Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention

25-hydroxycholesterol aggravates oxygen-glucose deprivation/reoxygenation-induced pyroptosis through promoting activation of NLRP3 inflammasome in H9C2 cardiomyocytes

25-hydroxycholesterol (25-HC) plays a role in the regulation of cell survival and immunity. However, the effect of 25-HC on myocardial ischemia/reperfusion (MI/R) injury remains unknown. Our present study aimed to investigate whether 25-HC aggravated MI/R injury through NLRP3 inflammasome-mediated pyroptosis. The overlapping differentially expressed genes (DEGs) in MI/R were identified from the GSE775, GSE45818, GSE58486, and GSE46395 datasets in Gene Expression Omnibus (GEO) database. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were conducted using the database of Annotation, Visualization and Integration Discovery (DAVID). The protein-protein interaction (PPI) network of the overlapping DEGs was established using the Search Tool for the Retrieval of Interacting Genes (STRING) database. These bioinformatics analyses indicated that cholesterol 25-hydroxylase (CH25H) was one of the crucial genes in MI/R injury. The oxygen-glucose deprivation/reoxygenation (OGD/R) cell model was established to simulate MI/R injury. Western blot and RT-qPCR analysis demonstrated that CH25H was significantly upregulated in OGD/R-stimulated H9C2 cardiomyocytes. Moreover, knockdown of CH25H inhibited the OGD/R-induced pyroptosis and nod-like receptor protein 3 (NLRP3) inflammasome activation, as demonstrated by cell counting kit-8 (CCK8), lactate dehydrogenase (LDH), RT-qPCR, and western blotting assays. Conversely, 25-HC, which is synthesized by CH25H, promoted activation of NLRP3 inflammasome in OGD/R-stimulated H9C2 cardiomyocytes. In addition, the NLRP3 inhibitor BAY11-7082 attenuated 25-HC-induced H9C2 cell injury and pyroptosis under OGD/R condition. In conclusion, 25-HC could aggravate OGD/R-induced pyroptosis through promoting activation of NLRP3 inflammasome in H9C2 cells.

MR Uniformity Ratio Estimates to Evaluate Ventricular Mechanical Dyssynchrony and Prognosis After ST-Segment Elevation Myocardial Infarction

BACKGROUND

The impact of left ventricular mechanical dyssynchrony (LVMD) on the long-term prognosis of ST-segment elevation myocardial infarction (STEMI) is unclear.

HYPOTHESIS

MR uniformity ratio estimates (URE) can detect LVMD and assess STEMI prognosis.

STUDY TYPE

Retrospective analysis of a prospective multicenter registry (EARLY-MYO trial, NCT03768453).

POPULATION

Overall, 450 patients (50 females) with first-time STEMI were analyzed, as well as 40 participants without cardiovascular disease as controls.

FIELD STRENGTH/SEQUENCE

3.0-T, balanced steady-state free precession cine and late gadolinium enhancement imaging.

ASSESSMENT

MRI data were acquired within 1 week of symptom onset. Major adverse cardiovascular events (MACEs), including cardiovascular death, nonfatal re-infarction, hospitalization for heart failure, and stroke, were the primary clinical outcomes. LVMD was represented by circumferential URE (CURE) and radial URE (RURE) calculated using strain measurements. The patients were grouped according to clinical outcomes or URE values. Patients' clinical characteristics and MR indicators were compared.

STATISTICAL TESTS

The Student's t-test, Mann-Whitney U test, chi-square test, Fisher's exact test, receiver operating characteristic curve analysis with area under the curve, Kaplan-Meier analysis, Cox regression, logistic regression, intraclass correlation coefficient, c-index, and integrated discrimination improvement were used. P < 0.05 was considered statistically significant.

RESULTS

CURE and RURE were significantly lower in patients with STEMI than in controls. The median follow-up was 60.5 months. Patients with both lower CURE and RURE values experienced a significantly higher incidence of MACEs by 3.525-fold. Both CURE and RURE were independent risk factors for MACEs. The addition of UREs improved diagnostic efficacy and risk stratification based on infarct size and left ventricular ejection fraction (LVEF). The indicators associated with LVMD included male sex, serum biomarkers (peak creatine phosphokinase and cardiac troponin I), infarct size, and LVEF.

DATA CONCLUSION

CURE and RURE may be useful to evaluate long-term prognosis after STEMI.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 2.

Prolonged Dual Antiplatelet Therapy in Acute Myocardial Infarction Patients Without Revascularization: China Acute Myocardial Infarction Registry Study

At least 12 months of dual antiplatelet therapy (DAPT) is 1 of the standards of care following percutaneous coronary intervention in patients with acute coronary syndrome. However, study on prolonged DAPT for patients with acute myocardial infarction (AMI) without revascularization is limited. We studied 1,744 patients with AMI without revascularization from the China Acute Myocardial Infarction registry between January 2013 and September 2014. These patients were on DAPT and did not experience AMI, stroke, or bleeding events at the 12-month follow-up. We divided them into 2 groups: 12-month DAPT group (DAPT for at least 12 months but <18 months) and 18-month DAPT group (DAPT for at least 18 months). The primary outcome was 24-month all-cause death. Overall, 1,221 patients (70.0%) took DAPT for ≥12 months but <18 months, whereas 523 patients (30.0%) took DAPT for ≥18 months. The proportion of patients at high ischemic risk and the proportion of patients at high bleeding risk were similar in the 2 groups. At 24 months, the all-cause mortality rate of the 18-month DAPT group was significantly lower than that for the 12-month DAPT group (3.7% vs 5.9%, p = 0.0471). The adjusted hazard ratio for all-cause death also showed statistical significance (0.59, 95% confidence interval 0.35 to 0.99, p = 0.0444). In conclusion, DAPT for at least 18 months appears to be associated with lower 24-month mortality for non-revascularization AMI patients without events within 12 months after onset.

Ultrasound robotics for precision therapy

In recent years, the application of microrobots in precision therapy has gained significant attention. The small size and maneuverability of these micromachines enable them to potentially access regions that are difficult to reach using traditional methods; thus, reducing off-target toxicities and maximizing treatment effectiveness. Specifically, acoustic actuation has emerged as a promising method to exert control. By harnessing the power of acoustic energy, these small machines potentially navigate the body, assemble at the desired sites, and deliver therapies with enhanced precision and effectiveness. Amidst the enthusiasm surrounding these miniature agents, their translation to clinical environments has proven difficult. The primary objectives of this review are threefold: firstly, to offer an overview of the fundamental acoustic principles employed in the field of microrobots; secondly, to assess their current applications in medical therapies, encompassing tissue targeting, drug delivery or even cell infiltration; and lastly, to delve into the continuous efforts aimed at integrating acoustic microrobots into in vivo applications.

Heart Failure at Admission Complicating ST-Elevation Myocardial Infarction in a Middle-Income Country. Experience of the ARGEN-IAM-ST Registry

Despite advances in the management of ST-elevation myocardial infarction (STEMI), when associated with heart failure (HF) its prognosis remains ominous. This study assessed the differences in admission and mortality of HF complicating STEMI at admission (HFad) in a middle-income country. Data from the National Registry of STEMI of Argentina (ARGEN-IAM-ST) from January 1, 2016, to September 30, 2020, were analyzed. HFad was defined by the identification of Killip/Kimball ≥2 at admission. About 3174 patients were analyzed (22.3% had HFad). Patients with HFad were older, more often women, hypertensive, and diabetic. Received less reperfusion (87.6% vs 92.6%, P < 0.001) and had increased in-hospital mortality (28.4% vs 3.0%, P < 0.001). In multivariate analysis HFad was an independent predictor of death (OR: 4.88 [95%CI: 3.33-7.18], P < 0.001) and reperfusion adjusted to HFad was associated with lower mortality (OR: 0.57 [95%CI: 0.34-0.95], P = 0.03). HFad in STEMI is associated with a worse clinical profile, receives fewer reperfusion strategies, and carries a higher risk of in-hospital mortality while reperfusion reduces mortality.

Long-term outcomes of periprocedural coronary dissection and perforation for patients undergoing percutaneous coronary intervention in a Japanese multicenter registry

Long-term outcomes of iatrogenic coronary dissection and perforation in patients undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 8,721 consecutive patients discharged after PCI between 2008 and 2019 from Keio Cardiovascular (KiCS) PCI multicenter prospective registry in the Tokyo metropolitan area. Significant coronary dissection was defined as persistent contrast medium extravasation or spiral or persistent filling defects with complete distal and impaired flow. The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting two years after discharge. We used a multivariable Cox hazard regression model to assess the effects of these complications. Among the patients, 68 (0.78%) had significant coronary dissections, and 61 (0.70%) had coronary perforations at the index PCI. Patients with significant coronary dissection had higher rates of the primary endpoint and heart failure than those without (25.0% versus 14.3%, P = 0.02; 10.3% versus 4.2%, P = 0.03); there were no significant differences in the primary outcomes between the patients with and without coronary perforation (i.e., primary outcome: 8.2% versus 14.5%, P = 0.23) at the two-year follow-up. After adjustments, patients with coronary dissection had a significantly higher rate of the primary endpoint than those without (HR 1.70, 95% CI 1.02-2.84; P = 0.04), but there was no significant difference in the primary endpoint between the patients with and without coronary perforation (HR 0.51, 95% CI 0.21-1.23; P = 0.13). For patients undergoing PCI, significant coronary dissection was associated with poor long-term outcomes, including heart failure readmission.

Trends in acute myocardial infarction mortality in the European Union, 2012-2020

AIMS

To assess the sex- and age-specific trends in acute myocardial infarction (AMI) mortality in the modern European Union (EU-27) member states between years 2012 and 2020.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for each country of the EU-27 were retrieved through a publicly available European Statistical Office (EUROSTAT) dataset for the years 2012 to 2020. AMI-related deaths were ascertained when codes for AMI (ICD-10 codes I21.0-I22.0) were listed as the underlying cause of death in the medical death certificate. Deaths occurring before the age of 65 years were defined as premature deaths. To calculate annual trends, we assessed the average annual percent change (AAPC) with relative 95% confidence intervals (CIs) using joinpoint regression. During the study period, 1 793 314 deaths (1 048 044 males and 745 270 females) occurred in the EU-27 due to of AMI. The proportion of AMI-related deaths per 1000 total deaths decline from 5.0% to 3.5% both in the entire population (P for trend < 0.001) and in males or females, separately. Joinpoint regression analysis revealed a continuous linear decrease in age-adjusted AMI-related mortality from 2012 to 2020 among EU-27 members [AAPC: -4.6% (95% CI: -5.1 to -4.0), P < 0.001]. The age-adjusted mortality rate showed a plateau in some Eastern European countries and was more pronounced in EU-27 females and in subjects aged ≥65 years.

CONCLUSION

Over the last decade, the age-adjusted AMI-related mortality has been continuously declining in most of the in EU-27 member states. However, some disparities still exist between western and eastern European countries.

Gender Differences in Long-Term Outcomes of Young Patients Who Underwent Percutaneous Coronary Intervention: Long-Term Outcome Analysis from a Multicenter Registry in Japan

Young patients who underwent percutaneous coronary intervention (PCI) have shown worse long-term outcomes but remain inadequately investigated. We analyzed 1,186 consecutive young patients (aged ≤55 years) from the Keio Cardiovascular PCI registry who were successfully discharged after PCI (2008 to 2019) and compared them to 5,048 older patients (aged 55 to 75 years). The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting within 2 years after discharge. In the young patients, the mean age was 48.4 ± 5.4 years, acute coronary syndrome cases accounted for 69.6%, and 92 (7.8%) were female. Body mass index; hemoglobin levels; and proportions of smoking, hyperlipidemia, and ST-elevation myocardial infarction were lower and dialysis or active cancer proportions were higher in young female patients than male patients. A higher number of young female than male patients reached the primary end point and all-cause death (15.2% vs 7.1%, p = 0.01; 4.3% vs 1.0%, p = 0.023), mainly because of noncardiac death (4.3% versus 0.5%, p = 0.001). After covariate adjustment, the primary end point rates were higher among young women than men (hazard ratio 2.00, 95% confidence interval 1.03 to 3.89, p = 0.042). Gender did not predict the primary end point among older patients (vs men; hazard ratio 0.84, 95% confidence interval 0.67 to 1.06, p = 0.14). In conclusion, young women showed worse outcomes during the 2-year post-PCI follow-up, but this gender difference was absent in patients aged 55 to 75 years.

The Relationship Between Myocardial Infarction and Estrogen Use: A Literature Review

This thorough literature evaluation was prompted by significant research into the complex interactions between estrogen use and myocardial infarction (MI). Estrogen has fascinated researchers because of its possible cardioprotective benefits and its impact on cardiovascular health. In order to clarify the connection between estrogen use and the risk of MI, this review critically examines the body of prior evidence. This review focuses on estrogen and its pivotal role in cardiovascular health, concentrating on lipid metabolism, vasodilation, inflammation, and endothelial function. It examines contentious data about estrogen therapy's heart-protective effects, taking into account age, initiation timing, dosage, and dosage of administration. Genetic and epigenetic influences on MI risk among estrogen users highlight intricate, personalized estrogen effects. The conclusion summarizes the main findings and emphasizes the need for an all-encompassing strategy for initiating and managing estrogen medication. It is crucial to consider patient-specific traits and risk factors to successfully customize treatment regimens. This review sheds vital light on the potential directions for better cardiovascular treatment for postmenopausal women by shedding light on the complex link between estrogen use and myocardial infarction. The review also identifies research gaps and future objectives in this area, highlighting the demand for novel medicines and individualized strategies to improve cardiovascular outcomes.

Are There Hopeful Therapeutic Strategies to Regenerate the Infarcted Hearts?

Ischemic heart disease remains the primary cause of morbidity and mortality worldwide. Despite significant advancements in pharmacological and revascularization techniques in the late 20th century, heart failure prevalence after myocardial infarction has gradually increased over the last 2 decades. After ischemic injury, pathological remodeling results in cardiomyocytes (CMs) loss and fibrosis, which leads to impaired heart function. Unfortunately, there are no clinical therapies to regenerate CMs to date, and the adult heart's limited turnover rate of CMs hinders its ability to self-regenerate. In this review, we present novel therapeutic strategies to regenerate injured myocardium, including (1) reconstruction of cardiac niche microenvironment, (2) recruitment of functional CMs by promoting their proliferation or differentiation, and (3) organizing 3-dimensional tissue construct beyond the CMs. Additionally, we highlight recent mechanistic insights that govern these strategies and identify current challenges in translating these approaches to human patients.

The Association Between Angiographically Derived Radial Wall Strain and the Risk of Acute Myocardial Infarction

BACKGROUND

The radial wall strain (RWS) is a novel angiography-based method to assess the biomechanical property of the coronary artery and whether it can predict future acute myocardial infarction (AMI) events remains to be elucidated.

OBJECTIVES

This study aimed to investigate the association between angiography-derived RWS and future AMI events in mild to intermediate lesions.

METHODS

We performed a matched case-control analysis nested in a retrospective cohort of patients who had received prior angiography (the index procedure) at least 1 month before and were hospitalized again for repeat angiography. Patients with at least 1 de novo mild to intermediate lesion identified at the index procedure and eligible for RWS analysis were enrolled. The study identified cases with target lesion-related AMI diagnosed at the repeat angiography, matching each case to 3 control subjects without AMI.

RESULTS

Altogether 44 patients with lesion-related AMI and 132 matched controls were enrolled. The median diameter stenosis of the overall interrogated lesions was 34.0%. The baseline maximum RWS (RWS_max), which was defined as the highest RWS in the stenotic segment, was significantly higher in lesions responsible for AMI than those that remained quiescent (median 13% vs 10%; P < 0.001). RWS_max was predictive of lesion-related AMI, with an area under the curve of 0.83 (95% CI: 0.76-0.90; P < 0.001) and an optimal cutoff >12%. RWS_max >12% was found to be independently associated with subsequent AMI events with a risk ratio of 7.25 (95% CI: 3.94-13.37; P < 0.001).

CONCLUSIONS

Among angiographically mild to intermediate lesions, a high-strain pattern identified by angiography-derived RWS was associated with an increased risk of AMI events.

A Review of ST-Elevation Myocardial Infarction in Patients with COVID-19

The Coronavirus disease 2019 (COVID-19) pandemic has led to a significant increase in worldwide morbidity and mortality. Patients with COVID-19 are at risk for developing a variety of cardiovascular conditions including acute coronary syndromes, stress-induced cardiomyopathy, and myocarditis. Patients with COVID-19 who develop ST-elevation myocardial infarction (STEMI) are at a higher risk of morbidity and mortality when compared with their age- and sex-matched STEMI patients without COVID-19. We review current knowledge on the pathophysiology of STEMI in patients with COVID-19, clinical presentation, outcomes, and the effect of the COVID-19 pandemic on overall STEMI care.

Sex differences in cardiovascular response to sepsis

Recently, there has been increased recognition of the importance of sex as a biological factor affecting disease and health. Many preclinical studies have suggested that males may experience a less favorable outcome in response to sepsis than females. The underlying mechanisms for these differences are still largely unknown but are thought to be related to the beneficial effects of estrogen. Furthermore, the immunosuppressive role of testosterone is also thought to contribute to the sex-dependent differences that are present in clinical sepsis. There are still significant knowledge gaps in this field. This mini-review will provide a brief overview of sex-dependent variables in relation to sepsis and the cardiovascular system. Preclinical animal models for sepsis research will also be discussed. The intent of this mini-review is to inspire interest for future considerations of sex-related variables in sepsis that should be addressed to increase our understanding of the underlying mechanisms in sepsis-induced cardiovascular dysfunction for the identification of therapeutic targets and improved sepsis management and treatment.

Construction and evaluation of nomogram model for individualized prediction of risk of major adverse cardiovascular events during hospitalization after percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction

Background

Emergency percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) helps to reduce the occurrence of major adverse cardiovascular events (MACEs) such as death, cardiogenic shock, and malignant arrhythmia, but in-hospital MACEs may still occur after emergency PCI, and their mortality is significantly increased once they occur. The aim of this study was to investigate the risk factors associated with MACE during hospitalization after PCI in STEMI patients, construct a nomogram prediction model and evaluate its effectiveness.

Methods

A retrospective analysis of 466 STEMI patients admitted to our hospital from January 2018 to June 2022. According to the occurrence of MACE during hospitalization, they were divided into MACE group (n = 127) and non-MACE group (n = 339), and the clinical data of the two groups were compared; least absolute shrinkage and selection operator (LASSO) regression was used to screen out the predictors with non-zero coefficients, and multivariate Logistic regression was used to analyze STEMI Independent risk factors for in-hospital MACE in patients after emergency PCI; a nomogram model for predicting the risk of in-hospital MACE in STEMI patients after PCI was constructed based on predictive factors, and the C-index was used to evaluate the predictive performance of the prediction model; the Bootstrap method was used to repeat sampling 1,000 Internal validation was carried out for the second time, the Hosmer-Lemeshow test was used to evaluate the model fit, and the calibration curve was drawn to evaluate the calibration degree of the model. Receiver operating characteristic (ROC) curves were drawn to evaluate the efficacy of the nomogram model and thrombolysis in myocardial infarction (TIMI) score in predicting in-hospital MACE in STEMI patients after acute PCI.

Results

The results of LASSO regression showed that systolic blood pressure, diastolic blood pressure, Killip grade II-IV, urea nitrogen and left ventricular ejection fraction (LVEF), IABP, NT-ProBNP were important predictors with non-zero coefficients, and multivariate logistic regression analysis was performed to analyze that Killip grade II-IV, urea nitrogen, LVEF, and NT-ProBNP were independent factors for in-hospital MACE after PCI in STEMI patients; a nomogram model for predicting the risk of in-hospital MACE after PCI in STEMI patients was constructed with the above independent predictors, with a C-index of 0.826 (95% CI: 0.785-0.868) having a good predictive power; the results of H-L goodness of fit test showed χ² = 1.3328, P = 0.25, the model calibration curve was close to the ideal model, and the internal validation C-index was 0.818; clinical decision analysis also showed that the nomogram model had a good clinical efficacy, especially when the threshold probability was 0.1-0.99, the nomogram model could bring clinical net benefits to patients. The nomogram model predicted a greater AUC (0.826) than the TIMI score (0.696) for in-hospital MACE after PCI in STEMI patients.

Conclusion

Urea nitrogen, Killip class II-IV, LVEF, and NT-ProBNP are independent factors for in-hospital MACE after PCI in STEMI patients, and nomogram models constructed based on the above factors have high predictive efficacy and feasibility.

Influence of Short and Long Hyperglycemia on Cardioprotection by Remote Ischemic Preconditioning-A Translational Approach

The adverse impact of common diseases like diabetes mellitus and acute hyperglycemia on morbidity and mortality from myocardial infarction (MI) has been well documented over the past years of research. In the clinical setting, the relationship between blood glucose and mortality appears linear, with amplifying risk associated with increasing blood glucose levels. Further, this seems to be independent of a diagnosis of diabetes. In the experimental setting, various comorbidities seem to impact ischemic and pharmacological conditioning strategies, protecting the heart against ischemia and reperfusion injury. In this translational experimental approach from bedside to bench, we set out to determine whether acute and/or prolonged hyperglycemia have an influence on the protective effect of transferred human RIPC-plasma and, therefore, might obstruct translation into the clinical setting. Control and RIPC plasma of young healthy men were transferred to isolated hearts of young male Wistar rats in vitro. Plasma was administered before global ischemia under either short hyperglycemic (HGs Con, HGs RIPC) conditions, prolonged hyperglycemia (HGl Con, HGl RIPC), or under normoglycemia (Con, RIPC). Infarct sizes were determined by TTC staining. Control hearts showed an infarct size of 55 ± 7%. Preconditioning with transferred RIPC plasma under normoglycemia significantly reduced infarct size to 25 ± 4% (p < 0.05 vs. Con). Under acute hyperglycemia, control hearts showed an infarct size of 63 ± 5%. Applying RIPC plasma under short hyperglycemic conditions led to a significant infarct size reduction of 41 ± 4% (p < 0.05 vs. HGs Con). However, the cardioprotective effect of RIPC plasma under normoglycemia was significantly stronger compared with acute hyperglycemic conditions (RIPC vs. HGs RIPC; p < 0.05). Prolonged hyperglycemia (HGl RIPC) completely abolished the cardioprotective effect of RIPC plasma (infarct size 60 ± 7%; p < 0.05 vs. HGl Con; HGl Con 59 ± 5%).

Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry

Importance

Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear.

Objective

To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US.

Design, Setting, and Participants

This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis.

Main Outcomes and Measures

In-hospital mortality and time-to-reperfusion metrics.

Results

This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06).

Conclusions and Relevance

In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

Incidence and Predictors of Adverse Events Among Initially Stable ST-Elevation Myocardial Infarction Patients Following Primary Percutaneous Coronary Intervention

Background

Cardiac intensive care units were originally created in the prerevascularization era for the early recognition of ventricular arrhythmias following a myocardial infarction. Many patients with stable ST‐segment–elevation myocardial infarction (STEMI) are still routinely triaged to cardiac intensive care units after a primary percutaneous coronary intervention (pPCI), independent of clinical risk or the provision of critical care therapies. The aim of this study was to determine factors associated with in‐hospital adverse events in a hemodynamically stable, postreperfusion population of patients with STEMI.

Methods and Results

Between April 2012 and November 2019, 2101 consecutive patients with STEMI who received pPCI in the Vancouver Coastal Health Authority were evaluated. Patients were stratified into those with and without subsequent adverse events, which were defined as cardiogenic shock, in‐hospital cardiac arrest, stroke, re‐infarction, and death. Multivariable logistic regression models were used to determine predictors of adverse events. After excluding patients presenting with cardiac arrest, cardiogenic shock, or heart failure, the final analysis cohort comprised 1770 stable patients with STEMI who had received pPCI. A total of 94 (5.3%) patients developed at least one adverse event: cardiogenic shock 55 (3.1%), in‐hospital cardiac arrest 42 (2.4%), death 28 (1.6%), stroke 21 (1.2%), and re‐infarction 5 (0.3%). Univariable predictors of adverse events were older age, female sex, prior stroke, chronic kidney disease, and atrial fibrillation. There was no significant difference in reperfusion times between those with and without adverse events. Following multivariable adjustment, moderate to severe chronic kidney disease (creatinine clearance <44 mL/min; 13% of cohort) was associated with adverse events (odds ratio 2.24 [95% CI, 1.12–4.48]) independent of reperfusion time, age, sex, smoking status, hypertension, diabetes, and prior myocardial infarction/PCI/coronary artery bypass grafting.

Conclusions

Only 1 in 20 initially stable patients with STEMI receiving pPCI developed an in‐hospital adverse event. Moderate to severe chronic kidney disease independently predicted the risk of future adverse events. These results indicate that the majority of patients with STEMI who receive pPCI may not require routine admission to a cardiac intensive care unit following reperfusion.

The Value of Different Short-Term Risk Scoring Models in Predicting Long-Term Death of Acute Myocardial Infarction

Background and aims: To compare the value of three commonly used cardiovascular short-term risk scoring models, the GRACE score, TIMI score, and HEART score, in predicting the long-term prognosis of patients with acute myocardial infarction. Methods: The hospitalization data of patients who were hospitalized in West China Hospital of Sichuan University from 2011 to 2013 and diagnosed with acute myocardial infarction (AMI) were collected. The patients were scored by GRACE score, TIMI score, and HEART score. The long-term follow-up of patients was conducted until the end of January 2021. All-cause death and time of death of patients were confirmed by telephone follow-up, electronic medical record query, and household registration information. The predictive ability of different risk scores for long-term prognosis was compared according to the receiver operating characteristic (ROC) area under the curve (AUC), and the ability to distinguish patients with different risk levels was compared according to Kaplan−Meier survival curves. Results: The study ultimately included 2220 patients, with a median follow-up of 8 years and 454 (20.5%) deaths until the end of follow-up. Whether in ST-segment elevation myocardial infarction (STEMI) patients or non-ST-segment elevation myocardial infarction (NSTEMI) patients, the AUC value of the GRACE score (both AUC = 0.734) was significantly higher than the TIMI score (AUC = 0.675, p < 0.01; AUC = 0.665, p < 0.01) and HEART score (AUC = 0.632, p < 0.01; AUC = 0.611, p < 0.01) until the end of follow-up. In terms of risk stratification, the Kaplan−Meier survival curve shows that both THE GRACE score and TIMI score can distinguish AMI patients with different risk levels (p < 0.01), but the risk stratification ability of the HEART score in AMI patients was poor (p > 0.05). Conclusion: The GRACE risk score could represent a more accurate model to assess long-term death of acute myocardial infarction, but further studies are required.

High Rates of Recurrent Revascularization in Acute Limb Ischemia - a National Surgical Quality Improvement Program Study

OBJECTIVES

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI.

METHODS

A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012-2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection.

RESULTS

2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. 13.8% required reoperation and 7.9% required readmission within 30 days. 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. 58.7% of patients were female and either overweight or obese. Younger age (OR 0.991 [0.984-0.999], p=0.02), underweight patients (OR 1.159 [0.667-2.01], p=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], p=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], p=0.04) predicted reoperations.

CONCLUSIONS

This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.

Demographics and Characteristics of Patients Admitted With Acute Coronary Syndrome to the Coronary Care Unit at King Abdulaziz University

Background

Over the previous decade, the incidence of cardiovascular diseases (CVDs) has risen in the Middle East and will increase mortality to 23 million individuals in Saudi Arabia by 2030, according to the Saudi Ministry of Health. CVDs, including acute coronary syndrome (ACS), are the most common cause of mortality globally. This study aimed to analyze the demographic and clinical characteristics of patients with ACS admitted to the coronary care unit (CCU) in a tertiary hospital in Jeddah, Saudi Arabia. To the best of our knowledge, a lack of research in this region has been undertaken.

Methods

This retrospective records review study was conducted in a tertiary center in Jeddah, Saudi Arabia. All patients admitted to our CCU in 2017 with a final diagnosis of ACS were retrospectively enrolled. Demographic details, coronary risk factors, investigation and procedures, management, and clinical outcomes are all part of the data.

Results

Of the 615 patients included in the study, 491 (79.84%) were males, 226 (36.75%) were 55-64 years old, and 161 (26.18%) were 45-54 years old. Males had a higher rate of ST-segment elevation myocardial infarction (STEMI) (214, 43.58%), while females had a higher rate of non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) (45.96% and 37.90%, respectively). Diabetes (62.60%), dyslipidemia (62.44%), and hypertension (61.46%) were the most prevalent risk factors. Angiography and percutaneous coronary intervention (PCI) were performed in 77.72% and 61.95% of patients, respectively. Coronary artery bypass graft was only performed in 4.39% of patients. PCI was performed more frequently in patients with STEMI than in those with NSTEMI/UA (P < 0.001). A large majority of patients (99.5%) recovered and were discharged. Of the 161 (26.18%) patients who attended a follow-up visit, only 45 (33.08%) met the therapeutic objective of 1.8 mmol/L (70 mg/dl) of low-density lipoprotein cholesterol. There were 100 (16.26%) patients readmitted to the CCU, and most of these were readmitted within a year after initial admission. Readmissions were more common in females and patients diagnosed with NSTEMI/UA during initial admission (15.47% and 19.35%, respectively).

Conclusion

This study revealed that our most common demographics were males between 45 and 64 years, which is a decade younger than the global average. STEMI was the most common presentation. The most common modifiable cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. The most common adverse event was reinfarction, which was closely linked to hypertension and diabetes. In this study, the recovery rate was higher than in studies from other countries; however, the majority of patients did not achieve the goal of cholesterol levels at follow-up. Our population's younger age at presentation necessitates greater attention and more stringent preventive strategies, such as lifestyle changes and evidence-based treatments for CVD risk factors, to reduce the incidence and burden of ACS on CCUs.

Aspirin to target arterial events in chronic kidney disease (ATTACK): study protocol for a multicentre, prospective, randomised, open-label, blinded endpoint, parallel group trial of low-dose aspirin vs. standard care for the primary prevention of cardiovascular disease in people with chronic kidney disease

Background

Chronic kidney disease (CKD) is a very common long-term condition and powerful risk factor for cardiovascular disease (CVD).

Low-dose aspirin is of proven benefit in the secondary prevention of myocardial infarction (MI) and stroke in people with pre-existing CVD. However, in people without CVD, the rates of MI and stroke are much lower, and the benefits of aspirin in the primary prevention of CVD are largely balanced by an increased risk of bleeding.

People with CKD are at greatly increased risk of CVD and so the absolute benefits of aspirin are likely to be greater than in lower-risk groups, even if the relative benefits are the same. Post hoc evidence suggests the relative benefits may be greater in the CKD population but the risk of bleeding may also be higher. A definitive study of aspirin for primary prevention in this high-risk group, recommended by the National Institute for Health and Care Excellence (NICE) in 2014, has never been conducted. The question has global significance given the rising burden of CKD worldwide and the low cost of aspirin.

Methods

ATTACK is a pragmatic multicentre, prospective, randomised, open-label, blinded endpoint adjudication superiority trial of aspirin 75 mg daily vs. standard care for the primary prevention of CVD in 25,210 people aged 18 years and over with CKD recruited from UK Primary Care.

Participants aged 18 years and over with CKD (GFR category G1-G4) will be identified in Primary Care and followed up using routinely collected data and annual questionnaires for an average of 5 years. The primary outcome is the time to first major vascular event (composite of non-fatal MI, non-fatal stroke and cardiovascular death [excluding confirmed intracranial haemorrhage and other fatal cardiovascular haemorrhage]). Deaths from other causes (including fatal bleeding) will be treated as competing events. The study will continue until 1827 major vascular events have occurred. The principal safety outcome is major intracranial and extracranial bleeding; this is hypothesised to be increased in those randomised to take aspirin. The key consideration is then whether and to what extent the benefits of aspirin from the expected reduction in CVD events exceed the risks of major bleeding.

Discussion

This will be the first definitive trial of aspirin for primary CVD prevention in CKD patients. The research will be of great interest to clinicians, guideline groups and policy-makers, in the UK and globally, particularly given the high and rising prevalence of CKD that is driven by population ageing and epidemics of obesity and diabetes. The low cost of aspirin means that a positive result would be of relevance to low- and middle-income countries and the impact in the developed world less diluted by any inequalities in health care access.

Trial registration

ISRCTN: ISRCTN40920200. EudraCT: 2018-000644-26. ClinicalTrials.gov: NCT03796156

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06132-z.

Coronary Artery and Cardiac Disease in Patients With Type 2 Myocardial Infarction: A Prospective Cohort Study

BACKGROUND

Type 2 myocardial infarction is caused by myocardial oxygen supply-demand imbalance, and its diagnosis is increasingly common with the advent of high-sensitivity cardiac troponin assays. Although this diagnosis is associated with poor outcomes, widespread uncertainty and confusion remain among clinicians as to how to investigate and manage this heterogeneous group of patients with type 2 myocardial infarction.

METHODS

In a prospective cohort study, 8064 consecutive patients with increased cardiac troponin concentrations were screened to identify patients with type 2 myocardial infarction. We excluded patients with frailty or renal or hepatic failure. All study participants underwent coronary (invasive or computed tomography angiography) and cardiac (magnetic resonance or echocardiography) imaging, and the underlying causes of infarction were independently adjudicated. The primary outcome was the prevalence of coronary artery disease.

RESULTS

In 100 patients with a provisional diagnosis of type 2 myocardial infarction (median age, 65 years [interquartile range, 55-74 years]; 43% women), coronary and cardiac imaging reclassified the diagnosis in 7 patients: type 1 or 4b myocardial infarction in 5 and acute myocardial injury in 2 patients. In those with type 2 myocardial infarction, median cardiac troponin I concentrations were 195 ng/L (interquartile range, 62-760 ng/L) at presentation and 1165 ng/L (interquartile range, 277-3782 ng/L) on repeat testing. The prevalence of coronary artery disease was 68% (63 of 93), which was obstructive in 30% (28 of 93). Infarct-pattern late gadolinium enhancement or regional wall motion abnormalities were observed in 42% (39 of 93), and left ventricular systolic dysfunction was seen in 34% (32 of 93). Only 10 patients had both normal coronary and normal cardiac imaging. Coronary artery disease and left ventricular systolic dysfunction were previously unrecognized in 60% (38 of 63) and 84% (27 of 32), respectively, with only 33% (21 of 63) and 19% (6 of 32) on evidence-based treatments.

CONCLUSIONS

Systematic coronary and cardiac imaging of patients with type 2 myocardial infarction identified coronary artery disease in two-thirds and left ventricular systolic dysfunction in one-third of patients. Unrecognized and untreated coronary or cardiac disease is seen in most patients with type 2 myocardial infarction, presenting opportunities for initiation of evidence-based treatments with major potential to improve clinical outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03338504.

Cardioprotective Properties of Humoral Factors Released after Remote Ischemic Preconditioning in CABG Patients with Propofol-Free Anesthesia-A Translational Approach from Bedside to Bench

The cardioprotective effect of remote ischemic preconditioning (RIPC) is well detectable in experimental studies but not in clinical trials. Propofol, a commonly used sedative, is discussed to negatively influence the release of humoral factors after RIPC. Further, results from experimental and clinical trials suggest various comorbidities interact with inducible cardioprotective properties of RIPC. In the present study, we went back from bedside to bench to investigate, in male patients undergoing CABG surgery, whether (1) humoral factors are released after RIPC during propofol-free anesthesia and/or (2) DM interacts with plasma factor release. Blood samples were taken from male patients with and without DM undergoing CABG surgery before (control) and after RIPC (RIPC). To investigate the release of cardioprotective humoral factors into the plasma, isolated perfused hearts of young rats (n = 5 per group) were used as a bioassay. The hearts were perfused with patients’ plasma without (Con) and with RIPC (RIPC) for 10 min (1% of coronary flow) before global ischemia and reperfusion. In additional groups, the plasma of patients with DM was administered (Con DM, RIPC DM). Infarct size was determined by TTC staining. Propofol-free RIPC plasma of male patients without DM showed an infarct size of 59 ± 5% compared to 61 ± 13% with Con plasma (p = 0.973). Infarct sizes from patients with DM showed similar results (RIPC DM: 55 ± 3% vs. Con DM: 56 ± 4%; p = 0.995). The release of humoral factors into the blood after RIPC in patients receiving propofol-free anesthesia undergoing CABG surgery did not show any cardioprotective properties independent of a pre-existing diabetes mellitus.

Targeting CaMKII-δ9 Ameliorates Cardiac Ischemia/Reperfusion Injury by Inhibiting Myocardial Inflammation

BACKGROUND

CaMKII (Ca²⁺/calmodulin-dependent kinase II) plays a central role in cardiac ischemia/reperfusion (I/R) injury-an important therapeutic target for ischemic heart disease. In the heart, CaMKII-δ is the predominant isoform and further alternatively spliced into 11 variants. In humans, CaMKII-δ9 and CaMKII-δ3, the major cardiac splice variants, inversely regulate cardiomyocyte viability with the former pro-death and the latter pro-survival. However, it is unknown whether specific inhibition of the detrimental CaMKII-δ9 prevents cardiac I/R injury and, if so, what is the underlying mechanism. Here, we aim to investigate the cardioprotective effect of specific CaMKII-δ9 inhibition against myocardial I/R damage and determine the underlying mechanisms.

METHODS

The role and mechanism of CaMKII-δ9 in cardiac I/R injury were investigated in mice in vivo, neonatal rat ventricular myocytes, and human embryonic stem cell-derived cardiomyocytes.

RESULTS

We demonstrate that CaMKII-δ9 inhibition with knockdown or knockout of its feature exon, exon 16, protects the heart against I/R-elicited injury and subsequent heart failure. I/R-induced cardiac inflammation was also ameliorated by CaMKII-δ9 inhibition, and compared with the previously well-studied CaMKII-δ2, CaMKII-δ9 overexpression caused more profound cardiac inflammation. Mechanistically, in addition to IKKβ (inhibitor of NF-κB [nuclear factor-κB] kinase subunit β), CaMKII-δ9, but not δ2, directly interacted with IκBα (NF-κB inhibitor α) with its feature exon 13-16-17 combination and increased IκBα phosphorylation and consequently elicited more pronounced activation of NF-κB signaling and inflammatory response. Furthermore, the essential role of CaMKII-δ9 in myocardial inflammation and damage was confirmed in human cardiomyocytes.

CONCLUSIONS

We not only identified CaMKII-δ9-IKK/IκB-NF-κB signaling as a new regulator of human cardiomyocyte inflammation but also demonstrated that specifically targeting CaMKII-δ9, the most abundant CaMKII-δ splice variant in human heart, markedly suppresses I/R-induced cardiac NF-κB activation, inflammation, and injury and subsequently ameliorates myocardial remodeling and heart failure, providing a novel therapeutic strategy for various ischemic heart diseases.

Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome

BACKGROUND

Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months.

RESULTS

The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month.

CONCLUSIONS

The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.

Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks' daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5-7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from - 16.2 ± 5.2 at baseline to - 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from - 15.5 ± 4.0 to - 15.2 ± 4.7, p = 0.81; for change: - 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (- 1.2 ± 4.4 versus - 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611 .

Safe Triage of STEMI Patients to General Telemetry Units After Successful Primary Percutaneous Coronary Intervention

Objective

To analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm.

Methods

We introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival.

Results

We identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P<.001). Two patients initially admitted to general telemetry required transfer to the CICU. There were 26 patients who required unplanned cardiovascular intervention within 30 days, 5 from the general telemetry unit; 540 patients survived to discharge. One in-hospital death occurred among those initially triaged to the general telemetry unit, and this was due to a noncardiac cause.

Conclusion

A Zwolle score–based algorithm can be used to safely triage post-PCI STEMI patients to a general telemetry unit.

CircRNA circ-NNT mediates myocardial ischemia/reperfusion injury through activating pyroptosis by sponging miR-33a-5p and regulating USP46 expression

Pyroptosis has been implicated in the pathophysiology of myocardial infarction (MI) in rodents, but its contribution to reperfusion injury in MI patients is unclear. Here, we evaluated pyroptosis in MI patients in vitro and in vivo models of myocardial ischemia/reperfusion (I/R) injury. We also investigated the molecular mechanisms that regulate pyroptosis and myocardial I/R injury in these in vitro and in vivo models. The study showed that MI patients exhibited elevated serum concentrations of the pyroptosis-related pro-inflammatory cytokines IL-1β and IL-18. Increased levels of IL-1β and IL-18 as well as the pyroptosis-related inflammatory caspases (caspase-1 and 11) were detected in cultured cardiomyocytes after anoxia/reoxygenation (A/R) and in cardiac tissues after I/R. Circ-NNT and USP46 were upregulated while miR-33a-5p was downregulated in MI patients, as well as in cultured cardiomyocytes after A/R and cardiac tissues after I/R. Circ-NNT or USP46 knockdown or miR-33a-5p overexpression inhibited the expression of pro-caspase-1, cleaved caspase-1, pro-caspase-11, cleaved caspase-11, IL-1β, and IL-18 in A/R cardiomyocytes and attenuated myocardial infarction in I/R mice. The results from luciferase reporter assays and gene overexpression/knockdown studies indicated that miR-33a-5p directly targets USP46, and circ-NNT regulates USP46 by acting as a miR-33a-5p sponge. Direct association between circ-NNT and miR-33a-5p in cardiomyocytes was confirmed by pull-down assays. In summary, pyroptosis is activated during myocardial I/R and contributes to reperfusion injury. Circ-NNT promotes pyroptosis and myocardial I/R injury by acting as a miR-33a-5p sponge to regulate USP46. This circ-NNT→miR-33a-5p→USP46 signaling axis may serve as a potential target for the development of cardio-protective agents to improve the clinical outcome of reperfusion therapy.

National Trends and Disparities in Hospitalization for Acute Hypertension Among Medicare Beneficiaries (1999-2019)

BACKGROUND

In the past 2 decades, hypertension control in the US population has not improved and there are widening disparities. Little is known about progress in reducing hospitalizations for acute hypertension.

METHODS

We conducted serial cross-sectional analysis of Medicare fee-for-service beneficiaries age 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files. We evaluated trends in national hospitalization rates for acute hypertension overall and by demographic and geographical subgroups. We identified all beneficiaries admitted with a primary discharge diagnosis of acute hypertension on the basis of International Classification of Diseases codes. We then used a mixed effects model with a Poisson link function and state-specific random intercepts, adjusting for age, sex, race and ethnicity, and dual-eligible status, to evaluate trends in hospitalizations.

RESULTS

The sample consisted of 397 238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for acute hypertension increased significantly, from 51.5 to 125.9 per 100 000 beneficiary-years; the absolute increase was most pronounced among the following subgroups: adults ≥85 years (66.8-274.1), females (64.9-160.1), Black people (144.4-369.5), and Medicare/Medicaid insured (dual-eligible, 93.1-270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Black and White people from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South. Among patients hospitalized for acute hypertension, the observed 30-day and 90-day all-cause mortality rates (95% CI) decreased from 2.6% (2.27-2.83) and 5.6% (5.18-5.99) to 1.7% (1.53-1.80) and 3.7% (3.45-3.84) and 30-day and 90-day all-cause readmission rates decreased from 15.7% (15.1-16.4) and 29.4% (28.6-30.2) to 11.8% (11.5-12.1) and 24.0% (23.5-24.6).

CONCLUSIONS

Among Medicare fee-for-service beneficiaries age 65 years or older, hospitalization rates for acute hypertension increased substantially and significantly from 1999 to 2019. Black adults had the highest hospitalization rate in 2019 across age, sex, race and ethnicity, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South.

Genetic blockade of lymphangiogenesis does not impair cardiac function after myocardial infarction

In recent decades, treatments for myocardial infarction (MI), such as stem and progenitor cell therapy, have attracted considerable scientific and clinical attention but failed to improve patient outcomes. These efforts indicate that more rigorous mechanistic and functional testing of potential MI therapies is required. Recent studies have suggested that augmenting post-MI lymphatic growth via VEGF-C administration improves cardiac function. However, the mechanisms underlying this proposed therapeutic approach remain vague and untested. To more rigorously test the role of lymphatic vessel growth after MI, we examined the post-MI cardiac function of mice in which lymphangiogenesis had been blocked genetically by pan-endothelial or lymphatic endothelial loss of the lymphangiogenic receptor VEGFR3 or global loss of the VEGF-C and VEGF-D ligands. The results obtained using all three genetic approaches were highly concordant and demonstrated that loss of lymphatic vessel growth did not impair left ventricular ejection fraction two weeks after MI in mice. We observed a trend toward excess fluid in the infarcted region of the left ventricle, but immune cell infiltration and clearance were unchanged with loss of expanded lymphatics. These studies refute the hypothesis that lymphangiogenesis contributes significantly to cardiac function after MI, and suggest that any effect of exogenous VEGF-C is likely to be mediated by non-lymphangiogenic mechanisms.

Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment-Elevation Myocardial Infarction: Insights From the COMPLETE Trial

[Figure: see text].

Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation

BACKGROUND

Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value.

OBJECTIVES

This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events.

METHODS

Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services.

RESULTS

Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending.

CONCLUSIONS

Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.

Combination of Cyclosporine A and Levosimendan Induces Cardioprotection under Acute Hyperglycemia

Prognosis of patients with myocardial infarction is detrimentally affected by comorbidities like diabetes mellitus. In the experimental setting, not only diabetes mellitus but also acute hyperglycemia is shown to hamper cardioprotective properties by multiple pharmacological agents. For Levosimendan-induced postconditioning, a strong infarct size reducing effect is demonstrated in healthy myocardium. However, acute hyperglycemia is suggested to block this protective effect. In the present study, we investigated whether (1) Levosimendan-induced postconditioning exerts a concentration-dependent effect under hyperglycemic conditions and (2) whether a combination with the mitochondrial permeability transition pore (mPTP) blocker cyclosporine A (CsA) restores the cardioprotective properties of Levosimendan under hyperglycemia. For this experimental investigation, hearts of male Wistar rats were randomized and mounted onto a Langendorff system, perfused with Krebs-Henseleit buffer with a constant pressure of 80 mmHg. All isolated hearts were subjected to 33 min of global ischemia and 60 min of reperfusion under hyperglycemic conditions. (1) Hearts were perfused with various concentrations of Levosimendan (Lev) (0.3–10 μM) for 10 min at the onset of reperfusion, in order to investigate a concentration–response relationship. In the second set of experiments (2), 0.3 μM Levosimendan was administered in combination with the mPTP blocker CsA, to elucidate the underlying mechanism of blocked cardioprotection under hyperglycemia. Infarct size was determined by tetrazolium chloride (TTC) staining. (1) Control (Con) hearts showed an infarct size of 52 ± 12%. None of the administered Levosimendan concentrations reduced the infarct size (Lev0.3: 49 ± 9%; Lev1: 57 ± 9%; Lev3: 47 ± 11%; Lev10: 50 ± 7%; all ns vs. Con). (2) Infarct size of Con and Lev0.3 hearts were 53 ± 4% and 56 ± 2%, respectively. CsA alone had no effect on infarct size (CsA: 50 ± 10%; ns vs. Con). The combination of Lev0.3 and CsA (Lev0.3 ± CsA) induced a significant infarct size reduction compared to Lev0.3 (Lev0.3+CsA: 35 ± 4%; p < 0.05 vs. Lev0.3). We demonstrated that (1) hyperglycemia blocks the infarct size reducing effects of Levosimendan-induced postconditioning and cannot be overcome by an increased concentration. (2) Furthermore, cardioprotection under hyperglycemia can be restored by combining Levosimendan and the mPTP blocker CsA.

Cardioprotection of Panax Notoginseng saponins against acute myocardial infarction and heart failure through inducing autophagy

Morbidity and mortality from acute myocardial infarction (AMI) remains substantial although interventional coronary reperfusion strategies are widely use and successful. MI remains the most common cause of heart failure (HF) worldwide. Here we demonstrated that Panax Notoginseng saponins (PNS), the extract of Panax notoginseng, exerts cardioprotective effect in AMI and the underlying mechanism refers to inducing cardiomyocyte autophagy, antiplatelet aggregation, enhancing endothelial migration and angiogenesis. PNS was initially tested to rescue the myocardial infarct size and cardiac function in left anterior descending (LAD) ligation-operated mice to mimic AMI. RNA-seq to profile transcriptome changes in the heart by treatment with PNS were then conducted. PNS and its main constituents Rg1 and Rd directly inhibited platelet aggregation of healthy subjects with VerifyNow Aspirin and P2Y12 assays but less affecting on coagulation compared with dual-antiplatelet (DAPT). In addition, wound healing scratch assay and heart staining demonstrated that PNS and its main constituents Rg1 and R1 significant enhanced the migration of endothelial cells and angiogenesis in response to MI injury. Interestingly, PNS rather than its constituents enhanced glucose deprivation (GD)-induced autophagy through phosphorylation of AMPK Thr172 and CaMKII Thr287 in cardiomyocytes. These findings provide new insights for drug development from natural products like PNS against ischemia heart diseases and HF post MI.

The Impact of COVID-19 Pandemic on the Presentation and Hospital Management of STEMI Patients in a Tertiary Care Center in Saudi Arabia

Background:

The COVID-19 Pandemic has put enormous pressure on the healthcare system globally, causing many healthcare organizations to cancel elective admission for coronary angiograms. The purpose of this study is to assess changes in ST segment elevation myocardial infarction (STEMI) practice, including the number of patients, door to balloon time and time from the onset of symptoms until reperfusion therapy in a tertiary center in Saudi Arabia.

Methods:

This is a single center retrospective observational study, comparing all STEMI patients in the last five months of 2019 (Pre-COVID-19 period) with the first 5 months of 2020 (COVID -19 period) in regards to the volume of STEMI patients, symptoms onset to ER arrival time, door to balloon timing and the reperfusion therapy strategy.

Results:

A total number of 173 STEMI patients were analyzed; 81 STEMI patients in the Pre-COVID-19 period and 92 STEMI patients in the COVID-19 period. When compared with pre-COVID period, there was a statistically non-significant increase in STEMI patients (12%), slight delay in the door to balloon timing; 94 vs 87 minutes. As well, there was more delay from onset of symptoms to presentation to the ER (>12 hours from symptoms onset to ER arrival (16% vs, 4% in group 1). Primary percutaneous coronary intervention (PPCI) was the main modality between the 2 groups without significant differences (100% Pre-COVID vs. 97% COVID-19 period).

Conclusion:

There was some delay of STEMI patient's presentation to the hospital during Covid-19 timing, without significant changes in the medical practice of care.

Clinical outcomes of patients with diabetes mellitus and acute ST-elevation myocardial infarction following fibrinolytic therapy: a nationwide inpatient sample (NIS) database analysis

The impact of diabetes mellitus (DM) on clinical outcomes of acute ST-segment elevation myocardial infarction (STEMI) following fibrinolytic therapy remains uncertain. We queried the National Inpatient Sample (NIS) for STEMI patients who received fibrinolytic therapy. Categorical and continuous variables were compared using the unadjusted odds ratio (uOR) and t-test analysis, respectively. A binary logistic regression model was used to control the outcomes for patient demographics, procedural characteristics, and baseline comorbidities. A total of 111,155 (no-DM 84,146, DM 27,009) were included. The unadjusted odds of in-hospital mortality (8.4% vs. 6.8%, uOR 1.25, 95% CI 1.19-1.31, P = <0.0001) and cardiogenic shock (7.7% vs. 6.2%, uOR 1.26, 95% CI 1.20-1.33, P = <0.0001) were significantly higher in patients with DM compared to those with no DM, respectively. The odds for major bleeding and cardiopulmonary arrest were significantly lower for in diabetes. The adjusted pooled estimates mirrored the unadjusted findings. Diabetic patients receiving fibrinolytic therapy for STEMI might have higher odds of all-cause mortality and cardiogenic shock compared to non-diabetic patients.

Anabolic Steroid-Induced Myocardial Infarction in a Young Male

Misuse of androgenic-anabolic steroids (AAS) has been well known to increase the risk for a cardiac problem, including acute myocardial infarction (MI). Steroids once thought a magic drug providing immediate relief to patients, also have a darker aspect of its severe side effects. AAS are widely used these days, especially in teenagers, bodybuilders, and athletes. MI is thought to be a disease of old age, but young patients with MI without risk factors draw attention to the possibility of drugs such as cocaine, AAS abuse, and amphetamine.  In this article, we report the case of a 38-year-old African-American male, with a history of AAS abuse, who arrived at the emergency department with complaints of severe chest pain radiating to the left arm. An electrocardiogram (ECG) revealed ST-elevation MI (STEMI) and elevated troponin. The patient was transferred to the cardiac catheterization lab for an emergent catheterization which showed 100% stenosis of the left anterior descending artery and a drug-eluting stent was placed. An echocardiogram showed an ejection fraction of 35%. All blood workup was negative. The patient was discharged on aspirin, ticagrelor, statin, ACE inhibitor, and B-blocker after three days. Chest pain in a young patient population secondary to MI is not uncommon these days and the most important thing to evaluate is drug history, including AAS use. Athletes, bodybuilders, and others who use steroids or other drugs that are responsible for MI should be under the supervision of physicians so that the complications of steroids are ascertained, and if steroids are needed for any medical illness, proper dosage and follow-up should be emphasized. Therefore, while taking history from a patient, it is essential for physicians to be aware of this association of steroids with coronary artery disease.

Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India

Background

Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome.

Methods

We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018–June 2019).

Results

The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR−3.306 C.I. 1.87–5.845), severe MR (OR−4.65, C.I.−1.187–18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.−2.5–10.63), higher Killip class (class III/IV) (OR−3.378,C.I.−1.292–8.849), AF (OR−3.25, C.I.−1,18–8.92), complete heart block (CHB) (OR−4.44,C.I.−2.09–9.43) and right bundle branch block (RBBB) (OR−2.86, C.I.−1.2–6.8) were significant predictors of in hospital mortality.

Conclusions

Our study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.

Hospitalization for Acute Myocardial Infarction: A Population-Based Registry

Fundamento:

O infarto agudo do miocárdio com supradesnivelamento do segmento ST (STEMI) é uma das principais apresentações clínicas da cardiopatia isquêmica. Dados de base populacional são relevantes para entendimento contemporâneo da epidemiologia da doença.

Objetivo:

Descrever incidência, manejo terapêutico, desfechos clínicos hospitalares e eventos cardiovasculares do primeiro ano de seguimento dos indivíduos hospitalizados por STEMI.

Métodos:

Estudo de coorte prospectiva de base populacional com registro consecutivo das hospitalizações por STEMI em uma cidade do Sul do Brasil entre 2011 e 2014. Foram incluídos indivíduos com STEMI que apresentaram sintomas de isquemia miocárdica aguda nas últimas 72 horas. Os valores de p < 0,05 foram considerados significativos.

Resultados:

A incidência anual de hospitalizações por STEMI foi de 108 casos por 100.000 habitantes. A incidência ajustada foi maior entre os mais velhos (risco relativo 64,9; IC95% 26,9 – 156,9; p para tendência linear < 0,001) e entre os homens (risco relativo 2,8; IC95% 2,3 – 3,3; p < 0,001). Ocorreram 530 hospitalizações durante o período avaliado e a taxa de reperfusão foi de 80,9%. A mortalidade hospitalar e a taxa de eventos cardiovasculares em 1 ano foram, respectivamente, 8,9% e 6,1%. Os mais velhos apresentaram maior mortalidade hospitalar (risco relativo 3,72; IC95% 1,57 – 8,82; p para tendência linear = 0,002) e mais eventos cardiovasculares em 1 ano (hazard ratio 2,35; IC95% 1,12 – 4,95; p = 0,03).

Conclusão:

Este registro demonstra abordagem terapêutica e mortalidade hospitalar semelhante às observadas em países desenvolvidos. Entretanto, a taxa de hospitalizações foi maior comparada com esses países.

Is two-dimensional echocardiography better than electrocardiography for predicting patient outcomes after cardiac arrest?

BACKGROUND

Coronary artery stenosis increases hospital mortality and leads to poor neurological recovery in cardiac arrest (CA) patients. However, electrocardiography (ECG) cannot fully predict the presence of coronary artery stenosis in CA patients. Hence, we aimed to determine whether regional wall motion abnormality (RWMA), as observed by two-dimensional echocardiography (2DE), predicted patient survival outcomes with greater accuracy than did ST segment elevation (STE) on ECG in CA patients who underwent coronary angiography (CAG) after return of spontaneous circulation.

METHODS

This was a retrospective observational study of adult patients with CA of presumed cardiac etiology who underwent CAG at a single tertiary care hospital. We investigated whether RWMA observed on 2DE predicted patient outcomes more accurately than did STE observed on ECG. The primary outcome was incidence of hospital mortality. The secondary outcomes were Glasgow-Pittsburgh Cerebral Performance Category scores measured 6 months after discharge and significant coronary artery stenosis on CAG.

RESULTS

Among the 145 patients, 36 (24.8%) experienced in-hospital death. In multivariable analysis of survival outcomes, only total arrest time (P=0.011) and STE (P=0.035) were significant. The odds ratio (OR) and 95% confidence interval (CI), which were obtained by adjusting the total arrest time for survival outcomes, were significant only for STE (OR, 0.40; 95% CI, 0.17-0.94). The presence of RWMA was not a significant factor.

CONCLUSIONS

While STE predicted survival outcomes in adult CA patients, RWMA did not. The decision to perform CAG after CA should include ECG under existing guidelines. The use of RWMA has limited benefits in treatment of this population.

Delirium is an important predictor of mortality in elderly patients with ST-elevation myocardial infarction: insight from National Inpatient Sample database

OBJECTIVE

Delirium is a frequently encountered clinical condition in hospitalized patients and is known to be associated with poor outcomes. This study aims to assess the impacts of delirium in elderly patients undergoing percutaneous coronary intervention (PCI) following ST-elevation myocardial infarction (STEMI).

METHODS

We queried the National Inpatient Samples from 2010 to 2014 to identify all patients aged 65 and older, and admitted with a primary diagnosis of STEMI undergoing PCI by using the International Classification of Diseases-Ninth Edition-Clinical Modification diagnosis codes. The patients with delirium from this cohort were further evaluated. Multivariate regression model with SPSS Statistics 25.0 (IBM Corp., Armonk, New York, USA) was used to study the association between delirium and clinical outcomes including in-hospital mortality and length of stay (LOS).

RESULTS

Out of weighted 42 980 patients aged ≥65 years with STEMI and PCI, delirium was present in 774 patients, accounting for 1.8% of this cohort. These patients were found to be older and had more underlying co-morbidities, compared to those without delirium [Median Charlson score 2 (1; 3) vs. 0 (0; 2); P < 0.001]. In-hospital mortality in STEMI patients with delirium was significantly higher than those without delirium [42.7% vs. 7.6%; unadjusted odds ratio (OR) 9.07; 95% confidence interval (CI) 6.55-12.57; P < 0.001; adjusted OR 1.86; 95% CI 1.13-3.04; P = 0.014].

CONCLUSION

Older age and comorbidities are known predisposing factors for delirium, which is in turn associated with higher in-hospital mortality and increased LOS in elderly patients with STEMI who undergo PCI. This study underscores the role of delirium and implicates the importance of further studies in recognition and targeted care of delirium.

Prediction of 1-Year Mortality from Acute Myocardial Infarction Using Machine Learning

Risk stratification at hospital discharge could be instrumental in guiding postdischarge care. In this study, the risk models for 1-year mortality using machine learning (ML) were evaluated for guiding management of acute myocardial infarction (AMI) patients. From the Korea Acute Myocardial Infarction Registry (KAMIR) dataset, 22,182 AMI patients were selected. The 1-year all-cause mortality was recorded at 12-month follow-up periods. Anomaly detection was conducted for removing outliers; principal component analysis for dimensionality reduction, recursive feature elimination algorithm for feature selection. Model selection and training were conducted with 70% of the dataset after the creation and cross-validation of hundreds of models with decision trees, ensembles, logistic regressions, and deepnets algorithms. The rest of the dataset (30%) was used for comparison between the ML and KAMIR score-based models. The mean age of the AMI patients was 64 years, 71.8% were male, and 56.7% were eventually diagnosed with ST-elevation myocardial infarction. There were 1,332 patients suffering from all-cause mortality (6%) during a median 338 days of follow-up. The ML models for 1-year mortality were well-calibrated (Hosmer-Lemeshow p >0.05) and showed good discrimination (area under the curve for test cohort: 0.918). Compared with the performance of the KAMIR score model, the ML model had a higher area under the curve, net reclassification improvement, and integrated discrimination improvement. The ML model for 1-year mortality was well-calibrated and had excellent discriminatory ability and higher performance. In a comprehensive clinical evaluation process, this model could support risk stratification and management in postdischarge AMI patients.

Association of decreasing hemoglobin levels with the incidence of acute kidney injury after percutaneous coronary intervention: a prospective multi-center study

Acute kidney injury (AKI) is common in patients undergoing percutaneous coronary intervention (PCI). One risk factor for AKI is periprocedural hemoglobin drop level (> 3 g/dL); however, whether the relationship between hemoglobin drop and AKI is linear or nonlinear remains unknown. We aimed to investigate the relationship between periprocedural hemoglobin drop and AKI after PCI. We evaluated 14,273 consecutive patients undergoing PCI between September 2008 and March 2019. AKI was defined as an absolute or a relative increase in serum creatinine level of 0.3 mg/dL or 50%, respectively. Restricted cubic spline was constructed to assess the association between hemoglobin drop and AKI by logistic regression and machine learning (ML) models, which were used to predict the risk of AKI. The patients' mean age was 68.4 ± 11.6 years; the AKI incidence was 10.5% (N = 1499). An absolute > 3 g/dL or 20% relative decrease in hemoglobin level was an independent predictor of AKI incidence (odds ratio, OR [95% confidence interval, CI]: 2.24 [1.92-2.61], P < 0.001; 2.35 [2.04-2.71], P < 0.001, respectively). An adjusted restricted cubic spline demonstrated that absolute/relative decrease in hemoglobin was linearly associated with AKI. Logistic and ML models with absolute/relative hemoglobin changes were comparable while estimating the risk of AKI (absolute area under the curve [AUC] (logistic):0.826, AUC (ML): 0.820; relative AUC (logistic): 0.818, AUC (ML): 0.816). An absolute/relative decrease in periprocedural hemoglobin after PCI was linearly associated with AKI. Detection of a relative/absolute decrease in hemoglobin may help clinicians identify individuals as high risk for AKI after PCI.

Anti-coagulant and anti-platelet therapy in the COVID-19 patient: a best practices quality initiative across a large health system

The coronavirus disease 2019 (COVID-19) pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health-care systems and physicians worldwide to attempt to provide the best care to their patients with an evolving understanding of this unique pathogen. This disease and its worldwide impact have sparked tremendous interest in the epidemiology, pathogenesis, and clinical consequences of COVID-19. This accumulating body of evidence has centered around case series and often empiric therapies as controlled trials are just getting underway. What is clear is that patients appear to be at higher risk for thrombotic disease states including acute coronary syndrome (ACS), venous thromboembolism (VTE) such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or stroke. Patients with underlying cardiovascular disease are also at higher risk for morbidity and mortality if infected. These patients are commonly treated with anticoagulation and/or antiplatelet medications and less commonly thrombolysis during hospitalization, potentially with great benefit but the management of these medications can be difficult in potentially critically ill patients. In an effort to align practice patterns across a large health system (Jefferson Health 2,622 staffed inpatient beds and 319 intensive care unit (ICU) beds across 14 facilities), a task force was assembled to address the utilization of anti-thrombotic and anti-platelet therapy in COVID-19 positive or suspected patients. The task force incorporated experts in Cardiology, Vascular Medicine, Hematology, Vascular Surgery, Pharmacy, and Vascular Neurology. Current guidelines, consensus documents, and policy documents from specialty organizations were used to formulate health system recommendations.

OBJECTIVE

Our goal is to provide guidance to the utilization of antithrombotic and antiplatelet therapies in patients with known or suspected COVID-19.

Left Ventricular Assist Devices for Acute Myocardial Infarct Size Reduction: Meta-analysis

We conducted a meta-analysis of preclinical studies that tested left ventricular assist device (LVAD) therapy for reducing myocardial infarct size in experimental acute myocardial infarction (AMI). Twenty-six articles were included with a total of 488 experimental animal subjects. The meta-analysis showed that infarct size was significantly decreased by LVAD support compared to control animals (SDM, - 2.19; 95% CI, - 2.70 to - 1.69; P < 0.001). The meta-regression analysis demonstrated a high degree of heterogeneity associated with time from coronary artery occlusion to LVAD support, which correlated positively with infarct size. Subgroup analysis suggested smaller infarct size in LVAD therapies that withdrew blood from left heart than those from right heart. The proportion of left ventricular support relative to total cardiac output was positively correlated with infarct size reduction in Impella studies. Thus, early initiation of LVAD after ischemia and effective left ventricular venting may be important factors to reduce infarct size in AMI.

Evidence-practice gaps in P2Y12 inhibitor use after hospitalisation for acute myocardial infarction: findings from a new population-level data linkage in Australia

Background

P2Y₁₂ inhibitor therapy is recommended for 12 months in patients hospitalised for acute myocardial infarction (AMI) unless the bleeding risk is high.

Aims

To describe real‐world use of P2Y₁₂ inhibitor therapy following AMI hospitalisation.

Methods

We used population‐level linked hospital data to identify all patients discharged from a public hospital with a primary diagnosis of AMI between July 2011 and June 2013 in New South Wales and Victoria, Australia. We used dispensing claims to examine dispensing of a P2Y₁₂ inhibitor (clopidogrel, prasugrel or ticagrelor) within 30 days of discharge and multilevel models to identify predictors of post‐discharge dispensing and persistence of therapy to 1 year.

Results

We identified 31 848 patients hospitalised for AMI, of whom 56.8% were dispensed a P2Y₁₂ inhibitor within 30 days of discharge. The proportion of patients with post‐discharge dispensing varied between hospitals (interquartile range: 25.0–56.5%), and significant between‐hospital variation remained after adjusting for patient characteristics. Patient factors associated with the lowest likelihood of post‐discharge dispensing were: having undergone coronary artery bypass grafting (odds ratio (OR): 0.17; 95% confidence intervals (CI): 0.15–0.20); having oral anticoagulants dispensed 180 days before or 30 days after discharge (OR: 0.39, 95% CI: 0.35–0.44); major bleeding (OR: 0.68, 95% CI: 0.61–0.76); or being aged ≥85 years (OR: 0.68, 95% CI: 0.62–0.75). A total of 26.8% of patients who were dispensed a P2Y₁₂ inhibitor post‐discharge discontinued therapy within 1 year.

Conclusion

Post‐hospitalisation use of P2Y₁₂ inhibitor therapy in AMI patients is low and varies substantially by hospital of discharge. Our findings suggest strategies addressing both health system (hospital and physician) and patient factors are needed to close this evidence‐practice gap.

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

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

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

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

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