A new simplified immediate prognostic risk score for patients with acute myocardial infarction

Peri-Procedural Blood Pressure Changes and Their Relationship with MACE in Patients Undergoing Percutaneous Coronary Intervention: A Cross-Sectional Study

Background

Peri-procedural blood-pressure (BP) changes were investigated and correlated to Major adverse cardiovascular events (MACE) as predictor of outcome for patients undergoing percutaneous coronary intervention (PCI); whether acute coronary syndrome (Unstable angina, or MI; STEMI or NSTEMI) or scheduled for elective PCI.

Methods

Resting BP in the 204 recruited patients undergoing PCI throughout 2018 was measured thrice – in the ward before transferring to the cardiac catheterization lab (cath lab), in the cath lab, and after transfer to the recovery room. Patients were categorized based on their systolic and diastolic BP peri-procedural difference as systolic (SBP): with a large difference (>20 mmHg, n=47), with a small difference (≤20 mmHg, n=157) (shock patients excluded); diastolic (DBP): with a large difference (>10 mmHg, n=65), and with a small difference (≤10 mmHg, n=139). The primary end-points were MACE including all-cause mortality, non-fatal myocardial infarction, and stroke during the hospital stay. The Mann–Whitney U and Chi-square tests were used to analyze the data accordingly (p<0.005).

Results

Within the category of MACE, cardiac mortality was the only adverse cardiac event encountered in the study sample. Cardiac mortality was significantly higher in both the large SBP-difference group versus the other group (10.6% vs 0.6%, p=0.003) and the large DBP-difference group versus the small-difference group (7.7% vs 0.7%, p=0.013).

Conclusion

Peri-procedural systolic and diastolic BP differences, greater than 20 mmHg and 10 mmHg, respectively, correlated with MACE in all patients undergoing PCI.

Prognostic impact of blood pressure and heart rate at admission on in-hospital mortality after primary percutaneous intervention for acute myocardial infarction with ST-segment elevation in western Romania

Background

The purpose of this retrospective study was to evaluate the prognostic impact of systolic blood pressure (SBP) and heart rate (HR) on in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI) patients, after primary percutaneous intervention (PCI).

Patients and methods

The study included 294 patients admitted for STEMI. They were divided into five groups according to the SBP at admission: group I, <105 mmHg; group II, 105–125 mmHg; group III, 126–140 mmHg; group IV, 141–158 mmHg; and group V, ≥159 mmHg. Increased HR was defined as ≥80 beats per minute (bpm). In-hospital death was defined as all-cause death during admission and classified into cardiac and noncardiac death.

Results

Among the 294 patients admitted for STEMI, 218 (74%) were men. The mean age was 62±17 years. In-hospital mortality rate was 6% (n=18), with 11 (3.7%) deaths having cardiac causes. The highest mortality was registered in group I (n=9, 16%, P=0.018). Compared to the other groups, group I patients were older (P=0.033), more often smokers (P=0.026), and had a history of myocardial infarction (P=0.003), systemic hypertension (P=0.023), diabetes (P=0.041), or chronic kidney disease (P=0.0200). They more often had a HR ≥80 bpm (P=0.028) and a Killip class 3 or 4 at admission (P=0.020). The peak creatine phosphokinase-MB level was significantly higher in this group (P=0.005), while the angiographic findings more often identified as culprit lesions were the right coronary artery (P=0.005), the left main trunk (P=0.040), or a multivessel coronary artery disease (P=0.044). Multivariate analysis showed that group I patients had a significantly higher risk for both all-cause death (P=0.006) and cardiac death (P=0.003). Patients with HR ≥80 bpm also had higher mortality rates (P=0.0272 for general mortality and P=0.0280 for cardiac mortality).

Conclusion

The present study suggests that SBP <105 mmHg and HR ≥80 bpm at admission of STEMI patients are associated with a higher risk of in-hospital death, even after primary PCI.

Prognostic value of clinical, echocardiographic and angiographic indicators in patients with large anterior ST-segment elevation myocardial infarction as a first acute coronary event

BACKGROUND

The risk of death in patients affected by ST-elevation segment myocardial infarction (STEMI) is well known, but more data are required to define the in-hospital mortality in special subsets. We sought to assess the prognostic value of indicators in patients with large anterior STEMI as a first acute coronary event, undergoing percutaneous coronary intervention (PCI) and intra-aortic balloon pump (IABP).

METHODS AND RESULTS

We evaluated 48 consecutive large anterior STEMI patients admitted as first acute coronary event, undergoing in acute phase both PCI and IABP. Patient demographics, clinical, noninvasive and invasive findings, together with in-hospital complications, were collected. Moreover, findings obtained after a 24-month follow-up were reported. The primary endpoint was in-hospital mortality, whereas the secondary endpoints were out of hospital mortality, rehospitalization for heart failure or reinfarction, and New York Heart Association (NYHA) class at least 2 at follow-up visit. The univariate analysis showed a significant association with symptom to balloon, left anterior descending coronary artery, myocardial blush grade, and wall motion score index. Results of the multivariable analysis revealed the strongest predictive power for in-hospital mortality of proximal left anterior descending coronary artery (odds ratio: 6.9; 95% confidence interval: 1.1-67.7) and of myocardial blush grade 0-1 (odds ratio: 5.5; 95% confidence interval: 1.0-38.8). In-hospital death occurred in 13 patients (27% of total cases), whereas, at follow-up, the mean of survival was 66.7 ± 7.0%.

CONCLUSION

The patients with large anterior STEMI as a first acute coronary event, undergoing PCI and IABP, had a very high in-hospital mortality, whereas the mortality rate over the follow-up period was lower. The involvement of a large territory at risk and the ineffective treatment in terms of myocardial reperfusion were the main predictors of in-hospital mortality.

Ischaemic Heart Disease at the University Hospital of the West Indies: Trends in Hospital Admissions and Inpatient Mortality Rates 2005-2010

OBJECTIVES

This study aimed to estimate hospital admission rates and inpatient mortality rates for ischaemic heart disease (IHD) and its subtypes at the University Hospital of the West Indies (UHWI) for the years 2005─2010, and to identify factors associated with inpatient mortality.

METHODS

Data from electronic discharge summaries for patients diagnosed with acute myocardial infarction (A-MI), unstable angina (UA) or other IHD were obtained from the Patient Information Management Systems database of the Medical Records Department of the UHWI. Data were entered into an electronic database and analysed using Stata 10.1. Random effects logistic regression was used to identify factors associated with inpatient mortality.

RESULTS

Analysis included 3794 admissions (2821 persons: 1415 males, 1406 females; mean age 63.9 ± 13.5 years). Overall admission rates for IHD were 12.1% (95% CI 11.7, 12.5) for medical admissions and 4.02% (95% CI 3.89, 4.15) for non-paediatric admissions. Admission rates were higher among males compared to females. There was a statistically significant trend for an overall increase in the rates for IHD admissions over the study period. Inpatient mortality rate was 18.9% for A-MI, 1.6% for UA and 7.8% for other IHD. In multivariable models, adjusted for age and gender, A-MI was associated with higher mortality compared to other IHD (OR 3.38, p < 0.001).

CONCLUSIONS

Ischaemic heart disease admission rate is increasing at the UHWI and accounts for approximately one of every eight medical admissions. Inpatient mortality for acute myocardial infarction is approximately 19%. Further studies are required to determine the factors associated with inpatient mortality and to inform strategies for improving outcomes.

Canada Acute Coronary Syndrome Risk Score: a new risk score for early prognostication in acute coronary syndromes

BACKGROUND

Despite the availability of several acute coronary syndrome (ACS) prognostic risk scores, there is no appropriate score for early-risk stratification at the time of the first medical contact with patients with ACS. The primary objective of this study is to develop a simple risk score that can be used for early-risk stratification of patients with ACS.

METHODS

We derived the risk score from the Acute Myocardial Infarction in Quebec and Canada ACS-1 registries and validated the risk score in 4 other large data sets of patients with ACS (Canada ACS-2 registry, Canada-GRACE, EFFECT-1, and the FAST-MI registries). The final risk score is named the Canada Acute Coronary Syndrome Risk Score (C-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of each of these variables: age ≥75 years, Killip >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min. The primary end points were short-term (inhospital or 30-day) and long-term (1- or 5-year) all-cause mortality.

RESULTS

The C-ACS has good predictive values for short- and long-term mortality of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation ACS. The negative predictive value of a C-ACS score ≥1 is excellent at ≥98% (95% CI 0.97-0.99) for short-term mortality and ≥93% (95% CI 0.91-0.96) for long-term mortality. In other words, a C-ACS score of 0 can potentially identify correctly ≥97% short-term survivors and ≥91% long-term survivors.

CONCLUSION

The C-ACS risk score permits rapid stratification of patients with ACS. Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.

Nonfatal myocardial infarction and long-term outcomes in coronary artery disease

BACKGROUND

Therapies may reduce short-term rates of nonfatal myocardial infarction (MI) without a detectable effect on mortality. We sought to estimate the long-term clinical implications of nonfatal MI occurring within the first 3 and 6 months after initial cardiac catheterization.

METHODS

We included consecutive patients with significant coronary artery disease (≥75% stenosis in ≥1 epicardial segments) undergoing diagnostic catheterization between January 1, 1999, and September 30, 2006. Landmark analyses were performed for patients surviving at 3- and 6-month follow-up. At these times, patients were divided into groups based upon occurrence of a nonfatal MI subsequent to catheterization.

RESULTS

Among 14,890 patients alive at 3 months (669 with MI and 14,221 without an MI), having an MI during the initial 3-month period was a significant predictor of reduced 4-year survival (77.1% vs 83.5%, hazard ratio 1.40, 95% CI 1.21-1.63, P < .001), survival free of MI (68.4% vs 78.5%, hazard ratio 1.50, 95% CI 1.32-1.71, P < .001), and survival free of MI or revascularization (59.7% vs 68.5%, hazard ratio 1.34, 95% CI 1.19-1.51, P < .001). Adjusted hazard ratios were similar for patients surviving to 6 months (804 with MI and 13,842 without an MI).

CONCLUSIONS

Nonfatal MIs occurring within the first 3 and 6 months after diagnostic catheterization are associated with a significant increase in the risk for subsequent clinical events. Clinical studies with limited follow-up periods may underestimate the long-term value of therapies that reduce early MI rates as downstream benefits continue to accrue over time.

Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients

BACKGROUND

Diagnosis of acute myocardial infarction (AMI) in out-of-hospital cardiac arrest (OHCA) patients is important because immediate coronary angiography with coronary angioplasty could improve outcome in this setting. However, the value of acute post-resuscitation electrocardiographic (ECG) data for the detection of AMI is debatable.

METHODS

We assessed the diagnostic characteristics of post-resuscitation ECG changes in a retrospective single centre study evaluating several ECG criteria of selection of patients undergoing AMI, in order to improve sensitivity, even at the expense of specificity. Immediate post resuscitation coronary angiogram was performed in all patients. AMI was defined angiographically using coronary flow and plaque morphology criteria.

RESULTS

We included 165 consecutive patients aged 56 (IQR 48-67) with sustained return of spontaneous circulation after OHCA between 2002 and 2008. 84 patients had shockable, 73 non-shockable and 8 unknown initial rhythm; 36% of the patients had an AMI. ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle branch block provided a sensitivity and negative predictive value of 100%, a specificity of 46% and a positive predictive value of 52%.

CONCLUSION

In patients with OHCA without obvious non-cardiac causes, selection for coronary angiogram based on the combined criterion would detect all AMI and avoid the performance of the procedure in 30% of the patients, in whom coronary angiogram did not have a therapeutic role.

Systemic Inflammatory Response Syndrome Predicts Mortality in Acute Coronary Syndrome without Congestive Heart Failure

INTRODUCTION

High levels of inflammatory biochemical markers are associated with an increased risk among patients with acute coronary syndrome (ACS). The objective of the current study was to evaluate the prognostic significance of the systemic inflammatory response syndrome (SIRS) among ACS patients with no clinical or radiological evidence of congestive heart failure (CHF).

METHODS

Consecutive patients with ACS and no clinical or radiological evidence of CHF in the emergency department (ED) were included in the study. The endpoint was hospital mortality. Categorical variables were compared by calculating proportions with 95% confidence intervals (CIs) and by using the Fisher Exact test. Continuous variables were compared by using the Wilcoxon Rank Sum test. The association of the variables with hospital mortality was assessed by using the logistic regression analysis.

RESULTS

The study included 196 patients (60 years; female 32.6 %). Six patients (3.1 %) died in hospital and 22 patients (11.2 %) had SIRS on admission to the ED. The following variables were predictors of hospital mortality: age with an odds ratio (OR) of 1.1 (95% CI, 1-1.2) for each one additional year (p <0.01), systolic arterial pressure with an OR 0.9 (95% CI, 0.9-1), diastolic arterial pressure with an OR 0.9 (95% CI, 0.8-1) for each one additional mmHg (p < 0.01), respiratory rate with an OR 1.5 (95% CI, 1.2-1.9) for each one additional breath per minute (p < 0.01), and SIRS with an OR 9 (95% CI, 1.7-47.8) (p 0.02). Because of the small number of events, it was not possible to assess the independence of these risk factors.

CONCLUSION

SIRS was a marker of increased risk of hospital mortality among patients with ACS and no clinical or radiological evidence of CHF.

Prognostic value of blood pressure measured during hospitalization after acute myocardial infarction: an insight from survival trials

BACKGROUND

The prognostic value of blood pressure measured during hospitalization after acute myocardial infarction (MI) has not been investigated, particularly with regard to arrhythmic death.

METHODS

A total of 3311 placebo patients (2612 men, median age 64 years; range 23-92) from the EMIAT, CAMIAT, SWORD, TRACE and DIAMOND-MI studies with left ventricular ejection fraction less than 40% or asymptomatic ventricular arrhythmia surviving more than 45 days after MI were pooled. Systolic and diastolic blood pressures and pulse pressures were measured soon after MI (median 6 days, range 0-53 days). Mortality up to 2 years was examined using Cox regression.

RESULTS

At the 2-year follow-up, after adjustment for age, sex, smoking, previous MI, hypertension, heart rate, New York Heart Association functional class, baseline treatments, study effect and diastolic blood pressure, reduced systolic blood pressure measured during hospitalization after acute MI significantly increased the risk of all-cause mortality [hazard ratio (HR) for 10% increase in systolic blood pressure 0.80, 95% confidence interval (CI) 0.71-0.90; P < 0.001] and arrhythmic mortality (HR 0.73, 95% CI 0.61-0.86; P = 0.001). Reduced diastolic blood pressure significantly increased the risk of all-cause mortality (HR 0.87, 95% CI 0.77-0.98; P = 0.02) and arrhythmic mortality (HR 0.80, 95% CI 0.68-0.93; P = 0.005).

CONCLUSION

In post-MI patients with left ventricular ejection fraction less than 40% or asymptomatic ventricular arrhythmia, reduced blood pressure measured during hospitalization after MI significantly predicts all-cause mortality and arrhythmic mortality, and can be reliably used to identify patients who are at risk of dying after MI.

Long-term performance of interstial fluid pressure and hypoxia as prognostic factors in cervix cancer

OBJECTIVES

Hypoxia and high interstitial fluid pressure (IFP) have been shown to independently predict for nodal and distant metastases, as well as survival, in patients with cervix cancer. Using data from our prospective trial, we updated a cohort of patients treated with definitive radiation alone without chemotherapy, to assess the long-term prognostic impact of these microenvironmental features.

METHODS

Between April 1994 and January 1999, 107 eligible patients with cervix cancer were entered into a prospective study of tumor oxygenation and IFP prior to primary radiation therapy. Oxygenation data are presented as the hypoxic proportion, defined as the percentage of pO(2) readings <5 mm Hg (abbreviated as HP(5)). Patients with HP(5) values >50% were considered to have hypoxic tumors. IFP is presented in mmHg, divided into high and low IFP groups by the median value. Patients ranged in age from 23 to 78 years with a mean of 53 years. The maximum tumor size ranged from 2 to 10 cm, with a median diameter of 5 cm. FIGO stage was IB in 28 patients, IIA in 4, IIB in 42 and IIIB in 33 patients. Twenty-two patients (21%) had evidence of pelvic lymph node involvement on staging CT abdomen/pelvis or MR pelvis. HP(5) ranged from 0% to 99% with a median of 48%. IFP ranged from -3 to 48 mm Hg (median 19 mm Hg). Median follow-up was 6.7 years (range 0.9-10.6).

RESULTS

Disease-free survival (DFS) at 5 years was 50%. Five year DFS was 42% for patients with hypoxic tumors (HP(5)>50%), and 58% in patients with oxygenated tumors (HR 1.01 per %, p=0.05). DFS at 5 years was 42% for patients with interstitial hypertension (IFP >19 mm Hg), and 63% in patients with IFP <or=19 mm Hg (HR 1.05 per mmHg, p=0.001). In a multivariate analysis only tumor size (HR 1.2, p=0.009) pelvic nodal metastases (HR 3.3, p=0.0004) and IFP (HR 1.06, p=0.0005) were predictive of DFS. Because an interaction between nodal status and oxygenation was observed (p=0.03), further analysis indicated a borderline significant impact of HP(5) in addition to tumor size in node negative patients (HR 1.01, p=0.06). These results were similar when local or distant relapse was used as an endpoint.

CONCLUSIONS

These results confirm our initial finding of the strong independent prognostic impact of IFP for relapse and survival in patients with cervix cancer. In contrast, the independent prognostic impact of HP(5) is of borderline significance and is limited to patients without imaging evidence of nodal metastases. However, these findings do not diminish the biologic significance of hypoxia, or the role of hypoxia and IFP as biomarkers of treatment response and as therapeutic targets.