Associations of changes in patient characteristics and management with decrease in mortality rates of men and women with ST-elevation myocardial infarction - a propensity score-matched analysis

Infarct-related artery and long-term mortality following recurrent ST-segment elevation myocardial infarction. Insights from a Polish nationwide registry

BACKGROUND

Recurrent ST-segment elevation myocardial infarction (rSTEMI) can be attributed to the same (target-vessel, TV-rSTEMI) or different culprit vessel (non-target, nonTV-rSTEMI) compared with the first infarction. We hypothesized that long-term mortality after rSTEMI depends on the infarct-related artery (the same or different compared with the first STEMI).

METHODS

Using the Polish Registry of Acute Coronary Syndromes (PL-ACS) we retrospectively identified survivors of first STEMI treated with PCI who experienced rSTEMI. We divided rSTEMI into TV-rSTEMI and nonTV-rSTEMI. We compared clinical, angiographic, and procedural characteristics and utilized propensity score matching to adjust for baseline differences. Primary outcome was 1-, 3- and 5-year all-cause mortality.

RESULTS

Between 2003 and 2019 a total of 3,411 patients (mean age 63.7 years, 76% male) had rSTEMI, of whom 1,916 (56%) had TV-rSTEMI and 1,495 (44%) had nonTV-rSTEMI. Median time since first infarction was 716 days (100, 1,807). Patients with nonTV-rSTEMI had higher body mass index (27.2 vs 26.7 kg/m², P = .041), more arterial hypertension (77.4 vs 73.7%, P = .015) and atrial fibrillation (4.8 vs 3.3%, P = .02), and lower left ventricular ejection fraction (43 [35, 50] vs 45 [38, 50]%, P <.001) compared with TV-rSTEMI. On coronary angiography nonTV-rSTEMI more frequently presented with Thrombolysis In Myocardial Infarction >1 flow (25.8 vs 15.7%, P < .001), multivessel disease (51.9 vs 40.8%, P =.002), culprit lesion located in circumflex artery (22.6 vs 5.6%, P < .001), and more frequently underwent stenting (88.8 vs 76.1%, P < .001) compared with TV-rSTEMI. There was no difference in unadjusted 1-, 3- and 5-year mortality between nonTV-rSTEMI and TV-rSTEMI. After propensity score analysis, 807 well-matched pairs of patients were selected. Adjusted 1-, 3- and 5-year mortality remained similar between nonTV-rSTEMI and TV-rSTEMI (14.7 vs 14.4%, P = .88; 23.6 vs 23.1%, P = .81; 30.0 vs 32.0%, P = .50 respectively).

CONCLUSIONS

Our study shows overall low frequency of rSTEMI. Patients with nonTV-rSTEMI have different clinical and angiographic characteristics compared with TV-rSTEMI. No long-term mortality difference was observed between both groups.

Perioperative Fluoroquinolone Treatment Deteriorates Prognosis Following Coronary Artery Bypass Grafting

Background: Former studies have revealed that fluoroquinolone (FQ) can induce aortic expansion and rupture. While FQ is widely used in perioperative anti-infection therapy, its impact on graft patency and patient survival is unknown. Methods: Coronary artery bypass grafting (CABG) data were extracted from the MIMIC-III database. Chi-square tests, Fisher’s exact tests, t-tests, or ANOVAs were used to compare baseline data between groups determined by FQ therapy status, depending on the data type. Propensity score matching was used to establish a balanced cohort. Cox regression was used to investigate the impact of FQ on CABG patient survival, whereas paired t-tests were used to analyze secondary results. Results: Of the 5030 patients who underwent CABG, 937 (18.6%) received oral or intravenous FQ therapy. Using propensity score matching, these 819 patients were successfully matched with 819 controls in a 1:1 ratio. Cox regression showed that FQ significantly decreased survival among CABG patients (HR: 1.62, 95% CI: 1.21−2.15, p = 0.001). Furthermore, FQ usage was associated with longer hospitalization (<0.0001), ICU duration (<0.0001), ventilation period (<0.0001), and duration of vasopressor administration (<0.0001). Conclusions: Perioperative FQ therapy was associated with worse prognosis and a more difficult recovery among patients with CABG.

Growth Differentiation Factor 15 is Related with Left Ventricular Recovery in Patients with ST-Elevation Myocardial Infarction after Successful Reperfusion by Primary Percutaneous Intervention

Background

The determinants of left ventricular (LV) recovery after successful revascularization in ST-elevation myocardial infarction (STEMI) patients are not clear. In addition, the relationship between growth differentiation factor15 (GDF-15) and left ventricular ejection fraction (LVEF) improvement is also unknown. This study hypothesizes that a low GDF-15 level would be associated with LVEF recovery.

Methods

One hundred and sixty-one STEMI patients were included in this study. Echocardiographic examinations were performed before and 12-18 weeks after discharge. The patients were divided into three groups according to the changes in LVEF as 62 patients with ≥ 10% change, 47 patients with 1-9% change, and 52 patients ≤ 0% change. LV recovery was defined as ≥ 10% LVEF improvement and the predictors of LV recovery were investigated. Moreover, two groups were created according to GDF-15 values, and the follow-up/baseline echocardiographic parameters were compared between these groups.

Results

LV recovery was detected in 38.5% of the patients. Low baseline LVEF [odds ratio (OR): 0.85, 95% confidence interval (CI) 0.82-0.94, p = 0.001], low GDF-15 (OR: 0.79, 95% CI 0.68-0.93, p = 0.004), previous angina (OR: 2.34, 95% CI 1.10-4.96, p = 0.027), and symptom-to-balloon time (OR: 0.97, 95% CI 0.95-1.00, p = 0.043) were independent predictors of LV recovery. The ratios of follow-up/baseline LV end-diastolic volume index, LV end-systolic volume index and wall motion score index were lower in the low GDF-15 group (0.96 vs. 1.04, p < 0.001; 0.96 vs. 1.10, p < 0.001; 0.89 vs. 0.96, p < 0.001). Moreover, being in the low GDF-15 group was associated with LV recovery (OR: 2.93, 95% CI 1.43-6.02, p = 0.001).

Conclusions

Lower GDF-15 level was associated with better LV improvement and less adverse remodeling in STEMI patients.

Improved coordination of care after acute myocardial infarction in Poland since 2017: Promising early results

A new model of complex patient care after acute myocardial infarction (AMI) has been in operation in Poland since late 2017, comprising invasive treatment, cardiac rehabilitation and scheduled outpatient follow-up. Its stated objectives are to improve secondary prevention measures, quality of care and long-term health outcomes in AMI-patients. The model implements all key aspects of post-MI care recommended by the European Society of Cardiology (ESC), representing the first nation-wide model of structured and comprehensive post-MI care that closely follows ESC guidelines. The aim of this paper is to describe the background of this reform, its content and implementation as well as to assess its results. Early outcomes seem promising, with significantly lower mortality rate and lower risk of serious cardiological events in patients participating in the new model of care compared to patients who were not included. A comprehensive assessment of the reform will require further clinical data, covering a larger population and a longer period of time, as well as a holistic analysis of the programme in its wider context, taking into account potential benefits and cost-effectiveness of improved primary prevention implemented outside of this model.