Trends in mortality of acute myocardial infarction after discharge from the hospital

Age shock index and age-modified shock index are valuable bedside prognostic tools for postdischarge mortality in ST-elevation myocardial infarction patients

BACKGROUND

The incidence of mortality is considerable after ST-elevation myocardial infarction (STEMI) hospitalization; risk assessment is needed to guide postdischarge management. Age shock index (SI) and age modified shock index (MSI) were described as useful prognosis instruments; nevertheless, their predictive effect on short and long-term postdischarge mortality has not yet been sufficiently confirmed.

METHODS

This analysis included 3389 prospective patients enrolled from 2016 to 2018. Endpoints were postdischarge mortality within 30 days and from 30 days to 1 year. Hazard ratios (HRs) were evaluated by Cox proportional-hazards regression. Predictive performances were assessed by area under the curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) and compared with TIMI risk score and GRACE score.

RESULTS

The AUCs were 0.753, 0.746 for age SI and 0.755, 0.755 for age MSI for short- and long-term postdischarge mortality. No significant AUC differences and NRI were observed compared with the classic scores; decreased IDI was observed especially for long-term postdischarge mortality. Multivariate analysis revealed significantly higher short- and long-term postdischarge mortality for patients with high age SI (HR: 5.44 (2.73-10.85), 5.34(3.18-8.96)), high age MSI (HR: 4.17(1.78-9.79), 5.75(3.20-10.31)) compared to counterparts with low indices. DCA observed comparable clinical usefulness for predicting short-term postdischarge mortality. Furthermore, age SI and age MSI were not significantly associated with postdischarge prognosis for patients who received fibrinolysis.

CONCLUSIONS

Age SI and age MSI were valuable instruments to identify high postdischarge mortality with comparable predictive ability compared with the classic scores, especially for events within 30 days after hospitalization.

Machine learning in the prediction of in-hospital mortality in patients with first acute myocardial infarction

BACKGROUND

Persistent efforts are required to further reduce the in-hospital mortality of patients suffering from acute myocardial infarction (AMI), even in the face of a global trend of declining AMI-related fatalities. We investigated deep machine learning models for in-hospital death prediction in patients on their first AMI.

METHOD

In this 2-center retrospective analysis, first AMI patients from Hospital I and Hospital II were included; 4783 patients from Hospital 1 were split in a 7:3 ratio between the training and testing sets. Data from 1053 AMI patients in Hospital II was used for further validation. 70 clinical information and laboratory examination parameters as predictive indicators were included. Logistic Regression Classifier (LR), Random Forests Classifier (RF), eXtreme Gradient Boosting (XGB), Support Vector Machine Classifier (SVM), Multilayer Perceptron (MLP), Gradient Boosting Machine (GBM), Bootstrapped Aggregation (Bagging) models with AMI patients were developed. The importance of selected variables was obtained through the Shapley Additive exPlanations (SHAP) method. The performance of each model was shown using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (Average Precision; AP).

RESULT

The in-hospital mortality for AMI in the training, testing, and validation sets were 5.7 %, 5.6 %, and 6.0 %, respectively. The top 8 predictors were D-dimer, brain natriuretic peptide, cardiogenic shock, neutrophil, prothrombin time, blood urea nitrogen, cardiac arrest, and phosphorus. In the testing cohort, the models of LR, RF, XGB, SVM, MLP, GBM, and Bagging yielded AUROC values of 0.929, 0.931, 0.907, 0.868, 0.907, 0.923, and 0.932, respectively. Bagging has good predictive value and certain clinical value in external validation with AUROC 0.893.

CONCLUSION

In order to improve the forecasting accuracy of the risk of AMI patients, guide clinical nursing practice, and lower AMI inpatient mortality, this study looked into significant indicators and the optimal models for predicting AMI inpatient mortality.

Pattern and Prognostic Impact of Regional Wall Motion Abnormalities in 255 697 Men and 236 641 Women Investigated with Echocardiography

Background Regional wall motion abnormalities (WMAs) after myocardial infarction are associated with adverse remodeling and increased mortality in the short to medium term. Their long-term prognostic impact is less well understood. Methods and Results Via the National Echo Database of Australia (2000-2019), we identified normal wall motion versus WMA for each left ventricular wall among 492 338 individuals aged 61.9±17.9 years. The wall motion score index was also calculated. We then examined actual 1- and 5-year mortality, plus adjusted risk of long-term mortality according to WMA status. Overall, 39 346/255 697 men (15.4%) and 17 834/236 641 women (7.5%) had a WMA. The likelihood of a WMA was associated with increasing age and greater systolic/diastolic dysfunction. A defect in the inferior versus anterior wall was the most and least common WMA in men (8.0% and 2.5%) and women (3.3% and 1.1%), respectively. Any WMA increased 5-year mortality from 17.5% to 29.7% in men and from 14.9% to 30.8% in women. Known myocardial infarction (hazard ratio [HR], 0.86 [95% CI, 0.80-0.93]) or revascularization (HR, 0.87 [95% CI, 0.82-0.92]) was independently associated with a better prognosis, whereas men (1.22-fold increase) and those with greater systolic/diastolic dysfunction had a worse prognosis. Among those with any WMA, apical (HR, 1.08 [95% CI, 1.02-1.13]) or inferior (HR, 1.09 [95% CI, 1.04-1.15]) akinesis, dyskinesis or aneurysm, or a wall motion score index >3.0 conveyed the worst prognosis. Conclusions In a large real-world clinical cohort, twice as many men as women have a WMA, with inferior WMA the most common. Any WMA confers a poor prognosis, especially inferoapical akinesis/dyskinesis/aneurysm.

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Optimal management of patients after acute coronary syndrome

Patients with clinically established atherosclerotic cardiovascular disease are at a very high risk of recurrent cardiovascular events. An adequate management of risk factors and the implementation of healthy behaviours significantly decrease the risk of unfavourable clinical outcomes and future cardiovascular events, including death. Patients discharged after an acute coronary syndrome should be managed according to their individual risk level in order to ensure the appropriate treatment. Nevertheless, care pathways should also take into consideration the available resources and the logistical/structural aspects. In this setting, cardiac rehabilitation is prosed as a multidisciplinary approach to improving daily function and reducing cardiovascular risk factors. The organization of a network with the involvement of different medical and non-medical figures is essential to ensure successful outcomes and expected cost-effectiveness.

Relation of Socioeconomic Status to 1-Year Readmission and Mortality in Patients With Acute Myocardial Infarction

Cardiovascular (CV) disease accounts for 1/3 of deaths worldwide and 1/4 of deaths nationwide. Socioeconomic status (SES) affects CV health and outcomes. Previous studies that examined the association of SES and CV outcomes have yielded mixed results. Using a large-scale database, the aim of this study was to assess the magnitude of the association between categorized median household income, an indicator for SES, and nonfatal or fatal acute myocardial infarction (AMI). Using logistic regression models, zip code median household income data from the United States Census Bureau were matched to 1-year rates of hospital readmission for AMI and CV death. Patient outcomes were obtained from the Myocardial Infarction Data Acquisition System, a comprehensive database that includes all patient CV disease admissions to acute care New Jersey hospitals. Our main results indicate that compared with those in the highest household income level (>$68,000), patients in the lowest-income group (<$43,000) had significantly higher risk for AMI readmission (adjusted odds ratio 1.1388, 95% confidence interval 1.0905 to 1.1893, p = 0) and CV death (odds ratio 1.0479, 95% confidence interval 1.0058 to 1.0917, p = 0.0254) after 1 year. This study also found that the likelihood of AMI readmission increased as household income levels decreased. Our findings suggest that healthcare professionals and policy makers should allocate additional resources to low-income communities to reduce disparities in AMI hospital readmissions and AMI case fatalities.

Protective roles of MITOL against myocardial senescence and ischemic injury partly via Drp1 regulation

Abnormal mitochondrial fragmentation by dynamin-related protein1 (Drp1) is associated with the progression of aging-associated heart diseases, including heart failure and myocardial infarction (MI). Here, we report a protective role of outer mitochondrial membrane (OMM)-localized E3 ubiquitin ligase MITOL/MARCH5 against cardiac senescence and MI, partly through Drp1 clearance by OMM-associated degradation (OMMAD). Persistent Drp1 accumulation in cardiomyocyte-specific MITOL conditional-knockout mice induced mitochondrial fragmentation and dysfunction, including reduced ATP production and increased ROS generation, ultimately leading to myocardial senescence and chronic heart failure. Furthermore, ischemic stress-induced acute downregulation of MITOL, which permitted mitochondrial accumulation of Drp1, resulted in mitochondrial fragmentation. Adeno-associated virus-mediated delivery of the MITOL gene to cardiomyocytes ameliorated cardiac dysfunction induced by MI. Our findings suggest that OMMAD activation by MITOL can be a therapeutic target for aging-associated heart diseases, including heart failure and MI.

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MITOL is essential for maintaining cardiac function partly via Drp1 clearance

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MITOL deficiency causes cardiac aging partly via Drp1 accumulation

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Ischemic stress induces a rapid downregulation of MITOL

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MITOL expression attenuates cardiac dysfunction in acute myocardial infarction

Prevalence and Prognostic Impact of Malnutrition in Critical Patients With Acute Myocardial Infarction: Results From Chinese CIN Cohort and American MIMIC-III Database

Background

Malnutrition is associated with poor prognosis in patients with acute myocardial infarction (AMI). However, the prognostic impact of malnutrition in critical patients with AMI has not been well addressed.

Methods

We analyzed two critical AMI cohorts from Cardiorenal ImprovemeNt (CIN) in China and Medical Information Mark for Intensive Care-III (MIMIC-III) in the United States. The primary outcome was all-cause mortality. Cox proportional hazards models were constructed to examine the risk of malnutrition for mortality in critical patients with AMI.

Results

There were 2,075 critical patients with AMI (mean age, 62.5 ± 12.3 years, 20.00% were female) from the CIN cohort and 887 critical patients with AMI (mean age, 70.1 ± 12.9 years, 37.43% were female) from MIMIC-III included in this study. Based on the Controlling Nutritional Status (CONUT) score, of the Chinese patients with AMI, the prevalence was 47.5, 28.3, and 3.5% for mild, moderate, and severe malnutrition, respectively. The percentage of mild, moderate, and severe malnutrition was 41.60, 30.55, and 7.32% in the MIMIC-III cohort, respectively. Controlling for confounders, worse nutritional state was significantly associated with increased risk for all-cause mortality [an adjusted hazard ratio for mild, moderate, and severe malnutrition, respectively, 1.10 (95% confidence interval (CI): 0.76–1.59), 1.49 (95% CI: 1.02–2.19), and 1.70 (95% CI: 1.00–2.88) in the CIN cohort and 1.41 (95% CI: 0.95–2.09), 1.97 (95% CI: 1.32–2.95), and 2.70 (95% CI: 1.67–4.37) in the MIMIC-III cohort].

Conclusion

Malnutrition was independently associated with an increased risk of all-cause mortality in critical patients with AMI after full adjustments. Further trials are needed to prospectively evaluate the efficacy of nutritional interventions in critical patients with AMI.

Impact of Modified Cardiac Rehabilitation Within a Stroke Recovery Program on All-Cause Hospital Readmissions

OBJECTIVE

A Stroke Recovery Program (SRP) including cardiac rehabilitation demonstrated lower all-cause mortality rates, improved cardiovascular function, and overall functional ability among stroke survivors. Neither an effect of SRP on acute care hospital readmission rates nor cost savings have been reported.

DESIGN

This prospective matched cohort study included 193 acute stroke survivors admitted to an inpatient rehabilitation facility between 2015 and 2017. The 105 SRP participants and 88 nonparticipants were matched exactly for stroke type, sex, and race and approximately for age, baseline functional scores, and medical complexity scores. Primary outcome measured acute care hospital readmission rate up to 1 yr post-stroke. Secondary outcomes measured costs.

RESULTS

A 22% absolute reduction (P = 0.006) in hospital readmissions was observed between the SRP participant (n = 47, or 45%) and nonparticipant (n = 59, or 67%) groups. This resulted in significant cost savings. The conventional care cost to the Center for Medicare and Medicaid Services for stroke patients for both readmissions and outpatient therapy is estimated at $9.67 billion annually. The yearly cost for these services with utilization of the SRP is $8.55 billion.

CONCLUSION

Acute care hospital readmissions were reduced in stroke survivors who participated in SRP. Future study is warranted to examine whether widespread application of a similar program may improve quality of life and decrease cost.

Impact of age, gender and heart failure on mortality trends after acute myocardial infarction in Italy

BACKGROUND

The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

METHODS

This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In-hospital mortality rate (I-MR) and 1-year post-discharge mortality rate (1-Y-MR) were assessed.

RESULTS

Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization. Both I-MR and 1-Y-MR significantly decreased over time (from 8.87% to 6.72%; mean annual change -0.23%; confidence intervals (CI): - 0.26% to -0.20% and from 12.24% to 10.59%; mean annual change -0.18%; CI: - 0.24% to -0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes. In AMI patients complicated by HF, both I-MR and 1-Y-MR were markedly high, regardless of age and gender.

CONCLUSIONS

This contemporary, nationwide study suggests that I-MR and 1-Y-MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.

Long-term mortality after ST-elevation myocardial infarction in the reperfusion and modern secondary prevention therapy era according to coronary artery disease extent: The FAST-MI registries

BACKGROUND

Historical cohorts have shown extent of coronary artery disease to be a predictor of poorer outcomes in ST-segment elevation myocardial infarction. However, contemporary data in the era of reperfusion and modern secondary prevention therapy are lacking.

AIM

To compare 3-year survival in patients with ST-segment elevation myocardial infarction with multivessel disease versus those with single-vessel disease.

METHODS

Using data from the FAST-MI 2005, 2010 and 2015 registries, three nationwide French surveys, we included all patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 24hours of symptom onset. Baseline characteristics, management and 3-year all-cause mortality were analysed according to coronary status (single-, two- and three-vessel disease).

RESULTS

Among 3907 patients (mean age 62.4±13.7 years; 75.9% male), patients with multivessel disease (two- or three-vessel disease) accounted for 47.9%; overall, they were older, with higher cardiovascular risk profiles. In a multivariable adjusted Cox proportional hazard regression model, only patients with three-vessel disease had a higher rate of mortality at 3 years compared with those with single-vessel disease (hazard ratio 1.52, 95% confidence interval 1.68-2.26; P<0.001). Finally, patients with multivessel disease with complete myocardial revascularization before discharge had a similar prognosis to patients with single-vessel disease (hazard ratio 1.17, 95% confidence interval 0.84-1.64; P=0.35).

CONCLUSIONS

Multivessel disease still represents an important proportion of patients with ST-segment elevation myocardial infarction. Although three-vessel disease is associated with higher 3-year mortality, patients with multivessel disease and complete myocardial revascularization in the contemporary era have a 3-year risk of death similar to that in patients with single-vessel disease.

Clinical Implication of Hypoxic Liver Injury for Predicting Hypoxic Hepatitis and In-Hospital Mortality in ST Elevation Myocardial Infarction Patients

PURPOSE

In this study, we aimed to determine the value of hypoxic liver injury (HLI) in the emergency room (ER) for predicting hypoxic hepatitis (HH) and in-hospital mortality in ST elevation myocardial infarction (STEMI) patients.

MATERIALS AND METHODS

1537 consecutive STEMI patients were enrolled. HLI in the ER was defined as a ≥2-fold increase in serum aspartate transaminase (AST). HH was defined as a ≥20-fold increase in peak serum transaminase. Patients were divided into four groups according to HLI and HH status (group 1, no HLI or HH; group 2, HLI, but no HH; group 3, no HLI, but HH; group 4, both HLI and HH).

RESULTS

The incidences of HLI and HH in the ER were 22% and 2%, respectively. In-hospital mortality rates were 3.1%, 11.8%, 28.6%, and 47.1% for groups 1, 2, 3, and 4, respectively. Patients with HLI and/or HH had worse Killip class, higher cardiac biomarker elevations, and lower left ventricular ejection fraction. Multivariate logistic regression analysis showed that HLI in the ER was an independent predictor of HH [odds ratio 2.572, 95% confidence interval (CI) 1.166-5.675, p=0.019]. The predictive value of HLI in the ER for the development of HH during hospitalization was favorable [area under the curve (AUC) 0.737, 95% CI 0.643-0.830, sensitivity 0.548, specificity 0.805, for cut-off value AST >80]. Furthermore, in terms of in-hospital mortality, predictive values of HLI in the ER and HH during hospitalization were comparable (AUC 0.701 for HLI at ER and AUC 0.674 for HH).

CONCLUSION

Among STEMI patients, HLI in the ER is a significant predictor for the development of HH and mortality during hospitalization (INTERSTELLAR ClinicalTrials.gov number, NCT02800421).

Epidemiology of Geographic Disparities of Myocardial Infarction Among Older Adults in the United States: Analysis of 2000-2017 Medicare Data

Background: There are substantial geographic disparities in the life expectancy (LE) across the U.S. with myocardial infarction (MI) contributing significantly to the differences between the states with highest (leading) and lowest (lagging) LE. This study aimed to systematically investigate the epidemiology of geographic disparities in MI among older adults.

Methods: Data on MI outcomes among adults aged 65+ were derived from the Center for Disease Control and Prevention-sponsored Wide-Ranging Online Data for Epidemiologic Research database and a 5% sample of Medicare Beneficiaries for 2000–2017. Death certificate-based mortality from MI as underlying/multiple cause of death (CBM-UCD/CBM-MCD), incidence-based mortality (IBM), incidence, prevalence, prevalence at age 65, and 1-, 3-, and 5-year survival, and remaining LE at age 65 were estimated and compared between the leading and lagging states. Cox model was used to investigate the effect of residence in the lagging states on MI incidence and survival.

Results: Between 2000 and 2017, MI mortality was higher in the lagging than in the leading states (per 100,000, CBM-UCD: 236.7–583.7 vs. 128.2–357.6, CBM-MCD: 322.7–707.7 vs. 182.4–437.7, IBM: 1330.5–1518.9 vs. 1003.3–1197.0). Compared to the leading states, lagging states had higher MI incidence (1.1–2.0% vs. 0.9–1.8%), prevalence (10.2–13.1% vs. 8.3–11.9%), pre-existing prevalence (2.5–5.1% vs. 1.4–3.6%), and lower survival (70.4 vs. 77.2% for 1-year, 63.2 vs. 67.2% for 3-year, and 52.1 vs. 58.7% for 5-year), and lower remaining LE at age 65 among MI patients (years, 8.8–10.9 vs. 9.9–12.8). Cox model results showed that the lagging states had greater risk of MI incidence [Adjusted hazards ratio, AHR (95% Confidence Interval, CI): 1.18 (1.16, 1.19)] and death after MI diagnosis [1.22 (1.21, 1.24)]. Study results also showed alarming declines in survival and remaining LE at age 65 among MI patients.

Conclusion: There are substantial geographic disparities in MI outcomes, with lagging states having higher MI mortality, incidence, and prevalence, lower survival and remaining LE at age 65. Disparities in MI mortality in a great extent could be due to between-the-state differences in MI incidence, prevalence at age 65 and survival. Observed declines in survival and remaining LE require an urgent analysis of contributing factors that must be addressed.

The mortality rates in registries of patients with STEMI are highly affected by inclusion criteria and population characteristics

BACKGROUND

Different mortality rates are reported in registries of patients with ST-segment elevation myocardial infarction (STEMI), but comparisons between registries are challenging.

AIMS

To determine whether the higher mortality rate in our regional French registry (SCALIM) is related to different inclusion criteria and demographic characteristics.

METHODS

The SCALIM registry included all patients with STEMI within the first 24 h in the region of Limousin, France (06/2011-01/2015). To compare mortality rates with other contemporary registries in France and European neighbouring countries, the others' inclusion criteria were applied to the SCALIM registry.

RESULTS

Among 1501 patients included, in-hospital and 1-month mortality were 8.2% and 8.8% respectively, significantly higher than many other registries. The use of inclusion criteria from EMUST (France), MINAP (UK) or LOMBARDIMA (Italy) markedly decreased the number of enrolled patients by 64%, 36%, and 21%, respectively. When those inclusion criteria were applied to the SCALIM registry, difference in in-hospital and 1-month mortality rates between other registries and ours remained significant. In the multivariate analysis, age, initial acute pulmonary oedema (Killip class ≥2), complication occurring before percutaneous coronary intervention, absence of transfer to an interventional cardiology centre for primary angioplasty and lack of reperfusion therapy within 12 h were associated with higher risk of 1-month mortality (all p < 0.05). Age (65 versus 63.3 years, p < 0.001) was higher and reperfusion rate (84.2 versus 74.7%, p < 0.001) was significantly lower in SCALIM than FAST-MI, the national French registry on STEMI patients. Interestingly, the 3% of patients included in SCALIM who would be excluded from FAST-MI registry had 91% mortality at one month.

CONCLUSION

Higher mortality rate in our regional SCALIM registry is in part due to differences in inclusion criteria and demographic data. Consensus should be made to harmonise inclusion criteria in STEMI registries for the sake of comparability.

Is coronary multivessel disease in acute myocardial infarction patients still associated with worse clinical outcomes at 1-year?

Background

ST‐elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) are associated with a worse prognosis. However, few comparisons are available according to coronary status in the era of modern reperfusion and optimized secondary prevention.

Hypothesis

We hypothesized that the difference in prognosis according to number of vessel disease in STEMI patients has reduced.

Methods

All consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptoms onset between January 1, 2014 and June 30, 2016 enrolled in the CRAC (Club Régional des Angioplasticiens de la région Centre) France PCI registry were analyzed. Baseline characteristics, management, and outcomes at 1‐year were analyzed according to coronary status (one‐, two‐, and three‐VD).

Results

A total of 1886 patients (mean age 62.2 ± 14.0 year; 74% of male) were included. Patients with MVD (two or three‐VD) represented 53.7%. They were older with higher cardiovascular risk factor profile. At 1 year, the rate of major adverse cardiovascular events (MACE, defined as all‐cause death, stroke or re‐MI) was 10%, 12%, and 12% in one‐, two, and three‐VD respectively (p = .28). In multivariable adjusted Cox proportional hazard regression model, two‐ and three‐VD were not associated with higher rate of MACE compared to patients with single VD (HR, 1.09; 95%CI 0.76–1.56 for two‐VD; HR, 0.74; 95%CI 0.48–1.14 for three‐VD).

Conclusions

MVD still represents an important proportion of STEMI patients but their prognoses were not associated with worse clinical outcomes at 1‐year compared with one‐VD patients in a modern reperfusion area and secondary medication prevention.

Resumption of sexual activity after acute myocardial infarction and long-term survival

AIMS

Sexual activity is an important factor in the overall quality of life. We examined whether resumption of sexual activity frequency within the first few months after myocardial infarction (MI) is associated with long-term survival.

METHODS AND RESULTS

Sexually active patients aged ≤65 years (n = 495; median age, 53 years), drawn from the longitudinal Israel Study of First Acute Myocardial Infarction, were interviewed during the index hospitalization (1992-93) and after 3-6 months. Resumption of sexual activity was defined as abstaining/decreasing or maintaining/increasing according to self-reported frequency post- vs. pre-MI. Patients were followed for all-cause and cause-specific mortality through national registries. A propensity score for sexual activity resumption was calculated, based on which inverse probability weighted Cox models were constructed to examine associations. Patients who maintained/increased frequency [n = 263 (53%)] were more likely to be of higher socioeconomic status and to express lower levels of depression than their abstained/decreased counterparts. In the propensity score-weighted synthetic sample, the distribution of measured baseline covariates was similar across exposure categories. During a median follow-up of 22 years, 211 (43%) patients died. Maintaining/increasing sexual activity frequency was inversely associated with all-cause mortality [hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.48-0.88], compared with abstaining/reducing. The inverse association was more robust for non-cardiovascular mortality (HR 0.56, 95% CI 0.36-0.85) than cardiovascular mortality (HR 0.90, 95% CI 0.53-1.51).

CONCLUSIONS

Resumption of sexual activity frequency within the first months after MI was strongly associated with improved long-term survival, highlighting the need for sexual counselling shortly after MI.

The interaction effect of cardiac and non-cardiac comorbidity on myocardial infarction mortality: A nationwide cohort study

BACKGROUND

Whether the prognostic impact of comorbidity on myocardial infarction (MI) mortality is due to comorbidity alone or/and its interaction effect is unknown.

METHODS

We used Danish medical registries to conduct a nationwide cohort study of all first-time MIs during 1995-2016 (n = 179,515) and a comparison cohort matched on age, sex, and individual comorbidities (n = 880,347). We calculated age-standardized 5-year all-cause mortality rates. Interaction was examined on an additive scale by calculating interaction contrasts (difference in rate differences).

RESULTS

Among individuals without comorbidity, the 30-day mortality rate per 1000 person-years was 1851 (95% CI: 1818-1884) for MI patients and 22 (21-24) for comparison cohort members (rate difference = 1829). For individuals with low comorbidity, corresponding baseline mortality rates were 2498 (2436-2560) in the MI and 54 (50-57) in the comparison cohort (rate difference = 2444). The interaction contrast (616) indicated that the interaction accounted for 25% (616/2498) of the total 30-day mortality rate in MI patients with low comorbidity. This percentage increased further for moderate (35%) and severe (45%) comorbidity levels. Absolute and relative interaction effects were largest within the first 30 days and younger individuals. Dose-response patterns were also observed during 31-365 days and 1-5 years of follow-up (p-values for trends<0.002). The interaction differed substantially between individual types of cardiac and non-cardiac comorbidities.

CONCLUSION

Cardiac and non-cardiac comorbidities interact with MI to increase short- and long-term mortality beyond that explained by their additive effects. The interaction had a dose-response relation with comorbidity burden and a magnitude of clinical importance.

Mortality following first-time hospitalization with acute myocardial infarction in Norway, 2001-2014: Time trends, underlying causes and place of death

BACKGROUND

Trends on cause-specific mortality following acute myocardial infarction (AMI) are poorly described and no studies have analyzed where do AMI patients die. We analyzed trends in 28-day and one-year mortality following an incident AMI with focus on changes over time in the underlying cause and place of death.

METHODS

We identified in the 'Cardiovascular Disease in Norway' Project all patients 25+ years, hospitalized with an incident AMI in Norway, 2001-2014. Information on date, underlying cause and place of death was obtained from the Cause of Death Registry.

RESULTS

Of 144,473 patients included in the study, 11.4% died within first 28 days. The adjusted 28-day mortality declined by 5.2% per year (p_trend < 0.001). Of 118,881 patients surviving first 28 days, 10.1% died within one year. The adjusted one-year CVD mortality declined by 6.2% per year (p_trend < 0.001) while non-CVD mortality increased by 1.4% per year (p_trend < 0.001), mainly influenced by increased risk of dying from neoplasms. We observed a shift over time in the underlying cause of death toward more non-CVD deaths, and in the place of death toward more deaths occurring in nursing homes.

CONCLUSIONS

We observed a decline in 28-day mortality following an incident AMI hospitalization. One-year CVD mortality declined while one-year risk of dying from non-CVD conditions increased. The resulting shift toward more non-CVD deaths and deaths occurring outside a hospital need to be considered when formulating priorities in treating and preventing adverse events among AMI survivors.

Relation Between Statewide Hospital Performance Reports on Myocardial Infarction and Cardiovascular Outcomes

Healthcare systems may be judged on quality of care and access to health services. Studies on the association of hospital quality of care scores and clinical outcomes have yielded mixed results. With the help of a richer and more representative database, the aim of our study was to shed light on these inconsistencies. We examined the association of 4 process of care scores (prescription of aspirin, β blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker used for left ventricular systolic dysfunction, and an overall composite score) for acute myocardial infarction (AMI), reported in the Hospital Performance Reports, with 30-day and 1-year rates of readmission for AMI and cardiovascular (CV) death. Clinical outcomes were from the Myocardial Infarction Data Acquisition System, an administrative database that comprises all patient CV disease admissions to acute care hospitals in New Jersey. CV death was related with overall score (adjusted odds ratio [OR] 0.821, 95% confidence interval [CI] 0.726 to 0.930, p = 0.002) at 30 days and with all 4 scores at 1 year (OR ranging from 0.829 to 0.997, p <0.01). Readmission due to AMI was associated with the overall score (OR 0.789, 95% CI 0.691 to 0.902, p <0.0001) and the aspirin score (OR 0.995, 95% CI 0.990 to 1, p = 0.046) at 30 days. Low hospital performance scores for AMI were associated with increased CV death and readmission for AMI. In conclusion, healthcare providers should allocate their resources to improving hospital performance to decrease AMI case fatality, AMI readmissions, and CV-related healthcare spending.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry

Background

The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI).

Methods

Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%).

Results

Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866).

Conclusions

Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

Different treatments for acute myocardial infarction patients via outpatient clinics and emergency department

To investigate relevant factors and patients with acute myocardial infarction (AMI) were admitted during between weekdays and weekends period.Retrospective population-based study setting: from the 2005 population-based national health insurance underwriting database of millions of people, random sampling (National Health Insurance Research Database [NHIRD]-Longitudinal Health Insurance Database [LHID] 2005).In 2000 to 2009 data of NHIRD, subjects presented with first episode AMI who had received the thrombolytic therapy (TPA), or percutaneous coronary artery intervention (PTCA) or coronary artery bypass graft (CABG) during between weekdays and weekends period.From 2000 to 2009 among patients with first AMI total of 2007 people, the weekday group 1453 people, the weekend group 554. The total mortality within 1 year showed 33.53%, the first-day mortality occupied 8.07% in 1 year of total mortality, increased mortality after admission 3 months later. Cox regression analysis showed that AMI has presented significant risk of death, there are 4 items: weekends, age, Charlson comorbidity index (CCI), thrombolytic therapy; in the other variables including emergency, hospital level, hospital ownership, and urban-rural gap are not significant differences. Further using hierarchical logistic regression analysis for Stratification of AMI mortality risk, it has significant that showed the hospital level, age, CCI, thrombolytic therapy; but emergency, PTCA and 3 CABG treatment are not significant differences.It was approved by the hierarchical logistic regression analysis after stratified correction that the present study will have a direct impact on weekdays and weekends death in the hospital level. It will also affect the individual level.

Contrast-induced acute kidney injury and adverse clinical outcomes risk in acute coronary syndrome patients undergoing percutaneous coronary intervention: a meta-analysis

Background

Recent studies have shown associations between contrast-induced acute kidney injury (CI-AKI) and increased risk of adverse clinical outcomes in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI); however, the estimates are inconsistent and vary widely. Therefore, this meta-analysis aimed to evaluate the precise associations between CI-AKI and adverse clinical consequences in patients undergoing PCI for ACS.

Methods

EMBASE, PubMed, Web of Science™ and Cochrane Library databases were systematically searched from inception to December 16, 2016 for cohort studies assessing the association between CI-AKI and any adverse clinical outcomes in ACS patients treated with PCI. The results were demonstrated as pooled risk ratios (RRs) with 95% confidence intervals (CI). Heterogeneity was explored by subgroup analyses.

Results

We identified 1857 articles in electronic search, of which 22 (n = 32,781) were included. Our meta-analysis revealed that in ACS patients undergoing PCI, CI-AKI significantly increased the risk of adverse clinical outcomes including all-cause mortality (18 studies; n = 28,367; RR = 3.16, 95% CI 2.52–3.97; I² = 56.9%), short-term all-cause mortality (9 studies; n = 13,895; RR = 5.55, 95% CI 3.53–8.73; I² = 60.1%), major adverse cardiac events (7 studies; n = 19,841; RR = 1.49, 95% CI: 1.34–1.65; I² = 0), major adverse cardiovascular and cerebrovascular events (3 studies; n = 2768; RR = 1.86, 95% CI: 1.42–2.43; I² = 0) and stent restenosis (3 studies; n = 130,678; RR = 1.50, 95% CI: 1.24–1.81; I² = 0), respectively. Subgroup analyses revealed that the studies with prospective cohort design, larger sample size and lower prevalence of CI-AKI might have higher short-term all-cause mortality risk.

Conclusions

CI-AKI may be a prognostic marker of adverse outcomes in ACS patients undergoing PCI. More attention should be paid to the diagnosis and management of CI-AKI.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1161-5) contains supplementary material, which is available to authorized users.

Postdischarge outcome after Takotsubo syndrome compared with patients post-ACS and those without prior CVD: ANZACS-QI 19

Objective

Takotsubo syndrome (TS) mimics acute coronary syndrome (ACS) but has a distinct pathophysiology. While in-hospital adverse outcomes appear similar to those presenting with an ACS, data on longer term postdischarge risk are conflicting. This study sought to assess the long-term prognosis of patients discharged alive after TS.

Methods

The clinical profile and in-hospital and long-term outcomes were prospectively assessed in consecutive patients with TS. Survival in patients with TS was compared with two representative age-matched and gender-matched comparison cohorts: a hospitalised ACS cohort and a community cohort without known cardiovascular disease (CVD).

Results

Two hundred and-twenty-five patients with TS (216 women, mean age 63.7±11.8 years) were included. In-hospital mortality was 1.8% and 1.9% for patients with TS and ACS, respectively. Of the 219 patients with TS with postdischarge follow-up, at a mean follow-up of 4.8±3.2 years, there were 19 (8.3%) deaths, 18 of which were from non-cardiac causes. When compared with the cohort without prior CVD, postdischarge patients with TS were at increased mortality risk (HR 2.00, 95% CI 1.26 to 3.17, p=0.003), but mortality in postdischarge patients with ACS was over threefold higher (HR 3.43, 95% CI 2.97 to 3.96, p<0.0001).

Conclusions

In-hospital mortality for patients diagnosed with TS and ACS was similar. However, while postdischarge survivors of TS had a long-term survival which was poorer than for a community-based cohort without known CVD, their survival was better than for postdischarge survivors of an ACS event. Late deaths in patients with TS were almost all from non-cardiac causes.

Predictive value of telomere length on outcome following acute myocardial infarction: evidence for contrasting effects of vascular vs. blood oxidative stress

Aims

Experimental evidence suggests that telomere length (TL) is shortened by oxidative DNA damage, reflecting biological aging. We explore the value of blood (BTL) and vascular TL (VTL) as biomarkers of systemic/vascular oxidative stress in humans and test the clinical predictive value of BTL in acute myocardial infarction (AMI).

Methods and results

In a prospective cohort of 290 patients surviving recent AMI, BTL measured on admission was a strong predictor of all-cause [hazard ratio (HR) [95% confidence interval (CI)]: 3.21 [1.46–7.06], P = 0.004] and cardiovascular mortality (HR [95% CI]: 3.96 [1.65–9.53], P = 0.002) 1 year after AMI (for comparisons of short vs. long BTL, as defined by a T/S ratio cut-off of 0.916, calculated using receiver operating characteristic analysis; P adjusted for age and other predictors). To explore the biological meaning of these findings, BTL was quantified in 727 consecutive patients undergoing coronary artery bypass grafting (CABG), and superoxide (O₂^.-) was measured in peripheral blood mononuclear cells (PBMNC). VTL/vascular O₂^.- were quantified in saphenous vein (SV) and mammary artery (IMA) segments. Patients were genotyped for functional genetic polymorphisms in P22^ph°^x (activating NADPH-oxidases) and vascular smooth muscle cells (VSMC) selected by genotype were cultured from vascular tissue. Short BTL was associated with high O₂^.- in PBMNC (P = 0.04) but not in vessels, whereas VTL was related to O₂^.- in IMA (ρ = −0.49, P = 0.004) and SV (ρ = −0.52, P = 0.01). Angiotensin II (AngII) incubation of VSMC (30 days), as a means of stimulating NADPH-oxidases, increased O₂^.- and reduced TL in carriers of the high-responsiveness P22^ph°^x alleles (P = 0.007).

Conclusion

BTL predicts cardiovascular outcomes post-AMI, independently of age, whereas VTL is a tissue-specific (rather than a global) biomarker of vascular oxidative stress. The lack of a strong association between BTL and VTL reveals the importance of systemic vs. vascular factors in determining clinical outcomes after AMI.

Selective inhibition of receptor activator of NF-κB ligand (RANKL) in hematopoietic cells improves outcome after experimental myocardial infarction

The RANK (receptor activator of nuclear factor κB)/RANKL (RANK ligand)/OPG (osteoprotegerin) axis is activated after myocardial infarction (MI), but its pathophysiological role is not well understood. Here, we investigated how global and cell compartment-selective inhibition of RANKL affects cardiac function and remodeling after MI in mice. Global RANKL inhibition was achieved by treatment of human RANKL knock-in (huRANKL-KI) mice with the monoclonal antibody AMG161. huRANKL-KI mice express a chimeric RANKL protein wherein part of the RANKL molecule is humanized. AMG161 inhibits human and chimeric but not murine RANKL. To dissect the pathophysiological role of RANKL derived from hematopoietic and mesenchymal cells, we selectively exchanged the hematopoietic cell compartment by lethal irradiation and across-genotype bone marrow transplantation between wild-type and huRANKL-KI mice, exploiting the specificity of AMG161. After permanent coronary artery ligation, mice were injected with AMG161 or an isotype control antibody over 4 weeks post-MI. MI increased RANKL expression mainly in cardiomyocytes and scar-infiltrating cells 4 weeks after MI. Only inhibition of RANKL derived from hematopoietic cellular sources, but not global or mesenchymal RANKL inhibition, improved post-infarct survival and cardiac function. Mechanistically, hematopoietic RANKL inhibition reduced expression of the pro-inflammatory cytokine IL-1ß in the cardiac cellular infiltrate. In conclusion, inhibition of RANKL derived from hematopoietic cellular sources is beneficial to maintain post-ischemic cardiac function by reduction of pro-inflammatory cytokine production. KEY MESSAGES: Experimental myocardial infarction (MI) augments cardiac RANKL expression in mice. RANKL expression is increased in cardiomyocytes and scar-infiltrating cells after MI. Global or mesenchymal cell RANKL inhibition has no influence on cardiac function after MI. Inhibition of RANKL derived from hematopoietic cells improves heart function post-MI. Hematopoietic RANKL inhibition reduces pro-inflammatory cytokines in scar-infiltrating cells.

Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Temporal trends in secondary prevention in myocardial infarction patients discharged with left ventricular systolic dysfunction in Poland

Background

The proportion of patients discharged after myocardial infarction with left ventricular systolic dysfunction remains high and the prognosis is unfavourable. The aim of this study was to analyse the temporal trends in the treatment and outcomes of a nationwide cohort of patients.

Methods and results

Data from the Polish Registry of Acute Coronary Syndromes and Acute Myocardial Infarction in Poland Registry were combined to achieve complete information on inhospital course, treatment and outcomes. An all-comer population of patients discharged with left ventricular ejection fraction of 40% or less formed the sample population ( n = 28,080). The patients were analysed for the incidence of significant temporal trends and their possible consequences. The implementation of guideline-based treatment at discharge was high. In the post-discharge course a trend towards a higher frequency of percutaneous coronary intervention and a lower prevalence of planned coronary artery bypass grafting procedures was observed. The number of implantable cardioverter defibrillator/cardiac resynchronisation therapy defibrillator implantations was increasing. Cardiac rehabilitation was performed in 19–23% cases. The post-discharge outpatient care was based on general practitioner visits, with only 47.9–48.1% of patients attending an ambulatory cardiology specialist visit. In 12 months of observation the frequency of heart failure rehospitalisations was 17.5–19.1%, while the prevalence of rehospitalisations due to myocardial infarction decreased (8.3% in 2009 to 6.7% in 2013, P < 0.001). A trend towards lower all-cause mortality was observed. Assessment of composite outcomes (death, myocardial infarction, stroke or heart failure rehospitalisation) adjusted for sex and age at 12 months revealed a significant decreasing trend.

Conclusion

The overall prognosis in this population is improving slowly. This may be due to the increasing prevalence of guideline-based forms of secondary prevention. Efforts aimed at maintaining these trends are essential, as overall compliance with these guideline remains suboptimal.

Long-term prognosis of patients with non-ST-segment elevation myocardial infarction according to coronary arteries atherosclerosis extent on coronary angiography: a historical cohort study

BACKGROUND

Patients with non-ST-segment elevation myocardial infarction (NSTEMI) without obstructive coronary artery disease (CAD) are often managed differently than those with obstructive CAD, therefore we aimed in this study to examine the long-term prognosis of patients with NSTEMI according to the degree of CAD on coronary angiography (CAG).

METHODS

We examined 8.889 consecutive patients admitted for first time NSTEMI during 2000-2011, to whom CAG was performed. Patients were classified by CAG into: 0-vessel disease (0VD), diffuse atherosclerosis (DA) (0% < stenosis <50%), 1-vessel disease (1VD), 2VD, and 3VD with stenosis ≥50%. Follow-up period: 13 years (median 4.5).

RESULTS

One-year mortality for NSTEMI patients with 0VD was 3.7%, DA 5.7%, 1VD 2.5%, 2VD 4.8%, and 3VD 11.5%. Non-diabetic 0VD patients had higher risk of mortality than 1VD patients (HR:1.59; 95% CI:1.21-2.02; P < 0.001), while those with diabetes mellitus (DM) had not significantly different risk. In addition 0VD group had higher risk of heart failure (HF) (HR 1.61; 95% CI: 1.39-1.88; P < 0.001), and lower risk of recurrent MI (HR:0.55; 95% CI:0.39-0.77; P < 0.001) compared with 1VD. For patients with DA; mortality and HF risks were higher than 1VD and not different than 2VD, while recurrent MI risk was not different than 1VD and lower than 2VD. Finally, the DA group had higher risk of mortality if they had DM, higher risk of recurrent MI, and not different risk of HF and stroke compared with the 0VD group patients.

CONCLUSION

Patients with NSTEMI and non-obstructive CAD (both normal coronaries and diffuse atherosclerosis) have a comparable prognosis to patients with one- or two-vessel disease. Patients with diffuse atherosclerosis have worse prognosis than those with angiographically normal coronary arteries.

Contemporary Risk Stratification After Myocardial Infarction in the Community: Performance of Scores and Incremental Value of Soluble Suppression of Tumorigenicity-2

BACKGROUND

Current American Heart Association/American College of Cardiology guidelines recommend the GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) scores to assess myocardial infarction (MI) prognosis. Changes in the epidemiological characteristics of MI and the availability of new biomarkers warrant an assessment of the performance of these scores in contemporary practice. We assessed the following: (1) the performance of GRACE and TIMI to predict 1-year mortality in a cohort of patients stratified by ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) and (2) the incremental discriminatory power of soluble suppression of tumorigenicity-2, a myocardial fibrosis biomarker.

METHODS AND RESULTS

Olmsted County, Minnesota, residents with incident MI (N=1401) were recruited prospectively from November 1, 2002 to December 31, 2012 (mean age, 67 years; 61% men; 79% with NSTEMI). Baseline data were used to calculate risk scores; soluble suppression of tumorigenicity-2 was measured in stored plasma samples obtained at index MI. C-statistics adapted to survival data were used to assess the discriminatory power of the risk scores and the improvement gained by adding other markers. During the first year of follow-up, 190 patients (14%) died. The discriminatory performance to predict death was reasonable for GRACE and poor for TIMI, and was generally worse in those with NSTEMI versus those with STEMI. In people with NSTEMI, sequential addition of comorbidities and soluble suppression of tumorigenicity-2 substantially improved the c-statistic over GRACE (from 0.78 to 0.80 to 0.84) and TIMI (from 0.61 to 0.73 to 0.81), respectively (all P≤0.05).

CONCLUSIONS

Guideline-recommended scores for risk assessment after MI underperform in contemporary community patients, particularly those with NSTEMI, which now represents most infarcts. Incorporating comorbidities and soluble suppression of tumorigenicity-2 substantially improves risk prediction, thereby delineating opportunities to improve clinical care.

Smoking Status and Incidence of Cancer After Myocardial Infarction: A Follow-Up Study of over 20 Years

OBJECTIVES

We evaluated long-term incidence of cancer after myocardial infarction among current, former, and never smokers, and assessed whether reducing cigarette consumption is associated with decreased cancer risk.

METHODS

Consecutive patients aged ≤65 years discharged from 8 hospitals in central Israel after first myocardial infarction in 1992-1993 were followed for cancer and death. Extensive data including smoking habits were obtained at the index hospitalization and 4 time points during follow-up. Survival methods were applied to assess the hazard ratios (HRs) for cancer associated with smoking categories.

RESULTS

Included in the study were 1486 cancer-free participants (mean age, 54 years; 81% men), among whom 787 were current smokers at baseline (average daily cigarette consumption = 29). Smokers were younger than nonsmokers and more likely to be male and of lower socioeconomic status. Over a median follow-up of 21.4 years, 273 (18.4%) patients developed cancer. Baseline smoking was associated with a ∼40% excess adjusted risk of cancer; ∼25% after accounting for death as a competing event. Considering changes in smoking during follow-up, the excess risk was confined to persistent smokers (adjusted HR 1.75; 95% confidence interval [CI], 1.22-2.50), whereas post- (HR 1.14; 95% CI, 0.80-1.62) and pre-myocardial infarction quitters (HR 1.02; 95% CI, 0.71-1.47) were comparable with never smokers. Among persistent smokers, each reduction of 10 cigarettes relative to pre-myocardial infarction consumption was associated with a ∼10% reduced adjusted risk.

CONCLUSION

Among young survivors of first myocardial infarction followed-up longitudinally, smoking cessation is associated with lower risk of cancer. Reducing consumption among smokers may also be beneficial.

Long-term mortality after acute myocardial infarction among individuals with and without diabetes: A systematic review and meta-analysis of studies in the post-reperfusion era

AIMS

To conduct a systematic review and meta-analysis with the aim of providing robust estimates of the association between diabetes and long-term (≥1 year) mortality after acute myocardial infarction (AMI).

MATERIAL AND METHODS

Medline, Embase and Web of Science databases were searched (January 1985 to July 2016) for terms related to long-term mortality, diabetes and AMI. Two authors independently abstracted the data. Hazard ratios (HRs) comparing mortality in people with and without diabetes were pooled across studies using Bayesian random-effects meta-analysis.

RESULTS

A total of 10 randomized controlled trials and 56 cohort studies, including 714 780 patients, reported an estimated total of 202 411 deaths over the median (range) follow-up of 2.0 (1-20) years. The risk of death over time was significantly higher among those with diabetes compared with those without (unadjusted HR 1.82, 95% credible interval [CrI] 1.73-1.91). Mortality remained higher in the analysis restricted to 23/64 cohorts reporting data adjusted for confounders (adjusted HR 1.48, 95% CrI 1.43-1.53). The excess long-term mortality in diabetes was evident irrespective of the phenotype and modern treatment of AMI, and persisted in early survivors (unadjusted HR 1.82, 95% CrI 1.70-1.95).

CONCLUSIONS

Despite medical advances, individuals with diabetes have a 50% greater long-term mortality compared with those without. Further research to understand the determinants of this excess risk are important for public health, given the predicted rise in global diabetes prevalence.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

Exchanging a few commercial, regularly consumed food items with improved fat quality reduces total cholesterol and LDL-cholesterol: a double-blind, randomised controlled trial

The healthy Nordic diet has been previously shown to have health beneficial effects among subjects at risk of CVD. However, the extent of food changes needed to achieve these effects is less explored. The aim of the present study was to investigate the effects of exchanging a few commercially available, regularly consumed key food items (e.g. spread on bread, fat for cooking, cheese, bread and cereals) with improved fat quality on total cholesterol, LDL-cholesterol and inflammatory markers in a double-blind randomised, controlled trial. In total, 115 moderately hypercholesterolaemic, non-statin-treated adults (25-70 years) were randomly assigned to an experimental diet group (Ex-diet group) or control diet group (C-diet group) for 8 weeks with commercially available food items with different fatty acid composition (replacing SFA with mostly n-6 PUFA). In the Ex-diet group, serum total cholesterol (P<0·001) and LDL-cholesterol (P<0·001) were reduced after 8 weeks, compared with the C-diet group. The difference in change between the two groups at the end of the study was -9 and -11 % in total cholesterol and LDL-cholesterol, respectively. No difference in change in plasma levels of inflammatory markers (high-sensitive C-reactive protein, IL-6, soluble TNF receptor 1 and interferon-γ) was observed between the groups. In conclusion, exchanging a few regularly consumed food items with improved fat quality reduces total cholesterol, with no negative effect on levels of inflammatory markers. This shows that an exchange of a few commercially available food items was easy and manageable and led to clinically relevant cholesterol reduction, potentially affecting future CVD risk.

Heart Failure Predictors in a Group of Patients with Myocardial Infarction

AIM

The present study considers of the prevalence of heart failure (HF) in patients suffering from acute myocardial infarction (AMI) in the University Hospital Centre of Tirana (UHCT) "Mother Theresa"; the demographic and clinical characteristics of the sample during hospitalization; and the main predictors of heart failure occurrence inside the group of patients suffering an AMI.

MATERIAL AND METHODS

During a period of study from 2013-2015 we studied demographic and clinical data from 587 consecutive patients presenting with AMI; Framingham criteria were adopted for classifying patients with HF upon admission.

RESULTS

A Killip class ≥ 2 was the main diagnostic criterion of HF during hospitalisation. HF was identified in 156 patients (26.6%). The subgroup with HF had significant differences when compared with the other patients with regard to age, sex (male), heart rate upon admission, systolic blood pressure on admission, previous episodes of AMI, glycemia on admission, previous antihypertensive treatment, previous revascularization procedures, peripheral vascular disease, chronic renal disease, ejection fraction (EF), anemia, and atrial fibrillation presence. Independent predictors for HF occurrence in the logistic regression model were EF, previous revascularization, peripheral vascular disease, age, sex, previous AMI, systolic blood pressure upon admission, and anaemia.

CONCLUSION

As a conclusion, HF seems to be a common occurrence after AMI, in spite of changes in the epidemiological profile of the acute coronary syndrome. An increase in the incidence is registered as well, parallel to a decrease in the mortality following AMI. Attention must be shown for highly risked subpopulations, aged persons, patients with the previous coronary disease, and concomitant conditions.

Long-term exposure to traffic-related air pollution and cancer among survivors of myocardial infarction: A 20-year follow-up study

BACKGROUND

Previous studies suggested a carcinogenic effect of exposure to traffic-related air pollution. Recently, higher rates of cancer incidence were observed among myocardial infarction survivors compared with the general population. We examined the association between chronic exposure to nitrogen oxides, a proxy measure for traffic-related air pollution, and cancer incidence and mortality in a cohort of myocardial infarction patients.

METHODS

Patients aged ≤65 years admitted to hospital in central Israel with a first myocardial infarction in 1992-1993 were followed to 2013 for cancer incidence and cause-specific mortality. Data on sociodemographic and cancer risk factors were obtained, including time-varying information on smoking. Using land use regression models, annual averages of nitrogen oxides during follow-up were estimated individually according to home addresses. Cox proportional hazards models were constructed to study the relationships with cancer outcomes.

RESULTS

During a mean follow-up of 16 (SD 7) years, 262 incident cancers and 105 cancer deaths were identified among 1393 cancer-free patients at baseline (mean age 54 years; 81% men). In adjusted models, a 10 ppb increase in mean nitrogen oxide exposure was associated with a hazard ratio (HR) of 1.06 (95% confidence interval (CI) 0.96-1.18) for cancer incidence and HR of 1.08 (95% CI 0.93-1.26) for cancer mortality. The association with lung, bladder, kidney or prostate cancer (previously linked to air pollution) was stronger (HR 1.16; 95% CI 1.00-1.33).

CONCLUSIONS

Chronic exposure to traffic-related air pollution may constitute an environmental risk factor for cancer post-myocardial infarction. Variation in the strength of association between specific cancers needs to be explored further.

A higher burden of metabolic risk factors and underutilization of therapy among women compared to men might influence a poorer prognosis: a study among acute myocardial patients in Albania, a transitional country in Southeastern Europe

Aim

To determine the clinical profile, burden of risk factors, and quality of care among patients hospitalized for an acute myocardial infarction (AMI) with special focus on gender differences.

Methods

The study included 256 AMI patients admitted to the Coronary Care Unit of “Mother Teresa” hospital in Tirana during 2013-2014. We obtained information on patients’ demographic data, AMI characteristics, complications (heart failure [HF] and ventricular fibrillation [VF]), risk factors and medication use prior and during the AMI hospitalization. Age-adjusted Poisson regression analyses were applied to explore gender differences (women vs men) with regard to clinical profile and quality of care and results are expressed as incidence rate ratios (IRR).

Results

55.4% of patients had ≥3 risk factors, 44.5% developed HF, and 5.7% developed VF. Only 40.4% of patients received all 4 medication classes (beta-blockers, angiotensin-converting-enzyme inhibitor/angiotensin receptor blockers, statins, and aspirin) and 46.4% had revascularization. Significantly more women than men were obese, (P = 0.042) had diabetes, (P = 0.001) developed HF (P < 0.001) or experienced a VF episode (P < 0.001). After adjusting for age, differences with regard to obesity (IRR = 2.17; 95% confidence interval [CI] 1.15-4.09), diabetes (IRR = 1.35; 95% CI 1.07-1.71), HF (IRR = 1.32; 95% CI 1.02-1.74) and VF (IRR = 2.82; 95% CI 1.07-7.43) remained significant. There were no differences with regard to individual drug classes taken. However, women had fewer revascularization procedures than men (IRR = 0.65; 95% CI 0.43-0.98).

Conclusion

Women were found to have more unfavorable clinical profile, higher complication rates, and underutilization of therapy, which may be influenced by socioeconomic differences between genders and lead to a differential prognosis.

Prognostic Impact of Combined Contrast-Induced Acute Kidney Injury and Hypoxic Liver Injury in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: Results from INTERSTELLAR Registry

BACKGROUND

Besides contrast-induced acute kidney injury(CI-AKI), adscititious vital organ damage such as hypoxic liver injury(HLI) may affect the survival in patients with ST-elevation myocardial infarction (STEMI). We sought to evaluate the prognostic impact of CI-AKI and HLI in STEMI patients who underwent primary percutaneous coronary intervention (PCI).

METHODS

A total of 668 consecutive patients (77.2% male, mean age 61.3±13.3 years) from the INTERSTELLAR STEMI registry who underwent primary PCI were analyzed. CI-AKI was defined as an increase of ≥0.5 mg/dL in serum creatinine level or 25% relative increase, within 48h after the index procedure. HLI was defined as ≥2-fold increase in serum aspartate transaminase above the upper normal limit on admission. Patients were divided into four groups according to their CI-AKI and HLI states. Major adverse cardiovascular and cerebrovascular events (MACCE) defined as a composite of all-cause mortality, non-fatal MI, non-fatal stroke, ischemia-driven target lesion revascularization and target vessel revascularization were recorded.

RESULTS

Over a mean follow-up period of 2.2±1.6 years, 94 MACCEs occurred with an event rate of 14.1%. The rates of MACCE and all-cause mortality were 9.7% and 5.2%, respectively, in the no organ damage group; 21.3% and 21.3% in CI-AKI group; 18.5% and 14.6% in HLI group; and 57.7% and 50.0% in combined CI-AKI and HLI group. Survival probability plots of composite MACCE and all-cause mortality revealed that the combined CI-AKI and HLI group was associated with the worst prognosis (p<0.0001 for both).

CONCLUSION

Combined CI-AKI after index procedure and HLI on admission is associated with poor clinical outcomes in patients with STEMI who underwent primary PCI. (INTERSTELLAR ClinicalTrials.gov number, NCT02800421.).

Long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction and renal dysfunction

Patients with renal impairment have decreased excretion of uric acid, thus being particularly prone to having elevated serum uric acid concentrations. No data are available on the long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction (STEMI) and renal dysfunction, submitted to percutaneous coronary intervention (PCI). We therefore prospectively assessed, in 329 patients with STEMI and renal dysfunction (admission estimated glomerular filtration rate <60 ml/min/1.73 m), all submitted to PCI, whether uric acid levels are associated with increased mortality at 1-year postdischarge follow-up.Patients in the third tertile of uric acid showed a higher BMI (P = 0.014), a higher incidence of hypertension (P = 0.029), and two or more comorbidities (P = 0.034). The highest incidence of bleeding and of acute kidney injury was detectable in patients in the third tertile (P = 0.011 and P < 0.001, respectively) who showed the highest mortality rate at 1-year postdischarge follow-up (P = 0.008). At Cox regression analysis, uric acid was an independent predictor of 1-year postdischarge mortality (hazard ratio 1.26, 95% confidence interval 1.06-1.51, P = 0.011).In STEMI patients with estimated glomerular filtration rate below 60 ml/min/1.73 m treated with PCI, uric acid helps in identifying a subset of patients at a higher risk of bleeding and acute kidney injury. Increased uric acid is an independent prognostic risk factor for 1-year mortality. Further studies performed in larger cohorts of patients are needed to confirm our findings and to evaluate whether lowering uric acid in these patients is beneficial.

Prognosis and management of myocardial infarction: Comparisons between the French FAST-MI 2010 registry and the French public health database

BACKGROUND

Multicentre registries of myocardial infarction management show a steady improvement in prognosis and greater access to myocardial revascularization in a more timely manner. While French registries are the standard references, the question arises: are data stemming solely from the activity of French cardiac intensive care units (ICUs) a true reflection of the entire French population with ST-segment elevation myocardial infarction (STEMI)?

AIM

To compare data on patients hospitalized for STEMI from two French registries: the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) and the Échantillon généraliste des bénéficiaires (EGB) database.

METHODS

We compared patients treated for STEMI listed in the FAST-MI 2010 registry (n=1716) with those listed in the EGB database, which comprises a sample of 1/97th of the French population, also from 2010 (n=403).

RESULTS

Compared with the FAST-MI 2010 registry, the EGB database population were older (67.2±15.3 vs 63.3±14.5 years; P<0.001), had a higher percentage of women (36.0% vs 24.7%; P<0.001), were less likely to undergo emergency coronary angiography (75.2% vs 96.3%; P<0.001) and were less often treated in university hospitals (27.1% vs 37.0%; P=0.001). There were no significant differences between the two registries in terms of cardiovascular risk factors, comorbidities and drug treatment at admission. Thirty-day mortality was higher in the EGB database (10.2% vs 4.4%; P<0.001).

CONCLUSIONS

Registries such as FAST-MI are indispensable, not only for assessing epidemiological changes over time, but also for evaluating the prognostic effect of modern STEMI management. Meanwhile, exploitation of data from general databases, such as EGB, provides additional relevant information, as they include a broader population not routinely admitted to cardiac ICUs.

Glycated haemoglobin and long-term mortality in patients with ST Elevation Myocardial Infarction

BACKGROUNDS/OBJECTIVES

We aimed at assessing the impact of increased HbA1c (≥6.5%) on 1-year mortality in consecutive patients with ST Elevation Myocardial Infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI).

METHODS

The study population comprises 1205 STEMI patients treated with primary PCI and consecutively admitted to our Center from 1 January 2004 to 31 December 2011.

RESULTS

Two hundred and seventy-six patients with previously diagnosed diabetes (276/1205, 22.9%, Group A), 78 patients without previously known diabetes and HbA1c at least 6.5% (78/1205, 6.5%, Group B) and 851 patients without previously known diabetes and HbA1c less than 6.5% (851/1205, 70.1%, Group C).At Cox regression analysis, HbA1c at least 6.5% was not related to 1-year postdischarge mortality in patients with previously diagnosed diabetes nor in those without previously known diabetes.Kaplan-Meier survival curve analysis showed that patients in Group A exhibited the lowest survival rate, while patients in Group B (i.e. patients without previously known diabetes and with HbA1c ≥6.5%) showed a significant reduction in their survival rate since 6 months after discharge.

CONCLUSION

In a large series of STEMI patients submitted to primary PCI, HbA1c levels were not related with outcomes at multivariable analysis.

Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: The 2005 French FAST-MI study

BACKGROUND

Clinical studies have shown a beneficial effect of cardiac rehabilitation (CR) on mortality.

OBJECTIVE

To study the effect of CR prescription at discharge on 5-year mortality in patients with acute myocardial infarction (AMI).

METHODS

Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n=1523) and non-STEMI (NSTEMI; n=1371). The effect of CR prescription on mortality was analysed using a Cox proportional hazards model.

RESULTS

At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs. 67.5years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients. Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P<0.001). After multivariable adjustment, the association between CR and mortality remained significant (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.60-0.96). Analyses stratified by sex, age (<60 vs.≥60years) and AMI type showed that the inverse association was stronger in men (HR 0.64, 95% CI 0.48-0.87) than in women (HR 0.95, 95% CI 0.64-1.39), in younger (HR 0.34, 95% CI 0.15-0.77) than in older patients (HR 0.84, 95% CI 0.65-1.07) and in NSTEMI (HR 0.63, 95% CI 0.46-0.88) than in STEMI (HR 0.99, 95% CI 0.69-1.40).

CONCLUSION

After hospitalization for AMI, referral to CR remains a significant predictor of improved patient survival; some subgroups seem to gain greater benefit.

Mortality Associated With Heart Failure After Myocardial Infarction: A Contemporary Community Perspective

BACKGROUND

Contemporary data are lacking on the prognostic importance of heart failure (HF) after myocardial infarction (MI). We evaluated the prognostic impact of HF post MI according to preserved/reduced ejection fraction and the timing of its occurrence.

METHODS AND RESULTS

All Olmsted County, Minnesota, residents (n=2596) with incident MI diagnosed in 1990 to 2010 and no prior HF were followed through March 2013. Cox models were used to examine (1) the hazard ratios for death associated with HF type and timing and (2) secular trends in survival by HF status. During a mean follow-up of 7.6 years, there were 1116 deaths, 634 in the 902 patients who developed HF (70%) and 482 in the 1694 patients who did not develop HF (28%). After adjustment for age and sex, HF as a time-dependent variable was strongly associated with mortality (hazard ratio =3.31, 95% confidence interval: 2.93-3.75), particularly from cardiovascular causes (hazard ratio =4.20, 95% confidence interval: 3.50-5.03). Further adjustment for MI severity and comorbidity, acute treatment, and recurrent MI moderately attenuated these associations (hazard ratio =2.49 and 2.94 for all-cause and cardiovascular mortality, respectively). Mortality did not differ by ejection fraction, but was higher for delayed- versus early-onset HF (P for heterogeneity =0.002). The age- and sex-adjusted 5-year survival estimates in 2001 to 2010 versus 1990 to 2000 were 82% and 81% among HF-free and 61% and 54% among HF patients, respectively (P for heterogeneity of trends =0.05).

CONCLUSIONS

HF markedly increases the risk of death after MI. This excess risk is similar regardless of ejection fraction but greater for delayed- versus early-onset HF. Mortality after MI declined over time, primarily as a result of improved HF survival.

Usefulness of a normal coronary angiogram in patients aged ≥65 years to foretell survival

A normal coronary angiogram (CA) has been reported to confer a good prognosis. However, how this applies to patients aged ≥65 years is not well known. From 1986 to 1996, 11,625 patients aged ≥65 underwent coronary angiography. We identified 271 patients with either normal (NORM, n = 160) CA or <30% diameter stenosis disease (NEAR-NORM, n = 111). Using the Myocardial Infarction Data Acquisition System, we examined the probability of survival and the risk of developing an ischemic event or undergoing a revascularization procedure during an average of 15.1 ± 6.2 years (range 0.5 to 25.8 years). Matched actuarial subjects were used to compare survival to the general population. The incidence of an ischemic event was low (2.0 events per 100 persons/year for the NORM and 2.8 patients per 100 persons/year for the NEAR-NORM group, p = NS). Rates of revascularization were higher in the NEAR-NORM group compared to the NORM group (1 per 100 persons/year vs 0.5 per 100 persons/year, p = 0.04). During the 25.8-year follow-up, there were 77 deaths (48.4%) for the NORM and 64 (57.1%) for the NEAR-NORM group (χ2 = 1.7, NS). The NORM group survived 6,789 days, 1,517 more days than the actuarial subjects (95% confidence interval [CI] 1,072 to 1,956; p <0.0001) and the NEAR-NORM group survived 5,922 days, 875 more days (95% CI 368 to 1,376; p <0.005). In conclusion, patients with normal or near-normal CA at age ≥65 years have a low rate of myocardial ischemic events and have significantly longer survival than matched subjects from the general population.