Pathophysiology of ST-segment elevation myocardial infarction: novel mechanisms and treatments

Recent advances in biomimetic nanodelivery systems for the treatment of myocardial ischemia reperfusion injury

Myocardial ischemia/reperfusion injury (MIRI) is a significant challenge in the treatment of myocardial infarction, a leading cause of global mortality due to irreversible cardiac damage. Biomimetic nanodelivery systems offer promising therapeutic strategies to address MIRI. In this review, we comprehensively investigate the underlying pathophysiological mechanisms of MIRI and discuss recent advances in biomimetic nanodelivery systems including cell membrane-coated nanoparticles, exosomes, and nanoenzymes as innovative approaches for MIRI treatment. We emphasize the advantages and potential of biomimetic strategies in enhancing therapeutic efficacy, assess the preclinical effectiveness of these nanodelivery systems, and discuss the challenges associated with translating these approaches into clinical practice. This paper aims to provide new perspectives on biomimetic strategies for MIRI treatment, contributing to the development of effective drug delivery systems.

Biomarkers of inflammation in sweat after myocardial infarction

ST-elevation myocardial infarction (STEMI) triggers a significant inflammatory response. Sweat may offer a novel, non-invasive medium for monitoring inflammation. In this prospective study, we characterized the inflammatory signatures in plasma and sweat collected from the skin surface of two patient groups: (1) 18 STEMI patients immediately following percutaneous coronary intervention (exposure) and (2) six patients who underwent outpatient angiography without subsequent intervention (control). Levels of 92 biomarkers were measured using a high-throughput proteomic assay and reassessed after 4-6 weeks in STEMI patients. Adjusting for patient group, sweat biomarkers did not show significant changes over time. In plasma, hepatocyte growth factor and interleukin-6 showed a significant decrease from the acute phase to follow-up, adjusted for patient group. STAM binding protein was significantly higher in the sweat of STEMI patients compared to controls, adjusted for time effects. While sweat was less sensitive than plasma for detecting biomarker levels in the setting of STEMI, its longitudinal analysis via wearable sensors holds promise for detecting specific markers.Trial registration: The trial is registered on www.clinicaltrials.gov with the trial registration number NCT05843006.

DIFFERENCES ON IN-HOSPITAL OUTCOMES IN PATIENTS WITH CARDIOGENIC SHOCK DUE TO STEMI VERSUS NSTEMI USING A NATIONWIDE DATABASE

ABSTRACT

Background: Our study aims to compare in-hospital management and outcomes in patients with cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI) versus non-ST-segment elevation myocardial infarction (NSTEMI). Methods: We conducted a retrospective cohort study using the National Inpatient Sample database between 2016-2019, including patients with STEMI/NSTEMI complicated by cardiogenic shock. An inverse probability treatment weighting analysis was performed to compare in-hospital management and outcomes between patients with STEMI and NSTEMI. Adjusted relative risks (aRR) with their 95% confidence intervals (CIs) were estimated. Results: A total of 150,395 patients with cardiogenic shock due to acute myocardial infarction were included, of whom 52.8% had STEMI. The median age was 68 years (60-77) and 35% were female. Percutaneous coronary intervention, intra-aortic balloon counterpulsation, percutaneous ventricular assist device, extracorporeal membrane oxygenation, and mechanical ventilation use were significantly higher in the STEMI group compared to NSTEMI. Coronary artery bypass grafting, renal replacement therapy, length of hospital stay, and total costs were lower in the STEMI group. Pulmonary arterial catheterization and cardiac transplantation were similar between both groups. Inverse probability treatment weighting analysis showed that in-hospital mortality was significantly higher in the STEMI group compared to NSTEMI (34.2% vs. 28.8%, aRR 1.19, 95% CI 1.14-1.23) and also major bleeding. Conclusion: In conclusion, patients with cardiogenic shock due to STEMI had worse prognosis, higher use of percutaneous coronary intervention/mechanical circulatory support, and major bleeding than the NSTEMI group. In contrast, patients with NSTEMI had greater use of coronary artery bypass grafting and hospital resources.

Regulatory T Cells in Pathological Cardiac Hypertrophy: Mechanisms and Therapeutic Potential

BACKGROUND

Pathological cardiac hypertrophy is linked to immune-inflammatory injury, and regulatory T cells (Tregs) play a crucial role in suppressing immune-inflammatory responses. However, the precise role of Tregs in pathological cardiac hypertrophy remains unclear.

OBJECTIVE

To summarize the current knowledge on the role and mechanisms of Tregs in pathological cardiac hypertrophy and explore their perspectives and challenges as a new therapeutic approach.

RESULTS

Treg cells may play an important protective role in pressure overload (hypertension, aortic stenosis), myocardial infarction, metabolic disorders (diabetes, obesity), acute myocarditis, cardiomyopathy (hypertrophic cardiomyopathy, storage diseases), and chronic obstructive pulmonary disease-related pathological cardiac hypertrophy. Although some challenges remain, the safety and efficacy of Treg-based therapies have been confirmed in some clinical trials, and engineered antigen-specific Treg cells may have better clinical application prospects due to stronger immunosuppressive function and stability.

CONCLUSION

Targeting the immune-inflammatory response via Treg-based therapies might provide a promising and novel future approach to the prevention and treatment of pathological cardiac hypertrophy.

Machine-learning clustering analysis identifies novel phenogroups in patients with ST-elevation acute myocardial infarction

BACKGROUND

Machine learning clustering of patients with ST-elevation acute myocardial infarction (STEMI) may provide important insights into their risk profile, management and prognosis.

METHODS

All adult discharges for STEMI in the National Inpatient Sample (October 2015 to December 2019) were included, excluding patients with prior myocardial infarction. Machine-learning clustering analysis was used to define clusters based on 21 clinical attributes of interest. Main outcomes of the study were cluster-based comparison of risk profile, in-hospital clinical outcomes and utilization of invasive management. Binomial hierarchical multivariable logistic regression with adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) was used to detect the between-cluster differences.

RESULTS

Out of overall 470,960 STEMI cases, the machine-learning analysis revealed 4 different clusters with 205,640 (cluster 0: 'behavioural risk cluster'), 146,400 (cluster 1: 'least comorbidity cluster'), 45,100 (cluster 2: 'diabetes with end-organ damage cluster') and 73,820 (cluster 3: 'cardiometabolic cluster') cases. Attributes with the highest importance for clustering were hypertension and diabetes. After multivariable adjustment, patients from 'diabetes with end-organ damage cluster' exhibited the worst mortality, MACCE and ischemic stroke (p < 0.001 for all), as well as the lowest utilization of invasive management (p < 0.001 for all), in comparison to other clusters. Patients from 'behavioural risk cluster' exhibited the best in-hospital prognosis and the highest utilization of invasive management, compared to other clusters (p < 0.001 for all).

CONCLUSIONS

Machine learning driven clustering of inpatients with STEMI reveals important population subgroups with distinct prevalence, risk profile, prognosis and management. Data driven approaches may identify high risk phenogroups and warrants further study.

Incidence and predictors of new-onset atrial fibrillation in ST-elevation myocardial infarction: A single-center study

Background and Aims

Atrial fibrillation (AF) is a common arrhythmia that occurs following ST-elevation myocardial infarction (STEMI) and can significantly impact clinical outcomes. We investigated the incidence and predictors of AF following STEMI in patients, as well as its association with major adverse cardiac and cerebrovascular events (MACCE).

Methods

We conducted a retrospective cohort study, including all STEMI patients who presented under code 247 to Tehran Heart Center between 2016 and 2020 and completed a 1-year follow-up. Patients were divided into two groups based on the development of AF during follow-up, and their baseline and clinical characteristics were compared. We used multivariable regression models to identify predictors of MACCE.

Results

Out of 3647 STEMI patients, 84 (2.3%) developed new-onset AF (NOAF). Patients with AF were significantly older and had lower levels of total and low-density lipoprotein cholesterol, triglyceride, and hemoglobin, but higher levels of fasting blood sugar and creatinine. AF patients were also more likely to have a history of hypertension, chronic kidney disease (CKD), congestive heart failure, and cerebrovascular accidents. The multivariable logistic regression model identified the CHA2DS2-VASc score and CKD as independent predictors of NOAF following primary percutaneous coronary intervention. Furthermore, the incidence of MACCE was higher in the AF group, and AF independently predicted MACCE with a hazard ratio of 2.766.

Conclusion

The CHA2DS2-VASc score and the presence of CKD can serve as useful predictors of NOAF among patients with STEMI. Early detection and appropriate management are crucial to improve outcomes.

Efficacy and safety of Panax notoginseng saponin injection in the treatment of acute myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

Purpose: This study aimed to assess the efficacy and safety of Panax notoginseng saponin (PNS) injection, when combined with conventional treatment (CT), for acute myocardial infarction (AMI). Methods: Comprehensive searches were conducted in seven databases from inception until 28 September 2023. The search aimed to identify relevant randomized controlled trials (RCTs) focusing on PNS injection in the context of AMI. This meta-analysis adhered to the PRISMA 2020 guidelines, and its protocol was registered with PROSPERO (number: CRD42023480131). Result: Twenty RCTs involving 1,881 patients were included. The meta-analysis revealed that PNS injection, used adjunctively with CT, significantly improved treatment outcomes compared to CT alone, as evidenced by the following points: (1) enhanced total effective rate [OR = 3.09, p < 0.05]; (2) decreased incidence of major adverse cardiac events [OR = 0.32, p < 0.05]; (3) reduction in myocardial infarct size [MD = -6.53, p < 0.05]; (4) lower ST segment elevation amplitude [MD = -0.48, p < 0.05]; (5) mitigated myocardial injury as indicated by decreased levels of creatine kinase isoenzymes [MD = -11.19, p < 0.05], cardiac troponin T [MD = -3.01, p < 0.05], and cardiac troponin I [MD = -10.72, p < 0.05]; (6) enhanced cardiac function, reflected in improved brain natriuretic peptide [MD = -91.57, p < 0.05], left ventricular ejection fraction [MD = 5.91, p < 0.05], left ventricular end-diastolic dimension [MD = -3.08, p < 0.05], and cardiac output [MD = 0.53, p < 0.05]; (7) reduced inflammatory response, as shown by lower levels of C-reactive protein [MD = -2.99, p < 0.05], tumor necrosis factor-α [MD = -6.47, p < 0.05], interleukin-6 [MD = -24.46, p < 0.05], and pentraxin-3 [MD = -2.26, p < 0.05]; (8) improved vascular endothelial function, demonstrated by decreased endothelin-1 [MD = -20.56, p < 0.05] and increased nitric oxide [MD = 1.33, p < 0.05]; (9) alleviated oxidative stress, evidenced by increased superoxide dismutase levels [MD = 25.84, p < 0.05]; (10) no significant difference in adverse events [OR = 1.00, p = 1.00]. Conclusion: This study highlighted the efficacy and safety of adjunctive PNS injections in enhancing AMI patient outcomes beyond CT alone. Future RCTs need to solidify these findings through rigorous methods. Systematic Review Registration: (https://www.crd.york.ac.uk/PROSPERO/), identifier (CRD42023480131).

Natural History and Clinical Outcomes After ST-Segment Elevation Myocardial Infarction Without Stent Insertion

After restoration of coronary perfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI), discrete severe stenotic coronary lesions are not always apparent. There remains ambiguity whether drug-eluting stent (DES) insertion or initial medical management is best practice. We sought to assess short-term clinical outcomes in patients presenting with STEMI without initial stent insertion. Patients who underwent percutaneous coronary intervention for STEMI between 2014 and 2020 were prospectively enrolled and assessed for inclusion. Patients presenting with in-stent restenosis or stent thrombosis, or who did not survive to hospital discharge were excluded. Of 13,871 patients presenting, 456 (3.3%) were treated without initial stenting. These patients were older than those treated with DES (66.1 ± 13.6 vs 62.3 ± 12.4 years, p <0.001), had higher rates of diabetes (23.5% vs 16.0%, p <0.001) and previous revascularization with either percutaneous coronary intervention (14.0% vs 7.3%, p <0.001) or coronary artery bypass graft (3.5% vs 1.8%, p = 0.008). Thirty-day mortality was elevated in patients treated without stenting compared to those receiving DES (4.2% vs 0.9%, p <0.001), as were rates of myocardial infarction (1.3% vs 0.5%, p = 0.026) and major adverse cardiac events (10.5% vs 2.4%, p <0.001). After propensity matching, a trend toward increased mortality remained (4.2% vs 2.0%, p = 0.055). In conclusion, a no-stenting initial strategy, compared with DES insertion, is associated with increased 30-day mortality in those presenting with STEMI without severe stenosis. These data suggest when appropriate, current-generation DES insertion should be undertaken.

Association of recent respiratory illness and influenza with acute myocardial infarction among the Bangladeshi population: A case-control study

Current evidence suggests that recent acute respiratory infections and seasonal influenza may precipitate acute myocardial infarction (AMI). This study examined the potential link between recent clinical respiratory illness (CRI) and influenza, and AMI in Bangladesh. Conducted during the 2018 influenza season at a Dhaka tertiary-level cardiovascular (CV) hospital, it included 150 AMI cases and two control groups: 44 hospitalized cardiac patients without AMI and 90 healthy individuals. Participants were matched by gender and age groups. The study focused on self-reported CRI and laboratory-confirmed influenza ascertained via quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) within the preceding week, analyzed using multivariable logistic regression. Results showed that cases reported CRI, significantly more frequently than healthy controls (27.3% vs. 13.3%, adjusted odds ratio (aOR): 2.21; 95% confidence interval (CI): 1.05-4.06), although this was not significantly different from all controls (27.3% vs. 22.4%; aOR: 1.19; 95% CI: 0.65-2.18). Influenza rates were insignificantly higher among cases than controls. The study suggests that recent respiratory illnesses may precede AMI onset among Bangladeshi patients. Infection prevention and control practices, as well as the uptake of the influenza vaccine, may be advocated for patients at high risk of acute CV events.

Influence of electrolyte imbalance on regional wall motion abnormalities in STEMI patients of North Indian origin

Assessing regional wall motion abnormalities (RWMA) in the myocardium may provide early diagnosis and treat chronic remodeling in STEMI patients. We assessed RWMA in 217 subjects with anterior STEMI admitted to Era University Hospital in Lucknow, UP, India. Besides abnormalities in the LAD territory, sub-sets of patients exhibited diffuse regional myocardial dysfunction. Interestingly, variations in serum electrolytes, specifically sodium and potassium, significantly affected the distribution and frequency of RWMA. Notably, RWMA occurred in the basal septum, apical septum, apex, and lateral wall in the anterior STEMI group. Additionally, the rate of regional dysfunction varied with serum urea and creatinine levels. This suggests that anterior STEMI can manifest myocardial abnormalities beyond the LAD territory. These findings indicate that ST-segment elevation might not be specific, possibly influenced by electrolyte changes affecting cardiac rhythm. Therefore, diagnosing and correcting region-specific wall motion abnormalities and electrolyte imbalances may improve outcomes in STEMI patients.

An ischemic area-targeting, peroxynitrite-responsive, biomimetic carbon monoxide nanogenerator for preventing myocardial ischemia-reperfusion injury

Myocardial ischemia-reperfusion (MI/R) injury is common in patients who undergo revascularization therapy for myocardial infarction, often leading to cardiac dysfunction. Carbon monoxide (CO) has emerged as a therapeutic molecule due to its beneficial properties such as anti-inflammatory, anti-apoptotic, and mitochondrial biogenesis-promoting properties. However, its clinical application is limited due to uncontrolled release, potential toxicity, and poor targeting efficiency. To address these limitations, a peroxynitrite (ONOO^-)-triggered CO donor (PCOD585) is utilized to generate a poly (lactic-co-glycolic acid) (PLGA)-based, biomimetic CO nanogenerator (M/PCOD@PLGA) that is coated with the macrophage membrane, which could target to the ischemic area and neutralize proinflammatory cytokines. In the ischemic area, local produced ONOO^- triggers the continuous release of CO from M/PCOD@PLGA, which efficiently ameliorates MI/R injury by clearing harmful ONOO^-, attenuating the inflammatory response, inhibiting cardiomyocyte apoptosis, and promoting mitochondrial biogenesis. This study provides a novel insight into the safe therapeutic use of CO for MI/R injury by utilizing a novel CO donor combined with biomimetic technology. The M/PCOD@PLGA nanogenerator offers targeted delivery of CO to the ischemic area, minimizing potential toxicity and enhancing therapeutic efficacy.

Thrombus architecture is influenced by the antiplatelet loading treatment in patients with acute myocardial infarction

BACKGROUND

Intracoronary thrombus formation is a main cause of acute myocardial infarction triggered by platelet activation. However, there are no data on the impact of different treatment strategies with antiplatelet agents before percutaneous coronary intervention (PCI) on histological characteristics of thrombus formation.

OBJECTIVE

In this study, we investigate the impact of preinterventional administration of the P2Y12-inhibitors clopidogrel and prasugrel on thrombus composition, highlighting significant changes associated with the antiplatelet pre-treatment.

METHODS

We prospectively enrolled 104 consecutive patients with ST-segment elevation myocardial infarction (STEMI) undergoing immediate PCI and thrombus aspiration by immunohistochemical staining along with RNA-sequencing employing Nanostring analysis. Fifty-two patients were treated with either prasugrel loading (60 mg) or clopidogrel loading (600 mg) prior to PCI, respectively.

RESULTS

In Patients with STEMI, intracoronary thrombus architecture was significantly altered between patients pre-treated with prasugrel when compared to clopidogrel. Fibrin content of thrombi was significantly decreased (41.8 % versus 66.7 %, p = 0.009) after pre-treatment with prasugrel compared to clopidogrel. Furthermore, levels of MPO positive cells in intracoronary thrombi were significantly decreased in patients with prasugrel pre-treatment (90.5 versus 201.1, p = 0.014) indicating an association of antiplatelet pre-treatment and the inflammatory responses during thrombus formation. Most strikingly, we observed significant differences among both pre-treatment groups regarding altered RNA expression and signaling pathways of thrombo-inflammatory processes within the thrombotic material, which were independently associated with antiplatelet strategies.

CONCLUSIONS

Our study elucidates the impact of antiplatelet pre-treatment on thrombus remodeling and architecture, thereby lowering the risk of recurrent adverse cardiovascular events in prasugrel-treated patients.

Characteristics and Outcomes of Young Patients With ST-Elevation Myocardial Infarction Without Standard Modifiable Risk Factors

Patients with ST-elevation myocardial infarction (STEMI) with no standard modifiable risk factors (SMuRFs: hypertension, diabetes mellitus, hypercholesterolemia, and smoking) have worse short-term mortality than those with SMuRFs. Whether this association extends to younger patients is unclear. A retrospective cohort study was performed of patients aged 18 to 45 years with STEMI at 3 Australian hospitals between 2010 and 2020. Nonatherosclerotic causes of STEMI were excluded. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 1 and 2-year mortality. Cox proportional hazards analysis was used. Of 597 patients, the median age was 42 (interquartile range 38 to 44) years, 85.1% were men and 8.4% were SMuRF-less. Patients who are SMuRF-less were >2 times more likely to have cardiac arrest (28.0% vs 12.6%, p = 0.003); require vasopressors (16.0% vs 6.8%, p = 0.018), mechanical support (10.0% vs 2.3%, p = 0.046), or intensive care admission (20.0% vs 5.7%, p <0.001); and have higher rate of left anterior descending artery infarcts than those with SMuRFs (62.0% vs 47.2%, p = 0.045). No significant differences in thrombolysis or percutaneous intervention were observed. Guideline-directed medical therapy at discharge was high (>90%), and not different in the SMuRF-less. 30-day mortality was almost fivefold higher in the SMuRF-less (hazard ratio 4.70, 95% confidence interval 1.66 to 13.35, p = 0.004), remaining significant at 1 and 2 years. In conclusion, young patients who are SMuRF-less have a higher 30-day mortality after STEMI than their counterparts with SMuRFs. This may be partially mediated by higher rates of cardiac arrest and left anterior descending artery territory events. These findings further highlight the need for improved prevention and management of SMuRF-less STEMI.

Skin wound healing as a mirror to cardiac wound healing

NEW FINDINGS

What is the topic of this review? Wound healing is a general response of the body to injury and can be divided into three phases: inflammation, inflammation resolution and repair. In this review, we compare the wound-healing response of the skin after an injury and the wound-healing response of the heart after a myocardial infarction. What advances does it highlight? We highlight differences and similarities between skin and cardiac wound healing and summarize how skin can be used to provide information about the heart.

ABSTRACT

Wound healing is a general response of the body to injury. All organs share in common three response elements to wound healing: inflammation to prevent infection and stimulate the removal of dead cells, active anti-inflammatory signalling to turn off the inflammatory response, and a repair phase characterized by extracellular matrix scar formation. The extent of scar formed depends on the ability of endogenous cells that populate each organ to regenerate. The skin has keratinocytes that have regenerative capacity, and in general, wounds are fully re-epithelialized. Heart, in contrast, has cardiac myocytes that have little to no regenerative capacity, and necrotic myocytes are entirely replaced by scars. Despite differences in tissue regeneration, the skin and heart share many wound-healing properties that can be exploited to predict the cardiac response to pathology. We summarize in this review article our current understanding of how the response of the skin to a wounding event can inform us about the ability of the myocardium to respond to a myocardial infarction.

Prognostic Value of Redox Status Biomarkers in Patients Presenting with STEMI or Non-STEMI: A Prospective Case-Control Clinical Study

(1) Background: The aim of our study was to determine the role of oxidative stress (OS) during early evaluation of acute ST-elevated myocardial infarction (STEMI) and non-ST-elevated myocardial infarction (NSTEMI) patients in order to define the role of redox balance in profiling the development of myocardial infarction (MI). (2) Methods: This prospective observational case-control study included 40 consecutive STEMI and 39 NSTEMI patients hospitalized in the coronary care unit of the cardiology clinic at the Kragujevac Clinical Center, Serbia, between 1 January 2016 and 1 January 2017. Blood samples were collected from all patients for measuring cardio-specific enzymes at admission and 12 h after admission to evaluate systemic oxidative stress biomarkers and the activity of antioxidant enzymes. (3) Results: In this study, participants were predominately female (52%), with a mean age of 56.17 ± 1.22 years old in the STEMI group and 69.17 ± 3.65 in the non-STEMI group. According to the Killip classification, the majority of patients (>50%) were at the second and third level. We confirmed the elevation of superoxide anion radicals in the non-STEMI group 6 h after admission in comparison with the STEMI and CTRL groups, but levels had decreased 12 h after admission. Levels of hydrogen peroxide were statistically significantly increased in the NSTEMI group. A positive correlation of superoxide anion radicals and levels of troponin I at admission was observed (r = 0.955; p = 0.045), as well as an inverse correlation between reduced glutathione and levels of NT-pBNP measured 6 h after admission (r = -0.973; p = 0.027). (4) Conclusions: We confirmed that superoxide anion radicals and reduced glutathione observed together with hs-troponin I at admission and NT-pBNP during hospital treatment could be predictors of ST evolution.

Vitamin D in atherosclerosis and cardiovascular events

Both experimental and clinical findings linking vitamin D to cardiovascular (CV) risk have prompted consideration of its supplementation to improve overall health. Yet several meta-analyses do not provide support for the clinical effectiveness of this strategy. Meanwhile, the understanding of the roles of vitamin D in the pathophysiology of CV diseases has evolved. Specifically, recent work has revealed some non-classical pleiotropic effects of vitamin D, increasing the complexity of vitamin D signalling. Within particular microenvironments (e.g. dysfunctional adipose tissue and atherosclerotic plaque), vitamin D can act locally at cellular level through intracrine/autocrine/paracrine feedforward and feedback circuits. Within atherosclerotic tissues, 'local' vitamin D levels may influence relevant systemic consequences independently of its circulating pool. Moreover, vitamin D links closely to other signalling pathways of CV relevance including those driving cellular senescence, ageing, and age-related diseases-among them CV conditions. This review updates knowledge on vitamin D biology aiming to clarify the widening gap between experimental and clinical evidence. It highlights the potential reverse causation confounding correlation between vitamin D status and CV health, and the need to consider novel pathophysiological concepts in the design of future clinical trials that explore the effects of vitamin D on atherosclerosis and risk of CV events.

Research progress on the effects of novel hypoglycemic drugs in diabetes combined with myocardial ischemia/reperfusion injury

Acute myocardial infarction (AMI) reperfusion is associated with ischemia/reperfusion (I/R) injury, which leads to enlarged myocardial infarction size, poor healing of the infarcted myocardium, and poor left ventricular remodeling, thus increasing the risk of major adverse cardiovascular events (MACEs). Diabetes increases myocardial susceptibility to I/R injury, decreases myocardial responsiveness to cardioprotective strategies, exacerbates myocardial I/R injury, and expands the infarct size of AMI, thereby increasing the incidence of malignant arrhythmias and heart failure. Currently, evidence regarding pharmacological interventions for diabetes combined with AMI and I/R injury is lacking. Traditional hypoglycemic drugs have a limited role in the prevention and treatment of diabetes combined with I/R injury. Current evidence suggests that novel hypoglycemic drugs may exert a preventive effect on diabetes combined with myocardial I/R injury, especially glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-dependent glucose transporter protein 2 inhibitors (SGLT2i), which may increase coronary blood flow, reduce acute thrombosis, attenuate I/R injury, decrease myocardial infarction size, inhibit structural and functional remodeling of the ischemic heart, improve cardiac function, and reduce the occurrence of MACEs of diabetes patients combined with AMI via mechanisms such as reduction of inflammatory response, inhibition of oxidative stress, and improvement of vascular endothelial function. This paper will systematically elaborate the protective role and molecular mechanisms of GLP-1 RA and SGLT2i in diabetes combined with myocardial I/R injury, aiming to provide clinical assistance.

Interaction between Acute Hepatic Injury and Early Coagulation Dysfunction on Mortality in Patients with Acute Myocardial Infarction

BACKGROUND

In acute myocardial infarction (AMI), acute hepatic injury is an independent risk factor for prognosis and is associated with complex coagulation dynamics. This study aims to determine the interaction between acute hepatic injury and coagulation dysfunction on outcomes in AMI patients.

METHODS

The Medical Information Mart for Intensive Care (MIMIC-III) database was used to identify AMI patients who underwent liver function testing within 24 h of admission. After ruling out previous hepatic injury, patients were divided into the hepatic injury group and the nonhepatic injury group based on whether the alanine transaminase (ALT) level at admission was >3 times the upper limit of normal (ULN). The primary outcome was intensive care unit (ICU) mortality.

RESULTS

Among 703 AMI patients (67.994% male, median age 65.139 years (55.757-76.859)), acute hepatic injury occurred in 15.220% (n = 107). Compared with the nonhepatic injury group, patients with hepatic injury had a higher Elixhauser comorbidity index (ECI) score (12 (6-18) vs. 7 (1-12), p < 0.001) and more severe coagulation dysfunction (85.047% vs. 68.960%, p < 0.001). In addition, acute hepatic injury was associated with increased in-hospital mortality (odds ratio (OR) = 3.906; 95% CI: 2.053-7.433; p < 0.001), ICU mortality (OR = 4.866; 95% CI: 2.489-9.514; p < 0.001), 28-day mortality (OR = 4.129; 95% CI: 2.215-7.695; p < 0.001) and 90-day mortality (OR = 3.407; 95% CI: 1.883-6.165; p < 0.001) only in patients with coagulation disorder but not with normal coagulation. Unlike patients with coagulation disorder and normal liver, patients with both coagulation disorder and acute hepatic injury had greater odds of ICU mortality (OR = 8.565; 95% CI: 3.467-21.160; p < 0.001) than those with normal coagulation.

CONCLUSIONS

The effects of acute hepatic injury on prognosis are likely to be modulated by early coagulation disorder in AMI patients.

Evaluation and subgroup analysis of the efficacy and safety of intensive rosuvastatin therapy combined with dual antiplatelet therapy in patients with acute ischemic stroke

OBJECTIVES

We investigated the efficacy of intensive rosuvastatin therapy plus 7-day dual antiplatelet therapy (DAPT) in reducing stroke recurrence for patients with acute ischemic stroke (AIS) and compared subgroups of patients.

METHODS

We enrolled patients with AIS whose time of onset to medication was ≤ 72 h, and the baseline scores of NIHSS (bNIHSS) were 0-10. The patients received intensive rosuvastatin therapy plus 7-day DAPT with aspirin and clopidogrel (study group) or rosuvastatin plus single antiplatelet therapy (SAPT, control group). The primary outcomes were recurrence of ischemic stroke, bleeding, statin-induced liver injury, and statin-associated myopathy (SAM) within 90 days. We also performed a subgroup analysis to assess the heterogeneity of the two therapy regimens in reducing recurrent stroke.

RESULTS

Recurrent stroke occurred in 10 patients in the study group and 42 patients in the control group (hazard ratio [HR], 0.373, 95% confidence interval [CI], 0.178-0.780; P = 0.009). Bleeding events occurred in 9 patients in the study group and 14 patients in the control group (HR, 1.019; 95%CI, 0.441-2.353; P = 0.966). Statin-induced liver injury and SAM were not recorded. Intensive rosuvastatin plus 7-day DAPT was generally effective in reducing the risk of recurrent stroke, except in the subgroup with bNIHSS ≤ 2. The therapy was particularly efficient in the elderly, male, high-bNIHSS, and hypertension, diabetes, and hyperlipidemia subgroups, with P < 0.02.

CONCLUSIONS

Without increasing bleeding and statin-associated adverse events, intensive rosuvastatin therapy plus 7-day DAPT significantly reduced the risk of recurrent stroke, especially for subgroups with high-risk factors.

CLINICAL TRIAL REGISTRATION

China Clinical Trial Registration Center (ChiCTR1800017809).

Heart Disease and Ageing: The Roles of Senescence, Mitochondria, and Telomerase in Cardiovascular Disease

During ageing molecular damage leads to the accumulation of several hallmarks of ageing including mitochondrial dysfunction, cellular senescence, genetic instability and chronic inflammation, which contribute to the development and progression of ageing-associated diseases including cardiovascular disease. Consequently, understanding how these hallmarks of biological ageing interact with the cardiovascular system and each other is fundamental to the pursuit of improving cardiovascular health globally. This review provides an overview of our current understanding of how candidate hallmarks contribute to cardiovascular diseases such as atherosclerosis, coronary artery disease and subsequent myocardial infarction, and age-related heart failure. Further, we consider the evidence that, even in the absence of chronological age, acute cellular stress leading to accelerated biological ageing expedites cardiovascular dysfunction and impacts on cardiovascular health. Finally, we consider the opportunities that modulating hallmarks of ageing offer for the development of novel cardiovascular therapeutics.

Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is defined by symptoms accompanied by typical electrocardiogram changes. However, the characterization of ischemic symptoms is unclear, especially in subgroups such as women and the elderly.

OBJECTIVES

To analyze the typification of ischemic symptoms, temporal metrics and observe the occurrence of in-hospital outcomes, in the analysis of predictive scores, in patients with STEMI, in a drug-invasive strategy.

METHODS

Study involving 2,290 patients. Types of predefined clinical presentations: typical pain, atypical pain, dyspnea, syncope. We measured the time between the onset of symptoms and demand for care and the interval between arrival at the medical unit and thrombolysis. Odds-ratios (OR; CI-95%) were estimated in a regression model. ROC curves were constructed for mortality predictors. The adopted significance level (alpha) was 5%.

RESULTS

Women had a high prevalence of atypical symptoms; longer time between the onset of symptoms and seeking care; delay between arrival at the emergency room and fibrinolysis. Hospital mortality was 5.6%. Risk prediction by Killip-Kimball classification: AUC: [0.77 (0.73-0.81)] in class ≥II. Subgroups studied [OR (CI-95%)]: women [2.06 (1.42-2.99); p=0.01]; chronic renal failure [3.39 (2.13-5.42); p<0.001]; elderly [2.09 (1.37-3.19) p<0.001]; diabetics [1.55 (1.04-2.29); p=0.02]; obese 1.56 [(1.01-2.40); p=0.04]: previous stroke [2.01 (1.02-3.96); p=0.04] correlated with higher mortality rates.

CONCLUSION

Despite higher mortality rates in some subgroups, significant disparity persists in women, with delays in symptom recognition and prompt thrombolysis. We highlight the applicability of the Killip-Kimball score in prediction, regardless of the clinical presentation.

Sacubitril/valsartan attenuates myocardial ischemia/reperfusion injury via inhibition of the GSK3β/NF-κB pathway in cardiomyocytes

In ischemia/reperfusion (I/R) injury, both inflammation and apoptosis play a vital role, and the inhibition of excessive inflammation and apoptosis show substantial clinical potential in the treatment of I/R disease. The role of sacubitril/valsartan (SAC/VAL)-a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI)-in inflammation regulation and apoptosis in the context of I/R injury needs to be further explored. In this study, we investigate the short- and long-term effects of SAC/VAL administration in treating adult murine I/R injury both in vivo and in vitro. Our results verified that the application of SAC/VAL could reduce infarct size and suppress apoptosis and the inflammatory response in the acute phase post I/R. Long-term application of SAC/VAL for four weeks significantly improved ventricular function and reversed pathological ventricular remodeling. Mechanistically, SAC/VAL treatment induces the inhibition of the GSK3β-mediated NF-κB pathway through synergistically blocking angiotensin 1 receptor (AT1R) and activating natriuretic peptide receptor (NPR). In summary, we reported the therapeutic role of SAC/VAL in regulating the GSK3β/NF-κB signaling pathway to suppress the inflammatory response and apoptosis, thereby reducing cardiac dysfunction and remodeling post I/R.

Machine learning assisted reflectance spectral characterisation of coronary thrombi correlates with microvascular injury in patients with ST-segment elevation acute coronary syndrome

Aims

We set out to further develop reflectance spectroscopy for the characterisation and quantification of coronary thrombi. Additionally, we explore the potential of our approach for use as a risk stratification tool by exploring the relation of reflectance spectra to indices of coronary microvascular injury.

Methods and results

We performed hyperspectral imaging of coronary thrombi aspirated from 306 patients presenting with ST-segment elevation acute coronary syndrome (STEACS). Spatially resolved reflected light spectra were analysed using unsupervised machine learning approaches. Invasive [index of coronary microvascular resistance (IMR)] and non-invasive [microvascular obstruction (MVO) at cardiac magnetic resonance imaging] indices of coronary microvascular injury were measured in a sub-cohort of 36 patients. The derived spectral signatures of coronary thrombi were correlated with both invasive and non-invasive indices of coronary microvascular injury. Successful machine-learning-based classification of the various thrombus image components, including differentiation between blood and thrombus, was achieved when classifying the pixel spectra into 11 groups. Fitting of the spectra to basis spectra recorded for separated blood components confirmed excellent correlation with visually inspected thrombi. In the 36 patients who underwent successful thrombectomy, spectral signatures were found to correlate well with the index of microcirculatory resistance and microvascular obstruction; R 2: 0.80, p < 0.0001, n = 21 and R 2: 0.64, p = 0.02, n = 17, respectively.

Conclusion

Machine learning assisted reflectance spectral analysis can provide a measure of thrombus composition and evaluate coronary microvascular injury in patients with STEACS. Future work will further validate its deployment as a point-of-care diagnostic and risk stratification tool for STEACS care.

Short- and long-term survival after ST-elevation myocardial infarction treated with pharmacoinvasive versus primary percutaneous coronary intervention strategy: a prospective cohort study

Objective

Compare survival in patients with ST-elevation myocardial infarction (STEMI) treated with a pharmacoinvasive (PI) or primary percutaneous coronary intervention (pPCI) strategy based on estimated time to PCI.

Design

Prospective observational cohort study. Consecutive STEMI patients were registered on admission to our PCI centre and classified in a PI or pPCI group, based on the reperfusion strategy chosen in the prehospital or local hospital location. Time and cause of death was provided by the Norwegian Cause of Death registry. Mortality at 30 days, Kaplan-Meier survival and incidence of cardiovascular (CV) death was estimated. Adjusted effect of PI versus pPCI strategy on survival was estimated using logistic and Cox regression and propensity score weighting.

Setting

Single-centre registry in Norway during 2005–2011, within a regional STEMI network allocating patients to a PI strategy if estimated time to PCI >120 min.

Primary outcomes

30-day mortality and survival during follow-up.

Secondary outcome

Incidence of CV death during follow-up.

Results

4061 STEMI patients <80 years were included, 527 (13%) treated with a PI strategy and 3534 (87%) with a pPCI strategy. Median symptom-to-needle time was 110 min (25–75th percentile 75–163) in the PI group vs symptom-to-balloon 230 min (149–435) in the pPCI group. 30-day mortality was 3.2% and 5.0% in the PI and pPCI groups (OR_adjusted0.58 (95% CI 0.30 to 1.13)) and 8-year survival was 85.9% (95% CI 80.9% to 89.6%) and 79.3% (95% CI 76.9% to 81.6%), respectively (HR_adjusted 0.72 (95% CI 0.53 to 0.99)). Unadjusted incidence of 8-year CV death was 7.0% (95% CI 4.4% to 10.4%) in the PI group vs 12.4% (95% CI 9.9% to 15.2%) in the pPCI group. Adjusted long-term CV death was also lower in the PI group.

Conclusion

STEMI patients treated with a PI strategy experienced better survival compared with a pPCI strategy, also when adjusting for baseline characteristics. This supports using a PI strategy for eligible STEMI patients when pPCI cannot be performed within 120 min.

Cardioprotective Effects and Possible Mechanisms of Luteolin for Myocardial Ischemia-Reperfusion Injury: A Systematic Review and Meta-Analysis of Preclinical Evidence

Background

At present, effective clinical therapies for myocardial ischemia-reperfusion injury (MIRI) are lacking. We investigated if luteolin conferred cardioprotective effects against MIRI and elucidated the potential underlying mechanisms.

Method

Four databases were searched for preclinical studies of luteolin for the treatment of MIRI. The primary outcomes were myocardial infarct size (IS) and intracardiac hemodynamics. The second outcomes were representative indicators of apoptosis, oxidative stress, and inflammatory. The Stata and RevMan software packages were utilized for data analysis.

Results

Luteolin administration was confirmed to reduce IS and ameliorate hemodynamics as compared to the control groups (p &lt; 0.01). IS had decreased by 2.50%, 2.14%, 2.54% in three subgroups. Amelioration of hemodynamics was apparent in two different myocardial infarct models (model of left anterior descending branch ligation and model of global heart ischemia), as left ventricular systolic pressure improved by 21.62 and 35.40 mmHg respectively, left ventricular end-diastolic pressure decreased by 7.79 and 4.73 mmHg respectively, maximum rate of left ventricular pressure rise increased by 737.48 and 750.47 mmHg/s respectively, and maximum rate of left ventricular pressure decrease increased by 605.66 and 790.64 mmHg/s respectively. Apoptosis of cardiomyocytes also significantly decreased, as indicated by thelevels of MDA, an oxidative stress product, and expression of the inflammatory factor TNF-α (p &lt; 0.001).

Conclusion

Pooling of the data demonstrated that luteolin exerts cardioprotective effects against MIRI through different signaling pathways. As possible mechanisms, luteolin exerts anti-apoptosis, anti-oxidation, and anti-inflammation effects against MIRI.

CPE Regulates Proliferation and Apoptosis of Primary Myocardial Cells Mediated by Ischemia and Hypoxia Injury

Objective

To observe the effect of carboxypeptidase E (CPE) on the ischemia and hypoxia (I/H) injury of primary cardiomyocytes.

Methods

Quantitative real-time polymerase chain reaction (qRT-PCR) technology was used to detect the expression of CPE in sham and myocardial infarction (MI) rat heart tissue, and the plasmid was transferred into primary cardiomyocytes by transfection technology. The apoptosis rate of cardiomyocytes was detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining, Annexin V-PI staining, and Cell Counting Kit-8 (CCK-8) assay. In addition, Caspase kit and qRT-PCR technology were used to detect the expression of apoptosis-related factors. The cell proliferation was detected by 5-ethynyl-2'-deoxyuridine (EdU) staining, flow cytometry, and qRT-PCR technology. In addition, Western blotting (WB) and qRT-PCR techniques were used to detect the Wnt/β-catenin pathway.

Results

First, we found that the expression of CPE in the marginal zone of MI was obviously reduced. Overexpression of CPE in primary cardiomyocytes can effectively inhibit ischemia/hypoxia (I/H)-induced apoptosis and decreased cell activity. In addition, CPE can promote cell proliferation and relieve the inhibitory effect of I/H on cardiomyocytes. At the same time, CPE can promote the expression of β-catenin and c-myc.

Conclusion

Overexpression of CPE in primary cardiomyocytes can effectively alleviate the decreased cell activity, increased apoptosis, and decreased proliferation caused by I/H and regulated by Wnt/β-catenin pathway.

Screening for Regulatory Network of miRNA–Inflammation, Oxidative Stress and Prognosis-Related mRNA in Acute Myocardial Infarction: An in silico and Validation Study

Background

Acute myocardial infarction (AMI), which commonly leads to heart failure, is among the leading causes of mortality worldwide. The aim of this study was to find potential regulatory network for miRNA-inflammation, oxidative stress and prognosis-related mRNA to uncover molecular mechanisms of AMI.

Methods

The expression profiles of miRNA and mRNA in the blood samples from AMI patients were downloaded from the Gene Expression Omnibus (GEO) dataset for differential expression analysis. Weighted gene co-expression network analysis (WGCNA) was used to further identify important mRNAs. The negatively regulatory network construction of miRNA–inflammation, oxidative stress and prognosis-related mRNAs was performed, followed by protein–protein interaction (PPI) and functional analysis of mRNAs.

Results

A total of three pairs of negatively regulatory network of miRNA–inflammation and prognosis-related mRNAs (hsa-miR-636/hsa-miR-491-3p/hsa-miR-188-5p/hsa-miR-188-3p-AQP9, hsa-miR-518a-3p-C5AR1 and hsa-miR-509-3-5p/hsa-miR-127-5p-PLAUR), two pairs of negatively regulatory network of miRNA–oxidative stress and prognosis-related mRNAs (hsa-miR-604-TLR4 and hsa-miR-139-5p-CXCL1) and three pairs of negatively regulatory network of miRNA-inflammation, oxidative stress and prognosis-related mRNA (hsa-miR-634/hsa-miR-591-TLR2, hsa-miR-938-NFKBIA and hsa-miR-520h/hsa-miR-450b-3p-ADM) were identified. In the KEGG analysis, some signaling pathways were identified, such as complement and coagulation cascades, pathogenic Escherichia coli infection, chemokine signaling pathway and cytokine–cytokine receptor interaction and Toll-like receptor signaling pathway.

Conclusion

Identified negatively regulatory network of miRNA-inflammation/oxidative stress and prognosis-related mRNA may be involved in the process of AMI. Those inflammation/oxidative stress and prognosis-related mRNAs may be diagnostic and prognostic biomarkers for AMI.

The Spiked Helmet Sign Predicting a Poor Outcome in a Patient with Non-Myocardial Infarction ST-Segment Elevation

Spiked helmet sign is a novel electrocardiogram marker that reflects a poor prognosis, and may mimic myocardial infarction, especially in patients with an acute alteration of mental status or out-of-hospital cardiac arrest. In cases where a spiked helmet sign is missed, there may be a delay in surgical intervention for the underlying conditions because of unnecessary cardiac catheterization. In addition, antiplatelet agents for acute coronary syndrome in such cases can lead to catastrophic complications. Therefore, early recognition of spiked helmet sign is useful for timely correction of the underlying disease and prevention of poor outcomes. Herein, we describe a rare case of a patient with internal bleeding and subarachnoid hemorrhage presenting with spiked helmet sign on an electrocardiogram.

Targeting Glycogen Synthase Kinase 3 Beta Regulates CD47 Expression After Myocardial Infarction in Rats via the NF-κB Signaling Pathway

The aim of this study was to investigate the effects of the GSK-3β/NF-κB pathway on integrin-associated protein (CD47) expression after myocardial infarction (MI) in rats. An MI Sprague Dawley rat model was established by ligating the left anterior descending coronary artery. The rats were divided into three groups: Sham, MI, and SB + MI (SB216763) groups. Immunohistochemistry was used to observe the changes in cardiac morphology. A significant reduction in the sizes of fibrotic scars was observed in the SB + MI group compared to that in the MI group. SB216763 decreased the mRNA and protein expression of CD47 and NF-κB during MI. Primary rat cardiomyocytes (RCMs) and the H9c2 cell line were used to establish in vitro hypoxia models. Quantitative real-time PCR and western blotting analyses were conducted to detect mRNA and protein expression levels of CD47 and NF-κB and apoptosis-related proteins, respectively. Apoptosis of hypoxic cells was assessed using flow cytometry. SB216763 reduced the protein expression of CD47 and NF-κB in RCMs and H9c2 cells under hypoxic conditions for 12 h, and alleviated hypoxia-induced apoptosis. SN50 (an NF-κB inhibitor) also decreased CD47 protein expression in RCMs and H9c2 cells under hypoxic conditions for 12 h and protected cells from apoptosis. GSK-3β upregulates CD47 expression in cardiac tissues after MI by activating NF-κB, which in turn leads to myocardial cell damage and apoptosis.

Senescence and senolytics in cardiovascular disease: Promise and potential pitfalls

Ageing is the biggest risk factor for impaired cardiovascular health, with cardiovascular disease being the cause of death in 40 % of individuals over 65 years old. Ageing is associated with an increased prevalence of atherosclerosis, coronary artery stenosis and subsequent myocardial infarction, thoracic aortic aneurysm, valvular heart disease and heart failure. An accumulation of senescence and increased inflammation, caused by the senescence-associated secretory phenotype, have been implicated in the aetiology and progression of these age-associated diseases. Recently it has been demonstrated that compounds targeting components of anti-apoptotic pathways expressed by senescent cells can preferentially induce senescence cells to apoptosis and have been termed senolytics. In this review, we discuss the evidence demonstrating that senescence contributes to cardiovascular disease, with a particular focus on studies that indicate the promise of senotherapy. Based on these data we suggest novel indications for senolytics as a treatment of cardiovascular diseases which have yet to be studied in the context of senotherapy. Finally, while the potential benefits are encouraging, several complications may result from senolytic treatment. We, therefore, consider these challenges in the context of the cardiovascular system.

MicroRNAs in Acute ST Elevation Myocardial Infarction-A New Tool for Diagnosis and Prognosis: Therapeutic Implications

Despite diagnostic and therapeutic advances, coronary artery disease and especially its extreme manifestation, ST elevation myocardial infarction (STEMI), remain the leading causes of morbidity and mortality worldwide. Early and prompt diagnosis is of great importance regarding the prognosis of STEMI patients. In recent years, microRNAs (miRNAs) have emerged as promising tools involved in many pathophysiological processes in various fields, including cardiovascular diseases. In acute coronary syndromes (ACS), circulating levels of miRNAs are significantly elevated, as an indicator of cardiac damage, making them a promising marker for early diagnosis of myocardial infarction. They also have prognostic value and great potential as therapeutic targets considering their key function in gene regulation. This review aims to summarize current information about miRNAs and their role as diagnostic, prognostic and therapeutic targets in STEMI patients.

Mean platelet volume/platelet count ratio as a predictor of stent thrombosis in patients with ST-segment-elevation myocardial infarction

BACKGROUND

Despite the important role of some haematological parameters in tendency to thrombosis is known, their relationship with long-term stent thrombosis (ST) remains unclear.

AIMS

This study aimed to investigate the association between the mean platelet volume (MPV) to platelet count (PC) ratio and long-term ST and mortality in patients with ST-segment-elevation myocardial infarction (STEMI) treated successfully by primary percutaneous coronary intervention (pPCI).

METHODS

In a retrospective cohort study, according to their baseline MPV/PC ratios, 3667 consecutive STEMI patients undergoing pPCI were divided into three groups: tertile 1 (T1) (n = 1222, 0.357 ≥ MPV/PC ≥ 0.043), tertile 2 (T2) (n = 1222, 0.033 < MPV/PC < 0.043) and tertile 3 (T3) (n = 1223, 0.009 ≤ MPV/PC ≤ 0.032). Patients were followed up with for 5 years, focusing on ST and all-cause mortality outcomes.

RESULTS

Patients with T1 displayed a greater 5-year ST rate, including a 2.76-fold greater (95% confidence interval 1.68-10.33) rate than that of patients with T3, who had the lowest rates and were used as the reference group. Meanwhile, the 5-year mortality rate was similarly higher among patients with T1 by 1.72 times (95% confidence interval 1.33-2.22) relative to that among patients with T3. These significant relationships persisted even after adjustment for all confounders.

CONCLUSION

We found that higher MPV/PC ratios were associated with long-term ST and mortality. The MPV/PC ratio may constitute both a rapid and an easily obtainable parameter for identifying reliably high-risk patients who have undergone pPCI.

Coronary Microvascular Dysfunction: PET, CMR and CT Assessment

Microvascular dysfunction is responsible for chest pain in various kinds of patients, including those with obstructive coronary artery disease and persistent symptoms despite revascularization, or those with myocardial disease without coronary stenosis. Its diagnosis can be performed with an advanced imaging technique such as positron emission tomography, which represents the gold standard for diagnosing microvascular abnormalities. In recent years, cardiovascular magnetic resonance and cardiac computed tomography have demonstrated to be emerging modalities for microcirculation assessment. The identification of microvascular disease represents a fundamental step in the characterization of patients with chest pain and no epicardial coronary disease: its identification is important to manage medical strategies and improve prognosis. The present overview summarizes the main techniques and current evidence of these advanced imaging strategies in assessing microvascular dysfunction and, if present, their relationship with invasive evaluation.

Wrapped left anterior descending artery STEMI: time to revisit

We report three cases of acute myocardial infarction caused by left anterior descending (LAD) artery occlusion presenting as ST elevation in the inferior. Therefore, coronary angiography showed an occlusion of the LAD coronary artery. Our cases show the rare occurrence of left coronary circulation dominance affecting inferior leads. These cases show an unusual and very rare form of left dominance coronary circulation where LAD is wrapped around the apex and continuing as a posterior descending artery. This would make inferior myocardial infarction because of occluded LAD or determine as wrapped LAD.

Dexmedetomidine exerts cardioprotective effect through miR-146a-3p targeting IRAK1 and TRAF6 via inhibition of the NF-κB pathway

BACKGROUND

Myocardial ischemia/reperfusion (I/R) injury is a common cause of mortality. Cardiac miR-146a is emerging as a potent regulator of myocardial function. Dexmedetomidine preconditioning provides cardioprotective effects, of which mechanisms related to miR-146a-3p are unclear.

METHODS

A myocardial I/R model in rats and a cellular anoxia/reoxygenation (A/R) model in H9C2 cells were established and preconditioned with dexmedetomidine or not. H9C2 cells were transfected with mimics, inhibitor, or negative controls of miR-146a-3p, and siRNAs of IRAK1 or TRAF6. Relative expressions of miR-146a-3p were determined by quantitative real-time polymerase chain reaction. The apoptosis rates and reactive oxygen species (ROS) levels in H9C2 cells were examined by flow cytometry. Protein expressions of IRAK1, TRAF6, cleaved Caspase-3, BAX, BCL-2, NF-κB p65, phosphorylated NF-κB p65 (p-NF-κB p65), IκBα, and phosphorylated IκBα (p-IκBα) in H9C2 cells were detected by Western blot.

RESULTS

Dexmedetomidine decreased myocardial infarction size and apoptosis rates of H9C2 cells. Dexmedetomidine upregulated expression of miR-146a-3p. Dexmedetomidine significantly decreased protein expressions of IRAK1, TRAF6, cleaved Caspase-3, BAX, and NF-κB p65, but increased expressions of BCL-2 in H9C2 cells. miR-146a-3p overexpression strengthened the anti-apoptotic effect induced by dexmedetomidine in H9C2 cells via decreasing protein levels of IRAK1, TRAF6, cleaved Caspase-3, BAX, NF-κB p65, p-NF-κB p65, and p-IκBα and increasing protein level of BCL-2. Downregulation of miR-146a-3p reversed the changes in these proteins in H9C2 cells. Expressions of NF-κB p65 and p-NF-κB p65 were further decreased following knockdown of IRAK1 or TRAF6. ROS emission was significantly increased after A/R, while significantly decreased following dexmedetomidine preconditioning in H9C2 cells transfected with siIRAK1 or siTRAF6.

CONCLUSION

miR-146a-3p targeting IRAK1 and TRAF6 through inhibition of NF-κB signaling pathway and ROS emission is involved in cardioprotection induced by dexmedetomidine pretreatment.

Oxidative stress and its association with ST resolution and clinical outcome measures in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention

OBJECTIVE

Reperfusion of ischemic myocardium generates oxidative stress, which itself can mediate myocardial injury. So, in this study, we investigated the level of oxidative stress markers and its association with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention.

RESULTS

As indicated in the results, Post MI (Myocardial Infarction) heart failure was significantly higher in the group A (11% vs 4%, p = 0.047). Complete STR (ST-segment resolution) was observed to be significantly higher in the group B (36% vs 17%, p = 0.006). The SOD (Superoxide dismutase) and GPX (Glutathione peroxidase) levels were significantly higher in the group B compared to the other group (1547.51 ± 328.29 vs. 1449.97 ± 246.06, p = 0.019 and 60.62 ± 11.95 vs 57.41 ± 10.14, p = 0.042). The levels of GPX and SOD were shown to be directly related with complete STR and post PCI (Percutaneous coronary intervention)TIMI(Thrombolysis in Myocardial Infarction) flow 3 in the group A (p = 0.002 and p < 0.01, p = 0.005 and p < 0.02, respectively).

Targeted miR-21 loaded liposomes for acute myocardial infarction

Acute and persistent myocardial ischemia is the main cause of acute myocardial infarction (AMI) and heart failure. MicroRNA-21(miR-21) contributes to the pathophysiological consequences of acute myocardial infarction by targeting downstream crucial regulators. Thus, miR-21 mimics are a promising strategy for the treatment of AMI. However, their poor stability and insufficient cellular uptake are the major challenges. Herein, we encapsulated miR-21 mimics into liposomes modified with the cardiac troponin T (cTnT) antibody for targeted delivery of miR-21(cT-21-LIPs) to the ischemic myocardium. The cT-21-LIPs exhibited enhanced targeting efficiency to hypoxia primary cardiomyocytes in vitro and improved accumulation in the ischemic heart of AMI rats after injection via the tail vein due to the specifical target to overexpressed troponin. The cT-21-LIPs could significantly improve the cardiac function and decrease the infarct size after AMI, while maintaining the viability of cardiomyocytes. This design provides a novel strategy for delivering small nucleotide drugs specifically to the infarcted heart, which may find great potential in clinics.

Canonical and Non-Canonical Roles of Connexin43 in Cardioprotection

Since the mid-20th century, ischemic heart disease has been the world’s leading cause of death. Developing effective clinical cardioprotection strategies would make a significant impact in improving both quality of life and longevity in the worldwide population. Both ex vivo and in vivo animal models of cardiac ischemia/reperfusion (I/R) injury are robustly used in research. Connexin43 (Cx43), the predominant gap junction channel-forming protein in cardiomyocytes, has emerged as a cardioprotective target. Cx43 posttranslational modifications as well as cellular distribution are altered during cardiac reperfusion injury, inducing phosphorylation states and localization detrimental to maintaining intercellular communication and cardiac conduction. Pre- (before ischemia) and post- (after ischemia but before reperfusion) conditioning can abrogate this injury process, preserving Cx43 and reducing cell death. Pre-/post-conditioning has been shown to largely rely on the presence of Cx43, including mitochondrial Cx43, which is implicated to play a major role in pre-conditioning. Posttranslational modifications of Cx43 after injury alter the protein interactome, inducing negative protein cascades and altering protein trafficking, which then causes further damage post-I/R injury. Recently, several peptides based on the Cx43 sequence have been found to successfully diminish cardiac injury in pre-clinical studies.

Citrate pretreatment attenuates hypoxia/reoxygenation-induced cardiomyocyte injury via regulating microRNA-142-3p/Rac1 aix

Purpose: Citrate has a positive effect on improving the pathophysiological changes of cardiomyocytes such as cardiac failure and auricular fibrillation. However, the underlying mechanism remains still unclear.Methods: Rat cardiomyocytes were used to establish hypoxia/reoxygenation (H/R) cell model. Citrate was conduct to pretreat with cardiomyocytes, and microRNA-142-3p (miR-142-3p) knockdown and overexpression were used to determine the underlying mechanism of their functions in cardiomyocytes. Cell viability and apoptosis were respectively detected by CCK-8 and flow cytometry. Protein and mRNA levels were determined by Western blot and qRT-PCR. Luciferase reporter assay and Targetscan were performed to study the regulation of miR-142-3p and Rac1.Results: The level of miR-142-3p was down-regulated in H/R model, but up-regulated in cardiomyocytes following citrate treatment. Citrates attenuated H/R injury induced miR-142-3p level and cell viability, and also inhibited H/R injury induced apoptosis, LDH, MDA and autophagy. Cell viability was improved, and autophagy was suppressed by miR-142-3p mimic, while inhibitor had opposite results. Compared with H/R + miR-142-3p inhibitor group, cell viability was higher, and apoptosis and autophagy were lower in Cit + H/R + miR-142-3p inhibitor group. Furthermore, Rac1 was target gene of miR-142-3p, and decreased by citrate, in comparison with H/R + miR-142-3p inhibitor group.Conclusion: Taken together, our findings indicated that citrate ameliorates H/R injury-induced cardiomyocytes autophagy by regulating miR-142-3p/Rac1 aix.

Macrophage Activities in Myocardial Infarction and Heart Failure

Heart diseases remain the major cause of death worldwide. Advances in pharmacological and biomedical management have resulted in an increasing proportion of patients surviving acute heart failure (HF). However, many survivors of HF in the early stages end up increasing the disease to chronic HF (CHF). HF is an established frequent complication of myocardial infarction (MI), and numerous influences including persistent myocardial ischemia, shocked myocardium, ventricular remodeling, infarct size, and mechanical impairments, as well as hibernating myocardium trigger the development of left ventricular systolic dysfunction following MI. Macrophage population is active in inflammatory process, yet the clear understanding of the causative roles for these macrophage cells in HF development and progression is actually incomplete. Long ago, it was thought that macrophages are of importance in the heart after MI. Also, though inflammation is as a result of adverse HF in patients, but despite the fact that broad immunosuppression therapeutic target has been used in various clinical trials, no positive results have showed up, but rather, the focus on proinflammatory cytokines has proved more benefits in patients with HF. Therefore, in this review, we discuss the recent findings and new development about macrophage activations in HF, its role in the healthy heart, and some therapeutic targets for myocardial repair. We have a strong believe that there is a need to give maximum attention to cardiac resident macrophages due to the fact that they perform various tasks in wound healing, self-renewal of the heart, and tissue remodeling. Currently, it has been discovered that the study of macrophages goes far beyond its phagocytotic roles. If researchers in future confirm that macrophages play a vital role in the heart, they can be therapeutically targeted for cardiac healing.

Huoxue Wentong Formula ameliorates myocardial infarction in rats through inhibiting CaMKII oxidation and phosphorylation

Background

The Chinese medicine Huoxue Wentong Formula (HXWTF) was used to treat thoracic obstruction and angina pectoris in clinic, which has not been investigated in myocardial ischemia-induced apoptosis and angiogenic function. Here we aimed to investigate the roles of HXWTF in rats with myocardial ischemia-induced apoptosis and angiogenesis disorders, as well as to reveal the potential mechanisms.

Methods

Male SD rats were subjected to coronary artery ligation followed by HXWTF (420, 840 and 1680 mg/kg/day, p.o.) or isosorbide mononitrate (6.3 mg/kg/day, p.o.) treatment for 4 weeks. Electrocardiogram (ECG) and Echocardiography (ECHO) were used to measure cardiac function. Hematoxylin and eosin (H&E) staining and CD34/α-SMA immunohistochemical staining were performed to observe the ischemic heart sections pathological changes and angiogenesis. Then, the effects on cardiomyocyte apoptosis of H9c2 and tube formation of HCMECs were observed, as well as the changes in the levels of total calmodulin dependent protein kinase II (t-CaMKII), phosphorylated CaMKII (p-CaMKII), oxidized CaMKII (ox-CaMKII), CD34, and Bcl-2/Bax ratio were detected.

Results

Rats with coronary artery ligation exhibited abnormal cardiac function, enlarged myocardial space, disorderly arranged myocardial fibers, inflammatory cells infiltrated, and aggravated myocardial cell apoptosis, along with angiogenesis dysfunction. The expressions of CD34, p-CaMKII, and ox-CaMKII were elevated and Bcl-2/Bax ratio was diminished in ischemic hearts and H/SD-treated H9c2 or HCMECs, while HXWTF treatment completely rescued angiogenic dysfunction, inhibited cardiomyocyte apoptosis, and down-regulated cardiac CaMKII oxidation and phosphorylation activities.

Conclusion

Our study demonstrates that HXWTF improves myocardial infarction possibly through inhibiting CaMKII oxidation and phosphorylation levels, facilitating angiogenic function and alleviating cardiomyocyte apoptosis. Thus, therapeutics targeting CaMKII activities may be a promising strategy for rescuing ischemic cardiomyopathy.

Functional Nanocomplexes with Vascular Endothelial Growth Factor A/C Isoforms Improve Collateral Circulation and Cardiac Function

Protein-based therapies are potential treatments for cancer, immunological, and cardiovascular diseases. However, effective delivery systems are needed because of their instability, immunogenicity, and so on. Crosslinked negatively charged heparin polysaccharide nanoparticle (HepNP) is proposed for protein delivery. HepNP can efficiently condense vascular endothelial growth factor (VEGF) because of the unique electronegative sulfonic acid and carboxyl domain of heparin. HepNP is then assembled with VEGF-C (Hep@VEGF-C) or VEGF-A (Hep@VEGF-A) protein for the therapy of myocardial infarction (MI) via intravenous (iv) injection. Hep@VEGF-A-mediated improvement of cardiac function by promoting angiogenesis is limited because of elevated vascular permeability, while Hep@VEGF-C effectively promotes lymphangiogenesis and reduces edema. On this basis, a graded delivery of VEGF-C (0.5-1 h post-MI) and VEGF-A (5 d post-MI) using HepNP is developed. At the dose ratio of 3:1 (Hep@VEGF-C vs Hep@VEGF-A), Hep@VEGF functional complexes substantially reduce the scar formation (≈-39%; p < 0.05) and improve cardiac function (≈+74%; p < 0.05). Such a HepNP delivery system provides a simple and effective therapeutic strategy for cardiovascular diseases by delivering functional proteins. Because of the unique binding ability of heparin with cytokines and growth factors, HepNP also has considerable application prospects in protein therapy for other serious diseases.

Impact of Red Wine Consumption on Cardiovascular Health

BACKGROUND

The devastating effects of heavy alcohol drinking have been long time recognized. In the last decades, potential benefits of modest red wine drinking were suggested. In European countries in which red wide intake is not negligible (such as France), the association between cholesterol and cardiovascular (CV) risk was less evident, suggesting the action of some protective molecules in red wine or other foods and drinks.

METHODS

This narrative review is based on the material searched for and obtained via PubMed up to May 2016. The search terms we used were: "red wine, cardiovascular, alcohol" in combination with "polyphenols, heart failure, infarction".

RESULTS

Epidemiological and mechanistic evidence of a J-shaped relationship between red wine intake and CV risk further supported the "French paradox". Specific components of red wine both in vitro and in animal models were discovered. Polyphenols and especially resveratrol largely contribute to CV prevention mainly through antioxidant properties. They exert beneficial effects on endothelial dysfunction and hypertension, dyslipidemia, metabolic diseases, thus reducing the risk of adverse CV events such as myocardial infarction ischemic stroke and heart failure. Of interest, recent studies pointed out the role of ethanol itself as a potential cardioprotective agent, but a clear epidemiological evidence is still missing. The aim of this narrative review is to update current knowledge on the intracellular mechanism underlying the cardioprotective effects of polyphenols and ethanol. Furthermore, we summarized the results of epidemiological studies, emphasizing their methodological criticisms and the need for randomized clinical trials able to clarify the potential role of red wine consumption in reducing CV risk.

CONCLUSION

Caution in avowing underestimation of the global burden of alcohol-related diseases was particularly used.

Acute ST-segment elevation myocardial infarction due to extrinsic compression of left coronary artery from pulmonary epithelioid hemangioendothelioma: A case report

RATIONALE

Acute myocardial infarction is usually caused by coronary atherosclerotic plaque disruption (rupture or erosion), also including other uncommon etiologies. Pulmonary epithelioid hemangioendothelioma (PEH) is a rare low to intermediate malignant vascular tumor originating from vascular endothelial cells. Here, we report a rare case of acute ST-segment elevation myocardial infarction (STEMI) due to extrinsic compression of left coronary artery from PEH.

PATIENT CONCERNS

A 63-year-old woman with pulmonary nodules received left pulmonary nodulectomy, and the pathological examination indicated PEH. Five months after the pulmonary nodulectomy, the patient was admitted due to progressive dyspnea.

DIAGNOSIS

Electrocardiography showed the obvious ST-segment elevation in the leads I, aVL, and V1-3, and laboratory tests revealed the elevated level of cardiac troponin T. Emergent coronary angiography and the contrast-enhanced computed tomography scan conformed STEMI due to extrinsic compression of left coronary artery from PEH.

INTERVENTIONS

The patient did not undergo further therapy after the pulmonary nodulectomy. During the present hospitalization, she received basic life support and nutritional support treatment.

OUTCOMES

The patient deteriorated rapidly into multi-organ failure and eventually died.

LESSONS

Acute STEMI could be caused by extrinsic compression of the coronary artery from the mass effects of PEH, and active therapy and close follow-up should be considered for patients with PEH.

High Serum Secreted Frizzled-Related Protein 5 Levels Associates with Early Improvement of Cardiac Function Following ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

AIM

Several members of secreted frizzled-related protein (SFRP) are involved in the process of myocardial ischemia-reperfusion injury. However, little is known about the role of SFRP5 in patients with acute ST-segment elevation myocardial infarction (STEMI).

METHODS

In this cross-sectional study, 85 patients with first-time anterior STEMI who underwent timely primary percutaneous coronary intervention (PCI) and 35 patients without coronary artery disease (CAD) were enrolled. Serum SFRP5 levels were measured using an enzyme-linked immunosorbent assay kit. Patients with STEMI were divided into low-SFRP5 and high-SFRP5 groups according to their median baseline serum SFRP5 levels. To evaluate cardiac function and structure after infarction, the left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV) were measured using echocardiography. The associations between changes in LVEF and reduced LVEF (≤ 50%) and clinical variables were determined by univariate and multivariate analyses.

RESULTS

Baseline serum SFRP5 levels were significantly higher in patients with STEMI than in those without CAD (23.3 ng/mL vs 19.8 ng/mL, P=0.008), although they decreased over time. Also, baseline serum SFRP5 levels were inversely correlated with peak hypersensitive cardiac troponin I (hs-cTnI) levels (r=-0.234, P=0.025) and peak hypersensitive C-reactive protein (hs-CRP) levels (r=-0.262, P=0.015). A multivariate linear regression model showed that changes in LVEF were positively correlated with serum SFRP5 levels at baseline (β= 0.249, 95% confidence interval (CI) 0.018-0.245, P=0.024) and 24 h after admission (β=0.220, 95% CI 0.003-0.264, P=0.045). At 3 months, LVEF in patients with high SFRP5 levels was significantly improved over baseline [(60.8±7.1) % vs (56.1±7.5) %, P=0.001]. LVEF was also significantly higher in patients with high SFRP5 levels than in those with low at the 3-month follow-up [(60.8±7.1) % vs (56.8±8.9) %, P=0.028]. Consequently, high serum SFRP5 levels at baseline were associated with a decreased risk of reduced LVEF at 3 months, independent of peak hs-cTnI and baseline cardiac function (hazard ratio 0.190, 95% CI 0.036-0.996; P=0.049).

CONCLUSIONS

High serum SFRP5 levels measured during the acute phase of STEMI were significantly associated with promoting myocardial recovery at an early phase following primary PCI, suggesting that SFRP5 is a potential therapeutic target in acute STEMI.