Significance of location (anterior versus inferior) and type (Q-wave versus non-Q-wave) of acute myocardial infarction in patients undergoing percutaneous transluminal coronary angioplasty for postinfarction ischemia

[[Long-term prognostic impact of the left anterior descending coronary artery as the STEMI-related culprit vessel: subanalysis of the EXAMINATION-EXTEND trial]]

Introduction and objectives

There is limited data on the impact of the culprit vessel on very long-term outcomes after ST-elevation myocardial infarction (STEMI). The aim was to analyze the impact of the left anterior descending coronary artery (LAD) as the culprit vessel of STEMI on very long-term outcomes.

Methods

We analyzed patients included in the EXAMINATION-EXTEND study (NCT04462315) treated with everolimus-eluting stents or bare-metal stents after STEMI (1498 patients) and stratified according to the culprit vessel (LAD vs other vessels). The primary endpoint was the patient-oriented composite endpoint (POCE), including all-cause mortality, myocardial infarction (MI) or revascularization at 10 years. Secondary endpoints were individual components of POCE, device-oriented composite endpoint and its individual components and stent thrombosis. We performed landmark analyses at 1 and 5 years. All endpoints were adjusted with multivariable Cox regression models.

Results

The LAD was the culprit vessel in 631 (42%) out of 1498 patients. The LAD-STEMI group had more smokers, advanced Killip class and worse left ventricular ejection fraction. Conversely, non-LAD-STEMI group showed more peripheral vascular disease, previous MI, or previous PCI. At 10 years, no differences were observed between groups regarding POCE (34.9% vs 35.4%; adjusted hazard ratio [HR], 0.95; 95% confidence interval [95%CI], 0.79-1.13; P = .56) or other endpoints. The all-cause mortality rate was higher in the LAD-STEMI group (P = .041) at 1-year.

Conclusions

In a contemporary cohort of STEMI patients, there were no differences in POCE between LAD as the STEMI-related culprit vessel and other vessels at 10 years follow-up. However, all-cause mortality was more common in the LAD-STEMI group within the first year after STEMI.

Development and validation of a risk score for predicting 30-day mortality in patients with ST elevation myocardial infarction

The existing risk sores for ST-elevation myocardial infarction (STEMI) patients cannot balance timeliness, feasibility, and accuracy. This study aimed to develop and validate a two-stage scoring system capable of dynamic evaluation for 30-day mortality among STEMI patients. We recruited 3939 patients and randomly assigned (7:3) to derivation (N = 2757) and internal validation (N = 1182) datasets, an independent cohort of 1315 STEMI patients was used for external validation. The two-stage scoring system was developed based on factors associated with 30-day mortality identified by multivariate analysis and their availability in course of management. The first medical contact (FMC) stage risk score comprised six predictors (age, gender, systolic blood pressure, heart rate, Killip class, and anterior myocardial infarction), the in-hospital risk score included serum creatinine and left ventricular ejection fraction on this basis. The area under the curve (AUC) were 0.816, 0.854, 0.843, and 0.876 in derivation and internal validation for FMC and in-hospital stage risk score with satisfactory calibration ability. FMC stage risk score displayed equivalent predictive ability with TIMI risk score and GRACE score, in-hospital stage risk score obtained promotion in AUC, integrated discrimination improvement, and net reclassification improvement (all P < 0.001) compared with the classic risk scores. The reproducibility and effectiveness of the risk scores were statistically confirmed in the external validation cohort. The two-stage scoring system had good ability for predicting 30-day mortality and useful to dynamically identify high-risk STEMI patients.Trial registration: [NCT02641262] [29 December 2015].

Anterior-wall and non-anterior-wall STEMIs do not differ in long-term mortality: results from the augsburg myocardial infarction registry

Background

Different ST-segment elevation myocardial infarction (STEMI) localizations go along with dissimilarities in the size of the affected myocardium, the causing coronary vessel occlusion, and the right ventricular participation. Therefore, this study aims to clarify if there is any difference in long-term survival between anterior- and non-anterior-wall STEMI.

Methods

This study included 2,195 incident STEMI cases that occurred between 2009 and 2017, recorded by the population-based Augsburg Myocardial Infarction Registry, Germany. The study population comprised 1.570 men and 625 women aged 25-84 years at acute myocardial infarction. The patients were observed from the day of their first acute event with an average follow-up period of 4.3 years, (standard deviation: 3.0). Survival analyses and multivariable Cox regression analyses were performed to examine the association between infarction localizations and long-term all-cause mortality.

Results

Of the 2,195 patients, 1,118 had an anterior (AWS)- and 1,077 a non-anterior-wall-STEMI (NAWS). No significant associations of the STEMI localization with long-term mortality were found. When comparing AWS with NAWS, a hazard ratio of 0.91 [95% confidence interval: 0.75-1.10] could be calculated after multivariable adjustment. In contrast to NAWS, AWS was associated with a greater <28 day mortality, less current or former smoking and higher creatine kinase-myocardial band levels (CK-MB) and went along with a higher frequency of impaired left ventricular ejection fraction (<30%).

Conclusions

Despite pathophysiological differences between AWS and NAWS, and identified differences in multiple clinical characteristics, no significant differences in long-term mortality between both groups were observed.

Effect of Infarction-Related Artery Location on Clinical Outcome of Patients With Acute Myocardial Infarction in the Contemporary Era of Percutaneous Coronary Intervention - Subanalysis From the Prospective Japan Acute Myocardial Infarction Registry (JAMIR)

BACKGROUND

Previous studies have reported that acute myocardial infarction (AMI) related to left anterior descending (LAD) lesion is associated with worse outcomes than left circumflex artery (LCX) or right coronary artery (RCA) lesions. However, it is unknown whether those relationships are still present in the contemporary era of primary percutaneous coronary intervention (PCI), using newer generation drug-eluting stents and potent antiplatelet agents.

METHODS AND RESULTS

This study is a sub-analysis of the Japan AMI Registry (JAMIR), a multicenter, prospective registry enrolling 3,411 AMI patients between December 2015 and May 2017. Among them, 2,780 patients undergoing primary PCI for only a culprit vessel were included and stratified based on infarction-related artery type (LAD, LCX, and RCA). The primary outcome was 1-year cardiovascular death. The overall incidence of cardiovascular death was 3.4%. Patients with LAD infarction had highest incidence of cardiovascular death compared to patients with LCX and RCA infarction (4.8%, 1.3%, and 2.4%, respectively); however, landmark analysis showed that culprit vessel had no significant effect on cardiovascular death if a patient survived 30 days after primary PCI. LAD lesion infarction was an independent risk factor for cardiovascular death in adjusted Cox regression analysis.

CONCLUSIONS

The present sub-analysis of the JAMIR demonstrated that LAD infarction is still associated with worse outcomes, especially during the first 30 days, even in the contemporary era of PCI.

Effects of Myocardial Perfusion Defect on the Frontal QRS-T Angle in Anterior Versus Inferior Myocardial Infarction

Objective The frontal QRS-T angle on a 12-lead electrocardiogram (ECG) has recently become accepted as a variable of ventricular repolarization. We compared the effects of myocardial perfusion defect (MPD) on the frontal QRS-T angle between anterior and inferior myocardial infarction (MI) using single-photon emission computed tomography. Methods The frontal QRS-T angle was defined as the absolute value of the difference between the frontal plane QRS axis and T-wave axis. A QRS-T angle more than 90° was considered abnormal. Patients Forty-two patients with anterior MI and 42 age- and sex-matched patients with inferior MI were enrolled. For controls, 42 age- and sex-matched patients with no MPD were selected. Results The mean frontal QRS-T angles in anterior MI, inferior MI and control subjects were 94.7±46.2°, 26.7±22.1° and 27.0±23.2°, respectively. Compared with controls, the frontal QRS-T angle was larger in anterior MI subjects (p<0.001), and similar in value to that in inferior MI subjects (p=0.69). An abnormal QRS-T angle was frequent in the anterior MI subjects than the inferior MI subjects (55% vs. 2%, p<0.001). In anterior MI subjects, MPD was significantly associated with the T-wave axis (ρ=0.46, p=0.002) and QRS-T angle (ρ=0.47, p=0.002), but was not with the QRS axis (ρ=0.07, p=0.66). In inferior MI subjects, there were no associations between MPD and the ECG variables. Conclusion Our data suggest that the frontal QRS-T angle in inferior MI subjects is not increased as evidently as that in anterior MI subjects.

Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction: Analysis from the HORIZONS-AMI trial

OBJECTIVES

We sought to identify clinical, electrocardiographic (ECG), and angiographic characteristics that are predictive of 3-year mortality after primary percutaneous coronary intervention (PCI) in patients with non-anterior ST-elevation myocardial infarction (NA-STEMI) from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial.

BACKGROUND

Which patients with NA-STEMI undergoing PCI have a poor prognosis is uncertain.

METHODS

NA-STEMI was defined as ST-segment elevation in lateral (V5, V6, I, aVL), inferior (II, III, aVF), or inferolateral (I, II, III, aVF, and V5-V6) ECG leads or posterior myocardial infarction with ST-segment depression of ≥1 mm in ≥2 contiguous anterior leads. Cox regression was used to identify independent predictors of 3-year mortality. Missing data were imputed using multiple imputation.

RESULTS

In HORIZONS-AMI, 2,578/3,602 patients had no prior coronary artery bypass grafting, underwent single-vessel PCI, and had baseline ECG data assessed in an independent core laboratory. Among them, 1,495 (58.0%) had NA-STEMI. Patients with NA-STEMI had lower 3-year mortality risk than those with anterior STEMI (4.5% versus 7.1%, P = 0.004). The independent predictors of increased 3-year mortality in NA-STEMI were older age (median > 59.0 years), diabetes, reduced LVEF (≤50%), Killip class ≥2, post-procedure TIMI flow 0-2 versus 3, renal insufficiency, and ST-resolution <30% at 60 min post-PCI. Patients with 0, 1, 2, 3, and ≥4 of these risk factors had 3-year mortality rates of 1.8%, 2.3%, 3.1%, 6.1%, and 36.3%, respectively (P < 0.0001).

CONCLUSIONS

Although NA-STEMI carries a better prognosis than anterior STEMI, high-risk patient cohorts with NA-STEMI may be identified who have substantial 3-year mortality.

Comparison of 30-Day MACE between Immediate versus Staged Complete Revascularization in Acute Myocardial Infarction with Multivessel Disease, and the Effect of Coronary Lesion Complexity

Background and objective: In patients with acute myocardial infarction and multivessel disease, the timing of intervention to non-culprit lesions is still a matter of debate, especially in patients without shock. This study aimed to compare the effect of multivessel intervention, performed at index percutaneous coronary intervention (PCI) (MVI-I) or index hospitalization (MVI-S), on the 30-day results of acute myocardial infarction (AMI), and to investigate the effect of coronary lesion complexity assessed by the Syntax (Sx) score on the timing of multivessel intervention. Materials and methods: We enrolled 180 patients with MVI-I, and 425 patients with MVI-S. The major adverse cardiovascular events (MACE) for this study were identified as mortality, nonfatal myocardial infarction, nonfatal stroke, acute heart failure, ischemia driven revascularization, major bleeding, and acute renal failure developed within 30 days. Results: The unadjusted MACE rates at 30 days were 11.2% and 5% among those who underwent MVI-I and MVI-S, respectively (OR 3.02; 95% confidence interval (CI) 1.51–6.02; p = 0.002). Associations were statistically significant after adjusting for covariates in the penalized multivariable model (adjusted OR 2.06; 95%CI 1.02–4.18; p = 0.043), propensity score adjusted multivariable model (adjusted OR 2.46; 95%CI 1.19–5.07; p = 0.015), and IPW (adjusted OR 2.11; 95%CI 1.28–3.47; p = 0.041). We found that the Syntax score of lesions did not affect the results. Conclusion: MVI-S was associated with a lower incidence of major adverse cardiovascular events within 30 days after discharge.

The role of retinol-binding protein 4 and its relationship with sex hormones in coronary artery disease

The role of retinol-binding protein 4 (RBP4) in patients with coronary artery disease (CAD) with different sexes has not been clearly established. Sex hormones, especially testosterone (T) and estradiol (E2), have been considered to play an important role in CAD. This study aimed to investigate the role of RBP4 and the possible association between RBP4 and T and E2 in CAD. The study included 658 individuals who underwent coronary angiography (CAG); they were assigned to CAD group (n = 440) and controls (n = 218). CAD group was subdivided into three subgroups. Serum RBP4 and T were assayed by enzyme-linked immunosorbent assay. Serum E2 was measured using electrochemiluminescence immunoassay. For men, RBP4 levels were lower in CAD group, especially those with acute myocardial infarction, than in controls (P < 0.05, P < 0.01, respectively). For women, no significant difference was found in RBP4 levels between both groups. RBP4 was positively correlated with T in male patients with CAD (r = 0.124, P < 0.05). Logistic regression analysis showed that RBP4 was a protective factor for CAD (odds ratio 0.975, 95% confidence interval 0.958-0.993; P = 0.007). In conclusion, RBP4 levels were significantly decreased and positively related with T in men with CAD. Higher RBP4 levels were associated with lower risk of CAD. RBP4 may play a potential protective role for CAD among men.

Culprit vessel: impact on short-term and long-term prognosis in patients with ST-elevation myocardial infarction

Background

ST-elevation myocardial infarction (STEMI) occurs as a result of rupture of an atherosclerotic plaque in the coronary arteries. Limited data exist regarding the impact of culprit coronary vessel on hard clinical event rates. This study investigated the impact of culprit vessel on outcomes after primary percutaneous coronary intervention (PCI) of STEMI.

Methods

A total of 29 832 previously cardiac healthy patients who underwent primary PCI between 2003 and 2014 were prospectively included from the Swedish Coronary Angiography and Angioplasty Registry and the Registry of Information and Knowledge about Swedish Heart Intensive care Admissions. Patients were stratified into three groups based on culprit vessel (right coronary artery (RCA), left anterior descending artery (LAD) and left circumflex artery (LCx)). The primary outcome was 1-year mortality. The secondary outcomes included 30-day and 5-year mortality, as well as heart failure, stroke, bleeding and myocardial reinfarction at 30 days, 1 year and 5 years. Univariable and multivariable analyses were done using Cox regression models.

Results

One-year analyses revealed that LAD infarctions had the highest increased risk of death, heart failure and stroke compared with RCA infarctions, which had the lowest risk. Sensitivity analyses revealed that reduced left ventricular ejection fraction on discharge partially explained this increased relative risk in mortality. Furthermore, landmark analyses revealed that culprit vessel had no significant influence on 1-year mortality if a patient survived 30 days after myocardial infarction. Subgroup analyses revealed female sex and multivessel disease (MVD) as significant high-risk groups with respect to 1-year mortality.

Conclusions

LAD and LCx infarctions had a relatively higher adjusted mortality rate compared with RCA infarctions, with LAD infarctions in particular being associated with an increased risk of heart failure, stroke and death. Culprit vessel had limited influence on mortality after 1 month. High-risk patient groups include LAD infarctions in women or with concomitant MVD.

Introducing ICD-resistant mortality as an end point to evaluate the clinical efficacy of an implantable cardioverter-defibrillator in ischaemic cardiomyopathy

OBJECTIVE

A new end point called ICD-resistant mortality was evaluated to assess the clinical efficacy of ICD implantations.

METHODS AND RESULTS

In 302 ICD patients with ischaemic cardiomyopathy, we investigated which clinical parameters predicted useful ICD implantations using cumulative incidence competing risk analysis. Implantation was deemed clinically useful when the ICD provided appropriate therapy and the patient survived implantation by 1 year and the first shock by 30 days. ICD-resistant mortality (ICDRM) was defined as death within 30 days after the first shock, within 1 year of implantation or without previous appropriate ICD therapy. After 5 years, ICDRM occurred in 23% of implantations, while 36% were clinically useful. After multivariable analysis, ICDRM was associated with LVEF <35% (HR: 2.63; p = .005), beta-blocker dose <50% (HR: 2.0; p = .01) and anterior or diffuse infarct location (HR: 3.61; p = .001 and HR: 2.89; p = .02). Useful ICD implantations were associated with beta-blocker dose <50% (HR: 1.64; p = .02) and non-anterior infarct location (HR: 3.22 vs anterior and 1.59 vs diffuse; combined p<.001).

CONCLUSIONS

Five years after implantation, an ICD could be classified as useful in 1 out of 3, while ICDRM occurred in one out of four patients. At 10 years, up to 80% of implantations could be categorized. Lower LVEF was related with significantly higher incidence of ICDRM. Anterior infarcts were associated with more ICDRM and less useful implantations than non-anterior infarcts. Future risk stratification for ICD should focus more on the discrimination between arrhythmic risk, probably preventable by ICDs and ICD-resistant mortality risk.

Therapeutic hypothermia in ST elevation myocardial infarction: a systematic review and meta-analysis of randomised control trials

OBJECTIVE

Our objective is to gain a better understanding of the efficacy and safety of therapeutic hypothermia (TH) in patients with acute ST elevation myocardial infarction (STEMI) through an analysis of randomised controlled trials (RCTs).

BACKGROUND

Several RCTs have suggested a positive outcome with the use of TH in the prevention of myocardial injury in the setting of an acute STEMI. However, there are currently no clinical trials that have conclusively shown any significant benefit.

METHODS

Electronic databases were used to identify RCTs of TH in the patient population with STEMI. The primary efficacy end point was major adverse cardiovascular event (MACE). Secondary efficacy end points included all-cause mortality, infarct size, new myocardial infarction and heart failure/pulmonary oedema (HF/PO). All-bleeding, ventricular arrhythmias and bradycardias were recorded as the safety end points.

RESULTS

Six RCTs were included in this meta-analysis, enrolling a total of 819 patients. There was no significant benefit from TH in preventing MACE (OR, 01.04; 95% CI 0.37 to 2.89), all-cause mortality (OR, 1.48; 95% CI 0.68 to 3.19), new myocardial infarction (OR, 0.99; 95% CI 0.20 to 4.94), HF/PO (OR, 0.52; 95% CI 0.15 to 1.77) or infarct size (standard difference of the mean (SDM), -0.1; 95% CI -0.23 to 0.04). However, a significant reduction of infarct size was observed with TH utilisation in anterior wall myocardial infarction (SDM, -0.23; 95% CI -0.45 to -0.02). There was no significant difference seen for the safety end points all-bleeding (OR 1.32; 95% CI 0.77 to 2.24), ventricular arrhythmias (OR, 0.85; 95% CI 0.54 to 1.36) or bradycardias (OR, 1.16; 95% CI 0.74 to 1.83).

CONCLUSIONS

Although TH appears to be safe in patients with STEMI, meta-analysis of published RCTs indicates that benefit is limited to reduction of infarct size in patients with anterior wall involvement with no demonstrable effect on all-cause mortality, recurrent myocardial infarction or HF/PO.

Retinol-binding protein 4 levels and susceptibility to ischaemic events in men

BACKGROUND

Many efforts in cardiovascular medicine have been focused in the identification of patients at risk of developing an acute ischaemic event. Biomarker discovery studies have become an essential research area, being proteomic technologies an excellent tool for biomarker identification. By applying proteomic approaches, we have detected changes in retinol-binding protein 4 (RBP4) in acute new-onset myocardial infarction patients (AMI) and in high-risk patients with heterozygous familial hypercholesterolaemia (FH).

MATERIALS AND METHODS

Differential serum proteome was analysed by two-dimensional electrophoresis and MALDI-TOF/TOF. Validation studies were performed by ELISA, and functional effects of RBP4 were tested in cell culture experiments.

RESULTS

Retinol-binding protein 4 proteomic characterization depicted two spots (pI = 5·4;Mw = 23·01/22·78 kDa) with decreased intensity in AMI patients. Total serum RBP4 levels were decreased in AMI patients (N = 68) compared with controls (N = 132; P < 0·0001). RBP4 was also decreased in FH patients who had an ischaemic event 2 years (±0·3) after their inclusion compared with FH patients without any cardiovascular episode at follow-up (P < 0·001; N = 187). In both cases, changes were limited to men. RBP4 induced a significant increase in eNOS expression in human endothelial vascular cells and in prostaglandin I2 release in coronary vascular smooth muscle cells.

CONCLUSIONS

We show decreased serum RBP4 levels in men in the acute phase of AMI, being this decrease already detected in men with FH previous to the presentation of an ischaemic event. The decrease in RBP4 levels could confer an increased susceptibility to the precipitation of an ischaemic event that could be mediated by the decrease in its vasculoprotective properties through NO and PGI2 .

Trends in myocardial infarction rates and case fatality by anatomical location in four United States communities, 1987 to 2008 (from the Atherosclerosis Risk in Communities Study)

Although the incidence of and mortality after ST-segment elevation myocardial infarction (STEMI) is decreasing, time trends in anatomical location of STEMI and associated short-term prognosis have not been examined in a population-based community study. We determined 22-year trends in age- and race-adjusted gender-specific incidences and 28-day case fatality of hospitalized STEMI by anatomic infarct location among a stratified random sample of 35- to 74-year-old residents of 4 communities in the Atherosclerosis Risk in Communities study. STEMI infarct location was assessed by 12-lead electrocardiograms from the hospital record and was coded as anterior, inferior, lateral, and multilocation STEMIs using the Minnesota code. From 1987 to 2008, a total of 4,845 patients had an incident STEMI; 37.2% were inferior STEMI, 32.8% were anterior, 16.8% occurred in multiple infarct locations, and 13.2% were lateral STEMI. For inferior, anterior, and lateral STEMIs in both men and women, significant decreases were observed in the age-adjusted annual incidence and the associated 28-day case fatality. In contrast, for STEMI in multiple infarct locations, neither the annual incidence nor the 28-day case fatality changed over time. The age- and race-adjusted annual incidence and associated 28-day case fatality of STEMI in anterior, inferior, and lateral infarct locations decreased during 22 years of surveillance; however, no decrease was observed for STEMI in multiple infarct locations. In conclusion, our findings suggest that there is room for improvement in the care of patients with multilocation STEMI.

B-type natriuretic peptide as a predictor of anterior wall location in patients with non-ST-elevation myocardial infarction

OBJECTIVE

Involvement of the left ventricular anterior wall in ST-elevation myocardial infarction has a worse prognosis compared with other regions. In non-ST-elevation myocardial infarction, noninvasive methods of locating the ischemic myocardial territory have been limited. The objective of this report is therefore to determine what factors are predictive of the anterior location of the ischemic myocardial territory.

METHODS

This study included 170 patients with non-ST-elevation myocardial infarction. Clinical, echocardiographic, and laboratory characteristics, including B-type natriuretic peptide measured within 24 hours of hospitalization, and coronary angiographic features were analyzed.

RESULTS

The mean age was 64.5 ± 12.3 years, and 112 of the patients were male (66%). The median follow-up was 23 months. The territory involved, as determined from the angiogram, was divided into anterior [n = 80 (47%)] regions and inferior and lateral [n = 90 (53%)] regions. Multivariate analysis showed that B-type natriuretic peptide was the only independent predictor of an anterior wall infarct [OR = 3.70 (95% CI: 1.61 - 8.53); P = 0.002] in non-STelevation myocardial infarction patients. Multivariate analysis also showed that B-type natriuretic peptide was an independent predictor of in-hospital cardiac events during index admission [OR = 5.05 (95% CI: 1.49 - 17.12); P = 0.009] and of cardiac events occurring during follow-up [HR = 1.79 (95% CI: 1.05 - 3.04); P = 0.032].

CONCLUSIONS

B-type natriuretic peptide was the only factor independently associated with anterior wall involvement in non-ST-elevation myocardial infarction, and the peptide levels upon admission predicted in-hospital and subsequent cardiac events.

Long-term mortality of patients undergoing cardiac catheterization for ST-elevation and non-ST-elevation myocardial infarction

BACKGROUND

There are limited contemporary data comparing long-term outcomes after cardiac catheterization for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI).

METHODS AND RESULTS

We studied patients undergoing cardiac catheterization for STEMI (n=2413) and NSTEMI (n=1974) between 1999 and 2005 with at least 1 significant coronary lesion > or =75%. We compared adjusted mortality rates over restricted time intervals and the differential impact of early revascularization on mortality stratified by ST-elevation status. Between 1999 and 2007, 1274 patients died, with a median follow-up of 4 years. A piece-wise analysis showed a higher adjusted mortality risk for STEMI during the first 2 months (adjusted hazard ratio, 1.85; 95% confidence interval, 1.45 to 2.38) and a lower adjusted mortality risk for STEMI after 2 months (adjusted hazard ratio, 0.68; 95% confidence interval, 0.59 to 0.83). Compared with late or no revascularization, early revascularization was associated with a lower adjusted risk of mortality for both STEMI (adjusted hazard ratio, 0.73; 95% confidence interval, 0.58 to 0.90) and NSTEMI (adjusted hazard ratio, 0.76; 95% confidence interval, 0.65 to 0.89) (P for interaction=0.22).

CONCLUSIONS

Among a contemporary cohort of acute MI patients with significant coronary disease during cardiac catheterization, STEMI was associated with a higher risk of short-term mortality, but NSTEMI was associated with a higher risk of long-term mortality. Early revascularization was associated with a similar improvement in long-term outcomes for both STEMI and NSTEMI. These data suggest that in clinical investigations of early revascularization among patients with NSTEMI, extended follow-up may be necessary to demonstrate treatment benefit.

Comparison of outcome in patients with ST-elevation versus non-ST-elevation acute myocardial infarction treated with percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are increasingly being treated with percutaneous coronary intervention (PCI) and we sought to determine risk of adverse outcomes by type of MI. Patients enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry from 1999 to 2004 who presented with an acute MI as an indication for PCI were studied. Baseline data and in-hospital and 1-year outcomes were compared based on ST-segment elevation (STEMI, n = 903; NSTEMI, n = 583) at presentation. Patients with STEMI were younger, had fewer co-morbidities, and had less extensive coronary artery disease than did patients with NSTEMI. Angiographic success and periprocedural complications were similar by MI type. In-hospital coronary artery bypass grafting, stroke, bleeding and recurrent MI were similar but mortality was higher in patients with STEMI (4.0% vs 1.4%, p = 0.004). Cardiogenic shock was associated with the greatest risk of in-hospital death (odds ratio 26.7, 95% confidence interval 11.4 to 62.3, p = 0.0001), but STEMI was also independently predictive of mortality. At 1 year, there was no influence of MI type on outcome. Age, cardiogenic shock, renal disease, peripheral vascular disease, and cancer were predictive of death and MI. Multivessel disease and a larger number of >50% lesions were associated with the need for repeat revascularization. In conclusion, STEMI was associated with a higher likelihood of in-hospital death than was NSTEMI, but long-term outcomes after PCI were independent of MI type. At 1 year, associated co-morbidities were strongly associated with death and MI, whereas only angiographic characteristics predicted the need for repeat revascularization.

Ten year mortality in subsets of patients with an acute coronary syndrome

OBJECTIVE

To describe the mortality during the subsequent 10 years for subsets of patients hospitalised for suspected acute coronary syndrome.

PATIENTS AND METHODS

All patients who were admitted to the emergency department in one hospital during 21 months for chest pain or other symptoms raising suspicion of an acute coronary syndrome were registered. From this baseline population three subgroups were defined among those being hospitalised: patients who developed a Q wave acute myocardial infarction (AMI) (n = 306); patients who developed a non-Q wave AMI (n = 527); and patients who developed confirmed or possible myocardial ischaemia (unstable angina pectoris) (n = 1274). These three groups were compared in terms of 10 year mortality.

RESULTS

Patients who developed a non-Q wave AMI had the highest 10 year mortality (70.3%), significantly higher than those who developed a Q wave AMI (60.1%; p = 0.004) and those who had confirmed or possible myocardial ischaemia (50.1%; p < 0.0001). There was no difference between patients with confirmed and those with possible myocardial ischaemia (50.0% and 50.1%, respectively). After correction for dissimilarities in age, sex, and history the adjusted risk ratio for death in patients with a non-Q wave AMI compared with Q wave AMI was 1.01 (95% confidence interval (CI) 0.82 to 1.25). The corresponding risk ratio for death in patients with a non-Q wave AMI compared with confirmed or possible myocardial ischaemia was 1.91 (95% CI 1.64 to 2.23). There was also an imbalance in drug regimens among groups.

CONCLUSION

This study shows that in a non-selected population of patients hospitalised with a suspected acute coronary syndrome, the highest risk of death is found in those with a non-Q wave AMI and the lowest in those with confirmed or possible myocardial ischaemia. Thus, patients with a Q wave AMI have a long term mortality risk intermediate between the two fractions defined as having unstable coronary artery disease. However, adjusting these results for age and history of cardiovascular disease eliminated the observed difference in mortality between non-Q wave and Q wave AMI. Furthermore, an imbalance in drug regimens might have affected the outcome.

Pathophysiology of early coronary angioplasty with stenting on non-Q-wave vs Q-wave myocardial infarction

This study was undertaken to evaluate the pathophysiologic and clinical effects of the early application of percutaneous transluminal coronary angioplasty (PTCA) supported by stenting on non-Q-wave myocardial infarction (MI). Ninety-four patients with non-Q-wave MI and 316 patients with Q-wave MI were studied. Early PTCA with provisional stenting (40%) was performed in all of them. A history of MI (22% vs 12%, p=0.018), preinfarction angina < or = 24 hours before the onset of MI (60% vs 33%, p<0.001), and patent infarct-related vessels (83% vs 21%, p<0.001) were significantly more common in non-Q-wave MI than in Q-wave MI. As predictors of the occurrence of non-Q-wave MI, preinfarction angina (p=0.001) and previous MI (p=0.021) were significant variables. Clinical outcomes showed more improvement in in-hospital death (0.0% vs 5.0%, p=0.036) and long-term event-free curves for death and/or MI (p=0.035) in non-Q-wave MI than Q-wave MI when patients with previous MI were excluded. There was no significant difference in clinical outcome between the two groups when patients with previous MI were included. The high incidence of patent infarct-related vessels and preinfarction angina as well as the improved outcome obtained by early PTCA/stenting suggest instability of coronary occlusion and culprit coronary lesions in non-Q-wave MI. In conclusion, non-Q-wave MI constitutes a characteristic feature of MI induced by unstable coronary lesions, and early interventional therapies are presumed to result in improved outcomes by stabilizing the unstable culprit lesions.

Prediction of functional recovery after revascularization in coronary artery disease using (18)F-FDG and (123)I-BMIPP SPECT

STUDY OBJECTIVES

Clinical studies comparing fatty acid and glucose metabolism in relation to functional recovery of ischemic myocardium after coronary revascularization are scarce. This study evaluated the recovery of regional and global left ventricular function after coronary revascularization in relation to uptake patterns of beta-methyl-iodophenyl-pentadecanoic acid (BMIPP) and fluorodeoxyglucose (FDG) in patients with ischemic myocardial dysfunction.

METHODS

Patients with ischemic regional wall motion abnormality underwent baseline viability imaging with (18)F-FDG, (123)I-BMIPP, and (99m)Tc- methoxyisobutylisonitrile, and the regions with evidence for maintained tissue viability were revascularized. Mismatch of uptake score between two different single-photon emission CT (SPECT) images in the same myocardial region was graded as low or high mismatch. Regional and global left ventricular functional changes after revascularization were analyzed in relation to mismatch severity and difference of total uptake score in each SPECT image pair. A total of 33 vessels in 30 patients related to the asynergic regions were revascularized, and a total of 100 myocardial segments perfused by the revascularized vessels were analyzed.

RESULTS

Segments showing high metabolic mismatch (FDG/BMIPP) had lowest regional wall motion score at baseline, representing the most severely impaired ischemic myocardium, and had highest improvement in regional wall motion score after revascularization. Difference of total uptake score between FDG and BMIPP showed a significant positive correlation with difference of ejection fraction between pre- and postrevascularization (r = 0.774, p < 0.0001).

CONCLUSIONS

Combined metabolic SPECT imaging with FDG and BMIPP has the potential to identify severely impaired ischemic myocardium leading to more efficient therapeutic management of patients with coronary artery disease.

Comparison of short- and long-term prognosis in patients with anterior wall versus inferior or lateral wall non-Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group

We evaluated the early and long-term prognosis of patients with a first non-Q-wave acute myocardial infarction (AMI) in relation to infarct site. Among 4,314 patients with a first AMI, 610 (14%) had a non-Q-wave AMI. Of them, 248 patients with anterior wall AMI were compared with 327 patients with inferior/lateral AMI. Baseline clinical characteristics were similar in both groups except for higher mean age in the anterior wall group. In-hospital complications were more common among patients with anterior wall AMI than in the inferior/lateral group. Patients with anterior wall AMI also had higher rates of in-hospital (15%), 1-year (12%), and 5-year (36%) postdischarge mortality compared with the inferior/lateral infarction group (10%, 6%, and 22%, respectively). The 1-year cardiac event rate (recurrent AMI and cardiac death) was significantly higher among the anterior wall AMI group than the inferior/lateral AMI group (14.2% and 4.8% respectively, p = 0.001). After adjustment for age, gender, systemic hypertension, diabetes mellitus, prior angina, and treatment with various medications, an increased risk for 1-year (odds ratio 1.31, 95% confidence interval [CI] 0.62 to 2.78) and 5-year mortality (relative risk 1.29, 95% CI 0.90 to 1.85) was observed, but it did not reach statistical significance. Anterior wall AMI location emerged as a predictor for higher 1-year cardiac event rate (odds ratio 3.15, 95% CI 1.59 to 6.78). These findings suggest that AMI location is an important prognostic variable for risk stratification of patients with a first non-Q-wave AMI.