In-hospital and 30-day major adverse cardiac events in patients referred for ST-segment elevation myocardial infarction in Dhaka, Bangladesh

The ability and optimal cutoff value of serum cell division cycle 42 in estimating major adverse cardiac event in STEMI patients treated with percutaneous coronary intervention

Cell division cycle 42 (CDC42) regulates cholesterol efflux, chronic inflammation, and reendothelialization in various atherosclerotic diseases. This study aimed to investigate the correlation of serum CDC42 with myocardial injury indicators and major adverse cardiac event (MACE) in ST-elevation myocardial infarction (STEMI) patients who were treated with percutaneous coronary intervention (PCI). In 250 STEMI patients about to receive PCI, serum samples were collected at enrollment before PCI treatment, and the serum samples were also obtained from 100 healthy controls (HCs) at enrollment. Serum CDC42 was detected by enzyme-linked immunosorbent assay. Serum CDC42 was decreased (versus HCs, P < 0.001) and negatively correlated with diabetes mellitus (P = 0.017), multivessel disease (P = 0.016), cardiac troponin I (P < 0.001), creatine kinase MB (P = 0.012), stent diameter ≥ 3.5 mm (P = 0.039), white blood cell (P < 0.001), low-density lipoprotein cholesterol (P = 0.049), and C-reactive protein (P < 0.001) in STEMI patients. Besides, 29 (11.6%) STEMI patients experienced MACE. The 1-year, 2-year, and 3-year accumulating MACE rates were 7.5%, 17.3%, and 19.3%, accordingly. Serum CDC42 was reduced in STEMI patients who experienced MACE compared to those who did not (P = 0.001). Serum CDC42 ≥ 250 pg/mL, ≥ 400 pg/mL, ≥ 700 pg/mL (cut by near integer value of 1/4th quartile, median, and 3/4th quartile) were associated with decreased accumulating MACE rates in STEMI patients (all P < 0.050). Notably, serum CDC42 ≥ 250 pg/mL (hazard ratio = 0.435, P = 0.031) was independently related to reduced accumulating MACE risk in STEMI patients. A serum CDC42 level of ≥ 250 pg/mL well predicts decreased MACE risk in STEMI patients who are treated with PCI.

Optimal timing of influenza vaccination among patients with acute myocardial infarction - Findings from the IAMI trial

Influenza vaccination reduces the risk of adverse cardiovascular events.The IAMI trial randomly assigned 2571 patients with acute myocardial infarction (AMI) to receive influenza vaccine or saline placebo during their index hospital admission. It was conducted at 30 centers in 8 countries from October 1, 2016 to March 1, 2020. In this post-hoc exploratory sub-study, we compare the trial outcomes in patients receiving early season vaccination (n = 1188) and late season vaccination (n = 1344).The primary endpoint wasthe composite of all-cause death, myocardial infarction (MI), or stent thrombosis at 12 months. Thecumulative incidence of the primary and key secondary endpoints by randomized treatment and early or late vaccination was estimated using the Kaplan-Meier method. In the early vaccinated group, the primary composite endpoint occurred in 36 participants (6.0%) assigned to influenza vaccine and 49 (8.4%) assigned to placebo (HR 0.69; 95% CI 0.45 to 1.07), compared to 31 participants (4.7%) assigned to influenza vaccine and 42 (6.2%) assigned to placebo (HR 0.74; 95% CI 0.47 to 1.18) in the late vaccinated group (P = 0.848 for interaction on HR scale at 1 year). We observed similar estimates for the key secondary endpoints of all-cause death and CV death. There was no statistically significant difference in vaccine effectiveness against adverse cardiovascular events by timing of vaccination. The effect of vaccination on all-cause death at one year was more pronounced in the group receiving early vaccination (HR 0.50; 95% CI, 0.29 to 0.86) compared late vaccination group (HR 0.75; 35% CI, 0.40 to 1.40) but there was no statistically significant difference between these groups (Interaction P = 0.335). In conclusion,there is insufficient evidence from the trial to establish whether there is a difference in efficacy between early and late vaccinationbut regardless of vaccination timing we strongly recommend influenza vaccination in all patients with cardiovascular diseases.

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40 years (young) and >40 years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40 years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p <0.001), diabetes (26.6% vs 36.4%, p <0.001), metabolic syndrome (14.8% vs 24%, p <0.001), history of IHD (5.8% vs 9.3%, p = 0.013) and a higher frequency of smoking (33% vs 24.7%, p <0.001), positive family history (8.2% vs 3.2%, p <0.001), and single-vessel involvement (60.1% vs 33.2%, p <0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p = 0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Clinical impact of influenza vaccination after ST- and non-ST-segment elevation myocardial infarction - insights from the IAMI trial

BACKGROUND

Influenza vaccination early after myocardial infarction (MI) improves prognosis but vaccine effectiveness may differ dependent on type of MI.

METHODS

A total of 2,571 participants were prospectively enrolled in the Influenza vaccination after myocardial infarction (IAMI) trial and randomly assigned to receive in-hospital inactivated influenza vaccine or saline placebo. The trial was conducted at 30 centers in eight countries from October 1, 2016 to March 1, 2020. Here we report vaccine effectiveness in the 2,467 participants with ST-segment elevation MI (STEMI, n = 1,348) or non-ST-segment elevation MI (NSTEMI, n = 1,119). The primary endpoint was the composite of all-cause death, MI, or stent thrombosis at 12 months. Cumulative incidence of the primary and key secondary endpoints by randomized treatment and NSTEMI/STEMI was estimated using the Kaplan-Meier method. Treatment effects were evaluated with formal interaction testing to assess for effect modification.

RESULTS

Baseline risk was higher in participants with NSTEMI. In the NSTEMI group the primary endpoint occurred in 6.5% of participants assigned to influenza vaccine and 10.5% assigned to placebo (hazard ratio [HR], 0.60; 95% CI, 0.39-0.91), compared to 4.1% assigned to influenza vaccine and 4.5% assigned to placebo in the STEMI group (HR, 0.90; 95% CI, 0.54-1.50, P = .237 for interaction). Similar findings were seen for the key secondary endpoints of all-cause death and cardiovascular death. The Kaplan-Meier risk difference in all-cause death at one year was more pronounced in participants with NSTEMI (NSTEMI: HR, 0.47; 95% CI 0.28-0.80, STEMI: HR, 0.86; 95% CI, 0.43-1.70, interaction P = .028).

CONCLUSIONS

The beneficial effect of influenza vaccination on adverse cardiovascular events may be enhanced in patients with NSTEMI compared to those with STEMI.

Undiagnosed SARS-CoV-2 infection and outcome in patients with acute MI and no COVID-19 symptoms

OBJECTIVE

We aimed to determine the prevalence and outcome of occult infection with SARS-CoV-2 and influenza in patients presenting with myocardial infarction (MI) without COVID-19 symptoms.

METHODS

We conducted an observational study from 28 June to 11 August 2020, enrolling patients admitted to the National Institute of Cardiovascular Disease Hospital, Dhaka, Bangladesh, with ST-segment elevation MI (STEMI) or non-ST-segment elevation MI who did not meet WHO criteria for suspected COVID-19. Samples were collected by nasopharyngeal swab to test for SARS-CoV-2 and influenza virus by real-time reverse transcriptase PCR. We followed up patients at 3 months (13 weeks) postadmission to record adverse cardiovascular outcomes: all-cause death, new MI, heart failure and new percutaneous coronary intervention or stent thrombosis. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

We enrolled 280 patients with MI, 79% male, mean age 54.5±11.8 years, 140 of whom were diagnosed with STEMI. We found 36 (13%) to be infected with SARS-CoV-2 and 1 with influenza. There was no significant difference between mortality rate observed among SARS-CoV-2 infected patients compared with non-infected (5 (14%) vs 26 (11%); p=0.564). A numerically shorter median time to a recurrent cardiovascular event was recorded among SARS-CoV-2 infected compared with non-infected patients (21 days, IQR: 8-46 vs 27 days, IQR: 7-44; p=0.378).

CONCLUSION

We found a substantial rate of occult SARS-CoV-2 infection in the studied cohort, suggesting SARS-CoV-2 may precipitate MI. Asymptomatic patients with COVID-19 admitted with MI may contribute to disease transmission and warrants widespread testing of hospital admissions.