Heart failure following STEMI: a contemporary cohort study of incidence and prognostic factors

Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome

PURPOSE OF REVIEW

This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences.

RECENT FINDINGS

The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.

The impact of the site of myocardial infarction on in-hospital outcomes for patients with STEMI

BACKGROUND

The territory and vessel involved in ST-elevation myocardial infarction (STEMI) is an important and there are limited contemporary studies from the national perspective.

METHODS

A retrospective cohort study was undertaken of national representative hospital admission in the National Inpatient Sample with a diagnosis of anterior or non-anterior STEMI between 2017 and 2020. Multiple logistic regression and multiple linear regressions were used to determine if there are any differences in in-hospital mortality, length of stay (LOS) and cost for anterior and non-anterior STEMI.

RESULTS

A total of 655 915 admissions with STEMI were included in the analysis (267 920 anterior STEMI, and 387 995 non-anterior STEMI). Non-anterior STEMI was associated with a significant reduction in mortality (OR 0.91 95% CI 0.89-0.99, P  = 0.011) and LOS (coefficient -0.15 95% CI -0.22 to -0.08, P  < 0.001) compared to anterior STEMI but there was no significant difference in healthcare costs (-297 95% CI -688 to 74). Analyses considering the infarct-related artery showed that the worse outcomes were associated with left main lesions and left-sided lesions had worse outcomes than right coronary artery lesions.

CONCLUSION

Non-anterior STEMI is associated with reduced mortality and LOS compared to anterior STEMI. Left-sided coronary lesions had worse outcomes, compared to right coronary lesions. STEMI should be considered in terms of the vessel or territory affected, in relation to outcomes and healthcare costs.

Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters

Objectives

Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear.

Methods

We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect.

Results

The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003).

Conclusion

Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.

Long-Term Outcomes of Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: A Study from Mexico City

Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI.

The spectrum of post-myocardial infarction care: From acute ischemia to heart failure

Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.

Cardiovascular magnetic resonance imaging-derived intraventricular pressure gradients in ST-segment elevation myocardial infarction: a long-term follow-up study

Aims

Recently, novel post-processing tools have become available that measure intraventricular pressure gradients (IVPGs) on routinely obtained long-axis cine cardiac magnetic resonance (CMR) images. IVPGs provide a comprehensive overview of both systolic and diastolic left ventricular (LV) functions. Whether IVPGs are associated with clinical outcome after ST-elevation myocardial infarction (STEMI) is currently unknown. Here, we investigated the association between CMR-derived LV-IVPGs and major adverse cardiovascular events (MACE) in a large reperfused STEMI cohort with long-term outcome.

Methods and results

In this prospectively enrolled multi-centre cohort study, 307 patients underwent CMR within 14 days after the first STEMI. LV-IVPGs (from apex-to-base) were estimated on the long-axis cine images. During a median follow-up of 9.7 (5.9-12.5) years, MACE (i.e. composite of cardiovascular death and de novo heart failure hospitalisation) occurred in 49 patients (16.0%). These patients had larger infarcts, more often microvascular injury, and impaired LV-IVPGs. In univariable Cox regression, overall LV-IVPG was significantly associated with MACE and remained significantly associated after adjustment for common clinical risk factors (hazard ratio (HR) 0.873, 95% confidence interval (CI) 0.794-0.961, P = 0.005) and myocardial injury parameters (HR 0.906, 95% CI 0.825-0.995, P = 0.038). However, adjusted for LV ejection fraction and LV global longitudinal strain (GLS), overall LV-IVPG does not provide additional prognostic information (HR 0.959, 95% CI 0.866-1.063, P = 0.426).

Conclusion

Early after STEMI, CMR-derived LV-IVPGs are univariably associated with MACE and this association remains significant after adjustment for common clinical risk factors and measures of infarct severity. However, LV-IVPGs do not add prognostic value to LV ejection fraction and LV GLS.

Cardiac Troponin, Kidney Function, Heart Failure and Mortality After Myocardial Infarction in Patients With and Without Kidney Impairment

Cardiac troponins (cTn) are routinely measured for the diagnosis and prognosis of myocardial infarction (MI). The relation between troponin levels, estimated glomerular filtration rate (eGFR), postinfarction heart failure (HF), and mortality is unclear in patients with kidney impairment. This is a retrospective, cross-sectional study of patients presenting to the Emergency Department at a single tertiary center. Participants presenting with confirmed type I MI from January 1, 2019, to December 31, 2021, were analyzed from the Myocardial Ischemia National Audit Project database. Main outcomes were acute HF, measured using Killip class, and inpatient mortality. Peak cardiac troponin T (cTnT) level was a secondary outcome. Data on 2,815 patients (67±14 years, 28% female) were analyzed. Ordinal logistic regression analysis was used to test for predictors of increasing Killip class. Binary logistic regression was used to test for predictors of inpatient mortality. Analysis of a sub-sample matched for age and diabetes mellitus status showed increased mortality in patients with eGFR <60 ml/min/1.73 m2 (12.2% vs 4.4%, p <0.001). Multivariate predictors of acute HF included log-transformed peak cTnT, eGFR, body mass index (BMI), and diabetes mellitus status. Multivariate predictors of inpatient mortality included log-transformed peak cTnT, eGFR, age, BMI, and Killip class 3/4. On multivariate analysis, eGFR, ST-elevation MI diagnosis, BMI, male gender, diabetes mellitus status, and hypertension were all predictive of peak cTnT after MI. In conclusion, peak cTnT level and eGFR at presentation after MI are independent predictors of acute HF severity and death in patients with and without kidney impairment.

Novel Biomarkers and Their Role in the Diagnosis and Prognosis of Acute Coronary Syndrome

The burden of cardiovascular diseases and the critical role of acute coronary syndrome (ACS) in their progression underscore the need for effective diagnostic and prognostic tools. Biomarkers have emerged as crucial instruments for ACS diagnosis, risk stratification, and prognosis assessment. Among these, high-sensitivity troponin (hs-cTn) has revolutionized ACS diagnosis due to its superior sensitivity and negative predictive value. However, challenges regarding specificity, standardization, and interpretation persist. Beyond troponins, various biomarkers reflecting myocardial injury, neurohormonal activation, inflammation, thrombosis, and other pathways are being explored to refine ACS management. This review article comprehensively explores the landscape of clinically used biomarkers intricately involved in the pathophysiology, diagnosis, and prognosis of ACS (i.e., troponins, creatine kinase MB (CK-MB), B-type natriuretic peptides (BNP), copeptin, C-reactive protein (CRP), interleukin-6 (IL-6), d-dimers, fibrinogen), especially focusing on the prognostic role of natriuretic peptides and of inflammatory indices. Research data on novel biomarkers (i.e., endocan, galectin, soluble suppression of tumorigenicity (sST2), microRNAs (miRNAs), soluble oxidized low-density lipoprotein receptor-1 (sLOX-1), F2 isoprostanes, and growth differentiation factor 15 (GDF-15)) are further analyzed, aiming to shed light on the multiplicity of pathophysiologic mechanisms implicated in the evolution of ACS. By elucidating the complex interplay of these biomarkers in ACS pathophysiology, diagnosis, and outcomes, this review aims to enhance our understanding of the evolving trajectory and advancements in ACS management. However, further research is necessary to establish the clinical utility and integration of these biomarkers into routine practice to improve patient outcomes.

Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients

We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4-94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening--rather than relying on either alone--may maximize ACS screening performance and equity.

Heart failure as a complication of myocardial infarction: rational therapy. Case report

Heart failure (HF) is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development and early initiation of guideline-directed HF therapy in these patients, can decrease the HF burden. This article aims at summarizing clinical data on established pharmacological therapies in treating post-MI patients with left ventricular systolic dysfunction and signs and symptoms of HF.

Primary left ventricular unloading with delayed reperfusion in patients with anterior ST-elevation myocardial infarction: Rationale and design of the STEMI-DTU randomized pivotal trial

BACKGROUND

Despite successful primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI), myocardial salvage is often suboptimal, resulting in large infarct size and increased rates of heart failure and mortality. Unloading of the left ventricle (LV) before primary PCI may reduce infarct size and improve prognosis.

STUDY DESIGN AND OBJECTIVES

STEMI-DTU (NCT03947619) is a prospective, randomized, multicenter trial designed to compare mechanical LV unloading with the Impella CP device for 30 minutes prior to primary PCI to primary PCI alone without LV unloading. The trial aims to enroll approximately 668 subjects, with a potential sample size adaptation, with anterior STEMI with a primary end point of infarct size as a percent of LV mass evaluated by cardiac magnetic resonance at 3-5 days after PCI. The key secondary efficacy end point is a hierarchical composite of the 1-year rates of cardiovascular mortality, cardiogenic shock ≥24 hours after PCI, use of a surgical left ventricular assist device or heart transplant, heart failure, intra-cardiac defibrillator or chronic resynchronization therapy placement, and infarct size at 3 to 5 days post-PCI. The key secondary safety end point is Impella CP-related major bleeding or major vascular complications within 30 days. Clinical follow-up is planned for 5 years.

CONCLUSIONS

STEMI-DTU is a large-scale, prospective, randomized trial evaluating whether mechanical unloading of the LV by the Impella CP prior to primary PCI reduces infarct size and improves prognosis in patients with STEMI compared to primary PCI alone without LV unloading.

Effect of Pomegranate Extract Consumption on Satiety Parameters in Healthy Volunteers: A Preliminary Randomized Study

There has been an increasing interest in nutraceuticals and functional foods in reducing appetite and to lose weight. We assessed the effect of oral pomegranate extract (PE) and PE juice (PJ) intake vs. placebo on satiety parameters in healthy volunteers. Twenty-eight subjects (mean age 34.5 ± 13.7 years, body mass index [BMI] 25.05 ± 3.91 kg/m2) were randomized to 3-week priming supplementation with PE (Pomanox®) or placebo. On week 3, satiety parameters were determined on 1 testing day after participants ingested a breakfast and a lunch meal with PJ juice, using 100-mm visual acuity scales (VAS) for hunger, desire to eat, fullness and satisfaction. Meal quality and palatability were also tested. The desire to eat was less at all time points in the PJ juice with PE priming group and participants were also less hungry (p = 0.044) than those who consumed placebo. There was an overall significant difference between the groups (p < 0.001). Participants in the PJ juice with PE priming group experienced significantly greater satisfaction (p = 0.036) and feeling of fullness (p = 0.02) than those in the placebo group. These findings suggest that consumption of PE could have the potential to modulate satiety indicators.

From Classic to Modern Prognostic Biomarkers in Patients with Acute Myocardial Infarction

Despite all the important advances in its diagnosis and treatment, acute myocardial infarction (AMI) is still one of the most prominent causes of morbidity and mortality worldwide. Early identification of patients at high risk of poor outcomes through the measurement of various biomarker concentrations might contribute to more accurate risk stratification and help to guide more individualized therapeutic strategies, thus improving prognoses. The aim of this article is to provide an overview of the role and applications of cardiac biomarkers in risk stratification and prognostic assessment for patients with myocardial infarction. Although there is no ideal biomarker that can provide prognostic information for risk assessment in patients with AMI, the results obtained in recent years are promising. Several novel biomarkers related to the pathophysiological processes found in patients with myocardial infarction, such as inflammation, neurohormonal activation, myocardial stress, myocardial necrosis, cardiac remodeling and vasoactive processes, have been identified; they may bring additional value for AMI prognosis when included in multi-biomarker strategies. Furthermore, the use of artificial intelligence algorithms for risk stratification and prognostic assessment in these patients may have an extremely important role in improving outcomes.

Door to balloon time in primary percutaneous coronary intervention in ST elevation myocardial infarction: every minute counts

OBJECTIVES

This study examines relationships between door to balloon (D2B) time and subsequent admissions due to heart failure (HF), acute coronary syndrome (ACS), and mortality for up to 1 year.

BACKGROUND

Current guidelines set 90-min for D2B time for primary percutaneous coronary intervention (PPCI) as a goal, which has been shown to reduce mortality and adverse events.

METHODS

Using the MDclone ADAMS system integrated with our electronic medical records, we conducted retrospective analysis of all patients admitted due to ST-elevation myocardial infarction from home, without any history of HF or coronary disease, and who underwent PPCI during 2013-2019. Data on D2B time, baseline clinical and demographic characteristics, and outcomes of HF, ACS and mortality were collected. Adjusted HR for each of the outcomes was calculated by multivariate Cox model.

RESULTS

A total of 826 patients were included in the final analysis. D2B had no significant effect on incidence of heart failure admissions for up to 1-year follow-up. D2B had a significant effect on mortality at 180 days, showing a 30% increase for each 30-min increase (HR 1.308; CI, 1.046-1.635) as for ACS at 90 days (HR 1.307; 1.025-1.638). The 30-min D2B cutoff showed a significant increase in ACS recurrence throughout the follow-up period at 90 days (HR 2.871, 1.239-6.648), 180 days (HR 2.607, 1.255-5.413), and 1 year (HR 1.886, 1.073-3.317).

CONCLUSIONS

Patients with shorter D2B times had significantly reduced mortality and recurrence of ACS, with no effect on heart failure admission incidence.

Comparison of angiographic results and clinical outcomes of no-reflow after stenting in left anterior descending (LAD) versus non-LAD culprit STEMI

Objectives:

No-reflow is a complication that frequently occurs after stenting during primary percutaneous coronary intervention. In this study, we focused on angiographic results and clinical outcomes after no-reflow in the left anterior descending (LAD) artery versus non–left anterior descending artery ST-elevation myocardial infarction (STEMI).

Methods:

In this prospective study, a total of 201 patients who had developed no-reflow during primary percutaneous coronary intervention were enrolled. The patients were divided into left anterior descending artery culprit and non-left anterior descending artery culprit groups. The primary endpoints were final thrombolysis in myocardial infarction flow, corrected thrombolysis in myocardial infarction frame count and final myocardial blush grade. Secondary endpoints were major adverse cardiovascular events in-hospital and at 1 month.

Results:

Out of the 201 patients, 60.19% had culprit left anterior descending artery. Pulse rate, baseline systolic and diastolic blood pressure, single-vessel disease, left ventricular ejection fraction <30%, baseline thrombolysis in myocardial infarction I flow and final thrombolysis in myocardial infarction II flow (24.8% vs 11.3%, p = .017), and thrombolysis in myocardial infarction frame count (28.17 ± 11.86 vs 24.38 ± 9.05, p = .016) were significantly higher in the left anterior descending artery group. In contrast, baseline Killip Class I, three-vessel disease, baseline thrombolysis in myocardial infarction II flow, final thrombolysis in myocardial infarction III flow (74.4% vs 87.5%, p = .024) and left ventricular ejection fraction >40% were significantly greater in the non–left anterior descending artery group. However, for both in-hospital and at 30 days, overall major adverse cardiovascular event was similar in the two groups. The demographics, clinical and medication profiles and the routes used to treat no-reflow were all comparable in both groups.

Conclusions:

No-reflow in left anterior descending artery ST-elevation myocardial infarction is associated with lower final thrombolysis in myocardial infarction III flow, higher thrombolysis in myocardial infarction frame count and relatively lower Grade III myocardial blush than non-left anterior descending artery ST-elevation myocardial infarction with subsequent lower left ventricular ejection fraction and a higher frequency of in-hospital heart failure and hospitalisation due to heart failure.

Heart Failure Incidence Following ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6 months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF) <50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF <50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p <0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF <50% independently predicted the development of HF and all-cause death.

Impact of WBC count on admission on early and longterm mortality in patients treated with primary percutaneous coronary intervention

Introduction: Inflammation plays a key role in the process of atherosclerosis, its formation, progression and destabilization of plaque. One of the main mediators of inflammation is white blood cells (WBC), whose number increases significantly during inflammation. Aim: The aim of this study was to determine the effect of WBC count at admission on early and long-term mortality in patients with ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Material and methods: A total of 700 consecutive STEMI patients admitted for primary PCI were included in our study. The patients included in the study were divided into two groups: group with normal and group with elevated WBC count. A leukocyte count >11000 / mm3 was considered elevated. Patients were followed-up at 30-days and at 1-year after enrollment. Results: Out off the 700 STEMI patients treated with primary PCI, 665 had WBC count data available at admission and were included in further analysis. From this number, elevated WBC count was registered in 380 patients (57.14%). Patients with increased WBC count were younger and smokers. Observing the characteristics of patients at admission, patients with elevated WBC count had a lower ejection fraction, higher CPK values as well as a higher incidence of heart failure. Thirty-day as well as 1-year mortality were significantly higher in patients with elevated WBC count. Patients with elevated WBC count were at three-fold higher risk for 30day mortality and at two-fold higher risk for 1-year morality. Conclusion: Patients with elevated WBC counts at admission had higher 30-day and 1-year mortality compared with patients with normal WBC counts. The WBC count was an independent predictor of thirty-day and one-year mortality.

An Enhanced Random Forests Approach to Predict Heart Failure From Small Imbalanced Gene Expression Data

Myocardial infarctions and heart failure are the cause of more than 17 million deaths annually worldwide. ST-segment elevation myocardial infarctions (STEMI) require timely treatment, because delays of minutes have serious clinical impacts. Machine learning can provide alternative ways to predict heart failure and identify genes involved in heart failure. For these scopes, we applied a Random Forests classifier enhanced with feature elimination to microarray gene expression of 111 patients diagnosed with STEMI, and measured the classification performance through standard metrics such as the Matthews correlation coefficient (MCC) and area under the receiver operating characteristic curve (ROC AUC). Afterwards, we used the same approach to rank all genes by importance, and to detect the genes more strongly associated with heart failure. We validated this ranking by literature review and gene set enrichment analysis. Our classifier employed to predict heart failure achieved MCC = +0.87 and ROC AUC = 0.918, and our analysis identified KLHL22, WDR11, OR4Q3, GPATCH3, and FAH as top five protein-coding genes related to heart failure. Our results confirm the effectiveness of machine learning feature elimination in predicting heart failure from gene expression, and the top genes found by our approach will be able to help biologists and cardiologists further our understanding of heart failure.

Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease

BACKGROUND

Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD.

METHODS

We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model.

RESULTS

Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease).

CONCLUSIONS

Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.

Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post-Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry

BACKGROUND

Magnetic resonance imaging (MRI) is the most accurate imaging technique for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of LVEF assessment at any time after ST-segment elevation myocardial infarction (STEMI) for subsequent major adverse cardiac event (MACE) prediction is uncertain.

PURPOSE

To explore the prognostic impact of MRI-derived LVEF at any time post-STEMI to predict subsequent MACE (cardiovascular death or re-admission for acute heart failure).

STUDY TYPE

Prospective.

POPULATION

One thousand thirteen STEMI patients were included in a multicenter registry.

FIELD STRENGTH/SEQUENCE

1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences.

ASSESSMENT

Post-infarction MRI-derived LVEF (reduced [r]: <40%; mid-range [mr]: 40%-49%; preserved [p]: ≥50%) was sequentially quantified at 1 week and after >3 months of follow-up.

STATISTICAL TESTS

Multi-state Markov model to determine the prognostic value of each LVEF state (r-, mr- or p-) at any time point assessed to predict subsequent MACE. A P-value <0.05 was considered to be statistically significant.

RESULTS

During a 6.2-year median follow-up, 105 MACE (10%) were registered. Transitions toward improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to a higher incidence of subsequent MACE. The observed transitions from r-LVEF, mr-LVEF, and p-LVEF states to MACE were: 15.3%, 6%, and 6.7%, respectively. Regarding the adjusted transition intensity ratios, patients in r-LVEF state were 4.52-fold more likely than those in mr-LVEF state and 5.01-fold more likely than those in p-LVEF state to move to MACE state. Nevertheless, no significant differences were found in transitions from mr-LVEF and p-LVEF states to MACE state (P-value = 0.6).

DATA CONCLUSION

LVEF is an important MRI index for simple and dynamic post-STEMI risk stratification. Detection of r-LVEF by MRI at any time during follow-up identifies a subset of patients at high risk of subsequent events.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 2.

Trimethylamine N-Oxide Was Not Associated With 30-Day Left Ventricular Systolic Dysfunction in Patients With a First Anterior ST-Segment Elevation Myocardial Infarction After Primary Revascularization: A Sub-analysis From an Optical Coherence Tomography Registry

Objective: Left ventricular systolic dysfunction (LVSD) after ST-segment elevation myocardial infarction (STEMI) is associated with poor outcome. Trimethylamine N-oxide (TMAO), a gut metabolite, is linked to cardiovascular diseases but its relationship with LVSD after STEMI remains unclear. The present study therefore aimed to investigate the relationship between TMAO and LVSD at 30 days after a first anterior STEMI.

Methods: This was a sub-study from the OCTAMI (Optical Coherence Tomography Examination in Acute Myocardial Infarction) registry. Eligible patients were included in current study if they: (1) presented with a first anterior STEMI; (2) had available baseline TMAO concentration; (3) completed a cardiovascular magnetic resonance examination at 30 days after STEMI. LVSD was defined as left ventricular ejection fraction < 50%. Associations between TMAO and left ventricular ejection fraction, infarct size and left ventricular global strain were examined.

Results: In total, 78 patients were included in final analysis. Overall, TMAO was moderately associated with peak cTnI (r = 0.27, p = 0.01), age (r = 0.34, p < 0.01), and estimated glomerular filtration rate (r = −0.30, p < 0.01). At 30-day follow-up, 41 patients were in the LVSD group and 37 in the non-LVSD group. Baseline TMAO levels were not significantly different between the two groups (LVSD vs. non-LVSD: median 1.9 μM, 25−75th percentiles 1.5–3.3 μM vs. median 1.9 μM, 25−75th percentiles 1.5–2.7 μM; p = 0.46). Linear regression analyses showed that TMAO was not associated with left ventricular ejection fraction, infarct size or left ventricular global strain at 30 days (all p > 0.05).

Conclusions: TMAO was not significantly correlated with 30-day LVSD in patients with a first anterior STEMI after primary revascularization.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03593928.

Heart failure after myocardial infarction: incidence and predictors

Aims

The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction.

Methods and results

Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction.

Conclusions

Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.

Ejection Fraction by Echocardiography for a Selective Use of Magnetic Resonance After Infarction

Background Cardiac magnetic resonance (CMR) permits robust risk stratification of discharged ST-segment-elevation myocardial infarction patients, but its indiscriminate use in all cases is not feasible. We evaluated the utility of left ventricular ejection fraction (LVEF) by echocardiography for a selective use of CMR after ST-segment-elevation myocardial infarction. Methods Echocardiography and CMR were performed in 1119 patients discharged for ST-segment-elevation myocardial infarction included in a multicenter registry. The prognostic power of CMR beyond echocardiography-LVEF was assessed using adjusted C statistic, net reclassification improvement index, and integrated discrimination improvement index. Results During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 readmissions for acute heart failure). In the entire group, CMR-LVEF (but not echocardiography-LVEF) independently predicted MACE occurrence. The MACE rate significantly increased only in patients with CMR-LVEF<40% (≥50%: 7%, 40%-49%: 9%, <40%: 27%, P<0.001). Most patients displayed echocardiography-LVEF≥50% (629, 56%), and they had a low MACE rate (57/629, 9%). In patients with echocardiography-LVEF<50% (n=490, 44%), the MACE rate was also low in those with CMR-LVEF≥40% (24/278, 9%) but significantly increased in patients with CMR-LVEF<40% (55/212, 26%; P<0.001). Compared with echocardiography-LVEF, CMR-LVEF significantly improved MACE prediction in the group of patients with echocardiography-LVEF<50% (C statistic, 0.80 versus 0.72; net reclassification improvement index, 0.73; integrated discrimination improvement index, 0.10) but not in those with echocardiography-LVEF≥50% (C statistic 0.66 versus 0.66; net reclassification improvement index, 0.17; integrated discrimination improvement index, 0.01). Conclusions A straightforward strategy based on a selective use of CMR for risk prediction in ST-segment-elevation myocardial infarction patients with echocardiography-LVEF<50% can provide insights into patient care. The cost-effectiveness of this approach, as well as the direct implications in clinical management, should be further explored.

Sibling history is associated with heart failure after a first myocardial infarction

Objective

Morbidity and mortality due to heart failure (HF) as a complication of myocardial infarction (MI) is high, and remains among the leading causes of death and hospitalisation. This study investigated the association between family history of MI with or without HF, and the risk of developing HF after first MI.

Methods

Through nationwide registries, we identified all individuals aged 18-50 years hospitalised with first MI from 1997 to 2016 in Denmark. We identified 13 810 patients with MI, and the cohort was followed until HF diagnosis, second MI, 3 years after index MI, emigration, death or the end of 2016, whichever occurred first. HRs were estimated by Cox hazard regression models adjusted for sex, age, calendar year and comorbidities (reference: patients with no family history of MI).

Results

After adjustment, we observed an increased risk of MI-induced HF for those having a sibling with MI with HF (HR 2.05, 95% CI 1.02 to 4.12). Those having a sibling with MI without HF also had a significant, but lower increased risk of HF (HR 1.39, 95% CI 1.05 to 1.84). Parental history of MI with or without HF was not associated with HF.

Conclusion

In this nationwide cohort, sibling history of MI with or without HF was associated with increased risk of HF after first MI, while a parental family history was not, suggesting that shared environmental factors may predominate in the determination of risk for developing HF.

Predictive value of high sensitivity C-reactive protein on progression to heart failure occurring after the first myocardial infarction

Background: High sensitivity C-reactive protein (hsCRP) predicts myocardial dysfunction after acute coronary syndromes. We aimed to study the association of hsCRP estimation at first acute myocardial infarction (AMI) with myocardial dysfunction and heart failure.

Methods: This research was carried out at the Department of Physiology and Department of Emergency Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. In this prospective study, 227 patients were studied. hsCRP levels were estimated when patients came to the emergency department at AMI, 7 days post AMI, and at 12 weeks of follow up after AMI. The outcome was change in myocardial functions, especially heart failure, 12 months after the attack.

Results: Based on a cutoff mean value of hsCRP levels at admission (10.05±12.68 mg/L), patients were grouped into high and low C-reactive protein (CRP.) The ejection fraction was significantly lower at follow up in the high CRP group (37.29±12.97) compared to the low CRP group (43.85±11.77, p<0.0198). hsCRP had significant inverse correlation with left ventricular ejection fraction (r=−0.283, p<0.01). About 38.1% patients showed heart failure, with 23.6% in the high CRP group and 14.5% in the low CRP group (OR 2.4, p=0.028). Receiver operating characteristic curve analysis showed that CRP levels at AMI had a specificity of 79% and sensitivity of 83% to predict heart failure.

Conclusion: A high hsCRP level measured at first AMI predicts myocardial dysfunction and heart failure. It is suggested that hsCRP plays an important role in the development of heart failure after myocardial infarction.