bluuebunny/crossref_metadata_2025 huggingface dataset:
The effect of sodium-glucose co-transporter-2 inhibitors following anterior ST-segment elevation myocardial infarction
Authors: Incesu G , Tokdil H , Tekin A M , Raimoglu U , Mutlu D , Yalman H , Yurtseven E , Durmaz E , Karadag B , Karpuz M H
Published: November 2023

Background

Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been clearly demonstrated to be associated with lower rate of new-onset heart failure(HF) in patients under risk of HF. In addition, due to lower rehospitalisation and better functional status in HF patients, SGLT-2 inhibitors have became the cornerstone of treatment regardless of the diabetes status. New-onset HF is very common in survivors of anterior ST-segment elevation myocardial infarction(STEMI) and requires preventive strategies, however the role of SGLT-2 inhibition in this population is not well established yet.

Purpose

In this study, we aimed to demonstrate the role of the SGLT-2 inhibitors in patients with anterior STEMI.

Methods

We prospectively enrolled patients with diabetes mellitus who had anterior STEMI, which was managed with primary percutaneous coronary intervention. Patients with previous myocardial infarction, heart failure, under SGLT-2 inhibitor treatment and chronic kidney disease were excluded. Patients were divided into two groups according to SGLT-2 inhibitor treatment; group 1 patients treated with empaglifosine or dapaglifosine and group 2 received other classes of diabetes medicine. Comorbidities regarding smoking history (p: 0.871), hypertension (p: 0.064), previous cerebrovascular accident(p: 0,348) and coronary artery disease(p: 0.201) were comparable between groups. Presence of multivessel coronary artery disease (p: 0.259) and left main coronary artery involvement (p: 0.062) were also similar between groups. Glucose level on admission was similar (p: 0.782) between groups, however HBa1C level was significantly higher in group 1(p: <0.001). Left ventricular ejection fraction which was calculated prior to hospital discharge was also similar between groups(p: 0.297). Mean follow-up duration was 12 months and new-onset heart failure was significantly lower in group 1 patients(p:<0.001). In line with the rate of new onset-heart failure, pro-BNP levels at the 12th month visit were lower in group 1 patients (p: 0.042) which was similar during the STEMI hospitalization (p: 0.668). Multivariate analyses demonstrated that the use of SGLT-2 inhibitors independently associated with lower rate of new-onset HF.

Conclusion

Our results indicate that SGLT-2 inhibitors decrease the rate of new-onset heart failure during the follow-up in patients with previous myocardial infarction.Baseline characteristicsUnivariate and multivariate analysis
Abbreviated versus standard dual antiplatelet therapy time after PCI in high bleeding risk patients with acute coronary syndrome - a report from the SWEDEHEART registry
Authors: Haakansson A , Koul S , Omerovic E , Andersson J , Agewall S , James S , Mokhtari A , Van Der Pals J , Wester A , Szummer K , Jernberg T , Erlinge D , Mohammad M A
Published: November 2023

Background

The use of a short duration of dual antiplatelet therapy (DAPT) has become increasingly common in patients with high bleeding risk (HBR). This study aimed to evaluate outcomes for an abbreviated DAPT strategy compared to standard DAPT time strategy for high bleeding risk-patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI).

Methods

A total of 22310 patients from the SWEDEHEART-registry with at least one high bleeding risk criteria who underwent PCI for ACS in Sweden between January 1, 2013, until January 15, 2021, were enrolled. Patients were grouped according to their planned DAPT time at discharge: standard DAPT with 12 months of any P2Y12 inhibitor and aspirin or an abbreviated DAPT duration (<6 months DAPT or 12-month single APT) and matched for intended P2Y12 inhibitor type (clopidogrel or prasugrel/ticagrelor). The primary outcome was net adverse clinical events (NACE) at one year defined as the first occurrence of cardiac mortality or hospitalization due to myocardial infarction, ischemic stroke or clinically significant bleeding. Major adverse cardiovascular events and the individual components of NACE were defined as secondary endpoints.

Results

No significant difference in NACE was observed between the abbreviated compared to standard DAPT time groups, Kaplan-Meier event rate: 12.9% (n = 584) vs 13.1% (n = 594) hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.88-1.11, p=0.83. No differences were observed for MACE (HR 1.08; 95% CI 0.94-1.25) or any of the elements of the primary composite outcome. The results were consistent in all HBR-subgroups.

Conclusion

For patients with a high bleeding risk undergoing PCI due to an ACS, an abbreviated DAPT strategy was associated with comparable rates of NACE and MACE as compared to a standard DAPT time strategy. The results add real-world evidence that abbreviated DAPT-regimes can be a viable treatment option for patients with ACS with a high bleeding risk.
Helicobacter pylori and pro-inflammatory protein biomarkers in myocardial infarction with and without obstructive coronary artery disease
Authors: Warme J , Sundqvist M , Hjort M , Svensson P , Lindahl B , Hofmann R , Tornvall P
Published: November 2023

Introduction

Myocardial infarction (MI) with (MI-CAD) and without (MINOCA) obstructive coronary artery disease affects different populations and may have separate pathophysiological mechanisms with greater inflammatory activity in MINOCA compared to MI-CAD. Helicobacter pylori (Hp) is the most common chronic infection globally. It can cause systemic inflammation and has been associated with cardiovascular disease (CVD). We aimed to investigate whether Hp infection is associated with concentrations of protein biomarkers of inflammation and CVD.

Methods

In a case-control study patients with MINOCA (n=99) in Sweden were included, complemented by subjects with MI-CAD (n=99) and controls (n=100) matched by age and sex. Protein biomarkers were measured with a proximity extension assay in plasma samples collected 3 months after MI. Seroprevalence of Hp and cytotoxin associated gene A (CagA) was determined using ELISA. The associations between protein levels and Hp status were studied with linear regression.

Results

The prevalence of Hp was 20.2%, 19.2% and 16.0% for MINOCA, MI-CAD and controls, respectively (p=0.73). Seven proteins were significantly associated with Hp in an adjusted model: tissue plasminogen activator (tPA), interleukin-6 (IL-6), myeloperoxidase (MPO), TNF-related activation-induced cytokine (TRANCE), pappalysin-1 (PAPPA), soluble urokinase plasminogen activator receptor (suPAR) and P-selectin glycoprotein ligand 1 (PSGL-1).

Conclusion

Hp infection was present in one in five patients with MI, irrespective of the presence of obstructive CAD. Proteins previously associated with MINOCA and MI-CAD were elevated in Hp positive subjects, suggesting that Hp might promote an inflammatory response and contribute to the development of MI with and without CAD.Forest plot of regression coefficients
Impact of nutritional status and systemic immune-inflammation index on mortality in patients with acute myocardial infarction
Authors: Lee J , Rhee E , Jung J , Chang E , Jung M , Kwak H , Park B , Park Y , Kim H , Kim N , Jang S , Bae M , Yang D , Park H , Cho Y
Published: November 2023

Background

It has been known that malnutrition and elevated inflammatory markers are associated with clinical outcome in patients with acute myocardial infarction (AMI). However, few studies have investigated the association between nutritional status, inflammatory markers and survival in patients with AMI.

Purpose

The aim of this study is to investigate combined impact of nutritional status and systemic immune-inflammatory index (SII) on outcome in patients with AMI.

Methods

We examined 1,984 patients (mean age = 64 ± 12 year-old, 1,493 males) admitted for AMI. Nutritional assessment was evaluated at the admission by geriatric nutritional risk index (GNRI) calculation. Malnutrition was defined as GRNI <92. We calculated SII from the equation, SII = P x N/L, where P, N and L are peripheral blood platelet, neutrophil and lymphocyte counts per liter at the time of admission, respectively. The primary endpoint was all-cause mortality at 1-year.

Results

GNRI was significantly correlated with SII (r = -0.135, p<0.001). GNRI (95.2 ± 8.4 versus 102.7 ± 7.3) was significantly lower, whereas SII (1,906.9 ± 2,016.0 x 109 cells/L versus 1,100.9 ± 981.6 x 109 cells/L) was significantly higher in non-survivors. Patients with malnutrition had significantly higher mortality compared with patients without malnutrition (19.2% versus 4.3%, log-rank p <0.001). In receiver operating characteristics curve analysis, area under the curve of SII for predicting all-cause mortality was 0.625. The optimum cut-off point for SII for a favorable prognosis was determined to be 1,425 x 109 cells/L. Patients with high SII had significantly higher mortality (9.6% versus 4.2%, log-rank p<0.001). The patients were divided into four groups based on GNRI & SII; high GNRI &low SII (Group 1), high GNRI & high SII (Group 2), low GNRI & low SII (Group 3), and low GNRI & high SII (Group 4). In Kaplan-Meier survival curve, all-cause mortality was significantly higher in Group 4 compared with Group 1, Group 2, and Group 3 (3.5% versus 6.7% versus 14.1% versus 25.6%, log-rank p<0.001; Figure). In Cox-proportional hazards model, compared with Group 1 (1, reference), Group 2 (HR 1.64, 95% CI 1.02 – 2.63; p=0.038), Group 3 (HR 1.97, 95% CI 1.06 – 3.68; p=0.032), and 4 (HR 4.17, 95% CI 2.40 – 7.24; p<0.001) was an independent predictor of all-cause mortality after adjusting for confounding variables.

Conclusion

Nutritional status was significantly correlated with immune-inflammatory index. Malnutrition and high SII was independent predictors of overall survival in patients with AMI.
Quality-of-care for patients with spontaneous coronary artery dissection- a systematic review and meta-analysis
Authors: Dang Q , Othman F , Sheahen B , Marschner S , Szirt R , Zaman S
Published: November 2023

Introduction

In 2018 the first consensus documents to guide investigation and treatment of spontaneous coronary artery dissection (SCAD) were published. The global quality-of-care of patients with SCAD, as measured by adherence to these recommendations, has not been systematically reviewed.

Purpose

We aimed to evaluate the quality-of-care, measured by adherence to five recommendations from the 2018 consensus statement [antiplatelets, beta-blockers, angiotensin converting enzyme inhibitors or aldosterone receptor blockers (ACEI/ARBs) in patients with left ventricular systolic dysfunction, screening for fibromuscular dysplasia (FMD) and referral to cardiac rehabilitation] in patients with SCAD. Secondary aims were to explore the relationship of high versus low guideline-recommendation adherence with major adverse cardiovascular events (MACE).

Methods

Four databases (MEDLINE, EMBASE, SCOPUS, CINAHL) were systematically searched from inception to 16th June 2022. Studies reporting any cohort of 11 or more patients with SCAD that included results of at least one consensus-recommendations were included. The proportion of patients receiving each of the treatments were analysed by random effects meta-analysis. Associations were assessed using meta-regression analysis.

Results

54 studies, n=8456 patients (mean age 50.1 years, 89.5% female) were included in the analysis. A random effects meta-analysis found, 94.5% [95% confidence interval (CI): 90.8,97.7)\] received at least one antiplatelet, 78% (CI: 74.2,82.7) received beta-blockers, 54.6% (CI:42.0,66.6) were screened for FMD and 70.5% (CI: 62.6,77.3) were referred to cardiac rehabilitation. 59.3% (CI: 53.1,65.3) received ACEI/ARBs with left ventricular ejection fraction not reported in most studies. A single North American cohort reported 30% of patients met all four recommendations. There was significant heterogeneity in quality-of-care parameters, except for cardiac rehabilitation, according to geographic region (test of heterogeneity, p<0.001). No significant difference was observed in adherence to recommendations in studies published before and after the consensus documents publication (2018), except for lower cardiac rehabilitation referrals after 2018 (test of heterogeneity, p=0.006). There was no association between antiplatelet or beta-blocker use or FMD screening and follow-up MACE. Higher adherence to ACEI/ARBs was associated with lower MACE (p=0.02).

Conclusion

Adherence to consensus recommendations for care of patients with SCAD is far from perfect and varies significantly between regions of the world. Raising awareness among clinicians about consensus recommendations for care, combined with better evidence on treatment that can reduce MACE in patients with SCAD, are urgently needed.
Recurrence of acute coronary syndrome in the elderly: predictors and prognosis - insights from a multicentre national registry
Authors: Cabral M , Goncalves C , Fernandes S , Carvalho M , Ruivo C , Pernencar S , Loureiro M F , Morais J
Published: November 2023

The burden of cardiovascular (CV) disease remains at the top of society's health problems, with acute coronary syndromes (ACS) undoubtedly being one of the major causes. Patients with a known history of CVD are at increased risk of recurrent events. However, this recurrence's incidence rate and clinical impact vary between populations. Elderly patients represent a large proportion of patients admitted for a second ACS. The decision on its management lacks support in clinical guidelines, as studies generally exclude patients with significant comorbidities and tend to underrepresent this group.

This study aimed to analyse the characteristics and outcomes of elderly patients admitted with ACS with a previous history of myocardial infarction (MI) versus those who did not.

The authors performed a retrospective analysis of patients older than 75 years included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between 2010 and 2022. Comparison tests were performed. A COX proportional hazard regression method was applied to generate the proposed risk models. A p-value less than 0.05 was considered statistically significant.

A total of 8658 patients older than 75 years admitted for ACS were analysed, 6630 (76.6%) without a history of MI (group 1) and 2028 (23.4%) with a previous MI. Table 1 shows the most important baseline characteristics and differences between groups. Table 2 demonstrates the group differences regarding admission diagnosis, complementary study results and treatment. Table 3 represents in-hospital complications. At discharge, 16.5% of group 1 and 21.2% of group 2 had a planned cardiac rehabilitation program (CRP) (p-value=0.01). At 1-year follow-up, 15,6% of patients with more than 75 years admitted for ACS died and 17.4% were re-hospitalized by a CV cause. COX-regression analysis identified the history of MI as a predictor factor of CV re-hospitalization (HR 1,43; 95%CI [1.10;1.86], p-value<0.01) and of the composite of mortality and CV re-hospitalization (HR 1,37; 95%CI [1.10;1.71], p-value<0.01).

In conclusion, the elderly with a second episode of ACS tends to have more CV risk factors and comorbidities than those without a MI history. Furthermore, the recurrence of MI seems to be an independent predictor of 1-year re-hospitalization and the composite of mortality and CV re-hospitalization. Then, these results should increase the awareness of this group of patients.Table 1Table 2 (incomplete) and Table 3
Cumulative incidence and risk factors of myocardial infarction during 21 years of follow-up: comparing two cohorts of middle-aged men born 30 years apart
Authors: Sakalaki M , Pivodic A , Svardsudd K , Hansson P O , Fu M
Published: November 2023

Background

The morbidity and mortality burden associated with coronary artery disease (CAD) has declined over the past decades which are believed to be attributable to reductions in the prevalence of major cardiovascular risk factors alongside with improvements in acute management of myocardial infarction (MI). Nevertheless, CAD remains one of the leading causes of death globally. Recent studies indicated that some major cardiovascular risk factors have been modified over time, with decreasing number of smokers and hypercholesterolemia and increasing rates of obesity and diabetes. This may have impact on the incidence of CAD. Therefore, further understanding of changes of major risk factors for CAD overtime is needed.

Aim

To study cumulative incidence and predictors of MI in two random general population samples consisting of middle-aged men born 30 years apart.

Method

The "Study of Men Born In 1913" and the "Study of Men Born In 1943" are two longitudinal cohort studies investigating cardiovascular risk factors and diseases, performed in the same geographic area and using the same methodology, with repeated examinations. Both cohorts were followed prospectively for 21 years from the 50 years of age. MI was defined as new onset of myocardial infarction, fatal or non-fatal.

Results

A total number of 1625 participants were included in the study. Men born in 1943 had a 34% lower risk of acute MI [HR 0.66 (0.50-0.88), p=0.0051] during follow-up as compared to men born in 1913. Both cohorts had similar risk factors and hypertension was associated with at least 2-fold higher risk for incident MI in men born in 1943 [HR 2.33 (95% CI 1.41 - 3.83)], p=0.0009 as compared to the risk in men born in 1913 [HR: 1.10 (0.74-1.62)].

Conclusion

Despite declining incidence of MI the last five decades, risk profile of MI remained almost the same, and hypertension became an increasingly prominent risk factor to MI. Greater efforts should be dedicated in primary prevention in order to further reduce the risk of MI.
Dramatic improvements in survival in women and men with acute myocardial infarction over 30 years: a nationwide cohort study
Authors: Batra G , Lindhagen L , Szummer K , Alfredsson J , Erlinge D , Held C , Ravn-Fischer A , Yndigegn T , Jernberg T , Wallentin L
Published: November 2023

Background

Treatment of myocardial infarction (MI) has improved over the last decades due to the implementation of early revascularization and medical therapies for secondary prevention. The impact of these treatment changes on survival in women and men has not been documented over a 30-year perspective.

Purpose

The aim of this study was to assess implementation of new treatment strategies and their effects on changes in long-term outcomes in all patients with MI in Sweden over 30 years.

Methods

In SWEDEHEART, the Swedish register for coronary heart disease, we investigated treatments and outcomes and their associations in patients admitted with MI between 1991-2021. Patients were stratified in 2-year blocks, starting with a 3-year block for 1991-1993. Primary outcome was 1-year risk of cardiovascular (CV) mortality. Effect of treatments on outcome was assessed comparing observed event rates with event rates standardized by logistic regression accounting for differences in baseline characteristics and treatment.

Results

A total of 433,524 cases with MI were hospitalized between 1991-2021. Between 1991-1993 and 2020-2021, treatment with reperfusion and revascularization increased from 34.7% to 77.3%; in-hospital PCI from 1.8% to 73.8 %; dual antiplatelet therapy (DAPT) from 0.0% to 73.8%; statins from 3.0% to 91.7%; beta-blockers from 66.4% to 88.3%; and renin-angiotensin-system (RAS) inhibitors from 21.6% to 81.6% (Figure 1A). During the same period, the rates of 1-year CV mortality decreased from 24.1% to 8.3%. For women, CV mortality decreased from 28.9% to 10.3% and for men from 21.7% to 7.3%. When comparing observed with standardized event rates, most of the mortality improvement was explained by the implementation of early revascularization with PCI (Figure 1B).

Conclusions

In this unique nationwide cohort of patients with MI over 30 years, there was a gradual implementation of revascularization and novel medical treatment. Concurrently, there was a gradual absolute reduction in 1-year risk of CV mortality with 16 percentage points, which was similar in women and men. Most of the improvement in survival was related to implementation of early revascularization strategies.

Figure 1 (A) Temporal trends in treatment and (B) crude and standardized rates of cardiovascular mortality within 1 year in patients with myocardial infarction over 30 years in Sweden.
Atrial fibrillation status in patients with ACS and percutaneous coronary intervention
Authors: Iwanaga Y , Nakai M , Inoko M , Miyamoto Y
Published: November 2023

Background

Patients with acute coronary syndrome (ACS) often develop atrial fibrillation (AF) as a comorbidity or complication. We investigated the impact of AF status on in-hospital mortality and complications in ACS patients who underwent percutaneous coronary intervention (PCI) using a recent large-scale nationwide dataset.

Methods

Using a nationwide claims-based dataset from 1022 hospitals in Japan between 2012 and 2017, hospitalized patients with ACS and PCI were identified and classified into three groups according to the AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts.

Results

In 273,828 hospitalized patients with ACS and PCI, prevalent AF and incident AF were observed in 5.2% and 1.7%, respectively; the AF rates increased over 5 years. There was a greater proportion of older patients and patients with comorbidities in AF patients. Prevalent and incident AF statuses were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, than prevalent AF. These outcomes did not change in each AF status over 5 years.

Conclusions

Prevalent and incident AFs in patients with ACS and PCI had deteriorating effects on in-hospital clinical outcomes, and particularly, incident AF was associated with worse adjusted outcomes and complications. Further efforts are necessary to improve the outcomes in an aging society where AF incidence is increasing.
Acute myocardial infarction in patients without standard modifiable risk factors - preliminary data on clinical and laboratory biomarkers from the beyond-smurfs study
Authors: Moysidis D , Papazoglou A , Anastasiou V , Daios S , Liatsos A , Kartas A , Karagiannidis E , Makedou K , Savvopoulos C , Kamperidis V , Ziakas A , Giannakoulas G , Vassilikos V , Giannopoulos G
Published: November 2023

Background

Acute myocardial infarction (AMI) remains the leading cause of mortality worldwide. The majority of patients who suffer an AMI have a history of at least one of the standard modifiable risk factors (SMuRFs): smoking, hypertension, dyslipidemia, and diabetes mellitus. However, emerging scientific evidence recognizes a clinically significant and increasing proportion of patients presenting with AMI without any SMuRF (SMuRF-less patients). This study aims to define specific risk factors or biomarkers associated with the development of AMI in this subpopulation.

Methods

This is an analysis of the prospective ‘‘Beyond-SMuRFs" study reporting preliminary data of the first 350 consecutive patients with AMI fulfilling inclusion criteria. More than 300 clinical, laboratory, echocardiographic and angiographic parameters-variables were compared between patients with and without SMuRFs. Multivariable logistic regression analysis was implemented to investigate independent prognostic factors associated with the occurrence of SΜuRF-less AMIs. Only univariably-significant (P<0.05) and clinically-relevant variables were inserted in in the models. Restricted spline curve models were utilized to demonstrate the association of significant continuous predictors with the risk of SMuRF-less AMI occurrence.

Results

Out of the 350 patients (mean age 60.8±12.0 years, 74.6% males) suffering AMI, 76 patients (21.7%) had no history of SMuRFS at baseline. Increased soluble urokinase plasminogen activator receptor (suPAR) levels, history of rheumatic or autoimmune disease, values of self-reported mental health status component of SF-36 questionnaire ≤50 prior to AMI and decreased age were univariably associated with increased risk for SMuRF-less AMI. In the multivariable regression model, increased suPAR levels (aOR= 1.001; 95% CI= 1.000-1.003; p=0.02 β=0.001), history of rheumatic or autoimmune disease (aOR= 2.634; 95% CI= 2.309-4.440; p<0.001; β=1.848) and impaired mental health status retained their statistical significance (aOR= 0.413, 95% CI= 0.229-0.746; p=0.003; β=0.884).

Conclusions

In this prospective cohort of 350 consecutive patients with AMI, more than a fifth of them were SMuRF-less. History of prior rheumatic or autoimmune disease, increased suPAR levels and decline in self-reported mental health status metrics prior to AMI were found to be independent predictors of SMuRF-less AMI.Multivariable logistic regression modelRestricted spline curve models
Myocardial infarction mortality after COVID-19: a nationwide population-based cohort study
Authors: Brodersen K D , Ulrichsen S P , Soerup S , Pedersen L , Thomsen R W , Soerensen H T , Schmidt M
Published: November 2023

Background

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of myocardial infarction (MI). Small studies suggest that MI in patients with recent COVID-19 may have a distinct clinical course and a worse prognosis, compared to MI without recent COVID-19. Whether previous COVID-19 vaccination modifies the clinical course of MI after recent COVID-19 is also unknown.

Purpose

To compare mortality in people with MI with and without recent COVID-19, and to examine the impact of previous COVID-19 vaccination.

Methods

Using Danish health registries, we conducted a nationwide population-based cohort study comprising all adults (≥18 years) with a first-time MI between 26 May 2020 and 9 March 2022. We excluded patients with <1 year of residence in Denmark prior to their MI. The exposure was recent COVID-19 defined by a positive SARS-CoV-2 PCR test ≤90 days before MI. We followed the patients for 30 days from the date of their MI admission until death (if any), or emigration, whichever came first. We used Cox proportional-hazards regression to compute hazard ratios (HRs) for death within 30 days after MI. Using propensity-score balancing of confounders with stabilised inverse probability weighting, we adjusted for differences in age, sex, DANCAMI comorbidity burden, use of selected medications, and calendar period between MI patients with and without recent COVID-19. We stratified by COVID-19 vaccination status.

Results

Of 11,919 included patients with MI, 332 patients had COVID-19 within 90 days before MI. The COVID-19 exposed patients were characterised by a larger proportion of males and COVID-19 vaccinations, lower age, and a longer median time from first COVID-19 vaccination to MI compared to the COVID-19 unexposed patients. 34 of the patients with recent COVID-19 (10.2%) and 702 of the patients without recent COVID-19 (6.1%) died within 30 days after their MI, resulting in a crude HR of 1.71 with a 95% confidence interval (CI) of 1.21–2.42 for the patients with recent COVID-19. After adjusting by stabilised inverse probability weighting, this HR further increased to 2.08 (95% CI: 1.23–3.52). Previous COVID-19 vaccination modified this association with a three-fold increased mortality in unvaccinated MI patients with recent COVID-19, while the mortality HR associated with recent COVID-19 was close to one in patients who were previously COVID-19 vaccinated.

Conclusion

Patients with recent COVID-19 had increased short-term mortality after MI, but only if unvaccinated.
Reticulated platelets predict cardiovascular death and adverse events in coronary artery disease
Authors: Bongiovanni D , Novelli L , Condello F , Laugwitz K L , Raake P , Kastrati A , Chiarito M , Bernlochner I
Published: November 2023

Background/Introduction

The pro-thrombotic immature or reticulated platelets (RPs) are known to be elevated in high risk patients and in different pathological settings. Several studies have shown that RPs correlate with an insufficient antiplatelet response to antiplatelet agents. In addition, RPs are emerging novel biomarkers for the prediction of adverse cardiovascular events in cardiovascular disease.

Purpose

The current study, using the totality of existing evidence, evaluated the prognostic role of RPs in patients with coronary artery disease.

Methods

We performed a systematic review and meta-analysis including trials of acute and chronic coronary syndrome reporting clinical outcomes according to RPs levels in the peripheral blood. Patients with elevated RPs were defined as RPshigh according to the single study definitions and compared to patients without elevated RPs (RPslow). Odds ratios (ORs) and 95% CIs were used as metric of choice for treatment effects with random-effects models. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). Secondary endpoints were cardiovascular death, myocardial infarction, ischemic stroke, urgent coronary revascularization and any bleeding. Prospero Registration number: CRD42022381282.

Results

A total of 7 studies, including 2213 patients, were included. The risk for MACCE was significantly higher in RPshigh compared to RPslow patients (OR 2.67 [1.87; 3.81], I2=43.8%, Figure 1). RPshigh were significantly associated with cardiovascular death (OR 2.09 [1.36; 3.22], I2=40.4%). No significant associations for RPshigh were detected with the other singular components of MACCE: myocardial infarction (OR 1.73 [0.89; 3.38] I2=60.5%) and stroke (OR 1.72 [0.59; 4.96] I2=21%). Urgent revascularization was not significantly associated with elevated RPs (OR 2.09 [0.90; 4.86] I2=55.5%). The risk of bleeding did not significantly differ between groups(OR 0.58 [0.15; 2.22] I2=86.1%).

Conclusion

Elevated RPs are significantly associated with increased risk of cardiovascular events and cardiovascular death in patients with coronary artery disease and should be considered a useful prognostic biomarker in this setting.Figure 1
How vigilant were we in the diagnosis of peri-operative myocardial infarction before 2022 ESC guidelines?
Authors: Celutkiene J , Januzyte L , Cerlinskaite-Bajore K , Platukis T , Barciene D , Dambrauskaite A , Jurgaityte J , Saukliene R , Jarasuniene D
Published: November 2023

Background

The diagnosis of myocardial infarction (MI) after non-cardiac surgical intervention is complicated due to possible absence of symptoms as well as of objective ECG or echocardiography signs of ischemia.

Aim

This is a retrospective analysis of the prevalence of clinically diagnosed MI after non-cardiac surgery in two district hospitals with large-scale surgical services in the period of 2017 - 2022.

Methods

We retrospectively collected study data using electronic hospital records of all patients that underwent surgical operations for 6 years. Peri-operative MI was selected according to code I21 following any surgical procedure and verified by symptoms, elevated TnI, ECG and Echo changes.

Results

Total 103 028 patients underwent orthopedic, vascular, abdominal, neuro- surgery from 2017 to 2022. We found 45 patients diagnosed with MI, what makes the prevalence of 0,04%. Diagnostic criteria were: median TnI levels 4925 [1171; 13162] ng/L, symptoms [62% had typical anginal pain, 38% felt dyspnea, 22% had no symptoms], ECG changes {40% with ST elevation, 42% with ST depression, 16% bundle branch block}. Three patients (7%) were administered with troponin test before surgery. Patients with peri-operative MI were 81 [70; 86] years old, 49% females, with the history of CAD (42%), hypertension (71%), diabetes (33%), CKD (13%), anemia (38%), atrial fibrillation (33%), heart failure (47%). The duration of anesthesia was from 20 min to 3h 05 min and it was general in most cases. Bleeding requiring blood transfusion was observed in 27% of cases. It is known that 42% of patients used beta-blockers, 22% used statins before the operation, and 33% saw cardiologist in last 5 years. STEMI occurred in 44%, NSTEMI in 38% of patients, in 18% MI was unspecified, PCI was performed in 44%. Patients were transferred to ICU in 78% of cases and in 20% to cardiology ward. In-hospital deaths occurred in 49% of cases.

Conclusions

Little number of peri-operative myocardial infarctions are recognized in current practice, however, the mortality of these patients is very high. These findings highlights the importance of implementation of non-cardiac surgery guidelines, namely, routine troponin evaluation in high-risk patients.
Association of coronary artery calcification with mortality and myocardial injury after noncardiac surgery
Authors: Park S , Kim J H , Lee S H , Kim S M , Park J C , Kim E K , Chang S A , Lee S C , Park S W
Published: November 2023

Objectives

This study aimed to evaluate the prognostic value of preoperative coronary artery calcium (CAC) scores for predicting in-hospital death and myocardial injury after noncardiac surgery (MINS).

Backgrounds

The CAC score is a surrogate marker for atherosclerosis and coronary artery disease. However, the association between preoperative CAC score and development of MINS has not been studied.

Methods

From 2010 to 2019, patients with CAC scores measured within three years prior to noncardiac surgery were enrolled from a tertiary hospital. Patients with a history of coronary revascularization were excluded from this study. The Agatston method was used to calculate CAC scores. The primary outcome was in-hospital death or MINS, defined as a peak high-sensitivity troponin I level higher than 0.040 ng/ml within 30 days after noncardiac surgery. The secondary outcome was 1-year mortality.

Results

A total of 740 patients were included in the analysis. The mean age was 67.0 years, and 68.9% were male. In-hospital death or MINS occurred in 129 (17.4 %) patients. The median CAC score was 164.0 and 70.5 in patients with and without in-hospital death or MINS, respectively (p=0.001). The preoperative CAC score was significantly associated with the development of in-hospital death or MINS (per 100 increases, odds ratio [OR] 1.05; 95% confidence interval [CI] 1.02–1.07). The best CAC score cutoff value for predicting in-hospital death or MINS was 619 (<619 vs. ≥619, OR 2.47; 95% CI 1.60–3.81; p<0.001), which was significant after adjustment for clinical risk factors. The 1-year mortality rate was significantly different according to CAC score strata.

Conclusions

A high preoperative CAC score was associated with a significant increase in in-hospital death or MINS independent of clinical risk factors.1-year mortality rate : CAC score1yr mortality rate by CAC score cut-off
Standard modifiable risk factors and mortality in patients with ST-segment elevation myocardial infarction: findings from the FRENCHIE cohort
Authors: Zeller M , Danchin N , Cottin Y , Rousseau A , Sauze D , Goube P , Cayla G , Prieur C , Auffret V , Simon T , Steg P G
Published: November 2023

Background

Improvements in the treatment of the 4 main standard modifiable cardiovascular (CV) risk factors (SMuRFs), hypertension (HTN), diabetes, hypercholesterolemia, and smoking, have led to better survival in patients with acute myocardial infarction (AMI). Recent large observational studies have reported that an increasing and sizable proportion of AMI patients have no SMuRF, and these SMURFless patients have (counterintuitively) worse outcomes than patients with at least one SMuRF.

Purpose

Using a French nationwide MI registry, we aimed to describe the proportion, characteristics and in-hospital mortality of ST-segment elevation MI (STEMI) patients according to the burden of SMuRFs.

Methods

The French Cohort of Myocardial Infarction Evaluation (FRENCHIE) is a large ongoing MI cohort, which collects data from all patients hospitalized for AMI < 48 h of symptom onset in 21 french centres. For the present analysis, patients with STEMI and without prior coronary artery disease (CAD) admitted in 2019 and 2020 were studied. SMuRFless patients were compared to patients with 1 SMuRF or ≥2 SMuRFs.

Results

Among 4692 STEMI patients, 986(21%) were SMuRFless, 2001(43%) had 1 SMuRF, and 1705(36%) had ≥2 SMuRFs . Among patients with SMuRFs, smoking (51.8%) and HTN (51.1%) were the most frequent SMuRF and HTN+hypercholesterolemia (10.3%) and HTN+smoking (8.3%) the most frequent SMuRFs associations. When compared with patients with 1 or ≥ 2 SMuRFs, SMuRFless patients were characterized by older age (64.1 vs 60.2 and 62.8 y, respectively), but lower rate of female sex (21.7 vs 22.2 and 26.2%, respectively), LVEF<40% (24.5 vs 26.7 and 26.2%), and lower admission CRP (14.8±38.3 vs 15.3±38.7 and 17.3±40.1 mg/L, respectively). There was a slight increase in BMI with increasing SMURFs (0 SMURF : 26±3.9 ; 1 SMuRF : 26.3±4.5 ; ≥2 SMuRFs : 28.0±5 kg/m²). As expected, SMuRFless patients were less frequently under chronic CV medications (7.9 vs 23.5 and 57.7%, respectively). However, acute STEMI medications were similar across the 3 groups. Crude in-hospital mortality showed a trend toward an increase with the number of SMuRFs (p = 0.123). By multivariate logistic regression analysis, the number of SMURFs was associated with increasing in-hospital mortality (Figure). In stratified analyses, the odds were similar for both sexes.

Conclusion

In French patients with an inaugural STEMI, one in 5 patient was SMURFless. The burden of risk factors was independently correlated to worse in-hospital survival. These observations emphasize the importance of standard RF on acute MI outcomes.SMuRF and in-hospital death(forest plot)
Inflammatory biomarkers and long-term outcome in young stable patients 3 months after a first myocardial infarction
Authors: Cederstrom S , Johansson F , Samnegard A , Silveira A , Tornvall P , Jernberg T , Lundman P
Published: November 2023

Background

Inflammation is an important driver of coronary artery disease (CAD). Several circulating inflammatory biomarkers have been associated with outcome, both before and after established CAD. However, studies in established CAD have often been limited by short follow-up period or blood sampling in the acute phase of a coronary event, which introduces a bias from the inflammatory response activated during a myocardial infarction (MI).

Purpose

This study aimed to compare the predictive value of several inflammatory biomarkers in a population of young stable patients 3 months after a first time MI.

Methods

382 men and women ≤60 years of age with a first time MI were included from three Swedish hospitals between 1996 and 2000. 383 age- and sex-matched healthy controls were recruited from the general population. Individuals with previous MI, chronic inflammatory disease, kidney disease (creatinine >200 µmol/L), diabetes mellitus type 1, drug addiction or psychiatric disease were excluded. Three months after the acute index event, 15 biomarkers known to be involved in atherosclerosis were analysed; C-reactive protein (CRP), serum amyloid A (SAA), interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-18, interferon-gamma (IFN-γ), tumor necrosis factor-alfa (TNF-α), monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase (MMP)-1, MMP-3 and MMP-9. The Swedish population register and national patient register were used to analyse cardiovascular outcome including all-cause mortality, recurrent MI and heart failure (HF) during 20 years of follow-up. A variable importance analysis and a Cox regression model were used. Biomarkers were divided in tertiles and compared with the lowest tertile as a reference.

Results

At inclusion, 82% of cases were men with a mean age of 52 years. 19% were smokers, 34% had a diagnosis of hypertension and 11% had diabetes mellitus. The level of each biomarker in cases and controls is shown in Table. When biomarkers were compared, IL-6 was identified as the most important biomarker to predict outcome. In cases, IL-6 was associated with a composite outcome of all-cause mortality, non-fatal MI and non-fatal HF in a model adjusted for age, sex and cardiovascular risk factors (HR 1.96, 95% CI 1.37-2.80) (Figure). IL-6 also was associated with all-cause mortality (HR 2.42, 95% CI 1.45-4.04) and HF (HR 2.58, 95% CI 1.54-4.33).

Conclusions

When 15 inflammatory markers involved in atherosclerosis were analysed, IL-6 was the most important biomarker to predict long-term cardiovascular outcome. This study is unique considering the extended follow-up period of 20 years in young individuals with blood sampled in a convalescent phase after a first myocardial infarction. IL-6 is a promising biomarker to predict long-term prognosis and a possible treatment target.Table.Medians for all 15 biomarkersOutcome in relation to IL-6 level
Sex and racial disparities in proportional mortality of premature myocardial infarction in the USA from 1999-2020
Authors: Gonuguntla K , Shaik A S , Chobufo M D C , Badu I B , Sandhyavenu H S , Taha A T , Sattar Y S , Thyagaturu H T , Balla S B , Gulati M G
Published: November 2023

Background

The incidence of premature myocardial infarction (PMI) (females <65 years and males <55 years) is increasing. We investigated proportional mortality trends related to PMI stratified by sex, race, and ethnicity from 1999-2020.

Methods

The CDC WONDER (Center for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths occurring within the U.S. between 1999- 2020. We calculated trends in the proportional mortality of PMI using the Joinpoint regression analysis.

Results

From 1999-2020, we identified a total of 3,017,826 AMI-related deaths. Of these 373,317 were PMI deaths, corresponding to proportional mortality of 12.5% (male 12%, female 14%). On trend analysis, the proportional mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 [AAPC of 1.0 (0.8 to 1.2, p<0.01)] with a significant increase in females from 10% in 1999 to 17% in 2020 [AAPC of 2.4 (1.8 to 3.0, p<0.01)] and no significant change in males, 11% in 1999 to 10% in 2020 [AAPC of -0.2 (-0.7 to 0.3, p=0.4)]. There was a significant increase in proportional mortality in both Blacks (18% in 1999 to 21% in 2020) and Whites (10% in 1999 to 12% in 2020), with no statistical difference among American Indian or Alaska Native, Asian or Pacific Islander, or Hispanics.

Conclusion

Over the last 2 decades there has been a significant increase in the proportional mortality of PMI in females and black population in spite of the overall downtrend in AMI-related mortality.AMI mortalityAMI mortality based on race
Choosing between coronary CT angiography and functional tests in patients with suspected coronary artery disease: mind the (gender) gap
Authors: Paiva M , Presume J P , Freitas P , Lopes P , Gomes D , Santos R , Guerreiro S , Abecasis J , Santos A C , Saraiva C , Mendes M , Ferreira A M
Published: November 2023

Introduction

There is a need for a simple method to choose between a functional vs. anatomical test as first line approach to patients with suspected coronary artery disease (CAD). While European Guidelines base the decision on pretest probability (PTP) without a clear threshold, American Guidelines rely uniquely on age, with a 65-year-old cut-off for both genders.

The aims of this study were: 1) to assess the proportion of patients undergoing coronary CT angiography (CCTA) in whom a functional test could have been more suitable due to extensive coronary artery calcification (CAC) and/or inconclusive CCTA results; 2) compare PTP vs. age to predict the presence of these suboptimal conditions for CCTA.

Methods

Individuals 40-80 years old were identified in a single center registry of patients with stable chest pain or dyspnea who underwent CCTA. Patients with known CAD, severe valvular disease, or irregular heart rhythms were excluded. PTP of obstructive CAD was calculated using age, sex, and symptom typicality.

Patients were considered to have suboptimal conditions for CCTA if extensive CAC was present (defined conservatively as an Agatston score >400) or if one or more segments >2mm were deemed non-evaluable despite CAC score ≤ 400.

Results

A total of 884 patients (57% women, mean age 62±10 years) were included. Symptoms consisted of chest pain in 705 patients (80%). The median PTP of obstructive CAD was 22% (IQR 14-32).

Overall, 162 patients (18%) had suboptimal conditions for CCTA due to CAC score >400 (n=140), or ≥1 non-evaluable segments (n=22). The proportion of patients with suboptimal conditions for CCTA was significantly higher in men than in women (27% vs. 12%, respectively; p<0.001). For both genders, the discriminative power to predict suboptimal CCTA conditions was significantly higher for age than for PTP (c-statistic in men 0.74 vs. 0.64, p<0.001; in women 0.71 vs. 0.62, p=0.012). In every age group, the proportion of patients with suboptimal conditions for CCTA was at least 2 times higher in men than in women, with a 10-15 year gap between genders - Fig.

Conclusion

Suboptimal conditions for a fully diagnostic CCTA were found in 18% of patients, were more strongly associated with age than with PTP, and were at least 2 times more frequent in men than in women across all age groups. These findings support the use of an age cut-off for anatomical vs. functional testing in men, and the use of CCTA as first line test in most women regardless of age.Proportion of patients suboptimal CCTA
Association of left ventricular geometry early after an acute coronary syndrome to long-term mortality
Authors: Greer C E , Adamson P D , Frampton C M , Pickering J W , Pilbrow A , Troughton R W , Doughty R N , Richards A M
Published: November 2023

Background

Markers of adverse left ventricular remodelling following myocardial infarction are associated with an increased risk of adverse events. Remodelling patterns can be classified using left ventricular mass index (LVMI) and relative wall thickness (RWT) into normal geometry, eccentric hypertrophy, concentric remodelling and concentric hypertrophy. In this analysis we evaluated the association between geometric classifications early after an acute coronary syndrome (ACS) and longer-term survival.

Methods

The Coronary Disease Cohort Study is a prospective multicentre observational cohort study. Between 2002-2010, 2140 ACS patients were recruited across New Zealand. Echocardiography and blood biomarker sampling were obtained at 1, 4 and 12 months of follow-up after ACS. Echocardiographic data from 1 month after ACS were analysed and patients classified into 4 groups based on geometry. The relationship between geometry and mortality at a median of 14 years follow up were evaluated using cox proportional hazards models after adjusting for demographics, clinical characteristics and biomarkers.

Results

Of 2140 patients, 401 (19%) had normal geometry, 747 (35%) concentric hypertrophy, 569 (26.5%) eccentric remodelling, 153 (7.1%) concentric remodelling, and 271 (12.7%) had incomplete data to classify. 874/2055 (43%) of participants had died at most recent follow up in 2022. Compared to those with normal geometry, the risk of death for patients with abnormal geometry was increased: concentric hypertrophy (hazard ratio [HR]:2.1; 95% confidence interval [CI]: 1.6 – 2.9); eccentric hypertrophy (HR: 1.7; 94% CI :1.3 – 2.4); concentric remodelling (HR: 1.7; 95% CI :1.1 – 2.6) after adjusting for baseline demographic, clinical, and biomarker covariates.

Conclusion

Abnormal left ventricular geometry documented one month after ACS portends an increased risk of death. Concentric hypertrophy carried the highest risk of death at long-term follow up.Unadjusted survival curves