Improved survival after acute myocardial infarction in patients with advanced Killip class

Predictive value of Killip classification in MINOCA patients

BACKGROUND

Killip classification is a practical clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) is still poorly explored. Our purpose was to evaluate the prognostic role of high Killip class in the specific setting of MINOCA and compare the results with a cohort of patients with obstructive coronary arteries myocardial infarction (MIOCA).

METHODS

This study included 2455 AMI patients of whom 255 were MINOCA. We compared the Killip classes of MINOCA with those of MIOCA and evaluated the prognostic impact of a high Killip class, defined if greater than I, on both populations' outcome. Short-term outcomes included in-hospital death, re-AMI and arrhythmias. Long-term outcomes were all-cause mortality, re-AMI, stroke, heart failure (HF) hospitalization and the composite endpoint of MACE.

RESULTS

Killip class >1 occurred in 25 (9.8%) MINOCA patients compared to 327 (14.9%) MIOCA cases. In MINOCA subjects, a high Killip class was associated with a greater in-hospital mortality (p = 0.002) and, at long term follow-up, with a three-fold increased mortality (p = 0.001) and a four-fold risk of HF hospitalization (p = 0.003). Among MINOCA, a high Killip class was identified as a strong independent predictor of MACE occurrence [HR 2.66, 95% CI (1.25-5.64), p = 0.01] together with older age and worse kidney function while in MIOCA population also left ventricular ejection fraction and troponin value predicted MACE.

CONCLUSIONS

Killip classification confirmed its prognostic impact on short- and long-term outcomes also in a selected MINOCA population, which still craves for a baseline risk stratification.

Prediction Factors of 6-Month Poor Prognosis in Acute Myocardial Infarction Patients

Background: Acute myocardial infarction (AMI) is among the leading causes of death worldwide. Patients with AMI may have the risk of developing recurrent cardiovascular events leading to rehospitalization or even death. The present study aimed to investigate the prediction factors of poor prognosis (mortality and/or readmission) after AMI during a 6-month follow-up.

Methods: A total of 206 consecutive patients hospitalized for the first visit with AMI were enrolled. Data collection included demographic characteristics, medical history, clinical information, laboratory results, and oral medications within 24 h of admission. At 1, 3, and 6 months after discharge, AMI patients were followed up to assess the occurrence of composite endpoint events including in-hospital and out-of-hospital death and/or readmission due to recurrent myocardial infarction (MI) or exacerbated symptoms of heart failure following MI.

Results: After 6-month follow-up, a total of 197 AMI patients were available and divided in two groups according to good prognosis (n = 144) and poor prognosis (n = 53). Our data identified serum myoglobin ≥651 ng/mL, serum creatinine ≥96 μM, Killip classification 2–4, and female gender as independent predictors of 6-month mortality and/or readmission after AMI. Moreover, we demonstrated that Killip classification 2–4 combined with either myoglobin (AUC_{Killip class 2−4+myoglobin} = 0.784, sensitivity = 69.8%, specificity = 79.9%) or creatinine (AUC_{Killip class 2−4+creatinine} = 0.805, sensitivity = 75.5%, specificity = 77.1%) could further enhance the predictive capacity of poor 6-month prognosis among AMI patients.

Conclusions: Patients with AMI ranked in the higher Killip class need to be evaluated and monitored with attention. Multibiomarker approach using Killip classification 2–4 and myoglobin or creatinine may be an effective way for 6-month prognosis prediction in AMI patients.

Effects of Liraglutide on Reperfusion Injury in Patients With ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Liraglutide, a glucagon-like peptide-1 analog, was reported to reduce reperfusion injury in mice. We planned to evaluate the effects of liraglutide on reperfusion injury in patients with acute ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention.

METHODS AND RESULTS

A total of 96 patients with ST-segment-elevation myocardial infarction undergoing emergency primary percutaneous coronary intervention were randomized to receive either subcutaneous liraglutide or placebo. Study treatment was commenced 30 minutes before intervention (1.8 mg) and maintained for 7 days after the procedure (0.6 mg for 2 days, 1.2 mg for 2 days, followed by 1.8 mg for 3 days). The salvage index was calculated from myocardial area at risk, measured during the index admission (35±12 hours), and final infarct size measured at 91±5 days after primary percutaneous coronary intervention by cardiac magnetic resonance. At 3 months, the primary end point, a higher salvage index was found in the liraglutide group than in the placebo group in 77 patients evaluated with cardiac magnetic resonance (0.66±0.14 versus 0.55±0.15; P=0.001). The final infarct size was lower in the liraglutide group than that in the placebo group (15±12 versus 21±15 g; P=0.05). Serum high-sensitivity C-reactive protein level was lower in the liraglutide group (P<0.001). During a 6-month follow-up period, no difference was observed in the incidence of major adverse cardiovascular event. Safety and tolerability were similar among the 2 groups.

CONCLUSIONS

Our study provides evidence that liraglutide improves myocardial salvage and infarct size after ST-segment-elevation myocardial infarction, possibly by reducing reperfusion injury, making it a promising treatment for evaluation in larger trials.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02001363.

Effects of liraglutide on left ventricular function in patients with non-ST-segment elevation myocardial infarction

The influence of glucagon-like peptide-1 has been studied in several studies in patients with acute myocardial infarction, but not in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We planned to evaluate the effects of liraglutide on left ventricular function in patients with NSTEMI. A total of 90 patients were randomized 1:1 to receive either liraglutide (0.6 mg for 2 days, 1.2 mg for 2 days, followed by 1.8 mg for 3 days) or placebo for 7 days. Eighty-three patients completed the trial. Transthoracic echocardiography was used to assess left ventricular function. At 3 months, the primary endpoint, the difference in the change in left ventricular ejection fraction between the two groups was +4.7 % (liraglutide vs. placebo 95 % CI +0.7 to +9.2 % P = 0.009) under intention-to-treat analysis. The difference in decrease in serum glycosylated hemoglobin levels was -0.2 % (liraglutide vs. placebo 95 % CI -0.1 to -0.3 %; P < 0.001). Inflammation and oxidative stress improved significantly in the liraglutide group compared to the placebo group. Liraglutide could improve left ventricular function in patients with NSTEMI, making it a potential adjuvant therapy for NSTEMI.

Effects of liraglutide on no-reflow in patients with acute ST-segment elevation myocardial infarction

BACKGROUND

The 'no-reflow' phenomenon after a percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is a strong predictor of both short- and long-term mortality. Glucagon-like peptide-1 (GLP-1) exerts a cardioprotective effect during ischemia reperfusion injury. We planned to evaluate the effects of liraglutide on myocardial no-reflow after PCI for STEMI.

METHODS

A total of 284 patients with STEMI undergoing PCI were enrolled in this study between September 2013 and March 2015. Of these, 210 patients were randomized 1:1 to receive either liraglutide or placebo 30 min before PCI (1.8 mg).

RESULTS

The primary end point, the prevalence of no-reflow, was significantly lower in the liraglutide group than in the control group (5% vs. 15%, P=0.01). Administration of liraglutide was consistently identified as a significant determinant for no-reflow ratio. There was a significant decrease in serum high-sensitivity C-reactive protein levels at 6-hour reperfusion in the liraglutide group compared to the control group (0.87 ± 0.09 mg/dL vs. 0.96 ± 0.10mg/dL, P<0.001). During a 3-month follow-up period, no difference was observed in the incidence of major adverse cardiovascular event.

CONCLUSIONS

Liraglutide may be associated with less no-reflow in STEMI, which should be confirmed by larger-scale trials.

Effects of liraglutide on left ventricular function in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Several studies have shown that exenatide protects against ischemia-reperfusion injury and improves cardiac function in patients with acute ST-segment elevation myocardial infarction (STEMI). The effects of liraglutide, a glucagon-like peptide-1 analogue, on STEMI patients remain unclear. We planned to evaluate the effects of liraglutide on left ventricular function after primary percutaneous coronary intervention for STEMI.

METHODS

A total of 92 patients were randomized 1:1 to receive either liraglutide or placebo for 7 days. Study treatment was commenced 30 minutes before intervention (1.8 mg) and maintained for 7 days after the procedure (0.6 mg for 2 days, 1.2 mg for 2 days, followed by 1.8 mg for 3 days). Eighty-five patients completed the trial. Transthoracic echocardiography was used to assess left ventricular function.

RESULTS

At 3 months, the primary end point, a difference in change of left ventricular ejection fraction between the two groups was +4.1% (95% CI +1.1% to +6.9%) (P < .001). There was a tendency for a lower rate of no-reflow in liraglutide group that did not reach statistical significance (7% vs control group 15%, P = .20). Liraglutide could significantly improve stress hyperglycemia (P < .05). In addition, liraglutide elicited favorable changes in markers of inflammation and endothelial function.

CONCLUSION

A short 7-day course of liraglutide in STEMI patients treated with primary percutaneous coronary intervention is associated with mild improvement in left ventricular ejection fraction at 3 months.

Influence of renal dysfunction on clinical outcomes in patients with congestive heart failure complicating acute myocardial infarction

The clinical course and medical treatment of patients with congestive heart failure (CHF) complicating acute myocardial infarction (AMI) are not well established, especially in patients with concomitant renal dysfunction. We performed a retrospective analysis of the prospective Korean Acute Myocardial Infarction Registry to assess the medical treatments and clinical outcomes of patients with CHF (Killip classes II or III) complicated by AMI, in the presence or absence of renal dysfunction. Of 13,498 patients with AMI, 2769 (20.5%) had CHF on admission. Compared to CHF patients with preserved renal function, in-hospital mortality and major adverse cardiac events were increased both at 1 month and at 1 year after discharge in patients with renal dysfunction (1154; 41.7%). Postdischarge use of aspirin, betablockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers and statins significantly reduced the 1-year mortality rate for CHF patients with renal dysfunction; such reduction was not observed for those without renal dysfunction, except in the case of aspirin. Patients with CHF complicating AMI, which is accompanied by renal dysfunction, are at higher risk for adverse cardiovascular outcomes than patients without renal dysfunction. However, they receive fewer medications proven to reduce mortality rates.

Transradial percutaneous coronary intervention for acute myocardial infarction reduces CCU stay in patients 80 or older

Transradial percutaneous coronary intervention (PCI), which is less invasive than transfemoral PCI, may facilitate early rehabilitation of patients with acute myocardial infarction (AMI). The aim of our study was to investigate whether transradial PCI is associated with a shorter coronary care unit (CCU) stay in very elderly AMI patients (≥ 80 years old). We enrolled 116 AMI patients aged ≥ 80 years. There were 39 patients in the transradial group and 77 patients in the non-transradial group. The length of CCU stay, the length of hospital stay, in-hospital mortality, the day of the monitored sitting and standing test, and the occurrence of delirium were compared between the two groups. The duration of CCU stay in the transradial and non-transradial groups was 3.6 ± 1.5 days and 5.0 ± 3.2 days, respectively (P = 0.001). The duration of hospital stay in the transradial and non-transradial groups was 13.3 ± 7.4 days and 19.2 ± 11.1 days, respectively (P = 0.001). In-hospital mortality was not different between the two groups (7.7% versus 2.6%, P = 0.20). The day of the monitored standing test in the transradial and non-transradial groups was 3.2 ± 0.7 and 4.6 ± 2.3, respectively (P < 0.0001). Multivariate logistic regression analysis identified a transradial approach as an independent predictor of short (≤ 3 days) CCU stay (OR: 3.01, 95%CI: 1.16-7.83, P = 0.02). In conclusion, transradial PCI was associated with a shorter CCU stay in AMI patients ≥ 80 years old. Furthermore, transradial PCI facilitated early rehabilitation in this high risk population.

Killip classification and glucose level in patients with acute myocardial infarction

OBJECTIVE

Killip classification is a valuable prognostic stratification for patients with acute myocardial infarction. Patients with high initial glucose levels also have adverse outcomes. We hypothesize that an increase in the Killip classification rank of patients with acute myocardial infarction might be associated with increase in initial glucose levels.

METHODS

In a retrospective cohort study, patients receiving percutaneous coronary angiography after an acute myocardial infarction were enrolled. Patients were accorded Killip classifications, and the data were compared using the χ(2) and 1-way analysis of variance tests.

RESULTS

The study was conducted on 246 eligible subjects. Higher initial glucose levels were associated with higher rate of hospitalization within 1 year as well as mortality (P < .05). Glucose levels among the 4 Killip classes were different (P < .05).

CONCLUSION

Patients ranked in the higher Killip classes had higher glucose levels than those ranked in the lower classes.

Do patients with heart failure appropriately undergo invasive procedures post-myocardial infarction? Results from a prospective multicentre study

BACKGROUND

The degree of adherence to guideline recommendations that patients following myocardial infarction (MI) with congestive heart failure (CHF) undergo early angiography, and angioplasty if indicated, is unknown.

METHODS

We prospectively evaluated the use of invasive procedures in patients with segment-elevation myocardial infarction (STEMI), non-STEMI and CHF, admitted in 1 month to 16 Australian hospitals.

RESULTS

Of 475 post-MI patients (248 (52.2%) with STEMI), 112 (23.6%) had CHF, (57 (23.0%) with STEMI). Patients with CHF, compared with those without CHF, were older (67.8 vs 63.2 years; P = 0.002) and were more often women (34 vs 24%, P = 0.03), but had similar rates of other risk factors. Compared with post-MI patients without CHF, patients with CHF had fewer invasive procedures: angiography 72.3% versus 85.1% (P = 0.002) and angioplasty 33.9% versus 52.9% (P < 0.001) (12 (2.5%) patients underwent coronary surgery in-hospital); and among STEMI patients (angiography 72.3% CHF vs 89.5% no CHF [P < 0.001]; angioplasty 50.9% CHF vs 69.1% no CHF [P = 0.011]); these differences remained significant after adjustment for clinical covariates. Of the 121 (25.5%) post-MI patients aged > or =75 years, compared with those <75 years, the frequencies of angiography and angioplasty procedures were 66.1% versus 87.6% (P < 0.001) and 33.9% versus 53.4% (P < 0.001), respectively; 66% of the elderly with, and without, CHF had angiography.

CONCLUSION

The presence of CHF post-MI resulted in lower rates of use of angiography and angioplasty, which was not explained by lower procedure rates in the elderly. As these guideline-recommended procedures may improve survival in patients with CHF post-MI, future strategies should aim to enhance their use.

Baseline comorbidities and treatment strategy in elderly patients are associated with outcome of cardiogenic shock in a community-based population

BACKGROUND

Cardiogenic shock (CGS) historically results in high inhospital mortality, particularly in elderly patients. Factors that contribute to increased mortality and treatment strategies that improve short- and long-term outcomes in patients with CGS remain to be established.

METHODS

The study consisted of 1263 consecutive patients with acute myocardial infarction admitted from Olmsted County, Minn, during the period 1988 to 2000; of these, 73 (6%) developed cardiogenic shock. Short- and long-term mortality was compared between the elderly and younger populations in both shock and nonshock groups.

RESULTS

In patients with acute myocardial infarction, age of > or =65 years was associated with increased long-term mortality for nonshock patients (unadjusted relative risk [RR] 5.23, 95% CI 4.10-6.67, P <.001) and to a lesser degree in patients with cardiogenic shock (unadjusted RR 2.02, 95% CI 1.12-3.65, P =.02). Among cardiogenic shock patients, estimated survival at 1 and 5 years for elderly patients was 38% and 24%, respectively, and in younger patients, 57% and 52%, respectively. When adjusted for confounding variables, elderly noncardiogenic shock patients had significantly increased long-term mortality (adjusted RR 4.38, 95% CI 3.42-5.61, P <.001) compared to younger nonshock patients. In contrast, elderly patients with cardiogenic shock demonstrated a weaker trend toward worse outcomes (adjusted RR 1.80, 95% CI 1.00-3.27, P =.051) compared to younger patients with shock.

CONCLUSIONS

The relationship between age and long-term mortality is stronger among patients who do not develop cardiogenic shock. Advanced age was not found to be as strong a risk factor for survival in patients with cardiogenic shock; comorbidities and less aggressive treatment appear to be the major factors resulting in poor outcomes in the elderly patient with cardiogenic shock.

Trends and Treatment of Heart Failure Developing After Acute Myocardial Infarction

The development of heart failure and/or left ventricular systolic dysfunction following acute myocardial infarction remains prevalent despite improvements in the diagnosis and management over the past decades. Although transient in some cases, the majority of these patients continue to carry a substantially higher mortality risk. New data on the benefits of eplerenone and carvedilol from large clinical trials have added to the complexity of polypharmacy in this patient subgroup, although aggressive medical strategies to prevent or reverse infarct-related left ventricular remodeling remains the most effective method to save lives and prevent disabilities.

Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2)

OBJECTIVES

The purpose of this study was to examine treatment and outcomes in patients admitted to the hospital with acute myocardial infarction (AMI) complicated by congestive heart failure (CHF).

BACKGROUND

Although cardiogenic shock complicating AMI has been studied extensively, the hospital course of patients presenting with CHF is less well established.

METHODS

The Second National Registry of Myocardial Infarction (NRMI-2) was analyzed to determine hospital outcomes for patients with ST-elevation AMI admitted with CHF (Killip classes II or III).

RESULTS

Of 190,518 patients with AMI, 36,303 (19.1%) had CHF on admission. Patients presenting with CHF were older (72.6 +/- 12.5 vs. 63.2 +/- 13.5 years), more often female (46.8% vs. 32.1%), had longer time to hospital presentation (2.80 +/- 2.6 vs. 2.50 +/- 2.4 h), and had higher prevalence of anterior/septal AMI (38.8% vs. 33.3%), diabetes (33.1% vs. 19.5%), and hypertension (54.6% vs. 46.1%) (all p < 0.0005). Also, they had longer lengths of stay (8.1 +/- 7.1 vs. 6.8 +/- 5.3 days, p < 0.00005) and greater risk for in-hospital death (21.4% vs. 7.2%; p < 0.0005). Patients with CHF were less likely to receive aspirin (75.7% vs. 89.0%), heparin (74.6% vs. 91.1%), oral beta-blockers (27.0% vs. 41.7%), fibrinolytics (33.4% vs. 58.0%), or primary angioplasty (8.6% vs. 14.6%), and more likely to receive angiotensin-converting enzyme inhibitors (25.4% vs. 13.0%). Congestive heart failure on admission was one of the strongest predictors of in-hospital death (adjusted odds ratio 1.68; 95% confidence interval 1.62, 1.75).

CONCLUSIONS

Patients with AMI presenting with CHF are at higher risk for adverse in-hospital outcomes. Despite this, they are less likely to be treated with reperfusion therapy and medications with proven mortality benefit.

Intercessory prayer and cardiovascular disease progression in a coronary care unit population: a randomized controlled trial

OBJECTIVE

To determine the effect of intercessory prayer, a widely practiced complementary therapy, on cardiovascular disease progression after hospital discharge.

PATIENTS AND METHODS

In this randomized controlled trial conducted between 1997 and 1999, a total of 799 coronary care unit patients were randomized at hospital discharge to the intercessory prayer group or to the control group. Intercessory prayer, ie, prayer by 1 or more persons on behalf of another, was administered at least once a week for 26 weeks by 5 intercessors per patient. The primary end point after 26 weeks was any of the following: death, cardiac arrest, rehospitalization for cardiovascular disease, coronary revascularization, or an emergency department visit for cardiovascular disease. Patients were divided into a high-risk group based on the presence of any of 5 risk factors (age = or >70 years, diabetes mellitus, prior myocardial infarction, cerebrovascular disease, or peripheral vascular disease) or a low-risk group (absence of risk factors) for subsequent primary events.

RESULTS

At 26 weeks, a primary end point had occurred in 25.6% of the intercessory prayer group and 29.3% of the control group (odds ratio [OR], 0.83 [95% confidence interval (CI), 0.60-1.14]; P=.25). Among high-risk patients, 31.0% in the prayer group vs 33.3% in the control group (OR, 0.90 [95% CI, 0.60-1.34]; P=.60) experienced a primary end point. Among low-risk patients, a primary end point occurred in 17.0% in the prayer group vs 24.1% in the control group (OR, 0.65 [95% CI, 0.20-1.36]; P=.12).

CONCLUSIONS

As delivered in this study, intercessory prayer had no significant effect on medical outcomes after hospitalization in a coronary care unit.