Heart failure in acute myocardial infarction: a comparison between patients with or without heart failure criteria from the FAST-MI registry

Heart Failure at Admission Complicating ST-Elevation Myocardial Infarction in a Middle-Income Country. Experience of the ARGEN-IAM-ST Registry

Despite advances in the management of ST-elevation myocardial infarction (STEMI), when associated with heart failure (HF) its prognosis remains ominous. This study assessed the differences in admission and mortality of HF complicating STEMI at admission (HFad) in a middle-income country. Data from the National Registry of STEMI of Argentina (ARGEN-IAM-ST) from January 1, 2016, to September 30, 2020, were analyzed. HFad was defined by the identification of Killip/Kimball ≥2 at admission. About 3174 patients were analyzed (22.3% had HFad). Patients with HFad were older, more often women, hypertensive, and diabetic. Received less reperfusion (87.6% vs 92.6%, P < 0.001) and had increased in-hospital mortality (28.4% vs 3.0%, P < 0.001). In multivariate analysis HFad was an independent predictor of death (OR: 4.88 [95%CI: 3.33-7.18], P < 0.001) and reperfusion adjusted to HFad was associated with lower mortality (OR: 0.57 [95%CI: 0.34-0.95], P = 0.03). HFad in STEMI is associated with a worse clinical profile, receives fewer reperfusion strategies, and carries a higher risk of in-hospital mortality while reperfusion reduces mortality.

Effect of once versus twice intracoronary injection of allogeneic-derived mesenchymal stromal cells after acute myocardial infarction: BOOSTER-TAHA7 randomized clinical trial

BACKGROUND

Mesenchymal stromal cell (MSC) transplantation can improve the left ventricular ejection fraction (LVEF) after an acute myocardial infarction (AMI). Transplanted MSCs exert a paracrine effect, which might be augmented if repeated doses are administered. This study aimed to compare the effects of single versus double transplantation of Wharton's jelly MSCs (WJ-MSCs) on LVEF post-AMI.

METHODS

We conducted a single-blind, randomized, multicenter trial. After 3-7 days of an AMI treated successfully by primary PCI, 70 patients younger than 65 with LVEF < 40% on baseline echocardiography were randomized to receive conventional care, a single intracoronary infusion of WJ-MSCs, or a repeated infusion 10 days later. The primary endpoint was the 6-month LVEF improvement as per cardiac magnetic resonance (CMR) imaging.

RESULTS

The mean baseline EF measured by CMR was similar (~ 40%) in all three groups. By the end of the trial, while all patients experienced a rise in EF, the most significant change was seen in the repeated intervention group. Compared to the control group (n = 25), single MSC transplantation (n = 20) improved the EF by 4.54 ± 2%, and repeated intervention (n = 20) did so by 7.45 ± 2% when measured by CMR imaging (P < 0.001); when evaluated by echocardiography, these values were 6.71 ± 2.4 and 10.71 ± 2.5%, respectively (P < 0.001).

CONCLUSIONS

Intracoronary transplantation of WJ-MSCs 3-7 days after AMI in selected patients significantly improves LVEF, with the infusion of a booster dose 10 days later augmenting this effect.

TRIAL REGISTRATION

Trial registration: Iranian Registry of Clinical Trials, IRCT20201116049408N1. Retrospectively Registered 20 Nov. 2020, https://en.irct.ir/trial/52357.

Increased serum albumin corrected anion gap levels are associated with increased incidence of new-onset HF and poor prognosis in patients with acute myocardial infarction

BACKGROUND

There is scant evidence on a relationship between metabolic acid load and acute myocardial infarction (AMI). We evaluated the relationship between serum albumin corrected anion gap (ACAG), a metabolic acid load biomarker, and post-myocardial infarction heart failure (post-MI HF) in patients with AMI.

METHODS

This prospective, single-center study enrolled 3,889 patients with AMI. The primary endpoint was the incidence of post-MI HF. Serum ACAG levels were calculated with the following formula: ACAG = AG + (40 - [albuminemia in g/l]) × 0.25.

RESULTS

After correction for multiple confounding factors, patients in the fourth quartile of ACAG (highest serum ACAG levels) showed 33.5% higher risk of out-of-hospital HF [hazard ratio (HR) = 1.335, 95% CI = 1.034-1.724, p = 0.027], and 60% higher risk of in-hospital HF [odds ratio (OR) = 1.600, 95% CI = 1.269-2.017, p < 0.001] than those in the first quartile of ACAG (lowest serum ACAG levels). Altered levels of eGFR mediated 31.07% and 37.39% of the association between serum ACAG levels with out-of-hospital HF and in-hospital HF, respectively. Furthermore, altered levels of hs-CRP mediated 20.85% and 18.91% of the association between serum ACAG levels with out-of-hospital and in-hospital HF, respectively.

CONCLUSION

Our study showed that higher metabolic acid load was associated with increased incidences of post-MI HF in the AMI patients. Furthermore, deterioration of renal function and the hyperinflammatory state partially mediated the association between metabolic acid load and the incidence of post-MI HF.

Potential traditional Chinese medicines with anti-inflammation in the prevention of heart failure following myocardial infarction

Inflammation plays an important role in the development of heart failure (HF) after myocardial infarction (MI). Suppression of post-infarction inflammatory cascade has become a new strategy to delay or block the progression of HF. At present, there are no approved anti-inflammatory drugs used to prevent HF following MI. Traditional Chinese medicine (TCM) has been used clinically for cardiovascular disease for a long time. Here, we summarized the recent progress about some TCM which could both improve cardiac function and inhibit inflammation in patients or experimental models with MI or HF, in order to provide evidence for their potential application in reducing the onset of HF following MI. Among them, single Chinese medicinal herbs (eg. Astragalus and Salvia miltiorrhiza) and Chinese herbal formulas (eg. Gualou Xiebai Decoction and Sini Tang) are discussed separately. The main targets for their anti-inflammation effect are mainly involved the TLR4/NF-κB signaling, as well as pro-inflammatory cytokines IL-1β, IL-6 or TNF-α. It is worthy of further evaluating their potential, experimentally or clinically, in the prevention or delay of HF following MI.

Carbohydrate antigen 125 combined with N-terminal pro-B-type natriuretic peptide in the prediction of acute heart failure following ST-elevation myocardial infarction

The value of serum carbohydrate antigen 125 (CA125) combined with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the evaluation of acute heart failure (AHF) after ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of this study was to evaluate the efficacy of CA125 combined with NT-proBNP in predicting AHF following STEMI. A total of 233 patients with STEMI were evaluated, including 39 patients with Killip II-IV and 194 patients with Killip I. The optimal cutoff point for predicting AHF was determined by receiver operating characteristic (ROC) curve, and the independent predictors of AHF were evaluated by multiple logistic regression. According to the cutoff value, it was divided into three groups: C1 = CA125 < 13.20 and NT-proBNP < 2300 (n = 138); C2 = CA125 ≥ 13.20 or NT-proBNP ≥ 2300 (n = 59); C3 = CA125 ≥ 13.20 and NT-proBNP ≥ 2300 (n = 36). Differences between groups were compared by odds ratio (OR). The levels of CA125 and NT-proBNP in AHF group were higher than those in non-AHF group (19.90 vs 10.00, P < .001; 2980.00 vs 1029.50, P < .001, respectively). The optimal cutoff values of CA125 and NT-proBNP for predicting AHF were 13.20 and 2300, both of which were independent predictors of AHF. The incidence of AHF during hospitalization was highest in C3 (69.44%), middle in C2 (20.34%) and lowest in C1 (1.45%). After adjustment for clinical confounding variables, compared with C1: C2 (OR = 6.41, 95% CI: 1.22-33.84, P = .029), C3 (OR = 19.27, 95% CI: 3.12-118.92, P = .001). Elevated CA125 and NT-proBNP are independent predictors of AHF in STEMI patients, and their combination can improve the recognition efficiency.

Transplantation of mesenchymal stem cells for prevention of acute myocardial infarction induced heart failure: study protocol of a phase III randomized clinical trial (Prevent-TAHA8)

Background

Results from recent clinical trials on bone marrow mononuclear cell (BM-MNC) transplantation show that this intervention can help reduce the incidence of heart failure (HF) after acute myocardial infarction (AMI). However, no study has evaluated the effect of the transplantation of mesenchymal stem cells (MSCs) on a clinical endpoint such as HF.

Methods

This single-blinded, randomized, multicenter trial aims to establish whether the intracoronary infusion of umbilical cord-derived Wharton’s jelly MSCs (WJ-MSCs) helps prevent HF development after AMI. The study will enroll 390 patients 3 to 7 days following AMI. Only patients aged below 65 years with impaired LV function (LVEF < 40%) will be included. They will be randomized (2:1 ratio) to either receive standard care or a single intracoronary infusion of 10⁷ WJ-MSCs. The primary outcome of this study is the assessment of HF development during long-term follow-up (3 years).

Discussion

Data will be collected until Nov 2024. Thereafter, the analysis will be conducted. Results are expected to be ready by Dec 2024. We will prepare and submit the related manuscript following the CONSORT guidelines. This study will help determine whether or not the infusion of intracoronary WJ-MSCs in patients with AMI will reduce the incidence of AMI-induced HF.

Trial registration

ClinicalTrials.gov NCT05043610, Registered on 14 September 2021 - retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06594-1.

Cardioprotection of Klotho against myocardial infarction-induced heart failure through inducing autophagy

Myocardial infarction (MI) is the most common cause of heart failure (HF) worldwide. The aim of this study was to investigate the role of Klotho in cardiac function and remodeling as well as its underlying mechanism in mice with MI-induced HF. For in vivo analyses, MI or sham MI were established in C57BL/6 mice. For in vitro analyses, the H9C2 cells were used to establish a model of oxygen glucose deprivation (OGD). The In vivo and in vitro models were treated with or without Klotho. 3-methyladenine (3-MA) was used to inhibit autophagy in MI mice and H9C2 cells. Cardiac function, cardiac fibrosis, cardiomyocyte autophagy, inflammatory cytokines and myocardial apoptosis were measured. Our results revealed that Klotho significantly improved cardiac function and remodeling, reduced cardiac fibrosis, and suppressed the levels of myocardial inflammatory factors and apoptosis in MI-induced HF model. Klotho enhanced autophagy in cardiomyocytes and inhibited PI3K/AKT/mTOR signaling pathway in the mouse model of MI. Similar observations were made in the OGD model after treatment with Klotho. However, the cardioprotective effects of Klotho was significantly suppressed by 3-MA. Our data indicate that Klotho exerts its cardioprotective effects against MI-induced HF by inducing autophagy through the inhibition of PI3k/AKT/mTOR signaling pathway.

Impact of elevated systolic arterial pulmonary pressure on the total mortality rate after acute myocardial infarction in the elderly

Reduced left ventricular ejection fraction (LVEF) is associated with increased mortality after acute myocardial infarction (AMI). However, the prognostic impact of elevated systolic pulmonary artery pressure (sPAP) in the very elderly patients after AMI is lacking. We aimed to study the impact of elevated sPAP on one- and five-year all-cause mortality after AMI in very elderly patients, 80 years of age and older. Of a total number of 353 patients (≥ 80 years) who were hospitalized with acute coronary syndrome, 162 patients presenting with AMI and with available data of sPAP on echocardiography were included and followed-up for 5 years. The survival analyses were performed using Cox-Regression models adjusted for conventional risk factors including LVEF. Altogether 66 of 162 patients (41%) had ST-segment elevation MI, and 121 (75%) of patients were treated with percutaneous coronary intervention in the acute phase. Echocardiography during the admission revealed that 78 patients (48%) had a LVEF ≤ 45% and 66 patients (41%) had a sPAP ≥ 40 mmHg. After one and five years of follow-up, 23% (n = 33) and 53% (n = 86) of patients died, respectively. A multivariable Cox-Regression analysis showed that the elevated sPAP (≥ 40 mmHg) was an independent predictor of increased mortality in both one and five years after AMI; HR of 2.63 (95%, CI 1.19-5.84, P 0.017) and HR of 2.08 (95%, CI 1.25-3.44, P 0.005) respectively, whereas LVEF ≤ 45% did not show any statistically significant impact, neither on one- nor on five-year mortality (HR 1.3, 95% CI 0.6-2.9, p = 0.469) and (HR 1.4, 95% CI 0.8-2.4, p = 0.158), respectively. Elevated sPAP was an independent risk factor for one- and five-year all-cause mortality after AMI in very elderly patients and sPAP seems to be a better prognostic predictor for all-cause mortality than LVEF. The risk of all-cause mortality after AMI increased with increasing sPAP.

Major cardiovascular events after bone marrow mononuclear cell transplantation following acute myocardial infarction: an updated post-BAMI meta-analysis of randomized controlled trials

Background

The effect of bone marrow-derived mononuclear cells (BM-MNCs) after acute myocardial infarction (AMI) on myocardial function indices such as left ventricular ejection fraction has been widely studied. However, the effect of this intervention on major adverse cardiovascular events (MACE) was not the principal purpose of most investigations and its role is unclear. The aim of this study was to investigate the possible long-term clinical efficacy of BM-MNCs on MACE after AMI.

Methods

A comprehensive search was conducted through electronic databases for potentially eligible randomized trials investigating the impact of BM-MNC therapy following acute MI on clinical outcomes. Risk of bias of the eligible studies was assessed using the Cochrane Collaboration’s tool. The effect of treatment was displayed by risk ratio (RR) and its 95% confidence interval (CI) using random-effects model.

Results

Initial database searching found 1540 records and 23 clinical trials with a total of 2286 participants eligible for meta-analysis. Injection of BM-MNCs was associated with lower risk of composite end points of hospitalization for congestive heart failure (CHF), re-infarction, and cardiac-related mortality (91/1191 vs. 111/812, RR = 0.643, 95% CI = 0.489 to 0.845, p = 0.002). This effect was derived from both reduction of CHF (47/1220 vs. 62/841, RR = 0.568, 95% CI = 0.382 to 0.844, p = 0.005) and re-infarction rate (23/1159 vs. 30/775, RR = 0.583, 95% CI = 0.343 to 0.991, p = 0.046), but not cardiac-related mortality (28/1290 vs. 31/871, RR = 0.722, 95% CI = 0.436 to 1.197, p = 0.207).

Conclusion

This is the first meta-analysis focused on the cardiovascular outcomes of stem cell therapy after AMI and it revealed that transplantation of BM-MNCs may reduce composite endpoint of hospitalization for CHF, re-infarction, and cardiac related mortality driven mainly by reducing reinfarction and hospitalization for heart failure rates but not cardiovascular mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02701-x.

Single vs. double intracoronary injection of mesenchymal stromal cell after acute myocardial infarction: the study protocol from a randomized clinical trial: BOOSTER-TAHA7 trial

Background

Meta-analysis from previous studies have shown that treatment with mesenchymal stromal cell (MCSs) may increase the left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI) by 3.84%, and the effect is greater in those who are not aged and have developed a reduced LVEF. However, it seems that MSC transplantation does its effect through an indirect paracrine effect, and direct differentiation to the cardiomyocytes does not occur. Therefore, it can be hypothesized that this paracrine effect would be augmented if repeated doses of MSC are transplanted. This study is conducted to compare single vs. double injection of MSCs.

Methods

This is a single-blind, randomized, multicenter trial aiming to determine whether intracoronary infusion of double doses of umbilical cord-derived Wharton’s jelly MSCs (WJ-MSCs) improves LVEF more after AMI compared to single administration. Sixty patients 3 to 7 days after AMI will be enrolled. The patients should be under 65 years old and have a severe impairment in LV function (LVEF < 40%). They will be randomized to three arms receiving single or double doses of intracoronary infusion of WJ-MSCs or placebo. The primary endpoint of this study is assessment of improvement in LVEF at 6-month post intervention as compared to the baseline.

Discussion

This investigation will help to determine whether infusion of booster (second) dose of intracoronary WJ-MSCs in patients with AMI will contribute to increasing its effect on the improvement of myocardial function.

Trial registration

Iranian Registry of Clinical Trials (www.IRCT.ir) IRCT20201116049408N1. Registered on November 26 2020

Mesenchymal stem cell transplantation after acute myocardial infarction: a meta-analysis of clinical trials

Background

Trials investigating the role of mesenchymal stem cells (MSCs) in increasing ejection fraction (LVEF) after acute myocardial infarction (AMI) have raised some controversies. This study was conducted to find whether transplantation of MSCs after AMI can help improve myocardial performance indices or clinical outcomes.

Methods

Randomized trials which evaluated transplantation of MSCs after AMI were enrolled. The primary outcome was LVEF change. We also assessed the role of cell origin, cell number, transplantation time interval after AMI, and route of cell delivery on the primary outcome.

Results

Thirteen trials including 956 patients (468 and 488 in the intervention and control arms) were enrolled. After excluding the biased data, LVEF was significantly increased compared to the baseline among those who received MSC (WMD = 3.78%, 95% CI: 2.14 to 5.42, p < 0.001, I² = 90.2%) with more pronounced effect if the transplantation occurred within the first week after AMI (MD = 5.74%, 95%CI: 4.297 to 7.183; I² = 79.2% p < 0.001). The efficacy of trans-endocardial injection was similar to that of intracoronary infusion (4% [95%CI: 2.741 to 5.259, p < 0.001] vs. 3.565% [95%CI: 1.912 to 5.218, p < 0.001], respectively). MSC doses of lower and higher than 10⁷ cells did not improve LVEF differently (5.24% [95%CI: 2.06 to 8.82, p = 0.001] vs. 3.19% [95%CI: 0.17 to 6.12, p = 0.04], respectively).

Conclusion

Transplantation of MSCs after AMI significantly increases LVEF, showing a higher efficacy if done in the first week. Further clinical studies should be conducted to investigate long-term clinical outcomes such as heart failure and cardiovascular mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02667-1.

Improving medication optimisation in left ventricular systolic dysfunction after acute myocardial infarction

Glasgow city has the highest cardiovascular disease (CVD) mortality rate in the UK. Patients with left ventricular systolic dysfunction after acute myocardial infarction represent a ‘high-risk’ cohort for adverse CVD outcomes. The optimisation of secondary prevention medication in this group is often suboptimal. Our aim was to improve the use and target dosing of ACE inhibitors (ACEI), angiotensin II receptor blockers (ARBs) and beta-blockers in such patients, through pharmacist-led clinics and cardiology multidisciplinary team collaboration. Retrospective audits characterised baseline care. Prospective pharmacist-led clinics were piloted and rolled out across seven hospitals and primary care localities over four Plan–Do–Study–Act cycles. ‘Hub’ and ‘spoke’ clinics utilised independent prescribing pharmacists with different levels of cardiology experience. Pharmacists were trained through a bespoke training programme—‘Teach and Treat’. Consultant cardiologists provided senior support and governance. Patients attending prospective pharmacist-led clinics were more likely to be prescribed an ACEI (or ARB) and beta-blocker (n=856/885 (97%) vs n=233/255 (91%), p<0.001 and n=813/885 (92%) vs n=224/255 (88%), p=0.048, respectively) and be on target dose of ACEI (or ARB) and beta-blocker (n=585/885 (66%) vs n=64/255 (25%), p<0.001 and n=218/885 (25%) vs n=17/255 (7%), p<0.001, respectively) compared with baseline. The mean dose of ACEI (or ARB) and beta-blocker was also higher (79% vs 48% of target dose, p<0.001% and 48% vs 33% of target dose, p<0.001, respectively) compared with baseline. Use of secondary prevention medication was significantly improved by pharmacist and cardiology collaboration. These improvements were sustained across a 4-year period, supported by a novel approach called ‘Teach and Treat’ which linked training to defined clinical service delivery. Further work is needed to assess the impact of the programme on long-term CVD outcomes.

Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort

BACKGROUND

There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.

METHODS AND FINDINGS

This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.

CONCLUSIONS

Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03037255.

Burden and Prevention of Adverse Cardiac Events in Patients with Concomitant Chronic Heart Failure and Coronary Artery Disease: A Literature Review

Background

Chronic heart failure (HF) or coronary artery disease (CAD) confers risk for thromboembolism and secondary adverse cardiac events (ACEs) (e.g., mortality, myocardial infarction, and stroke). When HF and CAD occur concomitantly, ACE risk is reported to be elevated. We investigated ACEs, their epidemiology, and the resulting burden among patients with concomitant HF and CAD through a structured review of recent literature. Antithrombotic treatment for ACE prevention was assessed.

Methods

Pertinent databases (PubMed, other) were searched for relevant articles published from January 2004 to March 2015. Data collected included ACE incidence, healthcare resource use, costs, change in quality of life attributed to ACEs, and treatment practice for prevention of ACEs in patients with concomitant HF and CAD.

Results

Mortality rates for patients with both HF and CAD ranged from 4.9–12.3% at 30 days to 13.7–86% for periods between 9.9 months and 10 years. Incidence of ACEs among HF patients with CAD is, respectively, at least 82% and 15% higher than for patients without HF or without CAD, except for stroke investigated in two studies. All‐cause and HF‐related hospitalization is the main driver of the economic burden in patients with HF, the majority of whom had CAD origin. Despite high prevalence of ischemic complications, there is limited evidence to support the use of warfarin‐type antithrombotics among HF patients.

Conclusion

This study confirms that patients with concomitant HF and CAD are at elevated risk for ACEs and suggests the need for effective new antithrombotic treatments to further decrease ischemic complication rates in this population.

Circulating Levels of IL-6 Receptor and gp130 and Long-Term Clinical Outcomes in ST-Elevation Myocardial Infarction

BACKGROUND

Reports on soluble interleukin-6 (IL-6) receptor (sIL-6R) and glycoprotein 130 (sgp130) in ST-elevation myocardial infarction (STEMI) are few and include a small number of patients. The aim of this study was to investigate the possible association between levels of these biomarkers in the acute phase of STEMI and future cardiovascular events.

METHODS AND RESULTS

Circulating IL-6, sgp130, sIL-6R, and C-reactive protein (CRP) were measured in 989 STEMI patients during 2007-2011, and cardiovascular events were recorded during follow-up. The primary endpoint was composite of all-cause mortality, myocardial infarction, stroke, unscheduled revascularization, or rehospitalization for heart failure. Cox regression models were used to estimate hazard ratios (HRs) for cardiovascular events in relation to biomarker levels. Median levels of sIL-6R, sgp130, IL-6, and CRP measured 24 hours (median) after symptom onset were 39.2 ng/mL, 240 ng/mL, 18.8 pg/mL, and 13.7 mg/L, respectively. During a median follow-up time of 4.6 years, 200 patients (20.2%) experienced a primary endpoint, and 82 patients (8.3%) died. Patients with sIL-6R levels in the upper quartile (>47.7 ng/mL) had significantly higher risk of future adverse events (primary endpoint) and mortality compared to patients with lower levels (adjusted HR, 1.54 [1.08, 2.21]; P=0.02 and 1.81 [1.04, 3.18]; P=0.04, respectively). Neither IL-6 nor sgp130 levels were related to future events, but patients with CRP levels in the upper quartile (>31.5 mg/L) had higher risk of death.

CONCLUSION

High levels of sIL-6R were associated with future cardiovascular events and mortality in STEMI patients, suggesting an important role of the IL-6 signaling system.

Influence of heart failure on the prognosis of patients with acute myocardial infarction in southwestern China

The impact of heart failure (HF) on acute myocardial infarction (AMI) in patients from southwestern China remains unclear. The present study aimed to compare in-hospital cardiovascular events, mortality and clinical therapies in AMI patients with or without HF in southwestern China. In total, 591 patients with AMI hospitalized between February 2009 and December 2012 were examined; those with a history of HF were excluded. The patients were divided into four groups according to AMI type (ST-elevated or non-ST-elevated AMI) and the presence of HF during hospitalization. Clinical characteristics, in-hospital cardiovascular events, mortality, coronary angiography and treatment were compared. Clinical therapies, specifically evidence-based drug use were analyzed in patients with HF during hospitalization, including angiotensin converting enzyme inhibitors (ACEIs) and β-blockers (BBs). AMI patients with HF had a higher frequency of co-morbidities, lower left ventricular ejection fraction, longer length of hospital stay and a greater risk of in-hospital mortality compared with AMI patients without HF. AMI patients with HF were less likely to be examined by cardiac angiography or treated with reperfusion therapy or recommended medications. AMI patients with HF co-treated with ACEIs and BBs had a significantly higher survival rate (94.4 vs. 67.5%; P<0.001) compared with untreated patients or patients treated with either ACEIs or BBs alone. Logistic regression analysis revealed that HF and cardiogenic shock in patients with AMI were the strongest predictors of in-hospital mortality. AMI patients with HF were at a higher risk of adverse outcomes. Cardiac angiography and timely standard recommended medications were associated with improved clinical outcomes.

Heart Failure Complicating Acute Myocardial Infarction; Burden and Timing of Occurrence: A Nation-wide Analysis Including 86 771 Patients From the Cardiovascular Disease in Norway (CVDNOR) Project

BACKGROUND

Coronary heart disease (CHD) represents often the underlying conditions for the development of heart failure (HF). We aimed at exploring the burden and timing of HF complicating an acute myocardial infarction (AMI), using the total population of AMI patients hospitalized during 2001-2009 in Norway.

METHODS AND RESULTS

A total of 86 771 patients with a first AMI during 2001-2009 and without previous HF were identified in the "Cardiovascular Disease in Norway" project and followed until HF development, death, or December 31, 2009. In 16 219 patients (18.7%), HF was present on admission or developed during hospitalization for the incident AMI. HF occurrence varied according to age (8.9%, 15.2%, and 25.6% among men and 10.2%, 16.8%, and 27.1% among women ages 25-54, 55-74, and 75-85 years). Among 63 853 patients discharged alive without HF, 8058 (12.6%) were hospitalized with or died because of HF during a median follow-up time of 3.2 years. HF incidence rates (IRs) per 1000 person-years during follow-up were 31 (95% CI, 30-32) for men and 46 (95% CI, 44-47) for women (P<0.01). IRs of HF were highest during the first 6 months of follow-up, after which they leveled off and remained stable until the end of follow-up.

CONCLUSIONS

In this nation-wide cohort study, we observed that HF remains a frequent complication of the first AMI; both during the acute phase and shortly after the discharge from the hospital.

Update on ischemic heart disease and critical care cardiology

This article summarizes the main developments reported during the year 2012 concerning ischemic heart disease, together with the most relevant innovations in the management of acute cardiac patients.