Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Poricoic acid A promotes angiogenesis and myocardial regeneration by inducing autophagy in myocardial infarction

Myocardial infarction (MI) is a kind of cardiovascular diseases with high morbidity and mortality. Poricoic acid A (PAA) is the main active substance in Poria cocos, which has been discovered to exhibit an ameliorative role in the progression of many diseases. However, no report has been focused on the regulatory effects of PAA on MI progression. In this study, at first, oxygen glucose deprivation (OGD) treatment was performed in human cardiac microvascular endothelial cells (HCMECs) to mimic MI cell model. Our findings demonstrated that cell proliferation was reduced post OGD treatment, but which was reversed by PAA treatment. Moreover, PAA suppressed cell apoptosis in OGD-triggered HCMEC cells. Next, it revealed that PAA induced autophagy in OGD-treated HCMEC cells through enhancing LC3-II/LC3-I level and reducing P62 level. In addition, PAA strengthened the angiogenesis ability and migration ability in OGD-induced HCMEC cells. Lastly, it was uncovered that PAA modulated the AMPK/mTOR signaling pathway through affecting the p-mTOR/mTOR and p-AMPK/AMPK levels. In conclusion, PAA can promote angiogenesis and myocardial regeneration after MI by inducing autophagy through modulating the AMPK/mTOR pathway. This work suggested that PAA may be a potential and useful drug for MI treatment.

Relation of Vasoreactivity in the Left and Right Coronary Arteries During Acetylcholine Spasm Provocation Testing

The diagnosis of vasospastic angina (VSA) according to Japanese guidelines involves an initial intracoronary acetylcholine (ACh) provocation test in the left coronary artery (LCA) followed by testing in the right coronary artery (RCA). However, global variations in test protocols often lead to the omission of ACh provocation in the RCA, potentially resulting in the underdiagnosis of VSA. This study assessed the validity of the LCA-only ACh provocation approach for the VSA diagnosis and whether vasoreactivity in the LCA aids in determining further provocation in the RCA. A total of 273 patients who underwent sequential intracoronary ACh provocation testing in the LCA and RCA were included. Patients with a positive ACh provocation test in the LCA were excluded. Relations between vasoreactivity in the LCA and ACh test outcomes (positivity and adverse events) in the RCA were evaluated. In patients with negative ACh test results in the LCA, subsequent ACh testing was positive in the RCA in 23 of 273 (8.4%) patients. In patients with minimal LCA vasoconstriction (<25%), only 3.0% had a positive ACh test in the RCA, whereas the ACh test in the RCA was positive in 13.5% of those with LCA constriction of 25% to 90% (p = 0.002). No major adverse events occurred during ACh testing in the RCA. In conclusion, for the VSA diagnosis, the omission of ACh provocation in the RCA may be clinically acceptable, particularly when vasoconstriction induced by ACh injection was minimal in the LCA. Further studies are needed to define ACh provocation protocols worldwide.

Advancements in Artificial Intelligence for Precision Diagnosis and Treatment of Myocardial Infarction: A Comprehensive Review of Clinical Trials and Randomized Controlled Trials

Coronary artery disease (CAD) is still a serious global health issue that has a substantial impact on death and illness rates. The goal of primary prevention strategies is to lower the risk of developing CAD. Nevertheless, current methods usually rely on simple risk assessment instruments that might overlook significant individual risk factors. This limitation highlights the need for innovative methods that can accurately assess cardiovascular risk and offer personalized preventive care. Recent advances in machine learning and artificial intelligence (AI) have opened up interesting new avenues for optimizing primary preventive efforts for CAD and improving risk prediction models. By leveraging large-scale databases and advanced computational techniques, AI has the potential to fundamentally alter how cardiovascular risk is evaluated and managed. This review looks at current randomized controlled studies and clinical trials that explore the application of AI and machine learning to improve primary preventive measures for CAD. The emphasis is on their ability to recognize and include a range of risk elements in sophisticated risk assessment models.

[Max Reger and his early death: could it have been avoided? : Would he have lived longer with adequate intensive care?]

BACKGROUND

Max Reger was an organist, university teacher and composer whose life, illnesses, death and dying are not or hardly known to many.

OBJECTIVES

Which illnesses determined Reger's life and did his lifestyle and illnesses influence his compositional work? Could his early death have been avoided? From today's point of view, could modern intensive care medicine have helped him?

MATERIAL AND METHODS

A detailed analysis of Reger's diseases was performed using scientific databases (medline, pubmed). All published articles were evaluated and examined in detail.

RESULTS

Max Reger was born in Brand in 1873 and received early lessons in violin, piano and organ playing. From 1890 he studied at the conservatory in Sondershausen, later at the conservatory in Wiesbaden. In 1901 he moved to Munich, and in 1907 to Leipzig, where he became university director and professor at the conservatory. Four years later he took over the court chapel in Meiningen, but ended this activity again in 1914. A year later he moved to Jena and wrote his late works in the "Jenaish style". Reger suffered from many illnesses, especially bipolar disorder with manic and depressive phases. He had metabolic syndrome with arterial hypertension, was overweight and smoked incredibly heavily. Overeating ("binge eating" syndrome) and polydipsia were other prominent findings. Reger's life was characterized by alcohol abuse, often aggravated by professional and/or human crises. In 1916 Reger died suddenly and unexpectedly in Leipzig of cardiovascular failure.

DISCUSSION

Reger was an outstanding personality who left behind an extensive oeuvre. Among the highlights of Max Reger's oeuvre are his chorale fantasies such as on "Ein' feste Burg ist unser Gott" (op. 27) or also the "Fantasia and Fugue on B A C H" (op. 46), but other compositions such as the Mozart Variations (op. 132) and the Clarinet Quintet (op. 146) are also world-famous. His lifestyle certainly favored coronary heart disease, the consequences of which caused Reger's sudden, unexpected and much too early death. Today's modern intensive care medicine could probably have prolonged his life.

Nanozyme-based visual diagnosis and therapeutics for myocardial infarction: The application and strategy

BACKGROUND

Myocardial infarction (MI) is a heart injury caused by ischemia and low oxygen conditions. The occurrence of MI lead to the activation of a large number of neutrophils and macrophages, inducing severe inflammatory injury. Meanwhile, the inflammatory response produces much more free radicals, further exacerbating the inflammatory response and tissue damage. Efforts are being dedicated to developing antioxidants and enzymes, as well as small molecule drugs, for treating myocardial ischemia. However, poor pharmacokinetics and potential side effects limit the clinical application of these drugs. Recent advances in nanotechnology have paved new pathways in biomedical and healthcare environments. Nanozymes exhibit the advantages of biological enzymes and nanomaterials, including with higher catalytic activity and stability than natural enzymes. Thus, nanozymes provide new possibilities for the diagnosis and treatment of oxidative stress and inflammation-related diseases.

AIM OF REVIEW

We describe the application of nanozymes in the diagnosis and therapy of MI, aiming to bridge the gap between the diagnostic and therapeutic needs of MI.

KEY SCIENTIFIC CONCEPTS OF REVIEW

We describe the application of nanozymes in the diagnosis and therapy of MI, and discuss the new strategies for improving the diagnosis and treatment of MI. We review in detail the applications of nanozymes to achieve highly sensitive detection of biomarkers of MI. Due to their unique enzyme catalytic capabilities, nanozymes have the ability to sensitively detect biomolecules through colorimetric, fluorescent, and electrochemical assays. In addition, nanozymes exhibit excellent antioxidase-mimicking activity to treat MI by modulating reduction/oxidation (REDOX) homeostasis. Nanozymes can also passively or actively target MI tissue sites, thereby protecting ischemic myocardial tissue and reducing the infarct area. These innovative applications of nanozymes in the field of biomedicine have shown promising results in the diagnosis and treatment of MI, offering a novel therapeutic strategy.

Comprehensive bioinformatics analysis reveals the role of cuproptosis-related gene Ube2d3 in myocardial infarction

Background

Myocardial infarction (MI) caused by severe coronary artery disease has high incidence and mortality rates, making its prevention and treatment a central and challenging aspect of clinical work for cardiovascular practitioners. Recently, researchers have turned their attention to a novel mechanism of cell death caused by Cu2+, cuproptosis.

Methods

This study integrated data from three MI-related bulk datasets downloaded from the Gene Expression Omnibus (GEO) database, and identified 16 differentially expressed genes (DEGs) related to cuproptosis by taking intersection of the 6378 DEGs obtained by differential analysis with 49 cuproptosis-related genes. Four hub genes, Dbt, Dlat, Ube2d1 and Ube2d3, were screened out through random forest analysis and Lasso analysis. In the disease group, Dbt, Dlat, and Ube2d1 showed low expression, while Ube2d3 exhibited high expression.

Results

Focusing on Ube2d3 for subsequent functional studies, we confirmed its high expression in the MI group through qRT-PCR and Western Blot detection after successful construction of a MI mouse model by left anterior descending (LAD) coronary artery ligation, and further clarified the correlation of cuproptosis with MI development by detecting the levels of cuproptosis-related proteins. Moreover, through in vitro experiments, Ube2d3 was confirmed to be highly expressed in oxygen-glucose deprivation (OGD)-treated cardiomyocytes AC16. In order to further clarify the role of Ube2d3, we knocked down Ube2d3 expression in OGD-treated AC16 cells, and confirmed Ube2d3's promoting role in the hypoxia damage of AC16 cells by inducing cuproptosis, as evidenced by the detection of MTT, TUNEL, LDH release and cuproptosis-related proteins.

Conclusion

In summary, our findings indicate that Ube2d3 regulates cuproptosis to affect the progression of MI.

Omitting 50 μg of intracoronary acetylcholine injection in the left coronary artery during spasm provocation test

BACKGROUND

Although guidelines recommend intracoronary administration of acetylcholine (ACh) with incremental doses of 20, 50, and 100 μg into the left coronary artery (LCA) during spasm provocation test for diagnosing vasospastic angina, 50 μg of ACh rarely induced significant coronary vasospasm when no vasoconstriction was observed with 20 μg of ACh in a previous report. The aim of this study was to evaluate the safety and feasibility of omitting 50 μg according to the vasoreactivity by 20 μg of ACh in the LCA.

METHODS

A total of 556 patients undergoing ACh provocation test with 20 μg followed by 50 and/or 100 μg were retrospectively included. Injection of 50 μg of ACh was primarily omitted when vasoconstriction <25 % was observed with 20 μg, which was left to operator's discretion. Adverse events were defined as a composite of ventricular fibrillation, sustained ventricular tachycardia, and cardiogenic shock during ACh test in the LCA.

RESULTS

Positive ACh test in the LCA was observed in 245 (44.1 %) patients. Overall, patients with LCA constriction <25 % by 20 μg of ACh had a lower rate of positive ACh test than their counterpart (24.0 % vs. 88.4 %, p < 0.001). In patients with LCA constriction ≥25 % by 20 μg, the incidence of adverse events was significantly higher than in those with LCA constriction <25 % during the provocation test at doses of 50 and 100 μg (2.3 % vs. 0 %, p = 0.009).

CONCLUSIONS

Omitting 50 μg of ACh in the LCA may be safe and feasible when little vasoconstriction was observed with preceding injection of 20 μg of ACh during spasm provocation test for diagnosing vasospastic angina. However, we believe that 50 μg of ACh should not be omitted when 20 μg of ACh induced LCA constriction ≥25 %.

Diagnostic ability of Japanese version of high bleeding risk criteria for ischemic outcomes in patients with acute myocardial infarction

The Japanese version of high bleeding risk (J-HBR) criteria was domestically proposed to identify patients at HBR after percutaneous coronary intervention (PCI). The applicability of J-HBR on bleeding events has been validated, while whether J-HBR predicts ischemic events is uncertain. This bi-center registry included 904 patients with acute myocardial infarction (MI) undergoing primary PCI. Patients were stratified by the J-HBR major (1 point) and minor (0.5 point) criteria. Patients with J-HBR ≥ 1 point were diagnosed as having HBR. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiovascular death, recurrent MI, and ischemic stroke, after discharge. Of the 904 patients, 451 (49.9%) had the J-HBR. The primary endpoint more frequently occurred in patients with J-HBR than in those without (10.9% vs. 4.9%, p < 0.001) during the median follow-up period of 522 days. Probability of MACE was progressively increased with the increase in the number of J-HBR major and minor criteria, in which severe anemia, severe chronic kidney disease, prior heart failure, peripheral artery disease, and prior ischemic stroke were identified as significant factors associated with MACE. In patients with acute MI undergoing PCI, the J-HBR criteria were predictive for ischemic outcomes after discharge, suggesting that the J-HBR criteria may be useful to identify patients at high bleeding and ischemic risks.

TBC1 domain family member 25 protects against myocardial apoptosis and the proinflammatory response triggered by ischemia-reperfusion injury through suppression of the TAK1-JNK/p38 MAPK signaling cascade

TBC1 domain family member 25 (TBC1D25) is a crucial mediator of signal transduction involved in the development of several diseases. Particularly, a cardioprotective role of TBC1D25 has been raised due to its antagonistic action on cardiac hypertrophy. However, whether TBC1D25 protects the myocardium from ischemia-reperfusion injury has not been reported. This work aimed to determine the role of TBC1D25 in myocardial ischemia-reperfusion (MIR) injury and to explore the potential mechanisms involved. Marked decreases in TBC1D25 levels occurred in cardiomyocytes suffering hypoxia/reoxygenation (H/R) injury in vitro and myocardium tissues of rats with MIR injury in vivo. Cardiomyocytes overexpressing TBC1D25 were protected from apoptosis and inflammation triggered by H/R, whereas TBC1D25-deficient cardiomyocytes were more sensitive to H/R injury. Intramyocardial injection of recombinant adenovirus expressing TBC1D25 into rats reduced infarct size and cardiac injury triggered by MIR injury accompanied by decreased myocardial apoptosis and inflammation. A subsequent mechanistic investigation revealed that the signaling cascade of transforming growth factor-β-activated kinase 1 (TAK1)-c-Jun N-terminal kinase (JNK)/p38 mitogen-activated protein kinase (MAPK) activated under H/R or MIR conditions was markedly restrained by TBC1D25 overexpression. Moreover, TAK1 blockade remarkably reversed the TBC1D25 deficiency-induced aggravating effect on H/R injury. The work concludes that TBC1D25 protects against MIR injury through action on the TAK1-JNK/p38 MAPK signaling cascade. This work suggests TBC1D25 as a potential therapeutic target for MIR injury.

Peripheral Inflammatory Factors and Acute Myocardial Infarction Risk: A Mendelian Randomization Study

Background

Previous observational studies have confirmed the relationship between inflammation and acute myocardial infarction (AMI), but genetic evidence is still lacking. The aim of this study was to explore the bidirectional association of multiple peripheral inflammatory factors with this disease at the genetic level.

Methods

Summary data for AMI and several peripheral inflammatory factors (such as interleukin-10 and interleukin-18) were collected from published genome-wide correlation studies. Based on the correlation, independence, and exclusivity assumptions, a total of 9 to 110 instrumental variables were selected from these summary data to predict the above traits. Two-sample Mendelian randomization methods, including inverse-variance weighted (IVW), were used to make causal inferences between exposures and outcomes. Sensitivity analyses including Cochran's Q, MR-Egger intercept, leave-one-out, forest plot, and MR-PRESSO were adopted to assess heterogeneity and horizontal pleiotropy.

Results

The IVW reported that elevated peripheral levels of interleukin-10 and interleukin-18 were nominally associated with a reduced risk of AMI (OR = 0.876, 95% CI = 0.788 ~ 0.974, P = 0.015; OR = 0.934, 95% CI = 0.875 ~ 0.997, P = 0.040). The IVW also reported that the risk of AMI nominally increased the peripheral level of interleukin-10 (OR = 1.062, 95% CI = 1.003 ~ 1.124, P = 0.040). No significant heterogeneity or horizontal pleiotropy were found by sensitivity analyses.

Conclusion

Both interleukin-10 and interleukin-18 were peripheral inflammatory factors genetically associated with AMI. In particular, combined with previous knowledge, interleukin-10 may have a protective effect on the onset, progression, and prognosis of the disease.

Automating venous thromboembolism risk assessment: a dual-branch deep learning method using electronic medical records

Background

Venous thromboembolism (VTE) is a prevalent cardiovascular disease. Although risk assessment and preventive measures are effective, manual assessment is inefficient and covers a small population in clinical practice. Hence, it is necessary to explore intelligent methods for VTE risk assessment.

Methods

The Padua scale has been widely used in VTE risk assessment, and we divided its assessment into disease category judgment and comprehensive clinical information judgment according to the characteristics of the Padua scale. We proposed a dual-branch deep learning (DB-DL) assessment method. First, in the disease category branch, we propose a deep learning-based Padua disease classification model (PDCM) for determining patients' Padua disease categories by considering patients' diagnosis, symptoms, and symptom weights. In the branch of comprehensive clinical information, we use the Chinese lexical analysis (LAC) word separation technique, combined with professional corpus and rules, to extract and judge the comprehensive clinical factors in the electronic medical record (EMR).

Results

We validated the accuracy of the method with the Padua assessment results of 7,690 Chinese clinical EMRs. First, our proposed method allows for a fully automated assessment, and the average time to assess one patient is only 0.37 s. Compared to the gold standard, our method has an Area Under Curve (AUC) value of 0.883, a specificity value of 0.957, and a sensitivity value of 0.816 for assessing the Padua risk patient class.

Conclusion

Our DB-DL assessment method automates VTE risk assessment, thereby addressing the challenges of time-consuming evaluation and limited population coverage. Thus, this method is highly clinically valuable.

Volume-Outcome Relations of Percutaneous Coronary Intervention in Patients Presenting With Acute Myocardial Infarction (from the J-PCI Registry)

A lower institutional primary percutaneous coronary intervention (PCI) volume is associated with a higher risk of postprocedural poor outcomes, particularly in urgent or emergent settings (e.g., PCI for acute myocardial infarction [MI]). However, the individual prognostic impact of PCI volume stratified by indication and the relative ratio remains unclear. Using the Japanese nationwide PCI database, we investigated 450,607 patients from 937 institutions who underwent either primary PCI for acute MI or elective PCI. The primary end point was the observed/predicted in-hospital mortality ratio. The predicted mortality per patient was calculated using the baseline variables and averaged for each institution. The relation between the annual primary, elective, and total PCI volumes and institutional in-hospital mortality after acute MI was evaluated. The association between the primary-to-total PCI volume per hospital and mortality was also investigated. Of the 450,607 patients, 117,430 (26.1%) underwent primary PCI for acute MI, of whom 7,047 (6.0%) died during hospitalization. The median total PCI volume and primary-to-total PCI volume ratio were 198 (interquartile range 115 to 311) and 0.27 (0.20 to 0.36). Overall, the observed in-hospital mortality and observed/predicted mortality ratio in patients with acute MI were higher in institutions with lower primary, elective, and total PCI volumes. The observed/predicted mortality ratio was also higher in institutions with lower primary-to-total PCI volume ratios, even in high-PCI volume hospitals. In conclusion, in this nationwide registry-based analysis, lower institutional PCI volumes, regardless of setting, were associated with higher in-hospital mortality after acute MI. The primary-to-total PCI volume ratio provided independent prognostic information.

Association between red blood cell distribution width-to-albumin ratio and prognosis of patients with acute myocardial infarction

BACKGROUND

Red blood cell distribution width (RDW) and albumin level were considered to be related to the prognosis of patients with acute myocardial infarction (AMI). This study aims to investigate the correlation between RAR and 90-day mortality in AMI patients.

METHODS

Data of AMI patients were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III) database. According to the median, RAR < 4.32 was regarded as low RAR level group, and RAR ≥ 4.32 as high RAR level group; low RDW level group was defined as < 14.00%, and high RDW level group as ≥ 14.00%; albumin < 3.30 g/dL was low level group, and albumin ≥ 3.30 g/dL as high level group. The outcome was the mortality rate within 90 days after admission to ICU. Univariate and multivariate Cox models were performed to determine the relationship between RAR and 90-day mortality in AMI patients with hazard ratio (HR) and 95% confidence interval (CI). Stratification analyses were conducted to explore the effect of RAR on 90-day mortality in different subgroups of age, gender, simplified acute physiology score II (SAPS II), elixhauser comorbidity index (ECI) score, treatment modalities and white blood cell.

RESULTS

Of the total 2081 AMI patients, 543 (26.09%) died within 90-day follow-up duration. The results showed that high RAR (HR = 1.65, 95% CI 1.34-2.03) and high RDW levels (HR = 1.31, 95% CI 1.08-1.61) were associated with an increased risk of death in AMI patients, and that high albumin level was related to a decreased risk of death (HR = 0.77, 95%CI 0.64-0.93). The relationship of RAR level and the mortality of AMI patients was also observed in the subgroup analysis. Additionally, the finding indicated that RAR might be a more effective biomarker for predicting 90-day mortality of AMI patients than albumin, RDW.

CONCLUSION

RAR may be a potential marker for the prognostic assessment of AMI, and a high RAR level was correlated with increased risk of 90-day mortality of AMI patients.

Prognostic Factors of In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Among patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS), in-hospital mortality remains high. In the present study, we aimed to identify factors associated with clinical outcomes of acute MI patients with CS in a contemporary setting. A total of 1102 patients with acute MI undergoing primary percutaneous coronary intervention were included, among whom 196 (17.8%) were complicated by CS. The primary outcome was all-cause death during hospitalization, and factors associated with in-hospital mortality were explored in patients with acute MI and CS. Of the 196 patients with acute MI complicated by CS, 77 (39.3%) died during hospitalization. The rates of non-ST-segment elevation MI (NSTEMI) (33.8% vs. 19.3%, p = 0.02) and culprit lesion in the left main or left anterior descending coronary artery (68.8% vs. 47.9%, p = 0.004) were higher, while left ventricular ejection fraction (LVEF) was lower (24.4 ± 11.7% vs. 39.7 ± 13.8%, p < 0.001) in non-survivors than in survivors. Multivariable analysis identified NSTEMI presentation and lower LVEF as independent predictors of in-hospital death. In conclusion, NSTEMI and low LVEF were identified as factors associated with higher in-hospital mortality. The identification of even higher-risk subsets and targeted therapeutic strategies may be warranted to improve survival of patients with acute MI and CS.

Factors Responsible for Prehospital Delay in Patients with Acute Coronary Syndrome in Bangladesh

Background: Acute coronary syndrome (ACS) remains a cause of high morbidity and mortality among adults, despite advances in treatment. Treatment modality and outcomes of ACS mainly depend on the time yielded since the onset of symptoms. Prehospital delay is the time between the onset of myocardial ischemia/infarction symptoms and arrival at the hospital, where either pharmacological or interventional revascularization is available. This delay remains unacceptably long in many countries worldwide, including Bangladesh. The current study investigates several sociodemographic characteristics as well as clinical, social, and treatment-seeking behaviors, with an aim to uncover the factors responsible for the decision time to get medical help and home-to-hospital delay. Materials and Methods: A prospective cross-sectional study was conducted between July 2019 and June 2020 in 21 district hospitals and 6 medical college hospitals where cardiac care facilities were available. The population selected for this study was patients with ACS who visited the studied hospitals during the study period. Following confirmation of ACS, a semi-structured data sheet was used to collect the patient data and was subsequently analyzed. Results: This study evaluated 678 ACS patients from 30 districts. The majority of the patients were male (81.9%), married (98.2%), rural residents (79.2), middle-aged (40–60 years of age) (55.8%), low-income holders (89.4%), and overweight (56.9%). It was found that 37.5% of the patients received their first medical care after 12 h of first symptom presentation. The study found that the patients’ age, residence, education, and employment status were significant factors associated with prehospital delay. The patients with previous myocardial infarction (MI) and chest pain arrived significantly earlier at the hospital following ACS onset. Location of symptom onset, first medical contact with a private physician, distance from symptom onset location to location of first medical contact, the decision about hospitalization, ignorance of symptoms, and mode of transportation were significantly associated with prehospital delay. Conclusions: Several factors of prehospital delay of the ACS patients in Bangladesh have been described in this study. The findings of this study may help the national health management system identify the factors related to treatment delay in ACS and thus reduce ACS-related morbidity and mortality.