Immediate and one-year outcome of patients presenting with acute coronary syndrome complicated by stroke: findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2)

Incidence and Outcomes of Cardiocerebral Infarction: A Cohort Study of 2 National Population-Based Registries

BACKGROUND

Cardiocerebral infarction (CCI), which is concomitant with acute myocardial infarction (AMI) and acute ischemic stroke (AIS), is a rare but severe presentation. However, there are few data on CCI, and the treatment options are uncertain. We investigated the characteristics and outcomes of CCI compared with AMI or AIS alone.

METHODS

We performed a retrospective cohort study of 120 531 patients with AMI and AIS from the national stroke and AMI registries in Singapore. Patients were categorized into AMI only, AIS only, synchronous CCI (same-day), and metachronous CCI (within 1 week). The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular mortality. The mortality risks were compared using Cox regression. Multivariable models were adjusted for baseline demographics, clinical variables, and treatment for AMI or AIS.

RESULTS

Of 127 919 patients identified, 120 531 (94.2%) were included; 74 219 (61.6%) patients had AMI only, 44 721 (37.1%) had AIS only, 625 (0.5%) had synchronous CCI, and 966 (0.8%) had metachronous CCI. The mean age was 67.7 (SD, 14.0) years. Synchronous and metachronous CCI had a higher risk of 30-day mortality (synchronous: adjusted HR [aHR], 2.41 [95% CI, 1.77-3.28]; metachronous: aHR, 2.80 [95% CI, 2.11-3.73]) than AMI only and AIS only (synchronous: aHR, 2.90 [95% CI, 1.87-4.51]; metachronous: aHR, 4.36 [95% CI, 3.03-6.27]). The risk of cardiovascular mortality was higher in synchronous and metachronous CCI than AMI (synchronous: aHR, 3.03 [95% CI, 2.15-4.28]; metachronous: aHR, 3.41 [95% CI, 2.50-4.65]) or AIS only (synchronous: aHR, 2.58 [95% CI, 1.52-4.36]; metachronous: aHR, 4.52 [95% CI, 2.95-6.92]). In synchronous CCI, AMI was less likely to be managed with PCI and secondary prevention medications (P<0.001) compared with AMI only.

CONCLUSIONS

Synchronous CCI occurred in 1 in 200 cases of AIS and AMI. Synchronous and metachronous CCI had higher mortality than AMI or AIS alone.

Identification of immune-related biomarkers co-occurring in acute ischemic stroke and acute myocardial infarction

Background

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) share several features on multiple levels. These two events may occur in conjunction or in rapid succession, and the occurrence of one event may increase the risk of the other. Owing to their similar pathophysiologies, we aimed to identify immune-related biomarkers common to AIS and AMI as potential therapeutic targets.

Methods

We identified differentially expressed genes (DEGs) between the AIS and control groups, as well as AMI and control groups using microarray data (GSE16561 and GSE123342). A weighted gene co-expression network analysis (WGCNA) approach was used to identify hub genes associated with AIS and/or AMI progression. The intersection of the four gene sets identified key genes, which were subjected to functional enrichment and protein-protein interaction (PPI) network analyses. We confirmed the expression levels of hub genes using two sets of gene expression profiles (GSE58294 and GSE66360), and the ability of the genes to distinguish patients with AIS and/or AMI from control patients was assessed by calculating the receiver operating characteristic values. Finally, the investigation of transcription factor (TF)-, miRNA-, and drug-gene interactions led to the discovery of therapeutic candidates.

Results

We identified 477 and 440 DEGs between the AIS and control groups and between the AMI and control groups, respectively. Using WGCNA, 2,776 and 2,811 genes in the key modules were identified for AIS and AMI, respectively. Sixty key genes were obtained from the intersection of the four gene sets, which were used to identify the 10 hub genes with the highest connection scores through PPI network analysis. Functional enrichment analysis revealed that the key genes were primarily involved in immunity-related processes. Finally, the upregulation of five hub genes was confirmed using two other datasets, and immune infiltration analysis revealed their correlation with certain immune cells. Regulatory network analyses indicated that GATA2 and hsa-mir-27a-3p might be important regulators of these genes.

Conclusion

Using comprehensive bioinformatics analyses, we identified five immune-related biomarkers that significantly contributed to the pathophysiological mechanisms of both AIS and AMI. These biomarkers can be used to monitor and prevent AIS after AMI, or vice versa.

Acute Ischemic Stroke and Transient Ischemic Attack in ST-Segment Elevation Myocardial Infarction Patients Who Underwent Primary Percutaneous Coronary Intervention

BACKGROUND

Acute ischemic stroke (AIS) is a rare but critical complication following ST-elevation myocardial infarction (STEMI). The risk of AIS or transient ischemic attack (TIA) may be amplified by invasive procedures, including primary percutaneous coronary intervention (PCI). This study aimed to investigate the factors associated with in-hospital AIS/TIA in patients with STEMI who required primary PCI.

METHODS

We included 941 STEMI patients who underwent primary PCI and divided them into an AIS/TIA group (n = 39) and a non-AIS/TIA group (n = 902), according to new-onset AIS/TIA. The primary interest was to find the factors associated with AIS/TIA by multivariate logistic regression analysis. We also compared clinical outcomes between the AIS/TIA and non-AIS/TIA groups.

RESULTS

The incidence of in-hospital deaths was significantly higher in the AIS/TIA group (46.2%) than in the non-AIS/TIA group (6.3%) (p < 0.001). Multivariate analysis revealed that cardiogenic shock (OR 3.228, 95% CI 1.492-6.986, p = 0.003), new-onset atrial fibrillation (AF) (OR 2.280, 95% CI 1.033-5.031, p = 0.041), trans-femoral approach (OR 2.336, 95% CI 1.093-4.992, p = 0.029), use of ≥4 catheters (OR 3.715, 95% CI 1.831-7.537, p < 0.001), and bleeding academic research consortium (BARC) type 3 or 5 bleeding (OR 2.932, 95% CI 1.256-6.846, p = 0.013) were significantly associated with AIS/TIA.

CONCLUSION

In STEMI patients with primary PCI, new-onset AIS/TIA was significantly associated with cardiogenic shock, new-onset AF, trans-femoral approach, the use of ≥4 catheters, and BARC type 3 or 5 bleeding. We should recognize these modifiable and unmodifiable risk factors for AIS/TIA in the treatment of STEMI.

Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) may co-occur simultaneously or in close temporal succession, with occurrence of one ischemic vascular event increasing a patient's risk for the other. Both employ time-sensitive treatments, and both benefit from expert consultation. Patients are at increased risk of stroke for up to 3 months following AMI, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, provided anterior wall myocardial involvement has been carefully evaluated. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality.

Stroke Complicating Acute ST Elevation Myocardial Infarction-Current Concepts

Myocardial infarction (MI) is one of the leading causes of mortality today both in developed and developing countries alike. Advancement in the pharmacotherapy and revascularization techniques has resulted in drastic improvement in survival. Most of the complications of MI can be managed adequately resulting in reduced mortality from MI in the recent years. However, mortality from stroke following acute MI remains high even today. Here, we discuss the incidence, risk factors, and management of stroke following acute ST elevation MI.

Self-reported sleep quality and depression in post myocardial infarction patients attending cardiology outpatient clinics in Oman

OBJECTIVE

This study aimed to examine the sleep quality and prevalence of depression in post myocardial infarction patients attending cardiology outpatient clinics of selected hospitals in Oman.

METHODS

A descriptive cross-sectional design was used to collect data from patients (n = 180) who were at least 4 weeks post myocardial infarction diagnosis and receiving follow-up care in the outpatient clinic. The Arabic version of the Pittsburgh Sleep Quality Index and Patient Health Questionnaire-9 were used to assess sleep quality and depressive symptoms, respectively.

RESULTS

The sample mean age was 62.0 ± 11.3 years. Poor sleep quality affected 61.1% of the participants. The significant predictors of poor sleep quality were gender (P ≤ 0.05), body mass index (P ≤ 0.05), and self-reported regular exercise (P ≤ 0.01). The most impacted domains of sleep quality were sleep latency, sleep duration, and sleep disturbances. The prevalence of major depression was low (5%) and the rate of re-infarction was 27.2%. The prevalence of minimal to mild major depression with a potential of transitioning into major depression overtime was very high. Self-reported regular exercise (P ≤ 0.01) was the only significant predictor of depressive symptoms.

CONCLUSION

The sleep quality of post myocardial infarction patients was poor and the prevalence of depression was low. There was no significant relationship between sleep quality or depression with re-infarction.

Increase in ticagrelor use over time is associated with lower rates of ischemic stroke following myocardial infarction

OBJECTIVES

To evaluate the impact of a rapid change in preferred treatment from clopidogrel to ticagrelor on the risk of ischemic stroke following acute myocardial infarction (AMI).

METHODS

Data for AMI patients treated with either clopidogrel or ticagrelor were obtained from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). Patients were divided into two cohorts, each covering a two-year time period; the initial prescription of ticagrelor (20 Dec 2011) was used as a cut-off point. Patients in the early cohort (n = 23,447) were treated with clopidogrel, while those in the later cohort (n = 24,227), were treated with either clopidogrel (47.9%) or ticagrelor (52.1%). Kaplan-Meier analyses were used to assess the risk of ischemic stroke over time, with multivariable Cox regression analyses used to identify predictors of ischemic stroke.

RESULTS

Of 47,674 patients, there were 1203 cases of ischemic stroke. Cumulative Kaplan-Meier incidence estimates of ischemic stroke after one year were 2.8% vs. 2.4% for the early and late cohorts, respectively (p = 0.001). Older age, hypertension, diabetes, previous stroke, congestive heart failure, atrial fibrillation, and ST-elevation myocardial infarction were associated with an increased risk of ischemic stroke. Percutaneous coronary intervention and statins at discharge were associated with a decreased risk of ischemic stroke, as was higher estimated glomerular filtration rate. Membership of the late cohort correlated with a 13% reduction in the relative risk of ischemic stroke.

CONCLUSIONS

The introduction of ticagrelor as well as an improved management of AMI was associated with a lower rate of ischemic stroke in a relatively unselected AMI population.

Reality of obesity paradox: Results of percutaneous coronary intervention in Middle Eastern patients

Objective

The aim of this study was to assess the baseline clinical characteristics, coronary angiographic features, and adverse cardiovascular events during hospitalization and at 1 year of follow-up in obese patients compared with overweight and normal/underweight patients.

Methods

A prospective, multicenter study of consecutive patients undergoing percutaneous coronary intervention was performed.

Results

Of 2425 enrolled patients, 699 (28.8%) were obese, 1178 (48.6%) were overweight, and 548 (22.6%) were normal/underweight. Obese patients were more likely to be female and to have a higher prevalence of diabetes, hypertension, hypercholesterolemia, or previous percutaneous coronary intervention. Acute coronary syndrome was the indication for percutaneous coronary intervention in 77.0% of obese, 76.4% of overweight, and 77.4% of normal/underweight patients. No significant differences in the prevalence of multi-vessel coronary artery disease or multi-vessel percutaneous coronary intervention were found among the three groups. Additionally, no significant differences were found in stent thrombosis, readmission bleeding rates, or cardiac mortality among the three groups during hospitalization, at 1 month, and at 1 year.

Conclusion

The major adverse cardiovascular event rate was the same among the three groups throughout the study period. Accordingly, body mass index is considered a weak risk factor for cardiovascular comorbidities in Arab Jordanian patients.

CHA2DS2-VASc risk factors as predictors of stroke after acute coronary syndrome: A systematic review and meta-analysis

Background:

Stroke is a rare but serious complication of acute coronary syndrome. At present, no specific score exists to identify patients at higher risk. The aim of the present study is to test whether each clinical variable included in the CHA2DS2-VASc score retains its predictive value in patients with recent acute coronary syndrome, irrespective of atrial fibrillation.

Methods:

The meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. All clinical trials and observational studies presenting data on the association between stroke/transient ischemic attack incidence and at least one CHA2DS2-VASc item in patients with a recent acute coronary syndrome were considered in the analysis. Atrial fibrillation diagnosis was also considered.

Results:

The whole cohort included 558,193 patients of which 7108 (1.3%) had an acute stroke and/or transient ischemic attack during follow-up (median nine months; 1st–3rd quartile 1–12 months). Age and previous stroke had the highest odds ratios (odds ratio 2.60; 95% confidence interval 2.21–3.06 and odds ratio 2.74; 95% confidence interval 2.19–3.42 respectively), in accordance with the two-point value given in the CHA2DS2-VASc score. All other factors were positively associated with stroke, although with lower odds ratios. Atrial fibrillation, while present in only 11.2% of the population, confirmed its association with an increased risk of stroke and/or transient ischemic attack (odds ratio 2.04; 95% confidence interval 1.71–2.44).

Conclusions:

All risk factors included in the CHA2DS2-VASc score are associated with stroke/ transient ischemic attack in patients with recent acute coronary syndrome, and retain similar odds ratios to what already seen in atrial fibrillation. The utility of CHA2DS2-VASc score for risk stratification of stroke in patients with acute coronary syndrome remains to be determined.

Incremental predictive value of mean platelet volume/platelet count ratio in in-hospital stroke after acute myocardial infarction

Stroke is a serious complication after acute myocardial infarction (AMI) and is associated with an increased risk of death. Though the pathophysiological mechanisms are not exactly known, increased inflammation and platelet reactivity could play an important role in the occurrence of stroke during AMI. We aimed to investigate the relationship between both mean platelet volume (MPV), a parameter of platelet function, and C-reactive protein (CRP) and the occurrence of in-hospital ischemic stroke (IHS) after AMI. Data were obtained from a French regional survey for AMI that included 5976 patients admitted to an intensive care unit (ICU) between 2001 and 2010. Patients were divided into two groups according to the occurrence of IHS. MPV, platelet count (PC), and CRP were routinely measured at admission to the ICU; 99 (1.6%) IHSs were recorded during hospitalization after admission for AMI. In multivariate analysis, IHS was independently associated with a history of stroke (OR: 1.99%, CI: 1.1-3.49, p = 0.01), impaired left ventricular ejection fraction <40% (OR: 1.88, 95% CI: 1.20-2.94, p = 0.006), impaired renal function (OR: 1.94, 95% CI: 1.27-2.95, p = 0.002), CRP > 10 mg/l (OR: 2.19, 95% CI: 1.44-3.33, p < 0.001), and MPV/PC ratio (OR: 1.04, 95% CI: 1.01-1.08, p = 0.023). Compared with the first to fourth quintiles, the last quintile of the MPV/PC ratio was associated with higher rates of IHS on survival curve analysis (p = 0.014). At hospital admission, a high MPV/PC ratio and a high level of CRP might help to identify patients at increased risk of IHS. Moreover, these results provide new insights into the potential role played by increased inflammation and platelet reactivity in the occurrence of stroke after AMI.

Clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with heart failure: an observational report from the Middle East

OBJECTIVES

The purpose of this study is to report the prevalence, clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with acute heart failure (HF).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicentre study of consecutive patients hospitalised with acute HF in 2012 in seven Middle Eastern countries and analysed according to the presence or absence of prior stroke; demographics, management and outcomes were compared.

PARTICIPANTS

A total of 5005 patients with HF.

OUTCOME MEASURES

In-hospital and 1-year outcome.

RESULTS

The prevalence of prior stroke in patients with HF was 8.1%. Patients with stroke with HF were more likely to be admitted under the care of internists rather than cardiologists. When compared with patients without stroke, patients with stroke were more likely to be older and to have diabetes mellitus, hypertension, atrial fibrillation, hyperlipidaemia, chronic kidney disease, ischaemic heart disease, peripheral arterial disease and left ventricular dysfunction (p=0.001 for all). Patients with stroke were less likely to be smokers (0.003). There were no significant differences in terms of precipitating risk factors for HF hospitalisation between the two groups. Patients with stroke with HF had a longer hospital stay (mean±SD days; 11±14 vs 9±13, p=0.03), higher risk of recurrent strokes and 1-year mortality rates (32.7% vs 23.2%, p=0.001). Multivariate logistic regression analysis showed that stroke is an independent predictor of in-hospital and 1-year mortality.

CONCLUSIONS

This observational study reports high prevalence of prior stroke in patients hospitalised with HF. Internists rather than cardiologists were the predominant caregivers in this high-risk group. Patients with stroke had higher risk of in-hospital recurrent strokes and long-term mortality rates.

TRIAL REGISTRATION NUMBER

NCT01467973.

Frequency and Predictors of Stroke After Acute Myocardial Infarction

Background and Purpose—

Stroke is a serious complication after acute myocardial infarction (AMI) and is closely associated with decreased survival. This study aimed to investigate the frequency, characteristics, and factors associated with in-hospital and postdischarge stroke in patients with AMI.

Methods—

Eight thousand four hundred eighty-five consecutive patients admitted to a cardiology intensive care unit for AMI, between January 2001 and July 2010. Stroke/transient ischemic attack were collected during 1-year follow-up.

Results—

One hundred twenty-three in-hospital strokes were recorded: 65 (52.8%) occurred on the first day after admission for AMI, and 108 (87%) within the first 5 days. One hundred six patients (86.2%-incidence rate 1.25%) experienced in-hospital ischemic stroke, and 14 patients (11.4%-incidence rate 0.16%) were diagnosed with an in-hospital hemorrhagic stroke. In-hospital ischemic stroke subtypes according to the Trial of Org 10 172 in Acute Stroke Treatment (TOAST) classification showed that only 2 types of stroke were identified more frequently. As expected, the leading subtype of in-hospital ischemic stroke was cardioembolic stroke (n=64, 60%), the second was stroke of undetermined pathogenesis (n=38, 36%). After multivariable backward regression analysis, female sex, previous transient ischemic attack (TIA)/stroke, new-onset atrial fibrillation, left ventricular ejection fraction (odds ratio per point of left ventricular ejection fraction), and C-reactive protein were independently associated with in-hospital ischemic stroke. When antiplatelet and anticoagulation therapy within the first 48 hours was introduced into the multivariable model, we found that implementing these treatments (≥1) was an independent protective factor of in-hospital stroke. In-hospital hemorrhagic stroke was dramatically increased (5-fold) when thrombolysis was prescribed as the reperfusion treatment. However, the different parenteral anticoagulants were not predictors of risk in univariable analysis. Finally, only 45 postdischarge strokes were recorded. Postdischarge stroke subtypes showed a more heterogeneous distribution of mechanisms. The annual rate of stroke post-AMI remained stable throughout the 10-year study period.

Conclusions—

The present study describes specific predictors of in-hospital and postdischarge stroke in patients with AMI. It showed a marked increase in the risk of death, both during hospitalization and in the year after AMI. After hospital discharge, stroke remains a rare event and is mostly associated with high cardiovascular risk.

Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program

In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as 'high volume', both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.