Outcomes following acute myocardial injury and type 2 myocardial infarction in patients with and without coronary artery disease

Background

Acute myocardial injury and type 2 myocardial infarction typically occur in the setting of a concurrent illness. Differentiating acute myocardial injury from type 2 myocardial infarction is challenging as it relies on the assessment of myocardial ischaemia. Indeed, some have questioned whether this distinction is important, as patients with both conditions are at increased risk of future cardiovascular events. Whether this risk is similar and the role of identifying those with coronary artery disease is uncertain.

Purpose

To determine whether future risk of cardiovascular events and death differs in patients with type 2 myocardial infarction and acute myocardial injury according to the presence or absence of prior coronary artery disease.

Methods

We conducted a secondary analysis of a multi-centre randomised controlled trial of 48,282 consecutive patients with suspected acute coronary syndrome. Patients with an adjudicated index diagnosis of acute myocardial injury and type 2 myocardial infarction were stratified according to whether they were known previously to have coronary artery disease defined as prior coronary revascularisation, myocardial infarction, or angina. Cardiovascular death or myocardial infarction adjusted for the competing risk of non-cardiovascular death and all-cause death at one year was compared.

Results

In 9,115 patients with elevated cardiac troponin concentrations, 1,676 (18%) and 1,121 (12%) had acute myocardial injury and type 2 myocardial infarction, respectively. Patients with either condition known to have coronary artery disease were older (mean [standard deviation] age 78 [11] versus 73 [16] years) and more likely to be female (55% versus 45%) than those with no prior history. Coronary artery disease was previously identified in 40% (454/1,121) and 30% (509/1,167) of those with type 2 myocardial infarction and acute myocardial injury, respectively. Cardiovascular death or myocardial infarction at one year was more common in patients known to have coronary artery disease than those without for both acute myocardial injury (23% [115/509]) versus 14% [158/1,167]; P<0.001) and type 2 myocardial infarction (20% [91/454] versus 10% [69/667]; log-rank P<0.001) (Figure 1). Similarly all-cause death at one year was higher in patients with known coronary artery disease for both acute myocardial injury (31% [357/1,167] versus 18% [123/667]; P<0.001) and type 2 myocardial infarction (40% [115/509] versus 30% [135/454]; P<0.001) (Figure 2).

Conclusion

Coronary artery disease is recognised in around one third of patients with acute myocardial injury and type 2 myocardial infarction and is associated with higher rates of cardiovascular events and all-cause death. Risk doubled in those with coronary artery disease and was similar whether the index diagnosis was myocardial injury or infarction, suggesting that coronary investigation and secondary prevention may have a role in both conditions.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The University of Edinburgh and British Heart Foundation

Speech disfluencies in typically developing Finnish-speaking children - preliminary results

We investigated the speech disfluencies of 54 typically fluent Finnish-speaking children: 14 children randomly selected from a longitudinal study (age levels 2, 3, and 4 years), and 40 children from a cross-sectional study (age levels 6, 7, 8, and 9 years). Speech samples, collected during a semi-structured conversation, were analysed for disfluencies per 100 words and 100 syllables. No significant within-age effect was found for the total frequency of disfluencies or disfluency types among the 2- to 4-year-olds. Across the 6- to 9-year-olds, between-group differences were found for the total frequency and type of disfluencies. Clinically relevant was that the criterion to distinguish normally fluent children from those who stutter, i.e., <3 stuttering-like disfluencies (SLD) per 100 syllables, was applicable in all age groups whereas the criterion <3SLD per 100 words was not. Consequently, these preliminary results suggest that different guidelines are needed for defining normal disfluency from stuttering in different languages.

Evaluation of Patient Engagement in a Clinical Emergency Care Network: Findings From the BC Emergency Medicine Network

The British Columbia Emergency Medicine Network (EM Network) has collaborated with patient partners to utilize their experiential knowledge to inform planning and implementation. Patient partners participated in several EM Network committees and initiatives. This study evaluated how patient partners and other leaders in the EM Network perceived patient engagement efforts 1 year after launch. The Public and Patient Engagement Evaluation Tool V2.0 found that there was an appropriate level of patient engagement at this early stage, an opportunity to attract more patient partners as the EM Network grows, and a need to ensure adequate resources to support more activities.

P3595Risk factors, comorbidities and early dynamic change in high-sensitive cardiac troponin T -The importance of initial troponin level at presentation

Background

The one-hour troponin-algorithm is recommended together with a clinical evaluation for rule-in and rule-out of acute coronary syndrome (ACS) in the emergency department (ED). Since risk factors and many comorbidities are associated with small elevations of high-sensitive cardiac troponin T (hs-cTnT), their additive value for discrimination of ACS have been questioned. However, the importance of the initial troponin level for how risk factors and/or comorbidities associate with early dynamic change in hs-cTnT is poorly studied.

Purpose

To investigate the association between risk factors and early dynamic change of hs-cTnT among those with an elevated compared to non-elevated initial hs-cTnT.

Methods

This was a retrospective study among patients admitted to four urban emergency departments (ED) between 2014–2016 with the chief complaint of chest pain and with two clinical routine hs-cTnT measurements at presentation and at >30–104 minutes later. Clinical data from the ED visit were cross-referenced to national registers retrieving information on diagnoses and treatments to identify: cardiovascular disease (CVD, defined as previous myocardial infarction, stroke or peripheral vascular disease), hypertension (HT), hyperlipidemia (HL), diabetes mellitus (DM), chronic kidney disease (CKD), Heart failure (CHF) and atrial fibrillation (AF). The association between risk factors and early dynamic change was studied separately for those with an elevated (>14ng/L, dynamic change set as >20%) and a non-elevated (≤14ng/L, dynamic change set as >2ng/L) initial hs-cTnT.

Results

9278 patients were identified. All risk factors and comorbidities were more common among those with an elevated hs-cTnT. Dynamic change was present in 236 (3.4%) of 7024 patients with an initial hs-cTnT ≤14ng/L and 307 (13.6%) of 2254 with an initial hs-cTnT >14ng/L respectively. Among those with non-elevated initial hs-cTnT those with dynamic change were more likely to be older: age >70 (odds ratio (OR); 95% CI: 1.5; 1.1–2.0), have CVD (1.7: 1.2–2.5), HT (1.4; 1.1–1.8), eGFR<60 (1.8; 1.3–2.5) or AF (1.5; 1.0–2.4). Conversely, in patients with initial elevated hs-cTnT most conditions were negatively associated with early dynamic change: age >70 (0.5; 0.4–0.6), CVD (0.5; 0.4–0.7), HT (0.6; 0.46–0.8), eGFR<60 (0.4; 0.3–0.6), CHF (0.4; 0.3–0.5), AF (0.4; 0.3–0.6) and no risk factors were positively associated with dynamic change. Different cut-offs for dynamic change for instance >4ng/L (at initial hs-cTnT <14ng/L) and >50% (initial >14ng/L) were tested but did not affect the overall results.

Fig 1. Forest plot dynamic hs-cTnT

Conclusions

Many risk factors and comorbidities show opposite associations with early dynamic change of hs-cTnT depending on the baseline concentration. The findings stress the importance of initial troponin level when assessing patients with risk factors presenting with ACS symptoms in the ED, however further investigations are needed to establish the definite dependency.

The British Columbia Emergency Medicine Network: A Paradigm Shift in a Provincial System of Emergency Care

As generalists, emergency practitioners face challenges in providing state-of-the-art care owing to the broad spectrum of practice and the rapid rate of new knowledge generation. Networks have become increasingly prevalent in health care, and it was in this backdrop, and the resulting opportunity to advance evidence-informed emergency care in the Canadian province of British Columbia (BC), that a new “Emergency Medicine Network” (EM Network) was launched in 2017. The EM Network consists of four programs, each led by a physician with expertise and a track record in the domain: (1) Clinical Resources; (2) Innovation; (3) Continuing Professional Development; and (4) Real-time Support. This paper provides an overview of the EM Network, including its background, purpose, programs, anticipated evolution, and impact on the BC health care system.

RAGE-dependent regulation of calcium-binding proteins S100A8 and S100A9 in human THP-1

Proinflammatory cell activation via the receptor for advanced glycation end products (RAGE) pathway may play a central pathogenetic role in atherosclerosis. Since S100A8/A9 was recently identified as ligand of RAGE, we determined the effects of proinflammatory cytokines on RAGE-mediated induction of gene expression of S100A8 and S100A9. mRNA levels of S100A8 and S100A9 were upregulated following cytokine stimulation with IL-6 (1, 10, 100 ng/ml) or TNFα (10 ng/ml) in human THP-1 cells. Preincubation of cells with 2000 ng/ml AGE (advanced glycation end products) before cytokine stimulation resulted in upregulation of RAGE. Pretreatment of THP-1 with AGE followed by stimulation with IL-6 (10 ng/ml) or TNFα (10 ng/ml) further increased S100A8 and S100A9 mRNA expression and S100A8/A9 release into cell culture supernatant, as compared to pretreatment with non-glycated albumin as control. Binding of AGE to RAGE was blocked with a neutralizing anti-RAGE antibody. Normal mouse IgG served as control. Cytokine-stimulated induction of S100A8 and S100A9 mRNA levels as well as of S100A8/A9 release after preincubation of cells with AGE were significantly suppressed by RAGE blockade, indicating a RAGE-dependent pathway of AGE-mediated S100A8/A9 expression.The cytokine-induced potentiated S100A8 and S100A9 expression under conditions with a high AGE burden is able to aggravate proinflammatory conditions via activation of the RAGE pathway.

Synthesis and characterization of photoswitchable lipids containing hemithioindigo chromophores

The synthesis of four lipids containing the hemithioindigo chromophore as part of the fatty acid is described. Heck reaction of bromophenyl thioacetate esters with acrylonitrile, followed by reduction, ester hydrolysis, and Friedel--Craft acylation--cyclization gave a substituted thioindoxyl that condensed with an alkoxy benzaldehyde to produce the hemithioindigo. "Solventless" nitrile hydrolysis followed by mixed anhydride coupling of the acid with glycerophosphocholine produced lipids bearing two hemithioindigo chromophores. The photochemistry of various hemithioindigo derivatives was studied to confirm the expected photoisomerization in both homogeneous organic solution, and in vesicle bilayer membranes. Characteristic changes in the UV--visible spectra are consistent with fully reversible Z--E photoisomerization. Chromatographic separation of the Z and E isomers of a compound containing a single hemithioindigo chromophore confirmed the spectroscopic analysis and provided a quantitative analysis of the compositions of Z--E isomer mixtures.

Low-dose rocuronium improves conditions for tracheal intubation after induction of anaesthesia with propofol and alfentanil

We studied 60 adult patients to assess if low doses of rocuronium improved conditions for tracheal intubation during induction of anaesthesia with propofol 2.5 mg kg-1 and alfentanil 10 micrograms kg-1. In a double-blind, randomized design, patients were allocated to one of three groups: group P = saline; group R1 = rocuronium 0.1 mg kg-1; and group R3 = rocuronium 0.3 mg kg-1. Intubation conditions were judged as optimal, suboptimal or failure, based on the scoring of ease of jaw opening and laryngoscopy, position of the vocal cords and degree of straining after tracheal intubation. Intubation conditions were judged as optimal in one patient in group P, in six patients in group R1 and in 18 patients in group R3. Conditions were judged as a failure in seven patients in group P, in one patient in group R1 and in none in group R3. No laryngospasm or other complications were observed in any patient. The addition of low doses of rocuronium significantly improved intubation conditions (P < < 0.001). Ventilation was controlled during surgery, and in no patient was any problem encountered with antagonism of neuromuscular block with neostigmine. Injection of rocuronium 0.3 mg kg-1 (ED95) with propofol and alfentanil provided a high proportion of optimal intubation conditions.