Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly

Interval training suppresses nod-like receptor protein 3 inflammasome activation to improve cardiac function in myocardial infarction rats by hindering the activation of the transforming growth factor-β1 pathway

OBJECTIVE

Myocardial infarction (MI) -induced cardiac dysfunction can be attenuated by aerobic exercises. This study explored the mechanism of interval training (IT) regulating cardiac function in MI rats, providing some theoretical basis for clarifying MI pathogenesis and new ideas for clinically treating MI.

METHODS

Rats were subjected to MI modeling, IT intervention, and treatments of the Transforming growth factor-β1 (TGF-β1) pathway or the nod-like receptor protein 3 (NLRP3) activators. Cardiac function and hemodynamic indicator alterations were observed. Myocardial pathological damage and fibrosis, reactive oxygen species (ROS) level, superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GSH-Px) activities, MDA content, inflammasome-associated protein levels, and inflammatory factor levels were assessed. The binding between TGF-β1 and receptor was detected.

RESULTS

MI rats exhibited decreased left ventricle ejection fraction (LVEF), left ventricle fractional shortening  (LVFS), left ventricular systolic pressure  (LVSP), positive and negative derivates max/min (dP/dt max/min) and increased left ventricular end-systolic pressure (LVEDP), a large number of scar areas in myocardium, disordered cell arrangement and extensive fibrotic lesions, increased TGF-β1 and receptor binding, elevated ROS level and MDA content and weakened SOD, CAT and GSH-Px activities, and up-regulated NLRP3, apoptosis-associated speck-like protein containing a CARD  (ASC) and cleaved-caspase-1 levels, while IT intervention caused ameliorated cardiac function. IT inactivated the TGF-β1 pathway to decrease oxidative stress in myocardial tissues of MI rats and inhibit NLRP3 inflammasome activation. Activating NLRP3 partially reversed IT-mediated improvement on cardiac function in MI rats.

CONCLUSION

IT diminished oxidative stress in myocardial tissues and suppressed NLRP3 inflammasome activation via inactivating the TGF-β1 pathway, thus improving the cardiac function of MI rats.

Time course of cardiac rupture after acute myocardial infarction and comparison of clinical features of different rupture types

Objective

This study aimed to investigate the time course of cardiac rupture (CR) after acute myocardial infarction (AMI) and the differences among different rupture types.

Method

We retrospectively analyzed 145 patients with CR after AMI at Shanxi Cardiovascular Hospital from June 2016 to September 2022. Firstly, according to the time from onset of chest pain to CR, the patients were divided into early CR (≤24 h) (n = 61 patients) and late CR (>24 h) (n = 75 patients) to explore the difference between early CR and late CR. Secondly, according to the type of CR, the patients were divided into free wall rupture (FWR) (n = 55) and ventricular septal rupture (VSR) (n = 90) to explore the difference between FWR and VSR.

Results

Multivariate logistic regression analysis showed that high white blood cell count (OR = 1.134, 95% CI: 1.019-1.260, P = 0.021), low creatinine (OR = 0.991, 95% CI: 0.982-0.999, P = 0.026) were independently associated with early CR. In addition, rapid heart rate (OR = 1.035, 95% CI: 1.009-1.061, P = 0.009), low systolic blood pressure (OR = 0.981, 95% CI: 0.962-1.000, P = 0.048), and anterior myocardial infarction (OR = 5.989, 95% CI: 1.978-18.136, P = 0.002) were independently associated with VSR.

Conclusion

In patients with CR, high white blood cell count and low creatinine were independently associated with early CR, rapid heart rate, low systolic blood pressure, and anterior myocardial infarction were independently associated with VSR.

Proteomic analysis of plasma proteins from patients with cardiac rupture after acute myocardial infarction using TMT-based quantitative proteomics approach

BACKGROUND

Cardiac rupture (CR) is a rare but catastrophic mechanical complication of acute myocardial infarction (AMI) that seriously threatens human health. However, the reliable biomarkers for clinical diagnosis and the underlying signaling pathways insights of CR has yet to be elucidated.

METHODS

In the present study, a quantitative approach with tandem mass tag (TMT) labeling and liquid chromatography-tandem mass spectrometry was used to characterize the differential protein expression profiles of patients with CR. Plasma samples were collected from patients with CR (n = 37), patients with AMI (n = 47), and healthy controls (n = 47). Candidate proteins were selected for validation by multiple reaction monitoring (MRM) and enzyme-linked immunosorbent assay (ELISA).

RESULTS

In total, 1208 proteins were quantified and 958 differentially expressed proteins (DEPs) were identified. The difference in the expression levels of the DEPs was more noticeable between the CR and Con groups than between the AMI and Con groups. Bioinformatics analysis showed most of the DEPs to be involved in numerous crucial biological processes and signaling pathways, such as RNA transport, ribosome, proteasome, and protein processing in the endoplasmic reticulum, as well as necroptosis and leukocyte transendothelial migration, which might play essential roles in the complex pathological processes associated with CR. MRM analysis confirmed the accuracy of the proteomic analysis results. Four proteins i.e., C-reactive protein (CRP), heat shock protein beta-1 (HSPB1), vinculin (VINC) and growth/differentiation factor 15 (GDF15), were further validated via ELISA. By receiver operating characteristic (ROC) analysis, combinations of these four proteins distinguished CR patients from AMI patients with a high area under the curve (AUC) value (0.895, 95% CI, 0.802-0.988, p < 0.001).

CONCLUSIONS

Our study highlights the value of comprehensive proteomic characterization for identifying plasma proteome changes in patients with CR. This pilot study could serve as a valid foundation and initiation point for elucidation of the mechanisms of CR, which might aid in identifying effective diagnostic biomarkers in the future.

Structural Complications Following ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample 2016 to 2020

ST-elevation myocardial infarction (STEMI) is a life-threatening emergency that can result in cardiac structural complications without timely revascularization. A retrospective study from the National Inpatient Sample included all patients with a diagnosis of STEMI between 2016 and 2020. Primary outcomes of interest were in-hospital mortality, length of stay (LoS), and healthcare costs for patients with and without structural complications. There were 994,300 hospital admissions included in the analysis (median age 64 years and 32.2% female). Structural complications occurred in 0.78% of patients. There was a three-fold increase in patients with cardiogenic shock (41.6% vs. 13.6%) and in-hospital mortality (30.6% vs. 10.7%) in the group with structural complications. The median LoS was longer (5 days vs. 3 days), and the median cost was significantly greater (USD 32,436 vs. USD 20,241) for patients with structural complications. After adjustments, in-hospital mortality was significantly greater for patients with structural complications (OR 1.99, 95% CI 1.73-2.30), and both LoS and costs were greater. There was a significant increase in mortality with ruptured cardiac wall (OR 9.16, 95% CI 5.91-14.20), hemopericardium (OR 3.20, 95% CI 1.91-5.35), and ventricular septal rupture (OR 2.57, 95% CI 1.98-3.35) compared with those with no complication. In conclusion, structural complications in STEMI patients are rare but potentially catastrophic events.

Study of mechanical complications in patients with acute ST-segment elevated myocardial infarction

This prospective observational study aimed to determine the proportion of mechanical complications in patients with acute STEMI and assess the associated outcomes. The study was conducted between June'21 and May'22, including 1307 patients. Mechanical complications were evaluated using 2D-Echo. Among the STEMI patients, 17 individuals (1.3 %) experienced mechanical complications. The most prevalent complication was FWR (n = 9), followed by VSR(n = 7) and PMR (n = 1). However, despite their low incidence, mechanical complications carry a significant mortality burden. Mortality rates were higher in older age and female patients.

The prediction model of the short-term outcome in elderly heart failure patients

This study was designed to investigate the effect of the comprehensive geriatric assessment on the short-term prognosis of the elderly heart failure patients (EHFP), analyze the relevant risk factors, and construct an effective risk prediction model. According to the selection and exclusion criteria, 617 patients were filtered from 800 patients from the cadre ward database of the first Hospital of Jilin University. The EHFP were randomly divided into the model group (432 cases) and the validation group (185 cases). A retrospective study on the general clinical data of patients in the model group was conducted to analyze the risk factors associated with the short-term outcomes of EHFP. Based on the risk factors, the risk prediction model was established and validated through the validation group. In the model group, the following independent risk factors were identified for the short-term outcomes in EHFP in the light of univariate logistic and cox regression analysis: female (β = 0.989, OR = 1.277, 95% CI: 1.090-1.847, P = 0.024), age (65-75 years, β = 0.654, OR = 2.320, 95% CI: 1.135-3.136, P = 0.012; 75-85 years, β = 1.123, OR = 3.159, 95% CI: 1.532-5.189, P = 0.001; age > 85 years old, β = 1.513, OR = 4.895, 95% CI: 1.866-979, P = 0.001), frailty (β = 1.015, OR = 2.761, 95% CI: 1.097-6.945, P = 0.031), malnutrition (β = 1.271, OR = 3.560, 95% CI: 1.122-11.325, P = 0.002), and EF≦40% (β = 1.250, OR = 3.498, 95% CI: 1.898-6.447, P = 0.001). The simple risk prediction score was set up in line with the five risk factors, including range (1-7), the area under ROC curve (0.771, 95% CI: 0.723-0.819), and H-L test (P = 0.393), so patients were divided into the low-risk group (1-3) and the high-risk group (4-8). As a result, the number of EHFP in the high-risk group was significantly much more than that in the low-risk group (70.1% versus 29.9%, P < 0.001). Besides, the area under ROC curve (0.758, 95% CI: 0.682-0.835) and H-L test (P = 0.669) of the validation group indicated that this model could be a promising prediction model for the short-term outcomes of EHFP. Female, age, frailty, malnutrition, and EF ≦ 40% are independent risk factors for short-term outcomes of EHFP. The risk prediction model based on the five risk factors provided compelling clinic predictive value for the short-term prognosis of EHFP.

Risk of cardiac rupture among elderly patients with diabetes presenting with first acute myocardial infarction

Objective

We aimed to analyze the risk of cardiac rupture (CR) in aged diabetic patients with acute ST-segment elevated myocardial infarction (STEMI) who were followed up for one month, and analyze its independent risk factors.

Methods

A total of 3063 aged patients with first onset STEMI admitted to Beijing Anzhen Hospital from January 2001 to December 2020 were retrospectively included. There were 2020 patients without diabetes mellitus (DM) and 1043 patients with DM. We used propensity scores matching (PSM) method to balance baseline exposure factors between patients with or without DM, and all were divided the DM group (1043 cases) and the non-DM group (1043 cases) after the PSM. The primary outcome was CR (the composite rate of papillary muscle rupture, ventricular septum perforation, free wall rupture), which was diagnosed based on clinical manifestations and/or echocardiographic findings. Kaplan-meier survival analyses and log-rank test was used to evaluate the risk of CR between the two groups, and Cox regression analysis was used to evaluate the independent risk factors for CR.

Results

After PSM, the baseline clinical data were similar between the DM and non-DM group (all P>0.05). However, level of glycated hemoglobin was significantly higher in the DM group (P<0.05). During 1 month of follow-up, there were 55 (2.64%) cases of CR, most occurred within 48h after admission (40 cases). Among the 55 cases, 11(0.53%) had papillary muscle rupture, 18(0.86%) had ventricular septum perforation, and 26(1.25%) had free wall rupture. Kaplan-meier survival analyses detected that the DM group was associated with significantly increased risk of CR (3.36% vs. 1.92%, HR=1.532, 95% CI: 1.054-2.346, P=0.030), ventricular septum perforation (1.05% vs. 0.67%, HR=1.464, 95% CI: 1.021-2.099, P=0.038) and free wall rupture (1.63% vs. 0.86%, HR=1.861, 95% CI: 1.074-3.225, P=0.027) than those in the non-DM group. Among the 2031 aged STEMI patients without CR, 144 cases (6.90%, 144/2086) died; and among the 55 patients with CR, 37 cases (1.77%, 37/2086) died due to CR. Therefore, twenty percent (20.44%, 37/181) of death was due to CR. Multivariate Cox regression analysis indicated that DM (HR=1.532, 95%CI: 1.054-2.346), age (HR=1.390, 95%CI: 1.079-1.791), female (HR=1.183, 95%CI: 1.049-1.334), troponin I (HR=1.364, 95%CI: 1.108-1.679), brain natriuretic peptide (HR=1.512, 95%CI: 1.069-2.139), revascularization (HR=0.827, 95%CI: 0.731-0.936) and β-receptor blocker (HR=0.849, 95%CI: 0.760-0.948) were independent risk factors of CR (all P<0.05).

Conclusion

DM as well as a few other factors, are independent determinants of CR. CR is not a rare event among the aged STEMI patients and twenty percent of deaths are due to CR. However, large sample-sized studies are warranted to confirm these findings.

Unveiling a rare case: Cardiac rupture secondary to acute occlusion of the distal left circumflex artery detected by contrast-enhanced spiral CT

A 79-year-old female patient was admitted to the hospital due to intense chest pain. Emergency percutaneous coronary intervention (PCI) revealed an occlusion in the distal portion of the left circumflex artery (LCx). The patient suffered from cardiac rupture, an uncommon yet extremely perilous condition, within 30 minutes following the procedure. This was verified through a computed tomography angiography (CTA) scan and bedside echocardiography. The etiology of cardiac rupture remains elusive, yet potential factors such as the patient's age, gender, initial acute myocardial infarction (AMI), and single-vessel disease without collateral circulation may be linked to this occurrence. This case report emphasizes that occluded tiny distal coronary arteries can also induce cardiac rupture and that a sufficient level of suspicion for the diagnosis of cardiac rupture should be raised when adequate fluid resuscitation fails to alleviate hypotension. Additionally, contrast-enhanced spiral computed tomography (CESCT) is highly effective in revealing certain pathological features associated with cardiac rupture.

Predictors, Outcomes and Impact of Mechanical Circulatory Support of Patients With Mechanical Complications After Acute Myocardial Infarction

BACKGROUND

Despite early and currently effective epicardial coronary recanalization, the mortality rate after mechanical complication (MC) remains high, especially in cardiogenic shock. There is an increase in the use of mechanical circulatory support in patients with cardiogenic shock and MC, however, evidence is still scarce and most studies exclude patients with mechanical complications.

METHODS

Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the predictors and outcomes of patients with MC, subtypes and the use of MCS.

RESULTS

We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC and of them 1320 (56.3 %) received MCS. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture (FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582-12.855, p < 0.001) in patients with MC compared to patients without MC (49.7 % vs. 4.6 %, p < 0.001) and all subtypes of MC showed a significant increase in mortality. The use of MCS was associated with decreased mortality in PMR (46.2 % to 34.8 %, p = 0.009) and pseudoaneurysm (64.7 % to 42.1 %, p < 0.001), however, with higher mortality in VSR.

CONCLUSIONS

The incidence of MC after an AMI is very low, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and with fewer comorbidities. The subtype with the highest frequency and highest mortality was VSR. The use of mechanical circulatory support was associated with better survival in PMR and pseudoaneurysm, but not overall survival.

Mechanical complications in STEMI: prevalence and mortality trends in the primary PCI era. The Ruti-STEMI registry

INTRODUCTION AND OBJECTIVES

Mechanical complications confer a dreadful prognosis in ST-elevation myocardial infarction (STEMI). Their prevalence and prognosis are not well-defined in the current era of primary percutaneous coronary intervention (pPCI) reperfusion networks. We aimed to analyze prevalence and mortality trends of post-STEMI mechanical complications over 2 decades, before and after the establishment of pPCI networks.

METHODS

Prospective, consecutive registry of STEMI patients within a region of 850 000 inhabitants over 2 decades: a pre-pPCI period (1990-2000) and a pPCI period (2007-2017). We analyzed the prevalence of mechanical complications, including ventricular septal rupture, papillary muscle rupture, and free wall rupture (FWR). Twenty eight-day and 1-year mortality trends were compared between the 2 studied decades.

RESULTS

A total of 6033 STEMI patients were included (pre-pPCI period, n=2250; pPCI period, n=3783). Reperfusion was supported by thrombolysis in the pre-pPCI period (99.1%) and by pPCI in in the pPCI period (95.7%). Mechanical complications developed in 135 patients (2.2%): ventricular septal rupture in 38 patients, papillary muscle rupture in 24, and FWR in 73 patients. FWR showed a relative reduction of 60% in the pPCI period (0.8% vs 2.0%, P<.001), without significant interperiod changes in the other mechanical complications. After multivariate adjustment, FWR remained higher in the pre-pPCI period (OR, 1.93; 95%CI, 1.10-3.41; P=.023). At 28 days and 1 year, mortality showed no significant changes in all the mechanical complications studied.

CONCLUSIONS

The establishment of regional pPCI networks has modified the landscape of mechanical complications in STEMI. FWR is less frequent in the pPCI era, likely due to reduced transmural infarcts.

Interventional management of mechanical complications in acute myocardial infarction

Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs -wherever this option is available-, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing.

Exercise improves cardiac function in the aged rats with myocardial infarction

Exercise can improve the cardiovascular health. However, the mechanism contributing to its beneficial effect on elderly patients with myocardial infarction is obscure. 20-month-old male Sprague-Dawley rats were used to establish myocardial infarction (MI) model by permanent ligation of the left anterior descending coronary artery (LAD) of the heart, followed by 4-week interval exercise training on a motor-driven rodent treadmill. The cardiac function, myocardial fibrosis, apoptosis, oxidative stress, and inflammatory responses were determined by using pressure transducer catheter, polygraph physiological data acquisition system, Masson's trichrome staining, and ELISA to evaluate the impact of post-MI exercise training on MI. Western blot were performed to detect the activation of AMPK/SIRT1/PGC-1alpha signaling in the hearts of aged rats. Exercise training significantly improved cardiac function and reduced the cardiac fibrosis. In infarcted heart, the apoptosis, oxidative stress, and inflammation were significantly reduced after 4-week exercise training. Mechanistically, AMPK/SIRT1/PGC-1alpha pathway was activated in the myocardial infarction area after exercise training, which might participate in the protection of cardiac function. Exercise training improves cardiac function in MI rats through reduction of apoptosis, oxidative stress, and inflammation, which may mediate by the activation of AMPK/SIRT1/PGC-1alpha signaling pathway.

Prognostic value of cardiac magnetic resonance early after ST-segment elevation myocardial infarction in older patients

BACKGROUND

older patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce.

METHODS

the registry comprised 247 STEMI patients over 70 years of age treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

RESULTS

during a 4.8-year mean follow-up, the number of first major adverse cardiac events (MACE) was 66 (26.7%): 27 all-cause deaths and 39 re-admissions for acute heart failure. Predictors of MACE were GRACE score (HR 1.03 [1.02-1.04], P < 0.001), CMR-LVEF (HR 0.97 [0.95-0.99] per percent increase, P = 0.006) and MVO (HR 1.24 [1.09-1.4] per segment, P = 0.001). Adding CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694-0.824] vs. 0.685 [0.613-0.756], NRI = 0.6, IDI = 0.08, P < 0.001). The best cut-offs for independent variables were GRACE score > 155, LVEF < 40% and MVO ≥ 2 segments. A simple score (0, 1, 2, 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (P < 0.001).

CONCLUSIONS

CMR data contribute valuable prognostic information in older patients submitted to undergo CMR soon after STEMI. The Older-STEMI-CMR score should be externally validated.

Outcomes and mechanical complications of acute myocardial infarction during the second wave pandemic in a Milan HUB center for cardiac emergencies

Aims

COVID-19 has dramatically impacted the healthcare system. Evidence from previous studies suggests a decline in in-hospital admissions for acute myocardial infarction (AMI) during the pandemic. However, the effect of the pandemic on mechanical complications (MC) in acute ST-segment elevation myocardial infarction (STEMI) has not been comprehensively investigated. Therefore, we evaluated the impact of the pandemic on MC and in-hospital outcomes in STEMI during the second wave, in which there was a huge SARS-CoV-2 diffusion in Italy.

Methods and results

Based on a single center cohort of AMI patients admitted with STEMI between February 1, 2019, and February 28, 2021, we compared the characteristics and outcomes of STEMI patients treated during the pandemic vs. those treated before the pandemic. In total, 479 STEMI patients were included, of which 64.5% were during the pandemic. Relative to before the pandemic, primary percutaneous coronary intervention (PCI) declined (87.7 vs. 94.7%, p = 0.014) during the pandemic. Compared to those admitted before the pandemic (10/2019 to 2/2020), STEMI patients admitted during the second wave (10/2020 to 2/2021) presented with a symptom onset-to-door time greater than 24 h (26.1 vs. 10.3%, p = 0.009) and a reduction of primary PCI (85.2 vs. 97.1%, p = 0.009). MC occurred more often in patients admitted during the second wave of the pandemic than in those admitted before the pandemic (7.0 vs. 0.0%, p = 0.032). In-hospital mortality increased during the second wave (10.6 vs. 2.9%, p = 0.058).

Conclusion

Although the experience gained during the first wave and a more advanced hub-and-spoke system for cardiovascular emergencies persists, late hospitalizations and a high incidence of mechanical complications in STEMI were observed even in the second wave.

Clinical Manifestation of Cardiac Rupture in Patients with ST-Segment Elevation Myocardial Infarction: Early Versus Late Primary Percutaneous Coronary Intervention

Background:

Cardiac rupture is one of the fatal complications of ST-Segment Elevation Myocardial Infarction (STEMI) in the primary percutaneous coronary intervention (PPCI) era. The present study aims to identify risk factors of cardiac rupture among patients suffering from STEMI, treated with early and late PPCI.

Methods:

This is a multicenter retrospective cohort study involving STEMI patients with cardiac rupture (CR group), matched with STEMI patients without CR (control group) in a 1:5 ratio. They were divided into the early (≤ 6 h) and the late (> 6 h) PCI groups. Multivariable logistic regression was utilized to identify risk factors for cardiac rupture.

Results:

Seventy-four patients in the CR and 370 in the control group were included. Multivariable regression identified lateral infarction (OR = 11.89, 95% CI 2.22–63.81, p < 0.01) in the early PCI phase as a significant risk factor for cardiac rupture. Thrombolysis in myocardial infarction (TIMI) grade 0-1 (early PCI: OR = 4.16, 95% CI 1.33-13.0, p = 0.01; late PCI: OR = 4.46, 95% CI 1.59–12.54, p < 0.01) was a risk factor for both early and late PCI groups. In contrast, TIMI grade 2 was associated with a higher rupture risk within the late (OR = 16.87, 95% CI 3.83–74.19, p < 0.001) but not for the early (OR = 5.44, 95% CI 0.76–39.07, p = 0.09) PCI groups. STEMI combined with Killip IV was associated with a higher rupture risk for the late PCI group (OR = 1.43, 95% CI 1.03–1.99, p = 0.04). Intra-aortic balloon pump (IABP) was protective against cardiac rupture within early PPCI (OR = 0.18, 95% CI 0.04–0.89, p = 0.04). In contrast, glycoprotein IIb/IIIa inhibitors were associated with lower rupture risks in both the early and late groups (early PCI: OR = 0.38, 95% CI 0.17–0.87, p = 0.02; late PCI: OR = 0.33, 95% CI 0.15–0.75, p < 0.01).

Conclusions:

No reflow or slow blood flow is associated with a higher risk of cardiac rupture in early and late PCI patients. Glycoprotein IIb/IIIa inhibitors are beneficial in preventing heart rupture, and the use of IABP in early PPCI is also helpful in preventing heart rupture.

A novel function of ATF3 in suppression of ferroptosis in mouse heart suffered ischemia/reperfusion

INTRODUCTION

Ferroptosis, a newly identified type of programmed cell death type, has been proven to contribute to the progression of myocardial ischemia/reperfusion (I/R) injury. However, little is known about ferroptosis regulation in I/R injury.

OBJECTIVES

We identified activating transcription factor 3 (ATF3) as a vital regulator of I/R induced ferroptosis and investigated the effects and potential mechanism of ATF3 in cardiac ferroptosis.

METHODS

In this study, the dynamic RNA-sequencing (RNA-seq) analysis were performed on mouse hearts exposed to different I/R schedules to identify that ATF3 represents an important modulatory molecule in myocardial I/R injury. Then knockout, rescue and overexpression methods were used in mice and neonatal mouse cells (NMCs) to illustrate the effect of ATF3 on myocardial I/R injury. Loss/gain of function techniques were used both in vivo and in vitro to explore the effects of ATF3 on ferroptosis in I/R injury. Furthermore, chromatin immunoprecipitation sequence (ChIP-seq) analysis was performed in the AC16 human cardiomyocyte cell line to investigate potential genes regulated by ATF3.

RESULTS

ATF3 expression reached highest level at early stage of reperfusion, knockout of ATF3 significantly aggravated I/R injury, which could be rescued by ATF3 re-expression. Knockout and the re-expression of ATF3 changed the transcription levels of multiple ferroptosis genes. In addition, results showed that overexpression of ATF3 inhibits cardiomyocyte ferroptosis triggered by erastin and RSL3. Lastly, ChIP-seq and dual luciferase activity analysis revealed ATF3 could bind to the transcription start site of Fanconi anaemia complementation group D2 (FANCD2) and increased the FANCD2 promoter activity. Furthermore, we first demonstrated that overexpression of FANCD2 exerts significant anti-ferroptosis and cardioprotective effect on AC16 cell H/R injury.

CONCLUSION

ATF3 inhibits cardiomyocyte ferroptotic death in I/R injury, which might be related with regulating FANCD2. Our study provides new insight into the molecular target for the therapy of myocardial I/R injury.

A case report of rescue of a patient with a left ventricular free wall rupture associated with a small subtle ST-elevation myocardial infarction

Background

Left ventricular (LV) free wall ruptures (LVFWRs) of myocardial infarctions (MIs) are still one of the most fatal mechanical complications after an acute MI (AMI). LVFWRs are estimated to occur in 0.01% to 0.52% of patients following an ST-elevation MI (STEMI) and are rarely reported in the setting of a non- or subtle-ST-elevation MI.

Case summary

We herein present a report of a 92-year-old male rescue case with an LVFWR following a small subtle-STEMI. Contrast cardiac computed tomography was useful to diagnose the LVFWR. An emergent cardiac surgery was performed. Finally, the patient’s life was saved.

Discussion

This case demonstrates that even without clinical evidence of transmural infarction such as non- or subtle-STEMI, those patients may carry a risk of fatal complications including LVFWR, especially in older age and a first lateral wall AMI without collateral flow, as in this present case. Thus, the physicians should be aware of the possibility of LVFWRs even in the setting of an AMI without or with subtle-ST-elevation. High clinical suspicion and vigilance are the cornerstones of a timely and accurate diagnosis of LVFWR. This is the first report of a rescue case of a patient with an LVFWR associated with a subtle-STEMI.

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes

BACKGROUND

Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm.

METHODS

An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year.

RESULTS

A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication.

CONCLUSIONS

Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.

Acquired Dynamic Left Ventricular Outflow Tract Obstruction: A Rare Complication of Acute Myocardial Infarction

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Reversible outflow tract obstruction is a rare complication of myocardial infarction.

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Immediate bedside echocardiogram can help recognize this complication.

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Sigmoid-shaped septum and narrow aortoseptal angle are likely anatomic contributors.

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Tachycardia, hypertension, and basal hypercontractility are hemodynamic factors.

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Early beta-blockers and revascularization can reverse this complication.

Trends in Ischemic Mitral Regurgitation Following ST-Elevation Myocardial Infarction Over a 20-Year Period

Background: Ischemic mitral regurgitation (IMR) is a common complication of acute ST-elevation myocardial infarction (STEMI). Little is known regarding the impact of IMR over a long period of follow up.

Methods: Of 3,208 consecutive STEMI patients from a prospective registry, full echocardiographic information was available for 2,985 patients between the years 2000 and 2020. We compared the two decades- 2001 to 2010 and 2011 to 2020, and assessed for the presence of IMR at baseline, 3 (range 2–6) months and 12 (range 10–14) months after the index event.

Results: One thousand six hundred and sixty six patients were included in the first decade, 1,319 in the second. Mean patient age was 61.3 ± 12.3 years, 21.1% female patients in the first decade vs. 60.9 ± 12.0 years and 22.2% female in the second (p = 0.40 and p = 0.212, respectively). Rates of moderate IMR or above during the index admission were 17.2% in the first period and 9.3% in the second one (p < 0.001). After 3 months, the rate of IMR was 48.5% for those who suffered from IMR at baseline, vs. 9.5% for those without IMR at baseline (HR- 4.2, p < 0.001). Death rates for those with moderate IMR or above were 14.7% and 17.8% after 1 and 2 years, respectively, vs. 7.3 and 9.6% for those without (p < 0.001 for both). IMR was associated with 1 year mortality in multivariate analysis (HR-1.37; 1.09–2.20, p = 0.009), as well as in propensity score matched analysis (HR 1.29; CI: 1.07–1.91; p < 0.001).

Conclusions: IMR is a common complication following acute STEMI, impacting prognosis. Rates of IMR have declined significantly over the years.

[Mechanical complications after myocardial infarction in a National Reference Hospital]

Objective

To determine the clinical characteristics, therapeutic and in-hospital mortality of patients with mechanical complications post myocardial infarction.

Materials and methods

Observational, descriptive and retrospective study. We included patients >18 years old with a diagnosis of mechanical complication post myocardial infarction hospitalized at the Instituto Nacional Cardiovascular- INCOR in Lima -Peru, from January 1, 2017 to December 31, 2021. Variables like clinical characteristics, treatments, complications, and in-hospital mortality were studied.

Results

We found 37 cases, with a predominance of males (73.0%) and a median age of 73 years old. The location of the myocardial infarction was 51.4% in the anterior wall and 43.2% in the inferior wall. The patients received reperfusion therapy with fibrinolysis in 5 cases (13.5%), coronary angioplasty in 5 (13.5%), and 73% received only medical management prior to the diagnosis of mechanical complications. Of the 37 patients, 13 (35.1%) presented isolated ventricular free wall rupture, 12 (32.4%) isolated interventricular septum rupture, 10 (27.0%) the combination of ventricular free wall rupture and interventricular septum, and 2 (5.4%) papillary muscle rupture. In-hospital mortality was 51.4%.

Conclusions

The ventricular free wall rupture was the most frequent complication, patients with mechanical complications after myocardial infarction still maintain high intra-hospital mortality rates, mainly in those who did not have adequate surgical treatment.

Post-infarction ventricular septal rupture with a contained right ventricular pseudoaneurysm formation

Mechanical complication of acute myocardial infarction, such as left ventricular free-wall or septal rupture, pseudo-aneurysm or true aneurysm, are uncommon but potentially fatal conditions, that require an early diagnosis and management. We describe a case of post-infarction ventricular septal rupture with pseudoaneurysm formation included in the right ventricle.

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research

Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.

Mechanical complications in ST-elevation myocardial infarction: The impact of pre-hospital delay

AIMS

Mechanical complications (MC) (i.e., free wall rupture (FWR), papillary muscle rupture (PMR) and ventricular septal rupture (VSR)) are rare complications of ST- elevation acute myocardial infarction (STEMI). Incidence of MC according to pre-hospital delay remains unknown. We aimed to determine the rates of MC according to pre-hospital delay.

METHODS

Analysis was conducted on the MODIF registry data. Patients were allocated to four groups according to pre-hospital delay: 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h.

RESULTS

6185 patients with complete data were analyzed. Mean age was 64.1 years old and 75.7% of patients were males. Eighty-three patients (1.34%) presented with MC: 44 (0.71%) experienced a FWR, 17 (0.27%) a PMR, and 22 (0.36%) a VSR. Global rates of MC were 0.82%, 1.43%, 1.24% and 5.07% in the four groups of pre-hospital delays - 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h - respectively (p < 0.001). In-hospital mortality rates were high: 44.2%, 47.1% and 54.6% for FWR, PMR and VSR, respectively. In multivariate analysis, factors independently related to the occurrence of MC were older age, female sex, simultaneous COVID-19 infection, absence of dyslipidemia, initial TIMI flow 0 or 1 in the culprit artery, 36 to 48 h-pre-hospital delay and absence of revascularization by percutaneous coronary intervention (PCI) with stent implantation.

CONCLUSION

The probability of MC in STEMI increases with pre-hospital delay. Mechanical complications of STEMI remain associated with a very poor prognosis.

Trends in Clinical Characteristics and Outcomes in ST-Elevation Myocardial Infarction Hospitalizations in the United States, 2002-2016

ST-segment Elevation Myocardial Infarction (STEMI) remains a major modern-day public health problem. We aimed to assess the demographic trends in STEMI related hospitalizations in the United States over a period of fifteen years. The nationwide inpatient sample was queried to obtain information of patients hospitalized with STEMI from January 1, 2002, to December 31, 2016. Annual hospitalization rates were calculated and annual percentage change (APC) was evaluated using regression analysis. A total of 4,121,155 eligible patients were included in this analysis. Overall, the total number of STEMI hospitalization decreased from 421,043 in 2002 to 208,510 in 2016 (P-trend <0.01). With the decreasing trend, the rate was relatively higher among males as compared to females, whites as compared to non-whites, and lower as compared to high socioeconomic status (SES). The rate of PCI in STEMI patients increased from 32.8% in 2002 to 67.8% in 2016 (APC = 5.392%, 95% CI [4.384-6.411], P < 0.001), but was higher among males as compared to females, urban as compared to rural hospitals and higher as compared to lower SES. In-hospital mortality decreased from 11% in 2002 to 10.5% in 2016 (APC = -0.771%, 95% CI [-1.230 to -0.311], P = 0.003), but remained higher among females, rural hospitals and low SES as compared to their correspondent groups. Among STEMI patients, the prevalence of individual comorbidities was noted to be increasing over the study period. Although there has been a declining trend in the number of STEMI hospitalizations, patients with modifiable risk factors presenting with STEMI has been on the rise. Females, rural communities and lower SES groups need special attention because of greater vulnerability.

Acute Coronary Syndrome in the Older Patient

Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.

Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

Mechanical Complications of Myocardial Infarction

In this retrospective observational study, we have examined the incidence, characteristics, and treatment of serious myocardial infarction (MI) -associated mechanical complications (MCs) occurring in Japanese patients in this era of percutaneous coronary intervention (PCI), focusing on frailty, nutrition, and clinical implication of surgery. Included were 883 patients who, having suffered an MI, had been admitted to Nihon University Hospital between January 2013 and April 2020. Fifteen (1.70%) of these patients had suffered a potentially catastrophic MC-ventricular free wall rupture (VFWR, n = 8), ventricular septal rupture (VSR, n = 6), or papillary muscle rupture (PMR, n = 1). Factors associated with the MCs were age, poor nutritional status, a high Killip class, delayed diagnosis of MI, a high lactate concentration, a low thrombolysis in myocardial infarction flow grade, and single-vessel disease. Thirty-day mortality among MC patients was 60% (9/15): 87.5% associated with VFWR, 33.3% associated with VSR and 0% associated with PMR. On adjusted multivariate analysis, occurrence of an MC was independently associated with 30-day mortality. Despite a high surgical risk (EuroSCORE II: 11.8 ± 4.7) with less frailty, 30-day mortality was lower among patients whose MC was treated surgically than among those whose MC was treated conservatively (40.0% versus 100.0%, respectively; P = 0.044).Our data suggest that surgical intervention can save patients with a life-threatening MI-associated MC and should be considered, if they are not particularly frail.

Recent insights into pathophysiology and management of mechanical complications of myocardial infarction

PURPOSE OF REVIEW

Mechanical complications of myocardial infarction are a group of postischemic events and include papillary muscle rupture resulting in ischemic mitral regurgitation, ventricular septal defect, left ventricle free wall rupture, pseudoaneurysm, and true aneurysm. Advances made in management strategies, such as the institution of 'Code STEMI' and percutaneous interventions, have lowered the incidence of these complications. However, their presentation is still associated with increased morbidity and mortality. Early diagnosis and appropriate management is crucial for facilitating better clinical outcomes.

RECENT FINDINGS

Although the exact timing of a curative intervention is not known, emerging percutaneous and transcatheter approaches and improving mechanical circulatory support (MCS) devices have greatly enhanced our ability to manage and treat some of the complications postinfarct.

SUMMARY

Although the incidence of mechanical complications of myocardial infarction has decreased over the past few decades, these complications are still associated with high rates of morbidity and mortality. The combination of early and accurate diagnosis and subsequent appropriate management are imperative for optimizing clinical outcomes. Although more randomized clinical trials are needed, mechanical circulatory support devices and emerging therapeutic strategies can be offered to carefully selected patients.

ST-segment elevation myocardial infarction: Management and association with prognosis during the COVID-19 pandemic in France

BACKGROUND

Systems of care have been challenged to control progression of the COVID-19 pandemic. Whether this has been associated with delayed reperfusion and worse outcomes in French patients with ST-segment elevation myocardial infarction (STEMI) is unknown.

AIM

To compare the rate of STEMI admissions, treatment delays, and outcomes between the first peak of the COVID-19 pandemic in France and the equivalent period in 2019.

METHODS

In this nationwide French survey, data from consecutive STEMI patients from 65 centres referred for urgent revascularization between 1 March and 31 May 2020, and between 1 March and 31 May 2019, were analysed. The primary outcome was a composite of in-hospital death or non-fatal mechanical complications of acute myocardial infarction.

RESULTS

A total of 6306 patients were included. During the pandemic peak, a 13.9±6.6% (P=0.003) decrease in STEMI admissions per week was observed. Delays between symptom onset and percutaneous coronary intervention were longer in 2020 versus 2019 (270 [interquartile range 150-705] vs 245 [140-646]min; P=0.013), driven by the increase in time from symptom onset to first medical contact (121 [60-360] vs 150 [62-420]min; P=0.002). During 2020, a greater number of mechanical complications was observed (0.9% vs 1.7%; P=0.029) leading to a significant difference in the primary outcome (112 patients [5.6%] in 2019 vs 129 [7.6%] in 2020; P=0.018). No significant difference was observed in rates of orotracheal intubation, in-hospital cardiac arrest, ventricular arrhythmias and cardiogenic shock.

CONCLUSIONS

During the first peak of the COVID-19 pandemic in France, there was a decrease in STEMI admissions, associated with longer ischaemic time, exclusively driven by an increase in patient-related delays and an increase in mechanical complications. These findings suggest the need to encourage the population to seek medical help in case of symptoms.

Mechanical Complications of Acute Myocardial Infarction: A Review

Importance

Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these complications now occur in fewer than 0.1% of patients following an acute myocardial infarction. However, mortality rates have not decreased in parallel, and mechanical complications remain an important determinant of outcomes after myocardial infarction. Early diagnosis and management are crucial to improving outcomes and require an understanding of the clinical findings that should raise suspicion of mechanical complications and the evolving surgical and percutaneous treatment options.

Observations

Mechanical complications most commonly occur within the first week after myocardial infarction. Cardiogenic shock or acute pulmonary edema are frequent presentations. Echocardiography is usually the first test used to identify the type, location, and hemodynamic consequences of the mechanical complication. Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support. Surgery is the definitive treatment, but the optimal timing remains unclear. Percutaneous therapies are emerging as an alternative treatment option for patients at prohibitive surgical risk.

Conclusions and Relevance

Mechanical complications present with acute and dramatic hemodynamic deterioration requiring rapid stabilization. Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction.

In-hospital outcomes of mechanical complications in acute myocardial infarction: Analysis from a nationwide Spanish database

BACKGROUND

Mechanical complications represent an important cause of mortality in myocardial infarction (MI) patients. This is a nationwide study performed to evaluate possible changes in epidemiology or prognosis of these complications with current available strategies.

METHODS

Information was obtained from the minimum basis data set of the Spanish National Health System, including all hospitalizations for acute myocardial infarction (AMI) from 2010 to 2015. Risk-standardized in-hospital mortality ratio was calculated using multilevel risk adjustment models.

RESULTS

A total of 241,760 AMI episodes were analyzed, MI mechanical complications were observed in 842 patients: cardiac tamponade in 587, ventricular septal rupture in 126, and mitral regurgitation due to papillary muscle or chordae tendineae rupture in 155 (there was more than one complication in 21 patients). In-hospital mortality was 59.5%. On multivariate adjustment, variables with significant impact on in-hospital mortality were: age (OR 1.06; 95% CI 1.04-1.07; p < 0.001), ST-segment elevation AMI (OR 2.91; 95% CI 1.88-4.5; p < 0.001), cardiogenic shock (OR 2.35; 95% CI 1.66-3.32; p < 0.001), cardio-respiratory failure (OR 3.48; 95% CI 2.37-5.09; p < 0.001), and chronic obstructive pulmonary disease (OR 1.85; 95% CI 1.07-3.20; p < 0.001). No significant trends in risk-adjusted in-hospital mortality were detected (IRR 0.997; p = 0.109). Cardiac intensive care unit availability and more experience with mechanical complications management were associated with lower adjusted mortality rates (56.7 ± 5.8 vs. 60.1 ± 4.5; and 57 ± 6.1 vs. 59.9 ± 5.6, respectively; p < 0.001).

CONCLUSIONS

Mechanical complications occur in 3.5 per thousand AMI, with no significant trends to better survival over the past few years. Advanced age, cardiogenic shock and cardio-respiratory failure are the most important risk factors for in-hospital mortality. Higher experience and specialized cardiac intensive care units are associated with better outcomes.

Role of Cardiovascular Magnetic Resonance in Ischemic Cardiomyopathy

Ischemic heart disease is the most common cause of cardiovascular morbidity and mortality. Cardiac magnetic resonance (CMR) improves on other noninvasive modalities in detection, assessment, and prognostication of ischemic heart disease. The incorporation of CMR in clinical trials allows for smaller patient samples without the sacrifice of power needed to demonstrate clinical efficacy. CMR can accurately quantify infarct acuity, size, and complications; guide therapy; and prognosticate recovery. Timing of revascularization remains the holy grail of ischemic heart disease, and viability assessment using CMR may be the missing link needed to help reduce morbidity and mortality associated with the disease.

Decrease of Cardiovascular Emergencies During the COVID-19 Pandemic

The new coronavirus (COVID-19) outbreak was declared a pandemic by the World Health Organization on March 11, 2020. Since then, important changes have been observed in the medical world, both in terms of patient management and patient presentations to the hospital. A dramatic decrease in the number of cardiovascular emergencies presenting to the emergency rooms has been reported in every country affected by the COVID-19 pandemic. This resulted mainly from the fear of patients to present at the hospital due to the risk of infection with the new coronavirus. Moreover, a significant increase in the time spent for investigations and specialized treatment has been reported for patients suffering from acute cardiovascular diseases. This adds to the longer times reported from symptom onset to presentation, and also to the longer period spent for triage in the emergency room. The aim of this paper is to highlight the dramatic reduction in the number of cardiovascular emergencies during the COVID-19 period and its possible explanations.

Trends in Short- and Long-Term ST-Segment-Elevation Myocardial Infarction Prognosis Over 3 Decades: A Mediterranean Population-Based ST-Segment-Elevation Myocardial Infarction Registry

Background Coronary artery disease remains a major cause of death despite better outcomes of ST-segment-elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti-STEMI registry of in-hospital, 28-day, and 1-year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28-day and 1-year STEMI mortality and in-hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28-day all-cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P<0.001), with a 40% reduction after multivariable adjustment (hazard ratio [HR], 0.6; 95% CI, 0.46-0.80; P<0.001). One-year all-cause mortality declined from period 1 to period 5 (11.7% versus 9.0%; P=0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60-0.98; P=0.036). A significant temporal reduction was observed for in-hospital complications including postinfarct angina (-78%), ventricular tachycardia (-57%), right ventricular dysfunction (-48%), atrioventricular block (-45%), pericarditis (-63%), and free wall rupture (-53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions In-hospital STEMI complications and 28-day and 1-year mortality rates have dropped markedly in the past 30 years. Reducing ischemia-driven primary ventricular fibrillation remains a major challenge.

Feasibility of management of hemodynamically stable patients with acute myocardial infarction following primary percutaneous coronary intervention in the general ward settings

BACKGROUND

Although current guidelines recommend admission to the intensive/coronary care unit (ICU/CCU) for patients with ST-segment elevation myocardial infarction (MI), routine use of the CCU in uncomplicated patients with acute MI remains controversial. We aimed to evaluate the safety of management in the general ward (GW) of hemodynamically stable patients with acute MI after primary percutaneous coronary intervention (PCI).

METHODS

Using a large nationwide administrative database, a cohort of 19426 patients diagnosed with acute MI in 52 hospitals where a CCU was available were retrospectively analyzed. Patients with mechanical cardiac support and Killip classification 4, and those without primary PCI on admission were excluded. A total of 5736 patients were included and divided into the CCU (n = 3488) and GW (n = 2248) groups according to the type of hospitalization room after primary PCI. Propensity score matching was performed, and 1644 pairs were matched. The primary endpoint was in-hospital mortality at 30 days.

RESULTS

The CCU group had a higher rate of Killip classification 3 and ambulance use than the GW group. There was no significant difference in the incidence of in-hospital mortality within 30 days among the matched subjects. Multivariable Cox proportional hazard model analysis among unmatched patients supported the findings (hazard ratio 1.12, 95% confidence interval 0.66-1.91, p = 0.67).

CONCLUSIONS

The use of the GW was not associated with higher in-hospital mortality in hemodynamically stable patients with acute MI after primary PCI. It may be feasible for the selected patients to be directly admitted to the GW after primary PCI.

Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction

OBJECTIVES

The aim of this study was to examine the temporal trends and outcomes of mechanical complications after myocardial infarction in the contemporary era.

BACKGROUND

Data regarding temporal trends and outcomes of mechanical complications after ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) are limited in the contemporary era.

METHODS

The National Inpatient Sample database (2003 to September 2015) was queried to identify all STEMI and NSTEMI hospitalizations. Temporal trends and outcomes of mechanical complications after STEMI and NSTEMI, including papillary muscle rupture, ventricular septal defect, and free wall rupture, were described.

RESULTS

The analysis included 3,951,861 STEMI and 5,114,270 NSTEMI hospitalizations. Mechanical complications occurred in 10,726 of STEMI hospitalizations (0.27%) and 3,041 of NSTEMI hospitalizations (0.06%), with no changes in trends (p = 0.13 and p = 0.83, respectively). The rates of in-hospital mortality in patients with mechanical complications were 42.4% after STEMI and 18.0% after NSTEMI, with no significant trend changes (p = 0.62 and p = 0.12, respectively). After multivariate adjustment, patients who had mechanical complications after myocardial infarction had higher in-hospital mortality, cardiogenic shock, acute kidney injury, hemodialysis, and respiratory complications compared with those without mechanical complications. Predictors of lower mortality in patients with mechanical complications who developed cardiogenic shock included surgical repair in the STEMI and NSTEMI cohorts and percutaneous coronary intervention in the STEMI cohort.

CONCLUSIONS

Contemporary data from a large national database show that the rates of mechanical complications are low in patients presenting with STEMI and NSTEMI. Post-myocardial infarction mechanical complications continue to be associated with high mortality rates, which did not improve during the study period.

Validation of diagnostic criteria and histopathological characterization of cardiac rupture in the mouse model of nonreperfused myocardial infarction

In patients with myocardial infarction (MI), cardiac rupture is an uncommon but catastrophic complication. In the mouse model of nonreperfused MI, reported rupture rates are highly variable and depend not only on the genetic background and sex of animals but also on the method used for documentation of rupture. In most studies, diagnosis of cardiac rupture is based on visual inspection during autopsy; however, criteria are poorly defined. We performed systematic histopathological analysis of whole hearts from C57BL/6J mice dying after nonreperfused MI and evaluated the reliability of autopsy-based criteria in identification of rupture. Moreover, we compared the cell biological environment of the infarct between rupture-related and rupture-independent deaths. Histopathological analysis documented rupture in 50% of mice dying during the first week post-MI. Identification of a gross rupture site was highly specific but had low sensitivity; in contrast, hemothorax had high sensitivity but low specificity. Mice with rupture had lower myofibroblast infiltration, accentuated macrophage influx, and a trend toward reduced collagen content in the infarct. Male mice had increased mortality and higher incidence of rupture. However, infarct myeloid cells harvested from male and female mice at the peak of the incidence of rupture had comparable inflammatory gene expression. In conclusion, the reliability of autopsy in documentation of rupture in infarcted mice is dependent on the specific criteria used. Macrophage-driven inflammation and reduced activation of collagen-secreting reparative myofibroblasts may be involved in the pathogenesis of post-MI cardiac rupture.NEW & NOTEWORTHY We show that cardiac rupture accounts for 50% of deaths in C57BL/6J mice undergoing nonreperfused myocardial infarction protocols. Overestimation of rupture events in published studies likely reflects the low specificity of hemothorax as a criterion for documentation of rupture. In contrast, identification of a gross rupture site has high specificity and low sensitivity. We also show that mice dying of rupture have increased macrophage influx and attenuated myofibroblast infiltration in the infarct. These findings are consistent with a role for perturbations in the balance between inflammatory and reparative responses in the pathogenesis of postinfarction cardiac rupture. We also report that the male predilection for rupture in infarcted mice is not associated with increased inflammatory activation of myeloid cells.

Plugging the Hole: Diagnosis and Management of Post-Myocardial Infarction Ventricular Septal Defect

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VSD after MI is a rare and often fatal complication.

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Echocardiography is essential in the diagnosis and management of these patients.

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Though urgent surgical repair is recommended, operative risk is often high.

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VA ECMO and percutaneous closure under echocardiographic guidance are alternatives.

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Echocardiography can identify persistent AV closure and stasis in the aortic root.

Outcomes and Hospital Utilization in Patients With Papillary Muscle Rupture Associated With Acute Myocardial Infarction

Papillary muscles rupture (PMR) is a rare complication of acute myocardial infarction (MI) that can lead to severe hemodynamic compromise, acute heart failure, and death. This study was designed to assess demographics, outcomes, and hospital utilization trends in the management of PMR associated with acute MI. Data were derived from the National Inpatient Sample for the years 2005 to 2014. ICD-9 codes 410.0 to 410.9 were used to identify patients with acute MI. ICD-9 code 429.6 was used to identify patients with PMR. ICD-9 procedures codes 35.23, 35.24, and 35.12 were used to identify patients who underwent mitral valve replacement (MVR) or repair. Of the 3,244,799 admissions, 932 were complicated by PMR (incidence of 0.029%). The majority of patients with PMR were ≥65 years old (60.1%) and male (60.4%). Of those with PMR, 57.5% underwent MVR. Compared to patients without PMR, those with PMR had a significantly higher in-hospital mortality rate (5.3 vs 36.3%, p <0.001), cost of hospitalization ($20,205 vs $74,383, p <0.001) and length of hospital stay (4.67 ± 02 vs 11.2 ± 0.80 days, p <0.001). Predictors of in-hospital mortality in PMR patients were age, inferior wall acute MI, and cardiac arrest. Predictors of MVR in PMR patients were age, female gender, concomitant coronary artery bypass grafting, mechanical circulatory support, longer length of stay, and admission to a large hospital. In conclusion, patients with PMR associated with acute MI have higher risk of in-hospital mortality, greater cost of hospitalization and longer length of stay than patients acute MI without PMR.