Epidemiology of myocardial infarction

Persistent transcriptional changes in cardiac adaptive immune cells following myocardial infarction: New evidence from the re-analysis of publicly available single cell and nuclei RNA-sequencing data sets

INTRODUCTION

Chronic immunopathology contributes to the development of heart failure after a myocardial infarction. Both T and B cells of the adaptive immune system are present in the myocardium and have been suggested to be involved in post-MI immunopathology.

METHODS

We analyzed the B and T cell populations isolated from previously published single cell RNA-sequencing data sets (PMID: 32130914, PMID: 35948637, PMID: 32971526 and PMID: 35926050), of the mouse and human heart, using differential expression analysis, functional enrichment analysis, gene regulatory inferences, and integration with autoimmune and cardiovascular GWAS.

RESULTS

Already at baseline, mature effector B and T cells are present in the human and mouse heart, having increased activity in transcription factors maintaining tolerance (e.g. DEAF1, JDP2, SPI-B). Following MI, T cells upregulate pro-inflammatory transcript levels (e.g. Cd11, Gzmk, Prf1), while B cells upregulate activation markers (e.g. Il6, Il1rn, Ccl6) and collagen (e.g. Col5a2, Col4a1, Col1a2). Importantly, pro-inflammatory and fibrotic transcription factors (e.g. NFKB1, CREM, REL) remain active in T cells, while B cells maintain elevated activity in transcription factors related to immunoglobulin production (e.g. ERG, REL) in both mouse and human post-MI hearts. Notably, genes differentially expressed in post-MI T and B cells are associated with cardiovascular and autoimmune disease.

CONCLUSION

These findings highlight the varied and time-dependent dynamic roles of post-MI T and B cells. They appear ready-to-go and are activated immediately after MI, thus participate in the acute wound healing response. However, they subsequently remain in a state of pro-inflammatory activation contributing to persistent immunopathology.

Enzyme-Responsive Nanoparticles for the Targeted Delivery of an MMP Inhibitor to Acute Myocardial Infarction

Herein, we have developed a drug-loaded matrix metalloproteinase (MMP)-responsive micellar nanoparticle (NP) intended for minimally invasive intravenous injection during the acute phase of myocardial infarction (MI) and prolonged retention in the heart for small-molecule drug delivery. Peptide-polymer amphiphiles (PPAs) bearing a small-molecule MMP inhibitor (MMPi), PD166793, were synthesized via ring-opening metathesis polymerization (ROMP) and formulated into spherical micelles by transitioning to aqueous solution. The resulting micellar NPs underwent MMP-induced aggregation, demonstrating enzyme responsiveness. Using a rat MI model, we observed that these NPs were capable of successfully extravasating into the infarcted region of the heart where they were retained due to the active, enzyme-mediated targeting, remaining detectable after 1 week post administration without increasing macrophage recruitment. Furthermore, in vitro studies show that these NPs demonstrated successful drug release following MMP treatment and maintained drug bioactivity as evidenced by comparable MMP inhibition to free MMPi. This work establishes a targeted NP platform for delivering small-molecule therapeutics to the heart after MI, opening possibilities for myocardial infarction treatment.

The role and medical prospects of long non-coding RNAs in cardiovascular disease

Cardiovascular disease (CVD) has reached epidemic proportions and is a leading cause of death worldwide. One of the long-standing goals of scientists is to repair heart tissue damaged by various forms of CVD such as cardiac hypertrophy, dilated cardiomyopathy, myocardial infarction, heart fibrosis, and genetic and developmental heart defects such as heart valve deformities. Damaged or defective heart tissue has limited regenerative capacity and results in a loss of functioning myocardium. Advances in transcriptomic profiling technology have revealed that long noncoding RNA (lncRNA) is transcribed from what was once considered "junk DNA." It has since been discovered that lncRNAs play a critical role in the pathogenesis of various CVDs and in myocardial regeneration. This review will explore how lncRNAs impact various forms of CVD as well as those involved in cardiomyocyte regeneration. Further, we discuss the potential of lncRNAs as a therapeutic modality for treating CVD.

Incidence and Predictors of Acute Limb Ischemia in Patients With Acute Myocardial Infarction-Insight from National Readmission Database

Acute limb ischemia (ALI) has been a rare complication of acute myocardial infarction (AMI), however, with the increasing use of mechanical circulatory devices it is seen more frequently. The incidence and predictors of ALI in patients with AMI in contemporary clinical practice are unknown. A retrospective review of patients with index hospitalization for AMI in the Nationwide Readmission Database from 2016 to 2019 was done. We evaluated the annual incidence of ALI and its impact on outcomes. We used multivariate logistic regression analysis to determine predictors of ALI. In 1,283,586 patients with AMI, 3,971 patients (0.31%) had ALI and 365 (0.03%) had limb amputation. The 3 major predictors of ALI were peripheral artery disease (odds ratio [OR] 11.91, 95% confidence interval [CI]: 10.78 to 13.51), intravascular microaxial left ventricular assist device (OR 4.39, 95% CI 3.86 to 5.00), and veno-arterial extracorporeal membrane oxygenation (OR 4.37, 95% CI 3.19 to 6.01). Intra-aortic balloon pump had a substantially lower predictive ability (OR 1.81, 95% CI 1.63 to 2.0, p <0.0001) than other forms of mechanical circulatory support. The mortality rate in patients with ALI was significantly higher than those without ALI (19.49% vs 4.85%, p <0.0001). Patients who developed ALI had higher rates of amputation (1.59% vs 0.02%, p <0.0001). This observational nationwide study showed that ALI is an important complication in patients with AMI and is more frequently seen in patients who have peripheral artery disease, and require a left ventricular assist device or venoarterial extracorporeal membrane oxygenation. This complication was also associated with significantly higher in-hospital mortality.

MiR-206 may regulate mitochondrial ROS contribute to the progression of Myocardial infarction via TREM1

Myocardial infarction (MI) is a leading cause of mortality. To better understand its molecular and cellular mechanisms, we used bioinformatic tools and molecular experiments to explore the pathogenesis and prognostic markers. Differential gene expression analysis was conducted using GSE60993 and GSE66360 datasets. Hub genes were identified through pathway enrichment analysis and PPI network construction, and four hub genes (AQP9, MMP9, FPR1, and TREM1) were evaluated for their predictive performance using AUC and qRT-PCR. miR-206 was identified as a potential regulator of TREM1. Finally, miR-206 was found to induce EC senescence and ER stress through upregulating mitochondrial ROS levels via TREM1. These findings may contribute to understanding the pathogenesis of MI and identifying potential prognostic markers.

Senescent cardiomyocytes contribute to cardiac dysfunction following myocardial infarction

Myocardial infarction is a leading cause of morbidity and mortality. While reperfusion is now standard therapy, pathological remodelling leading to heart failure remains a clinical problem. Cellular senescence has been shown to contribute to disease pathophysiology and treatment with the senolytic navitoclax attenuates inflammation, reduces adverse myocardial remodelling and results in improved functional recovery. However, it remains unclear which senescent cell populations contribute to these processes. To identify whether senescent cardiomyocytes contribute to disease pathophysiology post-myocardial infarction, we established a transgenic model in which p16 (CDKN2A) expression was specifically knocked-out in the cardiomyocyte population. Following myocardial infarction, mice lacking cardiomyocyte p16 expression demonstrated no difference in cardiomyocyte hypertrophy but exhibited improved cardiac function and significantly reduced scar size in comparison to control animals. This data demonstrates that senescent cardiomyocytes participate in pathological myocardial remodelling. Importantly, inhibition of cardiomyocyte senescence led to reduced senescence-associated inflammation and decreased senescence-associated markers within other myocardial lineages, consistent with the hypothesis that cardiomyocytes promote pathological remodelling by spreading senescence to other cell-types. Collectively this study presents the demonstration that senescent cardiomyocytes are major contributors to myocardial remodelling and dysfunction following a myocardial infarction. Therefore, to maximise the potential for clinical translation, it is important to further understand the mechanisms underlying cardiomyocyte senescence and how to optimise senolytic strategies to target this cell lineage.

Copeptin Reflect Left Ventricular Systolic Function at Early Stage of Acute Myocardial Infarction in a Pig Model

Introduction

Measurement of biomarkers early after acute myocardial infarction (AMI) might provide a cost-effective and widely available tool to assess infarct severity, myocardial dysfunction, and clinical outcomes. We aimed to induce AMI in miniature pigs, measure the levels of serum biomarkers and global LV function dynamically and explore the release kinetics and optimal sampling time points of copeptin and its correlation with global LV function.

Methods

We induced AMI in the experimental group using a closed-chest model. Left ventricular (LV) function was detected by dual-source computed tomography (DSCT) and serum copeptin was determined by ELISA.

Results

The serum copeptin levels were increased at 1 hour, peaked at 3 hours, gradually decreased after 6 hours, and returned to baseline 3 days after AMI. At 3 to 6 hours, the copeptin cutoff of 16.97 to 17.44 pmol/l had 100% sensitivity and 100% specificity (P ⩽ .001) for AMI. Serum copeptin levels at 3 hours and 3 days were negatively correlated with the 3-hours LVEF (P ⩽ .001), respectively.

Conclusion

Serum copeptin levels change in time, and measurements at 3 to 6 hours after AMI had the highest predictive value.

NT-proCNP levels predict higher atherosclerotic cardiovascular risk profile in patients with proliferative diabetic retinopathy

AIMS

In this study, we aimed to demonstrate the effectiveness of serum amino-terminal proCNP (NT-proCNP) levels in predicting coronary heart disease (CHD) and cardiovascular risk in type 2 diabetes mellitus (T2DM) patients.

METHODS

We recruited 73 patients with T2DM in the study. Additionally, we grouped the patients according to their status of diabetic retinopathy (DR) as no DR, non-proliferative DR, or proliferative DR. Serum NT-proCNP levels of the patients were measured and their atherosclerotic cardiovascular disease (ASCVD) risk scores were calculated.

RESULTS

There was no significant difference in terms of NT-proCNP levels between the groups (p = 0.3) and in terms of CHD and ASCVD risk scores (p = 0.4 and p = 0.4, respectively). In the correlation analysis, a significant correlation was observed between the NT-proCNP levels and the ASCVD risk score (r = 0.373; p = 0.008 among the entire cohort and r = 0.555; p = 0.01 in the non-proliferative-DR group), smoking status (r = 0.280; p = 0.03 among the entire cohort and r = 0.362; p = 0.035 in the non-proliferative-DR group), sBP (r = 0.278; p = 0.038 among the entire cohort), and dBP (r = 0.284; p = 0.034 among the entire cohort and r = 0.482; p = 0.004 in the proliferative-DR group). In the ROC analysis, we found that the NT-proCNP level predicted a high ASCVD risk score with 83.3% sensitivity and 70.8% specificity and a very high ASCVD risk score with 100% sensitivity and 69.2% specificity among the proliferative-DR patients. No cut-off value was calculated for the prediction of high and very-high ASCVD risk scores in patients with non-proliferative DR. Similarly, no cut-off value was revealed for the prediction of established coronary artery disease in all groups.

CONCLUSIONS

Our study revealed a significant association between NT-proCNP levels and high ASCVD risk scores in patients with proliferative DR.

Senescent cardiomyocytes contribute to cardiac dysfunction following myocardial infarction

Myocardial infarction is a leading cause of morbidity and mortality. While reperfusion is now standard therapy, pathological remodeling leading to heart failure remains a clinical problem. Cellular senescence has been shown to contribute to disease pathophysiology and treatment with the senolytic navitoclax attenuates inflammation, reduces adverse myocardial remodeling and results in improved functional recovery. However, it remains unclear which senescent cell populations contribute to these processes. To identify whether senescent cardiomyocytes contribute to disease pathophysiology post-myocardial infarction, we established a transgenic model in which p16 (CDKN2A) expression was specifically knocked-out in the cardiomyocyte population. Following myocardial infarction, mice lacking cardiomyocyte p16 expression demonstrated no difference in cardiomyocyte hypertrophy but exhibited improved cardiac function and significantly reduced scar size in comparison to control animals. This data demonstrates that senescent cardiomyocytes participate in pathological myocardial remodeling. Importantly, inhibition of cardiomyocyte senescence led to reduced senescence-associated inflammation and decreased senescence-associated markers within other myocardial lineages, consistent with the hypothesis that cardiomyocytes promote pathological remodeling by spreading senescence to other cell-types. Collectively this study presents a novel demonstration that senescent cardiomyocytes are major contributors to myocardial remodeling and dysfunction following a myocardial infarction. Therefore, to maximize the potential for clinical translation, it is important to further understand the mechanisms underlying cardiomyocyte senescence and how to optimize senolytic strategies to target this cell lineage.

Acute Coronary Syndrome, Stroke, and Mortality after Community-Acquired Pneumonia: Systematic Review and Meta-Analysis

One-third of adult inpatients with community-acquired pneumonia (CAP) develop acute coronary syndrome (ACS), stroke, heart failure (HF), arrhythmias, or die. The evidence linking CAP to cardiovascular disease (CVD) events is contradictory. We aimed to systematically review the role of CAP as a CVD risk factor. We registered the protocol (CRD42022352910) and searched for six databases from inception to 31 December 2022. We included 13 observational studies, 276,109 participants, 18,298 first ACS events, 12,421 first stroke events, 119 arrhythmic events, 75 episodes of new onset or worsening HF, 3379 deaths, and 218 incident CVD events. CAP increased the odds of ACS (OR 3.02; 95% CI 1.88–4.86), stroke (OR 2.88; 95% CI 2.09–3.96), mortality (OR 3.22; 95% CI 2.42–4.27), and all CVD events (OR 3.37; 95% CI 2.51–4.53). Heterogeneity was significant (I2 = 97%, p < 0.001). Subgroup analysis found differences according to the continent of origin of the study, the follow-up length, and the sample size (I2 > 40.0%, p < 0.10). CAP is a significant risk factor for all major CVD events including ACS, stroke, and mortality. However, these findings should be taken with caution due to the substantial heterogeneity and the possible publication bias.

IRGM/Irgm1 deficiency inhibits neutrophil-platelet interactions and thrombosis in experimental atherosclerosis and arterial injury

BACKGROUND

Neutrophil extracellular traps (NETs) closely link inflammation and thrombosis. The immune-related GTPase family M protein (IRGM) and its ortholog of mouse IRGM1 are positively correlated with plaque rupture during atherosclerosis process. However, whether and how IRGM/IRGM1 affects NETs formation and atherosclerotic thrombosis remains unknown, which will further promote the development of antithrombotic treatment tools.

METHODS

The thrombi images, platelet activation makers and NETs makers were detected in the serum of STEMI patients and controls. To futher investigate IRGM/IRGM1 affects NETs formation and atherothrombosis in vivo, ApoE^-/-Irgm1^+/- and ApoE^-/- mice received diets rich in fat and 2.5% FeCl₃ was then used to induce experimental arterial thrombosis in an atherosclerosis background. In vitro, PMA and thrombin were used to stimulate neutrophils and platelets, respectively, and the expression of IRGM/IRGM1 were modified. To reveal the molecular mechanisms, MAPK-cPLA2 signals inhibitors were used.

RESULTS

Serum IRGM was positively correlated with PF4 and neutrophil elastase. Subsequently, Irgm1 deficient mice have a longer occlusion time and lower growth rate. In vitro, as expected, IRGM/Irgm1 deficiency inhibits platelet activation and platelet-neutrophil interaction. More importantly, IRGM promoted NETs production through activating MAPK-cPLA2 signals in PMA stimulated neuropils, whereas inhibiting the production of NETs eliminated the difference in platelet activation and thrombosis caused by IRGM/Irgm1 modification in vivo and vitro. Similarly, inhibition of platelet activation also eliminated the influence of IRGM/Irgm1 modification on NETs production.

CONCLUSIONS

Overall, our data indicate that IRGM/Irgm1 deficiency in neuropils inhibits the intense interaction between neutrophils and platelets, and ultimately inhibits thrombosis.

Doppler Ultrasound Selection and Follow-Up of the Internal Mammary Artery as Coronary Graft

The impact of coronary artery disease (CAD) on all-cause mortality and overall disabilities is well-established. Percutaneous and/or surgical coronary revascularization procedures dramatically reduced the occurrence of adverse cardiovascular events in patients suffering from atherosclerosis. Specifically, guidelines from the European Society of Cardiology on the management of myocardial revascularization promoted coronary artery by-pass graft (CABG) intervention in patients with specific alterations in the coronary tree due to the higher beneficial effects of this procedure as compared to the percutaneous one. The left internal mammary artery (LIMA) is one of the best-performing vessels in CABG procedures due to its location and its own structural characteristics. Nevertheless, the non-invasive assessment of its patency is challenging. Doppler ultrasonography (DU) might perform as a reliable technique for the non-invasive evaluation of the patency of LIMA. Data from the literature revealed that DU may detect severe (>70%) stenosis of the LIMA graft. In this case, pulsed-wave Doppler might show peak diastolic velocity/peak systolic velocity < 0.5 and diastolic fraction < 50%. A stress test might also be adopted for the evaluation of patency of LIMA through DU. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow-up after CABG intervention.

Intelligent Recognition Algorithm of Multiple Myocardial Infarction Based on Morphological Feature Extraction

Myocardial infarction is a type of heart disease marked by rapid progression and high mortality. In this paper, a novel intelligent recognition algorithm of multiple myocardial infarctions using a bidirectional long short-term memory (BiLSTM) neural network classification was proposed. This algorithm was based on morphological feature extraction, which can greatly improve the diagnostic efficiency of doctors for different kinds of myocardial infarction diseases. The algorithm includes noise reduction and beat segmentation of electrocardiogram (ECG) signals from the Physikalisch-Technische Bundesanstalt (PTB) database. According to the medical diagnosis guide, the distance feature of the whole waveform and the amplitude feature of the branch lead waveform are extracted. According to the extracted features, the long short-term memory network (LSTM) and the BiLSTM neural networks are built to classify and recognize heartbeats. The experimental results show that the accuracy of the morphological feature + BiLSTM algorithm in MI detection is 99.4%. At the same time, among the six common myocardial infarction diseases, the location and recognition rate of the culprit vessel is high. The sensitivity, specificity, PPV, NPV, and F1 score parameters all reach more than 98.4%, and the kappa coefficient also reaches 0.983, while the overall accuracy reaches 98.6%. The accuracy of this algorithm is improved by at least 1% compared with that of other existing algorithms. Thus, this study exhibits a very important clinical application value.

Association between admission ECG changes and long-term mortality in patients with an incidental myocardial infarction: Results from the KORA myocardial infarction registry

BACKGROUND

The aim of this study was to examine the predictive value of specific changes in admission ECG on long-term outcome in acute myocardial infarction (AMI).

METHODS

From 2000 until 2017 all AMI cases (n = 9,689) in the study area of Augsburg, Germany, were prospectively recorded. For this study, all patients with a first-time AMI, who survived the first 28 days, were considered. Median observational time was 6.7 years (IQR: 3.6-10.9). Each case was assigned to one of the following groups according to the admission ECG: 'ST-segment elevation', 'ST-segment depression', 'T-wave inversion', 'unspecific changes', 'normal ECG' and 'bundle branch block' (BBB). Multivariable adjusted COX regression models were calculated to compare long-term all-cause mortality.

RESULTS

The final regression model revealed a significantly higher mortality among patients with BBB (HR: 1.52 [1.34-1.73], p-value: < 0.001) and 'ST-segment depression' (HR: 1.16 [1.03-1.29], p-value: 0.01252) compared to the STEMI group (reference group). The 'normal ECG' group (HR: 0.76 [0.66-0.87], p-value: < 0.001) on the other hand was associated with significantly lower long-term mortality. The 'T-wave inversion' group (HR: 1.08 [0.96-1.21]) and the 'unspecific changes' group (HR: 1.05 [0.94-1.17]) did not differ significantly from the STEMI group.

CONCLUSION

ST-segment depressions and BBB admission ECGs go along with higher long-term mortality in AMI patients compared to STEMI cases. This should be taken into account by physicians when treating patients with NSTEMIs. Only the complete absence of AMI-related ECG changes predicts a more favorable outcome.

Arrhythmogenesis in the aged heart following ischaemia-reperfusion: role of transient receptor potential vanilloid 4

AIMS

Cardiomyocyte Ca2+ homoeostasis is altered with ageing and predisposes the heart to Ca2+ intolerance and arrhythmia. Transient receptor potential vanilloid 4 (TRPV4) is an osmotically activated cation channel with expression in cardiomyocytes of the aged heart. The objective of this study was to examine the role of TRPV4 in Ca2+ handling and arrhythmogenesis following ischaemia-reperfusion (I/R), a pathological scenario associated with osmotic stress.

METHODS AND RESULTS

Cardiomyocyte membrane potential was monitored prior to and following I/R in Langendorff-perfused hearts of Aged (19-28 months) male and female C57BL/6 mice ± TRPV4 inhibition (1 μM HC067047, HC). Diastolic resting membrane potential was similar between Aged and Aged HC at baseline, but following I/R Aged exhibited depolarized diastolic membrane potential vs. Aged HC. The effects of TRPV4 on cardiomyocyte Ca2+ signalling following I/R were examined in isolated hearts of Aged cardiac-specific GCaMP6f mice (±HC) using high-speed confocal fluorescence microscopy, with cardiomyocytes of Aged exhibiting an increased incidence of pro-arrhythmic Ca2+ signalling vs. Aged HC. In the isolated cell environment, cardiomyocytes of Aged responded to sustained hypoosmotic stress (250mOsm) with an increase in Ca2+ transient amplitude (fluo-4) and higher incidence of pro-arrhythmic diastolic Ca2+ signals vs. Aged HC. Intracardiac electrocardiogram measurements in isolated hearts following I/R revealed an increased arrhythmia incidence, an accelerated time to ventricular arrhythmia, and increased arrhythmia score in Aged vs. Aged HC. Aged exhibited depolarized resting membrane potential, increased pro-arrhythmic diastolic Ca2+ signalling, and greater incidence of arrhythmia when compared with Young (3-5 months).

CONCLUSION

TRPV4 contributes to pro-arrhythmic cardiomyocyte Ca2+ signalling, electrophysiological abnormalities, and ventricular arrhythmia in the aged mouse heart.

Progress of Single-Cell RNA Sequencing Technology in Myocardial Infarction Research

After myocardial infarction, the heart enters a remodeling and repair phase that involves myocardial cell damage, inflammatory response, fibroblast activation, and, ultimately, angiogenesis. In this process, the proportions and functions of cardiomyocytes, immune cells, fibroblasts, endothelial cells, and other cells change. Identification of the potential differences in gene expression among cell types and/or transcriptome heterogeneity among cells of the same type greatly contribute to understanding the cellular changes that occur in heart and disease conditions. Recent advent of the single-cell transcriptome sequencing technology has facilitated the exploration of single cell diversity as well as comprehensive elucidation of the natural history and molecular mechanisms of myocardial infarction. In this manner, novel putative therapeutic targets for myocardial infarction treatment may be detected and clinically applied.

Immune response to a conserved enteroviral epitope of the major capsid VP1 protein is associated with lower risk of cardiovascular disease

Background

Major cardiac events including myocardial infarction (MI) are associated with viral infections. However, how specific infections contribute to the cardiovascular insults has remained largely unclear.

Methods

We employed next generation phage display mimotope-variation analysis (MVA) to explore the link between antibody-based immune response and severe cardiovascular conditions. Here, we used a case-control design, including the first-stage discovery cohort (n = 100), along with cohorts for second-stage discovery (n = 329) and validation (n = 466).

Findings

We observed strong antibody response to the peptide antigens with Gly-Ile-X-Asp (G-I-X-D) core structure in healthy individuals but not in patients with MI. Analysis of the origin of this epitope linked it with the N-terminus of the VP1 protein of poliovirus 3 (PV3), but also other species of picornaviruses. Consistently, we found low levels of antibody response to the G-I-X-D epitope in individuals with severe cardiac disease complications.

Interpretation

Our findings imply that antibody response to the G-I-X-D epitope is associated with polio vaccinations and that high antibody levels to this epitope could discriminate healthy individuals from prospective MI patients as a blood-derived biomarker. Together, these findings highlight the importance of epitope-specific antibody response and suggest that protective immunity against the polio- and non-polio enteroviral infections support improved cardiovascular health.

Funding

Estonian Ministry of Education (5.1-4/20/170), Estonian Research Council (PRG573, PRG805), H2020-MSCA-RISE-2016 (EU734791), H2020 PANBioRA (EU760921), European Union through the European Regional Development Fund (Project no. 2014-2020.4.01.15-0012), Helsinki University Hospital grants, Mary and Georg C. Ehrnrooth Foundation, Finnish Eye Foundation, Finska Läkaresällskapet, The Finnish Society of Sciences and Letters, Magnus Ehrnrooth Foundation and Sigrid Jusélius Foundation.

Detection and Localization of Myocardial Infarction Based on Multi-Scale ResNet and Attention Mechanism

PURPOSE

Myocardial infarction (MI) is one of the most common cardiovascular diseases, frequently resulting in death. Early and accurate diagnosis is therefore important, and the electrocardiogram (ECG) is a simple and effective method for achieving this. However, it requires assessment by a specialist; so many recent works have focused on the automatic assessment of ECG signals.

METHODS

For the detection and localization of MI, deep learning models have been proposed, but the diagnostic accuracy of this approaches still need to be improved. Moreover, with deep learning methods the way in which a given result was achieved lacks interpretability. In this study, ECG data was obtained from the PhysioBank open access database, and was analyzed as follows. Firstly, the 12-lead ECG signal was preprocessed to identify each beat and obtain each heart interval. Secondly, a multi-scale deep learning model combined with a residual network and attention mechanism was proposed, where the input was the 12-lead ECG recording. Through the SENet model and the Grad-CAM algorithm, the weighting of each lead was calculated and visualized. Using existing knowledge of the way in which different types of MI gave characteristic patterns in specific ECG leads, the model was used to provisionally diagnose the type of MI according to the characteristics of each of the 12 ECG leads.

RESULTS

Ten types of MI anterior, anterior lateral, anterior septal, inferior, inferior lateral, inferior posterior, inferior posterior lateral, lateral, posterior, and posterior lateral were diagnosed. The average accuracy, sensitivity, and specificity for MI detection of all lesion types was 99.98, 99.94, and 99.98%, respectively; and the average accuracy, sensitivity, and specificity for MI localization was 99.79, 99.88, and 99.98%, respectively.

CONCLUSION

When compared to existing models based on traditional machine learning methods, convolutional neural networks and recurrent neural networks, the results showed that the proposed model had better diagnostic performance, being superior in accuracy, sensitivity, and specificity.

Evaluation of efficacy and safety of improved transurethral plasma kinetic enucleation of the prostate in high-risk patients with benign prostatic hyperplasia and coronary artery disease

OBJECTIVE

This prospective study aimed to evaluate the safety of improved transurethral plasma kinetic enucleation of the prostate (iTUPKEP) in the perioperative period in high-risk patients with benign prostatic hyperplasia (BPH) and coronary artery disease.

METHODS

Patients with BPH underwent surgical treatment with transurethral vapour resection of the prostate (TUVP) or iTUPKEP. Serum endothelin-1, cardiac troponin-I, and high-sensitivity C-reactive protein concentrations were evaluated in the short term after surgery. The postvoid residual urine volume, maximum urinary flow rate, international prostate symptom score, and quality of life indicators were evaluated in the long term after surgery.

RESULTS

Endothelin-1 concentrations were lower in the iTUPKEP group than in the TUVP group at 1 and 2 days postoperatively. The iTUPKEP group had lower cardiac troponin-I and high-sensitivity C-reactive protein concentrations at all time points postoperatively. The postvoid residual urine volume, international prostate symptom score, and quality of life values were lower, but the maximum urinary flow rate was higher, in the iTUPKEP group than in the TUVP group.

CONCLUSIONS

The iTUPKEP procedure has a smaller effect on vascular endothelial function compared with TUVP. Therefore, iTUPKEP may reduce the incidence of postoperative cardiovascular adverse events in high-risk patients with BPH and coronary artery disease.

Clinical Characteristics, Achievement of Secondary Prevention Goals, and Outcomes of Patients with Recurrent Acute Coronary Syndrome

BACKGROUND

Because development of acute coronary syndrome (ACS) worsens the prognosis of patients with coronary artery disease, preventing recurrent ACS is crucial. However, the degree to which secondary prevention treatment goals are achieved in patients with recurrent ACS is unknown.

METHODS

214 consecutive ACS patients were classified as having First ACS (n=182) or Recurrent ACS (n=32), and the clinical characteristics of these groups were compared. Fifteen patients died or developed cardiovascular (CV) events during hospitalization, and the remaining 199 patients were followed from the date of hospital discharge to evaluate subsequent CV events.

RESULTS

Patients in the Recurrent ACS group were older than those in the First ACS group (76.8±10.8 years vs 68.8±13.4 years, p=0.002) and had a higher rate of diabetes mellitus (DM) (65.6% vs 36.8%, p=0.003). The rate of achieving a low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL in the Recurrent ACS group was only 28.1%, even though 68.8% of these patients were taking statins. An HbA1c level of <7.0% was achieved in 66.7% of patients with recurrent ACS who had been diagnosed with DM. Overall, 12.5% of patients with recurrent ACS had received optimal treatment for secondary prevention. CV events after hospital discharge were noted in 37.9% of the Recurrent ACS group and 21.2% of the First ACS group (log-rank test: p=0.004). However, recurrent ACS was not an independent risk factor for CV events (adjusted hazard ratio: 2.09, 95% confidence interval: 0.95 to 4.63, p=0.068).

CONCLUSION

Optimal treatment for secondary prevention was not achieved in some patients with recurrent ACS, and achievement of the guideline-recommended LDL-C goal for secondary prevention was especially low in this population.

Atypical Manifestations of Women Presenting with Myocardial Infarction at Tertiary Health Care Center: An Analytical Study

Introduction:

Typical chest pain symptoms are the cause that requires individuals to seek out medical care in Acute coronary syndrome(ACS). Evidence suggests, symptoms labelled as 'atypical 'is more common in women with ACS. The present study focuses on the need for the implementation of a gender specific approach in the current scenario by identifying gender based differences that exist in clinical presentations of the patients with ACS. Early identification of women's prodromal and acute symptoms of Myocardial Infarction is an important step in provision of appropriate treatment modality. Present study focus on need for implementation of gender-specific approach in current scenario by identifying gender based differences that exist in risk factors, clinical manifestations in patients presenting with MI.

Methodology:

Cross- sectional analytical study was conducted among 240 Participants (120 males and 120 females). Both men and women diagnosed with MI, who survived, stabilized after admission was included in the study. Consecutive sampling technique was used to select the participants. Data was collected on risk factors profile, clinical manifestations by administering structured questionnaire.

Results:

Risk factors such as history of diabetes, history of dyslipidemia was found to be homogenous among both men and women. 60% of men were ever smokers. Hypertension and known IHD was noted to be significant in women (p<0.002, p <0.001) but men presented with higher BMI (p<0.030). Females increasingly presented with atypical presentations when compared to males (p<0.005). Women commonly had squeezing and tightness type of pain and men reported tightness, burning, pricking type of pain (p<0.003). The majority of the women reported the onset of pain occurrence between 6am to 12 pm(p<0.004), whereas men significantly reported the onset of pain between 12 am -6 am(p<0.001).

Conclusion:

Gender based differences in risk factors and clinical presentation in men and women with myocardial infarction had been a focus in researches that emphasized need for focused assessment for women as they increasingly presents with atypical symptoms. The current study also supports the need of a gender specific approach to avoid delay in diagnosis and care of them.

rs41291957 controls miR-143 and miR-145 expression and impacts coronary artery disease risk

The role of single nucleotide polymorphisms (SNPs) in the etiopathogenesis of cardiovascular diseases is well known. The effect of SNPs on disease predisposition has been established not only for protein coding genes but also for genes encoding microRNAs (miRNAs). The miR-143/145 cluster is smooth muscle cell-specific and implicated in the pathogenesis of atherosclerosis. Whether SNPs within the genomic sequence of the miR-143/145 cluster are involved in cardiovascular disease development is not known. We thus searched annotated sequence databases for possible SNPs associated with miR-143/145. We identified one SNP, rs41291957 (G > A), located -91 bp from the mature miR-143 sequence, as the nearest genetic variation to this miRNA cluster, with a minor allele frequency > 10%. In silico and in vitro approaches determined that rs41291957 (A) upregulates miR-143 and miR-145, modulating phenotypic switching of vascular smooth cells towards a differentiated/contractile phenotype. Finally, we analysed association between rs41291957 and CAD in two cohorts of patients, finding that the SNP was a protective factor. In conclusion, our study links a genetic variation to a pathological outcome through involvement of miRNAs.

The incidence of acute myocardial infarction after elective spinal fusions or joint replacement surgery in the United States: a large-scale retrospective observational cohort study in 322,585 patients : Post-surgical myocardial infarction data

Background

Acute myocardial infarction (AMI) is an uncommon but fatal complication among patients undergoing elective spinal fusion surgery (SF), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Our objective was to estimate the incidence of AMI among adults undergoing elective SF, THA, and TKA in different post-operative risk windows and characterize high-risk sub-populations in the United States.

Methods

A retrospective cohort study was conducted using data from a longitudinal electronic healthcare record (EHR) database from January 1, 2007 to June 30, 2018. ICD codes were used to identify SF, THA, TKA, AMI, and selected clinical characteristics. Incidence proportions (IPs) and 95% confidence intervals were estimated in the following risk windows: index hospitalization, ≤ 30, ≤ 90, ≤ 180, and ≤ 365 days post-operation.

Results

A total of 67,533 SF patients, 87,572 THA patients, and 167,480 TKA patients were eligible for the study. The IP of AMI after SF, THA, and TKA ranged from 0.36, 0.28, and 0.25% during index hospitalization to 1.05, 0.93, and 0.85% ≤ 365 days post-operation, respectively. The IP of AMI was higher among patients who were older, male, with longer hospital stays, had a history of AMI, and had a history of diabetes.

Conclusion

The IP of post-operative AMI was generally highest among the SF cohort compared to the THA and TKA cohorts. Additionally, potential high-risk populations were identified. Future studies in this area are warranted to confirm these findings via improved confounder control and to identify effect measure modifiers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-021-00305-6.

Psoas Muscle Area Predicts Mortality after Left Ventricular Assist Device Implantation

Several risk scores and classifications are available to predict peri- and post-operative mortality of patients with end stage heart failure receiving Left Ventricular Assist Device (LVAD) therapy. Sarcopenia has been suggested as a sensitive predictor for post-operative mortality. We evaluated whether the psoas muscle area can predict mortality in patients undergoing LVAD implantation. The indexed psoas mean area (PMAi) was obtained by measuring the psoas muscle area at the superior endplate of the third lumbar vertebra correlated to body surface area of 106 adult patients undergoing LVAD implantation (Medtronic HVAD n = 41, Abbott HeartMate II n = 4, Abbott HeartMate 3 n = 61; mean age 65, IQR 12, 90.6% male; INTERMACS Level 1 24.5%; ischemic CMP 64.2%). Patients were divided in two groups: high/moderate and low muscle mass. The primary endpoint was 30-day mortality, assessed using a multivariate Cox proportional hazards model. Baseline characteristics did not differ between patients with high or moderate and low PMAi. Estimated survival calculated a significant higher 30-day mortality in patients with low PMAi (p = 0.04). Multivariable Cox proportional hazards regression analysis indicated low PMAi, history of previous cardiac surgery and levels of bilirubin as independent predictors of mortality in the first 30 days. In conclusion, indexed psoas muscle area predicts mortality after LVAD implantation and can be used as an additional tool for risk stratification.

PET Cardiac Imaging (Perfusion, Viability, Sarcoidosis, and Infection)

Cardiovascular disease is the leading cause of death worldwide. Given the increased availability of radiopharmaceuticals, improved positron emission tomography (PET) camera systems and proven higher diagnostic accuracy, PET is increasingly utilized in the management of various cardiovascular diseases. PET has high temporal and spatial resolution, when compared to Single Photon Emission Computed Tomography. In clinical practice, hybrid imaging with sequential PET and Computed Tomography acquisitions (PET/CT) or concurrent PET and Magnetic Resonance Imaging are standard. This article will review applications of cardiovascular PET/CT including myocardial perfusion, viability, cardiac sarcoidosis/inflammation, and infection.

Interactive Effects of Heart Rate Variability and P-QRS-T on the Power Density Spectra of ECG Signals

Different from the traditional methods of assessing the cardiac activities through heart rhythm statistics or P-QRS-T complexes separately, this study demonstrates their interactive effects on the power density spectrum (PDS) of ECG signal with applications for the diagnosis of ST-segment elevation myocardial infarction (STEMI) diseases. Firstly, a mathematical model of the PDS of ECG signal with a random pacing pulse train (PPT) mimicking S-A node firings was derived. Secondly, an experimental PDS analysis was performed on clinical ECG signals from 49 STEMI patients and 42 healthy subjects in PTB Diagnostic Database. It was found that besides the interactive effects which are consistent between theoretical and experimental results, the ECG PDSs of STEMI patients exhibited consistently significant power shift towards lower frequency range in ST-elevated leads in comparison with those of reference leads and leads of health subjects with the highest median frequency shift ratios at 51.39 12.94% found in anterior MI. Thirdly, the results of ECG simulation with systematic changes in PPT firing statistics over various lengths of ECG data ranging from 10s to 60 mins revealed that the mean and median frequency parameters were less affected by the heart rhythm statistics and the data length but more depended on the alterations of P-QRS-T complexes, which were further confirmed on 33 more STEMI patients in European ST-T Database, demonstrating that the frequency indexes could be potentially used as alternative indicators for STEMI diagnosis even with ultra-short-term ECG recordings suitable for wearable and mobile health applications in living-free environments.

Investigating the Pharmacological Mechanisms of SheXiang XinTongNing Against Coronary Heart Disease Based on Network Pharmacology and Experimental Evaluation

SheXiang XinTongNing (XTN), which is composed of six traditional Chinese herbs, is a commercially available Chinese patent medicine that has been widely used as the treatment of coronary heart disease (CHD). Its mechanisms against coronary heart disease, however, remain largely unknown. This study aimed to investigate the pharmacological mechanisms of XTN against CHD via network pharmacology and experimental evaluation. In this study, GO enrichment and KEGG pathway enrichment were firstly performed for acquiring the potentially active constituents of XTN, the candidate targets related to coronary heart disease, the drug-components-targets network as well as the protein-protein interaction network and further predicting the mechanisms of XTN against coronary heart disease. Subsequently, a series of in vitro experiments, specifically MTT assay, flow cytometry and Real-time quantitative polymerase chain reaction analysis, and a succession of in vivo experiments, including Tunel staining and immunohistochemical staining were conducted for further verification. Results showed that Bcl-2, IGF1, CASP3 were the key candidate targets which significantly associated with multiple pathways, namely PI3K-Akt signaling pathway and MAPK signaling pathway. It indicated that the potential mechanism of XTN against CHD may be predominantly associated with cell apoptosis. The in vitro experimental results showed that XTN treatment remarkably decreased the apoptotic rate and Bax/Bcl-2 ratio of H9c2 cells. Histological results confirmed that XTN not only effectively alleviated oxidative damage caused by myocardial ischemia but inhibited cell apoptosis. Given the above, through the combined utilization of virtual screening and experimental verification, the findings suggest that XTN makes a significant contribution in protecting the heart from oxidative stress via regulating apoptosis pathways, which lays the foundations and offers an innovative idea for future research.

Senescence and senolytics in cardiovascular disease: Promise and potential pitfalls

Ageing is the biggest risk factor for impaired cardiovascular health, with cardiovascular disease being the cause of death in 40 % of individuals over 65 years old. Ageing is associated with an increased prevalence of atherosclerosis, coronary artery stenosis and subsequent myocardial infarction, thoracic aortic aneurysm, valvular heart disease and heart failure. An accumulation of senescence and increased inflammation, caused by the senescence-associated secretory phenotype, have been implicated in the aetiology and progression of these age-associated diseases. Recently it has been demonstrated that compounds targeting components of anti-apoptotic pathways expressed by senescent cells can preferentially induce senescence cells to apoptosis and have been termed senolytics. In this review, we discuss the evidence demonstrating that senescence contributes to cardiovascular disease, with a particular focus on studies that indicate the promise of senotherapy. Based on these data we suggest novel indications for senolytics as a treatment of cardiovascular diseases which have yet to be studied in the context of senotherapy. Finally, while the potential benefits are encouraging, several complications may result from senolytic treatment. We, therefore, consider these challenges in the context of the cardiovascular system.

ABHD4-Regulating RNA Panel: Novel Biomarkers in Acute Coronary Syndrome Diagnosis

Background: Acute coronary syndrome (ACS) is a major cause of death all over the world. STEMI represents a type of myocardial infarction with acute ST elevation. We aimed to assess the predictive power of potential RNA panel expression in acute coronary syndrome. Method: We used in silico data analysis to retrieve RNAs related to glycerophospholipid metabolism dysregulation and specific to ACS that results in the selection of Alpha/Beta hydrolase fold domain4 (ABHD4) mRNA and its epigenetic regulators (Foxf1 adjacent noncoding developmental regulatory RNA (FENDRR) lncRNA, miRNA-221, and miRNA-197). We assessed the expression of the serum RNA panel in 68 patients with ACS, 21 patients with chest pain due to non-cardiac causes, and 21 healthy volunteers by quantitative real-time polymerase chain reaction. Results: The study data showed significant down regulation in the expression of the serum levels of FENDRR lncRNA and miRNA-221-3p by 120-fold and 22-fold in Unstable angina (UA) in comparison with healthy volunteers, and by 8.6-fold and 2-fold in ST segment elevation myocardial infarction (STEMI) patients versus UA; concomitant upregulation in the expression of ABHD4 mRNA and miRNA-197-5p by 444-fold and 10-fold in UA compared with healthy volunteers, and by 1.54-fold and 4.5-fold in STEMI versus unstable angina. Performance characteristics analysis showed that the ABHD4-regulating RNA panel were potential biomarkers for prediction of ACS. Moreover, there was a significant association between the 2 miRNAs and ABHD4 mRNA and the regulating FENDRR lncRNA. Conclusion: Collectively, ABHD4 mRNA regulating RNA panel based on putative interactions seems to be novel non-invasive biomarkers that could detect ACS early and stratify severity of the condition that could improve health outcome.

Hospitalization for acute coronary syndrome increases the long-term risk of pneumonia: a population-based cohort study

It is well established that the risk of acute coronary syndrome (ACS) increases after respiratory infection. However, the reverse association has not been evaluated. We tested the hypothesis that the long-term risk of pneumonia is increased after a new ACS event. A matched-cohort study was conducted using a nationally representative dataset. We identified patients with admission for ACS between 2004 and 2014, without a previous history of ACS or pneumonia. Incidence density sampling was used to match patients, on the basis of age and sex, to 3 controls who were also free from both ACS and pneumonia. We examined the incidence of pneumonia after ACS until the end of the cohort observation (Dec 31, 2014). The analysis cohort consisted of 5469 ACS cases and 16,392 controls (median age, 64 years; 68.3% men). The incidence rate ratios of the first and the total pneumonia episodes in the ACS group relative to the control group was 1.25 (95% confidence interval [CI], 1.11–1.41) and 1.23(95% CI 1.11–1.36), respectively. A significant ACS-related increase in the incidence of pneumonia was observed in the Cox-regression, shared frailty, and joint frailty model analyses, with hazard ratios of 1.25 (95% CI 1.09–1.42), 1.35 (95% CI 1.15–1.58), and 1.24 (95% CI 1.10–1.39), respectively. In this population-based cohort of patients who were initially free from both ACS and pneumonia, we found that hospitalization for ACS substantially increased the long term risk of pneumonia. This should be considered when formulating post-discharge care plans and preventive vaccination strategies in patients with ACS.

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction

Background:

Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities.

Methods and Results:

Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years.

Conclusions:

Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population.

In-Hospital Outcomes of Female Patients With Inferior Wall Myocardial Infarction

Background The aim of this study was to determine the in-hospital outcome of female patients with inferior wall myocardial infarction (MI). Methodology This study was conducted from January to December 2017 at the Department of Cardiology, National Institute of Cardiovascular Disease, Karachi. A total of 59 women admitted with inferior wall MI were enrolled in the study. In all patients, in-hospital outcomes were observed. Descriptive statistics were applied. Stratification was done using chi-square test, and p-value of ≤0.05 was considered significant. Results The mean age of study participants was 58.80 ± 9.17 years, while 247 (79.7%) participants were above 50 years of age. The mean onset of duration of sign and symptoms of inferior wall MI was 3.48 ± 1.53 hours. There were 36 (61.0%) patients who had diabetes mellitus, 46 (78.0%) had hypertension, 17 (28.8%) were obese, nine (15.3%) had a family history of MI, and three (5.1%) were smokers. There were 43 (72.9%) patients who were illiterate. In our study, eight (13.6%) females were found to have sinus bradycardia, seven (11.9%) had sinus tachycardia, three (5.1%) had atrial fibrillation, and 24 (40.7%) had complete heart block. Mortality was noted in five (8.5%) patients. Conclusions Women with an acute inferior wall MI had a higher rate of complete heart block and adverse in-hospital outcomes. Female gender itself with inferior wall MI may be at risk for in-hospital adverse outcomes.

Sex differences in distribution, management and outcomes of combined ischemic-bleeding risk following acute coronary syndrome

BACKGROUND

Risk factors for further bleeding and ischemic events after acute coronary syndrome (ACS) often overlap. Little is known about sex-based differences in the management and outcomes of ACS patients according to their combined bleeding-ischemic risk.

METHODS

All ACS hospitalizations in the United Kingdom (2010-2017) were retrospectively analyzed, stratified by sex and bleeding-ischemic risk combination (using CRUSADE and GRACE scores). Multivariable logistic regression was performed to examine association between risk-groups and 1) receipt of guideline-recommended management and 2) in-hospital outcomes.

RESULTS

Of 584,360 patients, a third of males (32.3%) and females (32.6%) were in the dual high-risk group (High CRUSADE- High GRACE). In comparison to the dual low-risk group (Low CRUSADE-Low GRACE), the dual high-risk patients of both sexes were 59-83% less likely to receive inpatient revascularisation (PCI or CABG) and 50% less likely to receive dual antiplatelet therapy (DAPT) on discharge, with a significant increase in odds of MACE (~8 to 9-fold), all-cause and cardiac mortality (25 to 35-fold), and bleeding (78-91%). The greatest difference in management and clinical outcomes between sexes was found in the dual-high risk group where females were less likely to receive guideline-recommended therapy (revascularisation and DAPT), compared to males, and were more likely to experience MACE, all-cause and cardiac mortality.

CONCLUSION

ACS patients with dual high-risk for bleeding and recurrent ischemia, especially females, are less likely to receive guideline-recommended therapy and experience significantly worse outcomes. Novel strategies are needed to effectively manage this highly prevalent, complex patient group and address the under-treatment of females.

Thrombus Imaging Using 3D Printed Middle Cerebral Artery Model and Preclinical Imaging Techniques: Application to Thrombus Targeting and Thrombolytic Studies

Diseases with the highest burden for society such as stroke, myocardial infarction, pulmonary embolism, and others are due to blood clots. Preclinical and clinical techniques to study blood clots are important tools for translational research of new diagnostic and therapeutic modalities that target blood clots. In this study, we employed a three-dimensional (3D) printed middle cerebral artery model to image clots under flow conditions using preclinical imaging techniques including fluorescent whole-body imaging, magnetic resonance imaging (MRI), and computed X-ray microtomography (microCT). Both liposome-based, fibrin-targeted, and non-targeted contrast agents were proven to provide a sufficient signal for clot imaging within the model under flow conditions. The application of the model for clot targeting studies and thrombolytic studies using preclinical imaging techniques is shown here. For the first time, a novel method of thrombus labeling utilizing barium sulphate (Micropaque^®) is presented here as an example of successfully employed contrast agents for in vitro experiments evaluating the time-course of thrombolysis and thus the efficacy of a thrombolytic drug, recombinant tissue plasminogen activator (rtPA). Finally, the proof-of-concept of in vivo clot imaging in a middle cerebral artery occlusion (MCAO) rat model using barium sulphate-labelled clots is presented, confirming the great potential of such an approach to make experiments comparable between in vitro and in vivo models, finally leading to a reduction in animals needed.

Proteomic Analysis Reveals the Effect of Trichostatin A and Bone Marrow-Derived Dendritic Cells on the Fatty Acid Metabolism of NIH3T3 Cells under Oxygen-Glucose Deprivation Conditions

Fibroblasts mediate acute wound healing and long-term tissue remodeling with scarring after tissue injury. Following myocardial infarction (MI), necrotized cardiomyocytes become replaced by secreted extracellular matrix proteins produced by fibroblasts. Dendritic cells (DCs) can migrate from the bone marrow to the infarct areas and infarct border areas to mediate collagen accumulation after MI. Trichostatin A (TSA) is known to regulate apoptosis and proliferation in fibroblasts and affect the functions of DCs under oxygen-glucose deprivation (OGD) conditions. In this study, we used label-free quantitative proteomics to investigate the effects of TSA and bone marrow-derived dendritic cells (BMDCs) on NIH3T3 fibroblasts under OGD conditions. The results showed that the fatty acid degradation pathway was significantly upregulated in NIH3T3 cells under OGD conditions and that the fatty acid synthesis pathway was significantly downregulated in NIH3T3 cells treated with conditioned media (CM) from BMDCs treated with TSA under OGD conditions [BMDCs-CM(TSA)]. In addition, BMDCs-CM(TSA) significantly decreased the levels of triglycerides and free fatty acids and mediated fatty acid metabolism-related proteins in NIH3T3 cells under OGD conditions. In summary, this proteomics analysis showed that TSA and BMDCs affect fatty acid metabolism in NIH3T3 cells under OGD conditions.

Patients' Preferences after Recurrent Coronary Narrowing: Discrete Choice Experiments

Fundamento:

Selecionar a estratégia de tratamento ideal para a revascularização coronária é um desafio. Um desfecho crucial a ser considerado no momento dessa escolha é a necessidade de refazer a revascularização, uma vez que ela se torna muito mais frequente após a intervenção coronária percutânea (ICP) do que após a cirurgia de revascularização do miocárdio (CRM).

Objetivo:

Pretende-se, com este estudo, trazer reflexões acerca das preferências dos pacientes pelas estratégias de revascularização sob a perspectiva de pacientes que tiveram que refazer a revascularização.

Métodos:

Selecionamos uma amostra de pacientes que haviam sido submetidos à ICP e hospitalizados para refazer a revascularização coronária e elicitamos suas preferências por nova ICP ou CRM. Morte perioperatória, mortalidade a longo prazo, infarto do miocárdio e repetir a revascularização foram utilizados para a construção de cenários a partir da descrição de tratamentos hipotéticos que foram rotulados como ICP ou CRM. A ICP era sempre apresentada como a opção com menor incidência de morte perioperatória e maior necessidade de se refazer o procedimento. O modelo logístico condicional foi empregado para analisar as escolhas dos pacientes, utilizando-se o software R. Valores de p <0,05 foram considerados estatisticamente significativos.

Resultados:

Ao todo, 144 pacientes participaram, a maioria dos quais (73,7%) preferiram a CRM à ICP (p < 0,001). Os coeficientes de regressão foram estatisticamente significativos para o rótulo ICP, mortalidade a longo prazo da ICP, morte perioperatória da CRM, mortalidade a longo prazo da CRM e refazer a CRM. O rótulo ICP foi o parâmetro mais importante (p < 0,05).

Conclusão:

A maioria dos pacientes que enfrentam a necessidade de refazer a revascularização coronária rejeitam uma nova ICP, com base em níveis realistas de riscos e benefícios. Incorporar as preferências dos pacientes à estimativa do risco-benefício e às recomendações de tratamento poderia melhorar o cuidado centrado no paciente.

Clearance of senescent cells during cardiac ischemia-reperfusion injury improves recovery

A key component of cardiac ischemia-reperfusion injury (IRI) is the increased generation of reactive oxygen species, leading to enhanced inflammation and tissue dysfunction in patients following intervention for myocardial infarction. In this study, we hypothesized that oxidative stress, due to ischemia-reperfusion, induces senescence which contributes to the pathophysiology of cardiac IRI. We demonstrate that IRI induces cellular senescence in both cardiomyocytes and interstitial cell populations and treatment with the senolytic drug navitoclax after ischemia-reperfusion improves left ventricular function, increases myocardial vascularization, and decreases scar size. SWATH-MS-based proteomics revealed that biological processes associated with fibrosis and inflammation that were increased following ischemia-reperfusion were attenuated upon senescent cell clearance. Furthermore, navitoclax treatment reduced the expression of pro-inflammatory, profibrotic, and anti-angiogenic cytokines, including interferon gamma-induced protein-10, TGF-β3, interleukin-11, interleukin-16, and fractalkine. Our study provides proof-of-concept evidence that cellular senescence contributes to impaired heart function and adverse remodeling following cardiac ischemia-reperfusion. We also establish that post-IRI the SASP plays a considerable role in the inflammatory response. Subsequently, senolytic treatment, at a clinically feasible time-point, attenuates multiple components of this response and improves clinically important parameters. Thus, cellular senescence represents a potential novel therapeutic avenue to improve patient outcomes following cardiac ischemia-reperfusion.

Novel thiazole-pyrazolone hybrids as potent ACE inhibitors and their cardioprotective effect on isoproterenol-induced myocardial infarction

A facile synthesis of a group of novel thiazole-pyrazolone hybrids and their investigation for angiotensin-converting enzyme (ACE) inhibition are reported in this study. These compounds were synthesized using a well-known approach, based on the condensation of ethyl acetoacetate with thiazolylhydrazines, and characterized by various spectroscopic and analytical techniques. The entire set of compounds displayed a moderate-to-excellent inhibitory activity against ACE. In particular, compound 4i was found to be the most potent ACE inhibitor and was further studied for cardioprotective effects against isoproterenol (ISO)-induced myocardial infarction (MI) in rats. Compound 4i improved the cardiac function and prevented cardiac injury induced by ISO in Sprague Dawley rats. The levels of oxidative stress and proinflammatory cytokines were also restored to near normal by 4i as compared with the ISO group. In the Western blot analysis, compound 4i prevented mitochondrial apoptosis after MI by downregulating the expression of cleaved caspase-3 and Bax, with the upregulation of Bcl-2, as compared with the ISO group.

The Impact of Coexistence of Smoking and Diabetes on the Coronary Artery Severity and Outcomes following Percutaneous Coronary Intervention: Results from the 1ST Jordanian PCI Registry

Introduction

Diabetes mellitus (DM) and smoking are highly prevalent among Middle Eastern patients admitted with acute coronary syndrome (ACS) or who undergo percutaneous coronary intervention (PCI).

Methods

This study used the analysis of the data from the first Jordanian PCI registry (JoPCR1) to determine the impact of coexistence of smoking and diabetes mellitus on the coronary artery severity and outcome following percutaneous coronary intervention in Middle Eastern patients.

Results

Of 2426 patients enrolled, 1300 (53.6%) and 1055 (43.5%) were diabetics and smokers, respectively. The patients' age was 59.0 ± 10.1 and ranged between 24 and 95 years. Males comprised 79.4% of all patients. The patients were divided into four groups: nondiabetic-nonsmokers (22.2%), diabetic-nonsmokers (34.3%), nondiabetic-smokers (24.2%), and diabetic-smokers (19.2%). Compared with the other three groups, patients in the diabetic-nonsmoker group were older, more likely to be females, and having a higher prevalence of hypertension, dyslipidemia, chronic renal disease, and history of CVD and revascularization. Consequently, the diabetic-nonsmoker patients (but not the diabetic-smokers) had a higher prevalence of multivessel CAD and PCI than the other three groups, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Furthermore, those patients had a higher incidence of ACS as an indication for PCI than the stable coronary disease (73% vs 27%) and the highest CRUSADE bleeding risk score (63.9%) among other groups. The in-hospital events including in-stent thrombosis and emergency CABG events did not significantly differ among groups (p = 0.5 and 0.22). Heart failure and major bleeding events occurred significantly higher among diabetic-nonsmokers compared to other groups. In-hospital deaths occurred significantly more among diabetic-nonsmokers. Moreover, the one-month and one-year follow-up outcome events (the mortality rate, in-stent thrombosis, readmission for ACS, coronary revascularization, and major bleedings) occurred more frequently in the diabetic-nonsmoker group. However, the difference was statistically significant only for major bleeding incidences.

Conclusions

In this analysis of a completed prospective Middle Eastern PCI registry, the majority of the diabetic-nonsmoker (and not the diabetic-smokers) patients (73%) presented with ACS. This group was the highest at risk for in-hospital PCI complications as well as the worst in outcomes after one year of follow-up. Those patients were more likely to be older, female, and have the worst cardiovascular baseline features, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Thus, more sufficient education about controlling CVD risk factors should be implemented in the Middle Eastern region.

Epidemiology and mortality in an Italian region after the adoption of the universal definition of myocardial infarction

AIMS

The aim of the study is to validate at the biochemical level (presence of myocardial damage) the discharge diagnosis code ICD-9-CM 410.x1, and to compare the acute myocardial infarction (AMI) epidemiology based on pure administrative data with the epidemiology based on troponin and clinical data.

METHODS

The health-related administrative databases of the Italian Region Friuli Venezia Giulia were used as the source of information. All the databases are anonymous and can be linked with each other at the individual patient level through a univocal stochastic key. Two methods were used to assess incidence in 2017: the first used the main hospital discharge diagnosis, validated by biochemical myocardial necrosis; the second identified from the cohort of all patients with any myocardial injury those with ischemic origin.

RESULTS

The positive-predictive value of the clinical diagnosis of AMI (410.x1), validated at the biochemical level, was 96.2%.About 40% of patients with a not trivial biochemical myocardial injury and an ischemic heart disease diagnosis (e.g. 411) were discharged without either ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) diagnosis, leading to a sensitivity of clinical discharge diagnosis of 47.6%.Thirty-day and 90-day mortality at multivariate analysis resulted respectively, 1.8 and 4.0% in NSTEMI, 6.6 and 9.8% in STEMI, 8.8 and 12.2% in patients with biochemical AMI and discharge diagnosis other than 410.x1.

CONCLUSION

Pure administrative data (clinical discharge diagnosis) are today insufficient to catch the whole hospital epidemiology of myocardial infarction missing an important proportion of AMI with an adverse prognosis comparable with STEMI.

Inflammation as the Common Biological Link Between Depression and Cardiovascular Diseases: Can Carnosine Exert a Protective Role?

Several epidemiological studies have clearly shown the high co-morbidity between depression and Cardiovascular Diseases (CVD). Different studies have been conducted to identify the common pathophysiological events of these diseases such as the overactivation of the hypothalamic- pituitary-adrenal axis and, most importantly, the dysregulation of immune system which causes a chronic pro-inflammatory status. The biological link between depression, inflammation, and CVD can be related to high levels of pro-inflammatory cytokines, such as IL-1β, TNF-α, and IL-6, released by macrophages which play a central role in the pathophysiology of both depression and CVD. Pro-inflammatory cytokines interfere with many of the pathophysiological mechanisms relevant to depression by upregulating the rate-limiting enzymes in the metabolic pathway of tryptophan and altering serotonin metabolism. These cytokines also increase the risk to develop CVD, because activation of macrophages under this pro-inflammatory status is closely associated with endothelial dysfunction and oxidative stress, a preamble to atherosclerosis and atherothrombosis. Carnosine (β-alanyl-L-histidine) is an endogenous dipeptide which exerts a strong antiinflammatory activity on macrophages by suppressing reactive species and pro-inflammatory cytokines production and altering pro-inflammatory/anti-inflammatory macrophage polarization. This dipeptide exhibits antioxidant properties scavenging reactive species and preventing oxidative stress-induced pathologies such as CVD. In the present review we will discuss the role of oxidative stress and chronic inflammation as common pathophysiological events both in depression and CVD and the preclinical and clinical evidence on the protective effect of carnosine in both diseases as well as the therapeutic potential of this dipeptide in depressed patients with a high co-morbidity of cardiovascular diseases.

Gait Speed at Discharge and Risk for Readmission or Death: A Prospective Study of an Emergency Ward Population

Background

There has been a growing interest in measuring gait speed for assessing long-term mortality and risk for hospital readmission in different populations.

Objective

We studied the association between a 10-meter gait speed test at hospital discharge and the risk for 30- and 90-day hospital readmission or death in a mixed population of patients hospitalized for emergency care.

Patients and Methods

Patients were prospectively included from 5 wards at the Karolinska University Hospital. The 10-meter gait speed test was measured on the day of discharge. Statistical analysis was performed using logistic regression.

Results

A total of 344 patients were included. Forty-one patients (n=41) were readmitted to hospital or died within 30 days, and 81 were readmitted or died within 90 days after discharge. Readmitted patients were older and had more comorbidities. A 0.1 m/s reduction in gait speed was associated with a 13% greater odds of readmission or death within 30 days (OR 1.13 [95% CI 1.00–1.26]). The area under the receiver operating characteristic curve (AUC) was 0.59 (95% CI 0.51–0.68). The results were similar for 90-day readmission or death where a 0.1 m/s decrement in gait speed was associated with an OR of 1.13 (95% CI 1.04–1.24). When age, eGFR, hemoglobin concentration, and active cancer, which all were univariate predictors of 30-day readmissions, were added to the model it yielded an AUC of 0.68 (95% CI 0.60 to 0.77).

Conclusion

In a mixed population of patients hospitalized for emergency care, low gait speed at discharge was associated with an increased risk of 30- and 90-day readmission or death. However, the test did not discriminate well between those who were readmitted or died and those who did not; therefore we do not recommend its use as a stand-alone test in this population.

Combined non-invasive scan and biomarkers to identify independent risk factors in patients with mild coronary stenosis

Background

Independent risk factors for major adverse cardiovascular events (MACEs) in patients with mild coronary stenosis are uncertain. This study aims to investigate predictive biomarkers for MACEs in patients with mild coronary stenosis.

Methods

Totally 381 patients with mild coronary stenosis were included and MACE incidences were recorded through a 24-month follow-up and 91 patients with unfavorable plaques characteristic are detected by CCTA. One unfavorable characteristic was recorded for 1 point and they were divided into three groups: high-risk group (HR, score =0), intermediate-risk group (IR, score =1) and low-risk group (LR, score/2). Specific blood biomarker measurements of high-sensitivity C-reactive protein (hs-CRP), matrix metallopeptidase 9 (MMP-9), and myeloperoxidase (MPO) were taken simultaneously.

Results

The mean age, hs-CRP and MPO levels in the HR and IR group were significantly higher than that in the LR group. A considerably higher level of MMP-9 showed in the HR group compared to the LR group. The incidence rates of MACE were remarkably higher in HR group than LR group and IR group. Kaplan-Meier survival analysis demonstrated that the cumulative event—free survival rate of HR was significantly higher than that in LR and IR group and there was no significant difference between LR and IR group. The univariate COX regression analysis indicated that the age, hs-CRP, MPO, and unfavorable plaque scores ≥2 were independent risk factors for MACEs.

Conclusions

High MPO levels were strongly correlated with MACEs in patients with mild coronary stenosis. Although confirmation is needed from larger trials, MPO could be a promising clinical tool to improve the risk stratification in patients with mild coronary stenosis and suggest strategies for the individualized prevention programs.

Changing Trends in the Landscape of Patients Hospitalized With Acute Myocardial Infarction (2001 to 2011) (from the Worcester Heart Attack Study)

During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient's demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level.

PD-1/PD-L1 in cardiovascular disease

The PD-1/PD-L1 coinhibitory pathway has critical roles in the immune response and autoimmunity via the regulation of T cell activity. Excessive activity and high expression of this pathway suppresses the function of T cells and immunity. Recent research has indicated that tumour cells express high levels of PD-L1, which has an immunosuppressive effect and can result in treatment failure. Anti-PD-L1 or anti-PD-1 agents have well-established beneficial effects on mortality and quality of life in cancer patients. Based on the regulatory effects and therapeutic value of the PD-1/PD-L1 pathway in malignant disorders, we propose that it also regulates cell immunity and in CHD and atherosclerosis. Low expression level of PD-1/ PD-L1 or anti-PD-1/PD-L1 therapy accelerates the immune processes in CHD and aggravates disease according to numerous studies. A few studies have provided strong evidence that changes in the expression levels of PD-1 or PD-L1 can alter the degree of inflammation and the state of coronary plaques in atherosclerosis. In this review, we summarise the alterations of the PD-1/PD-L1 pathway and discuss its role in CHD.

Polygenic risk for coronary heart disease acts through atherosclerosis in type 2 diabetes

Background

Type 2 diabetes increases the risk of coronary heart disease (CHD), yet the mechanisms involved remain poorly described. Polygenic risk scores (PRS) provide an opportunity to understand risk factors since they reflect etiologic pathways from the entire genome. We therefore tested whether a PRS for CHD influenced risk of CHD in individuals with type 2 diabetes and which risk factors were associated with this PRS.

Methods

We tested the association of a CHD PRS with CHD and its traditional clinical risk factors amongst individuals with type 2 diabetes in UK Biobank (N = 21,102). We next tested the association of the CHD PRS with atherosclerotic burden in a cohort of 352 genome-wide genotyped participants with type 2 diabetes who had undergone coronary angiograms.

Results

In the UK Biobank we found that the CHD PRS was strongly associated with CHD amongst individuals with type 2 diabetes (OR per standard deviation increase = 1.50; p = 1.5 × 10^− 59). But this CHD PRS was, at best, only weakly associated with traditional clinical risk factors, such as hypertension, hyperlipidemia, glycemic control, obesity and smoking. Conversely, in the angiographic cohort, the CHD PRS was strongly associated with multivessel stenosis (OR = 1.65; p = 4.9 × 10^− 4) and increased number of major stenotic lesions (OR = 1.35; p = 9.4 × 10^− 3).

Conclusions

Polygenic predisposition to CHD is strongly associated with atherosclerotic burden in individuals with type 2 diabetes and this effect is largely independent of traditional clinical risk factors. This suggests that genetic risk for CHD acts through atherosclerosis with little effect on most traditional risk factors, providing the opportunity to explore new biological pathways.

Radiomics for Distinguishing Myocardial Infarction from Myocarditis at Late Gadolinium Enhancement at MRI: Comparison with Subjective Visual Analysis

Purpose

To evaluate whether radiomics features of late gadolinium enhancement (LGE) regions at cardiac MRI enable distinction between myocardial infarction (MI) and myocarditis and to compare radiomics with subjective visual analyses by readers with different experience levels.

Materials and Methods

In this retrospective, institutional review board-approved study, consecutive MRI examinations of 111 patients with MI and 62 patients with myocarditis showing LGE were included. By using open-source software, classification performances attained from two-dimensional (2D) and three-dimensional (3D) texture analysis, shape, and first-order descriptors were compared, applying five different machine learning algorithms. A nested, stratified 10-fold cross-validation was performed. Classification performances were compared through Wilcoxon signed-rank tests. Supervised and unsupervised feature selection techniques were tested; the effect of resampling MR images was analyzed. Subjective image analysis was performed on 2D and 3D image sets by two independent, blinded readers with different experience levels.

Results

When trained with recursive feature elimination (RFE), a support vector machine achieved the best results (accuracy: 88%) for 2D features, whereas linear discriminant analysis (LDA) showed the highest accuracy (85%) for 3D features (P <.05). When trained with principal component analysis (PCA), LDA attained the highest accuracy with both 2D (86%) and 3D (89%; P =.4) features. Results found for classifiers trained with spline resampling were less accurate than those achieved with one-dimensional (1D) nearest-neighbor interpolation (P <.05), whereas results for classifiers trained with 1D nearest-neighbor interpolation and without resampling were similar (P =.1). As compared with the radiomics approach, subjective visual analysis performance was lower for the less experienced and higher for the experienced reader for both 2D and 3D data.

Conclusion

Radiomics features of LGE permit the distinction between MI and myocarditis with high accuracy by using either 2D features and RFE or 3D features and PCA.© RSNA, 2019Supplemental material is available for this article.

Protective Effect Of Vasicine Against Myocardial Infarction In Rats Via Modulation Of Oxidative Stress, Inflammation, And The PI3K/Akt Pathway

Background

Myocardial infarction is the leading cause of damage to the heart and is classified as a major cause of death related to cardiovascular disease. In the present study, we intended to investigate the protective effect of vasicine (VAS) against myocardial infarction in rats, and its mechanism.

Methods

Myocardial infarction was induced by isoproterenol (ISO, 100 mg/kg) at an interval of 24 h for 2 days. Different doses of VAS (2.5, 5, and 10 mg/kg body weight) were administered to the rats. The effect of VAS on oxidative stress markers such as, myocardial necrosis, myocardial ability and infarct volume, inflammatory cytokines, membrane-bound myocardial enzymes, and histopathological changes was investigated. Western blot analysis was also conducted to analyze the effect of VAS on autophagy (PI3K/Akt) and apoptosis (Bcl-2, Bax, and caspase-3). The number of apoptotic cells in the different groups was also identified using TUNEL.

Results

Results suggested that VAS causes reduction in myocardial necrosis by reduction of elevated LDH, CK-MB, and TnT levels. It also causes augmentation of left ventricular systolic pressure (LVSP) and myocardial contractility as determined in terms of +dp/dt_max and –dp/dt_max. Furthermore, VAS causes reduction of TNF-α and IL-6 levels. VAS also improved cardiac function via enhancing posterior wall thickness of the LV with concurrent increase in the mass of LV. In the present study, VAS caused activation of phosphorylated PI3K (p-PI3K) and phosphorylated Akt (p-Akt) in a dose-dependent manner. Furthermore, VAS suppressed apoptosis when tested on animals suffering from ISO-induced MI, by decreasing the expression of cleaved Caspase-3 and Bax while increasing the expression of Bcl-2.

Conclusion

In conclusion, vasicine has a protective effect against MI in vivo, through inhibiting oxidative stress, inflammation and excessive autophagy, to suppress apoptosis via activation of the PI3K/Akt/mTOR signaling pathway.

Antipsychotic use and risk of life-threatening medical events: umbrella review of observational studies

OBJECTIVE

To quantify the risk of hip fracture, thromboembolism, stroke, myocardial infarction, pneumonia and sudden cardiac death associated with exposure to antipsychotics.

METHODS

Systematic searches were conducted in Medline, Embase and PsycINFO from inception until 30/07/2018 for systematic reviews of observational studies. AMSTAR-2 was used for the quality assessment of systematic reviews, while the strength of associations was measured using GRADE and quantitative umbrella review criteria (URC).

RESULTS

Sixty-eight observational studies from six systematic reviews were included. The association between antipsychotic exposure and pneumonia was the strongest [URC = class I; GRADE = low quality; odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.62-2.09; participants = 28 726; age = 76.2 ± 12.3 years], followed by the association with hip fracture (URC = class II; GRADE = low quality; OR = 1.57, 95% CI = 1.42-1.74; participants = 5 288 118; age = 55.4 ± 12.5 years), and thromboembolism (URC = class II; GRADE = very low quality; OR = 1.55, 95% CI = 1.31-1.83; participants = 31 417 175; age = 55.5 ± 3.2 years). The association was weak for stroke (URC = class III; GRADE = very low quality; OR = 1.45, 95% CI = 1.24-1.70; participants = 65 700; age = 68.7 ± 13.8 years), sudden cardiac death (URC = class III; GRADE = very low quality; OR = 2.24, 95% CI = 1.45-3.46; participants = 77 488; age = 52.2 ± 6.2 years) and myocardial infarction (URC = class III; GRADE = very low quality; OR = 2.21, 95% CI = 1.41-3.46; participants = 399 868; age = 74.1 ± 9.3 years).

CONCLUSION

The most robust results were found for the risk of pneumonia, followed by the risk of hip fracture and thromboembolism. For stroke, sudden cardiac death and myocardial infarction, the strength of association was weak. The observational nature of the primary studies may represent a source of bias.