Comparison of management and outcomes of ST-segment elevation myocardial infarction patients in Estonia, Hungary, Norway and Sweden according to national ongoing registries

The IMproving Preclinical Assessment of Cardioprotective Therapies (IMPACT): multicenter pig study on the effect of ischemic preconditioning

Numerous cardioprotective interventions have been reported to reduce myocardial infarct size (IS) in pre-clinical studies. However, their translation for the benefit of patients with acute myocardial infarction (AMI) has been largely disappointing. One reason for the lack of translation is the lack of rigor and reproducibility in pre-clinical studies. To address this, we have established the European IMproving Preclinical Assessment of Cardioprotective Therapies (IMPACT) pig AMI network with centralized randomization and blinded core laboratory IS analysis and validated the network with ischemic preconditioning (IPC) as a positive control. Ten sites in the COST Innovators Grant (IG16225) network participated in the IMPACT network. Three sites were excluded from the final analysis through quality control of infarct images and use of pre-defined exclusion criteria. Using a centrally generated randomization list, pigs were allocated to myocardial ischemia/reperfusion (I/R, N = 5/site) or IPC + I/R (N = 5/site). The primary endpoint was IS [% area-at-risk (AAR)], as quantified by triphenyl-tetrazolium-chloride (TTC) staining in a centralized, blinded core laboratory (5 sites), or IS [% left-ventricular mass (LV)], as quantified by a centralized, blinded cardiac magnetic resonance (CMR) core laboratory (2 sites). In pooled analyses, IPC significantly reduced IS when compared to I/R (57 ± 14 versus 32 ± 19 [%AAR] N = 25 pigs/group; p < 0.001; 25 ± 13 versus 14 ± 8 [%LV]; N = 10 pigs/group; p = 0.021). In site-specific analyses, in 4 of the 5 sites, IS was significantly reduced by IPC when compared to I/R when quantified by TTC and in 1 of 2 sites when quantified by CMR. A pig AMI multicenter European network with centralized randomization and core blinded IS analysis was established and validated with the aim to improve the reproducibility of cardioprotective interventions in pre-clinical studies and the translation of cardioprotection for patient benefit.

Vago-splenic signal transduction of cardioprotection in humans

BACKGROUND AND AIMS

The spleen serves as an important relay organ that releases cardioprotective factor(s) upon vagal activation during remote ischaemic conditioning (RIC) in rats and pigs. The translation of these findings to humans was attempted.

METHODS

Remote ischaemic conditioning or electrical auricular tragus stimulation (ATS) were performed in 10 healthy young volunteers, 10 volunteers with splenectomy, and 20 matched controls. Venous blood samples were taken before and after RIC/ATS or placebo, and a plasma dialysate was infused into isolated perfused rat hearts subjected to global ischaemia/reperfusion.

RESULTS

Neither left nor right RIC or ATS altered heart rate and heart rate variability in the study cohorts. With the plasma dialysate prepared before RIC or ATS, respectively, infarct size (% ventricular mass) in the recipient rat heart was 36 ± 6% (left RIC), 34 ± 3% (right RIC) or 31 ± 5% (left ATS), 35 ± 5% (right ATS), and decreased with the plasma dialysate from healthy volunteers after RIC or ATS to 20 ± 4% (left RIC), 23 ± 6% (right RIC) or to 19 ± 4% (left ATS), 26 ± 9% (right ATS); infarct size was still reduced with plasma dialysate 4 days after ATS and 9 days after RIC. In a subgroup of six healthy volunteers, such infarct size reduction was abrogated by intravenous atropine. Infarct size reduction by RIC or ATS was also abrogated in 10 volunteers with splenectomy, but not in their 20 matched controls.

CONCLUSIONS

In humans, vagal innervation and the spleen as a relay organ are decisive for the cardioprotective signal transduction of RIC and ATS.

The Evaluation of Lipid-Lowering Treatment in Patients with Acute Coronary Syndrome in a Hungarian Invasive Centre in 2015, 2017, and during the COVID-19 Pandemic-The Comparison of the Achieved LDL-Cholesterol Values Calculated with Friedewald and Martin-Hopkins Methods

Background/Objectives: Patients with acute coronary syndrome (ACS) represent a vulnerable population. We aimed to investigate serum lipid levels of patients with ACS upon admission and during one year of the COVID-19 pandemic in a rural county hospital, and compared these findings with the data of patients with ACS in 2015 and 2017. The secondary aim of this paper was the comparison of the LDL-C values calculated with the Friedewald and Martin-Hopkins methods. Methods: A retrospective analysis of lipid-lowering data of patients treated with ACS in 2015, 2017 and in a COVID-19 year (1 April 2020-31 March 2021) was performed; the patient's numbers were 454, 513 and 531, respectively. Results: In the COVID-19 period one year after the index event, only 42% of the patients had lipid values available, while these ratios were 54% and 73% in 2017 and in 2015, respectively. Using the Friedewald formula, in the COVID-19 era the median of LDL cholesterol (LDL-F) was 1.64 (1.09-2.30) mmol/L at six months and 1.60 (1.19-2.27) mmol/L at one year, respectively. These values were 1.92 (1.33-2.27) mmol/L and 1.73 (1.36-2.43) mmol/L using the Martin-Hopkins method (LDL-MH). The LDL-F yielded significantly lower values (15% lower at six months, p = 0.044; and 8% lower at one year, p = 0.014). The LDL-F reached the previous target of 1.8 mmol/L during the COVID-19 pandemic 36% at one year vs. 48% in 2017, and 37% in 2015. The recent target LDL-C level of 1.4 mmol/L was achieved in 22% of cases in the COVID-19 pandemic, 16% in 2015 and 19% in 2017. Conclusions: A significantly lower proportion of patients with ACS had available lipid tests during the COVID-19 pandemic. Besides the lower number of available samples, the proportion of achieved 1.4 mmol/L LDL-C target lipids was stable. More rigorous outpatient care in the follow-up period may help to improve the quality of lipid lowering treatments and subsequent secondary cardiovascular prevention. If direct LDL-C determination is not available, we prefer the LDL calculation with the Martin-Hopkins method.

Myocardial ischemia/reperfusion: Translational pathophysiology of ischemic heart disease

Ischemic heart disease is the greatest health burden and most frequent cause of death worldwide. Myocardial ischemia/reperfusion is the pathophysiological substrate of ischemic heart disease. Improvements in prevention and treatment of ischemic heart disease have reduced mortality in developed countries over the last decades, but further progress is now stagnant, and morbidity and mortality from ischemic heart disease in developing countries are increasing. Significant problems remain to be resolved and require a better pathophysiological understanding. The present review attempts to briefly summarize the state of the art in myocardial ischemia/reperfusion research, with a view on both its coronary vascular and myocardial aspects, and to define the cutting edges where further mechanistic knowledge is needed to facilitate translation to clinical practice.

Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection

The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.

Cardiovascular disease care and outcomes in West and South European countries

Variations in cardiovascular disease (CVD) burden between West and South European countries are rarely reported. To address this knowledge gap, The Lancet Regional Health-Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This Review is specifically focused on West and South European countries. Mortality, risk factor and economic data for nine West European and six South European countries were sourced from the World Health Organisation, the Global Burden of Disease study and the World Bank. Healthcare data were collected by survey of participating countries. A key finding was of declines in age-standardised mortality rates (ASMRs) across all countries since 1990. In 2019 rates per 100,000 were lower in West European countries in males (279.7 (264.1-335.9) vs 337.2 (323.7-367.2)) and females (196.2 (183.3-228.8) vs 247.3 (232.2-268.3)). Differences in risk factor exposures were small, with the exception of physical activity and dietary factors, but across all countries the prevalence of obesity has increased, affecting >20% of adults in 2019. Healthcare delivery in 2019 showed inequalities with cardiovascular procedure rates lower in South compared with West European countries. Further declines in ASMRs in West and South European countries will require population strategies to reduce obesity and address inequalities in physical activity and dietary factors. Reducing the gap in procedure rates is unlikely to match the beneficial effects of population strategies for reducing CVD burden in South European countries.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Prevalence and prognostic impact of left ventricular systolic dysfunction or pulmonary congestion after acute myocardial infarction

AIMS

The aim was to describe the prevalence, characteristics, and outcome of patients with acute myocardial infarction (MI) developing left ventricular (LV) systolic dysfunction or pulmonary congestion by applying different criteria to define the population.

METHODS AND RESULTS

In patients with MI included in the Swedish web-system for enhancement and development of evidence-based care in heart disease (SWEDEHEART) registry, four different sets of criteria were applied, creating four not mutually exclusive subsets of patients: patients with MI and ejection fraction (EF) < 50% and/or pulmonary congestion (subset 1); EF < 40% and/or pulmonary congestion (subset 2); EF < 40% and/or pulmonary congestion and at least one high-risk feature (subset 3, PARADISE-MI like); and EF < 50% and no diabetes mellitus (subset 4, DAPA-MI like). Subsets 1, 2, 3, and 4 constituted 31.6%, 15.0%, 12.8%, and 22.8% of all patients with MI (n = 87 177), respectively. The age and prevalence of different co-morbidities varied between subsets. For median age, 70 to 77, for diabetes mellitus, 22 to 33%; for chronic kidney disease, 22 to 38%, for prior MI, 17 to 21%, for atrial fibrillation, 7 to 14%, and for ST-elevations, 38 to 50%. The cumulative incidence of death or heart failure hospitalization at 3 years was 17.4% (95% CI: 17.1-17.7%) in all MIs; 26.9% (26.3-27.4%) in subset 1; 37.6% (36.7-38.5%) in subset 2; 41.8% (40.7-42.8%) in subset 3; and 22.6% (22.0-23.2%) in subset 4.

CONCLUSIONS

Depending on the definition, LV systolic dysfunction or pulmonary congestion is present in 13-32% of all patients with MI and is associated with a two to three times higher risk of subsequent death or HF admission. There is a need to optimize management and improve outcomes for this high-risk population.

The effect of patient and imaging characteristics on coronary CT angiography assessed pericoronary adipose tissue attenuation and gradient

BACKGROUND

Coronary CT angiography (CCTA) pericoronary adipose tissue (PCAT) markers are promising indicators of inflammation.

OBJECTIVE

To determine the effect of patient and imaging parameters on the associations between non-calcified plaque (NCP) and PCAT attenuation and gradient.

METHODS

This was a single-center, retrospective analysis of consecutive patients with stable chest pain who underwent CCTA and had zero calcium scores. CCTA images were evaluated for the presence of NCP, obstructive stenosis, segment stenosis and involvement score (SSS, SIS), and high-risk plaque (HRP). PCAT markers were assessed using semi-automated software. Uni- and multivariable regression models correcting for patient and imaging characteristics between plaque and PCAT markers were evaluated.

RESULTS

Overall, 1652 patients had zero calcium score (mean age: 51 years ​± ​11 [SD], 871 women); PCAT attenuation values ranged between -123 HU and -51 HU, and 649 patients had plaque. In univariable analysis, the presence of NCP, SSS, SIS, and HRP were associated with PCAT attenuation (2, 1, 1, 6 HU; respectively; p ​< ​.001 all); while obstructive stenosis was not (1 HU, p ​= ​.58). In multivariable analysis, none of the plaque markers were associated with PCAT attenuation (0 HU p ​= ​.93, 0 HU p ​= ​.39, 1 HU p ​= ​.18, 2 HU p ​= ​.10, 1 HU p ​= ​.71, respectively), while patient and imaging characteristics showed significant associations, such as: male sex (1 HU, p ​= ​.003), heart rate [1/min] (-0.2 HU, p ​< ​.001), 120 ​kVp (8 HU, p ​< ​.001) and pixel spacing [mm³] (32 HU, p ​< ​.001). Similar results were observed for PCAT gradient.

CONCLUSION

PCAT markers were significantly associated with NCP, however the associations did not persist following correction for patient and imaging characteristics.

Time trends in incidence, treatment, and outcome in acute myocardial infarction in Norway 2013–19

Aims

Acute myocardial infarction (AMI) is a common cause of morbidity and mortality. The aim of the present study was to assess time trends in the incidence, treatment, and outcome of AMI in a nationwide registry–based cohort of patients.

Methods and results

All patients with a first AMI registered in the Norwegian Myocardial Infarction Registry between 2013 and 2019 were included in this cohort study. The number of patients admitted to Norwegian hospitals with a first AMI decreased from 8933 in 2013 to 8383 in 2019. The proportion of patients with ST-elevation myocardial infarction (STEMI) was stable at 30% throughout the period, and the percentage of STEMI undergoing coronary angiography was stable at 87%. The proportion of patients with non-STEMI undergoing coronary angiography increased by 2.4% per year (95% confidence interval 1.6–3.3) from 58% in 2013 to 68% in 2019. More patients were discharged with secondary preventive medication at the end of study period. Age-adjusted 1-year mortality was reduced from 16.4% in 2013 to 15.1% in 2018. The changes over time were primarily seen in the oldest patient groups.

Conclusion

In the period 2013–19 in Norway, we found a reduction in hospitalizations due to a first AMI. Both the percentage of patients undergoing coronary angiography as well as the percentage discharged with recommended secondary preventive therapy increased during the period, and the age-adjusted 1-year mortality after AMI decreased. A national AMI register provides important information about trends in incidence, treatment, and outcome, and may improve adherence to guideline recommendations.

Sex-related differences in the management and outcomes of patients hospitalized with ST-elevation myocardial infarction: a comparison within four European myocardial infarction registries

Aims

Data on how differences in risk factors, treatments, and outcomes differ between sexes in European countries are scarce. We aimed to study sex-related differences regarding baseline characteristics, in-hospital managements, and mortality of ST-elevation myocardial infarction (STEMI) patients in different European countries.

Methods and results

Patients over the age of 18 with STEMI who were treated in hospitals in 2014–17 and registered in one of the national myocardial infarction registers in Estonia (n = 5817), Hungary (n = 30 787), Norway (n = 33 054), and Sweden (n = 49 533) were included. Cardiovascular risk factors, hospital treatment, and recommendation of discharge medications were obtained from the infarction registries. The primary outcome was mortality, in-hospital, after 30 days and after 1 year. Logistic and cox regression models were used to study the associations of sex and outcomes in the respective countries. Women were older than men (70–78 and 62–68 years, respectively) and received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment, and evidence-based drugs to a lesser extent than men, in all countries. The crude mortality in-hospital rates (10.9–15.9 and 6.5–8.9%, respectively) at 30 days (13.0–19.9 and 8.2–10.9%, respectively) and at 1 year (20.3–28.1 and 12.4–17.2%, respectively) after hospitalization were higher in women than in men. In all countries, the sex-specific differences in mortality were attenuated in the adjusted analysis for 1-year mortality.

Conclusion

Despite improved awareness of the sex-specific inequalities on managing patients with acute myocardial infarction in Europe, country-level data from this study show that women still receive less guideline-recommended management.

Patient characteristics, treatment strategy, outcomes, and hospital costs of acute coronary syndrome: 3 years of data from a large high-volume centre in Central Europe

Managing patients with acute coronary syndrome (ACS) in an ageing population with comorbidities is clinically and economically challenging. Well-conducted unselected registries are essential for providing information on real-day clinical practice. The aim was to create a long term, very detail-controlled registry of unselected patients admitted with ACS to a high-volume centre in Central Europe. Consecutive patients admitted with confirmed ACS were entered into the prospective registry from 1 October 2018 to 30 September 2021. Data on 214 parameters, including clinical characteristics, angiographic findings, laboratory and therapeutic findings, financial costs, and in-hospital mortality, were obtained for all patients. Analyses were performed on the complete dataset of 1804 patients. Of these patients, 694 (38.5%) were admitted for ST-segment elevation myocardial infarction (STEMI) and 1110 (61.5%) were admitted for non-ST-elevation (NSTE)-ACS [779 with NSTE myocardial infarction (NSTE-MI) and 331 with unstable angina (UA)]. Almost all patients (99%) underwent coronary angiography. Primary percutaneous coronary intervention (PCI) was performed in 93.4% of STEMI patients and 74.5% of NSTE-ACS patients. Patients with NSTE-MI had the longest total hospital stay (8.1 ± 9.1 days) and highest financial costs (8579.5 ± 7173.2 euros). In-hospital mortality was 1.2% in UA, 6.2% in NSTE-MI, and 10.9% in STEMI patients. Age older than 75 years, pre-hospital cardiac arrest and/or mechanical ventilation, subacute STEMI, and ejection fraction below 40% were the most powerful predictors of in-hospital mortality as assessed by multivariate analyses. The in-hospital mortality of unselected NSTE-MI and STEMI patients in daily practice is not low despite very good implementation of guideline-recommended therapy with a high rate of revascularization. The highest financial costs are associated with NSTE-MI.