Type 2 myocardial infarction in general medical wards: Clinical features, treatment, and prognosis in comparison with type 1 myocardial infarction

The importance of intensive follow-up and achieving optimal chronic antithrombotic treatment in hospitalized medical patients with anemia: A prospective cohort study

BACKGROUND

Anemia is a global health concern, particularly among the elderly on chronic antithrombotic treatment. Close monitoring of hemoglobin (Hb) levels and achievement of an optimized treatment significantly enhance patients' quality of life. This study aimed to examine the impact of antithrombotic treatment on Hb levels and readmissions in hospitalized patients with anemia.

METHODS

This is a prospective cohort study of patients admitted to the Department of Internal Medicine of the University Hospital of Heraklion, Greece, from November 2021 to October 2022 with the diagnosis of anemia while receiving antithrombotic treatment. Data regarding demographics, past medical history, and laboratory and endoscopy findings were recorded. For those receiving inappropriate therapy according to international guidelines, antithrombotic treatment was optimized. Subsequent follow-ups occurred at one and six months post-discharge. Six- and twelve-month anemia-caused readmissions, as well as annual mortality, were evaluated.

RESULTS

In total, 104 patients were assessed. Among them, 34.6% were on antiplatelets, 56.7% were on anticoagulants, and 8.7% were on combination treatment. The mean age was 80 ± 8.2 years, and 54.8% were males. On admission, mean Hb levels were 6.86 ± 1.23 g/dL, while 56 (53.8%) patients had severe anemia. Gastroscopy and colonoscopy were performed in 75.0% and 41.4% of patients, respectively, confirming gastrointestinal bleeding in most of the cases. Treatment optimization was carried out for 56 patients. Follow-up revealed elevated Hb levels after one and six months post-discharge, while anemia-related readmissions stayed below 10%.

CONCLUSIONS

Most hospitalized anemic patients on antithrombotic treatment had endoscopic findings favoring gastrointestinal bleeding. Half received inappropriate antithrombotic therapy. Treatment optimization and regular follow-up improved Hb levels and reduced readmissions.

Utilization of Cardiovascular Procedures, Consultation Services, and Cardioprotective Medications Among Type 2 Myocardial Infarction Patients

BACKGROUND

Coronary atherosclerosis and recurrent cardiovascular events are common among individuals with type 2 myocardial infarction (T2MI). However, cardiovascular resource utilization among T2MI patients is unclear.

OBJECTIVES

The aim of the study was to characterize cardiovascular resource utilization among T2MI patients across the United States.

METHODS

Using Optum's de-identified Clinformatics Data Mart Database, cardiovascular procedures, physician services, and prescriptions within 6 months postdischarge were compared among patients with T2MI vs type 1 myocardial infarction (T1MI) between October 1, 2017, and June 30, 2020. Multivariable logistic regression examined the odds of resource utilization in T2MI vs T1MI and identified predictors of utilization for T2MI.

RESULTS

We identified 140,344 patients with myocardial infarction; 121,738 patients (87%) had T1MI and 18,606 (13%) had T2MI. All participants had 183 days of postdischarge follow-up. Within 6 months postdischarge, patients with T2MI were significantly less likely to fill new prescriptions for P2Y12 inhibitors (4.8% [603/14,176] vs 52.8% [44,833/99,593], adjusted OR: 0.28; 95% CI: 0.25-0.31), beta blockers (27.1% [2,070/14,176] vs 62.8% [38,219/99,593], OR: 0.59; 95% CI: 0.55-0.63), statins (19.1% [1,439/14,176] vs 59.1% [32,434/99,593], OR: 0.51; 95% CI: 0.47-0.55), and SGLT2i or glucagon-like peptide-1 agonists (4.8% [595/14,176] vs 35.4% [30,202/99,593], OR: 0.30; 95% CI: 0.27-0.33) as compared to T1MI. Patients with T2MI were significantly less likely to undergo an echocardiogram (71.8% [10,179/14,176] vs 82.9% [82,551/99,593], OR: 0.61; 95% CI: 0.58-0.64) and coronary angiogram (11.7% [1,664/14,176] vs 76.6% [76,327/99,593], OR: 0.10; 95% CI: 0.09-0.11) compared to T1MI.

CONCLUSIONS

In the United States, T2MI patients received less cardiovascular testing and secondary preventative therapies than T1MI patients.

Differences between MINOCA and type 2 myocardial infarction: An ITALIAN observational study

BACKGROUND

Myocardial infarction with non-obstructive coronary arteries (MINOCA) and type 2 myocardial infarction (MI), both presenting as non-ST-elevation MI (NSTEMI), are often grouped together due to overlapping symptoms. The aim of our study is to compare their characteristics and prognosis to distinguish between them.

METHODS

Among 7815 patients with NSTEMI who underwent coronary angiography between 2005 and 2022 we identified 538 patients with diagnosis of MINOCA (n = 301; 3,9 %) and type 2 MI (n = 237; 3 %). The outcome was a composite of all-cause mortality, non-fatal MI, hospitalisation for heart failure (HF) and transitory ischemic attack or non-fatal stroke.

RESULTS

The mean age of the entire cohort was 68 (11.5) years, with women being the most frequently represented group (65 %). Comparing the sub-cohorts, MINOCA patients were younger (66.3 (11.7) Vs. 70.6 (11) years, p < 0.01), and less likely to have typical cardiovascular risk than type 2 MI patients. At multivariable analysis different clinical (age, heart rate, typical chest pain, palpitations, postmenopausal status), and instrumental (cardiac rhythm, ST-segment changes, diastolic dysfunction, hypo/akinesia with non-coronary distribution) variables were independent predictors of MINOCA with AUC of 0.83 [95 % CI, 0.78-0.88], p < 0.01 at ROC analysis. At a median follow-up of 61 (IQR 34-100) months, MINOCA patients had significantly lower rate of the composite endpoint compared to type 2 MI (20 % Vs. 32 %, p < 0.01).

CONCLUSIONS

MINOCA cohort was associated with different characteristics compared to type 2 MI and had a better prognosis despite the number of events was not negligible.

Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care

INTRODUCTION

With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management.

METHODS

This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications.

RESULTS

Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting.

CONCLUSION

With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.

Myocardial infarction in a population-based cohort of patients with biopsy-confirmed giant cell arteritis in southern Sweden

OBJECTIVES

To determine the incidence rate (IR) of myocardial infarction (MI), relative risk of MI, and impact of incident MI on mortality in individuals with biopsy-confirmed giant cell arteritis (GCA).

METHODS

MIs in individuals diagnosed with GCA 1998-2016 in Skåne, Sweden were identified by searching the SWEDEHEART register, a record of all patients receiving care for MI in a coronary care unit (CCU). The regional diagnosis database, with subsequent case review, identified GCA patients receiving care for MI outside of a CCU. A cohort of 10 reference subjects for each GCA case, matched for age, sex and area of residence, was used to calculate the incidence rate ratio (IRR) of MI in GCA to that in the general population.

RESULTS

The GCA cohort comprised 1134 individuals. During 7958 person-years of follow-up, 102 were diagnosed with incident MI, yielding an IR of 12.8 per 1000 person-years (95% CI 10.3 to 15.3). The IR was highest in the 30 days following GCA diagnosis and declined thereafter. The IRR of MI in GCA to that of the background population was 1.29 (95% CI 1.05 to 1.59). Mortality was higher in GCA patients who experienced incident MI than in those without MI (HR 2.8; 95% CI 2.2 to 3.6).

CONCLUSIONS

The highest incidence of MI occurs within the 30 days following diagnosis of GCA. Individuals with GCA have a moderately increased risk of MI compared with a reference population. Incident MI has a major impact on mortality in GCA.

Proportional troponin changes and risk for outcomes with intervention strategies in non-ST-elevation acute coronary syndrome across kidney function

AIMS

This analysis evaluates whether proportional serial cardiac troponin (cTn) change predicts benefit from an early versus delayed invasive, or conservative treatment strategies across kidney function in non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

Patients diagnosed with NSTE-ACS in the Veterans Health Administration between 1999 and 2022 were categorized into terciles (<20%, 20 to ≤80%, >80%) of proportional change in serial cTn. Primary outcome included mortality or rehospitalization for myocardial infarction at 6 and 12 months, in survivors of index admission. Adjusted hazard ratio (HR) with 95% confidence Intervals (95% confidence interval [CI]) were calculated for the primary outcome for an early invasive (≤24 h of the index admission), delayed invasive (>24 h of index admission to 90-days postdischarge), or a conservative management.

RESULTS

Chronic kidney disease (CKD) was more prevalent (45.3%) in the lowest versus 42.2% and 43% in middle and highest terciles, respectively (p < 0.001). Primary outcome is more likely for conservative versus early invasive strategy at 6 (HR: 1.44, 95% CI: 1.37-1.50) and 12 months (HR: 1.44, 95% CI: 1.39-1.50). A >80% proportional change demonstrated HR (95% CI): 0.90 (0.83-0.97) and 0.93 (0.88-1.00; p = 0.041) for primary outcome at 6 and 12 months, respectively, when an early versus delayed invasive strategy was used, across CKD stages.

CONCLUSIONS

Overall, the invasive strategy was safe and associated with improved outcomes across kidney function in NSTE-ACS. Additionally, >80% proportional change in serial troponin in NSTE-ACS is associated with benefit from an early versus a delayed invasive strategy regardless of kidney function. These findings deserve confirmation in randomized controlled trials.

Association between troponin level and medium-term mortality in 20 000 hospital patients

INTRODUCTION

Cardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test.

METHOD

This prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital.

RESULTS

A total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10 cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted.

CONCLUSION

In a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.

Outcomes of Patients With Takotsubo Syndrome Compared With Type 1 and Type 2 Myocardial Infarction

Background Takotsubo syndrome (TS) and myocardial infarction (MI) share similar clinical and laboratory characteristics but have important differences in causes, demographics, management, and outcomes. Methods and Results In this observational study, the National Inpatient Sample and National Readmission Database were used to identify patients admitted with TS, type 1 MI, or type 2 MI in the United States between October 1, 2017, and December 31, 2019. We compared patients hospitalized with TS, type 1 MI, and type 2 MI with respect to key features and outcomes. Over the 27-month study period, 2 035 055 patients with type 1 MI, 639 075 patients with type 2 MI, and 43 335 patients with TS were identified. Cardiac arrest, ventricular fibrillation, and ventricular tachycardia were more prevalent in type 1 MI (4.02%, 3.2%, and 7.2%, respectively) compared with both type 2 MI (2.8%, 0.8%, and 5.4% respectively) and TS (2.7%, 1.8%, and 5.3%, respectively). Risk of mortality was lower in TS compared with both type 1 MI (3.3% versus 7.9%; adjusted odds ratio [OR], 0.3; P<0.001) and type 2 MI (3.3% versus 8.2%; adjusted OR, 0.3; P<0.001). Mortality rate (OR, 1.2; P<0.001) and cardiac-cause 30-day readmission rate (adjusted OR, 1.7; P<0.001) were higher in type 1 MI than in type 2 MI. Conclusions Patients with type 1 MI had the highest rates of in-hospital mortality and cardiac-cause 30-day readmission. Risk of all-cause 30-day readmission was highest in patients with type 2 MI. The risk of ventricular arrhythmias in patients with TS is lower than in patients with type 1 MI but higher than in patients with type 2 MI.

Clinical outcomes associated with type II myocardial infarction caused by bleeding

BACKGROUND

Type ll myocardial infarction (T2MI) is caused by a mismatch between myocardial oxygen supply and demand. One subset of individuals is T2MI caused by acute hemorrhage. Traditional MI treatments including antiplatelets, anticoagulants, and revascularization can worsen bleeding. We aim to report outcomes of T2MI patients due to bleeding, stratified by treatment approach.

METHODS

The MGB Research Patient Data Registry followed by manual physician adjudication was used to identify individuals with T2MI caused by bleeding between 2009 and 2022. We defined 3 treatment groups: (1) invasively managed, (2) pharmacologic, and (3) conservatively managed Clinical parameters and outcomes for 30-day, mortality, rebleeding, and readmission were abstracted compared between the treatment groups.

RESULTS

We identified 5,712 individuals coded with acute bleeding, of which 1,017 were coded with T2MI during their admission. After manual physician adjudication, 73 individuals met the criteria for T2MI caused by bleeding. 18 patients were managed invasively, 39 received pharmacologic therapy alone, and 16 were managed conservatively. The invasively managed group experienced lower mortality (P = .021) yet higher readmission (P = .045) than the conservatively managed group. The pharmacologic group also experienced lower mortality (P= .017) yet higher readmission (P = .005) than the conservatively managed group.

CONCLUSION

Individuals with T2MI associated with acute hemorrhage are a high-risk population. Patients treated with standard procedures experienced higher readmission but lower mortality than conservatively managed patients. These results raise the possibility of testing ischemia-reduction approaches for such high-risk populations. Future clinical trials are required to validate treatment strategies for T2MI caused by bleeding.

Cardiovascular outcomes of type 2 myocardial infarction among COVID-19 patients: a propensity matched national study

BACKGROUND

Myocardial infarction Type II (T2MI) is a prevalent cause of troponin elevation secondary to a variety of conditions causing stress/demand mismatch. The impact of T2MI on outcomes in patients hospitalized with COVID-19 is not well studied.

METHODS

The Nationwide Inpatient Sample database from the year 2020 was queried to identify COVID-19 patients with T2MI during the index hospitalization. Clinical Modification (ICD-10-CM) codes "U07.1" and "I21.A1" were used as disease identifiers for COVID-19 and T2MI respectively. Multivariate adjusted Odds ratio (aOR) and propensity score matching (PSM) was done to compare outcomes among COVID patients with and without T2MI. The primary outcome was in-hospital mortality.

RESULTS

A total of 1,678,995 COVID-19-weighted hospitalizations were identified in the year 2020, of which 41,755 (2.48%) patients had T2MI compared to 1,637,165 (97.5%) without T2MI. Patients with T2MI had higher adjusted odds of in-hospital mortality (aOR 1.44, PSM 32.27%, 95% CI 1.34-1.54) sudden cardiac arrest (aOR 1.29, PSM 6.6 %, 95% CI 1.17-1.43) and CS (aOR 2.16, PSM 2.73%, 95% CI 1.85-2.53) compared to patients without T2MI. The rate of coronary angiography (CA) in T2MI with COVID was 1.19 %, with significant use of CA among patients with T2MI complicated by CS compared to those without CS (4% vs 1.1%, p<0.001). Additionally, COVID-19 patients with T2MI had an increased prevalence of sepsis compared to COVID-19 without T2MI (48% vs 24.1%, p<0.001).

CONCLUSION

COVID-19 patients with T2MI had worse cardiovascular outcomes with significantly higher in-hospital mortality, SCA, and CS compared to those without T2MI. Long-term mortality and morbidity among COVID-19 patients who had T2MI will need to be clarified in future studies.

Comparison of outcome among type 2 vs type 1 myocardial infarction: a systematic review and meta-analysis

To date, there were limited studies available on myocardial infarction (MI), and consequently, the outcomes of patients with type 1 myocardial infarction (T1MI) compared to type 2 myocardial infarction (T2MI) remained inconclusive. We aimed to compare the outcomes of T1MI and T2MI patients in terms of mortality and adverse cardiovascular outcomes. We performed a systematic literature search on PubMed, Embase, and Scopus for relevant articles from inception until March 20, 2022. 341,049 patients had T1MI, while the remaining 67,537 patients had T2MI. Mean age was similar between both groups (T1MI: 67.3 years, T2MI: 71.03 years), while the proportion of females was lower in T1MI (37.81% vs 47.15%). Our analysis revealed that patients with T1MI had significantly lower odds of all-cause mortality (OR 0.45, 95% CI 0.36-0.56, p < 0.001), in-hospital mortality (OR 0.63, 95% CI 0.46-0.86, p < 0.001), 1-year mortality (OR 0.35, 95% CI 0.25-0.47, p < 0.001), and major adverse cardiovascular events (MACE) (OR 0.59, 95% CI 0.39-0.91, p = 0.02). There was no significant difference in terms of 30-day mortality (OR 0.58, 95% CI 0.25-1.36, p = 0.21), cardiovascular mortality (OR 0.95, 95% CI 0.68-1.32, p = 0.74), all-cause readmission (OR 0.84, 95% CI 0.62-1.14, p = 0.26), and readmission due to MI (OR 1.22, 95% CI 0.66-2.27, p = 0.53) between both groups. Patients with T1MI had favorable outcomes in terms of mortality and MACE compared to that of T2MI patients. Further studies should aim at determining the optimal management strategy for these high-risk patients for better patient outcomes.

Assessment of Oxygen Supply-Demand Imbalance and Outcomes Among Patients With Type 2 Myocardial Infarction: A Secondary Analysis of the High-STEACS Cluster Randomized Clinical Trial

Importance

Type 2 myocardial infarction occurs owing to multiple factors associated with myocardial oxygen supply-demand imbalance, which may confer different risks of adverse outcomes.

Objective

To evaluate the prevalence and outcomes of different factors associated with oxygen supply-demand imbalance among patients with type 2 myocardial infarction.

Design, Setting, and Participants

In this secondary analysis of a stepped-wedge, cluster randomized clinical trial conducted at 10 secondary and tertiary care hospitals in Scotland, 6096 patients with an adjudicated diagnosis of type 1 or type 2 myocardial infarction from June 10, 2013, to March 3, 2016, were identified, and the findings were reported on August 28, 2018. The trial enrolled consecutive patients with suspected acute coronary syndrome. The diagnosis of myocardial infarction was adjudicated according to the Fourth Universal Definition of Myocardial Infarction and the primary factor associated with oxygen supply-demand imbalance in type 2 myocardial infarction was defined. This secondary analysis was not prespecified. Statistical analysis was performed from July 7 to 30, 2020.

Intervention

Implementation of a high-sensitivity cardiac troponin I assay.

Main Outcomes and Measures

All-cause death at 1 year according to the factors associated with oxygen supply-demand imbalance among patients with type 2 myocardial infarction.

Results

Of 6096 patients (2602 women [43%]; median age, 70 years [IQR, 58-80 years]), 4981 patients had type 1 myocardial infarction, and 1115 patients had type 2 myocardial infarction. The most common factor associated with oxygen supply-demand imbalance was tachyarrhythmia (616 of 1115 [55%]), followed by hypoxemia (219 of 1115 [20%]), anemia (95 of 1115 [9%]), hypotension (89 of 1115 [8%]), severe hypertension (61 of 1115 [5%]), and coronary mechanisms (35 of 1115 [3%]). At 1 year, all-cause mortality occurred for 15% of patients (720 of 4981) with type 1 myocardial infarction and 23% of patients (285 of 1115) with type 2 myocardial infarction. Compared with patients with type 1 myocardial infarction, those with type 2 myocardial infarction owing to hypoxemia (adjusted odds ratio [aOR], 2.35; 95% CI, 1.72-3.18) and anemia (aOR, 1.83; 95% CI, 1.14-2.88) were at greatest risk of death, whereas those with type 2 myocardial infarction owing to tachyarrhythmia (aOR, 0.83; 95% CI, 0.65-1.06) or coronary mechanisms (aOR, 1.07; 95% CI, 0.17-3.86) were at similar risk of death as patients with type 1 myocardial infarction.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, mortality after type 2 myocardial infarction was associated with the underlying etiologic factor associated with oxygen supply-demand imbalance. Most type 2 myocardial infarctions were associated with tachyarrhythmia, with better prognosis, whereas hypoxemia and anemia accounted for one-third of cases, with double the mortality of type 1 myocardial infarction. These differential outcomes should be considered by clinicians when determining which cases need to be managed if patient outcomes are to improve.

Trial Registration

ClinicalTrials.gov Identifier: NCT01852123.

Association of Rural Hospital Admissions with Access, Treatment, and Mortality for Patients with Acute Myocardial Infarction in Shanxi, China

China recently launched healthcare reforms to reduce disparities in healthcare resources between urban and rural areas. However, few studies have determined how admission to rural hospitals has affected patient care and outcomes. This study aims to determine whether admission to a rural hospital is associated with changes in treatment and outcomes. Using a province-wide, administrative database of 62,380 patients (51,355 urban patients vs. 11,025 rural patients) with acute myocardial infarction (AMI) in Shanxi from 2015 to 2017, we identified the differential distance from the patient’s residential address to the nearest hospital and the nearest percutaneous coronary intervention (PCI)-capable hospital as instrumental variables. We estimated the risk-adjusted differences in outcomes and treatments for patients admitted to rural hospitals versus urban hospitals using a two-stage least squares instrumental variable analysis method. Based on instrumental variable analysis, admission to a rural hospital was associated with a 5.3% (95% CI, 0.012 to 0.093; p = 0.011) increase in mortality. There was a 59.8% (95% CI, −0.733 to −0.463; p-values < 0.0001) decrease in receiving PCI, an 18.8% (95% CI, −0.231 to −0.146; p-values < 0.0001) decrease in receiving fibrinolysis, and a 71.8% (95% CI, 0.586 to 0.849; p-values < 0.0001) increase in receiving medication-only treatment for patients admitted to rural hospitals. Rural hospitals in China thus offer relatively poor care for myocardial infarction. Hospital facilities and reperfusion therapies must be improved.

Coronary Artery and Cardiac Disease in Patients With Type 2 Myocardial Infarction: A Prospective Cohort Study

BACKGROUND

Type 2 myocardial infarction is caused by myocardial oxygen supply-demand imbalance, and its diagnosis is increasingly common with the advent of high-sensitivity cardiac troponin assays. Although this diagnosis is associated with poor outcomes, widespread uncertainty and confusion remain among clinicians as to how to investigate and manage this heterogeneous group of patients with type 2 myocardial infarction.

METHODS

In a prospective cohort study, 8064 consecutive patients with increased cardiac troponin concentrations were screened to identify patients with type 2 myocardial infarction. We excluded patients with frailty or renal or hepatic failure. All study participants underwent coronary (invasive or computed tomography angiography) and cardiac (magnetic resonance or echocardiography) imaging, and the underlying causes of infarction were independently adjudicated. The primary outcome was the prevalence of coronary artery disease.

RESULTS

In 100 patients with a provisional diagnosis of type 2 myocardial infarction (median age, 65 years [interquartile range, 55-74 years]; 43% women), coronary and cardiac imaging reclassified the diagnosis in 7 patients: type 1 or 4b myocardial infarction in 5 and acute myocardial injury in 2 patients. In those with type 2 myocardial infarction, median cardiac troponin I concentrations were 195 ng/L (interquartile range, 62-760 ng/L) at presentation and 1165 ng/L (interquartile range, 277-3782 ng/L) on repeat testing. The prevalence of coronary artery disease was 68% (63 of 93), which was obstructive in 30% (28 of 93). Infarct-pattern late gadolinium enhancement or regional wall motion abnormalities were observed in 42% (39 of 93), and left ventricular systolic dysfunction was seen in 34% (32 of 93). Only 10 patients had both normal coronary and normal cardiac imaging. Coronary artery disease and left ventricular systolic dysfunction were previously unrecognized in 60% (38 of 63) and 84% (27 of 32), respectively, with only 33% (21 of 63) and 19% (6 of 32) on evidence-based treatments.

CONCLUSIONS

Systematic coronary and cardiac imaging of patients with type 2 myocardial infarction identified coronary artery disease in two-thirds and left ventricular systolic dysfunction in one-third of patients. Unrecognized and untreated coronary or cardiac disease is seen in most patients with type 2 myocardial infarction, presenting opportunities for initiation of evidence-based treatments with major potential to improve clinical outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03338504.

Diagnostic features, management and prognosis of type 2 myocardial infarction compared to type 1 myocardial infarction: a systematic review and meta-analysis

IMPORTANCE

Distinguishing type 2 (T2MI) from type 1 myocardial infarction (T1MI) in clinical practice can be difficult, and the management and prognosis for T2MI remain uncertain.

OBJECTIVE

To compare precipitating factors, risk factors, investigations, management and outcomes for T2MI and T1MI.

DATA SOURCES

Medline and Embase databases as well as reference list of recent articles were searched January 2009 to December 2020 for term 'type 2 myocardial infarction'.

STUDY SELECTION

Studies were included if they used a universal definition of MI and reported quantitative data on at least one variable of interest.

DATA EXTRACTION AND SYNTHESIS

Data were pooled using random-effect meta-analysis. Risk of bias was assessed using Newcastle-Ottawa quality assessment tool. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. All review stages were conducted by two reviewers.

MAIN OUTCOMES AND MEASURES

Risk factors, presenting symptoms, cardiac investigations such as troponin and angiogram, management and outcomes such as mortality.

RESULTS

40 cohort studies comprising 98 930 patients with T1MI and 13 803 patients with T2MI were included. Compared with T1MI, patients with T2MI were: more likely to have pre-existing chronic kidney disease (OR 1.87; 95% CI 1.53 to 2.28) and chronic heart failure (OR 2.35; 95% CI 1.82 to 3.03), less likely to present with typical cardiac symptoms of chest pain (OR 0.19; 95% CI 0.13 to 0.26) and more likely to present with dyspnoea (OR 2.64; 95% CI 1.86 to 3.74); more likely to demonstrate non-specific ST-T wave changes on ECG (OR 2.62; 95% CI 1.81 to 3.79) and less likely to show ST elevation (OR 0.22; 95% CI 0.17 to 0.28); less likely to undergo coronary angiography (OR 0.09; 95% CI 0.06 to 0.12) and percutaneous coronary intervention (OR 0.06; 95% CI 0.04 to 0.10) or receive cardioprotective medications, such as statins (OR 0.25; 95% CI 0.16 to 0.38) and beta-blockers (OR 0.45; 95% CI 0.33 to 0.63). T2MI had greater risk of all cause 1-year mortality (OR 3.11; 95% CI 1.91 to 5.08), with no differences in short-term mortality (OR 1.34; 95% CI 0.63 to 2.85).

CONCLUSION AND RELEVANCE

This review has identified clinical, management and survival differences between T2MI and T1MI with greater precision and scope than previously reported. Differential use of coronary revascularisation and cardioprotective medications highlight ongoing uncertainty of their utility in T2MI compared with T1MI.

Meta-Regression Analysis of the Impact of Medical Therapy on Long-Term Mortality in Type 2 Myocardial Infarction

The first approach for Type-2 myocardial infarction (T2MI) consists of the elimination of the condition determining the oxygen supply/demand mismatch. However, the long-term impact of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors, used in the case of Type-1 myocardial infarction has been poorly investigated and remains unclear. We, therefore, sought to assess the impact of medical therapy on 1-year mortality in patients with T2MI using a meta-regression analysis. A meta-regression analysis was performed with studies involving in patients with T2MI: 1-year all-cause mortality, rates of beta blockers, statins, aspirin, and P2Y12 inhibitors use were recorded and analyzed. After careful study selection, 8 observational studies were pooled in the analysis, including 3,756 in patients. During meta-regression analysis, a borderline correlation between rates of aspirin, P2Y12 inhibitors, and statins use and 1-year mortality (p = 0.087, p = 0.05, and p = 0.067, respectively) was found; no significant correlation was found at multivariable analysis. In conclusion, in a meta-regression analysis, no significant correlation was found between rates of use of usual drug therapy indicated for Type-1 myocardial infarction (statins, aspirin, P2Y12 inhibitors, β-blockers) and 1-year mortality in T2MI patients.

Clinical characteristics and outcome of elderly patients admitted in emergency department with an oxygen mismatch and type 2 myocardial infarction or myocardial injury

BACKGROUND

Aging is a risk factor for type 2 myocardial infarction or myocardial injury, but few data are available on the elderly. We aimed to determine the factors associated with these pathologies and mortality in the elderly population and its age classes.

METHODS

A retrospective cohort of all patients with oxygen mismatch (anemia, hypoxia, tachycardia, hypo/hypertension) for whom a troponin drawn was performed at admission in 2 emergency departments. Medical records were reviewed and classified as having type 2 myocardial infarction, acute or chronic myocardial injury, or no myocardial injury.

RESULTS

Of the 824 patients who presented with oxygen mismatch, 675 (81.9%) were older than 65 years. Age over 85 years was a risk factor for acute non-ischemic myocardial injury (odds ratio, 95% confidence interval 2.23, 1.34-3.73). Non-ischemic myocardial injury was associated with hypoxemia, tachycardia, and acute renal failure in those older than 85 years, but only with acute infection in the 75-84-year-old group. Type 2 myocardial infarction was associated only with acute renal failure in the oldest group and, in the 75-84-year-old group, with acute heart failure and shock. Patients older than 85 years with acute myocardial injury, with or without infarction, had a higher in-hospital mortality, but subsequently, mortality depends more on the comorbidities than on age.

CONCLUSION

Factors associated with type 2 myocardial infarction and acute non-ischemic myocardial injury in elderly admitted with oxygen mismatch vary notably between age classes. They are associated with in-hospital mortality but not with subsequent mortality when other cormorbities are taken into account.

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

BACKGROUND

In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.

METHODS

All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.

RESULTS

A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all).

CONCLUSIONS

Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.

Al Wakra type II myocardial infarction-a case report in our emergency department

In our emergency department (ED), we found one interesting case that had dramatic deterioration. The patient initially presented with a fever that deteriorated to sepsis, then a septic shock and chest discomfort and finally resulting in an intensive care unit (ICU) admission. He waited more than 6 hours in the waiting area, for a bed in an observation room. Phlebotomy and supportive treatment were provided in the waiting area but maybe it needed more rapid treatment to avoid the serious complications. The case rapidly deteriorated as type II myocardial infarction (MI). Al WAKRA TYPE II MI, is a case report for type II MI developed in ED as complication of prolonged waiting time in overcrowded ED, its simple fever case getting deterioration to sepsis then type II MI after prolonged waiting time in the waiting area of ED to get a bed in the observation room. We aim to report a case of type II MI in ED as rare case developed in overcrowded ED, to put highlight about overcrowded ED and how to manage it to avoid this complication again, also to be aware about pre sepsis presentation in ED with full consideration about sepsis complication and management. It could be considered as a case study for the Quality in overcrowded ED.

Concordance and Prognostic Relevance of Angiographic and Clinical Definitions of Myocardial Infarction Type

BACKGROUND

Atherothrombosis is the principal mechanism of type 1 (T1) myocardial infarction (MI), while type 2 (T2) MI is typically diagnosed in the presence of triggers (anemia, arrhythmia, etc.). We aimed to evaluate the proportions of T1 vs. T2 MI based on angiographic and clinical definitions, their concordance and prognosis.

METHODS

Consecutive MI patients [n = 712, 61% male; age 64.6 ± 12.3 years] undergoing coronary angiography were classified according to the presence of atherothrombosis and identifiable triggers. Association of angiographic and clinical MI type criteria with adverse outcomes (Time follow-up was 1.5 years) was evaluated. Predictive ability of GRACE risk score for all-cause mortality was then assessed.

RESULTS

Atherothrombosis and clinical triggers were identified in 397 (55.6%) and 324 (45.5%) subjects, respectively. Only 247 (34.7%) patients had "true" T1MI (atherothrombosis+ / triggers-); 174 (24.4%) were diagnosed with "true" T2MI (atherothrombosis- / triggers+), while 291 (40.9%) had discordant clinical and angiographic characteristics. All-cause mortality in T2MI (20.1%) patients was higher than in T1MI (9.3%), P = 0.002. Presence of triggers [odds ratio (OR) 2.4, 95% CI 1.5-3.6, P < 0.0001] but not atherothrombosis [OR 0.8, 95% confidence interval (CI) 0.5-1.3, P = 0.26] was associated with worse prognosis. GRACE score is a better predictor of death in T1MI vs. T2MI: area under curve 0.893 (95% CI 0.830-0.956) vs 0.748 (95% CI 0.652-0.843), P = 0.013.

CONCLUSION

Angiographic and clinical definitions of MI type are discordant in a substantial proportion of patients. Clinical triggers are associated with all-cause mortality. Predictive performance of GRACE score is worse in T2MI patients.

Revascularization rates with coronary angioplasty and mortality in type 2 myocardial infarction: A meta-regression analysis

BACKGROUND

Percutaneous coronary intervention (PCI) represents the best therapeutic option for type-1 myocardial infarction (T1MI) in the majority of clinical settings; its role in the treatment of type-2 myocardial infarction (T2MI), however, remains unclear. We therefore sought to assess in a meta-regression analysis the impact of PCI rates on mortality in patients with T2MI according to available observational studies.

METHODS

We performed a meta-regression analysis including all the studies involving in-patients affected by T2MI. We excluded studies not reporting the rate of T2MI patients undergoing PCI and not specifying absolute in-hospital or 1-year all-cause mortality. In the meta-regression analysis we used the in-hospital mortality and 1-year mortality as dependent variables and the rate of PCI as independent; regression was weighted for studies' size.

RESULTS

After careful examination, 8 studies were selected for the assessment of in-hospital mortality and 8 for 1-year-mortality. We included 3155 and 3756 in-patients for in-hospital and 1-year mortality respectively. At meta-regression analysis, a borderline correlation between PCI rate and in-hospital mortality (p 0.05) and a statistically significant correlation with 1-year mortality (p < 0.01) in T2MI patients were found.

CONCLUSIONS

In a meta-regression analysis higher rates of PCI on T2MI in-patients were associated with lower mortality rates both in-hospital and at 1 year. Whether this association is related to the direct effect of PCI or better general conditions of T2MI patients undergoing a PCI still remains unclear.

Analysis of Predictors of Myocardial Infarction in Trauma With Development of a Trauma Cardiac Risk Index

STUDY OBJECTIVE

Trauma has historically been considered a disorder of the young and healthy, with a low risk of cardiac ischemia; hence most research on myocardial infarction in trauma has focused on direct cardiac damage from blunt chest trauma. However, the age and comorbidity of trauma patients are increasing, making the trauma population more vulnerable to myocardial infarction (MI). Cardiac risk assessment has emphasized morbidity and mortality in an elective surgical setting, but it is also important in acute trauma. Our study analyzes the risk factors for MI in a trauma population to create a scoring system to predict the risk of MI.

DESIGN

 Retrospective cohort analysis of a national trauma registry over a five-year period. Potential predictors of MI in trauma patients were identified and tested with univariate and multivariate statistics. A numerical score was created to predict the risk of MI based on these criteria.

SETTING

The National Trauma Data Bank (NTDB) is a large registry of selected trauma centers in the United States. Data include demographic, injury, treatment, and outcome variables pertaining to the index admission of each patient. The institutions range from community hospitals through level 1 trauma centers. The time period is the entire inpatient hospital admission from arrival from the field, through the emergency department, ICU, and floor up to discharge.

PATIENTS

3,437,959 trauma patients aged 18 years and older from various US trauma centers. 62.8% were male. The median age is 50 years with a standard deviation of 21.25. The median Injury Severity Score is 9 with a standard deviation of 9.04.

MEASUREMENTS

Demographic, traumatic, and comorbidity variables were collected from the NTDB. The primary outcome was MI during the initial trauma admission. Multivariate analysis was performed with logistic regression.

MAIN RESULTS

Over 8010 (0.23%) suffered an MI. The strongest risk factors for MI were a history of MI with an adjusted odds ratio (OR) of 7.0, and angina with an OR of 3.4. A procedure under general anesthesia (GA) conferred an OR of 2.3. Minor risk factors included torso injury and 10-year age interval over 50, both with an OR of 1.7, a 20-point interval of the Injury Severity Score (ISS) with OR 1.6, male gender with OR of 1.5, and various chronic disease comorbidities with OR ranging from 1.4 to 1.9. A Trauma Cardiac Risk Index (TCRI) was derived from these risk factors. The model showed good discrimination with a C statistic of 0.85.

CONCLUSIONS

Overall the trauma population has a low risk of MI. However, the risk is much higher for older patients with chronic comorbidity. The TCRI can be used to assess cardiac risk in trauma patients to help direct monitoring, testing, and risk reduction measures to those at the highest risk.

Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction

BACKGROUND

Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI.

OBJECTIVES

The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States.

METHODS

Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared.

RESULTS

There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission.

CONCLUSIONS

Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.