Incidence of, predictors for, and mortality associated with malignant ventricular arrhythmias in non-ST elevation myocardial infarction patients

The burden of sudden cardiac arrest in the setting of acute coronary syndrome

BACKGROUND

The incidence of sudden cardiac arrest (SCA) during acute coronary syndrome is somewhat unclear, since often subjects dying before the first healthcare contact are not included in the estimates. We aimed to investigate the complete incidence of SCA during ACS.

METHODS

The study population consists of two cohorts. The first cohort includes 472 ACS patients from Northern Ostrobothnia, Finland from year 2016 and the second cohort 162 autopsy-verified SCD subjects (extrapolated) from the same region and year, whose death was attributable to coronary artery disease (CAD) and ACS. An extrapolation of SCA incidence during ACS was done by utilizing autopsy data and data from prior autopsy study on this sample.

RESULTS

The overall incidence of SCA in the setting of ACS was 17.5%. The incidence of SCA was 20.6% in all ACS subjects without prior CAD diagnosis, and 25.4% in STEMI subjects without prior CAD diagnosis. In subjects with previously diagnosed CAD, the incidence of SCA was 10.9% in all ACS subjects and 16.1% in STEMI subjects. There was a statistically significant difference in the incidence of SCA between subjects with and without prior CAD diagnosis (p = 0.0052).

CONCLUSION

The inclusion of ACS-SCA subjects dying before the first emergency medical service (EMS) contact results in a higher and likely more accurate estimation of SCA during ACS. The incidence of SCA was higher among subjects without prior CAD diagnosis. The high mortality rate highlights the importance of early ACS detection to reduce the burden of CAD-related premature deaths.

Incidence of Ventricular Fibrillation and Sustained Ventricular Tachycardia Complicating Non-ST Segment Elevation Myocardial Infarction

Background: Primary ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) are potentially lethal complications in patients suffering from acute myocardial infarction (MI). In contrast with the profound data regarding the incidence and prognostic value of ventricular arrhythmias in ST elevation myocardial infarction (STEMI) patients, data regarding contemporary non-ST elevation myocardial infarction (NSTEMI) patients with ventricular arrhythmias is scarce. The aim of the current study was to investigate the incidence of VF/VT complicating NSTEMI among patients admitted to an intensive coronary care unit (ICCU). Methods: Prospective, single-center study of patients diagnosed with NSTEMI admitted to ICCU between June 2019 and December 2022. Data including demographics, presenting symptoms, comorbid conditions, and physical examination, as well as laboratory and imaging data, were analyzed. Patients were continuously monitored for arrhythmias during their admission. The study endpoint was the development of VF/sustained VT during admission. Results: A total of 732 patients were admitted to ICCU with a diagnosis of NSTEMI. Of them, six (0.8%) patients developed VF/VT during their admission. Nevertheless, three were excluded after they were misdiagnosed with NSTEMI instead of posterior ST elevation myocardial infarction (STEMI). Hence, only three (0.4%) NSTEMI patients had VF/VT during admission. None of the patients died during 1-year follow-up. Conclusions: VF/VT in NSTEMI patients treated according to contemporary guidelines including early invasive strategy is rare, suggesting these patients may not need routine monitoring and ICCU setup.

Occurrence of Severe Arrhythmias in Patients with Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS): A Retrospective Study

BACKGROUND

Non-ST elevation acute coronary syndrome (NSTE-ACS) is one of the most frequent manifestations of coronary artery disease. The occurrence of serious heart rhythm disorders (SHRDs) in NSTE-ACS is not well documented. However, continuous heart rhythm monitoring is recommended during the initial management of NSTE-ACS. The targeted monitoring of patients at greater risk for SHRDs could facilitate patients' care in emergency departments (EDs) where the flow of patients is continuously increasing.

METHODS

This retrospective single-center study included 480 patients from emergency and cardiology departments within the Strasbourg University Hospital between 1 January 2019 and 31 December 2020. The objective was to estimate the frequency of the occurrence of SHRDs among patients with NSTE-ACS. The secondary objective was to highlight the factors associated with a higher risk of SHRDs.

RESULTS

The proportion of SHRDs during the first 48 h of hospital care was 2.3% (CI95%: 1.2-4.1%, n = 11). Two time periods were considered: before coronary angiography (1.0%), and during, or after coronary angiography (1.3%). In the first group, two patients required immediate treatment (0.4% of the patients) and no death occurred. In the univariate analysis, the variables significantly associated with SHRDs were age, anticoagulant medication, a decrease in glomerular filtration rate, plasmatic hemoglobin, and left ventricle ejection fraction (LVEF), and an increase in plasmatic troponin, BNP, and CRP levels. In the multivariable analysis, plasmatic hemoglobin > 12 g/dL seemed to be a protective factor for SHRDs.

CONCLUSIONS

In this study, SHRDs were rare and, most often, spontaneously resolved. These data challenge the relevance of systematic rhythm monitoring during the initial management of patients with NSTE-ACS.

Clinical implication of totally occluded infarct-related coronary artery in non-ST-segment elevation myocardial infarction: the TOTAL-NSTEMI study

BACKGROUND

A subset ofpatients found to have total occlusion of the culprit artery (TOCA), present with non-ST-segment elevation myocardial infarction (NSTEMI) and elevated biomarkers. The aim of this study is to assess the effect of the TOCA in patients presenting with NSTEMI.

METHODS

This multicenter observational study was retrospectively conducted between 2015 and 2019. Thrombolysis in myocardial infarction (TIMI) flow grades 0-1 was defined as the TOCA. The primary end point included a combination of all-cause death, myocardial infarction, target vessel revascularization, stent thrombosis, and stroke.

RESULTS

Of 3272 patients, TIMI 0-1 flow in the culprit artery was present in 488 (14.9%) patients. TOCA was more likely to be of thrombotic origin (54.1% vs. 10.3%; P < 0.001) and visible collaterals (22.5% vs. 4.4%; P < 0.001). The rates of 30-day (14.3% vs. 7.2%; P < 0.001) and 2-year (25% vs. 19.1%; P = 0.003) primary end points were significantly higher in TOCA patients. Fatal arrhythmias were remarkably higher at 30-day (8.6% vs. 4%; P < 0.001) and 2-year (9% vs. 5.2%; P = 0.001) follow-ups. Mechanical complications were also higher in patients with TOCA at 30 days (0.8% vs. 0.2%; P = 0.013). Moreover, TOCA (OR, 1.379; P = 0.001) was one of the independent predictors of MACCE in NSTEMI patients.

CONCLUSION

The current data suggest that patients with TOCA in the context of NSTEMI are at higher risk of MACCE, fatal arrhythmias, and mechanical complications.

Impact of the caFFR-Guided Functional SYNTAX Score on Ventricular Tachycardia/Fibrillation Development in Patients With Acute Myocardial Infarction

Aims

To explore the relationship between the severity of coronary artery disease (CAD) and the occurrence of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with acute myocardial infarction (AMI).

Methods

We retrospectively enrolled 705 patients with AMI, who were hospitalized and underwent percutaneous coronary intervention (PCI), in Nanfang Hospital from July 2017 to July 2020. Logistic regression analysis and backward stepwise approach were taken to select the correlation factors. The left and the receiver operating characteristic curves (ROC) analysis were plotted to observe the discriminative power of the SYNTAX score (SS)/caFFR-guided functional SS (FSScaFFR) on the incident VT/VF.

Results

About 58 (8.2%) patients experienced life-threatening VT/VF. The FSScaFFR (OR: 1.155; 95% CI: 1.047 to 1.273; p = 0.004) was an independent predictor of VT/VF after AMI. The ROC analysis showed that the discriminative power of FSScaFFR on the incident VT/VF was significantly better than SS (0.759 vs.0.695, p < 0.0001). Patients with VT/VF were categorized into 2 groups according to the interval between the onset of AMI and the VT/VF. The logistic regression analysis revealed that FSScaFFR was a significant independent correlation of early- and late-VT/VF.

Conclusion

The incident VT/VF in patients with AMI is closely associated with the severity of CAD evaluated by SS and FSScaFFR. Compared to SS, FSScaFFR has a higher correlation with VT/VF, and FSScaFFR was demonstrated to be an independent correlation factor of incident VT/VF after AMI.

Prognosis of the non-ST elevation myocardial infarction complicated with early ventricular fibrillation at higher age

Early ventricular fibrillation (EVF) predicts mortality in ST-segment elevation myocardial infarction (STEMI) patients. Data are lacking about prognosis and management of non-ST-segment elevation myocardial infarction (NSTEMI) EMI with EVF, especially at higher age. In the daily clinical practice, there is no clear prognosis of patients surviving EVF. The present study aimed to investigate the risk factors and factors influencing the prognosis of NSTEMI patients surviving EVF, especially at higher age. Clinical data, including 30-day and 1-year mortality of 6179 NSTEMI patients, were examined; 2.44% (n=151) survived EVF and were further analyzed using chi-square test and uni- and multivariate analyses. Patients were divided into two age groups below and above the age of 70 years. Survival time was compared with Kaplan-Meier analysis. EVF was an independent risk factor for mortality in NSTEMI patients below (HR: 2.4) and above the age of 70 (HR: 2.1). Mortality rates between the two age groups of NSTEMI patients with EVF did not differ significantly: 30-day mortality was 24% vs 40% (p=0.2709) and 1-year mortality was 39% vs 55% (p=0.2085). Additional mortality after 30 days to 1 year was 15% vs 14.6% (p=0.9728). Clinical characteristics of patients with EVF differed significantly from those without in both age groups. EVF after revascularization—within 48 h—had 11.2 OR for 30-day mortality above the age of 70. EVF in NSTEMI was an independent risk factor for mortality in both age groups. Invasive management and revascularization of NSTEMI patients with EVF is highly recommended. Closer follow-up and selection of patients (independent of age) for ICD implantation in the critical first month is essential.

Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA)

Despite major therapeutic advances over the last decades, complex supraventricular and ventricular arrhythmias (VAs), particularly in the emergency setting or during revascularization for acute myocardial infarction (AMI), remain an important clinical problem. Although the incidence of VAs has declined in the hospital phase of acute coronary syndromes (ACS), mainly due to prompt revascularization and optimal medical therapy, still up to 6% patients with ACS develop ventricular tachycardia and/or ventricular fibrillation within the first hours of ACS symptoms. Despite sustained VAs being perceived predictors of worse in-hospital outcomes, specific associations between the type of VAs, arrhythmia timing, applied treatment strategies and long-term prognosis in AMI are vague. Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia that may be asymptomatic and/or may be associated with rapid haemodynamic deterioration requiring immediate treatment. It is estimated that over 20% AMI patients may have a history of AF, whereas the new-onset arrhythmia may occur in 5% patients with ST elevation myocardial infarction. Importantly, patients who were treated with primary percutaneous coronary intervention for AMI and developed AF have higher rates of adverse events and mortality compared with subjects free of arrhythmia. The scope of this position document is to cover the clinical implications and pharmacological/non-pharmacological management of arrhythmias in emergency presentations and during revascularization. Current evidence for clinical relevance of specific types of VAs complicating AMI in relation to arrhythmia timing has been discussed.

Prognostic Value of MicroRNAs in Patients after Myocardial Infarction: A Substudy of PRAGUE-18

Background

The evaluation of the long-term risk of major adverse cardiovascular events and cardiac death in patients after acute myocardial infarction (AMI) is an established clinical process. Laboratory markers may significantly help with the risk stratification of these patients. Our objective was to find the relation of selected microRNAs to the standard markers of AMI and determine if these microRNAs can be used to identify patients at increased risk.

Methods

Selected microRNAs (miR-1, miR-133a, and miR-499) were measured in a cohort of 122 patients from the PRAGUE-18 study (ticagrelor vs. prasugrel in AMI treated with primary percutaneous coronary intervention (pPCI)). The cohort was split into two subgroups: 116 patients who did not die (survivors) and 6 patients who died (nonsurvivors) during the 365-day period after AMI. Plasma levels of selected circulating miRNAs were then assessed in combination with high-sensitivity cardiac troponin T (hsTnT) and N-terminal probrain natriuretic peptide (NT-proBNP).

Results

miR-1, miR-133a, and miR-499 correlated positively with NT-proBNP and hsTnT 24 hours after admission and negatively with left ventricular ejection fraction (LVEF). Both miR-1 and miR-133a positively correlated with hsTnT at admission. Median relative levels of all selected miRNAs were higher in the subgroup of nonsurvivors (N = 6) in comparison with survivors (N = 116), but the difference did not reach statistical significance. All patients in the nonsurvivor subgroup had miR-499 and NT-proBNP levels above the cut-off values (891.5 ng/L for NT-proBNP and 0.088 for miR-499), whereas in the survivor subgroup, only 28.4% of patients were above the cut-off values (p = 0.001).

Conclusions

Statistically significant correlation was found between miR-1, miR-133a, and miR-499 and hsTnT, NT-proBNP, and LVEF. In addition, this analysis suggests that plasma levels of circulating miR-499 could contribute to the identification of patients at increased risk of death during the first year after AMI, especially when combined with NT-proBNP levels.

Development and validation of Women Acute Myocardial Infarction in-Hospital Mortality Score (WAMI Score)

BACKGROUND

A variety of risk models have been developed to predict acute myocardial infarction (AMI) in-hospital mortality risk. As a distinct, higher-risk population, women with AMI have different risk profiles from their men counterparts. Published researches have indicated that the interaction between variables in these models for in-hospital mortality and gender are significant. Due to the interaction and gender differences, the predicting value of these risk models for women could be controversial.

METHODS

Databases from the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) Retrospective AMI Study were utilized for model derivation (n=16,100, women were 4896) and databases from the China PEACE Prospective AMI Study for model validation (n=6207, women were 2090). A multivariable backward stepwise logistic regression was used to examine correlates of in-hospital mortality, and the variables were subsequently weighted and integrated into a scoring system.

RESULTS

We constructed a novel risk-predicting tool to estimate the baseline risk of in-hospital mortality among women with AMI. The risk score includes 8 variables [age, systolic blood pressure, heart rate, initial glomerular filtration rate (GFR), serum glucose, Killip class, cardiac arrest, ventricular tachycardia/ventricular fibrillation (VT/VF)]. The prognostic discriminatory capacity of the Women Acute Myocardial Infarction in-Hospital Mortality (WAMI) risk score was excellent (c statistic 0.84, 95% confidence interval [CI]: 0.83 to 0.86, p<0.001). External validation of the model showed better prognostic capacity (c statistic 0.87, 95% CI: 0.84 to 0.90, p<0.001) than the GRACE risk score (0.77, 95% CI 0.72-0.82, p<0.001) and TIMI risk score (0.72, 95% CI 0.68-0.77, p<0.001).

CONCLUSIONS

The WAMI Score is a simple robust tool for predicting the in-hospital mortality risk of women with AMI.

TRIAL REGISTRATION

"China PEACE-Retrospective AMI Study", NCT01624883, retrospectively registered: April 2012. Date of enrolment of the first participant to the trial: June 17, 2012. "China PEACE-Prospective AMI Study", NCT01624909, prospectively registered: December 2012. Date of enrolment of the first participant to the trial: June 17, 2012.

Outcomes of patients admitted with ventricular arrhythmias and sudden cardiac death in the United States

BACKGROUND

Mortality caused by ventricular arrhythmias (VAs) remains a problem of epidemic proportions. Understanding current trends on admission of VA, patient characteristics, morbidity, mortality, and health care utilization could help us improve allocation of health care resources and risk prediction.

OBJECTIVE

The purpose of this study was to investigate clinical outcomes of VA, including ventricular tachycardia (VT), implantable cardioverter-defibrillator (ICD) shocks, and sudden cardiac death (SCD); and to identify predictors of morbidity and mortality, patterns of utilization of ICD and VT ablation, and the impact of such metrics on overall health care utilization.

METHODS

From 2010-2015, we identified 290,998 VA hospitalizations, which were stratified into group 1: normal heart; group 2: ischemic heart disease (IHD); group 3: nonischemic heart disease (non-IHD); group 4: ICD shocks; and group 5: SCD (cardiac arrest without ICD shock).

RESULTS

The number of admissions for VA decreased during the study period (except for patients with SCD and ICD shock, which increased); in-hospital mortality in patients admitted with VA and SCD increased; utilization of VT ablation in patients with ICD shocks and IHD increased; ICD implantation decreased in non-IHD patients and IHD patients; and admission for SCD was the strongest predictor of in-hospital mortality, followed by patients with non-IHD, patients with ICD shocks, and all patients with a Charlson comorbidity index ≥2.

CONCLUSION

We report a decrease in admissions for VA, decreased ICD utilization, a change in pattern of VT ablation utilization, and an increase of in-hospital mortality in SCD patients. Predictors of adverse outcomes identified in our study should be considered when developing risk models for patients undergoing risk assessment for SCD.

Sudden Cardiac Death in Acute Coronary Syndromes

Sudden cardiac death in acute coronary syndromes mostly results from complex ventricular arrhythmias. Although the incidence has fallen with contemporary management, they still pose a threat for many patients. Treatment consists of immediate termination by electrical cardioversion and prompt coronary revascularization for relief of ischemia. Beta-blockers administered prophylactically have a protective effect. For recurrent episodes, pharmacologic treatment consists of beta-blockers and amiodarone, or, in nonresponsive patients, lidocaine. Other antiarrhythmic drugs play only a marginal role. Catheter ablation performed in qualified centers can be effective in recurrent episodes of ventricular tachycardia or ventricular fibrillation triggered by premature ventricular contractions.

At-admission risk stratification for in-hospital life-threatening ventricular arrhythmias and death in non-ST elevation myocardial infarction patients

AIMS

Identification of patients with non-ST elevation acute myocardial infarction (NSTEMI) at higher risk of in-hospital life-threatening ventricular arrhythmias (LT-VA) and death is crucial for determining appropriate levels of care/monitoring during hospitalisation. We assessed predictors of in-hospital LT-VA and all-cause mortality in a consecutive series of NSTEMI patients.

METHODS AND RESULTS

We prospectively studied 1325 consecutive patients (69.7% males, median age 70 (61-79) years) presenting with NSTEMI and undergoing continuous electrocardiographic monitoring. The primary study end-point was the occurrence of spontaneous (unrelated to coronary interventions) in-hospital LT-VA, including sustained ventricular tachycardia and ventricular fibrillation; the secondary end-point was in-hospital mortality from all causes. Of 1325 patients, 21 (1.5%) experienced LT-VA and 62 (4.7%) died from either arrhythmias (n=1) or other causes (n=61). Seven of the 20 patients who survived LT-VA subsequently died of heart failure. Independent predictors of in-hospital LT-VA were the Global Registry of Acute Coronary Events (GRACE) score >140 (odds ratio (OR)=7.5; 95% confidence interval (CI) 1.7-33.3; p=0.008) and left ventricular ejection fraction (LV-EF)<35% (OR=4.1; 95% CI 1.7-10.3; p=0.002). GRACE score >140 (OR=14.6; 95% CI 3.4-62) and LV-EF <35% (OR=4.4; 95% CI 1.9-10) also predicted in-hospital all-cause death. The cumulative probability of in-hospital LT-VA and death was respectively 9.2% and 23% in the 98 (7.4%) patients with GRACE score >140 and LV-EF<35%, while it was respectively 0.2% and 0% among the 627 (47.3%) with GRACE score ≤140 and LV-EF ≥35%.

CONCLUSIONS

Simple risk stratification at admission based on GRACE score and echocardiographic LV-EF allows early identification of NSTEMI patients at higher risk of both in-hospital LT-VA and all-cause mortality.

Outcomes of off-pump coronary bypass grafting with the bilateral internal thoracic artery for left ventricular dysfunction

This study evaluated the outcomes of off-pump coronary artery bypass surgery (OPCAB) with severe left ventricular dysfunction using composite bilateral internal thoracic artery grafting. From January 2001 to December 2008, 1,842 patients underwent primary isolated OPCAB with composite bilateral internal thoracic artery grafting. A total of 131 of these patients were diagnosed with a severely depressed preoperative left ventricle ejection fraction (LVEF) (≤ 0.35). These patient outcomes were compared with the outcomes of 830 patients that had mildly or moderately depressed LVEF (0.36 to 0.59) and 881 patients with normal LVEF (>0.6). The early mortality for patients with severe LVEF was 2.3%. The 3-yr and 7-yr survival rate for patients with severe LV dysfunction was 86.0% and 82.8%, respectively. Multivariate analysis showed that severe LV dysfunction EF increased the risk of all-cause death (P=0.012; hazard ratio [HR],2.14; 95% confidence interval [CI],1.19-3.88) and the risk of cardiac-related death (P=0.008; HR,3.38; 95% CI, 1.37-8.341). The study identified positive surgical outcomes of OPCAB, although severe LVEF was associated with two-fold increase in mortality risk compared with patients who had normal LVEF.