for AMI among young while hypertension among elderly patients.