MISSION!: optimization of acute and chronic care for patients with acute myocardial infarction

Prognostic Value of Follow-up Measures of Left Ventricular Global Longitudinal Strain in Patients With ST-Segment Elevation Myocardial Infarction

INTRODUCTION

After ST-segment elevation myocardial infarction (STEMI), follow-up imaging is currently recommended only in patients with left ventricular ejection fraction (LVEF) <40%. Left ventricular global longitudinal strain (LVGLS) was shown to improve risk stratification over LVEF in these patients but has not been thoroughly studied during follow-up. The aim of this study was to explore the changes in LVGLS after STEMI and their potential prognostic value.

MATERIALS AND METHODS

Data were analyzed from an ongoing STEMI registry. Echocardiography was performed during the index hospitalization and 1 year after STEMI; LVGLS was expressed as an absolute value and the relative LVGLS change (ΔGLS) was calculated. The study end point was all-cause mortality.

RESULTS

A total of 1,409 STEMI patients (age 60 ± 11 years; 75% men) who survived at least 1 year after STEMI and underwent echocardiography at follow-up were included. At 1-year follow-up, LVEF improved from 50% ± 8% to 53% ± 8% (P < .001) and LVGLS from 14% ± 4% to 16% ± 3% (P < .001). Median ΔGLS was 14% (interquartile range, 0.5%-32%) relative improvement. Starting 1 year after STEMI, a total of 87 patients died after a median follow-up of 69 (interquartile range, 38-103) months. The optimal ΔGLS threshold associated with the end point (derived by spline curve analysis) was a relative decrease >7%. Cumulative 10-year survival was 91% in patients with ΔGLS improvement or a nonsignificant decrease, versus 85% in patients with ΔGLS decrease of >7% (P = .001). On multivariate Cox regression analysis, ΔGLS decrease >7% remained independently associated with the end point (hazard ratio, 2.5 [95% CI, 1.5-4.1]; P < .001) after adjustment for clinical and echocardiographic parameters.

CONCLUSIONS

A significant decrease in LVGLS 1 year after STEMI was independently associated with long-term all-cause mortality and might help further risk stratification and management of these patients during follow-up.

Effects of Atrial Ischemia on Left Atrial Remodeling in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

Adverse left atrial (LA) remodeling after ST-segment elevation myocardial infarction (STEMI) has been associated with poor prognosis. Flow impairment in the dominant coronary atrial branch (CAB) may affect large areas of LA myocardium, potentially leading to adverse LA remodeling during follow-up. The aim of this study was to assess echocardiographic LA remodeling in patients with STEMI with impaired coronary flow in the dominant CAB.

METHODS

Of 897 patients with STEMI, 69 patients (mean age, 62 ± 11 years; 83% men) with impaired coronary flow in the dominant CAB (defined as Thrombolysis In Myocardial Infarction flow grade < 3) were retrospectively compared with an age- and sex-matched control group of 138 patients with normal dominant CAB coronary flow.

RESULTS

Patients with dominant CAB-impaired flow had higher peak troponin T (3.9 μg/L [interquartile range, 2.2-8.2 μg/L] vs 3.2 μg/L [interquartile range, 1.5-5.6 μg/L], P = .009). No differences in left ventricular ejection fraction or mitral regurgitation were observed between groups at baseline or at follow-up. LA remodeling assessment included maximum LA volume, speckle-tracking echocardiography-derived LA strain, and total atrial conduction time assessed on Doppler tissue imaging at baseline, 6 months, and 12 months. Patients with dominant CAB-impaired flow presented larger LA maximal volumes (26.9 ± 10.9 vs 18.1 ± 7.1 mL/m², P < .001) and longer total atrial conduction time (150 ± 23 vs 124 ± 22 msec, P < .001) at 6 months, remaining unchanged at 12 months. However, all LA strain parameters were significantly lower from baseline (reservoir, 20.3 ± 10.1% vs 27.1 ± 14.5% [P < .001]; conduit, 9.1 ± 5.6% vs 12.8 ± 8% [P < .001]; booster, 9.1 ± 5.6% vs 12.8 ± 8% [P < .001]), these differences being sustained at 6- and 12-month follow-up.

CONCLUSIONS

Atrial ischemia resulting from impaired coronary flow in the dominant CAB in patients with STEMI is associated with LA adverse anatomic and functional remodeling. Reduced LA strain preceded LA anatomic remodeling in early phases after STEMI.

Predictive value of oxidative, antioxidative, and inflammatory status for left ventricular systolic recovery after percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVE

This study aimed to evaluate the association between left ventricular ejection fraction recovery and the total oxidant status, total antioxidant capacity, and high-sensitivity C-reactive protein levels.

METHODS

A total of 264 ST-elevation myocardial infarction patients were classified into two groups according to baseline and 6-month follow-up left ventricular systolic function: reduced and recovery systolic function. Predictors of the recovery of left ventricular ejection fraction were determined by multivariate regression analyses.

RESULTS

Multivariable analysis indicated that oxidative status index, baseline left ventricular ejection fraction and peak creatine-kinase myocardial bundle level, and high-sensitivity C-reactive protein were independently associated with the decreased of left ventricular ejection fraction at 6-month follow-up.

CONCLUSION

Oxidative stress and inflammation parameters were detrimental to the recovery of left ventricular ejection fraction in patients with ST-elevation myocardial infarction.

Prognostic Relevance of Right Ventricular Remodeling after ST-Segment Elevation Myocardial Infarction in Patients Treated With Primary Percutaneous Coronary Intervention

ST-segment elevation myocardial infarction (STEMI) often leads to changes in right ventricular (RV) function and size over time. The prognostic implications of RV remodeling after STEMI, however, are unknown. RV remodeling in patients who underwent STEMI with primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI compared with baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis. Long-term outcomes were compared between patients with and without RV remodeling. A total of 2,280 patients were analyzed (mean age 60 ± 11 years, 76% were men). RV remodeling was present in 315 patients (14%). After a median follow-up of 76 months (interquartile range 51 to 106 months), 271 patients (12%) died (primary end point) and the composite end point of all-cause mortality and HF hospitalization (secondary end point) was observed in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality (hazard ratio [HR] = 1.44, 95% confidence interval [CI] 1.02 to 2.02, p = 0.038) and the composite of all-cause mortality and HF hospitalization (HR = 1.41, 95% CI 1.02 to 1.96, p = 0.040). Finally, patients with RV remodeling had a significantly lower survival rate (Log-rank, p = 0.006) and event-free survival rate than those without RV remodeling during follow-up (log-rank, p = 0.006). RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function.

The Box—eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis

Background

Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care.

Objective

The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI).

Methods

In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated.

Results

Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI –€275 to €1217; P=.22, US $–302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference –0.05, 95% CI –0.09 to –0.01; P=.01).

Conclusions

eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings.

Trial Registration

ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8038

Chronic Obstructive Pulmonary Disease and Risk of Atrial Arrhythmias After ST-Segment Elevation Myocardial Infarction

Background

ST-segment elevation myocardial infarction (STEMI) and cardiac arrhythmias frequently occur in patients with chronic obstructive pulmonary disease (COPD). However, little is known about the association of COPD with the occurrence of atrial arrhythmias after STEMI.

Methods

This retrospective analysis consisted of 320 patients with first STEMI without a history of atrial arrhythmias, with available 24-hour holter-ECG at 3- and/or 6 months follow-up. In total, 80 COPD patients were compared with 240 non-COPD patients, matched by age and gender (mean age 67±10 years, 74% male). Atrial arrhythmias were defined as: atrial fibrillation/flutter, atrial tachycardia (≥3 consecutive premature atrial contractions (PAC's)) and excessive supraventricular ectopy activity (ESVEA, ≥30 PAC's/hour or runs of ≥20 PAC's).

Results

Baseline characteristics were similar among COPD and non-COPD patients regarding infarct location, β-blocker use and cardiovascular risk profile except for smoking (69% vs. 49%, respectively, p=0.002). Additionally, atrial volumes, LVEF and TAPSE were comparable. During 1 year follow-up, a significantly higher prevalence of atrial tachycardia and ESVEA was observed in patients with COPD as compared to non-COPD patients (70% vs. 46%; p<0.001 and 21% vs. 11%; p=0.024, respectively). In multivariate analysis, COPD was independently associated with the occurrence of atrial arrhythmias (combined) during 1 year of follow-up (HR 3.59, 95% CI 1.78-7.22; p<0.001).

Conclusion

COPD patients after STEMI have a significantly higher prevalence of atrial tachycardia and ESVEA within 1 year follow-up as compared to age- and gender matched patients without COPD. Moreover, COPD is independently associated with an increased prevalence of atrial arrhythmias after STEMI.

Original Research: Long-Term Prognosis After ST-Elevation Myocardial Infarction in Patients with a Prior Cancer Diagnosis

Introduction

It is unknown how long-term prognosis after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis is impacted by cancer-related factors as diagnosis, stage, and treatment. We aimed to assess long-term survival trends after STEMI in this population to evaluate both cardiovascular and cancer-related drivers of prognosis over a follow-up period of 5 years.

Methods

In this retrospective single-center cohort study, patients with a prior cancer diagnosis admitted with STEMI between 2004 and 2014 and treated with primary percutaneous coronary intervention (PCI) were recruited from the STEMI clinical registry of our institution.

Results

In the 211 included patients, the cumulative incidence of all-cause death after 5 years of follow-up was 38.1% (N = 60). The cause of death was predominantly malignancy-related (N = 29, 48.3% of deaths) and nine patients (15.0%) died of a cardiovascular cause. After correcting for age and sex, a recent cancer diagnosis (< 1 year relative to > 10 years, HR_adj 2.98 [95% CI: 1.39–6.41], p = 0.005) and distant metastasis at presentation (HR_adj 4.02 [1.70–9.53], p = 0.002) were significant predictors of long-term mortality. While maximum levels of cardiac troponin-T and creatinine kinase showed significant association with mortality (resp. HR_adj 1.34 [1.08–1.66], p = 0.008; HR_adj 1.36 [1.05–1.76], p = 0.019), other known determinants of prognosis after STEMI, e.g., hypertension and renal insufficiency, were not significantly associated with survival.

Conclusions

Patients with a prior cancer diagnosis admitted with STEMI have a poor survival rate. However, when the STEMI is optimally treated with primary PCI and medication, cardiac mortality is low, and prognosis is mainly determined by factors related to cancer stage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-021-00244-4.

Changes in Global Left Ventricular Myocardial Work Indices and Stunning Detection 3 Months After ST-Segment Elevation Myocardial Infarction

Global left ventricular (LV) myocardial work (MW) indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure measurements. Changes in global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) after ST-segment elevation myocardial infarction (STEMI) have not been explored. The aim of present study was to assess the evolution of GLVMWI in STEMI patients from baseline (index infarct) to 3 months' follow-up. Three-hundred and fifty patients (265 men; mean age 61 ± 10 years) with STEMI treated with primary percutaneous coronary intervention (PCI) and guideline-based medical therapy were retrospectively evaluated. Clinical variables, conventional echocardiographic measures and GLVMWI were recorded at baseline within 48 hours post-primary PCI and 3 months' follow-up. LV ejection fraction (from 54 ± 10% to 57 ± 10%, p < 0.001), GWI (from 1449 ± 451 mm Hg% to 1953 ± 492 mm Hg%, p < 0.001), GCW (from 1624 ± 519 mm Hg% to 2228 ± 563 mm Hg%, p < 0.001) and GWE (from 93% (interquartile range (IQR) 86%-95%) to 95% (IQR 91%-96%), p < 0.001) improved significantly at 3 months' follow-up with no significant difference in GWW (from 101 mm Hg% (IQR 63-155 mm Hg%) to 96 mm Hg% (IQR 64-155 mm Hg%); p = 0.535). On multivariable linear regression analysis, lower values of troponin T at baseline, increase in systolic blood pressure and improvement in LV global longitudinal strain were independently associated with higher GWI and GCW at 3 months' follow-up. In conclusion, the evolution of GWI, GCW and GWE in STEMI patients may reflect myocardial stunning, whereas the stability in GWW may reflect permanent myocardial damage and the development of non-viable scar tissue.

The Box: Methods and Results of a Real World Experience of mHealth Implementation in Clinical Practice

Background

Mobile health (mHealth) is an emerging field of scientific interest worldwide. Potential benefits include increased patient engagement, improved clinical outcomes, and reduced health care costs. However, mHealth is often studied in projects or trials, and structural implantation in clinical practice is less common.

Objective

The purpose of this paper is to outline the design of the Box and its implementation and use in an outpatient clinic setting. The impact on logistical outcomes and patient and provider satisfaction is discussed.

Methods

In 2016, an mHealth care track including smartphone-compatible devices, named the Box, was implemented in the cardiology department of a tertiary medical center in the Netherlands. Patients with myocardial infarction, rhythm disorders, cardiac surgery, heart failure, and congenital heart disease received devices to measure daily weight, blood pressure, heart rate, temperature, and oxygen saturation. In addition, professional and patient user comments on the experience with the care track were obtained via structured interviews.

Results

From 2016 to April 2020, a total of 1140 patients were connected to the mHealth care track. On average, a Box cost €350 (US $375), not including extra staff costs. The median patient age was 60.8 (IQR 52.9-69.3) years, and 73.59% (839/1140) were male. A median of 260 (IQR 105-641) measurements was taken on a median of 189 (IQR 98-372) days. Patients praised the ease of use of the devices and felt more involved with their illness and care. Professionals reported more productive outpatient consultations as well as improved insight into health parameters such as blood pressure and weight. A feedback loop from the hospital to patient to focus on measurements was commented as an important improvement by both patients and professionals.

Conclusions

In this study, the design and implementation of an mHealth care track for outpatient follow-up of patients with various cardiovascular diseases is described. Data from these 4 years indicate that mHealth is feasible to incorporate in outpatient management and is generally well-accepted by patients and providers. Limitations include the need for manual measurement data checks and the risk of data overload. Moreover, the tertiary care setting in which the Box was introduced may limit the external validity of logistical and financial end points to other medical centers. More evidence is needed to show the effects of mHealth on clinical outcomes and on cost-effectiveness.

Referral and participation in cardiac rehabilitation of patients following acute coronary syndrome; lessons learned

PURPOSE

Cardiac rehabilitation (CR) after hospitalization for acute coronary syndrome (ACS) has shown to reduce mortality, readmissions, and improve quality of life. CR is recommended by international guidelines but previous studies have shown low participation rates. Systematic CR referral might improve CR participation.

METHODS

The present study evaluates CR referral and CR participation of patients hospitalized for ACS in 2017 and treated according to local protocol, which includes systematic CR referral. Participation rate was divided into a group that finished the CR program and drop outs. In addition, factors associated with CR referral and participation rate were evaluated.

RESULTS

A total of 469 patients eligible for CR were included in the study, of which 377 (80%) were referred for CR and 353 (75%) participated in CR. Ninety percent of participants completed the CR program. Factors independently associated with CR referral included age (50-60 year vs. > 70 year: odds ratio [OR] 4.7, 95% confidence interval [CI] 1.98-11.2), diagnosis (ST-elevation myocardial infarction vs. unstable angina: OR 17.7, CI 7.59-41.7), previous cardiovascular disease (OR 0.4, CI 0.19-0.73) and left ventricular dysfunction vs. normal function (OR 2.2, CI 1.11-4.52). A larger distance to the CR center was associated with lower CR participation (<5km vs. > 20 km: OR 3.1, CI 1.20-7.72).

CONCLUSIONS

Systematic CR referral in ACS patients results in high CR referral (80%) and participation (75%) rates. CR adherence might be further improved by increasing CR referral, especially in older patients and patients with NSTEMI or unstable angina.

Prevalence and Long-term Outcomes of Patients with Coronary Artery Ectasia Presenting with Acute Myocardial Infarction

Coronary artery ectasia (CAE) is described in 5% of patients undergoing coronary angiography. Previous studies have shown controversial results regarding the prognostic impact of CAE. The prevalence and prognostic value of CAE in patients with acute myocardial infarction (AMI) remain unknown. In 4788 patients presenting with AMI referred for coronary angiography the presence of CAE (defined as dilation of a coronary segment with a diameter ≥1.5 times of the adjacent normal segment) was confirmed in 174 (3.6%) patients (age 62 ± 12 years; 81% male), and was present in the culprit vessel in 79.9%. Multivessel CAE was frequent (67%). CAE patients were more frequently male, had high thrombus burden and were treated more often with thrombectomy and less often was stent implantation. Markis I was the most frequent angiographic phenotype (43%). During a median follow-up of 4 years (1-7), 1243 patients (26%) experienced a major adverse cardiovascular event (MACE): 282 (6%) died from a cardiac cause, 358 (8%) had a myocardial infarction, 945 (20%) underwent coronary revascularization and 58 (1%) presented with a stroke. Patients with CAE showed higher rates of MACE as compared to those without CAE (36.8% versus 25.6%; p <0.001). On multivariable analysis, CAE was associated with MACE (HR 1.597; 95% CI 1.238-2.060; p <0.001) after adjusting for risk factors, type of AMI and number of narrowed coronary arteries. In conclusion, the prevalence of CAE in patients presenting with AMI is relatively low but was independently associated with an increased risk of MACE at follow-up.

Left ventricular myocardial work in the culprit vessel territory and impact on left ventricular remodelling in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

AIMS

Adverse left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) is associated with poor outcome. Global and regional LV myocardial work (LVMW) derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings could provide information for prediction of LV remodelling after STEMI. The aim of the study was to assess the predictive value of global and regional LVMW for LV remodelling before discharge in patients with STEMI.

METHODS AND RESULTS

Three-hundred and fifty STEMI patients treated with primary percutaneous coronary intervention (PCI) were included [265 men (76%), mean age: 61 ± 10 years]. Clinical variables, conventional echocardiographic parameters, global and regional measures of myocardial work index (MWI), and myocardial work efficiency were recorded before discharge. The primary endpoint was early LV remodelling defined as increase in LV end-diastolic volume (LVEDV) ≥20% at 3 months after STEMI. Eighty-seven patients (25%) showed early LV remodelling. The global and regional LVMW in the culprit territory were significantly lower in patients with early LV remodelling. Peak troponin I (OR 1.109, 95% CI 1.046-1.177; P = 0.001), LVEDV (OR 0.972, 95% CI 0.959-0.984; P < 0.001) and regional MWI in the culprit vessel territory (OR 0.602, 95% CI 0.383-0.945; P = 0.027) were independently associated with early LV remodelling.

CONCLUSION

In STEMI patients treated with primary PCI and optimal medical therapy, the regional cardiac work index in the culprit vessel territory before discharge is independently associated with early adverse LV remodelling.

Prognostic Value of Multilayer Left Ventricular Global Longitudinal Strain in Patients with ST-segment Elevation Myocardial Infarction with Mildly Reduced Left Ventricular Ejection Fractions

Multilayer (epi-, mid- and endocardium) left ventricular (LV) global longitudinal strain (GLS) reflects the extent of myocardial damage after ST-segment myocardial infarction (STEMI). However, the prognostic implications of multilayer LV GLS remain unclear. We studied the association between multilayer LV GLS and prognosis in patients with mildly reduced or preserved LV ejection fraction (EF) after STEMI. Patients with first STEMI and LVEF>45% were evaluated retrospectively. Baseline multilayer (endocardial, mid-myocardial and epicardial) LV GLS were measured on 2-dimensional speckle tracking echocardiography. Patients were followed up for of all-cause mortality. A total of 569 patients (77% male, 60 ± 11 years) were included. After a median follow-up of 117 (interquartile range 106-132) months, 95 (17%) patients died. We observed no differences in baseline LVEF and peak troponin levels between survivors and non-survivors. However, non-survivors showed more impaired GLS at all layers (epicardium: -11.9 ± 2.8% vs. -13.4 ± 2.8%; mid-myocardium: -14.2 ± 3.2% vs. -15.6 ± 3.2%; endocardium: -16.5 ± 3.7% vs. -17.7 ± 3.6%, p <0.05, for all). On multivariable analysis, increasing age (hazard ratio 1.095; p<0.001) and impaired LV GLS of the epicardial layer (hazard ratio 1.085; p = 0.047) were independently associated with higher risk of all-cause mortality. In addition, LV GLS at the epicardium had incremental prognostic value for all-cause mortality (χ² = 114, p = 0.044). In conclusion, in contemporary STEMI patients with mildly reduced or preserved LVEF, ageing and reduced LV GLS of the epicardium (reflecting transmural scar formation) were independently associated with all-cause mortality after adjusting for clinical and echocardiographic variables.

Myocardial Work, an Echocardiographic Measure of Post Myocardial Infarct Scar on Contrast-Enhanced Cardiac Magnetic Resonance

This study investigates the relation of non-invasive myocardial work and myocardial viability following ST-segment elevation myocardial infarction (STEMI) assessed on late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) and characterizes the remote zone using non-invasive myocardial work parameters. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were included. Several non-invasive myocardial work parameters were derived from speckle tracking strain echocardiography and sphygmomanometric blood pressure, e.g.: myocardial work index (MWI), constructive work (CW), wasted work (WW) and myocardial work efficiency (MWE). LGE was quantified to determine infarct transmurality and scar burden. The core zone was defined as the segment with the largest extent of transmural LGE and the remote zone as the diametrically opposed segment without LGE. A total of 53 patients (89% male, mean age 58 ± 9 years) and 689 segments were analyzed. The mean scar burden was 14 ± 7% of the total LV mass, and 76 segments (11%) demonstrated transmural hyperenhancement, 280 (41%) non-transmural hyperenhancement and 333 (48%) no LGE. An inverse relation was observed between segmental MWI, CW and MWE and infarct transmurality (p < 0.05). MWI, CW and MWE were significantly lower in the core zone compared to the remote zone (p<0.05). In conclusion, non-invasive myocardial work parameters may serve as potential markers of segmental myocardial viability in post-STEMI patients who underwent primary PCI. Non-invasive myocardial work can also be utilized to characterize the remote zone, which is an emerging prognostic marker as well as a therapeutic target.

Left ventricular mechanical dispersion in ischaemic cardiomyopathy: association with myocardial scar burden and prognostic implications

AIMS

Left ventricular (LV) mechanical dispersion (MD) may result from heterogeneous electrical conduction and is associated with adverse events. The present study investigated (i) the association between LV MD and the extent of LV scar as assessed with contrast-enhanced cardiac magnetic resonance (CMR) and (ii) the prognostic implications of LV MD in patients after ST-segment elevation myocardial infarction.

METHODS AND RESULTS

LV MD was calculated by echocardiography and myocardial scar was analysed on CMR data retrospectively. Infarct core and border zone were defined as ≥50% and 35-50% of maximal signal intensity, respectively. Patients were followed for the occurrence of the combined endpoint (all-cause mortality and appropriate implantable cardioverter-defibrillator therapy). In total, 96 patients (87% male, 57 ± 10 years) were included. Median LV MD was 53.5 ms [interquartile range (IQR) 43.4-62.8]. On CMR, total scar burden was 11.4% (IQR 3.8-17.1%), infarct core tissue 6.2% (IQR 2.0-12.7%), and border zone was 3.5% (IQR 1.5-5.7%). Correlations were observed between LV MD and infarct core (r = 0.517, P < 0.001), total scar burden (r = 0.497, P < 0.001), and border zone (r = 0.298, P = 0.003). In total, 14 patients (15%) reached the combined endpoint. Patients with LV MD >53.5 ms showed higher event rates as compared to their counterparts. Finally, LV MD showed the highest area under the curve for the prediction of the combined endpoint.

CONCLUSION

LV MD is correlated with LV scar burden. In addition, patients with prolonged LV MD showed higher event rates. Finally, LV MD provided the highest predictive value for the combined endpoint when compared with other parameters.

Prognostic implications of left ventricular myocardial work index in patients with ST-segment elevation myocardial infarction and reduced left ventricular ejection fraction

AIMS

This study aimed to determine whether lower values of left ventricular (LV) global work index (GWI) at baseline were associated with a reduction in LV functional recovery and poorer long-term prognosis in patients with reduced LV ejection fraction (LVEF ≤40%) following ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

A total of 197 individuals (62 ± 12 years, 75% male) with STEMI treated with primary percutaneous coronary intervention and reduced LVEF were evaluated. All patients were followed up for the occurrence of all-cause mortality and the presence of LVEF normalization at 6 months (LVEF ≥50%). The median LVEF was 36% (interquartile range 32-38) and the mean value of LV GWI was 1041 ± 404 mmHg% at baseline. At 6-month follow-up, 41% of patients had normalized LVEF. On multivariable logistic regression, higher values of LV GWI were independently associated with LVEF normalization at 6 months of follow-up (odds ratio 1.32 per 250 mmHg%, P = 0.038). Over a median follow-up of 112 months, 40 patients (20%) died. LV GWI <750 mmHg% was independently associated with all-cause mortality (HR 3.85, P < 0.001) and was incremental to LV global longitudinal strain (P = 0.039) and LVEF (P < 0.001).

CONCLUSION

In individuals with an LVEF ≤40% following STEMI, higher values of LV GWI were associated with a greater probability of LVEF normalization at 6-month follow-up. In addition, lower values of LV GWI were independently associated with increased all-cause mortality at long-term follow-up, providing incremental prognostic value over LVEF and minor incremental prognostic value over LV global longitudinal strain.

Global Left Ventricular Myocardial Work Efficiency and Long-Term Prognosis in Patients After ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction in patients with ST-segment-elevation myocardial infarction. However, LV global longitudinal strain does not take into consideration the effect of afterload. Novel speckle-tracking echocardiographic indices of myocardial work integrate blood pressure measurements (afterload) with LV global longitudinal strain. The present study aimed to investigate the prognostic value of global LV myocardial work efficiency (GLVMWE; reflecting LV performance) obtained from pressure-strain loops with echocardiography in patients with ST-segment-elevation myocardial infarction.

METHODS

A total of 507 ST-segment-elevation myocardial infarction patients (mean age, 61±11 years; 76% men) were retrospectively analyzed. LV ejection fraction and GLVMWE were measured by transthoracic echocardiography within 48 hours of admission. GLVMWE was defined as the ratio of constructive work divided by the sum of constructive and wasted work in all LV segments and expressed as a percentage. Spline curve analysis was used to define the association between reduced GLVMWE and all-cause death.

RESULTS

After a median follow-up of 80 months (interquartile range, 67-97 months), 40 (8%) patients died. Patients with reduced GLVMWE (<86%) showed higher cumulative rates of all-cause mortality (17.5% versus 4.7%; log-rank P<0.001) in comparison with patients with preserved GLVMWE (≥86%). Reduced GLVMWE (<86%) showed an independent association with all-cause mortality (hazard ratio, 3.167 [95% CI, 1.679-5.972]; P<0.001).

CONCLUSIONS

Reduced GLVMWE (<86%) measured by transthoracic echocardiography within 48 hours of admission in ST-segment-elevation myocardial infarction patients is associated with worse long-term survival.

Prehospital triage of patients with acute cardiac complaints: study protocol of HART-c, a multicentre prospective study

INTRODUCTION

Emergency department (ED) overcrowding is a major healthcare problem associated with worse patient outcomes and increased costs. Attempts to reduce ED overcrowding of patients with cardiac complaints have so far focused on in-hospital triage and rapid risk stratification of patients with chest pain at the ED. The Hollands-Midden Acute Regional Triage-Cardiology (HART-c) study aimed to assess the amount of patients left at home in usual ambulance care as compared with the new prehospital triage method. This method combines paramedic assessment and expert cardiologist consultation using live monitoring, hospital data and real-time admission capacity.

METHODS AND ANALYSIS

Patients visited by the emergency medical services (EMS) for cardiac complaints are included. EMS consultation consists of medical history, physical examination and vital signs, and ECG measurements. All data are transferred to a newly developed platform for the triage cardiologist. Prehospital data, in-hospital medical records and real-time admission capacity are evaluated. Then a shared decision is made whether admission is necessary and, if so, which hospital is most appropriate. To evaluate safety, all patients left at home and their general practitioners (GPs) are contacted for 30-day adverse events.

ETHICS AND DISSEMINATION

The study is approved by the LUMC's Medical Ethics Committee. Patients are asked for consent for contacting their GPs. The main results of this trial will be disseminated in one paper.

DISCUSSION

The HART-c study evaluates the efficacy and feasibility of a prehospital triage method that combines prehospital patient assessment and direct consultation of a cardiologist who has access to live-monitored data, hospital data and real-time hospital admission capacity. We expect this triage method to substantially reduce unnecessary ED visits.

Noninvasive Myocardial Work Indices 3 Months after ST-Segment Elevation Myocardial Infarction: Prevalence and Characteristics of Patients with Postinfarction Cardiac Remodeling

BACKGROUND

Assessment of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) is pivotal for patient management. Noninvasive myocardial work indices obtained from echocardiography-derived strain-pressure loops provide a new tool that permits characterization of LV mechanics. We aimed at characterizing myocardial work indices in patients with LV remodeling after STEMI versus patients without remodeling.

METHODS

Six-hundred STEMI patients were retrospectively analyzed (456 men, mean age: 61 ± 11 years) and divided according to the presence of LV remodeling 3 months after the index admission (≥20% increase in LV end-diastolic volume). Noninvasive myocardial work indices were measured at 3 months after STEMI.

RESULTS

LV remodeling was observed in 150 patients (25%) who showed more impaired global myocardial work indices compared with their counterparts: work index (1,708 ± 522 mm Hg% vs 1,979 ± 450 mm Hg%; P < .001), constructive work (1,941 ± 598 mm Hg% vs 2,272 ± 519 mm Hg%; P < .001), and work efficiency (92% [range 88%-96%] vs 95% [range 93%-96%]; P < .001). In addition, patients with LV remodeling had significantly increased wasted work (116 mm Hg% [range 73-184 mm Hg%] vs 91 mm Hg% [range 61-132 mm Hg%]; P < .001). The frequency of impaired global work index, constructive and work efficiency, and increased wasted work was significantly higher among patients with LV remodeling compared with their counterparts: 21.3%, 34.7%, 34.7%, and 14.0%, respectively, versus 5.3%, 9.6%, 8.9%, and 4.9%, respectively (P < .001).

CONCLUSIONS

At 3-month follow-up after STEMI, patients with LV remodeling revealed more impaired myocardial work indices compared with patients without LV remodeling. The prevalence of impaired myocardial work indices was higher among patients with LV remodeling compared with patients without.

Association Between Flow Impairment in Dominant Coronary Atrial Branches and Atrial Arrhythmias in Patients With ST-Segment Elevation Myocardial Infarction

OBJECTIVES

The impact of atrial ischemia in the occurrence of atrial arrhythmias may vary based on the amount of jeopardized myocardium. We sought to determine the association between coronary flow impairment in dominant coronary atrial branches (CAB) and atrial arrhythmias at 1-year follow-up in ST-segment elevation myocardial infarction (STEMI) patients.

METHODS

Patients with STEMI involving the right or circumflex coronary artery were included. Dominant CAB was defined as the most developed CAB. Patients were followed-up during 1 year, including 24-h Holter ECG at 3 and 6 months. Atrial arrhythmias were defined as atrial fibrillation/flutter, atrial tachycardia (≥3 consecutive supraventricular ectopic beats) and excessive supraventricular ectopic activity (>30 supraventricular beats/h or runs ≥20 beats).

RESULTS

A dominant CAB was identified in 897 of 900 patients STEMI (age 61 ± 12 years, 79% male). TIMI flow < 3 at the dominant CAB was present in 69 (8%) patients. Compared to those with dominant CAB preserved flow, patients with dominant CAB flow impairment presented with higher levels of troponin T (3.9 [2.2-8.2] vs. 3.1 [1.3-5.8], P = 0.008)and higher rates of atrial tachycardia at 3 months (68% vs. 37%, P = 0.007) and more supraventricular ectopic beats both at 3 months (58 [21-235] vs. 33 [12-119], P = 0.02) and at 6 months (62 [24-156] vs. 32 [12-115]; P = 0.04) on 24-h Holter ECG. Age and an impaired coronary flow at the dominant CAB were independently related to a higher risk of developing atrial arrhythmias at 1-year follow-up.

CONCLUSION

Dominant CAB flow impairment is infrequent and is associated with the occurrence of atrial arrhythmias, in the form atrial tachycardia and supraventricular ectopic beats, at follow-up.

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.

METHODS

A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.

RESULTS

After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P < .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P < .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.

CONCLUSIONS

In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial

IMPORTANCE

Smart technology via smartphone-compatible devices might improve blood pressure (BP) regulation in patients after myocardial infarction.

OBJECTIVES

To investigate whether smart technology in clinical practice can improve BP regulation and to evaluate the feasibility of such an intervention.

DESIGN, SETTING, AND PARTICIPANTS

This study was an investigator-initiated, single-center, nonblinded, feasibility, randomized clinical trial conducted at the Department of Cardiology of the Leiden University Medical Center between May 2016 and December 2018. Two hundred patients, who were admitted with either ST-segment elevation myocardial infarction or non-ST-segment acute coronary syndrome, were randomized in a 1:1 fashion between follow-up groups using smart technology and regular care. Statistical analysis was performed from January 2019 to March 2019.

INTERVENTIONS

For patients randomized to regular care, 4 physical outpatient clinic visits were scheduled in the year following the initial event. In the intervention group, patients were given 4 smartphone-compatible devices (weight scale, BP monitor, rhythm monitor, and step counter). In addition, 2 in-person outpatient clinic visits were replaced by electronic visits.

MAIN OUTCOMES AND MEASURES

The primary outcome was BP control. Secondary outcomes, as a parameter of feasibility, included patient satisfaction (general questionnaire and smart technology-specific questionnaire), measurement adherence, all-cause mortality, and hospitalizations for nonfatal adverse cardiac events.

RESULTS

In total, 200 patients (median age, 59.7 years [interquartile range, 52.9-65.6 years]; 156 men [78%]) were included, of whom 100 were randomized to the intervention group and 100 to the control group. After 1 year, 79% of patients in the intervention group had controlled BP vs 76% of patients in the control group (P = .64). General satisfaction with care was the same between groups (mean [SD] scores, 82.6 [14.1] vs 82.0 [15.1]; P = .88). The all-cause mortality rate was 2% in both groups (P > .99). A total of 20 hospitalizations for nonfatal adverse cardiac events occurred (8 in the intervention group and 12 in the control group). Of all patients, 32% sent in measurements each week, with 63% sending data for more than 80% of the weeks they participated in the trial. In the intervention group only, 90.3% of patients were satisfied with the smart technology intervention.

CONCLUSIONS AND RELEVANCE

These findings suggest that smart technology yields similar percentages of patients with regulated BP compared with the standard of care. Such an intervention is feasible in clinical practice and is accepted by patients. More research is mandatory to improve patient selection of such an intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02976376.

Procedural-related coronary atrial branch occlusion during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and atrial arrhythmias at follow-up

OBJECTIVES

To evaluate the frequency of procedural-related atrial branch occlusion in ST-segment elevation myocardial infarction (STEMI) patients and its association with atrial arrhythmias at 1-year follow-up.

BACKGROUND

Atrial ischemia due to procedural-related coronary atrial branch occlusion in elective percutaneous coronary intervention (PCI) has been associated with atrial arrhythmias. Its role in a STEMI scenario is unknown.

METHODS

STEMI patients treated with primary PCI were classified according to the loss or patency of an atrial branch at the end of the procedure. The occurrence of atrial arrhythmias was documented on 24-hr Holter-ECG at 3 and 6 months or on ECG during 1-year follow-up visits.

RESULTS

Of 900 patients, 355 (age 61 ± 12 years, 79% male) underwent primary PCI involving the origin of an atrial branch. Procedural-related coronary atrial branch occlusion was observed in 18 (5%) individuals). During 1-year follow-up, 33% of patients with procedural-related atrial branch occlusion presented atrial arrhythmias, as compared with 55% in those with a patent atrial branch (p = .088). Age, no previous history of myocardial infarction, and a reduced flow in the culprit vessel were the only independent correlates of atrial arrhythmias.

CONCLUSIONS

The frequency of procedural-related atrial branch occlusion during primary PCI is low (5%) and is not associated with increased frequency of atrial arrhythmias at 1-year follow-up.

Left ventricular remodelling after ST-segment elevation myocardial infarction: sex differences and prognosis

Aims

Left ventricular (LV) remodelling after ST‐segment elevation myocardial infarction (STEMI) worsens outcome. The effect of sex on LV post‐infarct remodelling is unknown. We therefore investigated the sex distribution and long‐term prognosis of LV post‐infarct remodelling after STEMI in the contemporary era of primary percutaneous coronary intervention (PCI) and optimal pharmacotherapy.

Methods and results

Data were obtained from an ongoing primary PCI STEMI registry. LV remodelling was defined as ≥20% increase in LV end‐diastolic volume at either 3, 6, or 12 months post‐infarct, and LV remodelling impact on outcome was evaluated with a log‐rank test. A total population of 1995 STEMI patients were analysed (mean age 60 ± 12 years): 1527 (77%) men and 468 (23%) women. The mean age of male patients was 60±11 versus 63±13 years for women (P < 0.001). A total of 953 (48%) patients experienced LV remodelling in the first 12 months of follow‐up, and it was equally frequent amongst men (n = 729, 48%) and women (n = 224, 48%). After a median follow‐up of 94 (interquartile range 69–119) months, 225 patients died: 171 (11%) men and 54 (12%) women. No survival difference was seen between remodellers and non‐remodellers in the male (P = 0.113) and female (P = 0.920) groups.

Conclusion

LV post‐infarct remodelling incidence, as well as long‐term survival of LV remodellers and non‐remodellers, was similar in men and women who were treated with primary PCI and optimal pharmacotherapy post‐STEMI.

Myocardial infarction patients referred to the primary care physician after 1‑year treatment according to a guideline-based protocol have a good prognosis

Introduction

Identifying ST-elevation myocardial infarction (STEMI) patients who can be referred back to the general practitioner (GP) can improve patient-tailored care. However, the long-term prognosis of patients who are returned to the care of their GP is unknown. Therefore, the aim of this study was to assess the long-term prognosis of patients referred back to the GP after treatment in accordance with a 1-year institutional guideline-based protocol.

Methods

All consecutive patients treated between February 2004 up to May 2013 who completed the 1‑year institutional MISSION! Myocardial Infarction (MI) follow-up and who were referred to the GP were evaluated. After 1 year of protocolised monitoring, asymptomatic patients with a left ventricular ejection fraction >45% on echocardiography were referred to the GP. Long-term prognosis was assessed with Kaplan-Meier curves and Cox proportional hazards analysis was used to identify independent predictors for 5‑year all-cause mortality and major adverse cardiovascular events (MACE).

Results

In total, 922 STEMI patients were included in this study. Mean age was 61.6 ± 11.7 years and 74.4% were male. Median follow-up duration after the 1‑year MISSION! MI follow-up was 4.55 years (interquartile range [IQR] 2.28–5.00). The event-free survival was 93.2%. After multivariable analysis, age, not using an angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II (AT2) antagonist and impaired left ventricular function remained statistically significant predictors for 5‑year all-cause mortality. Kaplan-Meier curves revealed that 80.3% remained event-free for MACE after 5 years. Multivariable predictors for MACE were current smoking and a mitral regurgitation grade ≥2.

Conclusion

STEMI patients who are referred back to their GP have an excellent prognosis after being treated according to the 1‑year institutional MISSION! MI protocol.

ST-Segment Elevation Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: Prognostic Implications of Right Ventricular Systolic Dysfunction as Assessed with Two-Dimensional Speckle-Tracking Echocardiography

BACKGROUND

Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications.

METHODS

One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48 hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion <17 mm (TAPSE), tricuspid annular systolic velocity <6 cm/s (S'), RV fractional area change <35% (FAC), and RV longitudinal free wall strain (FWSL) measured with speckle-tracking echocardiography >-20%. Patients were followed for the occurrence of all-cause mortality.

RESULTS

RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69 ± 10; 74% male; mean, LVEF 47% ± 8%). Patients with COPD had significantly lower RV FAC (38% ± 11% vs 40% ± 9%; P = .04), equal TAPSE and S' (17.9 ± 3.7 vs 18.1 ± 3.8 mm, P = .72; and 8.4 ± 2.2 vs 8.5 ± 2.2 cm/sec, P = .605, respectively) and more impaired RV FWSL (-21.1% ± 6.6% vs -23.4% ± 6.5%, P = .005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P = .021). During a median follow-up of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >-20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P = .020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S'< 6 cm/sec, and TAPSE < 17 mm were not independently associated with survival.

CONCLUSION

In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL > -20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.

Global Left Ventricular Myocardial Work Efficiency in Healthy Individuals and Patients with Cardiovascular Disease

BACKGROUND

Global left ventricular (LV) myocardial work efficiency, the ratio of constructive to wasted work in all LV segments, reflects the efficiency by which mechanical energy is expended during the cardiac cycle. Global LV myocardial work efficiency can be derived from LV pressure-strain loop analysis incorporating both noninvasively estimated blood pressure recordings and echocardiographic strain data. The aim of this study was to characterize global LV myocardial work efficiency in healthy individuals and patients with cardiovascular (CV) risk factors or overt cardiac disease.

METHODS

We retrospectively included healthy individuals without structural heart disease or CV risk factors, who were selected from an ongoing database of normal individuals, and matched for age and sex with (1) individuals without structural heart disease but with CV risk factors, (2) postinfarct patients without heart failure, and (3) heart failure patients with reduced ejection fraction (HFrEF). Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements.

RESULTS

In total, 120 individuals (44% male, 53 ± 13 years) were included (n = 30 per group). In healthy individuals without structural heart disease or CV risk factors, global LV myocardial work efficiency was 96.0% (interquartile range, 95.0%-96.3%). Myocardial efficiency of the LV did not differ significantly between individuals without structural heart disease and those with CV risk factors (96.0% vs 96.0%; P = .589). Global LV myocardial work efficiency, however, was significantly decreased in postinfarct patients (96.0% vs 93.0%, P < .001) and in those with HFrEF (96.0% vs 69.0%; P < .001).

CONCLUSIONS

While global LV myocardial work efficiency was similar in normal individuals and in those with CV risk factors, it was decreased in postinfarct and HFrEF patients. The global LV myocardial work efficiency values presented here show distinct patterns in different cardiac pathologies.

eHealth to improve patient outcome in rehabilitating myocardial infarction patients

INTRODUCTION

Cardiac rehabilitation is aimed at risk factor modification and improving quality of life. eHealth has a couple of potential benefits to improve this aim. The primary purpose of this review is to summarize available literature for eHealth strategies that have been investigated in randomized controlled trials in post-myocardial infarction (MI) patients. The second purpose of this review is to investigate the clinical effectiveness in post-MI patients. Areas covered: The literature was searched using PubMed. Randomized controlled trials (RCTs) describing interventions in patients that had experienced an ST-elevation myocardial infarction or non-ST acute coronary syndrome were eligible for inclusion. Fifteen full-texts were included and their results are described in this review. These RCTs described interventions that used remote coaching or remote monitoring in post-MI patients. Most interventions resulted in an improved cardiovascular risk profile. Remote coaching had a positive effect on activity and dietary intake. Expert opinion: eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs. Further research needs to corroborate these findings.

Plasma LDL-Cholesterol Level at Admission is Independently Associated with Infarct Size in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Introduction

Hypercholesterolemia is a well-known risk factor for developing atherosclerosis and subsequently for the risk of a myocardial infarction (MI). Moreover, it might also be related to the extent of damaged myocardium in the event of a MI. The aim of this study was to evaluate the association of baseline low density lipoprotein-cholesterol (LDL-c) level with infarct size in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneously coronary intervention (pPCI).

Methods

Baseline blood samples were obtained from all patients admitted between 2004 and 2014 with STEMI who underwent pPCI. Patients were excluded in case of out of hospital cardiac arrest, treatment delay of at least 10 h or no complete reperfusion after pPCI in the culprit vessel. Peak creatine kinase (CK) level was used for infarct size estimation, defined as the maximal value during admission.

Results

A total of 2248 patients were included in this study (mean age 61.8 ± 12.2 years; 25.0% female). Mean LDL-c level was 3.6 ± 1.1 mmol/L and median peak CK level was 1275 U/L (IQR 564–2590 U/L). Baseline LDL-c level [β = 0.041; (95% CI 0.019–0.062); p < 0.001] was independently associated with peak CK level. Furthermore, left anterior descending artery as culprit vessel, initial TIMI 0–1 flow in the culprit vessel, male gender, and treatment delay were also correlated with high peak CK level (p < 0.05). Prior aspirin therapy was associated with lower peak CK level [β = − 0.073 (95% CI − 0.146 to 0.000), p = 0.050].

Conclusion

This study demonstrates that besides the more established predictors of infarct size, elevated LDL-c is associated with augmented infarct size in patients with STEMI treated with pPCI.

Electronic supplementary material

The online version of this article (10.1007/s40119-019-0126-5) contains supplementary material, which is available to authorized users.

Growth Differentiation Factor-15 Levels at Admission Provide Incremental Prognostic Information on All-Cause Long-term Mortality in ST-Segment Elevation Myocardial Infarction Patients Treated with Primary Percutaneous Coronary Intervention

INTRODUCTION

To investigate the additive prognostic value of growth differentiation factor (GDF-15) levels in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneously coronary intervention (pPCI) with 10-year mortality on top of clinical characteristics and known cardiac biomarkers.

METHODS

Baseline serum GDF-15 levels were measured in 290 STEMI patients treated with pPCI in the MISSION! intervention trial conducted from February 1, 2004 through October 31, 2006. The incremental prognostic value of GDF-15 and NTproBNP levels was evaluated on top of clinical characteristics using Cox proportional hazards analysis, Chi-square models and C-index. Outcome was 10-year all-cause mortality.

RESULTS

Mean age was 59.0 ± 11.5 years and 65 (22.4) patients were female. A total of 37 patients died during a follow-up of 9.4 (IQR 8.8-10.0) years. Multivariable Cox regression revealed GDF-15 and NTproBNP levels above median to be independently associated with 10-year all-cause mortality [HR GDF-15, 2.453 (95% CI 1.064-5.658), P = 0.04; HR NTproBNP, 2.413 (95% CI 1.043-5.564), P = 0.04] after correction for other clinical variables. Stratified by median GDF-15 (37.78 pmol/L) and NTproBNP (11.74 pmol/L) levels, Kaplan-Meier curves showed significant better survival for patients with GDF-15 and NTproBNP levels below the median versus above the median. The likelihood ratio test showed a significant incremental value of GDF-15 (P = 0.03) as compared with a model with clinically important variables and NTproBNP. The C-statistics for this model improved from 0.82 to 0.84 when adding GDF-15.

CONCLUSION

GDF-15 levels at admission in STEMI patients are independently associated with 10-year all-cause mortality rates and could improve risk stratification on top of clinical variables and other cardiac biomarkers.

Effect of Guideline-Based Therapy on Left Ventricular Systolic Function Recovery After ST-Segment Elevation Myocardial Infarction

Little is known about the proportion of ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention, who have reduced left ventricular ejection fraction (LVEF) within 48 hours (baseline) of admission and exhibit LVEF recovery under optimal guideline-based medical treatment. Therefore, the present study evaluates the evolution of LVEF in patients after STEMI and under guideline-based medical therapy. In 2,853 STEMI patients treated with primary percutaneous coronary intervention, echocardiography was performed at baseline and at 6 months follow-up. Patients with previous myocardial infarction, reinfarction, coronary artery bypass grafting or incomplete echocardiographic data at 6 months follow-up were excluded. Reduced LVEF at baseline was defined as <40%. LVEF recovery was defined as LVEF >50% at 6 months follow-up. The prevalence of LVEF <40% at baseline was 13% (n = 371 patients; mean age 60 [range 33 to 88] years; 76% men). At follow-up, 31% of patients remained with a LVEF <40%, 30% showed a LVEF between 41% and 49% and in 39% of patients LVEF improved to >50%. There were no differences in usage of guideline-based medications at discharge across groups. On multivariable analysis, peak troponin T levels (odds ratio [OR] 0.895; p < 0.001), baseline LVEF (OR 1.069; p = 0.023) and absence of significant mitral regurgitation (OR 0.376; p = 0.018) were independently associated with LV recovery at follow-up. In conclusion, the prevalence of LVEF <40% is low. With optimal medical therapy, LVEF normalizes in 39% of patients. Smaller enzymatic infarct size, baseline LVEF and absence of mitral regurgitation were independently associated with LVEF recovery at follow-up.

Long-term prognostic value of single-photon emission computed tomography myocardial perfusion imaging after primary PCI for STEMI

Aims

The aim of this study was to determine the long-term prognostic value of infarct size and myocardial ischaemia on single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Methods and results

In total, 1092 STEMI patients who underwent primary PCI and SPECT MPI within 1-6 months were included (median follow-up time of 6.9 years). In the entire cohort, SPECT infarct size was independently associated with the composite of cardiac death or reinfarction [hazard ratio (HR) per 10% increase in summed rest score 1.33; 95% confidence interval (95% CI) 1.12-1.58; P = 0.001], whereas myocardial ischaemia was not (HR per 5% increase in summed difference score 1.18; 95% CI 0.94-1.48; P = 0.16). Addition of SPECT infarct size to a model including the clinical variables provided significant incremental prognostic value for the prediction of cardiac death or reinfarction (global χ2 13.8 vs. 24.2; P = 0.002), whereas addition of SPECT ischaemia did not add significantly (global χ2 24.2 vs. 25.6; P = 0.24). In the subgroup of patients with left ventricular ejection fraction (LVEF) ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction (HR 1.59; 95% CI 1.15-2.22; P = 0.006), whereas in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction (HR 1.28; 95% CI 1.00-1.63; P = 0.050).

Conclusion

In patients with first STEMI and primary PCI, SPECT infarct size was independently associated with cardiac death and/or reinfarction, whereas myocardial ischaemia was not. In patients with LVEF ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction, whereas myocardial ischaemia was not. Conversely, in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction.

Apolipoproteins A1, B, and apoB/apoA1 ratio are associated with first ST-segment elevation myocardial infarction but not with recurrent events during long-term follow-up

INTRODUCTION

The current way to assess the risk of cardiovascular disease (CVD) is to measure conventional lipid and lipoprotein cholesterol fractions. Despite the success of statin treatment, residual cardiovascular risk remains high. Therefore, the value of extensive serum apolipoprotein (apo) profiling to assess the risk of ST-segment elevation myocardial infarction (STEMI) and of major adverse cardiac events (MACE) in patients with STEMI was investigated in a case-control design.

METHODS AND RESULTS

Serum apo levels were measured using liquid chromatography and mass spectrometry in 299 healthy individuals and 220 patients with STEMI. First, the association of apo profiles in baseline samples with risk of STEMI was examined, and second, the association of apo profiles at baseline with risk of recurrent MACE in patients with STEMI in a longitudinal study design was studied. High baseline (> 1.25 g/L) apoA1 levels were associated with a decreased risk of STEMI [odds ratio (OR) 0.17; 95% CI 0.11-0.26], whereas high apoB (> 1.00 g/L) levels (OR 2.17; 95% CI 1.40-3.36) and apoB/apoA1 ratio (OR per 1 SD (OR/SD): 2.16; 95% CI 1.76-2.65) were associated with an increased risk. Very-low-density-lipoprotein (VLDL)-associated apos gave conflicting results. Neither conventional lipid levels nor apo levels were associated with MACE in the STEMI group.

CONCLUSION

In conclusion, apoA1, apoB, and apoB/apoA1 were strongly associated with risk of STEMI. No clear relation between VLDL-associated apos and the risk of STEMI was found. Neither baseline serum apos nor lipids predicted MACE in statin-treated patients during long-term follow-up after a first STEMI.

Understanding ethno-cultural differences in cardiac medication adherence behavior: a Canadian study

BACKGROUND

There are ethno-cultural differences in cardiac patients' adherence to medications. It is unclear why this occurs. We thus aimed to generate an in-depth understanding about the decision-making process and potential ethno-cultural differences, of white, Chinese, and south Asian cardiac patients when making the decision to adhere to a medication regimen.

METHODS

A hierarchical descriptive decision-model was generated based on previous qualitative work, pilot tested, and revised to be more parsimonious. The final model was examined using a novel group of 286 cardiac patients, using their self-reported adherence as the reference. Thereafter, each node was examined to identify decision-making constructs that might be more applicable to white, Chinese or south Asian groups.

RESULTS

Non-adherent south Asians were most likely to identify a lack of receipt of detailed medication information, and less confidence and trust in the health care system and health care professionals. Both Chinese and south Asian participants were less likely to be adherent when they had doubts about western medicine (eg, the effects and safety of the medication). Being able to afford the cost of medications was associated with increased adherence. Being away from home reduced the likelihood of adherence in each group. The overall model had 67.1% concordance with the participants' initial self-reported adherence, largely due to participants' overreporting adherence.

CONCLUSION

These identified elements of the decision-making process are generally not considered in traditionally used medication adherence questionnaires. Importantly these elements are modifiable and ought to be the focus of both interventions and measurement of medication adherence.

Gender-Specific Differences in All-Cause Mortality Between Incomplete and Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease

The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women.

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review

OBJECTIVE

As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.

METHODS

This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.

RESULTS

The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).

CONCLUSIONS

While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Prediction for Improvement and Remodeling in First-Onset Myocardial Infarction by Speckle Tracking Echocardiography: Is Global or Regional Selection Better?

Cardiac function improvement and chamber remodeling after the onset of acute myocardial infarction (AMI) is crucial as it is closely related to the outcomes of patients. We sought to investigate the predictive value of left ventricular (LV) global and region of interest (ROI) assessment for prognosis of AMI patients by speckle tracking echocardiography (STE). We prospectively enrolled 81 first-onset AMI patients for baseline and 6-mo follow-up analysis. The echocardiography-derived parameters were compared in receiver operator characteristics (ROC) analysis for prediction of LV remodeling (LVR) (a minimum 20% increase of LV end-diastolic volume) and cardiac function improvement (a minimum 5% increase of LV ejection fraction). The ROI strain was selected by wall motion score index (WMSI) scores ≥2. The time of whole analysis process was recorded. Cut-off values of -9.92% for global circumferential strain (CS) and -5.53% for ROI CS predicted LVR. Cut-off values of -10.40% for global longitudinal strain (LS) and -5.33% for ROI LS predicted cardiac function improvement. Areas under curves of global and ROI parameters were comparable in ROC analysis (p > 0.05, all). The time of global analysis was less than the time of ROI analysis (p < 0.05) and the reproducibility of global analysis was slightly better than the ROI analysis. Our results demonstrated that STE was valuable for the prediction of LVR and cardiac function improvement after AMI. Compared with ROI parameters, global parameters were more integral and efficient as predictive factors with high predictive power, less analysis time and better reproducibility.

Using Smart Technology to Improve Outcomes in Myocardial Infarction Patients: Rationale and Design of a Protocol for a Randomized Controlled Trial, The Box

Background

Recent evidence suggests that frequent monitoring using smartphone-compatible wearable technologies might improve clinical effectiveness and patient satisfaction of care.

Objective

The aim of this study is to investigate the clinical effectiveness and patient satisfaction of a smart technology intervention in patients admitted with a ST elevation myocardial infarction (STEMI) or non-ST acute coronary syndrome (NST-ACS).

Methods

In this single center, open, randomized controlled trial patients who suffered from STEMI or NST-ACS will be randomized 1:1 to an intervention group or control group. Both groups will be followed up to one year after the index event. The intervention group will take daily measurements with a smartphone-compatible electrocardiogram device, blood pressure (BP) monitor, weight scale, and activity tracker. Furthermore, two of four outpatient clinic visits will be replaced by electronic visits (1 and 6 months after index event). The control group will receive regular care, consisting of four outpatient clinic visits (1, 3, 6, and 12 months after index event). All patients will be asked to fill in validated questionnaires about patient satisfaction, quality of life, propensity of medication adherence, and physical activity.

Results

The primary outcome of this trial will be percentage of patients with controlled BP. Secondary outcomes include patient satisfaction, health care utilization, major adverse cardiac events, medication adherence, physical activity, quality of life, and percentage of patients in which a sustained arrhythmia is detected.

Conclusions

Smart technology could potentially improve care in postmyocardial infarction patients. This trial will investigate whether usage of smart technology can improve clinical- and cost-effectiveness of care.

Trial Registration

Clinicaltrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376 (Archived by WebCite at http://www.webcitation.org/6tcvAdbdH)

Comparison of Left Ventricular Function and Myocardial Infarct Size Determined by 2-Dimensional Speckle Tracking Echocardiography in Patients With and Without Chronic Obstructive Pulmonary Disease After ST-Segment Elevation Myocardial Infarction

Patients with chronic obstructive pulmonary disease (COPD) have a high risk of mortality after acute ST-segment elevation myocardial infarction (STEMI). We compared STEMI patients with versus without COPD in terms of infarct size and left ventricular (LV) systolic function using advanced 2-dimensional speckle tracking echocardiography. Of 1,750 patients with STEMI (mean age 61 ± 12 years, 76% male), 133 (7.6%) had COPD. With transthoracic echocardiography, left ventricular ejection fraction (LVEF) and wall motion score index were measured. Infarct size was assessed using biomarkers (creatine kinase and troponin T). LV global longitudinal strain (GLS), reflecting active LV myocardial deformation, was measured with 2-dimensional speckle tracking echocardiography to estimate LV systolic function and infarct size. STEMI patients with COPD were significantly older, more likely to be former smokers, and had worse renal function compared with patients without COPD. There were no differences in infarct size based on peak levels of creatine kinase (1315 [613 to 2181] vs 1477 [682 to 3047] U/l, p = 0.106) and troponin T (3.3 [1.4 to 7.3] vs 3.9 [1.5 to 7.8] µg/l, p = 0.489). Left ventricular ejection fraction (46% vs 47%, p = 0.591) and wall motion score index (1.38 [1.25 to 1.66] vs 1.38 [1.19 to 1.69], p = 0.690) were comparable. In contrast, LV GLS was significantly more impaired in patients with COPD compared with patients without COPD (-13.9 ± 3.0% vs -14.7 ± 3.9%, p = 0.034). In conclusion, despite comparable myocardial infarct size and LV systolic function as assessed with biomarkers and conventional echocardiography, patients with COPD exhibit more impaired LV GLS on advanced echocardiography than patients without COPD, suggesting a greater functional impairment at an early stage after STEMI.

Early prediction of hospital admission for emergency department patients: a comparison between patients younger or older than 70 years

OBJECTIVE

The aim of this study was to develop models that predict hospital admission to ED of patients younger and older than 70 and compare their performance.

METHODS

Prediction models were derived in a retrospective observational study of all patients≥18 years old visiting the ED of a university hospital during the first 6 months of 2012. Patients were stratified into two age groups (<70 years old and ≥70 years old). Multivariable logistic regression analysis was used to identify predictors of hospital admission among factors available immediately after patient arrival to the ED. Validation of the prediction models was performed on patients presenting to the ED during the second half of the year 2012.

RESULTS

10 807 patients were included in the derivation and 10 480 in the validation cohorts. The strongest independent predictors of hospital admission among the 8728 patients <70 years old were age, sex, triage category, mode of arrival, performance of blood tests, chief complaint, ED revisit, type of specialist, phlebotomised blood sample and all vital signs. The area under the curve (AUC) of the validation cohort for those <70 years old was 0.86 (95% CI 0.85 to 0.87). Among the 2079 patients ≥70 years, the same factors were predictive, except for gender, type of specialist and heart rate; the AUC was 0.77 (95% CI 0.75 to 0.79). The prediction models could identify a group of 10% of patients with the highest risk in whom hospital admission was predicted at ED triage, with a positive predictive value (PPV) of 71% (95% CI 68% to 74%) in younger patients and PPV of 87% (95% CI 81% to 92%) in older patients.

CONCLUSION

Demographic and clinical factors readily available early in the ED visit can be useful in identifying patients who are likely to be admitted to the hospital. While the model for the younger patients had a higher AUC, the model for older patients had a higher PPV in identifying the patients at highest risk for admission. Of note, heart rate was not a useful predictor in the older patients.

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands

OBJECTIVE

Numerous studies have shown that a substantial number of patients suffer from adverse events (AEs) as a result of hospital care. However, specific data on AEs in acute cardiac care are scarce. The current manuscript describes the development and validation of a specific instrument to evaluate patient safety of a predefined care track for patients with acute myocardial infarction (AMI).

DESIGN

Retrospective patient record review study.

SETTING AND PARTICIPANTS

A total of 879 hospital admissions treated in a tertiary care centre for an AMI (age 64±12 years, 71% male).

MAIN OUTCOME MEASURE

In the first phase, the medical records of patients with AMI warranting coronary angiography or coronary intervention were analysed for process deviations. In the second phase, the medical records of these patients were checked for any harm that had occurred which was caused by the healthcare provider or the healthcare organisation (AE) and whether the harm that occurred was preventable.

RESULTS

Of all 879 patients included in the analysis, 40% (n=354) had 1 or more process deviation. Of these 354 patients, 116 (33%) had an AE. Patients with AE experienced more process deviations compared with patients without AE (2±1.7 vs 1.5±0.9 process deviations per patient, p=0.005). Inter-rater reliability in assessing a causal relation of healthcare with the origin of an AE showed a κ of 0.67 (95% CI 0.51 to 0.83).

CONCLUSIONS

This study shows that it is possible to develop a reliable method, which can objectively assess process deviations and the occurrence of AEs in a specified population. This method could be a starting point for developing an electronic tracking system for continuous monitoring in strictly predefined care tracks.

Prognosis of complete versus incomplete revascularisation of patients with STEMI with multivessel coronary artery disease: an observational study

Objective

The best strategy in patients with acute ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (CAD) regarding completeness of revascularisation of the non-culprit lesion(s) is still unclear. To establish which strategy should be followed, survival rates over a longer period should be evaluated. The aim of this study was to investigate whether complete revascularisation, compared with incomplete revascularisation, is associated with reduced short-term and long-term all-cause mortality in patients with first STEMI and multivessel CAD.

Methods

This retrospective study consisted of 518 patients with first STEMI with multivessel CAD. Complete revascularisation (45%) was defined as the treatment of any significant coronary artery stenosis (≥70% luminal narrowing) during primary or staged percutaneous coronary intervention prior to discharge. The primary end point was all-cause mortality.

Results

Incomplete revascularisation was not independently associated with 30-day all-cause mortality in patients with acute first STEMI and multivessel CAD (OR 1.98; 95% CI 0.62to6.37; p=0.25). During a median long-term follow-up of 6.7 years, patients with STEMI with multivessel CAD and incomplete revascularisation showed higher mortality rates compared with patients who received complete revascularisation (24% vs 12%, p<0.001), and these differences remained after excluding the first 30 days. However, in multivariate analysis, incomplete revascularisation was not independently associated with increased all-cause mortality during long-term follow-up in the group of patients with STEMI who survived the first 30 days post-STEMI (HR 1.53 95% CI 0.89-2.61, p=0.12).

Conclusion

In patients with acute first STEMI and multivessel CAD, incomplete revascularisation compared with complete revascularisation was not independently associated with increased short-term and long-term all-cause mortality.

Effect of gender on evidence-based practice for Australian patients with acute coronary syndrome: A retrospective multi-site study

BACKGROUND

Early acute coronary syndrome (ACS) care occurs in the emergency department (ED). Death and disability from ACS are reduced with access to evidence-based ACS care. In this study, we aimed to explore if gender influenced access to ACS care.

METHODS

A retrospective descriptive study was conducted for 288 (50% women, n=144) randomly selected adults with ACS admitted via the ED to three tertiary public hospitals in Victoria, Australia from 1.1.2013 to 30.6.2015.

RESULTS

Compared with men, women were older (79 vs 75.5 years; p=0.009) less often allocated triage category 2 (58.3 vs 71.5%; p=0.026) and waited longer for their first electrocardiograph (18.5 vs 15min; p=0.001). Fewer women were admitted to coronary care units (52.4 vs 65.3%; p=0.023), but were more often admitted to general medicine units (39.6 vs 22.9%; p=0.003) than men. The median length of stay was 4days for both genders, but women were admitted for significantly more bed days than men (IQR 3-7 vs 2-5; p=0.005).

CONCLUSIONS

There were a number of gender differences in ED care for ACS and women were at greater risk of variation from evidence-based guidelines. Further research is needed to understand why gender differences exist in ED ACS care.

Influence of Myocardial Ischemia Extent on Left Ventricular Global Longitudinal Strain in Patients After ST-Segment Elevation Myocardial Infarction

Two-dimensional echocardiographic left ventricular (LV) global longitudinal strain (GLS) after ST-segment elevation myocardial infarction (STEMI) is moderately correlated with infarct size and reflects the residual LV systolic function. This correlation may be influenced by the presence of myocardial ischemia. The present study investigated how myocardial ischemia modulates the correlation between LV GLS and infarct size determined with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with first STEMI treated with primary coronary intervention. A total of 1,128 patients (age 60 ± 11 years) who underwent SPECT MPI for the evaluation of infarct size and residual ischemia were evaluated. LV GLS was measured on transthoracic echocardiography. The time interval between echocardiography and SPECT MPI was 1 ± 1 month. A moderate correlation between echocardiographic LV GLS and infarct size on SPECT MPI was observed (r = 0.58, p <0.001). This correlation was weakened by the presence or extent of ischemia; in the group of patients without ischemia, the correlation between LV GLS and infarct size on SPECT MPI was r = 0.66 (p <0.001), whereas in patients with mild or moderate-to-severe ischemia, the correlations were r = 0.56 and 0.38, respectively (both p <0.001). Moderate-to-severe myocardial ischemia was independently associated with more impaired LV GLS after adjusting for infarct size, age, diabetes mellitus, and hypertension (β 0.60, 95% confidence interval 013 to 1.06). In conclusion, the presence of myocardial ischemia after STEMI impacts on the correlation between echocardiographic LV GLS and infarct size measured on SPECT MPI. Residual ischemia is independently associated with more impaired LV GLS.

Traditional Chinese medicine, Danlou tablets alleviate adverse left ventricular remodeling after myocardial infarction: results of a double-blind, randomized, placebo-controlled, pilot study

BACKGROUND

Danlou tablets, a patented Chinese Medicine, have been long approved for the treatment of ischemic heart disease in China. While numerous empirical observations suggested Danlou tablets could decrease frequency and duration of angina pectoris attacks, evidence supporting its efficacy on cardiac remodeling remains inadequate. Therefore, this pilot trial was designed to determine whether Danlou tablets would reduce adverse left ventricular (LV) remodeling in patients with myocardial infarction (MI).

METHODS AND RESULTS

Eligible patients with acute MI were enrolled and randomly assigned to Danlou tablets or placebo groups, superimposed on standard treatment for MI. Then, in addition to assessment of the clinical outcome, the changes in LV volumes were evaluated by a serial echocardiography. In total, 83 patients (Danlou tablets 42 and placebo 41) completed 90 days of treatment and had complete baseline and outcome data. Standard echocardiographic evaluations revealed significant differences in the change of LV end-diastolic volume index (LVEDVi) between group of patients treated with Danlou tablets and the placebo group (-4.49 ± 7.29 vs. -0.34 ± 9.01 mL/m2, P < 0.001). The reduction in LVEDVi was independent of beta-blocker, ACE inhibitors/ARBs use. Furthermore, treatment with Danlou tablets significantly reduced LV end-systolic volume index (-4.09 ± 5.85 vs. -0.54 ± 5.72 mL/m2, P < 0.001) and improved the LV ejection fraction (4.83 ± 9.23 vs. 0.23 ± 8.15 %, P < 0.001), as compared to placebo. Meaningfully, the incidence of the major adverse cardiovascular events was also lower in patients receiving Danlou tablets (P < 0.05).

CONCLUSION

Superimposed on the standard pharmacologic treatment, Danlou tablets significantly reversed post-MI adverse LV remodeling, thereby contributed to the overall positive clinical outcome.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT02675322 (February 1, 2016).

Prognostic Implications of Elevated Pulmonary Artery Pressure After ST-Segment Elevation Myocardial Infarction

Elevated systolic pulmonary artery pressure (SPAP) after ST-segment elevation myocardial infarction (STEMI) has been associated with adverse outcome. However, little is known about the development of increased SPAP after STEMI treated with primary percutaneous coronary intervention. The aims of this study were to investigate the incidence and determinants of elevated SPAP (SPAP ≥36 mm Hg at 12 months) after first STEMI and to analyze its prognostic implications. A total of 705 patients (60 ± 12 years; 75% men; left ventricular ejection fraction [LVEF] 47 ± 9%) with first STEMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was available at baseline and 12-month follow-up. Data on all-cause mortality were collected at long-term follow-up. Incident elevated SPAP was present in 5% (n = 38) of patients. Patients with incident elevated SPAP were older (66 ± 12 vs 60 ± 11 years, p = 0.001), had more systemic hypertension (58% vs 30%, p <0.001) and lower LVEF (43 ± 9% vs 48 ± 8%, p <0.001) than their counterparts. Left atrial volume was larger (23 ± 11 vs 18 ± 6 ml/m(2), p = 0.006), and moderate to severe mitral regurgitation was more prevalent in patients with incident elevated SPAP (16% vs 7%, p = 0.05). Independent correlates of incident elevated SPAP at 12-month follow-up were age (odds ratio [OR] 1.04, 95% CI 1.01 to 1.08, p = 0.01), hypertension (OR 2.52, 95% CI 1.23 to 5.14, p = 0.01), baseline LVEF (OR 0.94, 95% CI 0.90 to 0.98, p = 0.003), and baseline left atrial volume (OR 1.08, 95% CI 1.03 to 1.12, p = 0.001). Incident elevated SPAP was independently associated with all-cause mortality (hazard ratio 3.84, 95% CI 1.76 to 8.39, p = 0.001). In conclusion, although the incidence of elevated SPAP after STEMI is low, its presence is independently associated with increased risk of all-cause mortality at follow-up.

Time course, predictors, and prognostic implications of significant mitral regurgitation after ST-segment elevation myocardial infarction

BACKGROUND

Ischemic mitral regurgitation (MR) is a known complication of ST-segment elevation myocardial infarction (STEMI) with important prognostic implications. We evaluated changes over time in ischemic MR after STEMI and the prevalence and predictors of significant (grade ≥2) MR at 12 months. Furthermore, the prognostic additional value of significant MR at 12-month follow-up over acute MR was assessed.

METHODS

STEMI patients (n = 1,599; 77% male; 60 ± 12 years) treated with primary percutaneous coronary intervention underwent echocardiography <48 hours of admission (baseline) and at 12 months. Mortality data were collected during long-term follow-up.

RESULTS

At baseline, significant MR was present in 103 (6%) patients. After 12 months, MR worsened ≥1 grade in 321 (20%) patients, remained stable in 963 (60%), and improved ≥1 grade in 315 (20%). Significant MR was present in 135 patients at 12 months (8%, P = .01 vs baseline). Age, left ventricular end-systolic volume, and significant MR at baseline were independently associated with significant MR at follow-up. During follow-up (median, 50 months), 121 (8%) patients died (40% of cardiovascular cause). Significant MR at follow-up was independently associated with all-cause (hazard ratio, 1.65, 95% CI, 1.02-2.99) and cardiovascular mortality (hazard ratio, 2.47; 95% CI, 1.24-4.92), also after adjusting for significant MR at baseline.

CONCLUSIONS

The prevalence of significant MR after STEMI increases over time. Age, baseline left ventricular end-systolic volume, and baseline significant MR are independently associated with significant MR at follow-up. Significant MR at 12 months is associated with subsequent all-cause and cardiovascular mortality and shows additional prognostic value over acute MR.

Comparison of Changes in Global Longitudinal Peak Systolic Strain After ST-Segment Elevation Myocardial Infarction in Patients With Versus Without Diabetes Mellitus

Global longitudinal strain (GLS) measured by 2-dimensional longitudinal speckle-tracking echocardiography may be a more sensitive measure of left ventricular (LV) mechanics than conventional LV ejection fraction (EF) to characterize adverse post-ST-segment elevation myocardial infarction (STEMI) remodeling. The aim of the present evaluation was to compare changes in LV GLS in patients with versus without diabetes after the first STEMI. Patients with first STEMI and diabetes (n = 143; age 64 ± 12 years; 68% men; 50% left anterior descending artery as culprit vessel) and 290 patients with first STEMI and without diabetes matched on age, gender, and infarct location were included. LV volumes and function and 2-dimensional LV GLS were measured after primary percutaneous coronary intervention (baseline) and at 6-month follow-up. At baseline, patients with and without diabetes had similar LVEF (46.8 ± 0.7% vs 48.0 ± 0.5%, p = 0.19) and infarct size (peak cardiac troponin T: 3.1 [1.2 to 6.5] vs 3.7 [1.3 to 7.3] μg/l, p = 0.10; peak creatine phosphokinase:1,120 [537 to 2,371] vs 1,291 [586 to 2,613] U/l, p = 0.17), whereas LV GLS was significantly more impaired in diabetic patients (-13.7 ± 0.3% vs -15.3 ± 0.2%, p <0.001). Although diabetic patients showed an improvement in LVEF over time similar to nondiabetic patients (52.0 ± 0.8% vs 53.1 ± 0.6%, p = 0.25), GLS remained more impaired at 6-month follow-up compared with nondiabetic patients (-15.8 ± 0.3% vs -17.3 ± 0.2%, p <0.001). After adjusting for clinical and echocardiographic characteristics, diabetes was independently associated with changes in GLS from baseline to 6-month follow-up (β 1.41, 95% confidence interval 0.85 to 1.96, p <0.001). In conclusion, after STEMI, diabetic patients show more impaired LV GLS at both baseline and follow-up compared with a matched group of patients without diabetes, despite having similar infarct size and LVEF at baseline and follow-up.