Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Effect of Bendopnea on Achievement Medical Treatment Target Doses in Heart Failure

BACKGROUND

The newly described bendopnea in heart failure (HF) is associated with increased cardiac filling pressures. The aim of the study was to show the effect of bendopnea follow-up on reaching optimal medical treatment doses in HF.

METHODS

A total of 413 patients were screened, and we included 203 patients with HF who were previously evaluated for bendopnea. Demographic data, presence or absence of bendopnea, medical history, laboratory findings, and medical treatments were evaluated. Optimal medical therapy target doses at baseline and 3rd month were compared in groups with and without bendopnea.

RESULTS

On admission, 64 patients (31.5%) had bendopnea. The rate of patients with bendopnea decreased in the 3rd month (n=42, 20.7%). The proportion of patients who used at least 50% of the recommended medical treatment dose on admission and in the 3rd month was compared; angiotensin-converting enzyme inhibitor /angiotensin receptor blockers use increased from 40.6% to 71.9% in those with bendopnea (P=0.013), from 56.1% to 81.3% in those without bendopnea (P<0.001) and beta-blockers use increased from 28.2% to 60.9% in those with bendopnea (P=0.042), from 31.6% to 69.8% in those without bendopnea (P<0.001). However, aldosterone antagonists use decreased from 70.3% to 67.2% in those with bendopnea (P=0.961), from 68.4 % to 64.1% in those without bendopnea (P=0.334). Bendopnea was independently effective in achieving ACE-I/ARB target doses (OR: 0.359, CI 95%: 0.151-0.854, P=0.020).

CONCLUSION

Bendopnea follow-up in HF patients can provide a significant improvement in reaching the recommended treatment target doses.

Predictive factors of heart failure in acute coronary syndrome: Institutional cross-sectional study

Background

Heart failure complicating acute coronary syndrome (ACS) remains a challenge because it is associated with a high risk of mortality at 1 year.

Our objective is to highlight the factors frequently associated with heart failure following an ACS and thus deduce the predictive factors for the occurrence of heart failure.

Methods

ACS patients who were managed between 01/01/2021 to 06/30/2021 at the authors’ institution were included retrospectively in the analysis.

Results

One hundred twenty-one patients (121) included. Eighty-seven were males (72%), and the mean age was 59.4 ± 8.8. Most patients were smokers (58.7%),40% were diabetic, and 40.5% were hypertensive. Dyslipidemia was found in 37.2% of cases. 75% of patients were admitted for STEMI, and 25% for NSTEMI. The majority of patients (67.5%) were admitted out of time. The anterior electrical territory was found as a factor in the occurrence of heart failure (OR = 5.47, 95% CI (2.16–15.26), P = 0.0005). Among the patients who presented a heart failure, 64% had an LVEF <40%, and only 3% with an LVEF >50% (P < 0.001). Also, 76% had a Wall Motion Index Score (WMSI) of 1.5 (P < 0.001). Angioplasty was the treatment of choice in 65%, aortocoronary bypass in 7% of cases, and medical treatment alone, associated or not with ischemia/viability tests in 28% of cases. Patients admitted out of time (>12 h) were found to be a factor in the occurrence of HF (OR = 3.31,95% CI (1.21–10,60), P = 0.02). The outcome was favorable in 93% of cases. We observed 9 cases of complications including 4 deaths from cardiogenic, septic, and hemorrhagic shock.

Conclusions

This study allows us to identify patients at risk of developing heart failure and patients with a more reserved prognosis. Besides, our findings will allow our peers and colleagues to be able to detect early these factors and optimize adequate management to avoid heart failure.

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Heart failure complicating acute coronary syndrome (ACS) remains a challenge.

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It is associated with a high risk of mortality at 1 year.

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The delay in care is a determining factor in the occurrence of complications.

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Our health system have a weakness that should be corrected.

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The deadlines are far from the recommended deadlines.

A Long-Term Incidence of Heart Failure and Predictors Following Newly Developed Acute Myocardial Infarction: A 10 Years Retrospective Cohort Study with Korean National Health Insurance Data

Heart failure (HF) is the major mechanism of mortality in acute myocardial infarction (AMI) during early or intermediate post-AMI period. But heart failure is one of the most common long-term complications of AMI. Applied the retrospective cohort study design with nation representative population data, this study traced the incidence of late-onset heart failure since 1 year after newly developed acute myocardial infarction and assessed its risk factors. Methods and Results: Using the Korea National Health Insurance database, 18,328 newly developed AMI patients aged 40 years or older and first hospitalized in 2010 for 3 days or more, were set up as baseline cohort (12,403). The incidence rate of AMI per 100,000 persons was 79.8 overall, and 49.6 for women and 112.3 for men. A total of 2010 (1073 men, 937 women) were newly developed with HF during 6 years following post AMI. Cumulative incidences of HF per 1000 AMI patients for a year at each time period were 37.4 in initial hospitalization, 32.3 in 1 year after discharge, and 8.9 in 1-6 years. The overall and age-specific incidence rates of HF were higher in women than men. For late-onset HF, female, medical aid, pre-existing hypertension, severity of AMI, duration of hospital stay during index admission, reperfusion treatment, and drug prescription pattern including diuretics, affected the occurrence of late-onset HF. Conclusion: With respect to late-onset HF following AMI, appropriate management including hypertension and medical aid program in addition to quality improvement of AMI treatment are required to reduce the risk of late-onset heart failure.

Physical activity and the risk of heart failure: a systematic review and dose-response meta-analysis of prospective studies

Although physical activity is an established protective factor for cardiovascular diseases such as ischemic heart disease and stroke, less is known with regard to the association between specific domains of physical activity and heart failure, as well as the association between cardiorespiratory fitness and heart failure. We conducted a systematic review and meta-analysis of prospective observational studies to clarify the relations of total physical activity, domains of physical activity and cardiorespiratory fitness to risk of heart failure. PubMed and Embase databases were searched up to January 14th, 2020. Summary relative risks (RRs) were calculated using random effects models. Twenty-nine prospective studies (36 publications) were included in the review. The summary RRs for high versus low levels were 0.77 (95% CI 0.70–0.85, I² = 49%, n = 7) for total physical activity, 0.74 (95% CI 0.68–0.81, I² = 88.1%, n = 16) for leisure-time activity, 0.66 (95% CI 0.59–0.74, I² = 0%, n = 2) for vigorous activity, 0.81 (95% CI 0.69–0.94, I² = 86%, n = 3) for walking and bicycling combined, 0.90 (95% CI 0.86–0.95, I² = 0%, n = 3) for occupational activity, and 0.31 (95% CI 0.19–0.49, I² = 96%, n = 6) for cardiorespiratory fitness. In dose–response analyses, the summary RRs were 0.89 (95% CI 0.83–0.95, I² = 67%, n = 4) per 20 MET-hours per day of total activity and 0.71 (95% CI 0.65–0.78, I² = 85%, n = 11) per 20 MET-hours per week of leisure-time activity. Nonlinear associations were observed in both analyses with a flattening of the dose–response curve at 15–20 MET-hours/week for leisure-time activity. These findings suggest that high levels of total physical activity, leisure-time activity, vigorous activity, occupational activity, walking and bicycling combined and cardiorespiratory fitness are associated with reduced risk of developing heart failure.

Impact of Atrial Fibrillation on Acute Coronary Syndrome-Analysis of In-Hospital Outcomes and 30-Day Readmissions

With an aging population and significant overlap of risk factors, the cohort of patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is a sizable and growing one, with implications on cardiac reserve, anticoagulation and antiplatelet therapies, and related complications. The present study uses a large national database to analyze the impact of AF on patients admitted with an ACS. We queried the 2012 to 2014 National Readmissions Database to identify patients admitted with an ACS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. These patients were then subcategorized based on the presence or absence of AF. Analysis of their initial hospitalization, 30-day readmissions and healthcare utilization and the economic burden was performed. Among 1,558,205 patients with ACS, 270,966 (17.4%) were noted to have concomitant AF. At baseline, these patients were older and more likely female, with a significantly higher burden of comorbidities. Patients with AF had longer and more complicated index hospitalizations with significantly higher mortality rates (8.6% vs 4.6%). Coronary artery bypass graft was the preferred method of revascularization in patients with AF as compared to percutaneous coronary intervention. The 30-day readmissions were higher in the AF group (15.6 vs 10.8%), largely driven by noncardiac causes. This was associated with higher healthcare utilization with longer hospitalizations during index admission. Patients admitted with ACS and concomitant AF is a high-risk population with increased in-hospital complications and mortality, as well as short term readmissions. Coronary artery bypass graft appears favored over percutaneous coronary intervention for revascularization in patients with AF.

Do Patients need Lifelong β-Blockers after an Uncomplicated Myocardial Infarction?

The lifelong use of β-adrenoceptor antagonists (β-blockers) after a myocardial infarction (MI) has been the standard of care based on trials performed before the era of revascularization, when heart failure was common. Large randomized trials in the mid-1980s demonstrated that β-blockers played a major role in improving the in-hospital and long-term survival of patients admitted for MI. However, the implementation of rapid myocardial reperfusion led to a substantial survival benefit and a reduction of heart failure because of reduced infarct size. Modern large longitudinal registries did not provide sufficient evidence to support long-term β-blocker therapy in patients with uncomplicated acute MI. The long-term prescription of this therapy has become a matter of debate given the lack of contemporary evidence, frequent side effects, and treatment adherence issues. Furthermore, this shift into the reperfusion era led to a downgraded recommendation for the use of β-blockers in post-MI patients (class IIa B recommendation) in the 2017 European Society of Cardiology (ESC) recommendations for the treatment of ST-segment elevation MI (STEMI). Three large ongoing multicenter randomized trials (AβYSS, REDUCE-SWEDEHEART, and REBOOT-CNIC) are evaluating early discontinuation of β-blockers after an uncomplicated acute MI. The tested hypothesis is that β-blocker withdrawal is safe versus major adverse cardiovascular events and improves quality of life by reducing side effects. Thus, the present review summarizes the exhaustive evidence-based data for long-term β-blocker use after uncomplicated MI and the ongoing trials.

Decade Long Trends (2001-2011) in the Incidence Rates of Initial Acute Myocardial Infarction

Despite the magnitude and impact of acute coronary disease, there are limited population-based data in the United States describing relatively recent trends in the incidence rates of acute myocardial infarction (AMI). The objectives of this study were to describe decade long (2001-2011) trends in the incidence rates of initial hospitalized episodes of AMI, with further stratification of these rates by age, sex, and type of AMI, in residents of central Massachusetts hospitalized at 11 area medical centers. The study population consisted of 3,737 adults hospitalized with a first AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The median age of this study population was 70 years, 57% were men, and 90% were white. Patients hospitalized during the most recent study years (2009/11) were younger, more likely to be men, have more co-morbidities, and less in-hospital complications as compared with those in the earliest study years (2001/03). The overall age-adjusted hospital incidence rates (per 100,000 persons) of initial AMI declined (from 319 to 163), for men (from 422 to 219), women (from 232 to 120), for patients with a ST segment elevation (129 to 56), and for those with an non-ST segment elevation (190 to 107) between 2001 and 2011, respectively. In conclusion, the incidence rates of initial AMI declined appreciably in residents of central Massachusetts who were hospitalized with AMI during the years under study.

Diabetes mellitus, blood glucose and the risk of heart failure: A systematic review and meta-analysis of prospective studies

BACKGROUND AND AIM

The strength of the association between diabetes and risk of heart failure has differed between previous studies and the available studies have not been summarized in a meta-analysis. We therefore quantified the association between diabetes and blood glucose and heart failure in a systematic review and meta-analysis.

METHODS AND RESULTS

PubMed and Embase databases were searched up to May 3rd 2018. Prospective studies on diabetes mellitus or blood glucose and heart failure risk were included. A random effects model was used to calculate summary relative risks (RRs) and 95% confidence intervals (CIs). Seventy seven studies were included. Among the population-based prospective studies, the summary RR for individuals with diabetes vs. no diabetes was 2.06 (95% CIs: 1.73-2.46, I² = 99.8%, n = 30 studies, 401495 cases, 21416780 participants). The summary RR was 1.23 (95% CI: 1.15-1.32, I² = 78.2%, n = 10, 5344 cases, 91758 participants) per 20 mg/dl increase in blood glucose and there was evidence of a J-shaped association with nadir around 90 mg/dl and increased risk even within the pre-diabetic blood glucose range. Among the patient-based studies the summary RR was 1.69 (95% CI: 1.57-1.81, I² = 85.5%, p_{heterogeneity}<0.0001) for diabetes vs. no diabetes (n = 41, 100284 cases and >613925 participants) and 1.25 (95% CI: 0.89-1.75, I² = 95.6%, p_{heterogeneity}<0.0001) per 20 mg/dl increase in blood glucose (1016 cases, 34309 participants, n = 2). In the analyses of diabetes and heart failure there was low or no heterogeneity among the population-based studies that adjusted for alcohol intake and physical activity and among the patient-based studies there was no heterogeneity among studies with ≥10 years follow-up.

CONCLUSIONS

These results suggest that individuals with diabetes are at an increased risk of developing heart failure and there is evidence of increased risk even within the pre-diabetic range of blood glucose.

Tobacco smoking and the risk of heart failure: A systematic review and meta-analysis of prospective studies

Background

We conducted a systematic review and meta-analysis to clarify the association between smoking and the risk of developing heart failure.

Methods

PubMed and Embase databases were searched up to 24 July 2018. Prospective studies were included if they reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of heart failure associated with smoking. Summary RRs and 95% CIs were estimated using a random effects model.

Results

Twenty-six studies were included. The summary RR was 1.75 (95% CI: 1.54–1.99, I2 = 81%, n = 10) for current smokers, 1.16 (95% CI: 1.08–1.24, I2 = 51%, n = 9) for former smokers, and 1.44 (1.34–1.55, I2 = 83%, n = 10) for ever smokers compared with never smokers. The summary RR was 1.41 (95% CI: 1.01–1.96, I2 = 82%, n = 2) per 10 cigarettes per day, 1.11 (95% CI: 1.04–1.18, I2 = 70%, n = 3) and 1.08 (95% CI: 1.02–1.14, I2 = 34%, n = 2) per 10 pack-years among ever smokers and former smokers, respectively, and 0.79 (95% CI: 0.63–1.00, I2 = 96%, n = 2) per 10 years since quitting smoking. The association between smoking cessation and heart failure reached significance at 15 years of smoking cessation, and at 30 years the summary RR was 0.72 (95% CI: 0.57–0.90), only slightly higher than the summary RR for never smokers (0.64 (95% CI: 0.57–0.72)) when compared with current smokers.

Conclusion

Smoking is associated with increased risk of heart failure, but the risk decreases with increasing duration since smoking cessation. Any further studies should investigate the association between number of cigarettes per day, duration, pack-years and time since quitting smoking and risk of heart failure.

Twenty-Five-Year (1986-2011) Trends in the Incidence and Death Rates of Stroke Complicating Acute Myocardial Infarction

BACKGROUND

The occurrence of a stroke after an acute myocardial infarction is associated with increased morbidity and mortality rates. However, limited data are available, particularly from a population-based perspective, about recent trends in the incidence and mortality rates associated with stroke complicating an acute myocardial infarction. The purpose of this study was to examine 25-year trends (1986-2011) in the incidence and in-hospital mortality rates of initial episodes of stroke complicating acute myocardial infarction.

METHODS

The study population consisted of 11,436 adults hospitalized with acute myocardial infarction at all 11 medical centers in central Massachusetts on a biennial basis between 1986 and 2011.

RESULTS

In this study cohort, 159 patients (1.4%) experienced an acute first-ever stroke during hospitalization for acute myocardial infarction. The proportion of patients with acute myocardial infarction who developed a stroke increased through the 1990s but decreased slightly thereafter. Compared with patients who did not experience a stroke, those who experienced a stroke were significantly older, were more likely to be female, had a previous acute myocardial infarction, had a significant burden of comorbidities, and were more likely to have died (32.1% vs 10.8%) during their index hospitalization. Patients who developed a first stroke in the most recent study years (2003-2011) were more likely to have died during hospitalization than those hospitalized during earlier study years.

CONCLUSIONS

Although the incidence rates of acute stroke complicating acute myocardial infarction remained relatively stable during the years under study, the in-hospital mortality rates of those experiencing a stroke have not decreased.

Temporal Changes in Characteristics, Treatment and Outcomes of Heart Failure Patients Undergoing Percutaneous Coronary Intervention Findings From Melbourne Interventional Group Registry

BACKGROUND

Limited data exist on whether outcomes of patients with heart failure (HF) undergoing percutaneous coronary intervention (PCI) have improved over time. The purpose of this study was to assess temporal trends in patient characteristics, treatment and outcomes of patients with HF undergoing PCI.

METHODS

Using data from the Melbourne Interventional Group (MIG), we evaluated temporal trends of procedure volume, major adverse cardiac events (MACE; a composite of all-cause mortality, myocardial infarction and target vessel revascularisation) and rates of cardiovascular readmission, all-cause death and cardiovascular death in consecutive patients with HF undergoing PCI. Change over time was assessed by Box-Jenkins autoregressive integrated moving average (ARIMA) models.

RESULTS

Data from 1,604 patients were analysed. In our cohort, there were no significant changes in the number of procedures performed annually and patient characteristics between January 2005 and December 2014. Optimal use of HF therapy has improved over the study period. Planned clopidogrel therapy of more than 12 months increased in tandem with increasing use of drug-eluting stents (DES). Procedural success was high (≥90%). However, the rates of MACE, cardiovascular readmission, all-cause death and cardiovascular death remained unchanged throughout the study period.

CONCLUSIONS

Clinical outcomes in HF patients undergoing PCI have remained unchanged despite improvement in medical technology and contemporary therapeutic measures.

Heart failure following STEMI: a contemporary cohort study of incidence and prognostic factors

Objective

The aim of the current study was to determine the contemporary incidence, risk factors and prognosis of heart failure (HF) after ST-elevation myocardial infarction (STEMI).

Methods

We used the Arrhythmia Genetics in the Netherlands observational cohort study to identify patients with a first STEMI from 2001 onwards (n=1459). HF during follow-up was defined as hospitalisation for HF or an outpatient clinic visit for HF. Cox regression was performed to estimate the relationship between baseline covariates and the onset of HF.

Results

Follow-up was completed for 1360 (93.2%) patients with an overall median follow-up time of 6.7 years, 1232 (90.6%) of these patients had undergone primary percutaneous coronary intervention (PCI). A total of 85 patients (6.3%) developed HF during follow-up. HF cases were significantly older at their index MI (59.9 vs 57.2 years, P<0.001) and more commonly had a history of atrial fibrillation (6.1% vs 1.4%, P=0.001) than controls without HF. The crude incidence rate of HF after STEMI was 9.7 (95% CI 7.7 to 11.8) per 1000 person-years. In multivariable analysis, peak creatine kinase MB (CK-MB) levels (HR 1.11 per 100 U/L (95% CI 1.11 to 1.22)) and a left anterior descending artery (LAD) culprit lesion (HR 2.88 (95% CI 1.53 to 5.40)) were risk factors associated with HF.

Conclusions

We found a relatively low long-term contemporary incidence of HF after a first STEMI in the current PCI era in comparison with other reports. Higher CK-MB levels and a LAD culprit lesion at index STEMI were important risk factors for the development of HF after STEMI.

Trial registration number

NCT03007199; Results.

National Trends in the Incidence, Management, and Outcomes of Heart Failure Complications in Patients Hospitalized for ST-Segment Elevation Myocardial Infarction

Objective

To analyze contemporary trends in the incidence, management, and clinical outcomes of heart failure (HF) complications in patients hospitalized for ST-segment elevation myocardial infarction (STEMI) in the United States.

Patients and Methods

Using the 2003 through 2010 Nationwide Inpatient Sample databases, all patients with STEMI who were 18 years and older with acute HF were identified. Overall trends in the incidence of HF, coronary intervention, and in-hospital mortality were analyzed.

Results

Of 1,990,002 hospitalizations with a primary diagnosis of STEMI, 471,525 (23.7%) had HF complication (decreasing from 25.4% [95% CI, 25.3%-25.6%] in 2003 to 20.7% [95% CI, 20.5%-20.8%]) in 2010 (P trend<.001). The incidence of cardiogenic shock in patients with HF-complicated STEMI increased from 13.9% (95% CI, 13.6%-14.1%) to 22.6% (95% CI, 22.2%-23.0%) during this period (P trend<.001). From 2003 through 2010, the use of diagnostic coronary angiography and percutaneous coronary intervention increased in patients with HF-complicated STEMI from 44.3% to 62.1% and from 25.0% to 48.1%, respectively. In-hospital mortality decreased significantly in patients with HF-complicated STEMI (from 18.1% to 15.1%) and in subgroups of those with (from 42.4% to 29.9%) and without (from 14.1% to 10.8%) cardiogenic shock (all P trend<.001). The adjusted odds ratio (AOR) (per year) of death was 0.992 (95% CI, 0.988-0.997; P<.001), which changed significantly after additional adjustment for coronary intervention (AOR [per year], 1.012; 95% CI, 1.008-1.017; P<.001).

Conclusion

The incidence and in-hospital mortality of HF-complicated STEMI has decreased significantly during recent times along with increased use of percutaneous coronary intervention and diagnostic coronary angiography.

Heart failure after myocardial infarction in the era of primary percutaneous coronary intervention: Mechanisms, incidence and identification of patients at risk

Myocardial infarction (MI) remains the most common cause of heart failure (HF) worldwide. For almost 50 years HF has been recognised as a determinant of adverse prognosis after MI, but efforts to promote myocardial repair have failed to translate into clinical therapies. Primary percutaneous coronary intervention (PPCI) has driven improved early survival after MI, but its impact on the incidence of downstream HF is debated. The effects of PPCI are confounded by the changing epidemiology of MI and HF, with an ageing patient demographic, an increasing proportion of non-ST-elevation myocardial infarction, and the recognition of HF with preserved ejection fraction. Herein we review the mechanisms of HF after MI and discuss contemporary data on its incidence and outcomes. We review current and emerging strategies for early detection of patients at risk of HF after MI, with a view to identification of patient cohorts for novel therapeutic agents.

Correlation of Ventricular Arrhythmogenesis with Neuronal Remodeling of Cardiac Postganglionic Parasympathetic Neurons in the Late Stage of Heart Failure after Myocardial Infarction

Introduction: Ventricular arrhythmia is a major cause of sudden cardiac death in patients with chronic heart failure (CHF). Our recent study demonstrates that N-type Ca²⁺ currents in intracardiac ganglionic neurons are reduced in the late stage of CHF rats. Rat intracardiac ganglia are divided into the atrioventricular ganglion (AVG) and sinoatrial ganglion. Only AVG nerve terminals innervate the ventricular myocardium. In this study, we tested the correlation of electrical remodeling in AVG neurons with ventricular arrhythmogenesis in CHF rats. Methods and Results: CHF was induced in male Sprague-Dawley rats by surgical ligation of the left coronary artery. The data from 24-h continuous radiotelemetry ECG recording in conscious rats showed that ventricular tachycardia/fibrillation (VT/VF) occurred in 3 and 14-week CHF rats but not 8-week CHF rats. Additionally, as an index for vagal control of ventricular function, changes of left ventricular systolic pressure (LVSP) and the maximum rate of left ventricular pressure rise (LV dP/dt_max) in response to vagal efferent nerve stimulation were blunted in 14-week CHF rats but not 3 or 8-week CHF rats. Results from whole-cell patch clamp recording demonstrated that N-type Ca²⁺ currents in AVG neurons began to decrease in 8-week CHF rats, and that there was also a significant decrease in 14-week CHF rats. Correlation analysis revealed that N-type Ca²⁺ currents in AVG neurons negatively correlated with the cumulative duration of VT/VF in 14-week CHF rats, whereas there was no correlation between N-type Ca²⁺ currents in AVG neurons and the cumulative duration of VT/VF in 3-week CHF. Conclusion: Malignant ventricular arrhythmias mainly occur in the early and late stages of CHF. Electrical remodeling of AVG neurons highly correlates with the occurrence of ventricular arrhythmias in the late stage of CHF.

Trends in hospitalization for congestive heart failure, 1996-2009

BACKGROUND

Although heart failure (HF) is a common cause of hospital admissions, few data describe temporal trends in HF hospitalization. We present data on number of HF admissions, length of stay (LOS), and inpatient mortality in the United States, 1996-2009.

HYPOTHESIS

To assess HF hospitalizations in a national sample of United States population.

METHODS

Data were obtained from the National Hospital Discharge Survey (NHDS), a national probability sample survey of discharges conducted annually by the National Center for Health Statistics. Sampling weights are applied to raw NHDS data to produce national estimates. Hospitalizations with a primary diagnosis of HF were identified using ICD-9-CM codes. We excluded hospitalizations where HF was a secondary diagnosis. Weighted least squares regression was used to test for linear trends in HF hospitalizations.

RESULTS

Approximately 15.5 million weighted primary HF hospitalizations were included. The number of total primary HF hospitalizations increased from 1 000 766 in 1996 to about 1 173 832 in 2009 (β = 7371 hospitalizations per year; 95% confidence interval (CI): 552 to 14 190, P = 0.036). Mean LOS per hospitalization decreased from 6.07 days in 1996 to about 5.26 days in 2009 (β = -0.059 days per year; 95% CI: -0.079 to -0.039, P < 0.001). Inpatient mortality rates declined from 4.92% in 1996 to 3.41% in 2009 (β = -0.17% per year; 95% CI: -0.23 to -0.10, P < 0.001).

CONCLUSIONS

In a nationally representative sample of HF hospitalizations, mean LOS and inpatient mortality rates declined over the past 2 decades. HF management cost is most likely to be reduced by decreasing the number of HF admissions.

Predicting Outcomes Over Time in Patients With Heart Failure, Left Ventricular Systolic Dysfunction, or Both Following Acute Myocardial Infarction

Background

Most studies of risk assessment or stratification in patients with myocardial infarction (MI) have been static and fail to account for the evolving nature of clinical events and care processes. We sought to identify predictors of mortality, cardiovascular death or nonfatal MI, and cardiovascular death or nonfatal heart failure (HF) over time in patients with HF, left ventricular systolic dysfunction, or both post‐MI.

Methods and Results

Using data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial, we developed models to estimate the association between patient characteristics and the likelihood of experiencing an event from the time of a follow‐up visit until the next visit. The intervals are: hospital arrival to discharge or 14 days, whichever occurs first; hospital discharge to 30 days; 30 days to 6 months; and 6 months to 3 years. Models were also developed to predict the entire 3‐year follow‐up period using baseline information. Multivariable Cox proportional hazards modeling was used throughout with Wald chi‐squares as the comparator of strength for each predictor. For the baseline model of overall mortality, the 3 strongest predictors were age (adjusted hazard ratio [HR], 1.35; 95% CI, 1.28–1.42; P<0.0001), baseline heart rate (adjusted HR, 1.17; 95% CI, 1.14–1.21; P<0.0001), and creatinine clearance (≤100 mL/min; adjusted HR, 0.86; 95% CI, 0.84–0.89; P<0.0001). According to the integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices, the updated model had significant improvement over the model with baseline covariates only in all follow‐up periods and with all outcomes.

Conclusions

Patient information assessed closest to the time of the outcome was more valuable in predicting death when compared with information obtained at the time of the index hospitalization. Using updated patient information improves prognosis over using only the information available at the time of the index event.

Relation of Atrial Fibrillation in Acute Myocardial Infarction to In-Hospital Complications and Early Hospital Readmission

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and contributes to high rates of in-hospital adverse events. However, there are few contemporary studies examining rates of AF in the contemporary era of AMI or the impact of new-onset AF on key in-hospital and postdischarge outcomes. We examined trends in AF in 6,384 residents of Worcester, Massachusetts, who were hospitalized with confirmed AMI during 7 biennial periods between 1999 and 2011. Multivariate logistic regression analysis was used to examine associations between occurrence of AF and various in-hospital and postdischarge complications. The overall incidence of AF complicating AMI was 10.8%. Rates of new-onset AF increased from 1999 to 2003 (9.8% to 13.2%), and decreased thereafter. In multivariable adjusted models, patients developing new-onset AF after AMI were at a higher risk for in-hospital stroke (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.6 to 4.1), heart failure (OR 2.0, 95% CI 1.7 to 2.4), cardiogenic shock (OR 3.7, 95% CI 2.8 to 4.9), and death (OR 2.3, 95% CI 1.9 to 3.0) than patients without AF. Development of AF during hospitalization for AMI was associated with higher rates of readmission within 30 days after discharge (21.7% vs 16.0%), but no significant difference was noted in early postdischarge 30-day all-cause mortality rates (8.3% vs 5.1%). In conclusion, new-onset AF after AMI is strongly related to in-hospital complications of AMI and higher short-term readmission rates.

Body Mass Index, Abdominal Fatness, and Heart Failure Incidence and Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies

BACKGROUND

Obesity has been associated with increased risk of heart failure, but whether overweight also increases risk is unclear. It is also unclear whether abdominal adiposity is more strongly associated with heart failure risk than general adiposity. We conducted a systematic review and meta-analysis of prospective studies to clarify the strength and shape of the dose-response relationship between general and abdominal adiposity and the risk of heart failure.

METHODS AND RESULTS

PubMed and Embase databases were searched up to October 10, 2014. Summary relative risks were calculated using random-effects models. A total of 28 studies (27 publications) were included. Twenty-three prospective studies with >15 905 incident cases among 647 388 participants were included in the analysis of body mass index and heart failure incidence, and 4 studies were included for heart failure mortality. The summary relative risk for a 5-unit increment in body mass index was 1.41 (95% confidence interval, 1.34-1.47; I(2)=83%) for heart failure incidence and 1.26 (95% confidence interval, 0.85-1.87; I(2)=95%) heart failure mortality. Although the test for nonlinearity was significant (P<0.0001), this appeared to be attributable to a threshold at a body mass index of ≈23 to 24 kg/m(2); however, there was evidence of increased risk even in the overweight body mass index range. The summary relative risk for a 10-cm increase in waist circumference was 1.29 (95% confidence interval, 1.21-1.37; I(2)=89%) and per 0.1-unit increase in waist-to-hip ratio was 1.29 (95% confidence interval, 1.13-1.47; I(2)=82%).

CONCLUSION

Overweight and obesity and abdominal adiposity are associated with increased risk of heart failure.

Mortality Associated With Heart Failure After Myocardial Infarction: A Contemporary Community Perspective

BACKGROUND

Contemporary data are lacking on the prognostic importance of heart failure (HF) after myocardial infarction (MI). We evaluated the prognostic impact of HF post MI according to preserved/reduced ejection fraction and the timing of its occurrence.

METHODS AND RESULTS

All Olmsted County, Minnesota, residents (n=2596) with incident MI diagnosed in 1990 to 2010 and no prior HF were followed through March 2013. Cox models were used to examine (1) the hazard ratios for death associated with HF type and timing and (2) secular trends in survival by HF status. During a mean follow-up of 7.6 years, there were 1116 deaths, 634 in the 902 patients who developed HF (70%) and 482 in the 1694 patients who did not develop HF (28%). After adjustment for age and sex, HF as a time-dependent variable was strongly associated with mortality (hazard ratio =3.31, 95% confidence interval: 2.93-3.75), particularly from cardiovascular causes (hazard ratio =4.20, 95% confidence interval: 3.50-5.03). Further adjustment for MI severity and comorbidity, acute treatment, and recurrent MI moderately attenuated these associations (hazard ratio =2.49 and 2.94 for all-cause and cardiovascular mortality, respectively). Mortality did not differ by ejection fraction, but was higher for delayed- versus early-onset HF (P for heterogeneity =0.002). The age- and sex-adjusted 5-year survival estimates in 2001 to 2010 versus 1990 to 2000 were 82% and 81% among HF-free and 61% and 54% among HF patients, respectively (P for heterogeneity of trends =0.05).

CONCLUSIONS

HF markedly increases the risk of death after MI. This excess risk is similar regardless of ejection fraction but greater for delayed- versus early-onset HF. Mortality after MI declined over time, primarily as a result of improved HF survival.

Incidence, temporal trends, and prognostic impact of heart failure complicating acute myocardial infarction. The SWEDEHEART Registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies): a study of 199,851 patients admitted with index acute myocardial infarctions, 1996 to 2008

OBJECTIVES

The aim of this study was to examine temporal trends in the incidence and outcomes of heart failure (HF) complicating acute myocardial infarction (AMI) in a large national cohort.

BACKGROUND

There are limited and conflicting data concerning temporal trends in the incidence and prognostic implication of in-hospital HF that complicates AMI.

METHODS

The nationwide coronary care unit registry SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) records baseline characteristics, treatments, and outcome of consecutive patients with AMIs admitted to all hospitals in Sweden. The diagnosis of HF requires the presence of crackles (Killip class ≥II) or the use of intravenous diuretic agents or intravenous inotropes. This study included 199,851 patients admitted for index AMIs between 1996 and 2008.

RESULTS

The incidence of HF declined from 46% to 28% (p < 0.001). This decrease was more pronounced in patients with ST-segment elevation myocardial infarctions and left bundle branch block (from 50% to 28%) compared with those with non-ST-segment elevation myocardial infarctions (from 42% to 28%) (p < 0.001). The in-hospital, 30-day, and 1-year mortality rates for patients who developed HF during the index myocardial infarction decreased over the years from 19% to 13%, from 23% to 17%, and from 36% to 31%, respectively (p < 0.001 for all). Thirteen-year survival analysis showed higher mortality in patients with HF compared with those without HF (adjusted hazard ratio: 2.1; 95% confidence interval: 2.06 to 2.13).

CONCLUSIONS

A marked decrease was found in the incidence of HF complicating AMI between 1996 and 2008. However, HF continues to worsen the early-, intermediate-, and long-term adverse prognostic risk after AMI.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Short-term mortality risk of serum potassium levels in acute heart failure following myocardial infarction

AIMS

Diuretic treatment is often needed in acute heart failure following myocardial infarction (MI) and carries a risk of abnormal potassium levels. We examined the relation between different levels of potassium and mortality.

METHODS AND RESULTS

From Danish national registries we identified 2596 patients treated with loop diuretics after their first MI episode where potassium measurement was available within 3 months. All-cause mortality was examined according to seven predefined potassium levels: hypokalaemia <3.5 mmol/L, low normal potassium 3.5-3.8 mmol/L, normal potassium 3.9-4.2 mmol/L, normal potassium 4.3-4.5 mmol/L, high normal potassium 4.6-5.0 mmol/L, mild hyperkalaemia 5.1-5.5 mmol/L, and severe hyperkalaemia: >5.5 mmol/L. Follow-up was 90 days and using normal potassium 3.9-4.2 mmol/L as a reference, we estimated the risk of death with a multivariable-adjusted Cox proportional hazard model. After 90 days, the mortality rates in the seven potassium intervals were 15.7, 13.6, 7.3, 8.1, 10.6, 15.5, and 38.3%, respectively. Multivariable-adjusted risk for death was statistically significant for patients with hypokalaemia [hazard ratio (HR): 1.91, confidence interval (95%CI): 1.14-3.19], and mild and severe hyperkalaemia (HR: 2, CI: 1.25-3.18 and HR: 5.6, CI: 3.38-9.29, respectively). Low and high normal potassium were also associated with increased mortality (HR: 1.84, CI: 1.23-2.76 and HR: 1.55, CI: 1.09-2.22, respectively).

CONCLUSION

Potassium levels outside the interval 3.9-4.5 mmol/L were associated with a substantial risk of death in patients requiring diuretic treatment after an MI.

Peri-infarct zone pacing to prevent adverse left ventricular remodelling in patients with large myocardial infarction

AIMS

We sought to determine whether peri-infarct pacing prevents left ventricular (LV) remodelling and improves functional and clinical outcomes in patients with large first myocardial infarction (MI).

METHODS AND RESULTS

A total of 126 patients at 27 international sites within 10 days of onset of anterior or non-anterior MI with creatine phosphokinase >3000 U/L and QRS duration ≤120 ms were randomized 1:1:1 to dual-site biventricular pacing vs. single-site LV only pacing vs. non-implanted control. The primary endpoint was the echocardiographic core laboratory-assessed change in LV end-diastolic volume (ΔLVEDV) from baseline to 18 months between the pooled pacing therapy groups and the control group. ΔLVEDV increased by 15.3 ± 28.6 mL in the control group and by 16.7 ± 30.5 mL in the pooled pacing groups during follow-up (adjusted mean difference (95% CI) = 0.6 (-12.3, 13.5) mL, P = 0.92). There were also no significant between-group differences in the change in LV end-systolic volume or ejection fraction over time. Quality of life, as assessed by the Minnesota Living with Heart Failure (HF) and European Quality of Life-5 Dimension questionnaires and New York Heart Association class, was also similar between groups during 18-month follow-up. Six-minute walk distance improved during follow-up to an equal degree between groups, and there were no significant differences in the 18-month rates of death or HF hospitalization between the pooled pacing therapy vs. control groups (17.4 vs. 21.7% respectively, P = 0.59).

CONCLUSIONS

In the present multicentre, randomized trial, peri-infarct pacing did not prevent LV remodelling or improve functional or clinical outcomes during 18-month follow-up in patients with large first MI.

CLINICALTRIALSGOV IDENTIFIER

NCT01213251.

Nationwide trends in development of heart failure and mortality after first-time myocardial infarction 1997-2010: A Danish cohort study

AIMS

Pharmacological and revascularization strategies following myocardial infarction (MI) have changed substantially during the last two decades. We investigated the temporal trends in heart failure (HF) incidence and mortality during the first 90 days following first-time MI between 1997 and 2010 in Denmark.

METHODS AND RESULTS

Through administrative nationwide registers we identified 89,389 patients without prior HF hospitalized with first MI. The number of patients treated with percutaneous coronary intervention (PCI) days 0-1 after index MI increased from 2.5% in 1997-98 to 38.2% in 2009-10. Treatment with clopidogrel increased from 0.02% in 1997-98 to 68.1% in 2009-10 and statins from 8.1% in 1997-98 to 78.3% in 2009-10. The incidence of HF (defined as HF diagnosis or incident use of loop diuretics) decreased from 23.6% in 1997-98 to 19.6% in 2009-10 (p<0.001). Adjusted for age, sex, and comorbidity, hazard ratio was 0.77 (95% confidence interval [CI] 0.74-0.79) for developing HF in 2009-10, compared with 1997-98. Adjusted for coronary interventions, and pharmacotherapy HR increased to 0.82 (95% confidence interval (CI) 0.79-0.85) compared with 1997-98. The 90-day mortality decreased from 19.6% in 1997-98 to 11.7% in 2009-10 (p<0.001). Adjusted for age, sex, and comorbidity HR was 0.59 (CI 0.55-0.64) in 2009-10 compared with 1997-98; upon additional adjustment for coronary interventions and pharmacotherapy the estimate was 0.75 (95% CI 0.69-0.81).

CONCLUSION

We found a temporal decrease in HF incidence and mortality during the first 90 days after MI in 1997-2010. This could partly be explained by changes in interventional and pharmacological treatment strategies.

Influence of heart failure symptoms and ejection fraction on short- and long-term outcomes for older patients with non-ST-segment elevation myocardial infarction

BACKGROUND

Symptomatic heart failure (HF) and reduced ejection fraction (REF) are both associated with mortality, but the long-term outcomes associated with the development of HF in older non-ST-segment elevation myocardial infarction (NSTEMI) patients with preserved systolic function and REF are uncertain.

METHODS

We analyzed a total of 26,291 NSTEMI patients ≥65 years discharged alive in the CRUSADE Registry who had linked Medicare data. We evaluated 30-day and 1-year risks of mortality and HF readmission in 4 cohorts of patients stratified by symptomatic HF and ejection fraction: (1) no HF-PEF, (2) no HF-REF, (3) HF-PEF, and (4) HF-REF.

RESULTS

A total of 14,280 NSTEMI patients (54.3%) had no HF-PEF, 3,345 (12.7%) had no HF-REF, 4,913 (18.7%) had HF-PEF, and 3,753 (14.3%) had HF-REF. Compared with no HF-PEF patients, the 30-day mortality risk was higher among patients with no HF-REF (4.9% vs 1.7%, adjusted hazard ratio 2.11, 95% CI 1.69-2.63), HF-PEF (5.9% vs 1.7%, adjusted hazard ratio 1.99, 95% CI 1.64-2.41), and highest among those with HF-REF (9.3% vs 1.7%, adjusted hazard ratio 2.70, 95% CI 2.23-3.26). Similar relationships were noted in the adjusted 1-year mortality and the risks of 30-day and 1-year HF readmission.

CONCLUSIONS

Symptomatic HF and REF during the index NSTEMI hospitalization are both associated with an increased risk of short- and long-term mortality as well as HF readmission with an apparent additive prognostic impact of both factors.

Encouraging trends in acute myocardial infarction survival in the oldest old

BACKGROUND

There are limited data informing the optimal treatment strategy for acute myocardial infarction in the oldest old (aged ≥85 years). The study aim was to examine whether decade-long increases in guideline-based cardiac medication use mediate declines in post-discharge mortality among oldest old patients hospitalized with acute myocardial infarction.

METHODS

The study sample included 1137 patients aged ≥85 years hospitalized in 6 biennial periods between 1997 and 2007 for acute myocardial infarction at all 11 greater Worcester, Massachusetts, medical centers. We examined trends in 90-day survival after hospital discharge and guideline-based medication use (aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, lipid-lowering agents) for acute myocardial infarction during hospitalization and at discharge. Sequential multivariable Cox regression models examined the relationship among guideline-based medication use, study year, and 90-day post-discharge survival rates.

RESULTS

Patients hospitalized between 2003 and 2007 experienced higher 90-day survival rates than those hospitalized between 1997 and 2001 (69.1% vs 59.8%, P < .05). Between 1997 and 2007, the average number of guideline-based medications prescribed at discharge increased significantly (1.8 to 2.9, P < .001). The unadjusted hazard ratio for 90-day post-discharge mortality in 2003-2007 compared with 1997-2001 was 0.73 (95% confidence interval, 0.60-0.89); after adjustment for patient characteristics and guideline-based cardiac medication use, this relationship was no longer significant (hazard ratio, 1.26; 95% confidence interval, 1.00-1.58).

CONCLUSIONS

Between 1997 and 2007, 90-day survival improved among a population-based sample of patients aged ≥85 years hospitalized for acute myocardial infarction. This encouraging trend was explained by increased use of guideline-based medications.

Nitrates for acute heart failure syndromes

BACKGROUND

Current drug therapy for acute heart failure syndromes (AHFS) consists mainly of diuretics supplemented by vasodilators or inotropes. Nitrates have been used as vasodilators in AHFS for many years and have been shown to improve some aspects of AHFS in some small studies. The aim of this review was to determine the clinical efficacy and safety of nitrate vasodilators in AHFS.

OBJECTIVES

To quantify the effect of different nitrate preparations (isosorbide dinitrate and nitroglycerin) and the effect of route of administration of nitrates on clinical outcome, and to evaluate the safety and tolerability of nitrates in the management of AHFS.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to July week 2 2011) and EMBASE (1980 to week 28 2011). We searched the Current Controlled Trials MetaRegister of Clinical Trials (compiled by Current Science) (July 2011). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction.

SELECTION CRITERIA

Randomised controlled trials comparing nitrates (isosorbide dinitrate and nitroglycerin) with alternative interventions (frusemide and morphine, frusemide alone, hydralazine, prenalterol, intravenous nesiritide and placebo) in the management of AHFS in adults aged 18 and over.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using the Cochrane Collaboration tool for assessing risk of bias.

MAIN RESULTS

Four studies (634 participants) met the inclusion criteria. Two of the included studies included only patients with AHFS following acute myocardial infarction (AMI); one study excluded patients with overt AMI; and one study included participants with AHFS with and without acute coronary syndromes.Based on a single study, there was no significant difference in the rapidity of symptom relief between intravenous nitroglycerin/N-acetylcysteine and intravenous frusemide/morphine after 30 minutes (fixed-effect MD -0.30, 95% CI -0.65 to 0.05), 60 minutes (fixed-effect MD -0.20, 95% CI -0.65 to 0.25), three hours (fixed-effect MD 0.20, 95% CI -0.27 to 0.67) and 24 hours (fixed-effect MD 0.00, 95% CI -0.31 to 0.31). There is no evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following outcome measures: requirement for mechanical ventilation, systolic blood pressure (SBP) change after three hours and 24 hours, diastolic blood pressure (DBP) change after 30, 60 and 90 minutes, heart rate change at 30 minutes, 60 minutes, three hours and 24 hours, pulmonary artery occlusion pressure (PAOP) change after three hours and 18 hours, cardiac output (CO) change at 90 minutes and three hours and progression to myocardial infarction. There is a significantly higher incidence of adverse events after three hours with nitroglycerin compared with placebo (odds ratio 2.29, 95% CI 1.26 to 4.16) based on a single study. There was no consistent evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following secondary outcome measures: SBP change after 30 and 60 minutes, heart rate change after 90 minutes, and PAOP change after 90 minutes. None of the included studies reported healthcare costs as an outcome measure. There were no data reported by any of the studies relating to the acceptability of the treatment to the patients (patient satisfaction scores).Overall there was a paucity of relevant quality data in the included studies. Assessment of overall risk of bias in these studies was limited as three of the studies did not give sufficient detail to allow assessment of potential risk of bias.

AUTHORS' CONCLUSIONS

There appears to be no significant difference between nitrate vasodilator therapy and alternative interventions in the treatment of AHFS, with regard to symptom relief and haemodynamic variables. Nitrates may be associated with a lower incidence of adverse effects after three hours compared with placebo. However, there is a lack of data to draw any firm conclusions concerning the use of nitrates in AHFS because current evidence is based on few low-quality studies.

Gender differences in the pathophysiology, clinical presentation, and outcomes of ischemic heart failure

Despite advances in the treatment of acute myocardial infarction (MI), heart failure (HF) remains a frequent acute and long-term outcome of ischemic heart disease (IHD). In response to acute coronary ischemia, women are relatively protected from apoptosis, and experience less adverse cardiac remodeling than men, frequently resulting in preservation of left ventricular size and ejection fraction. Despite these advantages, women are at increased risk for HF- complicating acute MI when compared with men. However, women with HF retain a survival advantage over men with HF, including a decreased risk of sudden death. Sex-specific treatment of HF has been hindered by historical under-representation of women in clinical trials, though recent work has suggested that women may have a differential response to some therapies such as cardiac resynchronization. This review highlights the sex differences in the pathophysiology, clinical presentation and outcomes of ischemic heart failure and discusses key areas worthy of further investigation.

Increase in the proportion of patients hospitalized with acute myocardial infarction with do-not-resuscitate orders already in place between 2001 and 2007: a nonconcurrent prospective study

BACKGROUND AND OBJECTIVE

Shared decision making and advance planning in end-of-life decisions have become increasingly important aspects of the management of seriously ill patients. Here, we describe the use and timing of do-not-resuscitate (DNR) orders in patients hospitalized with acute myocardial infarction (AMI).

STUDY DESIGN AND SETTING

The nonconcurrent prospective study population consisted of 4182 patients hospitalized with AMI in central Massachusetts in four annual periods between 2001 and 2007.

RESULTS

One-quarter (25%) of patients had a DNR order written either prior to or during hospitalization. The frequency of DNR orders remained constant (24% in 2001; 26% in 2007). Among patients with DNR orders, there was a significant increase in orders written prior to hospitalization (2001: 9%; 2007: 55%). Older patients and those with a medical history of heart failure or myocardial infarction were more likely to have prior DNR orders than respective comparison groups. Patients with prior DNR orders were less likely to die 1 month after hospitalization than patients whose DNRs were written during hospitalization.

CONCLUSION

Although the use of DNR orders in patients hospitalized with AMI was stable during the period under study, in more recent years, patients are increasingly being hospitalized with DNR orders already in place.

Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates

Background

Heart failure (HF) is a serious complication of acute coronary syndromes (ACS), and is associated with high in-hospital mortality and poor long-term survival. The aims of this study were to describe the clinical characteristics, management and in-hospital outcomes of coronary syndrome (ACS) patients with HF in the United Arab Emirates.

Findings

The study was selected from the Gulf Registry of Acute Coronary Events (Gulf RACE), a prospective multi-national, multicenter registry of patients hospitalized with ACS in six Middle East countries. The present analysis was focused on participants admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 and were analyzed in terms of HF (Killip class II/III and IV) on admission. Of 1691 patients (mean age: 52.6 ± 11.7 years; 210 Females, 1481 Males) with ACS, 356 (21%) had an admission diagnosis of HF (Killip class II/III and IV). HF patients were less frequently males (19.2% vs. 34.3%; P < 0.001). HF was more frequently associated with hypertension (64.3% vs. 43.9%; P < 0.001), hyperlipidemia (49.4% vs. 31.8%; P < 0.001) and diabetes mellitus (DM) (51.1% vs. 36.2%; P < 0.001). HF was significantly associated with in-hospital mortality (OR = 11.821; 95% CI: 5.385-25.948; P < 0.001). In multivariate logistic regression, age, hyperlipidemia, heart rate and DM were associated with higher in-hospital HF.

Conclusions

HF is observed in about 1 in 5 patients with ACS in the UAE and is associated with a significant increase in in-hospital mortality and other adverse outcomes.

Pulse oximetry in the diagnosis of acute heart failure

INTRODUCTION AND OBJECTIVES

Oxygen saturation by pulse oximetry is commonly used for monitoring critical patients, but its utility as a diagnostic marker of acute heart failure has not been assessed. This study analyzed the diagnostic role of oxygen saturation by pulse oximetry in a series of patients with acute myocardial infarction.

METHODS

In a prospective observational cohort study of 220 consecutive patients with acute myocardial infarction, data collection included baseline oxygen saturation by pulse oximetry (without oxygen), physiologic measurements, Killip class and data from portable chest radiography, recorded at the same hour on each of the first three days after admission. Patients were followed up for one year.

RESULTS

There were 612 assessments. Baseline oxygen saturation by pulse oximetry decreased progressively in relation to the presence and the severity of acute heart failure assessed by Killip classes 1 to 3 (mean: 95, 92 and 85, respectively; P<.001) or by Radiology Score 0 to 4 (95, 94, 92, 89 and 83, respectively; P<.001), with a correlation coefficient of 0.66 and 0.63, respectively. Receiver operating characteristic curves disclosed the cut-off of oxygen saturation by pulse oximetry<93 to have the greatest area, with a sensitivity of 65%, specificity 90%, and overall test accuracy 83%. Patients grouped according to lowest oxygen saturation by pulse oximetry showed significantly different rates of one-year mortality or rehospitalization for heart failure.

CONCLUSIONS

Baseline oxygen saturation by pulse oximetry is useful in establishing the diagnosis and severity of heart failure in acute settings such as myocardial infarction and may have prognostic implications.The diagnosis may be suspected when baseline oxygen saturation by pulse oximetry is <93. Full English text available from:www.revespcardiol.org.

Heart failure in acute myocardial infarction: a comparison between patients with or without heart failure criteria from the FAST-MI registry

INTRODUCTION AND OBJECTIVES

To compare acute myocardial infarction patients with or without congestive heart failure in the French FAST-MI registry.

METHODS

The French FAST-MI registry included 374 centers and 3059 patients over a 1-month period at the end of 2005, with 1-year follow-up. Among this population, patients with at least one congestive heart failure criterion constituted group 1 (n=1149; 37.5%) and were compared to patients without congestive heart failure (group 2, n=1910; 62.5%). The congestive heart failure patients were further divided according to presence of both beta-blockers and antagonists of the renin-angiotensin-aldosterone system at hospital discharge (n=511) or not (n=498), in order to assess the real-world clinical importance of recommended medications.

RESULTS

Overall in-hospital and 1-year mortality rates were 3.4% and 13.2%, respectively. In hospital survivors, presence of congestive heart failure was associated with increased mortality (adjusted hazard ratio: 1.55; 95% confidence interval, 1.10-2.17; P=.01). Survival was higher in patients without congestive heart failure, compared with congestive heart failure patients receiving or not recommended medications (P<.001). Congestive heart failure patients receiving neither renin-angiotensin-aldosterone system blockers nor beta-blockers (adjusted hazard ratio: 1.66; 95% confidence interval, 1.08-2.55; P=.02) had a significantly higher risk of death than patients receiving both classes of medications (adjusted hazard ratio: 1.16; 95% confidence interval, 0.82-1.64; not statistically significant). Patients receiving only one of the recommended classes had an intermediate risk (adjusted hazard ratio: 1.47; 95% confidence interval, 1.04-2.07; P=.03).

CONCLUSIONS

Patients admitted for acute myocardial infarction with congestive heart failure criteria are still at very high risk of mortality. When receiving major recommended medications, they presented with significantly reduced mortality rates. Additional efforts should therefore be made to encourage the prescription of recommended medications in acute myocardial infarction patients with congestive heart failure.

Long-term trends in short-term outcomes in acute myocardial infarction

BACKGROUND

The objectives of this study were to examine the magnitude of, and 20-year trends in, age differences in short-term outcomes among men and women hospitalized with acute myocardial infarction (AMI) in central Massachusetts.

METHODS

The study population consisted of 5907 male and 4406 female residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers with AMI between 1986 and 2005.

RESULTS

Overall, among both men and women, older patients were significantly more likely to have developed atrial fibrillation, heart failure, and to have died during hospitalization and within 30 days after admission compared with patients aged <65 years. Among men, age differences in the risk of developing atrial fibrillation have widened over the past 2 decades, while differences in the risk of developing cardiogenic shock have narrowed for men 75 years and older as compared with those aged <65 years. Among women, age differences in the risk of developing these major complications of AMI have not changed significantly over time. Age differences in short-term mortality have remained relatively unchanged over the past 20 years in both sexes, although individuals of all ages have experienced decreases in short-term death rates over this period.

CONCLUSIONS

Elderly men and women are more likely to experience adverse short-term outcomes after AMI, and age differences in short-term mortality rates have remained relatively unchanged in both sexes over the past 20 years. More targeted treatment approaches during hospitalization for AMI and thereafter are needed for older patients to improve their prognosis.

Incidence and predictors of heart failure following percutaneous coronary intervention in ST-segment elevation myocardial infarction: the HORIZONS-AMI trial

BACKGROUND

Congestive heart failure (CHF) is a major source of morbidity, mortality, and health-care resource consumption. However, the incidence of symptomatic CHF after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) has rarely been fully reported. We therefore examined the early and late incidence, predictors, and implications of CHF in the large-scale, prospective, randomized HORIZONS-AMI trial.

METHODS AND RESULTS

New York Heart Association (NYHA) functional classification was prospectively collected from patient-level data at baseline, 30 days, 6 months, and at 1 and 2 years from 3,343 patients with STEMI undergoing PCI at 123 centers in 11 countries. The baseline incidence of CHF (before the index STEMI) was 2.6%, increasing to 4.6% 1 month after primary PCI (P < .0001), 4.7% at 1 year, and 5.1% at 2 years. The incidence of NYHA class III/IV symptoms was 0.4% at baseline and 0.8% at 2 years (P = .03). CHF at 1 year was associated with diabetes (P < .0001), dyslipidemia (P = .009), previous MI (P < .0001), previous revascularization (P = .01), anterior STEMI (P = .02), and baseline TIMI grade 0 flow (P = .01) but not procedural anticoagulation with bivalirudin versus heparin + GPIIb/IIIa inhibitors (P = .93) or use of drug-eluting versus bare metal stents (P = .66). Among patients in whom CHF was not present at baseline but developed after PCI, the rate of all-cause mortality was significantly higher during 2-year follow-up (7.3% vs 2.0%, P < .0001), as was cardiac mortality (2.4% vs 0.8%, P = .004), reinfarction (9.4% vs 5.2%, P = .0009), stent thrombosis (7.0% vs 3.8%, P = .007), and ischemic target vessel revascularization (19.4% vs 11.8%, P < .0001).

CONCLUSION

In the HORIZONS-AMI trial, the development of new-onset CHF within 2 years after contemporary PCI, although infrequent, was associated with significantly increased rates of mortality and major adverse ischemic events.

Thirty-year (1975 to 2005) trends in the incidence rates, clinical features, treatment practices, and short-term outcomes of patients <55 years of age hospitalized with an initial acute myocardial infarction

Sparse data are available describing recent trends in the magnitude, clinical features, treatment practices, and outcomes of comparatively young adults hospitalized with acute myocardial infarction (AMI). The objectives of this population-based study were to describe 3 decade-long trends (1975 to 2005) in these end points in adults <55 years old who were hospitalized with an initial AMI. The study population consisted of 1,703 residents of the Worcester (Massachusetts) metropolitan area 25 to 54 years of age who were hospitalized with initial AMIs at all central Massachusetts medical centers during 15 annual periods from 1975 through 2005. Overall hospital incidence rate (per 100,000 residents) of initial AMI in our study population was 66 (95% confidence interval 63 to 69) and incidence rates of AMI decreased inconsistently over time. Patients hospitalized during the most recent study years were more likely to have important cardiovascular risk factors and co-morbidities present but were less likely to have developed heart failure during their index hospitalization. In-hospital and 30-day death rates decreased by approximately 50% (p = 0.04) during the years under study concomitant with increasing use of effective cardiac therapies. In conclusion, the results of this community-wide investigation provide insights into the magnitude, changing characteristics, and short-term outcomes of comparatively young patients hospitalized with a first AMI. Decreasing odds of developing or dying from an initial AMI during the 30 years under study likely reflect increased primary and secondary prevention and treatment efforts.

Impact of concomitant heart failure on outcomes in patients undergoing percutaneous coronary interventions: analysis of the Melbourne Interventional Group registry

AIMS

The presence of heart failure (HF) is an established risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to determine the prevalence and impact of concomitant HF on major outcomes in contemporary PCI practice.

METHODS AND RESULTS

We analysed 5006 consecutive PCIs (2004-2006) enrolled in the Melbourne Interventional Group registry. Baseline characteristics, in-hospital, 30-day, and 12-month outcomes of patients with a history of HF (n = 189, 3.8%) were compared with patients without HF (n = 4817, 96.2%). Patients with a history of HF were older (mean age 72.9 ± 9.8 vs. 64.3 ± 12 years, P < 0.01) and had higher rates of diabetes (37.0 vs. 23.5%, P < 0.01), renal dysfunction (Cr > 200 μmol/L; 16.5 vs. 3.9%, P < 0.01), multi-vessel disease (79.8 vs. 58.7%, P < 0.01), and presentation with cardiogenic shock (4.8 vs. 2.1%, P = 0.02). At 12 months, patients with HF had higher overall mortality (13.7 vs. 3.5%, P < 0.01) and rates of HF admission (10.4 vs. 2.0%, P < 0.01). Independent predictors of recurrent HF admission included history of HF [odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.2, P < 0.01] and renal dysfunction (OR 2.5, 95% CI 1.4-4.4, P < 0.01). At 12 months, patients with HF had lower rates of statin (73.9 vs. 89.2%, P < 0.01) and beta-blocker use (55.6 vs. 59.0%, P < 0.01). Angiotensin-converting enzyme-inhibitor/angiotensin receptor blocker use was also relatively low in HF patients (79.6%).

CONCLUSION

While the overall incidence of HF in patients undergoing PCI is low, underutilization of HF therapies may contribute to an increased likelihood of subsequent re-admission and increased mortality.

30-year trends in heart failure in patients hospitalized with acute myocardial infarction

Despite significant advances in its treatment, acute myocardial infarction (AMI) remains an important cause of heart failure (HF). Contemporary data remain lacking, however, describing long-term trends in incidence rates, demographic and clinical profiles, and outcomes of patients who develop HF as a complication of AMI. Our study sample consisted of 11,061 residents of the Worcester (Massachusetts) metropolitan area hospitalized with AMI at all greater Worcester hospitals in 15 annual study periods from 1975 to 2005. Overall, 32.4% of patients (n = 3,582) with AMI developed new-onset HF during their acute hospitalization. Patients who developed HF were generally older, more likely to have pre-existing cardiovascular disease, and were less likely to receive cardiac medications or undergo revascularization procedures during their hospitalization than patients who did not develop HF (p <0.001). Incidence rates of HF remained relatively stable from 1975 to 1991 at 26% but decreased thereafter. Decreases were also noted in hospital and 30-day death rates in patients with acute HF (p <0.001). However, patients who developed new-onset HF remained at significantly higher risk for dying during their hospitalization (21.6%) than patients who did not develop this complication (8.3%, p <0.001). Our large community-based study of patients hospitalized with AMI demonstrates that incidence rates of and mortality attributable to HF have decreased over the previous 3 decades. In conclusion, HF remains a common and frequently fatal complication of AMI to which increased surveillance and treatment efforts should be directed.

The evolving epidemiology of acute coronary syndromes

The clinical entities that comprise acute coronary syndromes (ACS)-ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina-have been recognized as widespread causes of death and disability for more than a century. Seminal research in the past 50 years has led to important scientific and medical advances in our understanding of ACS. Rapid modernization of the developing world has led to a pandemic of coronary artery disease and its manifestation as ACS, with profound implications for personal, societal, and global health. Epidemiological studies have provided insight into the changing demographics of ACS, and highlighted the importance of modifiable risk factors and adherence to guideline-recommended therapy.

Changing patterns of ST elevation myocardial infarction epidemiology

Despite advances in both the early management and longer-term treatment of acute myocardial infarction, this condition still represents a leading cause of morbidity and mortality in western countries, making essential understanding its determinants. All epidemiologic studies examining prognosis after acute myocardial infarction have used data collected in the midst of the epidemic, possibly giving rise to conflicting results. Hospitalization rates for myocardial infarction have remained relatively stable for the past five decades, in the face of declining coronary heart disease risk factor prevalence and mortality rates, yielding to a paradoxical effect. Many factors like the decrease in severity of such disease and the changes in myocardial infarction definitions may have contributed to such phenomenon. Moreover, because non-ST elevation myocardial infarctions now constitute most of cases in communities, interventions must be designed that recognize this epidemiological reality. At the same time, improved survival in recent decades may have contributed to an increase in the pool of people at risk for developing HF. Thus, the epidemiology and treatment of this condition has not stood still.

Epidemiology and risk profile of heart failure

Heart failure (HF) is a major public health issue, with a prevalence of over 5.8 million in the USA, and over 23 million worldwide, and rising. The lifetime risk of developing HF is one in five. Although promising evidence shows that the age-adjusted incidence of HF may have plateaued, HF still carries substantial morbidity and mortality, with 5-year mortality that rival those of many cancers. HF represents a considerable burden to the health-care system, responsible for costs of more than $39 billion annually in the USA alone, and high rates of hospitalizations, readmissions, and outpatient visits. HF is not a single entity, but a clinical syndrome that may have different characteristics depending on age, sex, race or ethnicity, left ventricular ejection fraction (LVEF) status, and HF etiology. Furthermore, pathophysiological differences are observed among patients diagnosed with HF and reduced LVEF compared with HF and preserved LVEF, which are beginning to be better appreciated in epidemiological studies. A number of risk factors, such as ischemic heart disease, hypertension, smoking, obesity, and diabetes, among others, have been identified that both predict the incidence of HF as well as its severity. In this Review, we discuss key features of the epidemiology and risk profile of HF.

Declining length of stay for patients hospitalized with AMI: impact on mortality and readmissions

BACKGROUND

Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients.

METHODS

The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, 1997, 1999, 2001, 2003, 2005).

RESULTS

The average age of the study sample was 71 years, and 54% were men. The average length of stay decreased by nearly one third over the 10-year study period, from 7.2 days in 1995 to 5.0 days in 2005 (P <.001). Younger patients (<65 years), men, and patients with an uncomplicated hospital stay had significantly shorter lengths of stay than respective comparison groups. Lengths of stay shorter than the median were not associated with significantly higher odds of hospital readmission at 7 or 30 days postdischarge, or with mortality in the year after discharge. In contrast, longer lengths of stay were associated with significantly higher odds of short-term mortality. These findings did not vary by year under study.

CONCLUSIONS

Length of stay in patients hospitalized for acute myocardial infarction decreased significantly between 1995 and 2005. Declining length of stay is not associated with an increased risk for early readmission or all-cause mortality.