Treatment and outcomes of patients with recurrent myocardial infarction: A prospective observational cohort study

Comparing adverse events of tenecteplase and alteplase: a real-world analysis of the FDA adverse event reporting system (FAERS)

OBJECTIVES

The aim of this study is to monitor, identify, and compare the adverse events (AEs) related to tenecteplase and alteplase, with the objective of exploring the potential safety of tenecteplase for acute ischemic stroke (AIS) and guiding its use to enhance patient safety.

METHODS

In order to evaluate the disproportionality of AEs associated with tenecteplase and alteplase in real-world data, four algorithms (ROR, PRR, BCPNN, EBGM) were utilized as measures to detect signals of AEs related to both drugs. Subsequently, Breslow-Day statistical analysis was applied to compare the RORs of the main system organ classes (SOCs) and key preferred terms (PTs) between tenecteplase and alteplase.

RESULTS

A statistical analysis was performed utilizing data gleaned from the Food and Drug Administration Adverse Event Reporting System (FAERS) database, encompassing 19,514,140 case reports from 2004Q1 to 2023Q1. There were 1,004 cases where tenecteplase was reported as the primary suspected (PS) and 2,363 tenecteplase-related adverse drug reactions (ADRs) at the PTs level were identified, the two data of alteplase were 10,945 and 25,266, respectively. The occurrence of drug-induced ADRs was analyzed across 27 organ systems, The analysis revealed several expected ADRs, such as Haemorrhage, Hypersensitivity which were consistent with the two drug-labels. It is of note that the signal strengths of 'death,' 'ventricular fibrillation,' 'cardiogenic shock' and 'pneumonia aspiration' at the PT level were markedly higher for tenecteplase than for alteplase, whereas the signal strength of 'angioedema' at the PT level was significantly higher for alteplase in comparison to tenecteplase. Additionally, unexpected significant ADRs associated with ocular adverse reactions and pneumonia aspiration at the PT level were identified, indicating potential AEs not currently mentioned in the drug instructions.

CONCLUSION

This study identified and compared signals of ADRs associated with tenecteplase and alteplase, although tenecteplase is as effective as alteplase and has advantages such as ease of use and affordability, it cannot replace alteplase in the treatment of AIS until its safety profile is fully recognized. Additionally, previously unreported ocular ADRs and pneumonia were identified, providing valuable insights into the relationship between ADRs and the use of these thrombolytic drugs. These findings underscore the importance of continuous monitoring and effective detection of AEs to ultimately enhance the safety of AIS patients undergoing thrombolytic therapy.

A cross-sectional examination of post-myocardial infarction physical activity levels among US rural and urban residents: Findings from the 2017-2019 Behavioral Risk Factor Surveillance System

BACKGROUND

This study sought to examine the relationship between rural residence and physical activity levels among US myocardial infarction (MI) survivors.

METHODS

We conducted a cross-sectional study using nationally representative Behavioral Risk Factor Surveillance System surveys from 2017 and 2019. We determined the survey-weighted percentage of rural and urban MI survivors meeting US physical activity guidelines. Logistic regression models were used to examine the relationship between rural/urban residence and meeting physical activity guidelines, accounting for sociodemographic factors.

RESULTS

Our study included 22,732 MI survivors (37.3% rural residents). The percentage of rural MI survivors meeting physical activity guidelines (37.4%, 95% CI: 35.1%-39.7%) was significantly less than their urban counterparts (45.6%, 95% CI: 44.0%-47.2%). Rural residence was associated with a 28.8% (95% CI: 20.0%-36.7%) lower odds of meeting physical activity guidelines, with this changing to a 19.3% (95% CI: 9.3%-28.3%) lower odds after adjustment for sociodemographic factors.

CONCLUSIONS

A significant rural/urban disparity in physical activity levels exists among US MI survivors. Our findings support the need for further efforts to improve physical activity levels among rural MI survivors as part of successful secondary prevention in US high-MI burden rural areas.

Risk Factors of Secondary Cardiovascular Events in a Multi-Ethnic Asian Population with Acute Myocardial Infarction: A Retrospective Cohort Study from Malaysia

This retrospective cohort study investigated the incidence and risk factors of major adverse cardiovascular events (MACE) after 1 year of first-documented myocardial infarctions (MIs) in a multi-ethnic Asian population. Secondary MACE were observed in 231 (14.3%) individuals, including 92 (5.7%) cardiovascular-related deaths. Both histories of hypertension and diabetes were associated with secondary MACE after adjustment for age, sex, and ethnicity (HR 1.60 [95%CI 1.22-2.12] and 1.46 [95%CI 1.09-1.97], respectively). With further adjustments for traditional risk factors, individuals with conduction disturbances demonstrated higher risks of MACE: new left-bundle branch block (HR 2.86 [95%CI 1.15-6.55]), right-bundle branch block (HR 2.09 [95%CI 1.02-4.29]), and second-degree heart block (HR 2.45 [95%CI 0.59-10.16]). These associations were broadly similar across different age, sex, and ethnicity groups, although somewhat greater for history of hypertension and BMI among women versus men, for HbA1c control in individuals aged >50 years, and for LVEF ≤ 40% in those with Indian versus Chinese or Bumiputera ethnicities. Several traditional and cardiac risk factors are associated with a higher risk of secondary major adverse cardiovascular events. In addition to hypertension and diabetes, the identification of conduction disturbances in individuals with first-onset MI may be useful for the risk stratification of high-risk individuals.

Recurrent myocardial infarction and emergency department visits: a retrospective study on the Stockholm Area Chest Pain Cohort

BACKGROUND

Patients who experience acute myocardial infarction (AMI) are at risk of recurrent AMI. Contemporary data on recurrent AMI and its association with return emergency department (ED) visits for chest pain are needed.

METHODS

This Swedish retrospective cohort study linked patient-level data from six participating hospitals to four national registers to construct the Stockholm Area Chest Pain Cohort (SACPC). The AMI cohort included SACPC participants visiting the ED for chest pain diagnosed with AMI and discharged alive (first primary diagnosis of AMI during the study period not necessarily the patient's first AMI). The rate and timing of recurrent AMI events, return ED visits for chest pain and all-cause mortality were determined during the year following index AMI discharge.

RESULTS

Among 1 37 706 patients presenting to the ED with chest pain as principal complaint from 2011 to 2016, 5.5% (7579/137 706) were hospitalised with AMI. In total, 98.5% (7467/7579) of patients were discharged alive. In the year following index AMI discharge, 5.8% (432/7467) of AMI patients experienced ≥1 recurrent AMI event. Return ED visits for chest pain occurred in 27.0% (2017/7467) of index AMI survivors. During a return ED visit, recurrent AMI was diagnosed in 13.6% (274/2017) of patients. One-year all-cause mortality was 3.1% in the AMI cohort and 11.6% in the recurrent AMI cohort.

CONCLUSIONS

In this AMI population, 3 in 10 AMI survivors returned to the ED for chest pain in the year following AMI discharge. Furthermore, over 10% of patients with return ED visits were diagnosed with recurrent AMI during that visit. This study confirms the high residual ischaemic risk and associated mortality among AMI survivors.

Long-term follow-up of survivors of a first acute coronary syndrome: Results from the French MONICA registries from 2009 to 2017

AIM

The objectives of the study were to characterize the long-term risk of first recurrence of acute coronary syndrome (ACS) among survivors of an incident ACS, as a function of the STEMI/NSTEMI/UA diagnosis.

METHODS

Men and women (aged 35-74) hospitalized between 2009 and 2016 for an incident ACS in the French MONICA registries and still alive on discharge were followed-up until December 2017. Recurrent events were defined as the first (non-fatal or fatal) ACS occurring after hospital discharge from the incident event.

RESULTS

The study comprised 15,739 incident ACSs with 63,777 patient-years of follow-up. The cumulative probability [95% confidence interval] of recurrent ACS was 6.7% [6.3-7.1%] at 1 year and 18.4% [17.4-19.5%] at 9 years. The cumulative probability of fatal recurrent ACS was 1.4% [1.2-1.5%] at 1 year and 4.3% [3.6-4.9%] at 9 years. The risk of recurrence did not depend on the type of the incident ACS after adjustment for confounding factors. The most frequent forms of recurrence were NSTEMI and UA. The presence of a major complication (OR = 1.59) and an impaired left ventricular ejection fraction (LVEF) (OR > 1.26) increased the risk of recurrence. The annual 1-year recurrence rates decreased from 7.4% in 2009 to 4.0% in 2016 (p < 0.001).

CONCLUSION

The recurrence rate after an incident ACS remained high in France, and the risk of recurrence did not depend on the etiology of the first event. Our results emphasize the importance of targeting patients with a major complication and/or an impaired LVEF who are at a higher risk of recurrence.

The Association Between a Second Course of Cardiac Rehabilitation and Cardiovascular Outcomes Following Repeat Percutaneous Coronary Intervention Events

PURPOSE

Survivors of coronary artery disease (CAD) events are at risk for repeat events. Although evidence supports cardiac rehabilitation (CR) after an initial CAD event, it is unclear whether a repeat course of CR (CR × 2) is beneficial after a recurrent CAD event. The purpose of this study was to determine the association of CR × 2 with clinical outcomes in persons undergoing repeat percutaneous coronary intervention (PCI).

METHODS

We assessed the prevalence of CR × 2 and its impact on cardiovascular outcomes in individuals who experienced a repeat PCI at the Mayo Clinic hospitals between January 1, 1998, and December 31, 2013. Landmark analyses were used to calculate unadjusted and propensity score adjusted mortality rates and cardiovascular (CV) events rates for patients who underwent CR × 2 compared with those who did not.

RESULTS

Among 240 individuals who had a repeat PCI and who had participated in CR after their first PCI, 97 (40%) participated in CR × 2. Outcomes were assessed for a mean follow-up time of 7.8 yr (IQR 7.1-9.0 yr). Propensity score-based inverse probability weighting analysis revealed that CR × 2 was associated with significantly lower target lesion revascularization (HR = 0.47: 95% CI, 0.26-0.86; P = .014), lower combined end point of CV death, myocardial infarction, and target lesion revascularization (HR = 0.57: 95% CI, 0.36-0.89; P = .014), and lower CV hospitalization (HR = 0.60; 95% CI, 0.43-0.84; P = .003).

CONCLUSION

A second course of CR following repeat PCI is associated with a lower risk of adverse clinical outcomes. These findings support current policies that allow for repeat courses of CR following recurrent CV events.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand

OBJECTIVE

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported.

METHODS

First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity.

RESULTS

Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log₂(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084.

CONCLUSIONS

In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score.

TRIAL REGISTRATION NUMBER

ACTRN12615000676516.

Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention “Codi IAM” Network

Background

Despite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the “Codi IAM” network in Barcelona.

Methods

This is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality.

Results

The mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p &lt; 0.003), had longer reperfusion delays (p &lt; 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7–1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84–1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76–1.56).

Conclusion

Although the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.

Comparison of clinical profiles and care for patients with incident versus recurrent acute coronary syndromes in France: Data from the MONICA registries

Background

Recurrence is common after an acute coronary syndrome (ACS). In order to better assess the prognosis for patients with ACS, we compared clinical profiles, treatments, and case fatality rates for incident vs. recurrent ACS.

Methods

We enrolled 1,459 men and women (age: 35–74) living in three geographical areas covered by French MONICA registries and who had been admitted to hospital for an ACS in 2015/2016. We recorded and compared the clinical characteristics and medical care for patients with an incident vs. a recurrent ACS.

Results

Overall, 431 (30%) had a recurrent ACS. Relative to patients with an incident ACS, patients with recurrence were older (p<0.0001), had a greater frequency of NSTEMI or UA (p<0.0001), were less likely to show typical symptoms (p = 0.045), were more likely to have an altered LVEF (p<0.0001) and co-morbidities. Angioplasty was less frequently performed among patients with recurrent than incident NSTEMI (p<0.05). There were no intergroup differences in the prescription of the recommended secondary prevention measures upon hospital discharge, except for functional rehabilitation more frequently prescribed among incident patients (p<0.0001). Although the crude 1-year mortality rate was higher for recurrent cases (14%) than for incident cases (8%) (p<0.05), this difference was no longer significant after adjustment for age, sex, region, diagnosis category and LVEF.

Conclusion

Compared with incident patients, recurrent cases were more likely to have co-morbidities and to have suboptimal treatments prior to hospital stay, reinforcing the need for secondary prevention.

Temporal Trends and Outcome of Patients with Acute Coronary Syndrome and Prior Myocardial Infarction

Patients who have previously had a myocardial infarction (MI) are considered a high-risk group with increased risk for cardiovascular (CV) events. During the last decade, the outcome of acute coronary syndrome (ACS) patients has improved due to advances in medical therapy and interventional techniques. We aimed to examine temporal trends and outcomes of patients with prior MI admitted due to ACS from the Acute Coronary Syndrome Israeli Survey (ACSIS). Included were 16,934 ACS patients, of whom 31.4% had prior MI. For temporal trend analysis, the cohort was divided into an early period (2000-2008) and late period (2010-2018). For patients with prior MI, patients in the late period had a higher rate of CV risk factors and were treated more frequently with revascularization and guidelines-directed medical therapy. Recurrent MI (6.7% vs. 12%, p < 0.001), MACE (10.6% vs. 21%, p < 0.001) and 1-year mortality (10.7% vs. 14.6%, p < 0.001) were significantly lower in the late period. However, the mortality rate for patients with prior MI remained higher compared with patients without prior MI (10.7% vs. 6.8% p < 0.001) with an overall higher mortality rate in the STEMI group. Thus, despite significant improvement in outcome measures in the contemporary era, ACS patients with prior MI are still at increased risk for recurrent ischemic CV events and mortality.

Evaluation of the tolerability and effectiveness of Tenecteplase in patients with ST-Segment-Elevation Myocardial Infarction in a Secondary Hospital in Malaysia: A Retrospective Case Series

Background

In Malaysia, knowledge regarding the clinical efficacy of tenecteplase (TNK), a fibrin-specific tissue-plasminogen activator, is limited.

Objectives

To evaluate the effectiveness and tolerability of TNK in patients with ST-segment-elevation myocardial infarction in a secondary referral Malaysian hospital.

Methods

This was a single-center retrospective case series based on the medical records of patients with ST-segment-elevation myocardial infarction admitted to the cardiac care unit between January 2016 and May 2019. Data regarding the mortality status and date of death were collected from the database of the National Registration Department of Malaysia.

Results

Data for 30 patients with ST-segment-elevation myocardial infarction, who received weight-adjusted doses of TNK, were analyzed. The patients’ mean (SD) age was 62 (14) years, and 77% were men. The median time to treatment was 265 minutes (interquartile range = 228–660 minutes), and the clinical success rate of thrombolysis was 79%. The overall all-cause in-hospital mortality rate was 33%. The 1-year survival rates were higher in patients achieving a time to treatment ≤360 minutes (P = 0.03), with a trend toward greater survival in this group at 30 days. Similarly, a trend toward lower in-hospital all-cause mortality was observed in this group (21% vs 50%; P = 0.12). Only 1 patient (3%), who had a HAS-BLED score based on hypertension, abnormal liver/renal function, stroke history, bleeding history or predisposition, labile international normalized ratio, old age, drug/alcohol use of 5, developed major bleeding that required blood transfusion. No cases of ischemic stroke, nonmajor bleeding, in-hospital reinfarction, or TNK-induced allergic reaction were identified.

Conclusions

We hypothesized that the mortality-related outcomes of TNK in patients with ST-segment-elevation myocardial infarction were influenced by TTT, with TTT ≤360 minutes indicating a better prognosis than TTT >360 minutes. TNK-induced bleeding-related complications were minimal in low-risk patients. Further local studies are needed to compare TNK's profile with that of streptokinase, which is a common agent currently used in clinical practice in Malaysian public hospitals. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)

Characteristics and Outcomes of Early Recurrent Myocardial Infarction After Acute Myocardial Infarction

Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90-day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention (P=0.04) or coronary artery bypass grafting (P=0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all-cause mortality rate for patients with an early RMI was 49% (95% CI, 40%-57%) compared with 22% (95% CI, 21%-23%) for patients without an early RMI (P<0.0001). Conclusions Early RMI is a life-threatening condition with nearly 50% mortality within 5 years. Stent-related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.

Incidence and risk factors for major bleeding among patients undergoing percutaneous coronary intervention: Findings from the Norwegian Coronary Stent Trial (NORSTENT)

INTRODUCTION

Bleeding is a concern after percutaneous coronary intervention (PCI) and subsequent dual antiplatelet therapy (DAPT). We herein report the incidence and risk factors for major bleeding in the Norwegian Coronary Stent Trial (NORSTENT).

MATERIALS AND METHODS

NORSTENT was a randomized, double blind, pragmatic trial among patients with acute coronary syndrome or stable coronary disease undergoing PCI during 2008-11. The patients (N = 9,013) were randomized to receive either a drug-eluting stent or a bare-metal stent, and were treated with at least nine months of DAPT. The patients were followed for a median of five years, with Bleeding Academic Research Consortium (BARC) 3-5 major bleeding as one of the safety endpoints. We estimated cumulative incidence of major bleeding by a competing risks model and risk factors through cause-specific Cox models.

RESULTS

The 12-month cumulative incidence of major bleeding was 2.3%. Independent risk factors for major bleeding were chronic kidney disease, low bodyweight (< 60 kilograms), diabetes mellitus, and advanced age (> 80 years). A myocardial infarction (MI) or PCI during follow-up increased the risk of major bleeding (HR = 1.67, 95% CI 1-29-2.15).

CONCLUSIONS

The 12-month cumulative incidence of major bleeding in NORSTENT was higher than reported in previous, explanatory trials. This analysis strengthens the role of chronic kidney disease, advanced age, and low bodyweight as risk factors for major bleeding among patients receiving DAPT after PCI. The presence of diabetes mellitus or recurrent MI among patients is furthermore a signal of increased bleeding risk.

CLINICAL TRIAL REGISTRATION

Unique identifier NCT00811772; http://www.clinicaltrial.gov.

Associations between Subsequent Hospitalizations and Primary Ambulatory Services Utilization within the First Year after Acute Myocardial Infarction and Long-Term Mortality

Healthcare resource utilization peaks throughout the first year following acute myocardial infarction (AMI). Data linking the former and outcomes are sparse. We evaluated the associations between subsequent length of in-hospital stay (SLOS) and primary ambulatory visits (PAV) within the first year after AMI and long-term mortality. This retrospective analysis included patients who were discharged following an AMI. Study groups: low (0-1 days), intermediate (2-7) and high (≥8 days) SLOS; low (<10) and high (≥10 visits) PAV, throughout the first post-AMI year. All-cause mortality was set as the primary outcome. Overall, 8112 patients were included: 55.2%, 23.4% and 21.4% in low, intermediate and high SLOS groups respectively; 26.0% and 74.0% in low and high-PAV groups. Throughout the follow-up period (up to 18 years), 49.6% patients died. Multivariable analysis showed that an increased SLOS (Hazard ratio (HR) = 1.313 and HR = 1.714 for intermediate and high vs. low groups respectively) and a reduced number of PAV (HR = 1.24 for low vs. high groups) were independently associated with an increased risk for mortality (p < 0.001 for each). Long-term mortality following AMI is associated with high hospital and low primary ambulatory services utilization throughout the first-year post-discharge. Measures focusing on patients with increased SLOS and reduced PAV should be considered to improve patient outcomes.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016

INTRODUCTION AND OBJECTIVES

ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI.

METHODS

This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality.

RESULTS

From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).

CONCLUSIONS

Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

Effect of renin-angiotensin system inhibitors on major clinical outcomes in patients with acute myocardial infarction and prediabetes or diabetes after successful implantation of newer-generation drug-eluting stents

AIM

To investigate the comparative effectiveness of renin-angiotensin system inhibitor (RASI) therapy on major clinical outcomes in patients with acute myocardial infarction (AMI) and prediabetes or diabetes after successful percutaneous coronary intervention (PCI) with newer-generation drug-eluting stents (DESs).

METHODS

A total of 11,962 patients with AMI were divided into six groups according to glycemic status and the presence or absence of RASI therapy: normoglycemia (n = 3,080; RASI+ [n = 2,496], RASI- [n = 584]), prediabetes (n = 3,709; RASI+ [n = 2,944], RASI- [n = 765]), and diabetes (n = 5,173; RASI+ [n = 4,133], RASI- [n = 1,040]). The major endpoint was major adverse cardiac events (MACEs), defined as all-cause death, recurrent myocardial infarction (re-MI), or any repeat revascularization.

RESULTS

After adjustment, in RASI users, the cumulative incidence of re-MI of the diabetes group was significantly higher than that of the prediabetes group (aHR, 1.999; 95% CI, 1.153-3.467; p = 0.014). However, the cumulative incidences of MACEs, all-cause death, and any repeat revascularization were similar between the two groups during a 2-year follow-up period.

CONCLUSIONS

In the era of newer-generation DESs, RASI therapy did not reduce re-MI in patients with AMI and diabetes in this study.

Association Between Subsequent Hospitalizations and Recurrent Acute Myocardial Infarction Within 1 Year After Acute Myocardial Infarction

Background

Patients who survive acute myocardial infarction (AMI) are at high risk for recurrence. We determined whether rehospitalizations after AMI further increased risk of recurrent AMI.

Methods and Results

The study included Medicare fee‐for‐service patients aged ≥65 years discharged alive after AMI from acute‐care hospitals in fiscal years 2009–2014. The outcome was recurrent AMI within 1 year of the index AMI. The Clinical Classifications Software (CCS) was used to classify rehospitalizations into disease categories. A Cox regression model was fit accounting for CCS‐specific hospitalizations as time‐varying variables and patient characteristics at discharge for the index AMI, adjusting for the competing risk of death. The rate of 1‐year recurrent AMI was 5.3% (95% CI, 5.27%–5.41%), and median (interquartile range) time from discharge to recurrent AMI was 115 (34–230) days. Eleven disease categories (diabetes mellitus, anemia, hypertension, coronary atherosclerosis, chest pain, heart failure, pneumonia, chronic obstructive pulmonary disease, gastrointestinal hemorrhage, renal failure, complication of implant or graft) were associated with increased risk of recurrent AMI. Septicemia was associated with lower recurrence risk. Hazard ratios ranged from 1.6 (95% CI, 1.55–1.70, heart failure) to 1.1 (95% CI, 1.04–1.25, pneumonia) to 0.6 (95% CI, 0.58–0.71, septicemia).

Conclusions

Patient risk of recurrent AMI changed based on the occurrence of hospitalizations after the index AMI. Improving post–acute care to prevent unplanned rehospitalizations, especially rehospitalizations for chronic diseases, and extending the focus of outcomes measures to condition‐specific rehospitalizations within 30 days and beyond is important for the secondary prevention of AMI.

Psychological and social factors of adherence to treatment in patients with myocardial infarction

AIM

The aim of the study was to assess the impact of psychological and social factors on adherence to treatment in patients with primary and repeated myocardial infarction (MI).

MATERIALS AND METHODS

Patients with primary (n=61) and repeated (n=72) ST-segment elevation MI were enrolled in the study. State and trait anxiety, accentuation of personality traits, patient awareness, and adherence to treatment, represented by adherence rate to treatment were evaluated.

RESULTS

There were no statistically significant differences found in adherence to treatment between the study groups. Patients' adherence to treatment in the whole cohort was low positive. Patients with primary MI demonstrated higher state anxiety than patients with repeated MI (p=0.0173). The following accentuation of personality traits were determined: hypertimity, emotivity, anxiety, dysthymia and cyclothymic. They were comparable in their severity in primary and repeated MI patients. The regression analysis revealed that the higher the level of education, the higher (by 0.40 scores) adherence rate to treatment (p=0.0210). Higher patients' awareness resulted in increased adherence rate by 0.54 scores (p=0.0010).

CONCLUSION

The main factors contributing to increased adherence rate in patients with MI were the level of education and awareness on the issues of preventing an unfavorable cardiovascular prognosis.

Predicting death after acute myocardial infarction

Recognizing and understanding the risk factors for mortality after acute myocardial infarction (AMI) provide clinicians and patients important information to determine prognosis and guide treatment. Most risk stratification models use demographic and clinical information that exists prior to hospitalization plus clinical presentation characteristics to estimate a patient's risk of mortality. In this review, we summarize the most important risk factors and discuss current models to predict mortality.

Glycated hemoglobin level is an independent predictor of major adverse cardiac events after nonfatal acute myocardial infarction in nondiabetic patients: A retrospective observational study

The effect of glycemic control on the prognosis of nondiabetic patients after acute myocardial infarction (AMI) remains uncertain. We investigated whether glycated hemoglobin (HbA1c) is associated with adverse outcomes after AMI in nondiabetic patients. In this observational study, we enrolled nondiabetic patients with AMI in the emergency department of 2 medical centers from January 2011 to September 2014. All patients received primary percutaneous coronary intervention and were divided into 4 groups according to the interquartile range of average HbA1c level (Group I, ≤5.6%; Group II, 5.6%-5.8%; Group III, 5.8%-6.0%; and Group IV, >6.0%). Multivariate logistic analysis was performed to estimate the correlation of HbA1c with major adverse cardiac events (MACEs) after AMI. In total, 267 eligible patients were enrolled; 48 patients (18%) developed MACEs within a median follow-up of 178 days. Univariate analysis showed HbA1c > 6.0%, with a higher risk of MACEs in Group IV than in Group I (odds ratio [OR]: 2.733; 95% confidence interval [CI]: 1.123-6.651 vs OR: 1.511; 95% CI: 0.595-3.835). Multivariate analysis revealed an approximately 3.8 times higher risk of MACEs in Group IV than in Group I (OR: 3.769; 95% CI: 1.30-10.86). The HbA1 level is a significant predictor of MACEs after AMI in nondiabetic patients.

Examining the Impact of Rehospitalization on Healthcare Cost of Myocardial Infarction Patients in Beijing: A Retrospective Observational Study

INTRODUCTION

To examine the impact of rehospitalization on the healthcare expenditure of myocardial infarction (MI) patients in Beijing.

METHODS

Retrospective data of MI patients were retrieved from the Beijing Medical Insurance Database, an administrative database of social medical reimbursement activities for the urban population in Beijing, China. Ten percent of patients diagnosed with MI from January 1 to December 31, 2012 were randomly selected and their first hospitalization was considered as the index event. Their hospital utilization after the index event was extracted till September 30, 2013. Rehospitalization was defined as an event of hospital admission due to the same diagnosis and with a time interval of at least 14 days from the most recent admission. The healthcare cost of patients was analyzed, including inpatient cost and outpatient cost. Patients' demographic characteristics, co-morbidities, and length of hospital stay were also collected from the database.

RESULTS

Of the 1235 MI patients identified, 335 (mean age of 66.14 ± 15.04 years; 84.18% males) had rehospitalization. The rate of MI recurrence was 27.13%. The annual healthcare expense was significantly higher for MI patients with rehospitalization compared to MI patients without rehospitalization (99,920.43 ± 84,113.52 CNY vs. 58,877.89 ± 93,942.90 CNY; P < 0.001). The significant positive predictors of incurring healthcare expenditure were male gender, age 45 years old or more, length of stay at first hospital admission, whether having rehospitalization (yes/no), co-morbidity (heart failure and diabetes), and admission to a tertiary hospital at first hospital admission.

CONCLUSION

There was a high risk of MI recurrence for patients in Beijing. The annual healthcare cost of MI patients with rehospitalization was significantly higher than MI patients without rehospitalization. Male patients of 45 years old or more with heart failure and diabetes are likely to incur higher healthcare expenditure.