Treatment With Cardiovascular Medications: Prognosis in Patients With Myocardial Injury

Prognostic significance of chronic myocardial injury diagnosed by three different cardiac troponin assays in patients admitted with suspected acute coronary syndrome

OBJECTIVES

Chronic myocardial injury (CMI) is defined as stable concentrations of cardiac troponin T or I (cTnT or cTnI) above the assay-specific 99th percentile upper reference limit (URL) and signals poor outcome. The clinical implications of diagnosing CMI are unclear. We aimed to assess prevalence and association of CMI with long-term prognosis using three different high-sensitivity cTn (hs-cTn) assays.

METHODS

A total of 1,292 hospitalized patients without acute myocardial injury had cTn concentrations quantified by hs-cTn assays by Roche Diagnostics, Abbott Diagnostics and Siemens Healthineers. The median follow-up time was 4.1 years. The prevalence of CMI and hazard ratios for mortality and cardiovascular (CV) events were calculated based on the URL provided by the manufacturers and compared to the prognostic accuracy when lower percentiles of cTn (97.5, 95 or 90), limit of detection or the estimated bioequivalent concentrations between assays were used as cutoff values.

RESULTS

There was no major difference in prognostic accuracy between cTnT and cTnI analyzed as continuous variables. The correlation between cTnT and cTnI was high (r=0.724-0.785), but the cTnT assay diagnosed 3.9-4.5 times more patients with having CMI based on the sex-specific URLs (TnT, n=207; TnI Abbott, n=46, TnI Siemens, n=53) and had higher clinical sensitivity and AUC at the URL.

CONCLUSIONS

The prevalence of CMI is highly assay-dependent. cTnT and cTnI have similar prognostic accuracy for mortality or CV events when measured as continuous variables. However, a CMI diagnosis according to cTnT has higher prognostic accuracy compared to a CMI diagnosis according to cTnI.

Type 2 myocardial infarction: a diagnostic and therapeutic challenge in contemporary cardiology

In the expanding world of cardiovascular diseases, rapidly reaching pandemic proportions, the main focus is still on coronary atherosclerosis and its clinical consequences. However, at least in the Western world, middle-aged male patients with acute myocardial infarction are no more the rule. Due to a higher life expectancy and major medical advances, physicians are to treat older and frailer individuals, usually with multiple comorbidities. In this context, myocardial ischaemia and infarction frequently result from an imbalance between myocardial oxygen supply and demand-i.e., type 2 myocardial infarction (T2MI), according to the current universal definition-rather than coronary atherothrombosis. Moreover, the increasing use of high-sensitivity cardiac troponin assays has led to a heightened detection of T2MI-often causing relatively little myocardial injury-, which seems to have doubled its numbers in recent years. Nevertheless, owing to its multifaceted pathophysiology and clinical presentation, T2MI is still underdiagnosed. Perhaps more importantly, T2MI is also victim of undertreatment, as drugs that constitute the cornerstone of therapy in most cardiovascular diseases are much more unlikely to be prescribed in T2MI than in coronary atherothrombosis. In this paper, we review the recent literature on the classification, pathophysiology, epidemiology, and management of T2MI, trying to summarise the state-of-the-art knowledge about this increasingly important pathologic condition. Finally, based on the current scientific evidence, we also propose an algorithm that may be easily utilised in clinical practice, in order to improve T2MI diagnosis and risk stratification.

A review on the molecular basis underlying the protective effects of Andrographis paniculata and andrographolide against myocardial injury

Andrographolide is the major compound found in the medicinal plant, Andrographis paniculata (Burm.f.) Nees, which accounts for its medicinal properties. Both the plant extract and compound have been reported to exhibit potential cardiovascular activities. This review summarises related studies describing the biological activities and target mechanisms of A. paniculata and andrographolide in vivo and in vitro. The current evidence unambiguously indicated the protective effects provided by A. paniculata and andrographolide administration against myocardial injury. The intervention ameliorates the symptoms of myocardial injury by interfering with the inductive phase of a) inflammatory response mediated by nuclear factor-kappa B (NF-κB), phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt), mitogen-activated protein kinase (MAPK) and signal transducer and activator of transcription 3 (STAT3) signalling molecules; b) oxidative stress via activation of nuclear factor erythroid 2-related factor (Nrf-2) and reduction of enzymes responsible for generating reactive oxygen and nitrogen species; c) intrinsic and extrinsic mechanisms in apoptosis regulated by upstream insulin-like growth factor-1 receptor (IGF-1R) and peroxisome proliferator-activated receptor-alpha (PPAR-α); d) profibrotic growth factors thus reducing cardiac fibrosis, improving endothelial function and fibrinolytic function. In conclusion, A. paniculata and andrographolide possess therapeutic potential in the management of myocardial injury, which requires further validation in human clinical trials.

Associations of kidney tests at medical facilities and health checkups with incidence of end-stage kidney disease: a retrospective cohort study

No study has assessed the association between no health checkup and end-stage kidney disease (ESKD). This retrospective cohort study, including 69,147 adults aged ≥ 40 years in Japan who were insured by the National Health Insurance and the Late-Stage Medical Care System for the Elderly, assessed the associations of kidney tests at medical facilities and health checkups with incident ESKD. The main exposure was the histories of kidney tests using dipstick urinalysis and/or serum creatinine measurement at medical facilities and checkups in the past year: “checkups,” “no kidney test (without checkup),” and “kidney tests (without checkup)” groups. During the median observational period of 5.0 years, ESKD was observed in 246 (0.8%) men and 124 (0.3%) women. The “no kidney test” group was associated with ESKD in men (adjusted subhazard ratio of “no kidney test” vs. “checkups”: 1.66 [95% confidence interval, 1.04–2.65], but not in women. Age-specific subgroup analyses identified the “no kidney test” group as a high-risk population of ESKD in elderly men (1.30 [0.70–2.41] and 2.72 [1.39–5.33] in men aged 40–74 and ≥ 75 years, respectively). Elderly men with no kidney test at medical facilities and no health checkup were at higher risk of ESKD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment With Cardiovascular Medications: Prognosis in Patients With Myocardial Injury

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