Differential time trends of outcomes and costs of care for acute myocardial infarction hospitalizations by ST elevation and type of intervention in the United States, 2001-2011

Outcomes of Patients Presenting With Non-ST Elevation Myocardial Infarction Who Underwent Surgical Revascularization

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalization across Europe. This study evaluates the in-hospital and mid-term outcomes of patients who underwent coronary artery bypass graft (CABG) after NSTEMI. A retrospective analysis of all cases who underwent isolated CABG after NSTEMI from September 2017 to September 2022 at our center. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modeling. Kaplan-Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1,011 patients (median age 64 [56 to 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1,011 patients). Those who died were more likely to be New York Heart Association class III/IV, have left ventricular ejection fraction <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, preoperative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modeling revealed new postoperative stroke (odds ratio 22.0, 95% confidence interval 3.6 to 135.5, p = 0.001), preoperative IABP use (11.4; 2.4 to 53.7, p = 0.002), new hemodialysis (9.6; 2.7 to 34.7, p <0.001), PVD (5.6; 1.6 to 20.0, p = 0.008), and poor mobility (odds ratio 4.8, 95% confidence interval 1.3 to 18.2, p = 0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, preoperative IABP use, new hemodialysis, PVD, and poor mobility are independent predictors of mortality in patients with NSTEMI who underwent isolated CABG.

Impact of Body Mass Index on outcomes in hospitalized heart failure patients with reduced versus preserved ejection fraction: a 1,699,494-individual analysis from the United States National Inpatient Sample

BACKGROUND

Obesity's effect on outcomes in heart failure (HF) patients with reduced versus maintained ejection fraction (HFrEF and HFpEF) remains debatable. We evaluated hospital outcomes and healthcare expenditures in these patients based on their Body Mass Index (BMI).

METHODS

Using the USA National Inpatient Sample (NIS) database, patients >18 years admitted with a primary diagnosis of HFrEF or HFpEF between January 1, 2004, and August 31, 2015, were studied. Patients were stratified into the following BMI categories: underweight, normal weight, overweight, obese, and morbidly obese. Adjusted multivariable analyses using Poisson regression models were used to study the association between BMI and hospital outcomes and healthcare costs.

RESULTS

Overall, 1,699,494 patients were included. After full adjustment, obesity (OR=1.84; 95% CI: 1.22-2.76) and morbid obesity (OR=1.81; 95% CI: 1.22-2.70) increased the odds of in-hospital mortality compared with normal weight. When stratified per ejection fraction, underweight patients had higher odds of in-hospital mortality in HFrEF (OR=1.46; 95% CI: 1.06-2.01). Obese and morbidly obese patients had higher odds of in-hospital mortality in both HFrEF and HFpEF. Furthermore, obese and morbidly obese patients had a longer mean adjusted length of stay and higher health care expenses.

CONCLUSIONS

Being underweight is associated with increased risk of in-hospital mortality in HFrEF patients. Obesity and morbid obesity increase the risk of in-hospital mortality and higher healthcare costs in both HFrEF and HFpEF. These findings have clinical significance for HF patients, and further research is needed to investigate the ideal weight for HF patients.

Impact of chest pain center quality control indicators on mortality risk in ST-segment elevation myocardial infarction patients: a study based on Killip classification

Background

Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. This study evaluates the influence of CPC quality control indicators on mortality risk in STEMI patients receiving primary percutaneous coronary intervention (PPCI) during the COVID-19 pandemic.

Methods

A cohort of 664 consecutive STEMI patients undergoing PPCI from 2020 to 2022 was analyzed using Cox proportional hazards regression models. The cohort was stratified by Killip classification at admission (Class 1: n = 402, Class ≥2: n = 262).

Results

At a median follow-up of 17 months, 35 deaths were recorded. In Class ≥2, longer door-to-balloon (D-to-B) time, PCI informed consent time, catheterization laboratory activation time, and diagnosis-to-loading dose dual antiplatelet therapy (DAPT) time were associated with increased mortality risk. In Class 1, consultation time (notice to arrival) under 10 min reduced death risk. In Class ≥2, PCI informed consent time under 20 min decreased mortality risk.

Conclusion

CPC quality control metrics affect STEMI mortality based on Killip class. Key factors include time indicators and standardization of CPC management. The study provides guidance for quality care during COVID-19.

Efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway in patients with ST-elevation myocardial infarction: A meta-analysis

BACKGROUND

The NLRP3/IL-1β/IL-6 pathway plays a key role in mediating inflammatory responses after ST-elevation myocardial infarction (STEMI). However, the clinical benefits of inhibiting this pathway in STEMI are uncertain. We aimed to evaluate the efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway in STEMI patients.

METHODS

This study followed PRISMA guidelines. PubMed, Embase, CENTRAL and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) of inhibiting the NLRP3/IL-1β/IL-6 pathway in STEMI patients within 7 days of symptom onset. The efficacy outcomes included all-cause death, cardiovascular death, recurrent MI, new-onset or worsening heart failure (HF) and stroke. The safety outcomes were serious infection, gastrointestinal adverse events and injection site reactions.

RESULTS

Of 316 screened records, nine trials with 1211 patients were included in the meta-analysis. Colchicine reduced the risk of recurrent MI (RR 0.28, 95% CI 0.10-0.74; I2  = 0.0%). Anakinra was associated with reduced risk of new-onset or worsening HF (RR 0.32, 95% CI 0.13-0.77; I2  = 0.0%) and decreased C-reactive protein levels (SMD -1.34, 95% CI -2.04 to -0.65; I2  = 0.0%). Colchicine and anakinra increased the risk of gastrointestinal adverse events (RR 4.43, 95% CI 2.75-7.13; I2  = 38.1%) and injection site reactions (RR 4.52, 95% CI 1.32-15.49; I2  = 0.8%), respectively. None of the three medications affected the risks of all-cause death, cardiovascular death, stroke and serious infection.

CONCLUSIONS

There is still no large-scale RCT evidence on the efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway for the treatment of STEMI. Preliminary results from the available RCTs suggest colchicine and anakinra may respectively reduce the risks of recurrent MI and new-onset or worsening HF. The available RCTs in this meta-analysis lack power to determine any differences on mortality.

Serum total bilirubin level is associated with contrast induced nephropathy after primary percutaneous coronary intervention

Contrast Induced Nephropathy (CIN) is a major complication of angiographic procedures. Primary percutaneous coronary intervention (pPCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) but is associated with a risk of CIN. Oxidative stress and free radical damage play a role in the pathogenesis of CIN. Bilirubin has anti-inflammatory and antioxidant activity and has been shown to have a protective effect on endothelial cells. The present study aimed to assess the association between serum bilirubin level and development of CIN after pPCI. Sequential STEMI patients (n = 595) who underwent pPCI between January 2021 and December 2022 were enrolled. Among the participants, 116 (19.5%) developed CIN. Serum total bilirubin level was significantly lower in the CIN group (P = .001). In multivariate logistic regression analysis, serum bilirubin level was found as an independent predictor of CIN. Age, gender, contrast volume, and white blood cell count were other independent predictors of CIN. A higher serum bilirubin level is associated with a lower risk of CIN in the present study. In STEMI patients undergoing pPCI, serum bilirubin level may be helpful to predict the risk of CIN and may help ensure early initiation of preventive treatment and careful follow-up.

Reduced Left Ventricular Twist Early after Acute ST-Segment Elevation Myocardial Infarction as a Predictor of Left Ventricular Adverse Remodelling

BACKGROUND

The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients.

METHODS

The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%.

RESULTS

Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months.

Implementation of the ESC STEMI guidelines in female and elderly patients over a 20-year period in a large German registry

AIMS

We investigated the implementation of new guidelines in ST-segment elevation myocardial infarction (STEMI) patients in a large real-world patient population in the metropolitan area of Berlin (Germany) over a 20-year period.

METHODS

From January 2000 to December 2019, a total of 25 792 patients were admitted with STEMI to one of the 34 member hospitals of the Berlin-Brandenburg Myocardial Infarction Registry (B2HIR) and were stratified for sex and age < 75 and ≥ 75 years.

RESULTS

The median age of women was 72 years (IQR 61-81) compared to 61 years in men (IQR 51-71). PCI treatment as a standard of care was implemented in men earlier than in women across all age groups. It took two years from the 2017 class IA ESC STEMI guideline recommendation to prefer the radial access route rather than femoral until > 60% of patients were treated accordingly. In 2019, less than 60% of elderly women were treated via a radial access. While the majority of patients < 75 years already received ticagrelor or prasugrel as antiplatelet agent in the year of the class IA ESC STEMI guideline recommendation in 2012, men ≥ 75 years lagged two years and women ≥ 75 three years behind. Amongst the elderly, in-hospital mortality was 22.6% (737) for women and 17.3% (523) for men (p < 0.001). In patients < 75 years fatal outcome was less likely with 7.2% (305) in women and 5.8% (833) in men (p < 0.001). After adjustment for confounding variables, female sex was an independent predictor of in-hospital mortality in patients ≥ 75 years (OR 1.37, 95% CI 1.12-1.68, p = 0.002), but not in patients < 75 years (p = 0.076).

CONCLUSION

In-hospital mortality differs considerably by age and sex and remains highest in elderly patients and in particular in elderly females. In these patient groups, guideline recommended therapies were implemented with a significant delay.

Impact of right coronary artery dominance on the long-term mortality in the patients with acute total/subtotal occlusion of unprotected left main coronary artery

BACKGROUND

Patients with a right dominant coronary artery anatomy account for a significant proportion of acute myocardial infarction cases, and this condition is associated with a better prognosis. However, there are limited data on the impact of coronary dominance on patients with acute total/subtotal occlusion of unprotected left main coronary artery (ULMCA).

METHODS

This study aimed to assess the impact of right coronary artery (RCA) dominance on long-term mortality in patients with acute total/subtotal occlusion of the ULMCA. From a multicenter registry, 132 cases of consecutive patients who had undergone emergent percutaneous coronary intervention (PCI) due to acute total/subtotal occlusion of the ULMCA were reviewed.

RESULTS

Patients were classified into two groups according to the size of their RCA (dominant RCA group, n = 29; non-dominant RCA group, n = 103). Long-term outcomes were examined according to the presence of dominant RCA. Cardiopulmonary arrest (CPA) occurred in 52.3 % of patients before revascularization. All-cause death was significantly lower in the dominant RCA group than in the non-dominant RCA group. In the Cox regression model, dominant RCA was an independent predictor of all-cause death, as well as total occlusion of ULMCA, collateral from RCA, chronic kidney disease, and CPA. Patients were further analyzed according to the degree of stenosis of the ULMCA; patients with non-dominant RCA and total occlusive ULMCA had the worst outcome compared with the other groups.

CONCLUSIONS

A dominant RCA might improve long-term mortality in patients with acute total/subtotal occlusion of the ULMCA who were treated with PCI.

Circulating miR-183-5p levels are positively associated with the presence and severity of coronary artery disease

Background

Serum miR-183-5p levels are associated with carotid atherosclerosis, while less is known about the relationship between circulating miR-183-5p levels and stable coronary artery disease (CAD).

Methods

In this cross-sectional study, consecutive patients with chest pain who underwent coronary angiograms from January 2022 to March 2022 at our center were enrolled. Those presenting acute coronary syndrome or had a prior CAD were excluded. Clinical presentations, laboratory parameters, and angiographic findings were collected. Serum miR-183-5p levels were measured using quantitative real-time polymerase chain reaction. CAD severity was displayed as the number of diseased vessels and further evaluated by the Gensini score system.

Results

Overall, 135 patients (median age, 62.0 years; male, 52.6%) were included in the present study. Stable CAD was identified in 85.2% of the study population, with 45.9% having 1-vessel disease, 21.5% having 2-vessel disease, and 17.8% having 3-vessel or left main disease. Serum miR-183-5p levels were significantly increased in CAD patients with different severities than non-CAD patients (all adjusted p < 0.05). Serum miR-183-5p levels increased as tertiles of the Gensini score progressed (all adjusted p < 0.05). Importantly, serum miR-183-5p levels could predict the presence of CAD and 3-vessel or left main disease in the receiver operating characteristic curve analysis (both p < 0.01), and also in multivariate analysis adjusting for age, sex, body mass index, diabetes, hypersensitive-C-reactive protein (both p < 0.05).

Conclusion

Serum miR-183-5p levels are independently and positively correlated with CAD presence and severity.

Presentation, Management and Early Mortality of Patients with Acute Coronary Syndrome in a Large Sample Study of a Middle East Country

Background

Due to lack of contemporary data on the presentation, management, and mortality of acute coronary syndrome (ACS) admissions in Iran, in this prospective registry study, we aimed to evaluate the presentation, management, and mortality as the outcome of patients with ACS in Isfahan, Iran, 2001-2016 to address treatment and healthcare depletions.

Methods

Data of 62,276 patients admitted with the diagnosis of ACS from 2001 to 2016 prospectively were obtained by Surveillance Unit of Isfahan Cardiovascular Research Center, Isfahan, Iran, in 13 hospitals of Isfahan province. We evaluated data on presentation, management, and in-hospital and 28-day mortality.

Results

Nearly half of the patients ranged in age from 51 to 70 years (32050, 51.5%), which did not differ among ACS types (ST-segment myocardial infarction (STEMI): 53.9%; non-STEMI: 53.4%; unstable angina: 51.9%). In-hospital, anti-platelets use was high (84.9%). Thrombolytic were used in 48.1% of STEMI, 3.8% of non-STEMI, and 1.1% of unstable angina. Discharge medication rates were suboptimal. In-hospital and 28-day mortality were highest for STEMI (6.5 and 12.6%, respectively).

Conclusions

These data represent the large ACS registry in Iran. Data revealed the various presentations of ACS and demonstrated opportunities for improving ACS management by focusing on increasing use of recommended drugs especially after discharge due to suboptimal medical treatment in these patients. The high mortality rate needs to be taken into consideration in ACS patients.

Evaluation of Intermountain Risk Score for Short- and Long-Term Mortality in ST Elevation Myocardial Infarction Patients

The aim of this study was to examine the Intermountain Risk Score (IMRS) for short- and long-term mortality in ST elevation myocardial infarction (STEMI) patients and compare it with the well-known risk scores, such as the Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE). In this retrospective and cross-sectional study, 1057 consecutive patients with STEMI were evaluated. The end-points of the study were short- and long-term mortality. The overall mortality rate was 16% (n = 170 patients). The IMRS was significantly higher in STEMI patients who did not survive compared with those who survived. According to multivariable COX proportional regression analysis, the IMRS was independently related to both short- (HR: 1.482, 95% CI: 1.325-1.675, p < .001) and long-term mortality (HR: 1.915, 95% CI: 1.711-2.180, p < .001). The comparison of receiver operating characteristic curves revealed that the IMRS had non-inferior predictive capability for short- and long-term mortality than the TIMI and GRACE risk scores. To the best of our knowledge, this is the first study to show that the IMRS can predict short- and long-term prognosis of patients with STEMI. Further, the IMRS' predictive value for overall mortality was non-inferior compared with TIMI and GRACE scores.

ST elevation myocardial infarction - national trend analysis with mortality differences in outcomes based on day of hospitalization

BACKGROUND

Patientswho present with acute ST elevation myocardial infarction (STEMI) need emergent revascularization. Our study aims to investigate the outcomes in patients with STEMI admitted during weekends versus weekdays.

METHODS

We conducted a retrospective analysis of the nationwide inpatient sample database. Patients with an admitting diagnosis of STEMI identified by the International Classification of Disease code for the year 2016 were analyzed. A weighted descriptive analysis was performed to generate national estimates. Patients admitted over the weekend were compared to those admitted over the weekday. Patients were stratified by demographic and clinical factors including the Elixhauser comorbidity index. The primary outcome was in-hospital mortality and secondary outcomes were percutaneous coronary intervention (PCI) utilization rate, rate of transfer-out, length of stay (LOS), and total hospital charges. Statistical analysis including linear and logistic regression was performed using STATA.

RESULTS

A total of 163 715 adult patients were admitted with STEMI, of which 27.9% (45 635) were admitted over the weekend. There were 76.2% Caucasians, 9.3% African Americans, and 8.0% Hispanics. Mean age of the patients was 63.2 years (95% CI, 62.9-63.5) for the weekend group and 63.7 years (95% CI, 63.5-63.9) for weekday admissions. The majority of the patients in both groups had Medicare (43.7% and 45.8% on weekends and weekdays, respectively; P = 0.0047). After adjusting for age, sex, race, income, Elixhauser comorbidity index, PCI use, hospital location, teaching status, and bed size, mortality was not significantly different in weekend versus weekday admissions (odds ratios 1.04; P = 0.498; 95% CI, 0.93-1.16). There was no significant difference in mean total charge per admission during the weekend versus weekday admissions ($107 093 versus $106 869; P = 0.99.) Mean LOS was 4.1 days for both groups (P = 0.81).

CONCLUSIONS

There were no significant differences in mortality, LOS, or total hospital charge in STEMI patients being admitted during the weekend versus weekdays.

Reproducing extracellular matrix adverse remodelling of non-ST myocardial infarction in a large animal model

The rising incidence of non-ST-segment elevation myocardial infarction (NSTEMI) and associated long-term high mortality constitutes an urgent clinical issue. Unfortunately, the study of possible interventions to treat this pathology lacks a reproducible pre-clinical model. Indeed, currently adopted small and large animal models of MI mimic only full-thickness, ST-segment-elevation (STEMI) infarcts, and hence cater only for an investigation into therapeutics and interventions directed at this subset of MI. Thus, we develop an ovine model of NSTEMI by ligating the myocardial muscle at precise intervals parallel to the left anterior descending coronary artery. Upon histological and functional investigation to validate the proposed model and comparison with STEMI full ligation model, RNA-seq and proteomics show the distinctive features of post-NSTEMI tissue remodelling. Transcriptome and proteome-derived pathway analyses at acute (7 days) and late (28 days) post-NSTEMI pinpoint specific alterations in cardiac post-ischaemic extracellular matrix. Together with the rise of well-known markers of inflammation and fibrosis, NSTEMI ischaemic regions show distinctive patterns of complex galactosylated and sialylated N-glycans in cellular membranes and extracellular matrix. Identifying such changes in molecular moieties accessible to infusible and intra-myocardial injectable drugs sheds light on developing targeted pharmacological solutions to contrast adverse fibrotic remodelling.

T-MACS score vs HEART score identification of major adverse cardiac events in the emergency department

BACKGROUND

Ischemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising.

OBJECTIVE

The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain.

METHOD

This study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level.

RESULTS

The 514 patients included in our study had a mean age of 52.01 ± 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percutaneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the very low risk classification were 93.90% (86.3%-98.0%) and 97.7% (94.7%-99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%-93.1%) and 96.6% (94.2%-98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%-100%) and 97.2% (82.9%-99.6%), respectively for the T-MACS score and 95.14% (92.7%-97%) and 63.2% (51.4%-73.5%), respectively for the HEART score.

CONCLUSION

The T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

INTRODUCTION

Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.

OBJECTIVES

To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.

METHODS

We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.

RESULTS

Median DIDO time was 82 min (interquartile range, 61-132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062-1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).

CONCLUSION

A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Predictive value of myocardial strain on myocardial infarction size by cardiac magnetic resonance imaging in ST-segment elevation myocardial infarction with preserved left ventricular ejection fraction

Background: The correlation between myocardial strain and infraction size by cardiac magnetic resonance imaging in ST-segment elevation myocardial infarction (STEMI) with preserved left ventricular ejection fraction (LVEF) is not clear.

Objective: To investigate the correlation between myocardial strain and myocardial infarction size in patients of acute STEMI with preserved LVEF.

Materials and Methods: A retrospective study was conducted to assess 31 patients with acute ST-segment elevation myocardial infarction (STEMI)after primary percutaneous coronary intervention (PCI) who received cardiac magnetic resonance (CMR) imaging during hospitalization at the Central Hospital of Shandong First Medical University from 2019 to 2022 and whose echocardiography indicated preserved LVEF (LVEF≥50%). The control group consisted of 21 healthy adults who underwent CMR during the same period. We compared the CMR characteristics, global and segmental strain between the two groups. Furthermore, the correlation between the global strain and the segmental strain of the left ventricle and late gadolinium enhancement (LGE) were evaluated.

Results: Compared with healthy controls, the left ventricular ejection fraction (LVEF) of STEMI patients with preserved LVEF was significantly decreased (p < 0.05). Moreover, the global radial strain (GRS) (24.09% [IQR:17.88–29.60%] vs. 39.56% [IQR:29.19–42.20%], p < 0.05), global circumferential strain (GCS) [−14.66% (IQR: 17.91–11.56%) vs. −19.26% (IQR: 21.03–17.73%), p < 0.05], and global longitudinal strains (GLS) (−8.88 ± 2.25% vs. −13.46 ± 2.63%, p < 0.05) were damaged in patients. Furthermore, GCS and GLS were associated with LGE size (%left ventricle) (GCS: r = 0.58, p < 0.05; GLS: r = 0.37, p < 0.05). In the multivariate model, we found that LGE size was significantly associated with GCS (β coefficient = 2.110, p = 0.016) but was not associated with GLS (β coefficient = −0.102, p = 0.900) and LVEF (β coefficient = 0.227, p = 0.354). The receiver operating characteristic (ROC) results showed that GCS emerged as the strongest LGE size (LGE >25%) prognosticator among strain parameters (AUC: 0.836 [95% CI, 0.692—0.981], sensitivity: 91%, specificity: 80%) and was significantly better (p = 0.001) than GLS [AUC: 0.761 (95% CI, 0.583—0.939), sensitivity: 64%, specificity: 85%] and LVEF [AUC: 0.673 (95% CI, 0.469—0.877), sensitivity: 73%, specificity: 70%].

Conclusion: Among STEMI patients with preserved LVEF after PCI, CMR-FT-derived GCS had superior diagnostic accuracy than GLS and LVEF in predicting myocardial infarction size.

Trends, Advantages and Disadvantages in Combined Extracorporeal Lung and Kidney Support From a Technical Point of View

Extracorporeal membrane oxygenation (ECMO) provides pulmonary and/or cardiac support for critically ill patients. Due to their diseases, they are at high risk of developing acute kidney injury. In that case, continuous renal replacement therapy (CRRT) is applied to provide renal support and fluid management. The ECMO and CRRT circuits can be combined by an integrated or parallel approach. So far, all methods used for combined extracorporeal lung and kidney support present serious drawbacks. This includes not only high risks of circuit related complications such as bleeding, thrombus formation, and hemolysis, but also increase in technical workload and health care costs. In this sense, the development of a novel optimized artificial lung device with integrated renal support could offer important treatment benefits. Therefore, we conducted a review to provide technical background on existing techniques for extracorporeal lung and kidney support and give insight on important aspects to be addressed in the development of this novel highly integrated artificial lung device.

Differences in characteristics, treatments and outcomes in patients with non-ST-elevation myocardial infarction: novel insights from four national European continuous real-world registries

AIMS

To study baseline characteristics, in-hospital managements and mortality of non-ST-elevation myocardial infarction (NSTEMI) patients in different European countries.

METHODS AND RESULTS

NSTEMI patients enrolled in the national myocardial infarction (MI) registries [EMIR; n = 5817 (Estonia), HUMIR; n = 30 787 (Hungary), NORMI; n = 33 054 (Norway), and SWEDEHEART; n = 49 533 (Sweden)] from 2014 to 2017 were included and presented as aggregated data. The median age at admission ranged from 70 to 75 years. Current smoking status was numerically higher in Norway (24%), Estonia (22%), and Hungary (19%), as compared to Sweden (17%). Patients in Hungary had a high rate of diabetes mellitus (37%) and hypertension (84%). The proportion of performed coronary angiographies (58% vs. 75%) and percutaneous coronary interventions (38% vs. 56%), differed most between Norway and Hungary. Prescription of dual antiplatelet therapy at hospital discharge ranged from 60% (Estonia) to 81% (Hungary). In-hospital death ranged from 3.5% (Sweden) to 9% (Estonia). The crude mortality rate at 1 month was 12% in Norway and 5% in Sweden (5%), whereas the 1-year mortality rates were similar (20-23%) in Hungary, Estonia, and Norway and 15% in Sweden.

CONCLUSION

Cross-comparisons of four national European MI registries provide important data on differences in risk factors and treatment regiments that may explain some of the observed differences in death rates. A unified European continuous MI registry could be an option to better understand how implementation of guideline-recommended therapy can be used to reduce the burden of cardiovascular disease.

Evaluating the Impact of COVID-19 on a Regional Primary Percutaneous Coronary Intervention Service During the First Wave of COVID-19

Background: Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy in ST-segment elevation MI (STEMI). This study evaluates the impact of COVID-19 on the authors' pPCI service. Methods: A retrospective study of referrals to the Belfast pPCI service between 23 March and 9 June 2020 – the period of the first full lockdown in the UK – was performed. All ECGs were reviewed alongside patient history. A pPCI turndown was deemed inappropriate if the review demonstrated that the criteria to qualify for pPCI had been met. The number of pPCIs was compared with 2019. Results: The unit had 388 referrals in 78 days, from which 134 patients were accepted for pPCI and 235 referrals were turned down. Of these, nine (4%) were deemed inappropriate. No referrals were turned down because of COVID-19. Of the nine inappropriate cases, six had pPCI following re-referral, two had routine PCI and one had takotsubo syndrome. From the accepted cohort, 85% had pPCI. In the appropriate turndown cohort, there was a final cardiovascular diagnosis in 53% (n=127) of patients, 1-year mortality was 16% (n=38), 55% (n=21) of which were due to a cardiovascular death. There was a 29% reduction in the number of pPCIs performed compared with 2019. Conclusion: During the first wave of COVID-19 there was a significant reduction in the number of pPCIs performed at the Department of Cardiology at Royal Victoria Hospital in Belfast. This was not due to an increase in referrals being inappropriately turned down. The majority of the cohort who had their referral turned down had a final cardiovascular diagnosis unrelated to STEMI; 1-year mortality in this group was significant.

REPERFUSION INJURY IN ACUTE PERIOD OF MYOCARDIAL INFARCTION - WAYS OF PREVENTION AND CORRECTION

OBJECTIVE

The aim: To identify pathophysiological peculiarities of myocardial reperfusion injury and ways of its reduction based on the literature data analysis.

PATIENTS AND METHODS

Materials and methots: This literature review was made by searching the PubMed database using key words . Additional data were sought in the Google search engine by entering key words: " risk factors, ischemic heart disease, arrhythmia, sudden cardiac death, heart rhythm, heart failure." in the Polish, English, Russian and Ukrainian language versions.

CONCLUSION

Conclusions: Considering conducted data analysis, provided data indicate the prospects of phosphocreatine usage in treatment scheme of heart rhythm disorders and heart failure on the background of myocardial ischemia and elimination of reperfusion injury and myocardial remodeling consequences.

Myocardial Infarction Complications After Surgery in Vietnam: Estimates of Incremental Cost, Readmission Risk, and Length of Hospital Stay

Myocardial infarction is a considerable burden on public health. However, there is a lack of information about its economic impact on both the individual and national levels. This study aims to estimate the incremental cost, readmission risk, and length of hospital stay due to myocardial infarction as a post-operative complication. We used data from a standardized national system managed by the Vietnam Social Insurance database. The original sample size was 1,241,893 surgical patients who had undergone one of seven types of surgery. A propensity score matching method was applied to create a matched sample for cost analysis. A generalized linear model was used to estimate direct treatment costs, the length of stay, and the effect of the complication on the readmission of surgical patients. Myocardial infarction occurs most frequently after vascular surgery. Patients with a myocardial infarction complication were more likely to experience readmission within 30 and 90 days, with an OR of 3.45 (95%CI: 2.92–4.08) and 4.39 (95%CI: 3.78–5.10), respectively. The increments of total costs at 30 and 90 days due to post-operative myocardial infarction were 4,490.9 USD (95%CI: 3882.3–5099.5) and 4,724.6 USD (95%CI: 4111.5–5337.8) per case, while the increases in length of stay were 4.9 (95%CI: 3.6–6.2) and 5.7 (95%CI: 4.2–7.2) per case, respectively. Perioperative myocardial infarction contributes significantly to medical costs for the individual and the national economy. Patients with perioperative myocardial infarction are more likely to be readmitted and face a longer treatment duration.

Performance of Copeptin for Early Diagnosis of Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of 14,139 Patients

Diagnosis of acute coronary syndrome (ACS) based on copeptin level may enable one to confirm or rule-out acute myocardial infarction (AMI) with higher sensitivity and specificity, which may in turn further reduce mortality rate and decrease the economic costs of ACS treatment. We conducted a systematic review and meta-analysis to investigate the relationship between copeptin levels and type of ACS. We searched Scopus, PubMed, Web of Science, Embase, and Cochrane to locate all articles published up to 10 October 2021. We evaluated a meta-analysis with random-effects models to evaluate differences in copeptin levels. A total of 14,139 patients (4565 with ACS) were included from twenty-seven studies. Copeptin levels in AMI and non-AMI groups varied and amounted to 68.7 ± 74.7 versus 14.8 ± 19.9 pmol/L (SMD = 2.63; 95% CI: 2.02 to 3.24; p < 0.001). Copeptin levels in the AMI group was higher than in the unstable angina (UAP) group, at 51.9 ± 52.5 versus 12.8 ± 19.7 pmol/L (SMD = 1.53; 95% CI: 0.86 to 2.20; p < 0.001). Copeptin levels in ST-elevation myocardial infarction (STEMI) versus non-ST elevation myocardial infarction (NSTEMI) patient groups were 54.8 ± 53.0 versus 28.7 ± 46.8 pmol/L, respectively (SMD = 1.69; 95% CI: = 0.70 to 4.09; p = 0.17). In summary, elevated copeptin levels were observed in patients with ACS compared with patients without ACS. Given its clinical value, copeptin levels may be included in the assessment of patients with ACS as well as for the initial differentiation of ACS.

Zwolle Risk Score for Safety Assessment of Same-day Discharge after Primary Percutaneous Coronary Intervention

OBJECTIVES

The Zwolle risk score (ZRS) has been considered to be a useful tool for the systematic evaluation of patients for early discharge after primary percutaneous coronary intervention (PCI). Therefore, aim of this study was to evaluate the clinical utility of ZRS for the same-day discharge strategy after primary PCI at a tertiary care cardiac center of Karachi, Pakistan.

METHODS

This study was conducted at a tertiary care cardiac center between August 2019 and July 2020. Patients discharged within 24 h (same-day) of the primary PCI procedure were included. Patients were stratified as high- and low-risk based on ZRS score; low-risk (≤3) and high-risk (≥4). All patients were followed during 30-days post-procedure period for major adverse cardiac events (MACE).

RESULTS

Out of 487 patients, 83.2% (405) were male and mean age was 54.6 ± 10.87 years. Mean ZRS was 2.34 ± 1.64 with 16.0% (78) patients in high-risk (≥4) group. 30-days MACE rate was observed to be 5.3% (26) with significantly higher rate among high-risk patients as compared to low-risk patients 12.8% (10) vs. 3.9% (16); p = 0.004 respectively with OR of 3.61 [1.57-8.29]. The area under the curve (AUC) of ZRS for prediction of 30-day MACE was 0.67 [95% CI: 0.58-0.77], ZRS ≥4 had sensitivity of 38.5% and specificity of 85.2% with AUC of 0.62 [95% CI: 0.50-0.74] for prediction of 30-day MACE.

CONCLUSION

ZRS showed moderate discriminating potential in identifying patients with high-risk of MACE at 30-day after same-day discharge after primary PCI.

Effect of regional cooperative rescue systems based on chest pain centers for patients with acute myocardial infarction in a first-tier city in China

Given the increasing burden of acute myocardial infarction (AMI) in China, regional cooperative rescue systems have been constructed based on chest pain centers (CPCs). This study evaluated the effects of these regional cooperative rescue systems on reperfusion time and prognosis of AMI patients. This study included 1937 AMI patients, divided into two groups according to the date of admission, group A (July 2017-June 2018) and group B (July 2018-June 2019). Reperfusion time, the fatality rate for any cause during hospitalization, and the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the 6 months following discharge were compared between the two groups. The proportion of patients treated within the guideline goals for first medical contact to balloon (FMC-to-B) time showed improvement from 40.7% in group A to 50.4% in group B (P = 0.005). The fatality rate for any cause (5.5% vs. 8.0%, P = 0.026) during hospitalization was lower in the B group compared to the A group. Multivariate logistic regression analysis revealed that the fatality rate for any cause (OR 0.614, 95% CI 0.411-0.918, P = 0.017) was significantly lower in group B compared with group A. No significant differences were detected between the two groups for the incidence of MACCE and death for any cause at 6 months using the log-rank test and multivariate Cox regression analysis. The improvement of regional cooperative rescue systems shortened system delays and reduced in-hospital deaths. Although the system has resulted in some substantial improvements, additional improvement is needed.

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.

St-Elevation Myocardial Infarction Patients with Hyperglycemia: Effects of Intravenous Adenosine

BACKGROUND

Admission hyperglycemia is common in subjects with acute myocardial infarction (AMI). Reperfusion therapy with primary percutaneous coronary intervention (PPCI) represents the leading therapeutic choice, in particular in ST-segment elevation myocardial infarction (STEMI). Despite this, mortality, re-hospitalizations and complications remain a relevant problem. Adenosine, a purine nucleoside, may reduce no-reflow. Therefore, we studied the effects of intravenous infusion of adenosine in addition to primary percutaneous coronary intervention (PPCI) in hyperglycemic patients with STEMI.

METHODS

We evaluated 836 patients with STEMI and admission hyperglycemia (glycemia > 140 mg/dL). At the end, 399 patients were entered into the database. Patients were grouped on the basis of whether they received adenosine or not.

RESULTS

A total of 199 patients received intravenous adenosine infusion and PPCI and 200 patients did not. Kaplan-Meier analysis demonstrated significant differences in all death, cardiac death, re-hospitalization for heart failure and for acute coronary syndrome in the adenosine treated group.

CONCLUSIONS

The effects of intravenous infusion of adenosine and PPCI on clinical outcomes are significant but we need future larger studies with larger follow-up and statistical analysis to confirm our results.

Outcomes of Acute Myocardial Infarction in Patients with Familial Hypercholesteremia

BACKGROUND

There is a paucity of contemporary data regarding the outcomes of acute myocardial infarction among patients with familial hypercholesteremia.

METHODS

We queried the Nationwide Readmissions Database (2016-2018) for hospitalizations with acute myocardial infarction. Multivariable regression analysis was used to compare in-hospital outcomes and 30-day readmissions among patients with and without familial hypercholesteremia.

RESULTS

The analysis included 1,363,488 hospitalizations with acute myocardial infarction. The prevalence of familial hypercholesteremia was 0.07% among acute myocardial infarction admissions. Compared with those without familial hypercholesteremia, admissions with familial hypercholesteremia were younger and had less comorbidities but were more likely to have had prior infarct and revascularization. Admissions with familial hypercholesteremia were more likely to present with ST-elevation myocardial infarction and undergo revascularization. After multivariable adjustment, there was no difference in in-hospital case fatality among patients with hypercholesteremia compared with those without it (adjusted odds ratio [aOR] = 0.76; 95% confidence interval [CI] 0.41-1.39). Admissions with acute myocardial infarction and familial hypercholesteremia had higher adjusted rates of cardiac arrest and utilization of mechanical support. There were no group differences in overall 30-day readmission (aOR 0.75; 95% CI 0.51-1.10) or 30-day readmission for acute myocardial infarction. However, a nonsignificant trend toward higher readmission for percutaneous coronary intervention was observed among patients with familial hypercholesteremia (aOR 1.89; 95% CI 0.98-3.64).

CONCLUSION

In this contemporary nationwide observational analysis, patients with familial hypercholesteremia represent a small proportion of the overall population with acute myocardial infarction and have a distinctive clinical profile but do not appear to have worse in-hospital case fatality compared with those without familial hypercholesteremia.

Safety and Feasibility of Same Day Discharge Strategy for Primary Percutaneous Coronary Intervention

Background:

The strategy for early discharge after primary percutaneous coronary intervention (PCI) could have substantial financial benefits, especially in low-middle income countries. However, there is a lack of local evidence on feasibility and safety of the strategy for early discharge. Therefore, the aim of this study was to assess the safety of early discharge after primary PCI in selected low-risk patients in the population of Karachi, Pakistan.

Methods:

In this study 600 consecutive low-risk patients who were discharged within 48 hours of primary PCI were put under observation for major adverse cardiac events (MACE) after 7 and 30 days of discharge respectively. Patients were further stratified into discharge groups of very early (≤ 24 hours) and early (24 to 48 hours).

Results:

The sample consisted of 81.8% (491) male patients with mean age of 54.89 ± 11.08 years. Killip class was I in 90% (540) of the patients. The majority of patients (84%) were discharged within 24 hours of the procedure. Loss to follow-up after rate at 7 and 30 days was 4% (24) and 4.3% (26) respectively. Cumulative MACE rate after 7 and 30 days was observed in 3.5% and 4.9%, all-cause mortality in 1.4% and 2.3%, cerebrovascular events in 0.9% and 1.4%, unplanned revascularization in 0.9% and 1.2%, re-infarction in 0.3% and 0.5%, unplanned re-hospitalization in 0.5% and 0.5%, and bleeding events in 0.5% and 0.5% of the patients respectively.

Conclusion:

It was observed that very early (≤ 24 hours) discharge after primary PCI for low-risk patients is a safe strategy subjected to careful pre-discharge risk assessment with minimal rate of MACE after 7-days as well as 30-days.

Inhibiting miR-205 Alleviates Cardiac Ischemia/Reperfusion Injury by Regulating Oxidative Stress, Mitochondrial Function, and Apoptosis

BACKGROUND

miR-205 is important for oxidative stress, mitochondrial dysfunction, and apoptosis. The roles of miR-205 in cardiac ischemia/reperfusion (I/R) injury remain unknown. The aim of this research is to reveal whether miR-205 could regulate cardiac I/R injury by focusing upon the oxidative stress, mitochondrial function, and apoptosis.

METHODS

Levels of miR-205 and Rnd3 were examined in the hearts with I/R injury. Myocardial infarct size, cardiac function, oxidative stress, mitochondria function, and cardiomyocyte apoptosis were detected in mice with myocardial ischemia/reperfusion (MI/R) injury. The primary neonatal cardiomyocytes underwent hypoxia/reoxygenation (H/R) to simulate MI/R injury.

RESULTS

miR-205 levels were significantly elevated in cardiac tissues from I/R in comparison with those from Sham. In comparison with controls, levels of Rnd3 were significantly decreased in the hearts from mice with MI/R injury. Furthermore, inhibiting miR-205 alleviated MI/R-induced apoptosis, reduced infarct size, prevented oxidative stress increase and mitochondrial fragmentation, and improved mitochondrial functional capacity and cardiac function. Consistently, overexpression of miR-205 increased infarct size and promoted apoptosis, oxidative stress, and mitochondrial dysfunction in mice with MI/R injury. In cultured mouse neonatal cardiomyocytes, downregulation of miR-205 reduced oxidative stress in H/R-treated cardiomyocytes. Finally, inhibiting Rnd3 ablated the cardioprotective effects of miR-205 inhibitor in MI/R injury.

CONCLUSIONS

We conclude that inhibiting miR-205 reduces infarct size, improves cardiac function, and suppresses oxidative stress, mitochondrial dysfunction, and apoptosis by promoting Rnd3 in MI/R injury. miR-205 inhibitor-induced Rnd3 activation is a valid target to treat MI/R injury.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Economic Burden of Myocardial Infarction Combined With Dyslipidemia

Background: Dyslipidemia is a common comorbidity and an important risk factor for myocardial infarction (MI). This study aimed to examine the economic burden of MI combined with dyslipidemia in China. Methods: Patients who were hospitalized due to MI combined with dyslipidemia in 2016 were enrolled. Costs were measured based on electronic medical records and questionnaires. The annual costs were analyzed by conducting descriptive statistics, univariable, and multivariable analyses. Results: Data of 900 patients were analyzed, and 144 patients were dead during the follow-up. The majority of patients were aged 51-70 years (n = 563, 62.55%) and males (n = 706, 78.44%). For all-cause costs, the median annual direct medical costs, direct non-medical costs, indirect costs, and total costs were RMB 13,168 (5,212-29,369), RMB 600 (0-1,750), RMB 676 (0-1,787), RMB 15,361 (6,440-33,943), respectively; while for cardiovascular-related costs, the corresponding costs were RMB 12,233 (3,795-23,746), RMB 515 (0-1,680), RMB 587 (0-1,655), and RMB 14,223 (4,914-28,975), respectively. Lifestyle and complications significantly affected both all-cause costs and cardiovascular-related costs. Conclusions: Increasing attention should be paid to encourage healthy lifestyle, and evidence-based medicine should focus on optimal precautions and treatments for complications, to reduce the economic burden among MI patients with a comorbid dyslipidemia.

Outcomes After ST-Segment Versus Non-ST-Segment Elevation Myocardial Infarction Revascularized by Coronary Artery Bypass Grafting

The objectives of this study were to investigate the outcome differences between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients treated with coronary artery bypass grafting surgery (CABG). We conducted a multicenter, retrospective cohort follow-up study of consecutive patients with STEMI (surgery ≤48 hours of admission; n = 348) or NSTEMI (n = 1,160) revascularized with first-time isolated CABG in Finland using nationwide registries (median age 68 years, 24% women). The short- and long-term (10-year) outcomes were studied with inverse propensity probability weight adjustment for baseline features. The median follow-up was 5.2 years. In-hospital mortality (11.4% vs 5.3%; adj. odds ratio [OR] 2.27; confidence interval [CI] 1.41 to 3.66; p = 0.001) and re-sternotomy rates (6.9% vs 3.5%; adj. OR 2.07; CI 1.22 to 3.51; p = 0.007) were higher in STEMI patients. Long-term all-cause mortality did not differ between STEMI and NSTEMI patients among all operated patients (30.2% vs 28.3%; adj. HR 1.30; CI 0.97 to 1.75; p = 0.080) or hospital survivors (21.6 vs 24.3%; HR 0.93; CI 0.64 to 1.36; p = 0.713). Occurrence of major adverse cardiovascular event in hospital survivors within 10 years was 34.7% in STEMI versus 29.6% in NSTEMI (adj. HR 1.24; CI 0.88 to 1.76; p = 0.220). Occurrences of cardiovascular death (14.6% vs 14.4%; p = 0.773), myocardial infarction (MI; 15.2% vs 10.3%; p = 0.203), and stroke (10.8% vs 14.8%; p = 0.242) were also comparable. In conclusion, patients with STEMI have poorer short-term outcome compared to NSTEMI patients after revascularization by CABG, but the long-term outcomes are comparable regardless of MI type. Thus, both short- and long-term risks should be considered when evaluating patient´s for CABG eligibility by MI type.

Therapeutic Hypothermia in STEMI

In this review article we tried to find an answer to the question, should local coronary hypothermia be a part of the early reperfusion strategy in patients with STEMI to prevent reperfusion injury, no-reflow phenomenon, and to reduce the infarct size and mortality. Hypothermia can save cardiomyocytes if achieved in a timely fashion before reperfusion. Intracoronary hypothermia can be adjunct to PCI by lessening ischemia/reperfusion injury on cardiomyocytes and reduction in infarct size. Reperfusion induced Calcium overload, generation of ROS and subsequent activation of Mitochondrial permeability transition pore (MPT) are major contributors to reperfusion injury. Hypothermia reduces calcium loading of the cell and maintains cellular energy and tissue level glucose which can scavenger ROS. Hypothermia reduces MPT activation and thus reduces infarct size. Systemic cooling trials failed to reduce infarct size, perhaps because the target temperature was not reached fast enough, and it was associated with systemic side effects. The need for rapid induction of hypothermia to <35 °C with the ethical concern of delaying reperfusion while cooling the patient and the inconsistency of endovascular cooling results lead to a belief that endovascular cooling may exceed the acceptable level of invasiveness in the context of other novels cardioprotective, regenerative and reperfusion therapies. Clinical trials showed the safety and feasibility of novel intracoronary hypothermia with rapid induction and maintenance of hypothermia using routine PCI equipment ahead of reperfusion. Two phases of cooling were applied without significant delay in the door to balloon time. Cooling of the coronary artery leads to cooling of its dependant myocardium without affecting adjacent myocardium. Heat transfer occurred by heat conduction during the occlusion phase and heat convention during the reperfusion phase. Fine-tuning of saline temperature and infusion rate helped to improve the protocol. The best duration of hypothermia before and after reperfusion is not known and needs further investigation. A balance between the undoubted cardioprotective effects of hypothermia with iatrogenic prolongation of ischemia time needs to be established. A reduction in infarct size was observed but needs to be validated with large randomized trials. Furthermore, it might be possible to augment the cardioprotective effects of intracoronary hypothermia by combination with other cardioprotective approaches such as antioxidant drugs and afterload reducing agents.

Radial artery harvesting in coronary artery bypass grafting surgery-Endoscopic or open method? A meta-analysis

We analyzed the clinical outcomes of open radial artery harvesting (OAH) and endoscopic radial artery harvesting (EAH) undergoing coronary artery bypass grafting (CABG). We designed this meta-analysis conducted using Pubmed, Medline, the Cochrane Library, and EMBASE. Articles with comparisons of OAH and EAH undergoing CABG were included. Primary outcomes included the wound infection rate, the wound complication rate, neurological complications of the forearm, in-hospital mortality, long-term survival, and the patency rate. The results of our study included six randomized controlled trials (RCTs), two non-randomized controlled trials (NRCTs) with matching, and 10 NRCTs. In total, 2919 patients were included in 18 studies, while 1187 (40.7%) and 1732 (59.3%) patients received EAH and OAH, respectively. EAH was associated with a lower incidence of wound infection (RR = 0.29, 95% confidence interval (CI) = 0.14 to 0.60, p = 0.03), and neurological complications over the harvesting site (RR = 0.41, 95% CI = 0.27 to 0.62, p < 0.0001). There was no significant difference in 30-day mortality, long-term survival (over one year), and the graft patency rate. According to our analysis, endoscopic radial artery harvesting can improve the outcome of the harvesting site, without affecting the mortality, long-term survival, and graft patency.

Acute and 1-Year Hospitalization Costs for Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention: Results From the TRANSLATE-ACS Registry

Background

Hospitalization for acute myocardial infarction (MI) in the United States is both common and expensive, but those features alone provide little insight into cost‐saving opportunities.

Methods and Results

To understand the cost drivers during hospitalization for acute MI and in the following year, we prospectively studied 11 969 patients with acute MI undergoing percutaneous coronary intervention at 233 US hospitals (2010–2013) from the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) registry. Baseline costs were collected in a random subset (n=4619 patients, 54% ST‐segment–elevation MI [STEMI]), while follow‐up costs out to 1 year were collected for all patients. The mean index length of stay was 3.1 days (for both STEMI and non‐STEMI) and mean intensive care unit length of stay was 1.2 days (1.4 days for STEMI and 1.0 days for non‐STEMI). Index hospital costs averaged $18 931 ($19 327 for STEMI, $18 465 for non‐STEMI), with 45% catheterization laboratory–related and 20% attributable to postprocedure hospital stay. Patient factors, including severity of illness and extent of coronary disease, and hospital characteristics, including for profit status and geographic region, identified significant variations in cost. Intensive care was used for 53% of non‐STEMI and increased costs by $3282. Postdischarge 1‐year costs averaged $8037, and 48% of patients were rehospitalized (half within 2 months and 57% with a cardiovascular diagnosis).

Conclusions

While much of the cost of patients with acute MI treated with percutaneous coronary intervention is probably not modifiable by the care team, cost reductions are still possible through quality‐preserving practice efficiencies, such as need‐based use rather than routine use of intensive care unit for patients with stable non‐STEMI.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00097591.

See Editorial Weintraub

Trends of Clinical Outcomes and Health Care Resource Use in Heart Failure in the United States

Background Heart failure (HF) imparts a significant clinical and economic burden on the health system in the United States. Methods and Results We used the National Inpatient Sample database between September 2002 and December 2016. We examined trends of comorbidities, inpatient mortality, and healthcare resource use in patients admitted with acute HF. Outcomes were adjusted for demographic variables, comorbidities, and inflation. A total of 11 806 679 cases of acute HF hospitalization were identified. The burden of coronary artery disease, peripheral vascular disease, valvular heart disease, diabetes mellitus, hypertension, anemia, cancer, depression, and chronic kidney disease among patients admitted with acute HF increased over time. The adjusted mortality decreased from 6.8% in 2002 to 4.9% in 2016 (P-trend<0.001; average annual decline, 1.99%), which was consistent across age, sex, and race. The adjusted mean length of stay decreased from 8.6 to 6.5 days (P<0.001), but discharge disposition to a long-term care facility increased from 20.8% to 25.6% (P<0.001). The adjusted mean cost of stay increased from $51 548 to $72 075 (P<0.001; average annual increase, 2.78%), which was partially explained by the higher proportion of procedures (echocardiogram, right heart catheterization, use of ventricular assist devices, coronary artery bypass grafting) and the higher incidence of HF complications (cardiogenic shock, respiratory failure, ventilator, and renal failure requiring dialysis). Conclusions This national data set showed that despite increasing medical complexities, there was significant reduction in inpatient mortality and length of stay. However, these measures were counterbalanced by a higher proportion of discharge disposition to long-term care facilities and expensive cost of care.

Increases in early discharge following acute coronary syndrome hospitalisations and associated clinical outcomes in New Zealand between 2006 and 2015: ANZACS-QI-43 study

BACKGROUND

International guidelines recommend early discharge for uncomplicated acute coronary syndrome (ACS) patients within 3 days; however, there is a paucity of contemporary literature regarding the safety of this strategy.

AIMS

To report the trends in the proportion of ACS hospitalisations discharged within 3 days and their outcomes in New Zealand.

METHODS

ACS hospitalisations 2006-2015 using national routinely collected data were categorised by length of stay (LOS) into ≤3, 4-5 and >5 days, excluding deaths during the index admission. Trend analysis of death, cardiovascular and bleeding events and their composites (net adverse clinical events) at 30-day and 1-year post-discharge were performed using generalised linear mixed regression models adjusting for covariates by LOS subgroups.

RESULTS

Among 130 037 ACS hospitalisations, LOS ≤ 3 days increased from 32% in 2006 to 44% in 2016. This trend was observed for all demographics, ACS subtypes and management strategies. Event rates at 30 days and 1 year were the lowest for the LOS ≤3 days subgroup (all-cause mortality 1.6% and 9.1% respectively). Thirty-day and 1-year all-cause mortality rates were unchanged over time for this subgroup (adjusted odds ratio (95% confidence interval) of 1.011 (0.985-1.038) and 0.991 (0.979-1.003)), while net adverse clinical event rates significantly decreased (0.962 (0.950-0.973) and 0.972 (0.964-0.980) respectively).

CONCLUSION

There was a substantial increase in early discharge post-ACS over 10 years. These patients were associated with reduction in adverse clinical events up to 1 year and no increase in all-cause mortality. These findings from a comprehensive national register suggest that guideline recommendations on early discharge after uncomplicated ACS are safe and appropriate.

Early vs Late Discharge in Low-Risk ST-Elevation Myocardial Infarction Patients Treated With Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

BACKGROUND

For low-risk patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) the recommended optimal discharge timing is inconsistent in guidelines. The European Society of Cardiology guidelines recommend early discharge within 48-72 h, while the American College of Cardiology guidelines do not recommend a specific discharge strategy. In this systematic review and meta-analysis we compared outcomes with early discharge (≤3 days) versus late discharge (>3 days).

METHODS

Randomized controlled trials (RCTs) and observational studies were selected after searching MEDLINE and EMBASE database. Meta-analysis was stratified according to study design. Outcomes were reported as random effects risk ratios (RR) with 95% confidence intervals.

RESULTS

Seven RCTs comprising 1780 patients and 4 observational studies comprising 39,288 patients were selected. The RCT-restricted analysis did not demonstrate significant differences in terms of all-cause mortality (RR, 0.97 [0.23-4.05]) and major adverse cardiac events (MACE) (RR, 0.84 [0.56-1.26]). Conversely, observational study restricted analysis showed that early vs late discharge strategy was associated with a reduction in all-cause mortality (RR, 0.40 [0.23-0.71]) and MACE (RR, 0.45 [0.26-0.78]). There were no significant differences in hospital readmissions between early vs late discharge in both RCT or observational study analyses.

CONCLUSIONS

Early discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and it has the potential to improve cost of care.

Trends in long-term prognosis according to left ventricular ejection fraction after acute coronary syndrome

AIMS

Our aim was to investigate trends in prognosis among survivors of acute coronary syndrome according to left ventricular ejection fraction during a 16-year period.

METHODS

Data were derived from the Acute Coronary Syndrome Israeli Survey during the years 2000-2016. Patients aged 18 years and older were included in the analysis (N=11,725). Patients were classified into two groups based on their left ventricular ejection fraction: preserved (≥50%) and reduced (<50%) and also according to their acute coronary syndrome onset (2000-2006 early period vs. 2008-2016 late period). Endpoints were all-cause mortality rates at one and three years after the index event.

RESULTS

Preserved left ventricular ejection fraction was present in 5047/11,725 (43%) of patients. As expected, patients with preserved left ventricular ejection fraction had lower 1 and 3-year mortality rates as compared with reduced left ventricular ejection fraction regardless of the acute coronary syndrome period onset (6% vs. 19%, p<0.001). Nevertheless, in the late period the prevalence of reduced left ventricular ejection fraction decreased significantly, becoming equal to preserved left ventricular ejection fraction [2761 (50.5%) vs. 2713 (49.5%) respectively, p=0.3]. Moreover, prognosis during the late period as compared with the early period was improved only in patients with reduced left ventricular ejection fraction (HR 0.79; 95% CI 0.70-0.89, p=0.0001).

CONCLUSION

The prevalence of reduced left ventricular ejection fraction has decreased and prognosis has improved during the past several years but is still much worse than the prognosis of preserved left ventricular ejection fraction.

Is Duration of Symptoms Predictive of Acute Myocardial Infarction?

Patient interviews regarding the duration of symptoms are commonly conducted when evaluating a patient with possible acute myocardial infarction (AMI) and are believed to distinguish between AMI and non-AMI symptoms. In a single center, 569 patients evaluated in the emergency department (ED) for possible AMI from May 2013 to April 2015 were prospectively studied. Patients in the ED were asked by trained research personnel about the duration of their predominant symptom. The final diagnosis of AMI was determined by an independent cardiologist and emergency medicine physician in accordance with the third universal definition of AMI. Disagreements were settled by a third physician (cardiologist) who reviewed the case. There were 44 (8%) AMIs and 484 (85%) patients had chest pain as their predominant symptom. In the 26 type 1 AMIs, the median symptom duration was 3.3 hours, while in the 18 type 2 AMIs it was 1.3 hours. AMI was not present if symptom duration was under 20 minutes and was more likely during the 20-59 minute period. In conclusion, clinical symptoms still play a prominent role in the evaluation of a patient with possible AMI in the ED. Duration of symptoms was not very helpful in distinguishing between patients with AMI and those with non-AMI, except in the time interval of 20-59 minutes.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

aYAP modRNA reduces cardiac inflammation and hypertrophy in a murine ischemia-reperfusion model

Myocardial recovery from ischemia-reperfusion (IR) is shaped by the interaction of many signaling pathways and tissue repair processes, including the innate immune response. We and others previously showed that sustained expression of the transcriptional co-activator yes-associated protein (YAP) improves survival and myocardial outcome after myocardial infarction. Here, we asked whether transient YAP expression would improve myocardial outcome after IR injury. After IR, we transiently activated YAP in the myocardium with modified mRNA encoding a constitutively active form of YAP (aYAP modRNA). Histological studies 2 d after IR showed that aYAP modRNA reduced cardiomyocyte (CM) necrosis and neutrophil infiltration. 4 wk after IR, aYAP modRNA-treated mice had better heart function as well as reduced scar size and hypertrophic remodeling. In cultured neonatal and adult CMs, YAP attenuated H2O2- or LPS-induced CM necrosis. TLR signaling pathway components important for innate immune responses were suppressed by YAP/TEAD1. In summary, our findings demonstrate that aYAP modRNA treatment reduces CM necrosis, cardiac inflammation, and hypertrophic remodeling after IR stress.

Impact of immune thrombocytopenic purpura on clinical outcomes in patients with acute myocardial infarction

Background

Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP.

Methods

Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS).

Results

The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05‐1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions.

Conclusions

Patients with ITP admitted for AMI had a similar in‐hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population.

National Trends in Healthcare-Associated Infections for Five Common Cardiovascular Conditions

Healthcare-associated infections (HAI) are generally preventable causes of increased cost, morbidity, and mortality. Further, HAI carry penalties in the era of hospital value-based care. However, very little is known about the incidence and outcomes of HAI among patients hospitalized with common cardiovascular conditions. Using a national database, we identified adults aged ≥18 years hospitalized with 5 common cardiovascular conditions, including heart failure, acute myocardial infarction, coronary artery bypass grafting, cardiogenic shock, and atrial fibrillation or flutter. We assessed for temporal trends in incidence, cost, length of stay (LOS), and mortality associated with ventilator-associated pneumonia, catheter-associated urinary tract infections, central line-associated bloodstream infection, and Clostridium difficile infections. Between 2008 and 2015, we identified 159,021 hospitalizations ≥1 HAI (49.6% heart failure, 20.4% acute myocardial infarction, 10.5% coronary artery bypass grafting, 18.6% cardiogenic shock, and 11.9% atrial fibrillation or flutter). Clostridium difficile infections (75.4%) were the most common followed by catheter-associated urinary tract infections (15.1%), ventilator-associated pneumonia (7.9%), and central line-associated bloodstream infection (3.1%). Nearly half of the patients (46.3%) with HAI required discharge to a skilled care facility compared with 15.7% of patients who did not. After propensity matching, HAI remained associated with an increased LOS (4.9 vs 9.6 days, p <0.0001), total hospital charges ($79,227 vs $50,699, p <0.0001), and in-hospital mortality (13% vs 10.4%, p <0.0001) compared with patients who did not acquire a HAI. In conclusion, patients with cardiovascular disease acquiring a HAI had substantially higher costs, LOS, and mortality.

Performance of cardiovascular risk scores in mortality prediction ten years after Acute Coronary Syndromes

SUMMARY BACKGROUND The objective of this study was to evaluate the performance of the Framingham risk score (FRS) and risk score by the American College of Cardiology/American Heart Association (SR ACC/AHA) in predicting mortality of patients ten years after acute coronary syndrome (ACS). METHODS This is a retrospective cohort study that included patients aged ≥ 18 years with ACS who were hospitalized at the Coronary Intensive Care Unit (ICU) of the Botucatu Medical School Hospital from January 2005 to December of 2006. RESULTS A total of 447 patients were evaluated. Of these, 118 were excluded because the mortality in 10 years was not obtained. Thus, 329 patients aged 62.9 ± 13.0 years were studied. Among them, 58.4% were men, and 44.4% died within ten years of hospitalization. The median FRS was 16 (14-18) %, and the ACC/AHA RS was 18.5 (9.1-31.6). Patients who died had higher values of both scores. However, when we classified patients at high cardiovascular risk, only the ACC/AHA RS was associated with mortality (p <0.001). In the logistic regression analysis, both scores were associated with mortality at ten years (p <0.001). CONCLUSIONS Both FRS and SR ACC/AHA were associated with mortality. However, for patients classified as high risk, only the ACC/AHA RS was associated with mortality within ten years.

Long-Term Survival after Acute Myocardial Infarction in Lithuania during Transitional Period (1996-2015): Data from Population-Based Kaunas Ischemic Heart Disease Register

Background and Objective: There is a lack of reliable epidemiological data on the long-term survival after acute myocardial infarction (AMI) in the Lithuanian population. The aim of the study was to evaluate the long-term (36 months) survival after AMI among persons aged 25–64 years, who had experienced AMI in four time-periods 1996, 2003–2004, 2008, and 2012. Material and Methods: The source of the data was Kaunas population-based Ischemic heart disease (IHD) register. Long-term survival after AMI (36 months) was evaluated using the Kaplan–Meier method. The survival curves significantly differed when p < 0.05. Hazard ratio for all-cause mortality and their 95% CIs, adjusted for baseline characteristics, were estimated with the Cox proportional hazards regression model. Results: The analysis of data on 36 months long-term survival among Kaunas population by sex and age groups showed that the survival rates among men and women were 83.4% and 87.6%, respectively (p < 0.05) and among 25–54 years-old and 55–64 years-old persons, 89.2% and 81.7%, respectively (p < 0.05). The rates of long-term survival of post-AMI Kaunas population were better in past periods than in first period. According to the data of the Kaplan-Meier survival analysis, long-term survival of 25 to 64-year-old post-AMI Kaunas population was without significantly difference in 1996, 2003–2004, 2008 and 2012 (Log-rank = 6.736, p = 0.081). The adjusted risk of all-cause mortality during 36 months among men and 25 to 54-year-old patients was on the average by 35% and 60% lower in 2012 than in 1996, respectively. Conclusion: It was found that 36 months survival post MI among women and younger (25–54 years) persons was significant better compared to men and older (55–64 years) persons. Long-term survival among 55 to 64-year-old post-AMI Kaunas population had a tendency to decrease during last period, while among 25–54 years old persons long-term survival was without significant changes. The results highlight the fact that AMI survivors, especially in youngest age, remain a high-risk group and reinforce the importance of primary and secondary prevention for the improvement of long-term prognosis of AMI patients.

ST-segment elevation myocardial infarction

ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies.

Novel Acute Myocardial Infarction Risk Stratification (nARS) System Reduces the Length of Hospitalization for Acute Myocardial Infarction

BACKGROUND

The novel Acute Myocardial Infarction (AMI) Risk Stratification (nARS) system was recently developed based on original criteria. The use of nARS may reduce the length of hospitalization. Methods and Results: We allocated 560 AMI patients into the pre-nARS group (before adopting nARS) or the nARS group. Patients in the nARS group were subdivided into the low (L), intermediate (I), and high (H) risk groups, whereas patients in the pre-nARS group were subdivided into the equivalent L (eL), equivalent I (eI), or equivalent H (eH) risk groups based on the nARS criteria. Length of coronary care unit (CCU) stay was significantly shorter in the nARS group (2.8±3.5 days) compared with the pre-nARS group (4.4±5.4 days; P<0.001). Length of hospital stay was also shorter in the nARS group (9.4±8.9 days) compared with the pre-nARS group (13.4±12.8 days; P<0.001). Length of CCU stay was significantly shorter in the L (1.1±1.0 days), I (2.8±3.5 days), and H (5.0±4.8 days) risk groups compared with corresponding eL (2.2±1.1 days), eI (4.4±5.4 days), and eH (7.1±7.8 days) risk groups.

CONCLUSIONS

Length of CCU and hospital stay were significantly shorter in the nARS group compared with the pre-nARS group. The use of nARS may save medical resources in the treatment of AMI in the regional health-care system.

Versorgungsstrukturen und Mengen-Ergebnis-Beziehung beim akuten Herzinfarkt – Verlaufsbetrachtung der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2015

Hintergrund Studien haben beschrieben, dass höhere Herzinfarktfallzahlen des behandelnden Krankenhauses mit besseren Behandlungsergebnissen assoziiert sind. Vor diesem Hintergrund wird die Entwicklung der akutstationären Herzinfarktversorgung sowie der Mengen-Ergebnisbeziehung im Zeitverlauf analysiert. Ziel der Arbeit ist, die Entwicklungen zu bewerten und Anhaltspunkte für eine Verbesserung der Herzinfarktversorgung in Deutschland abzuleiten.

Methode Anhand der deutschlandweiten Krankenhausabrechnungsdaten (DRG-Statistik) von 2005 bis 2015 wurden Patienten mit akutem Herzinfarkt im erstbehandelnden Krankenhaus identifiziert und anhand der jährlichen Herzinfarktfallzahl des behandelnden Krankenhauses in fallzahlgleiche Quintile eingeteilt.

Ergebnisse Im Beobachtungszeitraum zeigte sich ein zunehmender Anteil interventionell versorgter Herzinfarktpatienten. Die Krankenhaussterblichkeit im erstbehandelnden Krankenhaus ging insgesamt von 12,1 auf 8,7% zurück. In allen Jahren wurde in den höheren Fallzahlquintilen eine geringere Sterblichkeit im Vergleich zum unteren Fallzahlquintil beobachtet. Im Jahr 2015 zeigte sich im Vergleich zur Behandlung in Krankenhäusern mit sehr geringer Fallzahl ein um 20% reduziertes Sterberisiko (adjustiertes OR jeweils 0,8 [95% KI 0,7–0,9]) in Krankenhäusern mit mittlerer, hoher oder sehr hoher Fallzahl. Mehr als 40% der Krankenhäuser mit sehr geringer Fallzahl waren in städtischen Regionen lokalisiert.

Schlussfolgerung Eine gezieltere Steuerung von Patienten mit Herzinfarktsymptomen in Krankenhäuser mit hohen Herzinfarktfallzahlen könnte die Versorgung weiter verbessern. Eine solche Versorgungssteuerung ist sowohl aus Gründen der medizinischen Qualität als auch der Wirtschaftlichkeit insbesondere in städtischen Regionen erforderlich.