The universal 2012 definition of myocardial infarction compared to the 2007 definition

Does alcohol play the role of confounder or neuroprotective agent in acute carbon monoxide poisoning?

Objectives: This study investigated whether alcohol influences the predictive value of initial blood lactate concentration and Glasgow Coma Scale (GCS) score at presentation for the severity of acute carbon monoxide (CO) poisoning and neurologic outcome in patients with acute CO poisoning. Additionally, whether alcohol has a neuroprotective effect after acute CO poisoning was evaluated.Methods: This retrospective study included 158 patients who presented with acute CO poisoning between January 2017 and July 2018 and had an available blood alcohol content (BAC) at presentation. The baseline characteristics, clinical course during hospitalization and neurologic status at 30 days after acute CO poisoning were collected and compared according to BAC. To account for possible confounding or neuroprotective effects of alcohol, BAC was introduced as a continuous variable and a stratified categorical variable in the analysis.Results: The mean and maximum BAC at presentation were 56.8 mg/dl and 408 mg/dl, respectively, in 158 patients presented at a mean of 1.0 hour after acute CO poisoning. Lactate, adjusted for previously suggested predictors, was not associated with acute CO poisoning severity; however, after additional adjustment with BAC variables, lactate was associated with CO poisoning severity. Initial GCS score was associated with CO poisoning severity during hospitalization and neurologic outcome at 30 days after acute CO poisoning, regardless of BAC adjustment. BAC variables were negatively associated with CO poisoning severity but not neurologic outcome at 30 days.Discussion and conclusion: The severity of CO poisoning should never be predicted based on serum lactate alone without adjusting for BAC. However, the initial GCS score can be used as a predictor of CO poisoning severity and the neurologic outcome at 30 days after acute CO poisoning, regardless of alcohol consumption history. Alcohol does not have a neuroprotective effect on acute CO poisoning. Further study is needed to validate these results.

Plasma Levels of microRNA-221 (miR-221) are Increased in Patients with Acute Pulmonary Embolism

Background

The aim of this study was to measure and compare the plasma levels of the microRNA (miRNA), miR-221, in patients with acute pulmonary embolism (PE) with healthy individuals and to evaluate the potential role of miR-221 as a diagnostic biomarker for acute PE.

Material/Methods

In blood samples collected from 60 patients with acute PE and 50 healthy volunteers, plasma levels of microRNA were identified using a microRNA microarray, and miR-221 expression was detected using real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). Brain natriuretic peptide (BNP) and troponin I were measured using an automated immunoassay analyzer. D-dimer levels were measured with an enzyme-linked immunosorbent assay (ELISA).

Results

From the evaluation of 32 differentially expressed plasma miRNAs, miR-221 was significantly upregulated in the plasma of patients with acute PE compared with normal individuals (P<0.05). Correlation analysis showed that plasma miR-221 levels in patients with acute PE were positively correlated with levels of BNP (r=0.842, P<0.05), troponin I (r=0.853; P<0.05), and D-dimer (r=0.838; P<0.05). The receiver operating characteristic (ROC) area under the curve (AUC) for plasma miR-221 was 0.823 (95% CI, 0.757–0.906) (P<0.05), compared with the AUC for D-dimer of 0.768 (95% CI, 0.727–0.853), the AUC for troponin I of 0.713 (95% CI, 0.646–0.868), and the AUC for BNP of 0.648 (95% CI, 0.601–0.723).

Conclusions

Plasma levels of miR-221 were significantly increased in patients with acute PE when compared with healthy individuals.

Diagnostic accuracy of prehospital electrocardiograms interpreted remotely by emergency physicians in myocardial infarction patients

BACKGROUND

Prehospital 12‑lead electrocardiogram (ECG) is the most widely used screening tool for recognition of ST-segment elevation myocardial infarction (STEMI). However, prehospital diagnosis of STEMI based solely on ECGs can be challenging.

OBJECTIVES

To evaluate the ability of emergency department (ED) physicians to accurately interpret prehospital 12‑lead ECGs from a remote location.

METHODS

All suspected prehospital STEMI patients who were transported by EMS and underwent angiography between 2006 and 2014 were included. We reviewed prehospital ECGs and grouped them based on: 1) presence or absence of a culprit artery lesion following angiography; and 2) whether they met the 3rd Universal Definition of Myocardial Infarction. We also described characteristics of ECGs that were misinterpreted by ED physicians.

RESULTS

A total of 625 suspected STEMI cases were reviewed. Following angiography, 94% (590/625) of patients were found having a culprit artery lesion, while 6% (35/625) did not. Among these 35 patients, 24 had ECGs that mimicked STEMI criteria and 9 had non-ischemic signs. Upon ECG reinterpretation, 92% (577/625) had standard STEMI criteria while 8% (48/625) did not. Among these 48 patients, 35 had ischemic signs ECGs and 13 did not. Characteristics of misinterpreted ECGs included pericarditis, early repolarization, STE > 1 mm (1‑lead only), and negative T-wave.

CONCLUSIONS

Remote interpretation of prehospital 12‑lead ECGs by ED physicians was a useful diagnostic tool in this EMS system. Even if the rate of ECG misinterpretation is low, there is still room for ED physicians operating from a remote location to improve their ability to accurately diagnose STEMI patients.

Long-term outcomes following left main bifurcation stenting in Indian population-Analysis based on SYNTAX I and II scores

Background

Syntax 1 and recently Syntax 2 (SS2) scores are validated risk prediction models in coronary disease.

Objectives

To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2 (SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population.

Methods

Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test.

Results

Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5% at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7%). There were 4 deaths (3.8%). The mean left ventricular ejection fraction (LVEF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events.

Conclusions

Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LVEF was the most useful predictor of events after LM PCI.

Circulating miR-23b as a Novel Biomarker for Early Risk Stratification After ST-Elevation Myocardial Infarction

Background

miR-23b overexpression can promote cardiomyocyte apoptosis and reduce cell growth under hypoxic conditions, suggesting that miR-23b acts as a biomarker for ST-elevation myocardial infarction (STEMI). The aim of this study was to investigate the effect of miR-23b on STEMI patients.

Material/Methods

We enrolled 80 eligible patients with STEMI and 60 control subjects. Blood samples were obtained at 6 h, 12 h, 24 h, 48 h, 3 days, and 7 days after the onset of symptoms. Another blood sample was collected before and after percutaneous coronary intervention (PCI). The samples were used for real-time quantitative PCR analysis. A Siemens Immulite2000 detector (Germany) was used for cTnI detection, and the serum CK-MB content was detected by electrochemical luminescence method.

Results

The expression level of miR-23b was increased in patients with STEMI (P<0.05). No significance difference was observed among risk factors, although the clinical data was comparable (P>0.05). The level of miR-23b in STEMI patients after PCI was lower (P<0.05). The ROC curve of plasma miR-23b showed a separation, with an AUC of 0.809 (95%CI, 0.737–0.936, P<0.05), compared to CK-MB with an AUC of 0.753 (95%CI, 0.707–0.896) and cTnI with an AUC of 0.783 (95%CI, 0.723–0.917).

Conclusions

The present study reveals that miR-23b is a useful biomarker of STEMI, providing a novel insight for the diagnosis for STEMI.

Incidence, Frequency, and Clinical Characteristics of Type 3 Myocardial Infarction in Clinical Practice

OBJECTIVES

Cardiac death in a patient with symptoms and electrocardiographic changes indicative of myocardial ischemia but without available measurements of cardiac biomarkers is designated a type 3 myocardial infarction. We wanted to investigate the incidence, the frequency, and the characteristics of patients diagnosed as type 3 myocardial infarction.

METHODS

The occurrence of deaths in a well-defined geographic region was retrieved from the Danish Civil Registration System during a 1-year period from 2010 to 2011. Complementary data concerning causes of deaths were obtained from the Danish Register of Causes of Death, and ambulance and hospital patient files. Adjudication of the diagnosis was done by 2 local experts and one external senior cardiologist.

RESULTS

A total of 2766 of the 246,723 adult residents in the region had died. A type 3 myocardial infarction was diagnosed in 18 individuals, corresponding to an annual incidence of 7.3/100,000 person-years. During the same 1-year period, 488 patients had other types of myocardial infarction implying a 3.6% frequency of type 3 myocardial infarction (18 of 506) among all myocardial infarctions.

CONCLUSION

Type 3 myocardial infarction is a rare observation in clinical practice with an annual incidence below 10/100,000 person-years and a frequency of 3%-4% among all types of myocardial infarction. If autopsy data are included, the number of type 3 myocardial infarctions will increase.

Prognostic Impact of In-Hospital and Postdischarge Heart Failure in Patients With Acute Myocardial Infarction: A Nationwide Analysis Using Data From the Cardiovascular Disease in Norway (CVDNOR) Project

BACKGROUND

Heart failure (HF) is a serious complication of acute myocardial infarction (AMI). We explored the excess mortality associated with HF as an early or late complication of AMI and describe changes over time in such excess mortality.

METHODS AND RESULTS

All patients hospitalized with an incident AMI and without history of prior HF hospitalization were followed up to 1 year after AMI discharge for episodes of HF. New HF episodes were classified as in-hospital HF if diagnosed during the AMI hospitalization or postdischarge HF if diagnosed within 1 year after discharge from the incident AMI. Logistic and Cox regression models were used to explore the excess mortality associated with HF categories. Changes over time in the excess mortality were assessed by testing the interaction between HF status and study year. In-hospital HF increased in-hospital mortality 1.79 times (odds ratio [OR], 1.79; 95% CI: 1.68-1.91). The excess mortality associated with HF increased by 4.3 times from 2001 to 2009 (P interaction<0.001) as a consequence of a greater decline of in-hospital mortality among AMI patients without (9% per year) compared to those with in-hospital HF (3% per year). Postdischarge HF increased all-cause and CVD mortality 5.98 times (hazard ratio, 5.98; 95% CI: 5.39-6.64) and 7.93 times (subhazard ratio, 7.93; 95% CI: 6.84 -9.19), respectively. The relative excess 1-year mortality associated with HF did not change significantly over time.

CONCLUSIONS

Development of HF-either as an early or late complication of AMI-has a negative impact on patients' survival. Changes in the excess mortality associated with HF are driven by modest improvements in survival among AMI patients with HF as compared to those without HF.