Changes in mitral regurgitation following acute myocardial infarction: early and long-term follow-up

Background

Mitral regurgitation (MR) is commonly observed following acute myocardial infarction (MI). Localised left ventricular (LV) remodelling in the region of papillary muscles together with impaired myocardial contractility promote MR. There is a paucity of long-term follow-up studies to determine whether the severity of MR observed post-MI, changes with time.

Purpose

This study retrospectively followed up patients with MR detected following acute MI (AMI) to investigate changes in MR severity with time and assess for pre-discharge predictors of MR regression or progression.

Methods

Clinical records of 1000 patients admitted with AMI between 2016 and 2017 to a single centre were retrospectively interrogated. One hundred and nine patients met the inclusion criteria of MR on pre-discharge transthoracic echocardiography (TTE) and follow-up TTE scans. Echocardiographic parameters were investigated to determine predictors of progression or regression at follow-up. Patients were divided according to those who had early follow-up TTE (within 1-year) and late follow-up TTE (beyond 1-year).

Results

Early follow-up TTE was performed in 73 patients at a median of 6 (IQR 3–9) months. Patients had a mean age of 69±13 years and were predominantly male 50/73 (68%). At baseline, relative MR severities were: 49/73 (67%) mild MR, 23/73 (32%) moderate MR and 1 (1%) severe MR. At follow-up, MR had completely resolved in 18/73 (23%) patients, while 39/73 (53%) had mild MR, 15/73 (21%) moderate MR and 1 (1%) severe MR. Compared to patients with no resolution of MR, those with completel resolution were younger (mean age 62±16 vs 72±11 years; p=0.015) but there were no other significant differences between the groups. Resolution at early follow-up did not significantly influence long-term mortality rates. Late follow-up TTE was performed in 69 patients at a median 2.4 (IQR 2–3.2) years. Pre-discharge, 49/69 (71%) patients had mild MR and 20/69 (29%) moderate MR. At follow-up, MR had completely resolved in 18/69 (26%), and amongst patients with persistent MR, proportion of severities were: 37/69 (54%) mild MR, 11/69 (16%) moderate MR and 3/69 (4%) severe MR. Patients with progression of mild MR were more likely to have lower left ventricular ejection fraction (LVEF: 47±15 vs 57±12%; p=0.010) and greater indexed left ventricular end-systolic volume (LVESVi: 37±23 vs 25±14 ml/m2; p<0.001) on pre-discharge TTE. Resolution of MR at late follow-up was associated with a reduction in long-term mortality [deaths: 2/55 (3%) vs 3/14 (21%); p=0.022] at a mean follow-up of 4.2 years from MI.

Conclusion

MR observed following AMI completely resolved in approximately one-quarter of patients at 6-month and 2-year follow-up. Progression of mild MR at long-term follow-up appears to be associated with increased mortality and is predicted by lower LVEF and greater LVESVi pre-discharge.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular function and clinical heart failure after myocardial infarction revascularized with percutaneous coronary intervention - comparison between STEMI and NSTEMI in modern practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVSD) is a common consequence of myocardial infarction (MI). Data from historic series identified LVSD in up to 60% of patients post-MI. However, in modern practice, with high-sensitivity cardiac biomarkers leading to early detection of MI and widespread use of early revascularization, the prevalence of LVSD in the acute phase of MI and its impact on subsequent clinical heart failure remains unknown.

Purpose

To ascertain the prevalence of LVSD on pre-discharge echocardiography and its impact on subsequent clinical heart failure after type 1 MI treated with percutaneous coronary intervention (PCI) in a UK tertiary cardiac centre.

Methods

A retrospective electronic patient records review of consecutive patients with type 1 MI treated with PCI between January 2016 - December 2017. Patients treated conservatively or with surgical revascularization were excluded.

Results

1000 consecutive patients were identified and 948/1000 who had an inpatient echocardiogram prior to discharge were included in this analysis – 413 ST elevation MI (STEMI) and 535 non-ST elevation (NSTEMI). Median door to balloon time for STEMI was 42 minutes (IQR 28-79). Median time from symptom onset to intervention for NSTEMI was 3 days (IQR 1-6). LVSD was defined as left ventricular ejection fraction (LVEF) <50% on transthoracic echocardiogram carried out during the hospital episode. LVSD was significantly more prevalent in patients with STEMI compared to NSTEMI (37.4% vs 17.3%, p < 0.001). Median LVEF was significantly lower in the STEMI population (55%, IQR 45-60) compared to patients with NSTEMI (60%, IQR 54-65), p < 0.001. However, rates of clinical heart failure at index presentation with MI did not vary significantly between STEMI and NSTEMI patients (6.1% vs 4.9%, p = 0.414). In stepwise multivariate regression models: age, peak troponin and previous coronary artery bypass grafting were predictors of LVEF, whereas LVEF and previous MI were predictors of clinical heart failure

Patients with LVSD on pre-discharge echocardiography had significantly higher rates of 30-day readmission with heart failure (2.9% vs 0.7%, p = 0.017), 30-day all-cause mortality (6.1% vs 2%, p = 0.001), 30-day cardiac mortality (5.7% vs 1%, p < 0.001) and 2-year all-cause mortality (5.7% vs 1.6%, p = 0.001). However, at 2-years, there was no difference in hospital readmission with heart failure (0.8% vs 0.3%, p = 0.276). There were no significant differences between STEMI and NSTEMI patients for these endpoints.

Conclusions

Early revascularisation with PCI has led to a reduction in the prevalence of early LVSD post-MI compared to historical data. However, the presence of LVSD remains a powerful predictor of adverse clinical outcomes. Despite lower rates of LVSD on pre-discharge echocardiography in patients with NSTEMI compared with STEMI, the incidence of subsequent clinical heart failure is similar. This however may be underestimated due to survival bias.

Ischaemic mitral regurgitation: incidence, clinical and angiographic characteristics of 1000 patients with type 1 myocardial infarction undergoing percutaneous coronary intervention

Background

Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation.

Purpose

To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI.

Methods

This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification.

Results

MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3).

Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p<0.001), male (75% vs 64%; p<0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p<0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p<0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p<0.0001).

MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p<0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups.

Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061).

Conclusion

Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI.

Funding Acknowledgement

Type of funding source: None

Risk stratification on echocardiography and outcome in ischaemic mitral regurgitation

Background

Ischaemic mitral regurgitation (IMR) confers a poor prognosis. Transcatheter intervention may improve survival but benefit is likely to depend on severity of IMR relative to LV remodelling following myocardial infarction (MI). In theory, those with “discordant” IMR (significant regurgitant volume without severe LV dilatation or impairment), are expected to benefit most from mitral intervention. While subcategorization may help to inform treatment, there are no data on post-MI patients in this respect.

Purpose

To determine the incidence of discordant & concordant IMR categorised on echocardiography post-MI and impact on outcomes.

Methods

1000 consecutive patients admitted to our hospital with myocardial infarction who underwent coronary angioplasty were included. Early inpatient TTE was performed by accredited echocardiographers using standard multiparametric quantification.

Using TTE parameters, 4 subgroups were identified (figure) according to the degree of MR relative to LV remodelling. Thresholds were based on European guidelines (± 2SD from normal) and median value among survivors for vena contracta (VC):

– LVEF: 52% (♂), 54% (♀)

– Indexed LV end diastolic volume (LVEDVi): 74ml/m2 (♂), 61ml/m2 (♀)

– Effective regurgitant orifice area (EROA) ≥0.2cm2

– Regurgitant volume (RVol) ≥30ml

– VC ≥0.5cm

Results

MR was seen in 294/1000 patients (29.4%) with a severity of mild (76%), moderate (21%) and severe (3%). Concordant and discordant IMR were each seen in 16/294 (5%) of IMR patients post-MI.

After a mean follow up of 3.2 years, IMR patients had a 3% rate of heart failure (HF) within 1 year and 19% mortality. Non-survivors had significantly worse IMR (PISA 0.65±0.25cm vs 0.54±0.19cm; p=0.033; VC 0.63±0.25cm vs 0.49±0.18cm; p=0.014), worse LV function (LVEF 44±17% vs 51±13%; p<0.001), larger LV (LVEDVi 67±23ml/m2 vs 60±22ml/m2; p=0.032) and larger indexed LA volume (LAVi) (44±22ml vs 35±15ml; p<0.001). Those with concordant IMR had the worst survival (50%) although almost 1 in 5 of those with discordant MR died within the follow up period (19%). Using multivariable Cox regression, significant predictors of mortality included LVEF (p<0.001; HR 0.96, 0.94–0.98) and LAVi (p<0.001; HR 1.02, 1.01–1.03) but not LVEDVi.

Conclusion

1) Significant predictors of mortality in IMR include LA dilatation and decline in LVEF, but not LV dilatation.

2) Although discordant severe IMR is uncommon following MI, mortality if left untreated remains high. Attention should be paid to early selection of this cohort for intervention.

Funding Acknowledgement

Type of funding source: None

Phyto-Therapeutic and Nanomedicinal Approaches to Cure Alzheimer's Disease: Present Status and Future Opportunities

Alzheimer's disease (AD) is characterized by cognitive inability manifested due to the accumulation of β-amyloid, formation of hyper phosphorylated neurofibrillary tangles, and a malfunctioned cholinergic system. The degeneration integrity of the neuronal network can appear long after the onset of the disease. Nanotechnology-based interventions have opened an exciting area via theranostics of AD in terms of tailored nanomedicine, which are able to target and deliver drugs across the blood-brain barrier (BBB). The exciting interface existing between medicinal plants and nanotechnology is an emerging marvel in medicine, which has delivered promising results in the treatment of AD. In order to assess the potential applications of the medicinal plants, their derived components, and various nanomedicinal approaches, a review of literature was deemed as necessary. In the present review, numerous phytochemicals and various feats in nanomedicine for the treatment of AD have been discussed mechanistically for the first time. Furthermore, recent trends in nanotechnology such as green synthesis of metal nanoparticles with reference to the treatment of AD have been elaborated. Foreseeing the recent progress, we hope that the interface of medicinal plants and nanotechnology will lead to highly effective theranostic strategies for the treatment of AD in the near future.

Stable and reproducible synthesis of gold nanorods for biomedical applications: a comprehensive study

Gold nanorods (GNRs) are ideal choice in biomedical research due to their amenability of synthesis, tunable plasmonic properties, less toxicity and ease of detection but their diverse biological applications necessitate stable structure. Despite two decades' efforts made towards reproducible anisotropic structures synthesis, still the kinetic control during GNRs growth has not been achieved. This study is an attempt to apprehend thermodynamic and kinetic parameters for synthesising mono‐disperse, reproducible and highly stable GNRs with desired aspect ratios. Effects of various growth parameters and assay steps on the facile and reproducible synthesis of GNRs are analysed. GNRs' environmental and biological colloidal stability is studied through UV–Vis spectroscopy based particle instability parameter (PIP < 0.1). The authors hereby report GNRs with tunable longitudinal surface plasmon resonance (682–906 nm) having different aspect ratios (2.5–4.6) that are stable at 28–60°C; however, prolonged high temperature ( > 60°C) and alkaline pH can trigger colloidal instability. GNRs remain stable at higher salt concentration, physiological and slightly acidic pH. GNRs can be stored in 0.001 M cetyltrimethylammonium bromide for 3 months without compromising their stability. PEGylated GNRs are quite stable in cellular media solution (PIP < 0.1). With current optimised growth conditions, no aggregation at physiological pH and stability at high temperatures make GNRs an ideal candidate in biomedical applications.

Treatment of advanced chemo-refractory epithelial ovarian cancer with aromatase inhibitor

e16561

Background: In advanced epithelial ovarian cancer non-steroidal antiestrogens yields clinical responses in a significant number of patients. This raises the possibility of therapeutic effectiveness of aromatase inhibitors in epithelial ovarian cancer in post menopausal women. Therefore this study was carried out to document the effectiveness of an aromatase inhibitor, in advanced epithelial ovarian cancer patients with unknown hormone receptor status. Methods: From January 2006 to April 2007, a total of 38 patients were enrolled. Patients with histopathologically confirmed advanced epithelial ovarian cancer were included. Other eligibility requirements were: postmenopausal women, failure of third-line chemotherapy, age between 50–70 years, bidimensionally measurable disease, and CA-125 of more than 100 u/mL. An adequate hematologic, hepatic, and renal profile, and ECOG performance of 0–2 was required. Tablet letrozole 2.5 mg orally once daily was given for 03 months. CA-125 and Miller criteria were used for response evaluation. Results: No patient showed the evidence of complete or partial clinical response. Four patients had stable disease for 8 weeks. All patients showed progressive disease on week 12. Conclusions: In this small series no evidence of effectiveness of aromatase inhibitor letrozole in chemo refractory epithelial ovarian cancer is documented in patients with unknown hormone receptor status. It is, therefore, recommended that further study should only be carried out in the selected patient population with documented positive ER/PR hormone receptors.

No significant financial relationships to disclose.

A phase II feasibility study of cytarabine and idarubicin combination in relapsed or refractory adult acute lymphoblastic leukemia

e18002

Background: Most patients with adult ALL eventually relapse. Salvage regimens in these patients and in patients with primary refractory disease are generally based on cytarabine in combination with other agents. Exact merit of each combination remains undefined as these continue to be tested in non randomized trials. This study was conducted with the objectives to find out the efficacy and toxicity of cytarabine and idarubicin combination. Methods: From December 2006 to March 2008, 30 patients were enrolled in this prospective, nonrandomized single institution phase II feasibility study. It was empirically decided that the study will only be considered feasible if more then ten patients achieve a complete remission. Patients who relapsed during maintenance therapy or were refractory and were at least 16-years-old were considered eligible provided they have received at least vincristine and prednisone as induction. No prior cytarabine was allowed. Cytarabine 100 mg/m2 continuous infusion for seven days along with idarubicin 12 mg/m2 day 1 to 3, IV bolus was given. Bone marrow examination was done 15 days after the completion of chemotherapy. Results: All thirty patients completed planned treatment. Five patients died of infection during treatment. Eleven patients achieved complete remission. All patients relapsed within eight months. Conclusions: The regimen of cytrarabine and idarubicin is feasible and sufficiently effective in relapsed or refractory adult ALL with manageable toxicity.

No significant financial relationships to disclose.

An assessment of the main metabolic variables of cardiovascular risk in a sample population of workers in Rome

BACKGROUND

The last few years have seen an increased necessity to assess the cardiovascular risk factors on large samples of the population in Italy. A look at the citizens of a small rural town Brisighella is well known.

METHODS

Three hundred and five individuals of average age 40.8 years (+/-8.22), recruited between September 1988 and December 1989 (198 men, 107 women) were taken into consideration. Clinical and instrumental investigations were then performed (intern visits with data obtained from primary anthropometric, otorhinolaryngological and ocular variables, heart X-ray, electrocardiogram). The following analyses were also performed: haemochrome, ESR, uricemia, azotemia, glycemia, AST, ALT, bilirubinemia, protein electrophoresis, triglyceridemia, total cholesterol, HDL cholesterol, creatinine level and urine analysis. Women also received PAP-test. Another variable was lifestyle habits which may be considered a risk for cardiovascular disease. Hygienic and diet suggestions were made. After seven years, in 1997, 100 of these individuals (51 men, 49 women - mean age 42.7+/-6.5 years) were chosen at random and administered the same clinical and laboratory examinations as before.

RESULTS

The analysis of the data show average BMI values 24.07+/-2.7 in men and 22.8+/-2.6 in women, inferior to those found in other Italian investigations. We observed an increase of BMI along with age, despite measures of preventive medicine, in married subjects and along with education and occupation level. Mean values of cholesterol level in men increased between the ages 30 and 39 and stabilised after 40 years; in women they increased only after the 5th decade of life.

CONCLUSIONS

We observed a direct correlation between the increase of uricemia and triglyceride levels, triglyceride and cholesterol levels, BMI and triglyceride levels conferming the tight bond among these metabolisms and the importance of obesity as a risk factor. Uricemia levels correlate with systolic and diastolic blood pressure.

Life habits and cardiovascular risk in a group of bank employees in Rome

BACKGROUND

For the past thirty years, many countries, especially the USA, have been performing clinical and laboratory studies to establish the most prominent disease risk factors, in particular those involved in cardiovascular diseases. The main aim of these studies is to reduce disease related risks by intervening at an early age.

METHODS

We studied 305 patients, 198 males and 107 females, all employees in Rome, mean age 40.8 years (+/- 8.22), enrolled from September 1988 to December 1989. We measured the main anthropometric parameters and performed otolaryngologic and ocular examination, a telecardiogram and an EKG; the following analyses were performed: hemochrome, ESR uric acid, azotemia, glycemia, AST, ALT, gamma GT, bilirubinemia, proteic electrophoresis, triglyceridemia, total cholesterolemia, HDL cholesterolemia, creatinine, urine examination, Pap-Test for women. Lifestyle habits that might be considered cardiovascular disease risk factors were considered and hygienic eating habits were suggested. Seven years later, in 1997, 100 of these patients were randomly selected (51 man and 49 women) and underwent the same clinical and laboratory tests as before.

RESULTS

The results suggest a deep correlation between lifestyles and the increase of some cardiovascular risk factors.

CONCLUSIONS

The authors believe that this study can be of some help in guiding future preventive medicine interventions that may be carried out on this population sample.

Ovarian cancer and unilateral naevoid telangiectasia: a rare association

The Authors describe the case of a 58-year-old woman affected by erythematous telangiectasis lesions on the antero-lateral surface of the right hip during papillary serous cystoadenocarcinoma of the right ovary. The diagnosis, based on clinical and histological findings, was unilateral naevoid telangiectasia. After a review of literature the Authors assume a possible role of the oestrogens in the pathogenesis of such infrequent disease.

[Juvenile dyslipidemia as early risk factor for atherosclerosis. Analysis of a sample of school age boys]

Atherosclerosis appears already in the first years of life. Several factors may accelerate the age of onset and the gravity of its symptoms. Particular importance is attributed to lipid metabolism in youth. Ther Authors studied the rates of cholesterol, HDL, LDL, triglycerides, apolipoproteins AI and B100, lipoprotein a and several anamnestic and anthropometric parameters in a group of 103 young people of Rome, between 16 and 19 years of age. They processed these data statistically and compared them with those of a similar American group. The results showed a tendency to fatness in the Italian sample, and to dyslipidosis in the American group. Besides, the subjects who had been breast-fed presented higher blood levels of cholesterol and apolipoprotein B100.