Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury

Frequency of ischemic cardiac events in patients receiving long-term multikinase inhibitor: A report of three cases

Objective

To investigate the incidence and characteristics of ischemic cardiac events, specifically major adverse cardiac events (MACE), in patients undergoing long-term treatment with multikinase inhibitors (MKIs) such as lenvatinib and sorafenib.

Methods

A single-center retrospective analysis was conducted on 41 patients treated with lenvatinib or sorafenib for more than one year at our institution from 2015 to 2022. Patient records were reviewed to collect data on demographics, cancer type, cardiovascular risk factors, MKI treatment duration, and MACE incidence. MACE events, defined as acute heart failure, fatal arrhythmia, acute myocardial infarction, and coronary revascularization, were analyzed to determine potential correlations with MKI therapy.

Results

Among the 41 patients, three (7.3%) developed MACE, presenting as acute heart failure, fatal arrhythmia, and acute myocardial infarction, all associated with significant coronary artery stenosis. Notably, none of these patients had a prior history of cardiovascular disease. Despite variations in clinical presentation, all cases suggested a link between long-term MKI administration and accelerated coronary atherosclerosis. Factors involved in atherosclerosis were significantly older and tended to be more hypertensive in the non-MACE group.

Conclusions

Long-term MKI therapy may increase the risk of severe ischemic cardiac events, likely due to accelerated atherosclerosis. Clinicians and oncology nurses should monitor patients closely for early signs of angina, especially in an outpatient setting, to prevent acute cardiac events. Further large-scale studies are warranted to establish a clearer causal relationship between MKI therapy and cardiovascular risks.

Unselected cardiac troponin testing and the diagnosis of myocardial infarction in the emergency department

BACKGROUND

This research examines the role of systematic cardiac troponin evaluation in identifying type 1 myocardial infarction among patients presenting to the emergency department with collected blood samples.

METHODS

This was a prospective study of consecutive adult patients presenting to the emergency department of a university hospital between October 22, 2020, and January 11, 2021. Cardiac troponin I levels were measured in all patients, including those with suspected acute coronary syndrome (clinical testing) and a control group undergoing routine blood tests (non-clinical testing). The primary outcomes were the prevalence of type 1 myocardial infarction and the positive predictive value of cardiac troponin I, which were assessed using established statistical methods.

RESULTS

Elevated cardiac troponin levels were identified in 13.4% of the study population (382/2,853). This included 19.5% of patients with clinically guided tests and 10.1% of those with non-clinical testing. The overall prevalence of type 1 myocardial infarction was 2%, with a positive predictive value of 14.9% (95% CI: 13.6-16.2). Among clinically guided tests, type 1 myocardial infarction prevalence was 5.8%, yielding a positive predictive value of 29.5% (95% CI: 26.7-32.4). Cases from non-clinically guided tests were primarily attributed to type 2 myocardial infarction or non-ischemic myocardial injury.

CONCLUSION

Using a generalized approach to cardiac troponin testing in emergency department patients significantly lowers the diagnostic accuracy for type 1 myocardial infarction, reducing the positive predictive value and frequently indicating non-ischemic myocardial injury.

Cancer and myocardial injury in patients with suspected acute coronary syndrome

BACKGROUND

Cancer and cardiovascular diseases are the leading causes of mortality worldwide, as they share common risk factors and exacerbate cardiovascular outcomes when they coexist. This study aimed to assess the clinical characteristics and cardiovascular outcomes of patients with a history of cancer and myocardial injury (MI) presenting with suspected acute coronary syndrome (ACS) in an emergency setting.

METHODS

This retrospective cohort study included 3,626 patients admitted to the emergency department with suspected ACS between 2012 and 2013. Patients were categorized on the basis of their cancer history and the presence of MI. Clinical variables and the associations between cancer history and MI with all-cause mortality were analyzed over a four-year follow-up period via univariate and multivariate Cox regression models.

RESULTS

Of the cohort, 10.6% (n = 384) had a history of cancer. Compared with other groups, cancer patients with MI were older, had more comorbidities, and presented a higher incidence of type 2 myocardial infarction (T2MI). At the four-year follow-up, all-cause mortality was significantly greater among cancer patients with MI (68.8%) than among cancer patients without MI (32.4%) and noncancer patients with or without MI (42.5% vs. 11.3%, respectively). Multivariate analysis identified cancer patients, particularly those with MI, as independent predictors of mortality.

CONCLUSIONS

Patients who present to emergency departments with suspected ACS, a history of cancer, or the presence of MI face greater cardiovascular risk and mortality than other patients do. The higher prevalence of T2MI in this population underscores the need for tailored management strategies.

Prognostication in emergency room patients: comparing ultrasensitive and contemporary quantification of cardiac troponin levels below the 99th percentile

Introduction

Cardiac troponin levels below the 99th percentile improve the predictive efficacy for cardiovascular events when associated with relevant clinical variables. However, whether ultra-sensitive analytical methods improve this predictive efficacy over less sensitive or contemporary analytical methods remains unknown.

Methods

This retrospective observational study involved consecutive patients who presented to the emergency department for suspected acute coronary syndrome and underwent measurement of ultra-sensitive cardiac troponin I (Singulex) and contemporary cardiac troponin I (Siemens) with levels below the 99th percentile. The clinical characteristics of these patients were analysed, and the efficacy of both analytical methods for predicting cardiovascular events over a 4-year follow-up period was compared.

Results

In total, 838 patients were analysed (mean age, 62.9 ± 16.6 years; 42.2% women). Their cumulative incidence of the composite cardiovascular event (death, readmission for myocardial infarction, and readmission for heart failure) was 25.9% over the 4-year follow-up. Both Singulex cardiac troponin I (analysed by quartiles) and Siemens cardiac troponin (analysed as detectable/undetectable) improved the predictive efficacy for the combined event over clinical variables [Harrell's C-index (95% confidence interval): 0.77 (0.74-0.80) vs. 0.79 (0.76-0.81) and 0.77 (0.74-0.80) vs. 0.78 (0.75-0.81), respectively; p = 0.018]. However, there were no statistically significant difference between the two predictive models that included the aforementioned troponin assays.

Conclusions

Detectable levels of cardiac troponin using a contemporary analytical method or those near the 99th percentile using an ultra-sensitive analytical method improve the predictive efficacy for cardiovascular events, with no differences between the two methods.

Prevalence, Clinical Features, Treatment, and Outcomes in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries

AIM

To study clinical and demographic characteristics, treatment options, and clinical outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) compared with patients with myocardial infarction with obstructive coronary arteries (MIOCA).

MATERIAL AND METHODS

This single-center prospective observational study included 712 successive patients diagnosed with acute myocardial infarction (MI), who routinely underwent direct coronary angiography. Based on the presence of stenosing coronary atherosclerosis, the patients were divided into two groups: MIOCA (coronary stenosis ≥50%) and MINOCA (coronary stenosis <50% without other, alternative causes). Clinical outcomes included in-hospital and long-term overall mortality, and cardiovascular rehospitalization. The median follow-up was 1.5 years.

RESULTS

MINOCA was diagnosed in 73 (10.3%) patients, 37 (50%) of whom were women. The median age of patients with MINOCA was 61 years and in the MIOCA group 65 years. No significant differences in cardiovascular risk factors were found between patients with MINOCA and MIOCA. In 53.4% of cases, the cause of MINOCA was a discrepancy between the myocardial oxygen demand and supply, and in 35.6% of cases, the cause was hypertensive crisis and pulmonary edema. The factors associated with MINOCA included an age ≤58 years, female gender, absence of the ST-segment elevation, absence of areas of impaired local contractility, and presence of aortic stenosis and bronchopulmonary infection. Patients with MINOCA were less likely to be prescribed acetylsalicylic acid, P2Y12 inhibitors, dual antiplatelet therapy, beta-blockers, and statins (p<0.05). Data on long-term outcomes were available for 87.5% of patients (n=623). The prognosis of patients with MIOCA was comparable for in-hospital mortality (1.5% vs. 6.2%; p=0.161) and long-term overall mortality (6.1% vs. 14.7%; p=0.059). Cardiovascular rehospitalizations were more frequent in the MINOCA group (33.3% vs. 21.5%; p=0.042).

CONCLUSION

The prevalence of MINOCA in our study was 10.3% among all patients with acute MI. MINOCA patients had comparable generally recognized cardiovascular risk factors with MIOCA patients. MINOCA patients had a comparable prognosis for in-hospital and long-term mortality and more often required cardiovascular rehospitalization.

Sex-related differences in non-ischemic myocardial injury in the emergency department: A real-world perspective

BACKGROUND

Myocardial injury is associated with adverse outcomes. No data are reported about sex differences in incidence and factors associated with myocardial injury in an emergency department (ED) setting from a real-world perspective. We aimed to assess whether sex plays a major role in the diagnosis of myocardial injury in the ED.

METHODS

In this subanalysis of a retrospective study, patients presenting at the ED with at least one high-sensitivity cardiac troponin T (hs-cTnT) value and without acute coronary syndromes diagnosis were compared.

RESULTS

31,383 patients were admitted to the ED, 4660 had one hs-cTnT value, and 3937 were enrolled: 1943 females (49.4%) and 1994 males (50.6%). The diagnosis of myocardial injury was higher among men (36.8% vs. 32.9%, p < 0.01). Male sex was independently associated with myocardial injury. An older age, an elevated NT-proB-type Natriuretic Peptide and a lower estimated glomerular filtrate rate were independently associated with myocardial injury in both sexes.

CONCLUSIONS

In the ED, from a real-world perspective, myocardial injury occurred more frequently in males, and it was associated with older age and the presence of cardiac, lung, and kidney disease but not higher hs-cTnT values.

Impact of clinical diagnosis of myocardial infarction in patients with elevated cardiac troponin

OBJECTIVE

Type 2 myocardial infarction (MI) and myocardial injury are common conditions associated with an adverse prognosis. Physicians experience uncertainty how to distinguish these conditions, as well as how to manage and treat them. Therefore, the objective of this study was to compare treatment and prognosis in patients with an adjudicated diagnosis of type 2 MI and myocardial injury, who were discharged with and without a clinical diagnosis of MI.

DESIGN

The study consisted of two cohorts, 964 and 281 consecutive patients with elevated cardiac troponin, discharged with and without a clinical diagnosis of MI, respectively. All cases were adjudicated into MI type 1-5 or myocardial injury and followed regarding all-cause death.

RESULTS

The adjudication identified 138 and 37 cases of type 2 MI, and 86 and 185 of myocardial injury, with and without a clinical MI diagnosis, respectively. In patients with type 2 MI, a clinical MI diagnosis was associated with more coronary angiography investigations (39.1% vs 5.4%, p<0.001) and an increased use of secondary prevention medications (all p<0.001). However, no difference was observed in adjusted 5-year mortality between patients with and without a clinical MI diagnosis (HR: 0.77 with 95% CI 0.43 to 1.38). The results were similar for adjudicated myocardial injury.

CONCLUSION

In both type 2 MI and myocardial injury, a clinical diagnosis of MI at discharge was associated with more investigations and treatments. However, no prognostic effect of receiving a clinical MI diagnosis was observed.

Diagnosis and Prognosis of Type 2 Myocardial Infarction Using Objective Evidence of Acute Myocardial Ischemia: A Validation Study

BACKGROUND

Differentiating type 2 myocardial infarction from myocardial injury can be difficult. In addition, the presence of objective evidence of myocardial ischemia may facilitate identification of high-risk type 2 myocardial infarction patients.

METHODS

This was an observational cohort study of adult emergency department patients undergoing high-sensitivity cardiac troponin T (hs-cTnT) measurement. Patients with ≥1 hs-cTnT >99th percentile were adjudicated following the Fourth Universal Definition of Myocardial Infarction. Patients were categorized as "subjective type 2 myocardial infarction" when ischemic symptoms were the lone criteria supporting type 2 myocardial infarction, or "objective type 2 myocardial infarction" when there was ≥1 objective clinical feature (electrocardiography, imaging, angiography) of acute myocardial ischemia. The primary outcome was mortality.

RESULTS

A total of 857 patients were included, among which 55 (6.4%) were classified as subjective type 2 myocardial infarction, 36 (4.2%) as objective type 2 myocardial infarction, and 702 (82%) as myocardial injury. Those with objective type 2 myocardial infarction had a higher risk of mortality during the index presentation (17% vs 1.7%, P < .0001; hazard ratio 11.1; 95% confidence interval, 3.7-33.4) and at 2-year follow-up (47% vs 31%, P = .04; hazard ratio 1.92; 95% confidence interval, 1.17-3.14) than those with myocardial injury. Objective type 2 myocardial infarction had a higher mortality than subjective type 2 myocardial infarction at index presentation (17% vs 2.0%, P = .01) and at 1 (25% vs 9.1%, P = .04) and 3 months (31% vs 13%, P = .04) follow-up. There were no mortality differences between subjective type 2 myocardial infarction and myocardial injury.

CONCLUSION

In patients diagnosed with type 2 myocardial infarction, those with objective evidence of myocardial ischemia have significantly worse outcomes compared with those with myocardial injury and subjective type 2 myocardial infarction. A more rigorous type 2 myocardial infarction definition that emphasizes these criteria may facilitate diagnosis and risk-stratification.

L'infarctus du myocarde type 2

Type 2 MI is a category of myocardial infarction according to the UDMI, frequently encountered in routine practice but still poorly understood in terms of prevalence, diagnostic and therapeutic approach, it affects a heterogeneous population at high risk of major cardiovascular events and non-cardiac death. It is due to an inadequacy between oxygen supply and demand in the absence of a primary coronary event, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension or hypotension. Diagnosis has traditionally required an integrated history assessment, with some combination of indirect evidence of myocardial necrosis based on biochemical, electrocardiographic, and imaging modalities. Differentiation between type 1 and type 2 MI is more complicated than it appears. Treatment of the underlying pathology is the primary goal of treatment.

Type 2 Myocardial Infarction and Long-Term Mortality Risk Factors: A Retrospective Cohort Study

INTRODUCTION

In-hospital risk factors for type 1 myocardial infarction (MI) have been extensively investigated, but risk factors for type 2 MI are still emerging. Moreover, type 2 MI remains an underdiagnosed and under-researched condition. Our aim was to assess survival rates after type 2 MI and to analyze the risk factors for patient prognosis after hospitalization.

METHODS

We conducted a retrospective database analysis of patients with MI diagnosis who were treated in Vilnius University Hospital Santaros Klinikos. A total of 6495 patients with the diagnosis of MI were screened. The primary study endpoint was long-term all-cause mortality. The predictive value of laboratory tests was estimated including blood hemoglobin, D dimer, creatinine, brain natriuretic peptide (BNP), C-reactive protein (CRP), and troponin levels.

RESULTS

Out of all the patients diagnosed with MI there were 129 cases of type 2 MI (1.98%). Death rate almost doubled from 19.4% at 6 months to 36.4% after 2 years of follow-up. Higher age and impaired kidney function were risk factors for death both during hospitalization and after 2 years of follow-up. Lower hemoglobin (116.6 vs. 98.9 g/L), higher creatinine (90 vs. 161.9 μmol/L), higher CRP (31.4 vs. 63.3 mg/l), BNP (707.9 vs. 2999.3 ng/L), and lower left ventricle ejection fraction were all predictors of worse survival after 2 years of follow-up. Preventive medication during hospitalization can decrease the mortality risk: angiotensin-converting enzyme inhibitor (ACEi) (HR 0.485, 95% CI 0.286-0.820) and statins (HR 0.549, 95% CI 0.335-0.900). No significant influence was found for beta blockers (HR 0.662, 95% CI 0.371-1.181) or aspirin (HR 0.901, 95% CI 0.527-1.539).

CONCLUSIONS

There is significant underdiagnosis of type 2 MI (1.98% out of all MIs). If the patient is prescribed a preventive medication like ACEi or statins, the mortality risk is lower. Increased awareness of elevation of laboratory results could help to improve the treatment of these patients and identify the most vulnerable groups.

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.

Outcome of patients admitted with oxygen mismatch and myocardial injury or infarction in emergency departments

AIMS

To describe the outcomes and associated factors in a population of patients admitted to emergency departments with at least one condition of oxygen supply/demand imbalance, regardless of the troponin result or restrictive criteria for type 2 myocardial infarction.

METHODS

We constituted a retrospective cohort of 824 patients. Medical records of patients having undergone a troponin assay were reviewed for selection and classification, and data including in-hospital stay and readmissions were collected. The reported outcomes are in-hospital mortality, 3-year mortality, and major adverse cardiovascular events.

RESULTS

Patients with myocardial infarction or injury, either chronic or acute, were older, with more history of hypertension and chronic heart or renal failure but not for other cardiovascular risk factors and medical history. Acute myocardial injury and type 2 myocardial infarction were significantly associated with in-hospital mortality [odds ratio (OR) 3.71 95% confidence interval (CI) 1.90-7.33 and OR 3.15 95% CI 1.59-6.28, respectively]. However, the long-term mortality does not differ in comparison with patients presenting chronic myocardial injury or nonelevated troponin, ranging from 26.9 to 34.3%. Patients with chronic myocardial injury and type 2 myocardial infarction had more long-term major cardiovascular events (39.3 and 38.8%), but only for acute heart failure, and none was associated with this outcome after adjustment.

CONCLUSION

Among patients admitted to emergency departments with an oxygen supply/demand imbalance, acute myocardial injury and type 2 myocardial infarction are strongly associated with in-hospital mortality. However, they are not associated with higher long-term mortality or major cardiovascular events after discharge, which tend to occur in elderly people with comorbidities.

Artificial intelligence-augmented electrocardiography for left ventricular systolic dysfunction in patients undergoing high-sensitivity cardiac troponin T

AIMS

Our goal was to evaluate a previously validated artificial intelligence-augmented electrocardiography (AI-ECG) screening tool for left ventricular systolic dysfunction (LVSD) in patients undergoing high-sensitivity-cardiac troponin T (hs-cTnT).

METHODS AND RESULTS

Retrospective application of AI-ECG for LVSD in emergency department (ED) patients undergoing hs-cTnT. AI-ECG scores (0-1) for probability of LVSD (left ventricular ejection fraction ≤ 35%) were obtained. An AI-ECG score ≥0.256 indicates a positive screen. The primary endpoint was a composite of post-discharge major adverse cardiovascular events (MACEs) at two years follow-up. Among 1977 patients, 248 (13%) had a positive AI-ECG. When compared with patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE [48 vs. 21%, P < 0.0001, adjusted hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.11-1.75]. This was largely because of a higher rate of deaths (32 vs. 14%, P < 0.0001; adjusted HR 1.26, 95% 0.95-1.66) and heart failure hospitalizations (26 vs. 6.1%, P < 0.001; adjusted HR 1.75, 95% CI 1.25-2.45). Together, hs-cTnT and AI-ECG resulted in the following MACE rates and adjusted HRs: hs-cTnT < 99th percentile and negative AI-ECG: 116/1176 (11%; reference), hs-cTnT < 99th percentile and positive AI-ECG: 28/107 (26%; adjusted HR 1.54, 95% CI 1.01-2.36), hs-cTnT > 99th percentile and negative AI-ECG: 233/553 (42%; adjusted HR 2.12, 95% CI 1.66, 2.70), and hs-cTnT > 99th percentile and positive AI-ECG: 91/141 (65%; adjusted HR 2.83, 95% CI 2.06, 3.87).

CONCLUSION

Among ED patients evaluated with hs-cTnT, a positive AI-ECG for LVSD identifies patients at high risk for MACE. The conjoint use of hs-cTnT and AI-ECG facilitates risk stratification.

Association between troponin and outcome in patients with chest pain and rapid atrial fibrillation: a retrospective study of a single-center 10-year cohort

BACKGROUND AND OBJECTIVE

The prognosis of myocardial infarction in patients with rapid atrial fibrillation (RAF) is poorly known. We sought to ascertain if troponin concentrations are associated with a higher risk of major adverse cardiovascular events (MACE) in patients with RAF and chest discomfort suggestive of coronary origin.

METHODS

We retrospectively reviewed all consecutive patients attending an emergency department of a single-center (2008-2017) with chest pain suggestive of coronary origin who had RAF and at least one troponin determination. Patients were classified as having normal/increased troponin. They were followed until December 2019 to detect MACE (primary outcome), which included acute coronary syndrome (ACS), revascularization, stroke, or all-cause death. In addition to cardiovascular death and type I myocardial infarction, these were considered secondary outcomes. The adjusted risk was determined by Cox regression, and sensitivity analysis were run. Relationship between troponin as a continuous variable and outcomes was also evaluated, as well as interaction by sex.

RESULTS

We included 574 patients (median = 76.5 years, IQR = 14, women 56.8%, increased troponin 34.1%) followed by a median of 3.8 years (IQR = 4.8). MACE occurred in 200 patients (34.8%). Increased troponin was independently associated with MACE (adjusted hazard ratio, 1.502, 95% CI, 1.130-1.998), ACS (adjusted hazard ratio, 2.488, 95% CI, 1.256-4.928), type I myocardial infarction (adjusted hazard ratio, 2.771, 95% CI, 1.212-6.333) and stroke (adjusted hazard ratio, 3.580, 95% CI, 1.888-6.787) but not with death, cardiovascular death or revascularization. Sensitivity analyses were consistent with these results. There was no interaction by sex. When assessed continuously, an increase in troponin concentrations was lineally associated with a steady increase in the risk of MACE.

CONCLUSIONS

In patients with RAF who complain of chest pain, increased troponin levels are related to adverse cardiovascular outcomes.

Clinical Characteristics, Outcomes, and Epidemiological Trends of Patients Admitted With Type 2 Myocardial Infarction

Background

Type 2 myocardial infarction (T2MI) was first established as a unique entity in 2007. However, its clinical features are not well characterized. This study aimed to determine the clinical characteristics, predictors of mortality, and hospitalization trends of patients with T2MI.

Methods

The National Inpatient Sample database was queried for patients hospitalized in the United States with T2MI (January 2018 to December 2019). Data were used to assess baseline characteristics, primary diagnoses, predictors of mortality, and hospitalization and mortality trends of T2MI.

Results

During the 24-month study period, 1,789,485 (76%) patients were admitted with type 1 myocardial infarction (T1MI) and 563,695 (24%) were admitted with T2MI. Patients with T2MI were more likely to be older (71 vs 68 years; P < .001) and female (47.5% vs 38.3%; P < .001), with fewer comorbidities related to coronary atherosclerosis. African Americans were the only race with a significantly higher rate of hospitalization for T2MI (15.9% vs 11.6%; P < .001). The predictors of mortality were similar in both the T2MI and T1MI cohorts. Sepsis (23.47%), hypertensive heart disease (15.35%), and atrial arrhythmias (4.49%) were the most common principal diagnoses for T2MI. T2MI hospitalizations trended consistently upward during the study period. Monthly in-hospital mortality rates were consistently higher for T2MI versus T1MI (P < .001).

Conclusions

T2MI is a unique and heterogeneous clinical entity. Despite increased awareness, there is a lack of standardization of medical management and timing for revascularization, even as mortality rates remain persistently elevated compared with T1MI. Certain demographics, including African Americans, may be disproportionately affected.

Major adverse cardiovascular events after diagnosis of myocardial injury and types 1 and 2 myocardial infarction

AIMS

Limited US outcome data exist among patients with myocardial injury and types 1 and 2 myocardial infarction (MI) evaluated with high-sensitivity cardiac troponin (hs-cTn).

METHODS AND RESULTS

This is an observational US cohort study of emergency department (ED) patients undergoing hs-cTnT measurement. Cases with ≥1 hs-cTnT increase >99th percentile were adjudicated following the Fourth Universal Definition of MI. Post-discharge major adverse cardiovascular events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischaemic attack, and new-onset atrial fibrillation or flutter during 2 years follow-up. Among 2002 patients, 857 (43%) had ≥1 hs-cTnT >99th percentile. Among these, 702 (81.9%) had myocardial injury, 64 (7.5%) had type 1 MI, and 91 (10.6%) had type 2 MI. Compared with patients without myocardial injury, type 2 MI [8.4 vs. 50%; adjusted hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.49-3.58] and myocardial injury (8.4 vs. 47%; adjusted HR 3.13, 95% CI 2.39-4.09) had a higher risk of MACE, in large part because of death and HF hospitalizations. Compared with patients with type 1 MI, type 2 MI (23 vs. 50%; adjusted HR 2.24; 95% CI 1.23-4.10) and myocardial injury (23 vs. 47%; adjusted HR 2.02; 95% CI 1.20-3.40) also have a higher risk of MACE.

CONCLUSION

Among unselected US ED patients undergoing hs-cTnT measurement, most increases are due to myocardial injury, and type 2 MI is more frequent than type 1 MI. Patients with myocardial injury and type 2 MI have morbid outcomes, in large part due to death and HF.

A Nomogram Model for Predicting Type-2 Myocardial Infarction Induced by Acute Upper Gastrointestinal Bleeding

OBJECTIVE

To examine the independent risk factors of type-2 myocardial infarction (T2MI) elicited by acute upper gastrointestinal bleeding (AUGIB), and to establish a nomogram model for the prediction of AUGIB-induced T2MI.

METHODS

A nomogram model was established on the basis of a retrospective study that involved 533 patients who suffered from AUGIB in the Department of Critical Care Medicine (CCM) or Emergency Intensive Care Unit (EICU) of Renmin Hospital of Wuhan University, Wuhan, China, from January 2017 to December 2020. The predictive accuracy and discriminative power of the nomogram were initially evaluated by internal validation, which involved drawing the receiver operating characteristic (ROC) curve, calculating the area under the curve (AUC), plotting the calibration curve derived from 1000 resampled bootstrap data sets, and computing the root mean square error (RMSE). The predictive ability of the nomogram was further validated through the prospective and multicenter study conducted by the investigators, which enrolled 240 AUGIB patients [including 88 cases from Renmin Hospital of Wuhan University, 73 cases from Qilu Hospital of Shandong University (Qingdao), and 79 cases from Northern Jiangsu People's Hospital)], who were admitted to the Department of CCM or EICU, from February 2021 to July 2021.

RESULTS

Among the 533 patients in the training cohort, 78 (14.6%) patients were assigned to the T2MI group and 455 (85.4%) patients were assigned to the non-T2MI group. The multivariate analysis revealed that age >65, hemorrhagic shock, cerebral stroke, heart failure, chronic kidney disease, increased blood urea nitrogen, decreased hematocrit, and elevated D-Dimer were independent risk factors for AUGIB-induced T2MI. All these factors were incorporated into the nomogram model. The AUC for the nomogram for predicting T2MI was 0.829 (95% CI, 0.783-0.875) in the internal validation cohort and 0.848 (95% CI, 0.794-0.902) in the external validation cohort. The calibration curve for the risk of T2MI exhibited good consistency between the prediction by the nomogram and the actual clinical observation in both the internal validation (RMSE=0.016) and external validation (RMSE=0.020).

CONCLUSION

The nomogram was proven to be a useful tool for the risk stratification of T2MI in AUGIB patients, and is helpful for the early identification of AUGIB patients who are prone to T2MI for early intervention, especially in emergency departments and intensive care units.

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.

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.

Statin Therapy and Intensity: Prognosis in Patients with Myocardial Injury

BACKGROUND

No guideline-directed pharmacological therapy has been established for patients with myocardial injury without type 1 myocardial infarction. We investigated the impact of statin treatment in patients with myocardial injury.

METHODS

Patients with myocardial injury (nonischemic acute and chronic myocardial injury), type 2 myocardial infarction, and type 1 myocardial infarction with at least 1 emergency department visit for chest pain from 2011 to 2014 were included. Dispensed prescriptions of all types of statins with dosage within 180 days from the index visit were collected. In total, 2054 patients were divided into 3 groups: 1) acute myocardial injury (type 2 myocardial infarction, acute nonischemic myocardial injury), 2) chronic myocardial injury, and 3) type 1 myocardial infarction. We estimated the adjusted hazard ratio with 95% confidence interval for death with low- (reference), moderate-, and high-intensity statin therapy.

RESULTS

The mean follow-up was 4.2 ± 1.8 years. Only 13% of patients with acute and chronic myocardial injury and 30% with type 1 myocardial infarction were treated with high-intensity statins. Adjusted mortality rates were higher in patients with acute and chronic myocardial injury than in those with type 1 myocardial infarction across all statin intensity categories. In patients with type 1 myocardial infarction, the adjusted mortality risk was 20% (hazard ratio, 0.80; 95% confidence interval, 0.36-1.77) lower in patients with high-intensity therapy. Point estimates in the adjusted models indicated similar associations between statin intensity and mortality risk in patients with acute and chronic myocardial injury.

CONCLUSION

Patients with myocardial injury may benefit from high-intensity statin treatment, but the associations were not statistically significant when adjusting for confounders.

Relation of High-Sensitivity Troponin to 1 Year Mortality in 20,000 Consecutive Hospital Patients Undergoing a Blood Test for Any Reason

This was an observational study of the 1-year outcomes of the 20,000 patients included in the original CHARIOT study. The aim of the study was to assess the association between high sensitivity troponin I (hs-cTnI) concentration and 1 year mortality in this cohort. The original CHARIOT study included a consecutive cohort of in- and out-patients undergoing blood tests for any reason. Hs-cTnI concentrations were measured regardless of whether the clinician requested them. These results were nested and not revealed to the team unless requested for clinical reasons. One year mortality data was obtained from NHS Digital as originally planned. Overall, 1782 (8.9%) patients had died at 1 year. Multivariable Cox regression analysis showed that a hs-cTnI concentration above the upper limit of normal was independently associated with the hazard of mortality (HR 2.23; 95% confidence intervals 1.97 to 2.52). Furthermore, the log (10) hs-cTnI concentration was independently associated with the hazard of 1 year mortality (HR 1.77; 95% confidence intervals 1.64 to 1.91). In conclusion, in a large, unselected hospital population of both in- and out-patients, in 18,282 (91.4%) of whom there was no clinical indication for testing, hs-cTnI concentration was associated with 1 year mortality.

Types of myocardial injury and mid-term outcomes in patients with COVID-19

AIMS

To evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes.

METHODS AND RESULTS

Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44-5.06; acute: HR 4.72, 95% CI 4.14-5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15-7.33; acute: HR 4.13, 95% CI 2.75-6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94-1.36), except for a worse prognostic impact of acute myocardial injury in patients <65 years of age (P-interaction = 0.043) and in those without coronary artery disease (P-interaction = 0.041).

CONCLUSION

Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.

Sex differences in investigations and outcomes among patients with type 2 myocardial infarction

OBJECTIVES

Type 2 myocardial infarction (MI) is a heterogenous condition and whether there are differences between women and men is unknown. We evaluated sex differences in clinical characteristics, investigations and outcomes in patients with type 2 MI.

METHODS

In the Swedish Web based system for Enhancement and Development of Evidence based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we compared patients admitted to coronary care units with a diagnosis of type 1 or type 2 MI. Sex-stratified Cox regression models evaluated the association with all-cause death in men and women separately.

RESULTS

We included 57 264 (median age 73 years, 65% men) and 6485 (median age 78 years, 50% men) patients with type 1 and type 2 MI, respectively. No differences were observed in the proportion of men and women with type 2 MI who underwent echocardiography and coronary angiography, but women were less likely than men to have left ventricular (LV) impairment and obstructive coronary artery disease (CAD). Compared with type 1 MI, patients with type 2 MI had higher risk of death regardless of sex (men: adjusted HR 1.55 (95% CI 1.44 to 1.67); women: adjusted HR 1.34 (95% CI 1.24 to 1.45)). In those with type 2 MI, the risk of death was lower for women than men (adjusted HR 0.85 (95% CI 0.76 to 0.92) (men, reference)).

CONCLUSIONS

Type 2 MI occurred in men and women equally and we found no evidence of sex bias in the selection of patients for cardiac investigations. Patients with type 2 MI had worse outcomes, but women were less likely to have obstructive CAD or severe LV impairment and were more likely to survive than men.

Clinical characteristics and prognostic implications of diabetes and myocardial injury in patients admitted to the emergency room

BACKGROUND

This study aimed to investigate the clinical features and prognosis of diabetes and myocardial injury in patients admitted to the emergency department.

METHODS

We analyzed the clinical data of all consecutive patients admitted to the emergency department during the years 2012 and 2013 with at least 1 cardiac Troponin I (cTnI Ultra Siemens, Advia Centaur) determination, and were classified according to the status of diabetes mellitus (DM) and myocardial injury (MI). Clinical events were evaluated in a 4-year follow-up.

RESULTS

A total of 3622 patients were classified according to the presence of DM (n = 924 (25.55%)) and MI (n = 1049 (28.96%)). The proportion of MI in patients with DM was 40% and 25% in patients without DM. Mortality during follow-up was 10.9% in non-DM patients without MI, 21.3% in DM patients without MI, 40.1% in non-DM patients with MI, and 52.8% in DM patients with MI. A competitive risk model was used to obtain the Hazard Ratio (HR) for readmission for myocardial infarction or heart failure. There was a similar proportion of readmission for myocardial infarction and heart failure at a four-year follow-up in patients with DM or MI, which was much higher when DM was associated with MI, with respect to patients without DM or MI. The HR (95% Coefficient Interval) for myocardial infarction in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2511 (1592-3960), 2682 (1739-4138), and 5036 (3221-7876), respectively. The HR (95% CI) for the risk of readmission for heart failure in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2663 (1825-3886), 2562 (1753-3744) and 4292 (2936-6274), respectively.

CONCLUSIONS

The association of DM and MI in patients treated in an Emergency Service identifies patients at very high risk of mortality and cardiovascular events.

Outcomes and Resource Utilization of Atrial Fibrillation Hospitalizations With Type 2 Myocardial Infarction

Scarce data exist on the prognostic impact of type 2 myocardial infarction (MI) in patients with AF. The Nationwide Readmission Database 2018 was queried for primary AF hospitalizations with and without type 2 MI. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions). Of 382,896 weighted primary AF hospitalizations included in this study, 7,375 (1.9%) had type 2 MI. AF with type 2 MI is associated with significantly higher in-hospital mortality (adjusted OR [aOR] 1.76; 95% CI 1.30 to 2.38), LOS (adjusted parameter estimate [aPE] 0.48; 95% CI 0.35 to 0.62), hospital costs (aPE 1307.75; 95% CI 986.05 to 1647.44), discharges to nursing facility (aOR 1.38; 95% CI 1.24 to 1.54), and 30-day all-cause readmissions (adjusted hazard ratio 1.17; 95% CI 1.07 to 1.27) compared to AF without type 2 MI. Heart failure, chronic kidney disease, neurologic disorders, and age (per year) were identified as independent predictors of mortality among AF patients with type 2 MI. In conclusion, type 2 MI in the setting of AF hospitalization is associated with high in-hospital mortality and increased resource utilization.

Poor long-term prognosis in patients admitted with strong suspicion of acute myocardial infarction but discharged with another diagnosis

BACKGROUND

Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well-described.

OBJECTIVES

To compare background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis.

METHODS

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end-point of this subgroup analysis was the incidence of all-cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow-up of 2.1 years (median; range: 1-3.7 years) irrespective of randomized treatment.

RESULTS

1619 (24%) received a non-MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non-MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end-point was 2.8% (45 of 1619) in non-MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end-points. However, for the long-term follow-up, the incidence of the composite end-point increased in the non-MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all-cause death, stroke and HF.

CONCLUSIONS

Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short-term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long-term prognosis.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BACKGROUND

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes.

METHODS

The Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI.

RESULTS

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88-0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] -0.28; 95% CI -0.38-0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI -1916.04-1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05-1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97-1.04; P = 0.841).

CONCLUSION

Among T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury

The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease.

Clinical application of the 4th Universal Definition of Myocardial Infarction

AIMS

The recently released 4th version of the Universal Definition of Myocardial Infarction (UDMI) introduces an increased emphasis on the entities of acute and chronic myocardial injury. We applied the 4th UDMI retrospectively in patients presenting to the emergency department with symptoms potentially indicating myocardial infarction (MI) to investigate its effect on diagnosis and prognosis.

METHODS AND RESULTS

We included 2302 patients presenting to the emergency department with symptoms suggestive of MI. The final diagnosis was adjudicated sequentially according to the 3rd and 4th UDMI. Reclassification after readjudication was assessed. Established diagnostic algorithms for patients with suspected MI were applied to compare diagnostic accuracy. All patients were followed to assess mortality, recurrent MI, revascularization, and rehospitalization to investigate the effect of the 4th UDMI on prognosis. After readjudication, 697 patients were reclassified. Most of these patients were reclassified as having acute (n = 78) and chronic myocardial injury (n = 585). Four hundred and thirty-four (18.9%) patients were diagnosed with MI, compared with 501 (21.8%) MIs when adjudication was based on the 3rd UDMI. In the non-MI population, patients with myocardial injury (n = 663) were older, more often female and had worse renal function compared with patients without myocardial injury (n = 1205). Application of diagnostic algorithms for patients with suspected MI revealed a high accuracy after readjudication. Reclassified patients had a substantially higher rate of cardiovascular events compared with not-reclassified patients, particularly patients reclassified to the category of myocardial injury.

CONCLUSION

By accentuating the categories of acute and chronic myocardial injury the 4th UDMI succeeds to identify patients with higher risk for cardiovascular events and poorer outcome and thus seems to improve risk assessment in patients with suspected MI. Application of established diagnostic algorithms remains safe when using the 4th UDMI.

Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level

Background

The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury.

Methods

We included all patients presenting to public emergency departments in South Australia between June 2011–Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia.

Results

372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia.

Conclusions

Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.

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.

The Multifaceted Interplay between Atrial Fibrillation and Myocardial Infarction: A Review

This review was conducted to emphasize the complex interplay between atrial fibrillation (AF) and myocardial infraction (MI). In type 1 (T1) MI, AF is frequent and associated with excess mortality. Moreover, AF after hospital discharge for T1MI is not rare, suggesting the need to improve AF screening and to develop therapeutic strategies for AF recurrence. Additionally, AF is a common trigger for type 2 MI (T2MI), and recent data have shown that tachyarrhythmia or bradyarrhythmia could be a causal factor in, respectively, 13-47% or 2-7% of T2MI. In addition, AF is involved in T2MI pathogenesis as a result of severe anemia related to anticoagulants. AF is also an underestimated and frequent cause of coronary artery embolism (CE), as a situation at risk of myocardial infarction with non-obstructive coronary arteries. AF-causing CE is difficult to diagnose and requires specific management. Moreover, patients with both AF and chronic coronary syndromes represent a therapeutic challenge because the treatment of AF include anticoagulation, depending on the embolic risk, and ischemic heart disease management paradoxically includes antiplatelet therapy.

Treatment With Cardiovascular Medications: Prognosis in Patients With Myocardial Injury

Background There is no clinical guidance on treatment in patients with non-ischemic myocardial injury and type 2 myocardial infarction (T2MI). Methods and Results In a cohort of 22 589 patients in the emergency department at Karolinska University Hospital in Sweden during 2011 to 2014 we identified 3853 patients who were categorized into either type 1 myocardial infarction, T2MI, non-ischemic acute and chronic myocardial injury. Data from all dispensed prescriptions within 180 days of the visit to the emergency department were obtained concerning β-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, statins, and platelet inhibitors. We estimated adjusted hazard ratios (HR) with 95% CI for all-cause mortality in relationship to the number of medications (categorized into 0-1 [referent], 2-3 and 4 medications) in the groups of myocardial injury. In patients with T2MI, treatment with 2 to 3 and 4 medications was associated with a 50% and 56% lower mortality, respectively (adjusted HR [95% CI], 0.50 [0.25-1.01], and 0.43 [0.19-0.96]), while corresponding associations in patients with acute myocardial injury were 24% and 29%, respectively (adjusted HR [95% CI], 0.76 [0.59-0.99] and 0.71 [0.5-1.02]), and in patients with chronic myocardial injury 27% and 37%, respectively (adjusted HR [95% CI], 0.73 [0.58-0.92] and 0.63 [0.46-0.87]). Conclusions Patients with T2MI and non-ischemic acute or chronic myocardial injury are infrequently prescribed common cardiovascular medications compared with patients with type 1 myocardial infarction. However, treatment with guideline recommended drugs in patients with T2MI and acute or chronic myocardial injury is associated with a lower risk of death after adjustment for confounders.

Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital

INTRODUCTION AND OBJECTIVES

Cardiac troponin, a marker of myocardial injury, is frequently observed in patients with COVID-19 infection. Our objective was to analyze myocardial injury and its prognostic implications in patients with and without COVID-19 infection treated in the same period of time.

METHODS

The present study included patients treated in a university hospital with cardiac troponin I measurements and with suspected COVID-19 infection, confirmed or ruled out by polymerase chain reaction analysis. The impact was analyzed of cardiac troponin I positivity on 30-day mortality.

RESULTS

In total, 433 patients were distributed among the following groups: confirmed COVID-19 (n=186), 22% with myocardial injury (n=41); and ruled out COVID-19 (n=247), 21.5% with myocardial injury (n=52). The confirmed and ruled out COVID-19 groups had a similar age, sex, and cardiovascular history. Mortality was significantly higher in the confirmed COVID-19 group than in the ruled out group (19.9% vs 5.3%, P <.001). In Cox multivariate regression analysis, cardiac troponin I was a predictor of mortality in both groups (confirmed COVID-19 group: HR, 3.54; 95%CI, 1.70-7.34; P=.001; ruled out COVID-19 group: HR, 5.57; 95%CI, 1.70-18.20; P=.004). The predictive model analyzed by ROC curves was similar in the 2 groups (P=.701), with AUCs of 0.808 in the confirmed COVID-19 group (0.750-0.865) and 0.812 in the ruled out COVID-19 group (0.760-0.864).

CONCLUSIONS

Myocardial injury is detected in 1 in every 5 patients with confirmed or ruled out COVID-19 and predicts 30-day mortality to a similar extent in both circumstances.

[Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital]

INTRODUCTION AND OBJECTIVES

Cardiac troponin, a marker of myocardial injury, is frequently observed in patients with COVID-19 infection. Our objective was to analyze myocardial injury and its prognostic implications in patients with and without COVID-19 infection treated in the same period of time.

METHODS

The present study included patients treated in a university hospital with cardiac troponin I measurements and with suspected COVID-19 infection, confirmed or ruled out by polymerase chain reaction analysis. The impact was analyzed of cardiac troponin I positivity on 30-day mortality.

RESULTS

In total, 433 patients were distributed among the following groups: confirmed COVID-19 (n = 186), 22% with myocardial injury (n = 41); and ruled out COVID-19 (n = 247), 21.5% with myocardial injury (n = 52). The confirmed and ruled out COVID-19 groups had a similar age, sex, and cardiovascular history. Mortality was significantly higher in the confirmed COVID-19 group than in the ruled out group (19.9% vs 5.3%, P < .001). In Cox multivariate regression analysis, cardiac troponin I was a predictor of mortality in both groups (confirmed COVID-19 group: HR, 3.54; 95%CI, 1.70-7.34; P = .001; ruled out COVID-19 group: HR, 5.57; 95%CI, 1.70-18.20; P = .004). The predictive model analyzed by ROC curves was similar in the 2 groups (P = .701), with AUCs of 0.808 in the confirmed COVID-19 group (0.750-0.865) and 0.812 in the ruled out COVID-19 group (0.760-0.864).

CONCLUSIONS

Myocardial injury is detected in 1 in every 5 patients with confirmed or ruled out COVID-19 and predicts 30-day mortality to a similar extent in both circumstances.

[The Frequency of Type 2 Myocardial Infarction in the Structure of Hospital Mortality According to 7-Years Data of a State University Clinic]

 Aim      To evaluate the proportion of type 2 myocardial infarction (MI) in the structure of mortality at a multidisciplinary hospital; to describe major causes for MI development, and characteristics of patients with a verified diagnosis of type 2 MI by data of postmortem examination.Material and methods  1574 protocols of the autopsies performed at the Central Pathology Department of the I.I. Mechnikov North-West State Medical University from 01.01.10 through 31.12.16 were studied retrospectively by the continuous sampling method. A group with verified diagnosis of type 2 MI was isolated from the total sample of autopsies. Major causes for and the proportion of type 2 MI among the causes of death were studied. Also, major demographic parameters, hospitalization profile, and condition of coronary arteries (CA) were compared in patients with fatal type 2 MI and those who died from atherothrombotic type 1 MI.Results Analysis of 1574 fatal cases among patients of the multidisciplinary hospital showed that in 360 cases (22.87 %), the cause of death was MI, including 137 cases of fatal type 2 MI. Proportions of men and women among the patients with postmortem verification of type 2 MI were comparable. Analysis of the age structure showed the highest incidence of type 2 MI in elderly (48.2 %) and senile (34.3 %) age. Mean age of patients with type 2 MI was 71.7 years (68.2 years for men and 75.3 years for women), which was comparable with the age range of patients with fatal type 1 MI. In both groups, men with fatal MI were significantly younger than women. Analysis of causes for type 2 MI demonstrated that the most frequent ones were tachysystolic arrhythmias (59.12 %) and severe hypoxia of different origin (35.04 %). Analysis of the type of CA lesions showed that significant lesions were significantly more frequently absent in type 2 MI (32.85 %) while in type 1 MI, the proportion of patients with unchanged CA was 1.84 %. In the group of patients with fatal type 1 MI, 67.29 % had multivascular lesions, and one in two patients had an occlusive lesion. In the group with type 2 MI, multivascular lesions were half as frequent (31.38 %), and only 4.38 % of patients had a complete occlusion of a coronary vessel. Comparison of death rate in different departments of the multidisciplinary hospital showed that only 29.2 % of patients with type 2 MI originally were managed at a specialized cardiological department; 45.3 % of patients were admitted to an internal medicine department for different conditions often not related with ischemic heart disease. Furthermore, 25.5 % of patients with subsequently developed type 2 MI originally even received scheduled or emergency medical care for a leading surgical condition.Conclusion      Cardiovascular diseases predominate among causes of mortality in a multidisciplinary hospital. This study showed that almost one in four patients dies from MI, and type 2 MI accounts for more than one third of fatal MIs. Among major causes for type 2 MI, tachysystolic arrhythmias (59.12 %) and pronounced hypoxia associated with anemia and severe respiratory failure (35.04 %) should be noted. Gender and age characteristics of patients with type 2 MI were comparable with those of patients with fatal type 1 MI. Furthermore, surgical patients accounted for 25.5 % of fatal cases of type 2 MI.

Application of the fourth universal definition of myocardial infarction in clinical practice

Purpose: The Fourth Universal Definition of Myocardial Infarction (MI) has highlighted the different pathophysiological mechanisms that may lead to ischaemic and non-ischaemic myocardial injury and has emphasised that the diagnosis of myocardial infarction requires the presence of acute myocardial ischaemia in the setting of acute myocardial injury. This case based review intends to illustrate basic principles on how to apply this new, revised definition in clinical practice.Methods and Results: The distinction between different types of MIs (type 1 or type 2) and the delineation of MI from acute non-ischaemic myocardial injury may be challenging in individual patients, which is illustrated by presenting and discussing real-life routine cases.Conclusions: Type 1 MI is a consequence of coronary plaque rupture or erosion with intracoronary thrombus formation that is usually apparent on coronary angiography. Plausible triggering mechanisms causing myocardial oxygen supply/demand mismatch must be identified for the diagnosis of type 2 MI and its treatment should focus initially on management of the underlying disease attributable to acute myocardial ischaemia.

Meta-analysis Comparing Outcomes of Type 2 Myocardial Infarction and Type 1 Myocardial Infarction With a Focus on Dual Antiplatelet Therapy

BACKGROUND

There are important knowledge gaps in type 2 myocardial infarction (T2MI). Our primary objective was to compare the outcomes of patients with T2MI with those of patients with type 1 myocardial infarction (T1MI). Our secondary objective was to determine whether randomized controlled trials (RCTs) evaluating dual antiplatelets (DAPTs) have explicitly included patients with T2MI.

METHODS

We performed a meta-analysis comparing outcomes of patients with T2MI with patients with T1MI and a separate systematic review to evaluate the inclusion of T2MI in RCTs evaluating DAPT. There were 19 cohorts enrolling 48,829 patients (40,604 with T1MI and 5361 with T2MI) and 51 RCTs enrolling 188,132 patients with acute coronary syndrome.

RESULTS

Patients with T2MI had approximately 2-fold increases in unadjusted odds of long-term mortality compared with patients with T1MI (odds ratio, 2.47; 95% confidence interval, 2.06-2.96; P < 0.0001) and a 45% increase in adjusted odds of long-term mortality (odds ratio, 1.45; 95% confidence interval, 1.25-1.69; P < 0.0001, respectively). There was no published evaluation of efficacy, effectiveness, and safety of DAPT in patients with T2MI.

CONCLUSION

Patients with T2MI are at increased risk of adjusted all-cause long-term mortality compared with patients with T1MI. The role of DAPT remains unclear in T2MI.

Causes of Death in Patients With Acute and Chronic Myocardial Injury

BACKGROUND

Information about causes of death in patients with myocardial injury is limited. The purpose of this study was to explore causes of death in patients with myocardial injury.

METHODS

In a cohort of 22,589 patients, 3853 patients with myocardial injury were identified and categorized into: type 1 myocardial infarction, type 2 myocardial infarction, and nonischemic acute and chronic myocardial injury. We included all 1466/3853 (38%) patients who died during follow-up (3.9 ± 2 years). We estimated rates and adjusted odds ratio (OR) with 95% confidence interval (CI) for causes of death in the 4 categories of myocardial injury using patients without myocardial injury 819/17,932 (4.6%) who died as reference.

RESULTS

The study cohort included 2285 patients. The proportion of cardiovascular deaths was higher in patients with type 1 myocardial infarction (48%), acute (43%), and chronic (45%) myocardial injury and type 2 myocardial infarction (39%) compared with patients without myocardial injury (25%). Adjusted rates for cardiovascular death were similar in patients with myocardial injury. Type 1 myocardial infarction, acute, and chronic myocardial injury was associated with a 77% (OR: 1.77, 95% CI 1.29-2.41), 40% (OR: 1.40, 95% CI: 1.07-1.84), and 36% (OR: 1.36, 95% CI: 1.05-1.76) higher risk of cardiovascular death.

CONCLUSIONS

Patients with type 1 myocardial infarction and acute or chronic myocardial injury have similar proportions and high risks for cardiovascular death. We believe that these findings stress the need for investigating patients without known heart diseases who present with nonischemic myocardial injury, or type 2 myocardial infarction.

Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types

Advances in cardiovascular (CV) imaging, redefined electrocardiogram criteria, and high-sensitivity CV biomarker assays have enabled more differentiated etiological classification of myocardial infarction (MI). Type 1 MI has a different underlying pathophysiology than type 2 through type 5 MI; type 1 MI is characterized primarily by intracoronary atherothrombosis and the other types by a variety of mechanisms, which can occur with or without an atherosclerotic component. In type 2 MI, there is evidence of myocardial oxygen supply-demand imbalance unrelated to acute coronary atherothrombosis. Types 1 and 2 MI are spontaneous events, while type 4 and type 5 are procedure-related; type 3 MI is identified only after death. Most type 1 and type 2 MI present as non-ST-elevation MI (NSTEMI), although both types can also present as ST-elevation MI. Because of their different underlying etiologies, type 1 and type 2 NSTEMI have different presentation and prognosis and should be managed differently. In this article, we discuss the epidemiology, prognosis, and management of NSTEMI occurring in the setting of underlying type 1 or type 2 pathophysiology. Most NSTEMI (65%-90%) are type 1 MI. Patients with type 2 MI have multiple comorbidities and causes of in-hospital mortality among these patients are not always CV-related. It is important to distinguish between type 1 and type 2 NSTEMI early in the clinical course to allow for the use of the most appropriate treatments that will provide the greatest benefit for these patients.

Type 2 Myocardial Infarction: JACC Review Topic of the Week

Acute myocardial infarction (MI) can occur from increased myocardial oxygen demand and/or reduced supply in the absence of acute atherothrombotic plaque disruption; a condition called type 2 myocardial infarction (T2MI). As with any MI subtype, there must be clinical evidence of myocardial ischemia to make the diagnosis. This condition is increasingly diagnosed due to the increasing sensitivity of cardiac troponin assays and is associated with adverse short-term and long-term prognoses. Limited data exist defining optimal management strategies because T2MI is a heterogeneous entity with varying etiologies and triggers. Thus, these patients require individualized care. A major barrier is the absence of a uniform definition that can be operationalized with high reproducibility. This document provides a synthesis of the data about T2MI to assist clinicians' understanding of its pathobiology, when to deploy the diagnosis, and its associated treatments. It also clarifies prognosis, identifies gaps in knowledge, and provides recommendations for moving forward.

Acute versus chronic myocardial injury and long-term outcomes

OBJECTIVE

There is a paucity of data regarding prognosis in patients with acute versus chronic myocardial injury for long-term outcomes. We hypothesised that patients with chronic myocardial injury have a similar long-term prognosis as patients with acute myocardial injury.

METHODS

In an observational cohort study of 22 589 patients who had high-sensitivity cardiac troponin T (hs-cTnT) measured in the emergency department during 2011-2014, we identified all patients with level >14 ng/L and categorised them as acute myocardial injury, type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI) or chronic myocardial injury through adjudication. We estimated adjusted HRs with 95% CIs for the primary outcome all-cause mortality and secondary outcomes MI, and heart failure in patients with acute myocardial injury, T1MI and T2MI compared with chronic myocardial injury.

RESULTS

In total, 3853 patients were included. During 3.9 (±2) years of follow-up, 48%, 24%, 44% and 49% of patients with acute myocardial injury, T1MI, T2MI and chronic myocardial injury died, respectively. Patients with acute myocardial injury had higher adjusted risks of death (1.21, 95% CI 1.08 to 1.36) and heart failure (1.24, 95% CI 1.07 to 1.43), but a similar risk for myocardial infarction (MI) compared with the reference group. Patients with T1MI had a lower adjusted risk of death (0.86, 95% CI 0.74 to 1.00) and higher risk of MI (2.09, 95% CI 1.62 to 2.68), but a similar risk of heart failure. Patients with T2MI had a higher adjusted risk of death (1.46, 95% CI 1.18 to 1.80) and heart failure (1.30, 95% CI 1.00 to 1.69) compared with patients with chronic myocardial injury.

CONCLUSIONS

Absolute long-term risks for death are similar, and adjusted risks are slightly higher, among patients with acute myocardial injury and T2MI, respectively, compared with chronic myocardial injury. The lowest risk of long-term mortality was found in patients with T1MI. Both acute and chronic myocardial injury are associated with very high risks of adverse outcomes.

Causes of death in relation to stable troponin levels including chronic myocardial injury

BACKGROUND

Many patients presenting with chest pain in the emergency department have stable concentrations of high-sensitivity cardiac troponin T (hs-cTnT) without any acute medical condition. Stable hs-cTnT levels are associated with a high risk of death. This study aimed to investigate causes of death in relation to hs-cTnT concentrations.

METHODS

In a cohort of 19,460 patients with chest pain and stable hs-cTnT levels measured 2011-2014, of whom 1528 (7.9%) had chronic myocardial injury, we included all patients who died during follow-up (4.0 ± 1.3 years). Rates of cause-specific death were calculated for hs-cTnT concentrations and adjusted odds ratios (OR) estimated for causes of death at hs-cTnT 5-14 ng/l and >14 ng/l (referent hs-cTnT < 5 ng/l).

RESULTS

The study cohort comprised 1577 patients (8.1%), of whom 684 (43%) had chronic myocardial injury (hs-cTnT > 14 ng/l). Annual cardiovascular and non-cardiovascular death rates increased with increasing hs-cTnT from 0.07% and 0.4% (<5 ng/l) to 17% and 15% (≥50 ng/l), respectively. The ratio of cardiovascular to non-cardiovascular death increased with higher hs-cTnT. Patients with hs-cTnT 5-14 ng/l were 87% more likely to die from cardiovascular causes than those with hs-cTnT < 5 ng/l (adjusted OR: 1.87, 95% CI: 1.24-2.80). The association was similar for patients with chronic myocardial injury.

CONCLUSIONS

Hs-cTnT concentrations of 5-14 ng/l and >14 ng/l are associated with an almost twofold risk of cardiovascular death, whereas cardiovascular death almost never occurs in patients with undetectable troponin. Only with hs-cTnT concentrations ≥ 50 ng/l were cardiovascular diseases the predominant cause of death.

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

OBJECTIVES

The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR.

BACKGROUND

About one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown.

METHODS

Consecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction.

RESULTS

A total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non-ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively.

CONCLUSIONS

Approximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality.