Diabetes Is Associated With Worse Long-term Outcomes in Young Adults After Myocardial Infarction: The Partners YOUNG-MI Registry

OBJECTIVE

We sought to determine the prevalence of diabetes and associated cardiovascular outcomes in a contemporary cohort of young individuals presenting with their first myocardial infarction (MI) at age ≤50 years.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed records of patients presenting with a first type 1 MI at age ≤50 years from 2000 to 2016. Diabetes was defined as a hemoglobin A1c ≥6.5% (48 mmol/mol) or a documented diagnosis of or treatment for diabetes. Vital status was ascertained for all patients, and cause of death was adjudicated.

RESULTS

Among 2,097 young patients who had a type 1 MI (mean age 44.0 ± 5.1 years, 19.3% female, 73% white), diabetes was present in 416 (20%), of whom 172 (41%) were receiving insulin. Over a median follow-up of 11.2 years (interquartile range 7.3-14.2 years), diabetes was associated with a higher all-cause mortality (hazard ratio 2.30; P < 0.001) and cardiovascular mortality (2.68; P < 0.001). These associations persisted after adjusting for baseline covariates (all-cause mortality: 1.65; P = 0.008; cardiovascular mortality: 2.10; P = 0.004).

CONCLUSIONS

Diabetes was present in 20% of patients who presented with their first MI at age ≤50 years and was associated with worse long-term all-cause and cardiovascular mortality. These findings highlight the need for implementing more aggressive therapies aimed at preventing future adverse cardiovascular events in this population.

Cocaine and Marijuana Use Among Young Adults With Myocardial Infarction

BACKGROUND

Substance abuse is increasingly prevalent among young adults, but data on cardiovascular outcomes remain limited.

OBJECTIVES

The objectives of this study were to assess the prevalence of cocaine and marijuana use in adults with their first myocardial infarction (MI) at ≤50 years and to determine its association with long-term outcomes.

METHODS

The study retrospectively analyzed records of patients presenting with a type 1 MI at ≤50 years at 2 academic hospitals from 2000 to 2016. Substance abuse was determined by review of records for either patient-reported substance abuse during the week before MI or substance detection on toxicology screen. Vital status was identified by the Social Security Administration's Death Master File. Cause of death was adjudicated using electronic health records and death certificates. Cox modeling was performed for survival free from all-cause and cardiovascular death.

RESULTS

A total of 2,097 patients had type 1 MI (mean age 44.0 ± 5.1 years, 19.3% female, 73% white), with median follow-up of 11.2 years (interquartile range: 7.3 to 14.2 years). Use of cocaine and/or marijuana was present in 224 (10.7%) patients; cocaine in 99 (4.7%) patients, and marijuana in 125 (6.0%). Individuals with substance use had significantly lower rates of diabetes (14.7% vs. 20.4%; p = 0.05) and hyperlipidemia (45.7% vs. 60.8%; p < 0.001), but they were significantly more likely to use tobacco (70.3% vs. 49.1%; p < 0.001). The use of cocaine and/or marijuana was associated with significantly higher cardiovascular mortality (hazard ratio: 2.22; 95% confidence interval: 1.27 to 3.70; p = 0.005) and all-cause mortality (hazard ratio: 1.99; 95% confidence interval: 1.35 to 2.97; p = 0.001) after adjusting for baseline covariates.

CONCLUSIONS

Cocaine and/or marijuana use is present in 10% of patients with an MI at age ≤50 years and is associated with worse all-cause and cardiovascular mortality. These findings reinforce current recommendations for substance use screening among young adults with an MI, and they highlight the need for counseling to prevent future adverse events.

Cardiovascular Risk and Statin Eligibility of Young Adults After an MI: Partners YOUNG-MI Registry

BACKGROUND

Despite significant progress in primary prevention, the rate of MI has not declined in young adults.

OBJECTIVES

The purpose of this study was to evaluate statin eligibility based on the 2013 American College of Cardiology/American Heart Association guidelines for treatment of blood cholesterol and 2016 U.S. Preventive Services Task Force recommendations for statin use in primary prevention in a cohort of adults who experienced a first-time myocardial infarction (MI) at a young age.

METHODS

The YOUNG-MI registry is a retrospective cohort from 2 large academic centers, which includes patients who experienced an MI at age ≤50 years. Diagnosis of type 1 MI was adjudicated by study physicians. Pooled cohort risk equations were used to estimate atherosclerotic cardiovascular disease risk score based on data available prior to MI or at the time of presentation.

RESULTS

Of 1,685 patients meeting inclusion criteria, 210 (12.5%) were on statin therapy prior to MI and were excluded. Among the remaining 1,475 individuals, the median age was 45 years, there were 294 (20%) women, and 846 (57%) had ST-segment elevation MI. At least 1 cardiovascular risk factor was present in 1,225 (83%) patients. The median 10-year atherosclerotic cardiovascular disease risk score of the cohort was 4.8% (interquartile range: 2.8% to 8.0%). Only 724 (49%) and 430 (29%) would have met criteria for statin eligibility per the 2013 American College of Cardiology/American Heart Association guidelines and 2016 U.S. Preventive Services Task Force recommendations, respectively. This finding was even more pronounced in women, in whom 184 (63%) were not eligible for statins by either guideline, compared with 549 (46%) men (p < 0.001).

CONCLUSIONS

The vast majority of adults who present with an MI at a young age would not have met current guideline-based treatment thresholds for statin therapy prior to their MI. These findings highlight the need for better risk assessment tools among young adults.

Effects of dietary electrolyte balance on subluxation of the femoral head in growing dogs

Effects of increased dietary chloride and reduced sodium and potassium ion concentrations on coxofemoral joint conformation, as assessed by radiography, were examined in growing dogs. Dietary electrolyte balance was quantified by dietary anion gap (DAG), defined as Na+ + K+ - Cl- in milli-equivalents per 100 g of food. Diets had anion gap ranging from 8 to 41 mEq/100 g of food. One hundred sixty-seven pups from 27 litters representing 5 breeds were studied during the period of rapid growth. The extent of subluxation of the femoral head was measured on radiographs, using the method of Norberg. On average, less subluxation of the femoral head (P < 0.05) was observed when diets with lower DAG were fed. Differences in DAG balance did not result in different rates of weight gain; therefore, the reduction in coxofemoral joint subluxation attributable to low DAG was unrelated to weight gain. Norberg angles measured at 30 weeks of age were highly correlated with coxofemoral joint status at 2 years of age, as measured by the Swedish diagnostic system and the scoring system of the Orthopedic Foundation for Animals (lrl > or = 0.70, P < 0.0002, n = 24). This diet-related improvement in coxofemoral joint subluxation would be expected, on average, to delay or mitigate the characteristic clinical and radiographic signs of hip dysplasia in growing dogs.

Angioplasty-induced vasospasm in rabbit model. Mechanisms and treatment

Angioplasty of the distal iliac and proximal femoral arteries in rabbits resulted in focal and diffuse vasospasm similar to that seen in humans. The focal vasospasm occurred in all experiments immediately distal to the site of angioplasty. Occasional diffuse vasospasm was preceded by intravascular thrombosis or extravasation. Heparin reduced the incidence of diffuse vasospasm and reduced the severity of focal vasospasm. Verapamil and Dazoxiben reversed focal vasospasm, but only Verapamil in the presence of heparin prevented vasospasm. Prazocin had no effect on vasospasm.

Experimental intracranial septic infarction: magnetic resonance enhancement

Intracranial brain abscess was produced in three monkeys by embolization of a small pledget of polyvinyl alcohol (PVA) soaked in a broth of Staphylococcus aureus. Imaging of the chronic stable abscess was performed on the General Electric 8800 CT unit (Milwaukee, Wis.) and a 1.4 T superconducting small bore imaging system. Magnetic resonance imaging included saturation recovery, inversion recovery, and spin echo techniques. MR imaging was also performed after paramagnetic enhancement using gadolinium-DPTA (Gd-DTPA). Our results show that paramagnetic enhancement with T1-weighted imaging adds specificity and enables rapid assessment of abnormalities of the blood-brain barrier. T2-weighted imaging without paramagnetic enhancement was very sensitive in defining areas of abnormality in the brain but in our experiment lacked specificity. T2-weighted imaging with Gd-DTPA demonstrated no obvious change in the appearance of the lesion. The combination of T1-weighted Gd-DTPA and T2-weighted imaging appeared complementary in our experiment, and these images correlated well with the pathologic findings.

Magnetic resonance evaluation of hydronephrosis in the dog

The ability of magnetic resonance (MR) imaging to detect and distinguish various stages of obstruction in the canine kidney was investigated. MR images were obtained at acute, subacute, and chronic stages of experimentally produced hydronephrosis. The renal cortex was distinguished from the renal medulla in the normal dog and in the acute and subacute stages of hydronephrosis. T1 relaxation times of the renal cortex and medulla were measured in vitro in 14 normal and nine experimental animals. These values were used to compute the amount of tissue contrast between the cortex and medulla and were compared with the degree of corticomedullary differentiation seen in the image. A relationship was noted between increasing T1 values and increasing water content. Corticomedullary contrast decreased with obstruction. The variation in corticomedullary image contrast may be useful for assessing the duration of hydronephrosis.

Gadolinium enhanced nuclear magnetic resonance images of experimental brain abscess

Gadolinium-DTPA, a paramagnetic contrast agent that distributes throughout the body in a manner similar to diatrizoate, was intravenously administered to a monkey with a hematogenously induced experimental intracranial abscess. Contrast enhanced computed tomography (CT) and gadolinium enhanced saturation-recovery nuclear magnetic resonance (NMR) were both performed immediately and repeated after a 30 min delay. The NMR images revealed marked ring enhancement at a time when CT showed a nodule. Both imaging modalities were analyzed with respect to the pathological specimen. Gadolinium-DTPA may be an effective agent for imaging alterations of the blood-brain barrier.

Trigonal-colonic anastomosis: a urinary diversion procedure in dogs

Trigonal-colonic anastomosis for diversion of urine into the colon was performed in 12 clinically normal dogs and in 10 incontinent dogs with diseases of the urinary bladder or urethra. Dogs were studied from 1 to 30 months after surgery. The surgical procedure was technically satisfactory. Fifteen of 22 dogs were studied with intravenous urography, and only 1 case of hydronephrosis was found. Pyelitis was a common histopathologic finding in both groups of dogs. Pyelonephritis developed in 30% of dogs, regardless of duration of anastomosis. Glomerular filtration rate was reduced in all dogs studied, but renal failure was infrequent. Values for blood urea nitrogen and serum inorganic phosphorus were elevated due to intestinal recycling of nitrogenous products and phosphate. Electrolyte imbalances were not a problem, but gastrointestinal disturbances developed in 3 of the 10 diseased dogs. Six of 10 diseased dogs survived from 9 months to more than 3 years. Trigonal-colonic anastomosis appears to be a satisfactory salvage procedure for incontinent dogs with diseases of the urinary bladder or urethra that do not respond to other forms of therapy.