Clinical characteristics and short-term outcomes in patients with elevated admission systolic blood pressure after acute ST-elevation myocardial infarction: a population-based study

Prediction models for major adverse cardiovascular events following ST-segment elevation myocardial infarction and subgroup-specific performance

Background

ST-segment elevation myocardial infarction (STEMI) patients are at a high residual risk of major adverse cardiovascular events (MACEs) after revascularization. Risk factors modify prognostic risk in distinct ways in different STEMI subpopulations. We developed a MACEs prediction model in patients with STEMI and examined its performance across subgroups.

Methods

Machine-learning models based on 63 clinical features were trained in patients with STEMI who underwent PCI. The best-performing model (the iPROMPT score) was further validated in an external cohort. Its predictive value and variable contribution were studied in the entire population and subgroups.

Results

Over 2.56 and 2.84 years, 5.0% and 8.33% of patients experienced MACEs in the derivation and external validation cohorts, respectively. The iPROMPT score predictors were ST-segment deviation, brain natriuretic peptide (BNP), low-density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR), age, hemoglobin, and white blood cell (WBC) count. The iPROMPT score improved the predictive value of the existing risk score, with an increase in the area under the curve to 0.837 [95% confidence interval (CI): 0.784-0.889] in the derivation cohort and 0.730 (95% CI: 0.293-1.162) in the external validation cohort. Comparable performance was observed between subgroups. The ST-segment deviation was the most important predictor, followed by LDL-C in hypertensive patients, BNP in males, WBC count in females with diabetes mellitus, and eGFR in patients without diabetes mellitus. Hemoglobin was the top predictor in non-hypertensive patients.

Conclusion

The iPROMPT score predicts long-term MACEs following STEMI and provides insights into the pathophysiological mechanisms for subgroup differences.

Using Restricted Cubic Splines to Study the Trajectory of Systolic Blood Pressure in the Prognosis of Acute Myocardial Infarction

Background: Acute myocardial infarction (AMI) is still the most serious manifestation of coronary artery disease. Systolic blood pressure (SBP) is the best predictor of blood pressure in AMI. Thus, its influence on AMI is necessary to be explored. Methods: A total of 4,277 patients with AMI were extracted from the Medical Information Mart for Intensive Care database. Chi-square test or Student's t-test was used to judge differences between groups, and Cox regression was used to identify factors that affect AMI prognosis. SBP was classified as low (<90 mmHg), normal (90-140 mmHg), or high (>140 mmHg), and a non-linear test was performed. Meaningful variables were incorporated into models for sensitivity analysis. Patient age was classified as low and high for subgroup analysis, and the cutoff value of the trajectory was identified. P < 0.05 indicates statistical significance. Results: The effect of SBP on the prognosis of patients with AMI is non-linear. The risks in models 1-3 with low SBP are 6.717, 4.910, and 3.080 times those of the models with normal SBP, respectively. The risks in models 1-3 with high SBP are 1.483, 1.637, and 2.937 times those of the models with normal SBP, respectively. The cutoff point (95% confidence interval) of the trajectory is 114.489 mmHg (111.275-117.702 mmHg, all P < 0.001). Conclusions: SBP has a non-linear effect on AMI prognosis. Low and high SBP show risks, and the risk of low SBP is obviously greater than that of high SBP.

Prognostic impact of bundle branch blocks in patients with ST-segment elevation myocardial infarction

BACKGROUND

In this study we aim to determine and compare short term outcomes of all type bundle branch blocks (BBB) according to their onset time among those patients presented with ST-Segment elevation myocardial infarction (STEMI) and underwent primary percutaneous coronary intervention (pPCI).

METHOD

Three thousand fifty-seven ST-segment elevation myocardial infarction patients who underwent pPCI were retrospectively evaluated. Those patients with BBB in their ECG on admission were re-evaluated for their prior ECG records. A composite of death, recurrent myocardial infarction (re-MI) and stroke in one moth follow up were defined as major adverse cardiovascular events (MACE).

RESULTS

Three thousand fifty-seven STEMI patients underwent pPCI were enrolled to the study. Among these patients 134 (4.4%) had LBBB, and 120 (3.9%) had RBBB. Bundle brunch block was classified according to the timing of their onset as follows; New or Presumably New BBB, Old BBB, Indeterminate Onset BBB. At one month, 4.8% of the patients died, 2.6% had re-MI/stent thrombosis, 0.5% had stroke. MACE occurred in 7.6% of patients. Left ventricle ejection fraction, BBB, estimated glomerular filtration rate (eGFR), shock and age were ranked as the strongest predictors of MACE. Compared to non-BBB, all BBBs except for old RBBB was found to be associated with increased MACE. New onset LBBB was the strongest predictor (OR:13.1, 95%CI:3.98-43.4, p < .001) at one month MACE.

CONCLUSION

Compared to non-BBB, all BBBs except for old RBBB was found to be associated with increased MACE. New onset LBBB was the strongest predictor for MACE at one month.

Secondary prevention strategies after an acute ST-segment elevation myocardial infarction in the AMI code era: beyond myocardial mechanical reperfusion

BACKGROUND

The AMI code is a regional network enhancing a rapid and widespread access to reperfusion therapy (giving priority to primary angioplasty) in patients with acute ST-segment elevation myocardial infarction (STEMI). We aimed to assess the long-term control of conventional cardiovascular risk factors after a STEMI among patients included in the AMI code registry.

DESIGN AND METHODS

Four hundred and fifty-four patients were prospectively included between June-2009 and April-2013. Clinical characteristics were collected at baseline. The long-term control of cardiovascular risk factors and cardiovascular morbidity/mortality was assessed among the 6-months survivors.

RESULTS

A total of 423 patients overcame the first 6 months after the STEMI episode, of whom 370 (87%) underwent reperfusion therapy (363, 98% of them, with primary angioplasty). At 1-year follow-up, only 263 (62%) had adequate blood pressure control, 123 (29%) had LDL-cholesterol within targeted levels, 126/210 (60%) smokers had withdrawn from their habit and 40/112 (36%) diabetic patients had adequate glycosylated hemoglobin levels. During a median follow-up of 20 (11-30) months, cumulative mortality of 6 month-survivors was 6.1%, with 9.9% of hospital cardiovascular readmissions. The lack of assessment of LDL and HDL-cholesterol were significantly associated with higher mortality and cardiovascular readmission rates.

CONCLUSIONS

Whereas implementation of the AMI code resulted in a widespread access to rapid reperfusion therapy, its long-term therapeutic benefit may be partially counterbalanced by a manifestly suboptimal control of cardiovascular risk factors. Further efforts should be devoted to secondary prevention strategies after STEMI.

Morbidity and mortality risk among patients with screening-detected severe hypertension in the Malmö Preventive Project

OBJECTIVE

Screening of hypertension has been advocated for early detection and treatment. Severe hypertension (grade 3 hypertension) is a strong predictor for cardiovascular disease. This study aimed to evaluate not only the risk factors for developing severe hypertension, but also the prospective morbidity and mortality risk associated with severe hypertension in a population-based screening and intervention programme.

RESEARCH DESIGN AND METHODS

In all, 18,200 individuals from a population-based cohort underwent a baseline examination in 1972-1992 and were re-examined in 2002-2006 in Malmö, Sweden. In total, 300 (1.6%) patients with severe hypertension were identified at re-examination, and predictive risk factors from baseline were calculated. Total and cause-specific morbidity and mortality were followed in national registers in all severe hypertension patients, as well as in age and sex-matched normotensive controls. Cox analyses for hazard ratios were used.

RESULTS

Men developing severe hypertension differed from matched controls in baseline variables associated with the metabolic syndrome, as well as paternal history of hypertension (P < 0.001). Women with later severe hypertension were characterized by elevated BMI and a positive maternal history for hypertension at baseline. The risk of mortality, coronary events, stroke and diabetes during follow-up was higher among severe hypertension patients compared to controls. For coronary events, the risk remained elevated adjusted for other risk factors [hazard ratio 2.31, 95% confidence interval (CI) 1.22-4.40, P = 0.011].

CONCLUSION

Family history and variables associated with metabolic syndrome are predictors for severe hypertension after a long-term follow-up. Severe hypertension is associated with increased mortality, cardiovascular morbidity and incident diabetes in spite of treatment. This calls for improved risk factor control in patients with severe hypertension.