Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)

Deep-learning survival analysis for patients with calcific aortic valve disease undergoing valve replacement

Calcification of the aortic valve (CAVDS) is a major cause of aortic stenosis (AS) leading to loss of valve function which requires the substitution by surgical aortic valve replacement (SAVR) or transcatheter aortic valve intervention (TAVI). These procedures are associated with high post-intervention mortality, then the corresponding risk assessment is relevant from a clinical standpoint. This study compares the traditional Cox Proportional Hazard (CPH) against Machine Learning (ML) based methods, such as Deep Learning Survival (DeepSurv) and Random Survival Forest (RSF), to identify variables able to estimate the risk of death one year after the intervention, in patients undergoing either to SAVR or TAVI. We found that with all three approaches the combination of six variables, named albumin, age, BMI, glucose, hypertension, and clonal hemopoiesis of indeterminate potential (CHIP), allows for predicting mortality with a c-index of approximately 80 % . Importantly, we found that the ML models have a better prediction capability, making them as effective for statistical analysis in medicine as most state-of-the-art approaches, with the additional advantage that they may expose non-linear relationships. This study aims to improve the early identification of patients at higher risk of death, who could then benefit from a more appropriate therapeutic intervention.

The relationship between C-reactive protein to lymphocyte ratio and the prevalence of myocardial infarction in US adults: A cross-sectional study

Objective

C-reactive protein to lymphocyte ratio (CLR) has been identified as a novel inflammatory biomarker. However, the role of CLR in myocardial infarction is unclear. Thus, this study designs to investigate the association of CLR with the prevalence of myocardial infarction in a large multiracial population in the United States.

Methods

Participants from the National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 Pre-pandemic were included in this cross-sectional study. Multivariable regression and subgroup analyses, controlling for demographic variables, were performed to examine the association between CLR and its quintiles and myocardial infarction. A smooth curve fitting was used to model the non-linear relationship between them.

Results

A total of 12,615 participants aged ≥18 years were recruited, of whom 609 (4.83%) self-reported a history of myocardial infarction. Compared to those in the lowest quartile of ln-transformed CLR (Q1), the myocardial infarction risks for subjects in Q2, Q3, and Q4 were 1.64, 1.71, and 1.79 times, respectively. Obvious upward trends were observed when ln-transformed CLR increased (P for trend <0.01). In continuous analyses, the fully adjusted odds ratios (OR) for myocardial infarction prevalence per ln-transformed increment in CLR was 1.46 (95% CI: 1.16-1.84, P < 0.01). Furthermore, a linear association was detected for ln-transformed CLR with the risk of myocardial infarction. Interaction test showed that the effect of CLR on myocardial infarction was significantly affected by age (P for interaction = 0.04).

Conclusions

Data from a large, cross-sectional cohort program show that CLR is positively associated with myocardial infarction prevalence. Our findings highlight that CLR may be a novel inflammation warning biomarker for myocardial infarction.

Cardiovascular Remodeling Post-Ischemia: Herbs, Diet, and Drug Interventions

Cardiovascular disease (CVD) is a serious health burden with increasing prevalence, and CVD continues to be the principal global source of illness and mortality. For several disorders, including CVD, the use of dietary and medicinal herbs instead of pharmaceutical drugs continues to be an alternate therapy strategy. Despite the prevalent use of synthetic pharmaceutical medications, there is currently an unprecedented push for the use of diet and herbal preparations in contemporary medical systems. This urge is fueled by a number of factors, the two most important being the common perception that they are safe and more cost-effective than modern pharmaceutical medicines. However, there is a lack of research focused on novel treatment targets that combine all these strategies-pharmaceuticals, diet, and herbs. In this review, we looked at the reported effects of pharmaceutical drugs and diet, as well as medicinal herbs, and propose a combination of these approaches to target independent pathways that could synergistically be efficacious in treating cardiovascular disease.

Macrophages in myocardial infarction

The heart contains a population of resident macrophages that markedly expands following injury through recruitment of monocytes and through proliferation of macrophages. In myocardial infarction, macrophages have been implicated in both injurious and reparative responses. In coronary atherosclerotic lesions, macrophages have been implicated in disease progression and in the pathogenesis of plaque rupture. Following myocardial infarction, resident macrophages contribute to initiation and regulation of the inflammatory response. Phagocytosis and efferocytosis are major functions of macrophages during the inflammatory phase of infarct healing, and mediate phenotypic changes, leading to acquisition of an anti-inflammatory macrophage phenotype. Infarct macrophages respond to changes in the cytokine content and extracellular matrix composition of their environment and secrete fibrogenic and angiogenic mediators, playing a central role in repair of the infarcted heart. Macrophages may also play a role in scar maturation and may contribute to chronic adverse remodeling of noninfarcted segments. Single cell studies have revealed a remarkable heterogeneity of macrophage populations in infarcted hearts; however, the relations between transcriptomic profiles and functional properties remain poorly defined. This review manuscript discusses the fate, mechanisms of expansion and activation, and role of macrophages in the infarcted heart. Considering their critical role in injury, repair, and remodeling, macrophages are important, but challenging, targets for therapeutic interventions in myocardial infarction.

Left ventricular remodelling post-myocardial infarction: pathophysiology, imaging, and novel therapies

Most patients survive acute myocardial infarction (MI). Yet this encouraging development has certain drawbacks: heart failure (HF) prevalence is increasing and patients affected tend to have more comorbidities worsening economic strain on healthcare systems and impeding effective medical management. The heart’s pathological changes in structure and/or function, termed myocardial remodelling, significantly impact on patient outcomes. Risk factors like diabetes, chronic obstructive pulmonary disease, female sex, and others distinctly shape disease progression on the ‘road to HF’. Despite the availability of HF drugs that interact with general pathways involved in myocardial remodelling, targeted drugs remain absent, and patient risk stratification is poor. Hence, in this review, we highlight the pathophysiological basis, current diagnostic methods and available treatments for cardiac remodelling following MI. We further aim to provide a roadmap for developing improved risk stratification and novel medical and interventional therapies.

Elevated Expression of TLR2 in Aging Hearts Exacerbates Cardiac Inflammatory Response and Adverse Remodeling Following Ischemia and Reperfusion Injury

This study tested the hypothesis that Toll-like receptor 2 (TLR2) augments the inflammatory responses and adverse remodeling in aging hearts to exacerbate myocardial injury and cardiac dysfunction.

Methods

Old (20-22 months old) and adult (4-6 months old) mice of C57BL/6 wild-type and TLR2 knockout (KO) were subjected to coronary artery ligation (30 minutes) and reperfusion (3 or 14 days). Left ventricle function was assessed using a pressure-volume microcatheter. Cardiac infarct size was determined by histology. Levels of vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), matrix metalloproteinase 9 (MMP 9), and collagen I in non-ischemic myocardium were assessed by immunoblotting. Monocyte chemoattractant protein-1 (MCP-1), keratinocyte chemoattractant (KC), and interleukin-6 (IL-6) levels in ischemic and non-ischemic myocardium were measured by enzyme-linked immunosorbent assay (ELISA). TLR2 expression in the myocardium of untreated wild type mice was also measured by immunoblotting.

Results

Higher levels of MCP-1, KC, IL-6 were induced in both ischemic and non-ischemic myocardium of old wild type mice at day 3 and 14 following ischemia/reperfusion (I/R) than those of adult wild type mice. The hyper-inflammatory responses to I/R in aging hearts were associated with elevated levels of myocardial TLR2. TLR2 KO markedly down-regulated the expression of MCP-1, KC, IL-6, ICAM-1 and VCAM-1 in aging hearts at day 3 and 14 following I/R. The down-regulated inflammatory activity in aging TLR2 KO hearts was associated with attenuated production of MMP 9 and collagen I at day 14 and resulted in reduced infarct size and improved cardiac function.

Conclusion

Elevated expression of myocardial TLR2 contributes to the mechanism by which aging exacerbates the inflammatory responses, adverse remodeling and cardiac dysfunction following myocardial I/R in aging.

Preoperative evaluation of geriatric patients undergoing liver transplantation

PURPOSE OF REVIEW

As the population of the world is aging the number of geriatric patients undergoing liver transplantation (LT) is also increasing. They pose a unique challenge for the caregivers, as they have age-related physiological changes, multiple comorbidities and cirrhosis-related pathologies.

RECENT FINDINGS

Twenty-two percent of patients who undergo LT are older than 65 years. Many patients suffer from nonalcoholic steatohepatitis (NASH), hepatocellular carcinoma and hepatitis-C virus. Incidence of NASH tends to increase with age, obesity, diabetes and metabolic syndrome. Elderly patients require comprehensive cognitive, cardiac and pulmonary evaluation prior to LT. Cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension and frailty are of specific concern.

SUMMARY

Proportion of elderly patients who are undergoing LT continues to increase. These patients require comprehensive cardiopulmonary and frailty evaluation. Consensus-based practice advisories need to be developed to standardize preoperative evaluation of geriatric patients awaiting LT.

Proteomic analysis of the heart in normal aging mice

Aging induces pathological cardiovascular changes such as cardiac dysfunction and arteriosclerosis. With aging, heart cells, especially, become more susceptible to lethal damage. In this report, we tried to understand the precise mechanism of myocardial change resulting from aging by examining the heart proteome in aging mice using two-dimensional gel electrophoresis (2DE). The proteins were stained with fluorescence dyes (SYPRO Ruby and Pro-Q Diamond) and identified by subsequent MALDI-TOF-MS / MS. As a result, markedly altered levels of 14 proteins and 7 phosphoproteins were detected in the hearts of 3-, 7-, 11-, and 20-month-old mice. The functions of these identified proteins and phosphoproteins were energy metabolism, muscle contraction, glycolysis, and cytoskeletal support. Additionally, the results of Western blotting confirmed changes in the expression of FTH, CPNE5, and SUCLA2. These findings showed that aging modified the expression of proteins and phosphoproteins in the heart. We suggest that changes in the expression of these proteins are critical to the development of cardiac dysfunction resulting from aging. J. Med. Invest. 69 : 217-223, August, 2022.

Lipidomic and Metabolomic Signature of Progression of Chronic Kidney Disease in Patients with Severe Obesity

Severe obesity is a major risk for chronic kidney disease (CKD). Early detection and careful monitoring of renal function are critical for the prevention of CKD during obesity, since biopsies are not performed in patients with CKD and diagnosis is dependent on the assessment of clinical parameters. To explore whether distinct lipid and metabolic signatures in obesity may signify early stages of pathogenesis toward CKD, liquid chromatography-mass spectrometry (LC-MS) and gas chromatography-high resolution accurate mass-mass spectrometry (GC-HRAM-MS) analyses were performed in the serum and the urine of severely obese patients with and without CKD. Moreover, the impact of bariatric surgery (BS) in lipid and metabolic signature was also studied, through LC-MS and GC-HRAM-MS analyses in the serum and urine of patients with severe obesity and CKD before and after undergoing BS. Regarding patients with severe obesity and CKD compared to severely obese patients without CKD, serum lipidome analysis revealed significant differences in lipid signature. Furthermore, serum metabolomics profile revealed significant changes in specific amino acids, with isoleucine and tyrosine, increased in CKD patients compared with patients without CKD. LC-MS and GC-HRAM-MS analysis in serum of patients with severe obesity and CKD after BS showed downregulation of levels of triglycerides (TGs) and diglycerides (DGs) as well as a decrease in branched-chain amino acid (BCAA), lysine, threonine, proline, and serine. In addition, BS removed most of the correlations in CKD patients against biochemical parameters related to kidney dysfunction. Concerning urine analysis, hippuric acid, valine and glutamine were significantly decreased in urine from CKD patients after surgery. Interestingly, bariatric surgery did not restore all the lipid species, some of them decreased, hence drawing attention to them as potential targets for early diagnosis or therapeutic intervention. Results obtained in this study would justify the use of comprehensive mass spectrometry-based lipidomics to measure other lipids aside from conventional lipid profiles and to validate possible early markers of risk of CKD in patients with severe obesity.

Cardioprotective Properties of Ginkgo Biloba Extract 80 via the Activation of AKT/GSK3β/β-Catenin Signaling Pathway

Elderly people are more likely to experience myocardial infarction (MI) than young people, with worse post-MI mortality and prognosis. Ginkgo biloba extract 50 (GBE50) is an oral GBE product that matches the German product, EGb761, which has been used to treat acute myocardial infarction (AMI). The extraction purity of GBE50 was improved to form a new formulation, Ginkgo biloba extract 80 (GBE80). This study investigates the effect of GBE80 on aged acute myocardial infarction rats. GBE80 injection is a novel formulation that was prepared by mixing Ginkgo flavonoids and lactones in a 4:1 weight ratio, with a Ginkgo content of more than 80%. Cell Counting Kit-8 was used to determine the biological safety and protective effect of GBE80 on cardiomyocytes against oxidative damage. An aged AMI rat model was developed and used to determine the myocardial infarction weight ratio using triphenyltetrazolium chloride staining. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) was applied to detect cell apoptosis in myocardial tissue. Western blotting and immunohistochemistry were used to measure the protein levels of members of the AKT/GSK3β/β-catenin pathway in vitro and in vivo, respectively. We found that GBE80 in vitro suppressed H₂O₂-induced cytotoxicity by promoting AKT/GSK3β/β-catenin signaling, while it did not show cytotoxicity to normal cardiomyocytes in the 0–500 μg/ml dose range. After 7 days of administration to aged AMI rats, GBE80 markedly reduced the weight ratio of the infarction and inhibited cell apoptosis in myocardial tissue. Furthermore, the AKT/GSK3β/β-catenin signaling pathway was activated by GBE80. These results suggest that GBE80 injection effectively inhibited AMI-induced myocardial damage and in vitro H₂O₂-induced cardiomyocyte cytotoxicity by activating the AKT/GSK3β/β-catenin signaling pathway.

Aging-Associated Differences in Epitranscriptomic m6A Regulation in Response to Acute Cardiac Ischemia/Reperfusion Injury in Female Mice

Elderly patients are more susceptible to ischemic injury. N6-methyladenosine (m6A) modification is the most abundant reversible epitranscriptomic modification in mammalian RNA and plays a vital role in many biological processes. However, it is unclear whether age difference impacts m6A RNA methylation in hearts and their response to acute myocardial ischemia/reperfusion (I/R) injury. In this study, we measured the global level of m6A RNA methylation as well as the expression of m6A RNA "writers" (methylation enzymes) and "erasers" (demethylation enzymes) in the hearts of young and elderly female mice undergone sham surgery or acute MI/R injury. We found that m6A RNA level and associate modifier gene expression was similar in intact young and old female hearts. However, young hearts show a significant reduction in m6A RNA while elderly hearts showed only a slight reduction in m6A RNA in response to acute I/R injury. To explore the mechanism of differential level of m6A RNA modification, we use qRT-PCR and Western blotting to compare the mRNA and protein expression of major m6A-related "writers" (Mettl3, Mettl14, and WTAP) and 'erasers" (ALKBH5 and FTO). Mettl3 mRNA and protein expression were significantly reduced in both young and elderly hearts. However, the levels of FTO's mRNA and protein were only significantly reduced in ischemic elderly hearts, and age-related downregulation of FTO may offset the effect of reduced Mettl3 on reduced m6A RNA level in the hearts of aging mice hearts with acute I/R injury, indicating aging-related differences in epitranscriptomic m6A regulation in hearts in response to acute I/R injury. To further investigate specific I/R related targets of Mettl3, we overexpressed Mettl3 in cardiomyocyte line (HL1) using lentiviral vector, and the m6A enrichment of Bcl2, Bax and PTEN were quantified with m6A RIP-qPCR, we found that m6A modification of PTEN mRNA decreased after in vitro hypoxia/reperfusion injury (iH/R) while Mettl3 augments m6A levels of both Bax and PTEN after iH/R, indicating that Bax and PTEN are target genes of Mettl3 under iH/R stress.

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.

Host pre-conditioning improves human adipose-derived stem cell transplantation in ageing rats after myocardial infarction: Role of NLRP3 inflammasome

Functional decline of stem cell transplantation in ageing hosts is well documented. The mechanism for this is poorly understood, although it is known that advancing age does not provide an optimal milieu for exogenous stem cells to survive, engraft and differentiate. We showed that n‐butylidenephthalide improved human adipose–derived stem cell (hADSC) engraftment via attenuating the production of reactive oxygen species (ROS). It remained unclear whether pre‐treated hosts with n‐butylidenephthalide can rejuvenate the ageing heart and improve hADSC engraftment by regulating the ROS/NLRP3 inflammasome‐mediated cardiac fibrosis after myocardial infarction. One hour after coronary ligation, hADSCs were transplanted into the hearts of young and ageing Wistar rats that were pre‐treated with or without n‐butylidenephthalide for 3 days. At day 3 after infarction, myocardial infarction was associated with an increase in ROS levels and NLRP3 inflammasome activity with age. hADSC transplant effectively provided a significant decrease in ROS levels, NLRP3 inflammasome activity, IL‐1β levels and cardiac fibrosis in either young or old infarcted rats. However, the beneficial effects of hADSCs were greater in young compared with old rats in terms of NLRP3 inflammasome activity. The infarcted ageing rats pre‐conditioned by n‐butylidenephthalide improved engraftment and differentiation of hADSCs and additionally attenuated cardiac fibrosis compared with hADSCs alone. The anti‐inflammation effects of n‐butylidenephthalide were reversed by SIN‐1. In conclusions, the increased NLRP3 inflammasome activity plays the pathogenesis of ageing‐related functional hADSC decline in the ageing hosts. n‐butylidenephthalide‐pre‐treated ageing hosts reversibly ameliorate the harsh microenvironments, improve stem cell engraftment and attenuate cardiac fibrosis after myocardial infarction.

Therapeutic Potential of Senolytics in Cardiovascular Disease

Ageing is the biggest risk factor for impaired cardiovascular health, with cardiovascular disease being the leading cause of death in 40% of individuals over 65 years old. Ageing is associated with both an increased prevalence of cardiovascular disease including heart failure, coronary artery disease, and myocardial infarction. Furthermore, ageing is associated with a poorer prognosis to these diseases. Genetic models allowing the elimination of senescent cells revealed that an accumulation of senescence contributes to the pathophysiology of cardiovascular ageing and promotes the progression of cardiovascular disease through the expression of a proinflammatory and profibrotic senescence-associated secretory phenotype. These studies have resulted in an effort to identify pharmacological therapeutics that enable the specific elimination of senescent cells through apoptosis induction. These senescent cell apoptosis-inducing compounds are termed senolytics and their potential to ameliorate age-associated cardiovascular disease is the focus of this review.

Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by symptoms of acute de novo heart failure is associated with excess mortality. Whether development of heart failure and its outcomes differ by sex is unknown.

OBJECTIVES

This study sought to examine the relationships among sex, acute heart failure, and related outcomes after STEMI in patients with no prior history of heart failure recorded at baseline.

METHODS

Patients were recruited from a network of hospitals in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776). Main outcome measures were incidence of Killip class ≥II at hospital presentation and risk-adjusted 30-day mortality rates were estimated using inverse probability of weighting and logistic regression models.

RESULTS

This study included 10,443 patients (3,112 women). After covariate adjustment and matching for age, cardiovascular risk factors, comorbidities, disease severity, and delay to hospital presentation, the incidence of de novo heart failure at hospital presentation was significantly higher for women than for men (25.1% vs. 20.0%, odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.21 to 1.48). Women with de novo heart failure had higher 30-day mortality than did their male counterparts (25.1% vs. 20.6%; OR: 1.29; 95% CI: 1.05 to 1.58). The sex-related difference in mortality rates was still apparent in patients with de novo heart failure undergoing reperfusion therapy after hospital presentation (21.3% vs. 15.7%; OR: 1.45; 95% CI: 1.07 to 1.96).

CONCLUSIONS

Women are at higher risk to develop de novo heart failure after STEMI and women with de novo heart failure have worse survival than do their male counterparts. Therefore, de novo heart failure is a key feature to explain mortality gap after STEMI among women and men.

Relationships Between Chemoreflex Responses, Sleep Quality, and Hematocrit in Andean Men and Women

Andean highlanders are challenged by chronic hypoxia and many exhibit elevated hematocrit (Hct) and blunted ventilation compared to other high-altitude populations. While many Andeans develop Chronic Mountain Sickness (CMS) and excessive erythrocytosis, Hct varies markedly within Andean men and women and may be driven by individual differences in ventilatory control and/or sleep events which exacerbate hypoxemia. To test this hypothesis, we quantified relationships between resting ventilation and ventilatory chemoreflexes, sleep desaturation, breathing disturbance, and Hct in Andean men and women. Ventilatory measures were made in 109 individuals (n = 63 men; n = 46 women), and sleep measures in 45 of these participants (n = 22 men; n = 23 women). In both men and women, high Hct was associated with low daytime SpO₂ (p < 0.001 and p < 0.002, respectively) and decreased sleep SpO₂ (mean, nadir, and time <80%; all p < 0.02). In men, high Hct was also associated with increased end-tidal P_CO2 (p < 0.009). While ventilatory responses to hypoxia and hypercapnia did not predict Hct, decreased hypoxic ventilatory responses were associated with lower daytime SpO₂ in men (p < 0.01) and women (p < 0.009) and with lower nadir sleep SpO₂ in women (p < 0.02). Decreased ventilatory responses to CO₂ were associated with more time below 80% SpO₂ during sleep in men (p < 0.05). The obstructive apnea index and apnea-hypopnea index also predicted Hct and CMS scores in men after accounting for age, BMI, and SpO₂ during sleep. Finally, heart rate response to hypoxia was lower in men with higher Hct (p < 0.0001). These data support the idea that hypoventilation and decreased ventilatory sensitivity to hypoxia are associated with decreased day time and nighttime SpO₂ levels that may exacerbate the stimulus for erythropoiesis in Andean men and women. However, interventional and longitudinal studies are required to establish the causal relationships between these associations.

Ageing, sex, and cardioprotection

Translation of cardioprotective interventions aimed at reducing myocardial injury during ischaemia-reperfusion from experimental studies to clinical practice is an important yet unmet need in cardiovascular medicine. One particular challenge facing translation is the existence of demographic and clinical factors that influence the pathophysiology of ischaemia-reperfusion injury of the heart and the effects of treatments aimed at preventing it. Among these factors, age and sex are prominent and have a recognised role in the susceptibility and outcome of ischaemic heart disease. Remarkably, some of the most powerful cardioprotective strategies proven to be effective in young animals become ineffective during ageing. This article reviews the mechanisms and implications of the modulatory effects of ageing and sex on myocardial ischaemia-reperfusion injury and their potential effects on cardioprotective interventions. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc.

A risk score model for predicting cardiac rupture after acute myocardial infarction

Background:

Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.

Methods:

This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiver-operating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.

Results:

Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n = 39; ventricular septal rupture, n = 14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m², lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC] = 0.895, 95% confidence interval: 0.845–0.944, optimism-corrected AUC = 0.821, P < 0.001).

Conclusion:

This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

From pediatrics to geriatrics: Mechanisms of heart failure across the life-course

Heart failure (HF) is a significant public health problem and a disease with high 5-year mortality. Although age is the primary risk factor for development of HF, it is a disease which impacts patients of all ages. Historically, HF has been studied as a one-size fits all strategy- with the majority of both clinical and basic science investigations employing adult male subjects or adult male pre-clinical animal models. We postulate that inclusion of biological variables in HF studies is necessary to improve our understanding of mechanisms of HF and improve outcomes. In this review, we will discuss age-specific differences in HF patients, particularly focusing on the pediatric and geriatric age groups. In addition, we will also discuss the biological variable of sex. Characterizing and understanding the mechanistic differences in these distinct HF populations can provide insights that will benefit and personalize therapeutic interventions. Further, we propose that future investigations into the cellular mechanisms involved in the developing and juvenile heart may provide valuable insights for targets that would be beneficial in aging patients.

Emerging roles of extracellular vesicles in cardiac repair and rejuvenation

Cell therapy has received significant attention as a therapeutic approach to restore cardiac function after myocardial infarction. Accumulating evidence supports that beneficial effects observed with cell therapy are due to paracrine secretion of multiple factors from transplanted cells, which alter the tissue microenvironment and orchestrate cardiac repair processes. Of these paracrine factors, extracellular vesicles (EVs) have emerged as a key effector of cell therapy. EVs regulate cellular function through the transfer of cargo, such as microRNAs and proteins, which act on multiple biological pathways within recipient cells. These discoveries have led to the development of cell-free therapies using EVs to improve cardiac repair after a myocardial infarction. Here, we present an overview of the current use of EVs to enhance cardiac repair after myocardial infarction. We also discuss the emerging use of EVs for rejuvenation-based therapies. Finally, future directions for the use of EVs as therapeutic agents for cardiac regenerative medicine are also discussed.

Comparison of epidemiology, treatments and outcomes of ST segment elevation myocardial infarction between young and elderly patients

BACKGROUND

With an ageing population, there is a need to understand the relative risk/benefit of interventions for elderly ST segment elevation myocardial infarction (STEMI) patients. The primary aim of this study was to compare epidemiology, treatments and outcomes between young and elderly STEMI patients. Our secondary aim was to determine the cut-off age when the benefits of primary percutaneous coronary intervention (PCI) were less pronounced.

METHODS

Data were collected by the Singapore Myocardial Infarction Registry. Patients were categorised into young (age <65 years) and elderly STEMI (age ≥65 years) patients.

RESULTS

We analysed 14 006 STEMI cases collected between January 2007 and December 2014; 33.9% were elderly STEMI patients. Elderly STEMI patients had longer median door to balloon (73 vs 64 min, P<0.001) time and were less likely to receive PCI (proportion difference=-23.6%, 95% CI -25.3 to -22.0). In the absence of PCI, elderly STEMI patients had a higher mortality within 30 days (elderly: HR 1.65, 95% CI 1.36 to 1.99, P<0.001; young: HR 1.10, 95% CI 0.79 to 1.54, P=0.573) and 1 year (elderly: HR 1.83, 95% CI 1.57 to 2.14, P<0.001; young: HR 1.41, 95% CI 1.09 to 1.83, P=0.009) of admission. The 1 year survival benefit of PCI started to decline after the age of 65 years.

CONCLUSION

Elderly STEMI patients were less likely to receive PCI and had longer door to balloon times. Survival benefit of PCI decreased after the age of 65 years, with the decline most evident from age 85 years onwards. The risks of PCI need to be weighed carefully against its benefits, especially in very elderly patients.

Left ventricular free-wall rupture that occurred during a cardiopulmonary exercise test

Although exercise testing has become a standard procedure before discharge for patients with acute coronary syndrome, a fatal accident during the test is extremely rare. A 60-year-old man was admitted for a non-ST-segment elevation myocardial infarction. A coronary angiogram showed stenosis at the distal lesion of the circumflex, and a balloon angioplasty was performed. His recovery was smooth, and a cardiopulmonary exercise test was performed 5 days after admission. At 2.5 metabolic equivalents, he suddenly went into cardiac arrest, and percutaneous cardiopulmonary support was initiated. Echocardiography revealed the presence of a large amount of pericardial effusion, and emergency cardiac surgery was performed to repair the free-wall rupture. This highlights the importance of careful monitoring of patients with percutaneous coronary intervention during cardiopulmonary exercise testing.

Acute Coronary Syndromes in the Elderly

The clinical evidence for treatment of acute coronary syndrome (ACS) in the elderly is less robust than in patients younger than 75 years. The elderly have the highest incidence of cardiovascular disease and frequently present with ACS. This number can be expected to increase over time because society is aging. Older adults often sustain unfavorable outcomes from ACS because of atypical presentation and delay in recognition. In addition, elderly patients commonly do not receive optimal guideline-directed ACS treatment. Owing to their high baseline risk of ischemic complications, the elderly also fare worse even with optimal ACS treatment as they frequently have more complex coronary disease, more comorbidities, less cardiovascular reserve, and a higher risk of treatment complications. They are also subjected to a broader range of pharmacologic treatment. Treatment complications can be mitigated to some extent by meticulous dose adjustment of antithrombotic and adjunctive therapies. While careful transitions of care and appropriate utilization of post-discharge secondary preventive measures are important in ACS patients of all ages, the elderly are more vulnerable to system errors and thus deserve special attention from the clinician.

Prognostic Impact of Age and Hemoglobin in Acute ST-Segment Elevation Myocardial Infarction Treated With Reperfusion Therapy

Advanced age and low hemoglobin levels have been associated with a poor prognosis in ST-segment elevation myocardial infarction (STEMI). We studied 1,111 patients with STEMI who received reperfusion treatment (1,032 [92.9%] primary angioplasty and 79 [7.1%] fibrinolysis without rescue percutaneous coronary intervention). Mean age was 64.1 ± 14.0 years, and 23.2% were women. Patients in the last age quartile (>76 years) were more frequently women, presented more risk factors (except smoking), received thrombolysis less frequently, had less complete revascularization, and presented more complications and higher mortality. Hemoglobin level at admission was associated with age and ranged from 14.8 ± 1.5 g/dl in the first quartile to 13.2 ± 1.8 g/dl in the last, p <0.001. Multivariate analysis identified age as a predictor of in-hospital and long-term mortality (odds ratio 1.04, 95% confidence interval [CI] 1.00 to 1.07, hazard ratio 1.06, 95% CI 1.04 to 1.08). Hemoglobin levels were associated with better survival (odds ratio 0.8, 95% CI 0.6 to 0.9, hazard ratio 0.85, 95% CI 0.78 to 0.92). The other predictors of inhospital mortality were Killip class, chronic kidney disease, left ventricular ejection fraction, significant pericardial effusion, and ventricular arrhythmias. The association of hemoglobin with hospital mortality was seen in men and in women ≥65 years. In men ≥65 years, this association was also present in those with hemoglobin levels in the normal range. In conclusion, in patients with STEMI, hemoglobin is an independent predictor of inhospital and long-term mortality, especially in those aged ≥65 years. This association is also present in men ≥65 years with normal hemoglobin levels.

The Growth Differentiation Factor 11 (GDF11) and Myostatin (MSTN) in tissue specific aging

Growth differentiation factor 11 (GDF11) and myostatin (MSTN) are evolutionarily conserved homologues proteins which are closely related members of the transforming growth factor β superfamily. They are often perceived to serve similar or overlapping roles. Recently, GDF11 has been identified as playing a role during aging, however there are conflicting reports as to the nature of this role. In this review, we will discuss the literature regarding functions of GDF11 and myostatin in the heart, brain, and skeletal muscle during aging. Consequently we expect to develop a deeper understanding about the function of these two proteins in organismal aging and disease.

Biochemistry and Biology of GDF11 and Myostatin: Similarities, Differences, and Questions for Future Investigation

Growth differentiation factor 11 (GDF11) and myostatin (or GDF8) are closely related members of the transforming growth factor β superfamily and are often perceived to serve similar or overlapping roles. Yet, despite commonalities in protein sequence, receptor utilization and signaling, accumulating evidence suggests that these 2 ligands can have distinct functions in many situations. GDF11 is essential for mammalian development and has been suggested to regulate aging of multiple tissues, whereas myostatin is a well-described negative regulator of postnatal skeletal and cardiac muscle mass and modulates metabolic processes. In this review, we discuss the biochemical regulation of GDF11 and myostatin and their functions in the heart, skeletal muscle, and brain. We also highlight recent clinical findings with respect to a potential role for GDF11 and/or myostatin in humans with heart disease. Finally, we address key outstanding questions related to GDF11 and myostatin dynamics and signaling during development, growth, and aging.

Acute Complications of Myocardial Infarction in the Current Era: Diagnosis and Management

Coronary heart disease is a major cause of mortality and morbidity worldwide. The incidence of mechanical complications of acute myocardial infarction (AMI) has gone down to less than 1% since the advent of percutaneous coronary intervention, but although mortality resulting from AMI has gone down in recent years, the burden remains high. Mechanical complications of AMI include cardiogenic shock, free wall rupture, ventricular septal rupture, acute mitral regurgitation, and right ventricular infarction. Detailed knowledge of the complications and their risk factors can help clinicians in making an early diagnosis. Prompt diagnosis with appropriate medical therapy and timely surgical intervention are necessary for favorable outcomes.

Abrogation of Age-Induced MicroRNA-195 Rejuvenates the Senescent Mesenchymal Stem Cells by Reactivating Telomerase

Previously, we reported that a novel subpopulation of young mesenchymal stem cells (YMSCs) existed in old bone marrow, which possessed high antiaging properties as well as excellent efficacy for cardiac repair. MicroRNAs (miRNAs) have emerged as key regulators in post-transcriptional gene expression programs, and however, it is unknown whether miRNAs directly control stem cell senescence. Here we present the first evidence that miR-195 overexpressed in old MSCs (OMSCs) induces stem cell senescence deteriorating their regenerative ability by directly deactivating telomerase reverse transcriptase (Tert), and abrogation of miR-195 can reverse stem cell aging. MiRNAs profiling analysis in YMSCs and OMSCs by microarray showed that miR-140, miR-146a/b, and miR-195 were significantly upregulated in OMSCs, which led us to hypothesize that these are age-induced miRNAs involved in stem cell senescence. Of these miRNAs, we found miR-195 directly targeted 3'-untranslated region of Tert gene by computational target prediction analysis and luciferase assay, and knockdown of miR-195 significantly increased Tert expression in OMSCs. Strikingly, miR-195 inhibition significantly induced telomere relengthening in OMSCs along with reduced expression of senescence-associated β-galactosidase. Moreover, silencing miR-195 in OMSCs by transfection of miR-195 inhibitor significantly restored antiaging factors expression including Tert and Sirt1 as well as phosphorylation of Akt and FOXO1. Notably, abrogation of miR-195 markedly restored proliferative abilities in OMSCs. Transplantation of OMSCs with knocked out miR-195 reduced infarction size and improved LV function. In conclusion, rejuvenation of aged stem cells by miR-195 inhibition would be a promising autologous therapeutic strategy for cardiac repair in the elderly patients.

The effects of aging on apoptosis following myocardial infarction

BACKGROUND

Aging is associated with higher incidence of heart failure and death following myocardial infarction (MI). The molecular and cellular changes that lead to these worse outcomes are not known.

METHODS AND RESULTS

Young and aging mice underwent induction of MI by LAD ligation. There was a significant increase in mortality in the aging mice. Neither the young nor aging hearts after MI had inducible ventricular tachycardia. Cardiomyocyte apoptosis increases early after MI in young and aging mice, but to a much greater degree in the aging mice. Caspase inhibition with Ac-DEVD-CHO resulted in a 61% reduction in activated caspase-3 and an 84% reduction in apoptosis in cardiomyocytes in young mice (P < 0.05), but not in aging mice. Gene pathway profiling demonstrated activation of both the caspase and Map3k1/Mapk10 pathways in aging mice following MI, which may contribute to their resistance to caspase inhibition.

CONCLUSIONS

Aging hearts activate distinct apoptotic pathways have more cardiomyocyte apoptosis and are resistant to antiapoptotic therapies following MI. Novel or combination approaches may be required to improve outcomes in aging patients following MI.

Pharmacological options to protect the aged heart from ischemia and reperfusion injury by targeting the PKA-BK(Ca) signaling pathway

The beneficial effects of many cardioprotective strategies including ischemic or pharmacological conditioning are reduced in the aged heart. The underlying reason(s) for the age-dependent loss of cardioprotection is unclear. Recently, we demonstrated that protein kinase A (PKA) dependent cardioprotection is lost in the aged heart. However, activation of large-conductance Ca(2+)-sensitive K(+) (BK(Ca)) channels, a putative PKA downstream target, initiated cardioprotection also in the aged heart. Therefore, we aimed to investigate whether 1) BK(Ca) channels are critically involved in PKA activation induced cardioprotection and 2) the age-dependent loss of cardioprotection is caused by differences in PKA regulation. Using an in vivo rat model with regional myocardial ischemia, we treated young (2-4 months) and aged (22-24 months) Wistar rats with PKA activator forskolin, BK(Ca) channel activator NS1619 and/or BK(Ca) channel blocker iberiotoxin. Forskolin induced infarct size reduction was 1) age-dependent and 2) prevented by iberiotoxin. The effect of forskolin on myocardial PKA activity was comparable in young and aged animals. In addition, NS1619 initiated cardioprotection also in the aged heart both when administered before ischemia and during early reperfusion phase. Activation of BK(Ca) channels is critically involved in forskolin induced cardioprotection. The age-dependency of forskolin induced cardioprotection is not caused by age-dependent differences in PKA activation. Pharmacological targeting of BK(Ca) channels before or after myocardial ischemia is a promising therapeutic strategy to protect the aged heart from ischemia and reperfusion injury.

Pathological ventricular remodeling: mechanisms: part 1 of 2

Despite declines in heart failure morbidity and mortality with current therapies, rehospitalization rates remain distressingly high, substantially affecting individuals, society, and the economy. As a result, the need for new therapeutic advances and novel medical devices is urgent. Disease-related left ventricular remodeling is a complex process involving cardiac myocyte growth and death, vascular rarefaction, fibrosis, inflammation, and electrophysiological remodeling. Because these events are highly interrelated, targeting a single molecule or process may not be sufficient. Here, we review molecular and cellular mechanisms governing pathological ventricular remodeling.

Aging Impairs the Proliferative Capacity of Cardiospheres, Cardiac Progenitor Cells and Cardiac Fibroblasts: Implications for Cell Therapy

INTRODUCTION

Cardiospheres (CS) are self-assembling clusters of cells that can be grown from cardiac tissue. They contain a heterogeneous cell population that includes cardiac progenitor cells (CPCs) and cardiac fibroblasts. CS and CPCs have been shown to improve cardiac function after myocardial infarction (MI) in experimental models and are now being studied in clinical trials. The effects of aging on the proliferative capacity of CS and CPCs, and the paracrine signaling between cell types, remain incompletely understood.

METHODS AND RESULTS

We compared the growth of CS from young and aging murine hearts at baseline and following MI. The number of CS from young and aging hearts was similar at baseline. However, after MI, young hearts had a dramatic increase in the number of CS that grew, but this proliferative response to MI was virtually abolished in the aging heart. Further, the proportion of cells within the CS that were CPCs (defined as Sca-1(stem cell antigen-1)(+)/CD45(-)) was significantly lower in aging hearts than young hearts. Thus the number of available CPCs after culture from aging hearts was substantially lower than from young hearts. Cardiac fibroblasts from aging hearts proliferated more slowly in culture than those from young hearts. We then investigated the interaction between aging cardiac fibroblasts and CPCs. We found no significant paracrine effects on proliferation between these cell types, suggesting the impaired proliferation is a cell-autonomous problem.

CONCLUSIONS

Aging hearts generate fewer CPCs, and aging CPCs have significantly reduced proliferative potential following MI. Aging cardiac fibroblasts also have reduced proliferative capacity, but these appear to be cell-autonomous problems, not caused by paracrine signaling between cell types.

Effect of ATP-dependent channel modulators on ischemia-induced arrhythmia change depending on age and gender

The number of ATP-dependent potassium channels in myocardial cells has been previously shown to change depending on gender and age. Different effects of the ATP-dependent potassium channel blocker, glybenclamide and ATP-dependent potassium channel opener, pinacidil on ischemia or reperfusion-induced arrhythmia observed in various research might depend on different ages and genders of the animals used. The aim of this study is to research the effect of ATP-dependent potassium channel modulators on ischemia-induced arrhythmia in animals of different ages and genders. Sprague-Dawley rats of different ages and genders were used in this study. Ischemia was produced by the ligation of the left coronary artery for 30 min. Electrocardiogram (ECG), blood pressure, infarct area and blood glucose were determined during the 30 min of ischemia. An arrhythmia score from an ECG recorded during 30 min of ischemia was determined by examining the duration and type of arrhythmia. Different effects of glybenclamide and pinacidil on the arrhythmias were observed in male and female young and middle-age rats. Pinacidil decreased the infarct zone in younger female rats, but differences in the type and length of ischemia-induced arrhythmias between females and males disappeared in older age. The results of this study showed that the effect of ATP-dependent potassium channel modulators on ischemia-induced arrhythmia changed due to the age and gender of rats.

Identification of small juvenile stem cells in aged bone marrow and their therapeutic potential for repair of the ischemic heart

Stem cell-mediated cardiac regeneration is impaired with age. In this study, we identified a novel subpopulation of small juvenile stem cells (SJSCs) isolated from aged bone marrow-derived stem cells (BMSCs) with high proliferation and differentiation potential. SJSCs expressed mesenchymal stem cell markers, CD29(+)/CD44(+)/CD59(+)/CD90(+), but were negative for CD45(-)/CD117(-) as examined by flow cytometry analysis. SJSCs showed higher proliferation, colony formation, and differentiation abilities compared with BMSCs. We also observed that SJSCs significantly expressed cardiac lineage markers (Gata-4 and myocyte-specific enhancer factor 2C) and pluripotency markers (octamer-binding transcription factor 4, sex-determining region Y box 2, stage-specific embryonic antigen 1, and Nanog) as well as antiaging factors such as telomerase reverse transcriptase and sirtuin 1. Interestingly, SJSCs either from young or aged animals showed significantly longer telomere length as well as lower senescence-associated β-galactosidase expression, suggesting that SJSCs possess antiaging properties, whereas aged BMSCs have limited potential for proliferation and differentiation. Furthermore, transplantation of aged SJSCs into the infarcted rat heart significantly reduced the infarction size and improved left ventricular function, whereas transplantation of aged BMSCs was less effective. Moreover, neovascularization as well as cardiomyogenic differentiation in the peri-infarcted area were significantly increased in the SJSC-transplanted group compared with the BMSC-transplated group, as evaluated by immunohistochemical analysis. Taken together, these findings demonstrate that SJSCs possess characteristics of antiaging, pluripotency, and high proliferation and differentiation rates, and, therefore, these cells offer great therapeutic potential for repair of the injured myocardium.

New-onset atrial fibrillation and prognosis in nonagenarians after acute myocardial infarction

Background

The influence of new-onset atrial fibrillation (AF) on the long-term prognosis of nonagenarians who survive acute myocardial infarction (AMI) has not been demonstrated.

Objective

Our aim was to study the association between new-onset AF and long-term prognosis of nonagenarians who survive AMI.

Methods

From a total of 96 patients aged ≥89 years admitted during a 5-year period, 64 (67 %) were discharged alive and are the focus of this study.

Results

Mean age was 91.0 ± 2.0 years, and 39 patients (61 %) were women. During admission, 9 patients (14 %) presented new-onset AF, 51 (80 %) did not present AF, and 4 (6 %) had chronic AF. During follow-up (mean 2.3 ± 2.6 years; 6.6 ± 3.6 years in survivors), 58 patients (91 %) died, including the 9 patients with new-onset AF. Cumulative survival at 6, 12, 18, 24, and 30 months was 68.3 %, 57.2 %, 49.2 %, 47.6 %, and 31.8 %, respectively. The only two independent predictors of mortality in the multivariate analysis were age (hazard ratio [HR] 1.14; 95 % confidence interval [CI] 1.01–1.28; p = 0.04) and new-onset AF (HR 2.3; 95 % CI 1.1–4.8; p = 0.02).

Conclusion

New-onset AF is a marker of poor prognosis in nonagenarians who survive AMI.

Discharge after primary angioplasty at 24 h: feasible and safe or a step too far?

Current clinical practice regarding surveillance period and length of hospital stay after an ST elevation myocardial infarction is very variable among different countries and hospitals. In general, there has been a significant reduction in length of stay overall, which is mainly due to the increasing use of primary percutaneous coronary intervention. Length of stay after a ST elevation myocardial infaction, which is a rather common event, has a major impact on health care costs and patients' quality of life. We try to evaluate how far we could push the limits.

Cardiac remodeling and subcellular defects in heart failure due to myocardial infarction and aging

Although several risk factors including hypertension, cardiac hypertrophy, coronary artery disease, and diabetes are known to result in heart failure, elderly subjects are more susceptible to myocardial infarction and more likely to develop heart failure. This article is intended to discuss that cardiac dysfunction in hearts failing due to myocardial infarction and aging is associated with cardiac remodeling and defects in the subcellular organelles such as sarcolemma (SL), sarcoplasmic reticulum (SR), and myofibrils. Despite some differences in the pattern of heart failure due to myocardial infarction and aging with respect to their etiology and sequence of events, evidence has been presented to show that subcellular remodeling plays a critical role in the occurrence of intracellular Ca(2+)-overload and development of cardiac dysfunction in both types of failing heart. In particular, alterations in gene expression for SL and SR proteins induce Ca(2+)-handling abnormalities in cardiomyocytes, whereas those for myofibrillar proteins impair the interaction of Ca(2+) with myofibrils in hearts failing due to myocardial infarction and aging. In addition, different phosphorylation mechanisms, which regulate the activities of Ca(2+)-cycling proteins in SL and SR membranes as well as Ca(2+)-binding proteins in myofibrils, become defective in the failing heart. Accordingly, it is suggested that subcellular remodeling involving defects in Ca(2+)-handling and Ca(2+)-binding proteins as well as their regulatory mechanisms is intimately associated with cardiac remodeling and heart failure due to myocardial infarction and aging.

Relationship between inflammatory markers and new cardiovascular events in patients with acute myocardial infarction who underwent primary angioplasty

Introduction:

The determination of inflammation markers in circulation has enabled an important improvement in the study of cardiovascular diseases. It was tested the hypothesis that non-specific markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and fibrinogen may provide prognostic information in patients with acute myocardial infarction with persistent ST-segment elevation (STEMI) undergoing primary angioplasty (PCI).

Methods:

Patients: A cohort of 197 consecutive patients with STEMI undergoing primary PCI was enrolled, evaluating during hospitalization, the peak values of the following markers of inflammation: ESR, CRP and fibrinogen. A telephone follow-up has been made in order to investigate any possible new cardiovascular events after hospital discharge and the procedure performed.

Results:

Higher values of CRP were statistically associated with adverse future events as composite endpoint and with the single endpoint of death. Furthermore, higher age, presence of hypertension, history of previous cardiovascular events, were statistically significantly associated with cardiac events at follow up. In this group were also overrepresented subjects with anterior myocardial infarction in the anterior localization and with an EF ≤ 35% at discharge.

Conclusions:

CRP appears to be a predictor of future cardiovascular events, confirming that a pro-inflammatory state promotes the progression of atherosclerotic disease and its complications.

Stable haemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair

OBJECTIVES

Acute type A aortic dissection (AAD) is a medical emergency with high mortality even with emergency repair. We explored the prognostic factors of in-hospital mortality for AAD repair.

METHODS

One hundred and thirty-three consecutive patients operated on for AAD between 1997 and 2011 were enrolled in our study. They were assigned to the in-hospital mortality or the survival group. We evaluated 101 variables to predict in-hospital mortality. All data were collected retrospectively.

RESULTS

The 30-day mortality, including intraoperative deaths, was 12.8% (17/133 patients) and in-hospital mortality was 18.0% (24/133). Univariate analysis disclosed 10 significant prognostic factors. Multivariate analysis confirmed that preoperative shock or hypotension (odds ratio (OR) = 4.71; P = 0.004), an initial 24 h of bleeding >1500 ml (OR = 5.17; P = 0.01) and age ≥ 75 years (OR = 3.70; P = 0.019) were independent prognostic factors of in-hospital mortality. On the contrary, an electrocardiogram (ECG) showing no abnormalities (OR = 0.22; P = 0.008) is a good prognostic factor for survival. Interestingly, patients with stable haemodynamics without abnormal ECG findings had an excellent result of 1.6% (1/63) in-hospital mortality.

CONCLUSIONS

Stable haemodynamics and no significant abnormal ECG findings predicted excellent in-hospital survival. Cardiac surgeons and cardiologists should be aware of these positive predictors when treating patients diagnosed with AAD.

Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion

Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥ 3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.