Elevated levels of Lp(a) are associated with coronary lesion complexity in patients hospitalized for an acute myocardial infarction: data from the French RICO Survey

Background

Although patients with elevated Lp(a) are at high risk of acute myocardial infarction (MI), coronary artery disease (CAD) burden associated with Lp(a) remains poorly investigated.

Methods

Single center study including all consecutive patients hospitalized for an acute MI in Coronary Care Unit from the RICO database (2019–2021) who underwent coronary angiography and blood sample for Lp(a) assessment on admission. Coronary lesion complexity was retrospectively assessed by SYNTAX score and pre-specified angiographic criteria. Patients were compared according to their Lp(a) levels: <50 mg/dL (normal), ≥50 mg/dL and ≤100 mg/dL (high) and >100 mg/dL (very high).

Results

921 patients were included, of whom 177 (19.2%) had elevated Lp(a) >50 mg/dL, including 121 (13.1%) with high and 56 (6.1%) with very high Lp(a). Median (IQR) age was similar across the 3 groups (normal: 68 (58–78)y; high: 70 (60–80)y; very high: 69 (61–78)y, p=0.381). When compared with patients with normal Lp(a), patients with high and very high Lp(a) levels had increased prevalence of personal history of CAD (19%, 28% and 29%, respectively, p=0.026) and family history of CAD (19%, 26% and 29%, p=0.032, respectively). The rate of women was more common in very high Lp(a) level than in high and normal groups (46%, 33%, and 29%, respectively, p=0.016). Rate of ST-segment elevation MI was similar for the 3 groups (p=0.961). At coronary angiography, CAD burden, as assessed by SYNTAX score was much higher in elevated Lp(a) groups (11 (6–19), 15 (8–24), 17 (7–25), p=0.001, respectively). Moreover, patients with elevated Lp(a) had more complex coronary lesions (p=0.034), characterized by left main (p=0.021), and calcified lesions (p=0.002) (figure). In-hospital mortality gradually increased across the 3 groups (2.8%, 6.6%, 8.9%, p=0.010, respectively).

Conclusions

This retrospective study in patients with acute MI shows that elevated Lp(a) were common, associated with high risk for in-hospital mortality. Patients with high Lp(a) were characterized by severe CAD burden, with complex anatomy features including left main and calcified lesions. The long-term prognostic impact of Lp(a)-associated CAD burden needs to be explored.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): ARS Bourgogne Franche ComtéCHU Dijon BourgogneAssociation de Cardiologie de Bourgogne

Prognostic and diagnostic impact of new pathophysiology-based categorization of type 1 and type 2 myocardial infarction: data from the French RICO survey

Background

A new classification of type 1 and 2 myocardial infarction (MI) derived from the fourth universal definition of MI (UDMI) has been recently proposed, based on pathophysiology of coronary artery disease (CAD),. We assessed the impact of this new MI categorization on epidemiology and outcomes.

Methods

Retrospective study including all consecutive patients hospitalized for an acute MI in a multicenter database (RICO). MI was defined according to current UDMI. Rates and outcomes of T1MI and T2MI were addressed according to the new classification.

Results

Among the 4573 patients included on our study, 3710 patients (81.1%) were initially diagnosed with T1M1 and 863 (18.9%) with T2MI. After reclassification, 96 T2MI patients were moved into the T1MI category. Out of the remaining 767 patients with T2MI, 567 underwent coronary angiography, and were adjudicated as type 2A MI (68.6%) with obstructive CAD, and type 2B MI (31.4%) without obstructive CAD.

When compared with T1MI and T2BMI, T2AMI patients had worse in-hospital outcomes, including heart failure (p<0.001), recurrent infarction (p<0.048) and mechanical complications such as mitral insufficiency (p=0.001). The 3 groups (T1AMI, T2AMI and T2BMI) had similar all-cause and cardiovascular death rates, with a trend for a higher all-cause mortality in T2AMI patients.

Kaplan-Meier one-year survival curves showed higher all-cause and cardiovascular causes mortality in T2AMI patients compared to T1MI and T2BMI (p<0.001). In multivariate Cox regression, type of MI was independent predictor of death.

Conclusion

Our large observational multicenter study shows major disparities in mortality according to type of MI and support the relevance of the new MI classification to improve risk classification. Our findings may will help identifying specific phenotypes and considering personalized diagnostic and management strategies.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Agence Régionale de Santé (ARS) de Bourgogne Franche-ComtéRegional Council of Bourgogne Franche-Comté.

Temporal trends over 20 years of smoking prevalence in patients with acute myocardial infarction. Data from the RICO survey

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): ARS Bourgogne Franche Comté

Background

Over the last 2 decades, tobacco smoking, a major cardiovascular (CV) risk factor, has decreased in France, but remains among the highest in European countries.

Aim

From a large database of patients with acute myocardial infarction (MI), we aimed to investigate the evolution of smoker’s prevalence and characteristics over a 20-y period.

Methods

From the RICO survey, 18,769 patients hospitalized from 2001 to 2020 for an acute MI in one region of France were included. Current smokers were compared with ex-smokers or non-smokers and according to gender.

Results

Temporal trends showed that smoking rate did not decrease in men and dramatically increased in women by 50% (figure). Rate of smoking was higher in men than in women (34% vs 18%, p<0.001). Median age increased across the year groups whatever the smoking status. When compared with ex or non-smokers, smokers were much younger (54 vs 71 y for men and 56 vs 79 y for women, p<0.001), had more frequent family history of CAD but less modifiable risk factors such as diabetes and hypertension. ST-segment elevation MI was more common in smokers, for both sex. Although in-hospital adjusted mortality was similar for both groups, smokers had more common ventricular arrhythmias (VF/VT).

Conclusions

Over the last 2 decades, tobacco use remains common in patients with acute MI and is associated with a younger age of occurrence and severe acute complications. Our findings also reveal an alarming increasing prevalence of smoking in women. More effective prevention strategies are necessary to reduce tobacco use, in particular in women.

High prevalence of complex coronary artery lesions in sport-related myocardial infarction. Contemporary data from the RICO survey

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Agence régionale de santé de Bourgogne Franche-Comté

Background

Underlying mechanisms for sport-related acute myocardial infarction (SR-AMI) are only poorly understood. Moreover, their coronary artery disease (CAD) characteristics and lesion complexity are poorly described.

Purpose

To characterize coronary angiographic feature of patients with SR-AMI

Methods

From the RICO database, a large regional acute MI survey, all consecutive patients hospitalized in our University Hospital from 2010 to 2021 who underwent coronary angiography for SR-MI were retrospectively analysed. SR-MI was defined as MI occurring during sport activity or within the first hour of recovery.

Results

Among the 174 patients included, most were male (n=157(91%)). Median (IQR) age was 59 y (48-66), and had ST segment elevation MI (STEMI) (n= 112 (64%)). The SR-MI often occurred while cycling (41%), jogging (23%), hiking (9%) or playing soccer (9%). Patients commonly experienced pre-hospital (PH) sudden cardiac arrest (SCA) (17%). Atherothrombotic risk factors were dyslipidaemia (32%), current smoking (31%) or hypertension (28%). A history of CAD was documented in 31 (18%) patients. Most (n=156(91%)) had significant lesions, of whom 140 (81%) were considered as culprit. Culprit lesions were located on left anterior descending (39%), circumflex (14%) and right coronary artery (33%). Median (IQR) Syntax score was 10.5 (6-15). The vast majority of patients (n=152 (87%)) had at least one complex lesion; 114 of them had several characteristics of complex lesion. Lesions were eccentric in 68 (39%) patients; an intraluminal thrombus was documented in 85 patients (49%), in 55% of STEMI and 37% of non-STEMI (p =0.027). However, 18 subjects (10%) had optically normal coronary angiogram or non-significant lesions, suggesting alternative mechanism such as type 2 MI. Treatment of the lesions was mainly achieved by PCI and/or stenting (n=132(77%)) or coronary artery bypass grafting (n=11(6%)). In-hospital death occurred in 11 patients (6%), of whom 10 experienced a PH-SCA and one was admitted with a cardiogenic shock during the Covid-19 pandemics lockdown. Among the 5 patients treated with extracorporeal membrane oxygenator, only one survived.

Conclusion

In our large retrospective study, SR-MI was commonly associated with complex coronary lesions, often characterized by intraluminal thrombus. Our findings suggest that the mechanisms of these events could be mainly related to type 1 MI patterns Moreover, PH-SCA was frequent, thus justifying mass-education to basic life support and deployment of automated external defibrillators, especially in the sport settings.

Psychosocial and behavioral characteristics of still smokers at 6 months after acute cerebro or cardiovascular events: preliminary findings from INEV@L, a prospective pilot study

Introduction

Considering the benefits of smoking cessation, and evolving new tobacco-product consumption, such as e-cigarettes (e-cig), contemporary behavioral and psychosocial factors (PSF) associated with smoking after acute stroke or myocardial infarction (MI) remain to be investigated.

Methods

From INEV@L, a prospective pilot study in 128 workers hospitalized for MI or stroke (MI/stroke: 199/57) <65 y, between 2016 and 2017 in CHU Dijon. Among them, 67 (52%) current smokers were analyzed. PSF (education level (EL), socioeconomic status (SES), perceived disease severity (PDS), anxiety/depression), and health behavior (adhesion to Mediterranean diet (AMD), BMI, physical activity (PA), smoking) were collected at the acute phase and at 6 Months Follow-Up. Patients who quit smoking were compared with non-quitting patients.

Results

Still smokers at 6-M FU were frequent (30 (45%)) and had similar risk factors including age (51±7 y) than quitters. Rate of overweight/obese patients and AMD were similar (52 vs 65%, p=0.281 and 29±6 vs 26±7, p=0.207). SES and EL were slightly higher in still smokers group. The level of anxiety or depression was as high in the 2 groups (63 vs 68%, and 19 vs 20%, p=0.717 and 0.911). Although similar at the acute phase (p=0.867), PDS at 6-M FU, trended to be lower in non-quitters (57 vs 78%, p=0.057). At FU, only few returned to work (57% for both groups). Overweight/obese who reduced their weight were more common in non-quitters (60 vs 38%, p=0.170). Patients who improved AMD or PA level were similar (62 vs 78%, p=0.166, and 67 vs 92%, p=0.317). The vast majority of non-quitters introduced the use of e-cig (80% vs 0%, p<0.001).

Conclusion

Our pilot study in young workers highlights the low rate of smoking cessation, and generalized dual use of electronic+conventional cigarette at mid-term after acute MI or stroke. Our findings further suggest specific PSF pattern of non-quitters, associated with loss of perceived disease severity.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Conseil Régional de Bourgogne Franche Comté et CHU Dijon Bourgogne

High levels of lipoprotein(a) are associated with the severity of coronary disease in patients with acute myocardial infarction. Data from the RICO survey

Background

High level of lipoprotein(a), Lp(a), is a well-recognized independent risk factor for atherosclerotic cardiovascular disease (ASCVD) including acute myocardial infarction (MI). However, limited data are available on the relationship between coronary artery disease (CAD) burden and Lp(a) levels in patients with acute MI.

Methods

CAD burden was addressed in 1213 consecutive patients hospitalized for an acute MI in 2019–2020 who underwent coronary angiography from the RICO survey. Patients were compared according to Lp(a) levels (Lp(a) <50 mg/dL (normal), ≥50 mg/dL and ≤100 mg/dL (high) and >100 mg/dL (very high)).

Results

The prevalence of high and very high Lp(a) was elevated (13% and 6%, respectively). Median (IQR) age (normal: 68 (58–79)y; high: 70 (61–80)y; very high: 69 (60–78)y, p=0.502) and rate of diabetes (p=0.448) were similar across the 3 groups. When compared with normal Lp(a), patients with very high Lp(a) had more frequently hypertension, were more often under chronic statin therapy and their corrected LDL-cholesterol was lower. There was a gradual increase in prior ASCVD rates across the 3 Lp(a) groups (p=0.001). When compared with patients with high or normal Lp(a), patients with very high Lp(a) levels had elevated SYNTAX score at coronary angiography, (17 (6–25) vs 12 (6–19) and 10 (5–18), p=0.006, respectively), and had more frequently multivessel disease (74% vs 64% and 56%, p=0.003). By multivariate analysis, very high Lp(a) (OR(95% CI): 1.879 (1.065–3.312)) remained associated with high CAD burden, beyond confounding including age, diabetes and dyslipidemia.

Conclusion

Among real world patients hospitalized for an acute MI, high Lp(a) levels are common (≈20%) and independently associated with a severe CAD burden, beyond traditional risk factors, identifying a subset of patients with features of high ASCVD risk.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne ARS Bourgogne Franche Comté

Endotoxemia and cardiometabolic biomarkers in patients with acute myocardial infarction. Data from the RICO survey

Background

The complex interplay between endotoxemia, inflammation and cardiometabolic diseases including acute myocardial infarction is poorly understood.

Aim

Our prospective study aimed to address the determinants of endotoxemia, including blood lipids and metabolic biomarkers, in patients admitted for an acute MI.

Methods

From the RICO survey, patients admitted to the coronary care unit of our University Hospital for type 1 acute MI were prospectively included between 2016 and 2018. Patients with prior coronary artery disease (CAD) or chronic kidney disease were excluded. Blood samples for biomarkers measurement were taken on admission. Endotoxemia was assessed by the LCMSMS measurement of circulating levels of LPS-derived 3-hydroxymyristate (3HM), a component of the lipid A moiety.

Results

Among the 245 patients included, mean age was 62±13 y, most were male (72%), almost half were hypertensive (43%), or current smokers (44%), 38% had hypercholesterolemia, or family history of CAD (31%), median (IQR) BMI was 27 (25–29) kg/m2 and 14% had diabetes. Median LDL-cholesterol was at 132 mg/dL, HDL-cholesterol at 47 mg/dL, total cholesterol at 209 mg/dL and triglycerides (TG) at 116 mg/dL. Median (IQR) 3HM levels were at 106 (83–131) pmol/L. Among biomarkers, TG levels were the most strongly correlated with LPS levels (r=0.201, p=0.002), beyond HbA1c (r=0.197, p=0.002), BMI (r=0.192, p=0.003), cholesterol (r=0.191, p=0.003), blood glucose (r=0.174, p=0.006) and age (r=0.173, p=0.007). Inflammatory biomarkers and cytokines (CRP, IL6, IL8, TNF α) did not significantly relate to 3HM levels. When compared with patients without diabetes, patients with diabetes had ≈40% higher levels of 3HM (140 vs 103 pmol/L, p<0.001). By multivariate regression linear analysis, TG (β(95% CI)=0.288 (7.757–20.357), p<0.001) remained an independent determinant of 3HM levels, beyond age (β(95% CI)=0.184 (0.274–1.374), p=0.003), and HbA1c (β(95% CI)=0.157 (1.764–15.390), p=0.014).

Conclusions

In a former analysis of our prospective study in patients with acute MI, endotoxemia levels related mainly to chronic metabolic disorders including diabetes and hypercholesterolemia. The underlying mechanisms for the LPS-associated TG elevations and its clinical significance at the acute phase of MI remains to be explored.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne ARS Bourgogne Franche comté

Sport-related acute myocardial infarction. Contemporary data from IMACS survey

Background

Sport-related (SR) acute cardiovascular (CV) events are the main cause of sudden cardiac death in the setting of sport activities. However, data are very scarce regarding onset and follow-up of SR acute myocardial infarction (AMI).

Methods

From the prospective study IMACS (Infarctus du Myocarde et Arret Cardiaque au cours du Sport) patients admitted for a SR-AMI in our university hospital from April 2018 to March 2020 were included. A 12 months follow-up (FU) was achieved through telephone interview to address CV outcomes and sport practice information. Information was obtained from relatives in case of out of hospital sudden cardiac arrest (OH-SCA).

Results

Among the 55 patients included, all were male, with median (IQR) age at 62 (55–69) y. Most common sports were cycling (n=21), fitness (n=7), swimming (n=5) and hiking (n=5). The SR-AMI occurred during effort for 39 subjects and during recovery for 16. Most SR-AMI occurred in public area (n=24), at home (n=16), or in a specific sport location (n=14). An Automated External Defibrillator (AED) was available in the SR-AMI location in only 10, but was missing in 43 (unknown for 2). In 1 subject with OH-SCA, cardiopulmonary resuscitation (CPR), initiated by witnesses, using a public AED, was unsuccessful. The 4 other patients with OH-SCA underwent successful CPR. Among the 55 subjects, 4 were vapers, of whom 1 was a dual user, 17 were current tobacco smokers, 18 were ex-smokers and 2 experienced cannabis and cocaine use. Among the smokers, most smoked (n=10) or consumed cannabis (n=1) <2h before the event. Strikingly, CV history and/or recent symptoms were present in almost half (n=25). Only 10 felt symptoms exclusively during the sport session. Moreover, a medical advice for recent symptoms was found only for 3 subjects. Three patients who experienced prior AMI have neglected symptoms during the index event. Most were ST segment elevated MI (n=35). Only one patient (with OH-SCA) died <3 days after hospital admission. During hospitalization, most underwent revascularization with coronary stenting (n=44) (drug eluting stent in 43 patients), or coronary artery bypass graft (n=6) and no death nor significant CV event occurred. At 1-FU, most attended a rehabilitation program (n=41) and the majority of smokers quitted (14/17), with 3 persistent smokers starting to vape. Almost half patients (n=23) decreased their physical activity, and 21 increased it. A significant rate of patient (n=9) added fitness in their usual activity, and as a main sport for 4 of them.

Conclusions

In this on-going monocentric prospective survey in SR-AMI, a high proportion of subjects had prodromal symptoms, of whom only few led to sport cessation and medical advices, when requested, failed to prevent the AMI. Our findings highlight that public and medical education are urgently warranted for SR-AMI prevention.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne Franche Comté et ARS Bourgogne Franche Comté

Characteristics and prognosis of patients with elevated triglycerides in acute myocardial infarction: observational data from a large database over a 17 years period

Background and aim

From a large database of a regional registry, we aimed to address the prevalence, characteristics and prognosis of patients with elevated triglycerides (TG) in patients hospitalized for an acute myocardial infarction (MI).

Methods

From the multicenter database (RICO survey), all consecutive patients hospitalized for an acute MI (2001–2017) and alive at discharge were included. Patients with TG >500 mg/dL, lost to follow-up (FU), or under chronic fibrate treatment were excluded. Patients with high TG (>200 mg/dL) on admission were compared to those with TG ≤200 mg/dL. Endpoints were recurrent ischemic events (i.e. recurrent MI, angina, unstable angina, stroke or urgent revascularization (PCI or CABG)) at 1-year FU.

Results

Among the 10667 patients included, 1886 (17.7%) had elevated TG. When compared with patients with TG ≤200 mg/dL, patients with high TG were younger (59 vs 69 y, p<0.001), had a higher BMI (28 vs 26 kg/m2, p<0.001), were more frequently men (77 vs 68%, p<0.001), diabetic (27 vs 21%, p<0.001), and smokers (42 vs 28%, p<0.001). The rate of statin therapy at discharge was similar for the 2 groups (79 vs 77%, p=0.285), as well as SYNTAX score and rate of multivessel disease (p=0.368 and p=0.791). In high TG group, LDL cholesterol was higher (130 vs 120 mg/dL, p<0.001) and HDL-cholesterol was lower (37 vs 46 mg/dL). At 1-Y FU, recurrent ischemic events were more frequent in elevated TG patients (11.2 vs 9.1%, p=0.004). In multivariate logistic regression analysis, high TG (OR (95% CI): 1.356 (1.095–1.679)) remains an independent estimate for recurrent ischemic event, even after adjustment for confounding (GRACE score, diabetes, obesity).

Conclusions

In our large population-based cohort, elevated TG are common in acute MI, and associated with residual risk of recurrent ischemic events, beyond traditional prognostic markers. Our data may help to identify candidates for targeted therapies to reduce recurrent ischemic risk after MI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amarin

Coronary artery ectasia in acute myocardial infarction: to be culprit or not to be?

Background

Coronary artery ectasia (CAE), is only found in about 1% of acute myocardial infarction (AMI), but represents a clinical challenge in the setting of percutaneous coronary intervention (PCI), considering 1) culprit lesion or not, 2) a solely CAE or mixt 3) number, localization and size of CAE, 4) etiology and 5) therapeutic strategies. Only few studies from small cohorts have focused on infarct-related arteries. We aim to assess the impact of CAE as culprit artery on management strategy.

Methods

From 2010 to 2019, this study prospectively analyzed the characteristics, and management of 70 consecutive admitted for an AMI and with CAE at coronary angiography. Patients with ectatic infarcted-related artery (ERIA) were compared with patients without ectasia localized on infarcted-related (No ERIA).

Results

Among the 70 patients included, most had ERIA 47 (67%). ERIA patients had more frequently diabetes than patients without ERIA (32 vs 4%, p=0.01). The rate of other CV risk factors, and chronic medications, including antiplatelet agents and anticoagulants,.were similar for the 2 groups. Moreover, no difference was observed between the 2 groups for clinical parameters and biological data. Whatever the group, the ectatic artery is mainly located on the right coronary artery (RCA) (73%), of which most were ERIA (77%). ERIA group had less frequently anterior wall location STEMI (18 vs 65%, p= <0.001). The rate of diffuse coronary artery disease (91 vs 92%) and maximum CAE diameter (6.36 (6.00–7.00) mm vs 6.14 (5.53–7.64) mm, p=0.571) were similar for the 2 groups. SYNTAX was lower in ERIA patients (9.5 (2.0–18.0) vs 13.5 (7.0–23.0), p=0.031). A complete reperfusion was more frequently achieved in no ERIA group (70 vs 47%, p=0.073).

PCI data and hospital mortality are shown in Table.

Conclusion

CAE management is strongly dependent on the presence of CAE on IRA. Although rare, the optimal treatment strategy of patients with AMI and CAE remains to be elucidated. The place of intravascular ultrasound imaging needs to be investigated.

Funding Acknowledgement

Type of funding source: None

Coronary lesion complexity in patients with familial hypercholesterolemia hospitalized for an acute myocardial infarction: data from the French RICO Survey

Background

Although patients with familial heterozygous hypercholesterolemia (FH) are at high risk of early myocardial infarction (MI), coronary artery disease (CAD) burden of FH patients with acute MI remains to be investigated.

Methods

All consecutive patients hospitalized for an acute MI in a multicenter database (RICO) from 2012–2017 who underwent coronary angiography were considered. FH (n=86) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥6). The angiographic features of FH patients were compared with patients without FH (score 0–2) (n=166), after matching for age, sex and diabetes (1:2).

Results

When compared with patients without FH, patients with FH had higher prevalence of personal and familial history of CAD (17 vs 5%, and 74 vs 5%, p=0.002 and p<0.001, respectively), and hypertension (54 vs 36%, p=0.006). Chronic statin treatment was used in only 45% of FH patients. At coronary angiography, FH had increased extent of CAD (SYNTAX score 11 (4–21) vs 8 (3–16), p=0.049) and multivessel disease (58% vs 43%, p=0.021). Significant stenosis was more frequent in left and right marginal coronary arteries. FH patients showed a trend toward more complex lesions, with less thrombus (28 vs 39%, p=0.076), but a 2 times higher rate of bifurcation lesions and calcifications (23 vs 12% and 20 vs 10%, p=0.021 and p=0.036).

Conclusions

This study addressing the coronary lesions features of FH patients with acute MI shows that FH patients had more severe CAD burden, and were characterized by complex anatomy features.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ARS Bourgogne Franche Comté, CHU Dijon Bourgogne

High levels of lipoprotein(a) are associated with the severity of coronary disease in patients with acute myocardial infarction. Data from the RICO survey

Background

High level of Lipoprotein(a), Lp(a), is a well-recognised independent risk factor for atherosclerotic cardiovascular disease (ASCVD). However, limited data are available on the prevalence of high Lp(a) levels and on the threshold associated to coronary artery disease (CAD) burden in patients with acute myocardial infarction (MI).

Methods

We aim at assessing CAD burden in 651 consecutive patients hospitalized for an acute MI from January 2019 to September 2019 who underwent coronary angiography. Patients characteristics and angiographic features were compared for patients with Lp(a) <50 mg/dL (normal), ≥50 mg/dL (high) and >80 mg/dL (i.e >90th percentile) (very high).

Results

The prevalence of Lp(a) ≥50 mg/dL was elevated (19.0%) and 65 patients (10.0%) were in the >90th percentile. Median (IQR) age was similar across the 3 groups (normal: 68 (59–79)y; high: 74 (63–80)y; very high: 71 (57–82)y, p=0.239). When compared with patients with normal Lp(a), patients with very high levels (≥80 mg/dL) had higher prevalence of personal history of ASCVD (29 vs 16%, p=0.021) and family history of CAD (37 vs 19%, p=0.005), and were more frequently women (43 vs 29%, p=0.009). At coronary angiography, patients with very high Lp(a) levels had increased extent of CAD (Median SYNTAX score 17 (5–25) vs 10 (5–17), p=0.002) and more frequent multivessel disease (69 vs 54%, p=0.02).

Conclusion

Among real world patients hospitalized for an acute MI, Lp(a) levels >80 mg/dL are associated with an increased CAD burden and this threshold identifies a subset of patients with features of high ASCVD risk.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ARS Bourgogne Franche Comté; CHU Dijon Bourgogne

Simultaneous cardio-cerebral embolization. A prospective study

Background

Atrial Fibrillation (AF) is a common cause of ischemic stroke but also the most common cause of Coronary Artery Embolism (CE). Many previous case of coexistence of coronary and cerebral embolism have been reported in the literature but in specific situations were clinical signs of stroke but also indisputable clinical and/or electrocardiographic (ECG) signs leaded to the realization of coronarography in emergency.

Objectives

The aim of the study was to determine the existence of simultaneous cardio-cerebral embolization associated in patients with ischemic embolic stroke on de novo AF, in the absence of clinical and/or ECG signs evocative of myocardial infarction (MI).

Methods

We prospectively included patients hospitalized in our institution for ischemic embolic stroke on de novo AF. Patients with history of ischemic disease were excluded. All patients had: 1/ troponin assay; 2/ Cardiac Magnetic Resonance (CMR) imaging with Late-Gadolinium Enhancement (LGE) in order to detect myocardial infarction; 3/ coronary exploration by cardiac CT scan or coronarography to exclude patients with significant coronary lesion.

Results

Between January and December 2019, 32 patients were included. Of them, 15 had subendocardial or transmural LGE on CMR, evocative of MI. Among these 15 MIs we classified acute MIs according to the level of troponin at the admission in stroke unit, the coronarography and T2 hypersignal on cardiac MRI. Median delay of cardiac MRI was 6 days for acute MIs.

CE was clearly identified by coronarography for 4 patients with acute simultaneous cardio-cerebral infarction (56%). The MRI abnormalities showed that lesions of all MIs were transmural, relatively small (average 1.3±0.44 segments) and in most cases in the inferior cardiac wall (47%) and these abnormalities were comparable in sequelae and acute MI. Moreover, the left appendage morphology was a “cactus” in 62.7% of simultaneous acute cardio-cerebral infarction and only 33% in patients without MI or sequelae MI. Strokes were mainly localized in the superficial territory of the middle cerebral artery, and were similar in patients with or without MI. In addition, the rate of sequelae strokes was higher in isolated stroke group than “cardiocerebral infarction” (29.5% versus 13.3%).

Conclusion

Simultaneous acute cardio-cerebral infarction is not uncommon, diagnosed in 22% of our prospective cohort of embolic stroke. Cardiac MRI may help us to diagnose a concomitant cardiac embolization and evaluate the prognosis. Unfortunately optimal therapeutic strategy of these patients is still unknown.

Flow Chart

Funding Acknowledgement

Type of funding source: None

[Prognostic value of HbA1c and plasma glucose on one-year mortality in non-diabetic patients after myocardial infarction]

BACKGROUND

The usefulness of the combined assessment of HbA1c and plasma glucose (PG) in acute myocardial infarction (AMI) in non-diabetic patients remains unclear.

PURPOSE

In a large observational study, we aimed to identify the prognostic values of these biomarkers regarding one-year all-cause mortality in non-diabetic patients after AMI.

METHODS

From the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey database, we included all consecutive non-diabetic patients with AMI (n=6617) from May 2001 to December 2016. Exclusion criteria were: admission known or unknown diabetes, in-hospital death. The primary endpoint was all-cause one-year mortality. The secondary endpoints were: MACE, infarct size, LVEF<40% and GRACE risk score. Cut-off levels (high/low) were determined by ROC curve analysis for the prediction of one-year death (HbA1c 5.9% and PG 131mg/dL) to set up 4 groups: low HbA1c/low glucose (n=3158), low HbA1c/high glucose (n=1264), high HbA1c/low glucose (n=1378) and high HbA1c/high glucose (n=817).

RESULTS

Elevation of PG was associated with elevated rate of LVEF<40%, STEMI, anterior wall location, DFG<60mL/min/m² and higher troponin Ic pic (all P<0.001); HbA1c>5.9% was associated with elevated rate of CRP>3mg/L (P<0.001); high HbA1c and high PG together were associated with higher rate of MACE (P<0.001). By multivariate logistic regression analysis, elevated admission PG remained a strong predictor of one-year all-cause [OR (95%CI): 1.64 (1.31-2.05)] mortality and cardiovascular mortality [OR (95%CI): 1.75 (1.33-2.31)], beyond GRACE score [OR (95%CI): 1.03 (1.03-1.04)], as well as elevated HbA1c [OR (95%CI): 1.43 (1.15-1.78) and OR (95%CI): 1.83 (1.39-2.41) respectively].

CONCLUSIONS

Admission PG and HbA1c had strong independent predictive value regarding one-year all-cause mortality in our non-diabetic patients with AMI. These biomarkers could be useful to identify the most-at-risk patients after AMI in order to reduce residual risk in this target population.

P6389Infection and type 2 myocardial infarction: a large observational study from emergency department

Background

Troponin elevation is frequent in patients with acute infection (AI) admitted to emergency unit (EU). Acute infection (AI) has been suggested as a common trigger in type 2 myocardial infarction (T2MI), corresponding to a myocardial oxygen supply-demand mismatch without atherothrombosis. We aim to characterize risk factors of T2MI occurrence and in-hospital mortality among patients admitted to an EU with AI and elevated troponin.

Methods

Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital EU (n=82 543), patients with a diagnosis of AI and elevated troponin Ic (≥0.10μg/L) (n=714) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes).

Results

Among the 714 patients included (aged 85, 50% male), 185 (26%) were classified as T2MI, of whom infection site was pulmonary tract (n=111), urinary tract (n=27), skin (n=15), digestive tract (n=9) or other or indefinite site (n=23). By multivariate analysis, a history of chronic obstructive pulmonary disease (COPD) (OR (95% CI): 0.53 (0.30–0.96)), high temperature (OR: 0.86 (0.74–0.99) per °C) and elevated creatinine (0R 0.998 (0.996–1.000) per μmol/L) were associated with a lower risk of T2MI, whereas age, site of infection, C-reactive protein and troponin rates were not predictors of T2MI. Death rate was similar among patients with or without T2MI (21 vs 23%, p=0.6). In contrast, age, troponine, creatinine or C-reactive protein elevations were independent co-variates associated with mortality.

Conclusions

Our large real-life study shows that in patients admitted to an EU with AI and troponin elevation, T2MI is a common feature, in the absence of temperature elevation, renal insufficiency or history of COPD. In such patients, inflammatory and cardiac biomarkers levels were independently associated with early mortality.

P4570Prognostic interest of HbA1c and plasma glucose assessment on one-year mortality in non-diabetic patients after acute myocardial infarction

Background

The usefulness of the combined assessment of HbA1c and plasma glucose (PG) in acute myocardial infarction (AMI) in nondiabetic patients remains unclear.

Purpose

In a large observational study, we aimed to identify the prognostic values of these biomarkers regarding one-year all-cause mortality in nondiabetic patients after AMI.

Methods

From the “obseRvatoire des Infarctus de Côte d'Or” (RICO) survey database, we included all consecutive nondiabetic patients with AMI (n=6617) from May 2001 to December 2016. Exclusion criteria were: admission known or unknown diabetes, in-hospital death. The primary endpoint was all-cause one-year mortality. The secondary endpoints were: MACE, infarct size, LVEF<40% and GRACE risk score. Cut off levels (high/low) were determined by ROC curve analysis for the prediction of one-year death (HbA1c 5.9% and PG 7.3mmol/L) to set up 4 groups: low HbA1c/low glucose (n=3158), low HbA1c/high glucose (n=1264), high HbA1c/low glucose (n=1378) and high HbA1c/high glucose (n=817).

Results

Elevation of PG was associated with elevated rate of LVEF<40%, STEMI, anterior wall location, DFG<60mL/min/m2 and higher troponin Ic pic (all p<0.001); HbA1c>5.9% was associated with elevated rate of CRP>3mg/L (p<0.001); High HbA1C and high PG together were associated with higher rate of MACE (p<0.001). By multivariate logistic regression analysis, elevated admission PG remained a strong predictor of one-year all-cause (OR (95% CI): 1.64 (1.31–2.05)) mortality and cardiovascular mortality (OR (95% CI): 1.75 (1.33–2.31)), beyond GRACE score (OR (95% CI): 1.03 (1.03–1.04)), as well as elevated HbA1c (OR (95% CI): 1.43 (1.15–1.78) and OR (95% CI): 1.83 (1.39–2.41) respectively).

Conclusions

Admission PG and HbA1c had strong independent predictive value regarding one-year all-cause mortality in our nondiabetic patients with AMI. These biomarkers could be useful to identify the most-at-risk patients after AMI in order to reduce residual risk in this target population.

Acknowledgement/Funding

University Hospital Center Dijon Bourgogne, France

P852Frequency and prognosis of type 2 myocardial infarction vs non ischemic myocardial injury: large observational study from an emergency department

Background

Type 2 Myocardial Infarction (T2MI), due to myocardial oxygen supply-demand mismatch in the absence of atherothrombosis and non-ischemic myocardial injury (NIMI), corresponding to troponin elevation without overt ischemia, are emerging concepts which are suspected to be common in patients hospitalized. However, their respective frequencies, risk profiles and short term prognosis in current routine clinical practice of emergency unit remains to be investigated.

Methods

Among the medical records of all the patients admitted from January 2014 to December 2016 in a university hospital emergency unit (n=82 543), patients with elevated troponin Ic (≥0.10μg/L) (n=4568) were systematically adjudicated as T2MI in the presence of symptoms or signs of myocardial ischemia (typical chest pain and/or ECG changes), or as NIMI without such signs. Patients with missing biological data on admission (n=112) or T1MI diagnosis (n=2467) were excluded.

Results

Among the 1989 patients included, 539 (27%) were classified as T2MI and 1450 (73%) as NIMI. When compared with patients with NIMI, T2MI had higher troponin levels (0.27 (0.14–0.71) vs 0.22 (0.13–0.54) μg/L, p=0.008, respectively). NIMI and T2MI had similar risk factors (age (84 (74–90) vs 84 (75–91) y, p=0.3), male sex (43 vs 48%, p=0.07), hypertension (67 vs 71%, p=0.133), diabetes (25 vs 25%, p=0.9), prior CAD (24 vs 26%, p=0.342), systemic inflammatory response syndrome (SIRS, 47 vs 49%, p=0.3), and systolic blood pressure (SBP) (130 (111–153) vs 132 (112–153) mmHg, p=0.545). Biological data on admission were also similar (hyperglycemia (glucose ≥11 mmol/L), 14 vs 13%, p=0.37, creatinine (96 (72–148) vs 94 (72–141) μmole/L, p=0.598), anemia (Hemoglobin rate ≤10g/dL, 13 vs 14%, p=0.5), C-reactive protein elevation (CRP ≥3 mg/L, 88 vs 89%, p=0.7)). Moreover, in-hospital mortality was high and similar for both groups (15 vs 18%, p=0.2). In multivariate analysis, age, troponin rate, SIRS, anemia, SBP, hyperglycemia, creatinine and CRP elevation were independent factors associated with hospital mortality, but not T2MI (vs NIMI) (OR: 0.88 (0.66–1.17)). Older age and hyperglycemia were specific covariates associated with increased risk of mortality in T2MI, but not in NIMI.

Conclusions

This large real-life study of non-T1MI inpatients with elevated troponins from emergency department shows that myocardial injury without necrosis and T2MI share the same risk factors, characterized by a high rate of infections and anemia and a high risk of hospital mortality.

Acknowledgement/Funding

University Hospital Center Dijon Bourgogne, France

2214Prevalence and severity of coronary disease in patients with familial hypercholesterolemia hospitalized for an acute myocardial infarction: data from the RICO survey

Aim

Individuals with heterozygous familial hypercholesterolemia (FH) are at high risk of early myocardial infarction (MI). However, coronary artery disease (CAD) burden of FH remains not well described. From a large database of a regional registry of acute MI, we aimed to address prevalence of FH and severity of CAD.

Methods

Consecutive patients hospitalized with MI in a multicentre database from 2001–2017 were considered. An algorithm, adapted from Dutch Lipid Clinic Network criteria, was built upon 4 variables (LDL-cholesterol (LDL-C) and lipid lowering agents, premature and family history of CAD) to identify FH probabilities.

Results

Among the 11624 patients included in the survey, 249 (2.1%) had probable/definite FH (score ≥6), and 2405 (20.7%) had possible FH (score 3–5). When compared with patients without FH (score 0–2), FH patients (score ≥6) were 20y younger (51 (46–57) vs 71 (61–80) y, p<0.001), with a lower rate of hypertension (47 vs 59%, p<0.001), diabetes (17 vs 25%, p<0.001) and prior stroke (4 vs 8%, p=0.016), but a higher prevalence of smokers (56 vs 23%, p<0.001), personal (20 vs 15%, p=0.02) or familial history of CAD (78 vs 18%, p<0.001). Chronic statin treatment was only used in 48% of FH patients and ezetimibe in 8%. After adjustment for age, sex and diabetes, FH patients were characterized by increased extent of CAD (syntax score 11 (4–19) vs 7 (1–13), p<0.001) and multivessel disease (55 vs 40%, p<0.001).

Conclusion

In this large real world population of acute MI, a high prevalence of FH was found. FH patients were characterized by their young age associated with the severity of CAD burden and limited use of preventive lipid lowering therapy.

Acknowledgement/Funding

University Hospital Center Dijon Bourgogne, Agence Régionale de Santé Bourgogne Franche Comté, France

P4573In patients with acute myocardial infarction, PCSK9 levels do not predict severity and recurrence of cardiovascular events

Background

In patients with coronary artery disease (CAD), it remains unclear whether serum PCSK9 levels can predict the severity of the disease and the risk of future cardiovascular events.

Methods

Among the patients admitted for an acute myocardial infarction (MI) from September 2015 to December 2016 in an intensive care unit from a university hospital, serum PCSK9 levels were measured on admission in patients not previously receiving statin therapy. We aimed to evaluate the association between PCSK9 levels, metabolic parameters, severity of CAD on coronary angiography, and the risk of in-hospital events and at one-year follow-up.

Results

In a total of 648 patients (mean age: 66 years, 67% male), the median PCSK9 was 263 ng/ml, higher for females compared with males (270 vs 256 ng/ml, p=0.009). Serum PCSK9 was associated with LDL cholesterol (r=0.083, p=0.036), total cholesterol (r=0.136, p=0.001) and triglycerides (r=0.137, p=0.001). A positive association was also observed in the subgroup of patients with CRP >10 mg/L (p<0.001), but not with NT-proBNP, troponin and creatine kinase. PCSK9 levels were similar whatever the SYNTAX score or the number of significant coronary lesions. Moreover, PCSK9 levels were not predictive of in-hospital events (death, recurrent MI and stroke) and events (cardiovascular death, cardiovascular events, recurrent MI) at one-year follow-up.

Conclusion

In this large cohort of patients hospitalized for acute MI and not previously receiving statin therapy, PCSK9 levels was not associated with the severity or the recurrence of cardiovascular events. The clinical utility of measuring PCSK9 levels remains to be demonstrated for this category of patients.

P4550Growth differentiation factor 15 as an integrative biomarker of heart failure in patients with acute myocardial infarction

Background

Growth differentiation factor 15 (GDF15), a stress-responsive cytokine member of the transforming growth factor-β family, is an emerging biomarker in cardiovascular (CV) diseases. GDF15 is weakly expressed in normal condition but increased in pathological situations such as inflammation, oxidative stress, and left ventricular remodeling. Recent data suggest GDF15 as a marker in heart failure (HF).

Purpose

We aimed to identify the determinants of GDF15 circulating levels in patients admitted for an acute myocardial infarction (AMI).

Methods

In our prospective study, all consecutive patients admitted from June 2016 to February 2018 for type 1 AMI in the Coronary Care unit from our University Hospital were included. Chronic HF patients were excluded. In-hospital severe HF was defined as killip class>2. Blood samples were taken on admission and serum levels of GDF15 were measured using a commercially available ELISA kit.

Results

Among the 284 AMI patients, median age was at 67 (57–78) y, 27% were women, 23% had diabetes and 59% were hypertensive. GDF15 levels (median = 1,144 (775–1,891) ng/L were strongly correlated with age (r=0.493, p<0.001), and elevated with most CV risk factors (i.e. hypertension, diabetes), prior CAD, chronic kidney disease (p<0.001 for all) and in patients with CRP >3 mg/L (p<0.001). When compared with patients who didn't develop severe HF (274/284), patients experiencing HF (10/284), GDF15 was more than twice higher (figure). By Receiving Operating Curve analysis, GDF15 was associated with HF (AUC (95% CI) = 0.716 (0.52–0.91), p=0.021). Moreover, GDF15 levels were negatively correlated with Left Ventricular Ejection Fraction (LVEF) (r=−0.193, p=0.001). Multivariate logistic regression analysis showed that GDF15 >5,000 ng/L [OR: 8.43; 95% CI (1.57–45.32)] is as independent estimate of HF, beyond age and other confounding (i.e. admission systolic blood pressure, LVEF and Log N-terminal pro-Brain Natriuretic Peptide).

GDF15 levels according to HF development

Conclusions

These preliminary results suggest that GDF15 could be an integrative biomarker of severe HF in patient with AMI. Further studies are needed to elucidate the underlying mechanisms linking the cytokine with the development of HF.

Glycaemic variability is associated with severity of coronary artery disease in patients with poorly controlled type 2 diabetes and acute myocardial infarction

BACKGROUND

In patients with type 2 diabetes (T2D), glycaemic variability (GV), another component of glycaemic abnormalities, is a novel potentially aggravating factor for coronary artery disease (CAD).

OBJECTIVES

The aim of our study was to identify interactions between GV and severity of CAD in diabetes patients admitted for acute myocardial infarction (AMI).

METHODS

All patients with T2D admitted to our university hospital for AMI from March 2015 to February 2017 who received intravenous (IV) insulin therapy and underwent coronary angiography were included. GV was assessed by mean amplitude of blood glucose excursion (MAGE) values taken within 2 days of admission. Patients with higher GV (highest MAGE tertile) were compared with those with lower GV (first and second MAGE tertiles).

RESULTS

A total of 204 patients were included: median age was 72 (61-81) years; 32% were female; HbA_1c was 7.3% (6.4-8.2%); diabetes duration was 10 (2-17.5) years; and MAGE value was 0.65 (0.43-0.92) g/L. Compared with those with lower GV, patients with the highest GV were more often women, treated with previous insulin, and had higher blood glucose and HbA_1c levels. In addition, patients with elevated GV had significantly higher SYNTAX scores: 17 (10-28) vs. 12 (6-22) (P = 0.009). Indeed, SYNTAX scores (OR: 1.05, 95% CI: 1.02-1.08; P = 0.001) remained independently associated with high GV beyond HbA_1c levels (OR: 1.51, 95% CI: 1.2-1.89; P <  0.001).

CONCLUSION

In AMI patients with poorly controlled diabetes, GV is associated with CAD severity beyond chronic hyperglycaemia. Although no causality can be determined from our observational study, the results suggest that, in AMI, early evaluation of GV might contribute to the identification of those diabetes patients at high risk, and serve as a therapeutic target for both primary and secondary prevention.