Trends in Premature Mortality From Acute Myocardial Infarction in the United States, 1999 to 2019

Recurrent events after acute ST-segment elevation myocardial infarction: predictors and features of plaque progression and stent failure

OBJECTIVES

Patients with acute ST-segment elevation myocardial infarction (STEMI) are at high risk for recurrent coronary events (RCE). Non-culprit plaque progression and stent failure are the main causes of RCEs. We sought to identify the incidence and predictors of RCEs.

METHODS

Eight hundred thirty patients with STEMI were enrolled and followed up for 5 years. All patients underwent blood test analysis at hospital admission, at 1-month and at 12-month follow-up times. Patients were divided into RCE group and control group. RCE group was further categorized into non-culprit plaque progression and stent failure subgroups.

RESULTS

Among 830 patients with STEMI, 63 patients had a RCE (7.6%). At hospital admission, HDL was numerically lower in RCE group, while LDL at both 1-month and 12-month follow-up times were significantly higher in RCE group. Both HDL at hospital admission and LDL at 12-month follow-up were independently associated with RCEs (OR 0.90, 95% CI 0.81-0.99 and OR 1.041, 95% CI 1.01-1.07, respectively). RCEs were due to non-culprit plaque progression in 47.6% of cases, while in 36.5% due to stent failure. The mean time frame between pPCI and RCE was significantly greater for non-culprit plaque progression subgroup as compared to stent failure subgroup (27 ± 18 months and 16 ± 14 months, P  = 0.032).

CONCLUSION

RCEs still affect patients after pPCI. Low levels of HDL at admission and high levels of LDL at 12 months after pPCI significantly predicted RCEs. A RCE results in non-culprit plaque progression presents much later than an event due to stent failure.

Plasma Biomarker Profiles for Premature and Nonpremature Coronary Heart Disease in Women

BACKGROUND

Premature coronary heart disease (CHD) is a major cause of death in women. We aimed to characterize biomarker profiles of women who developed CHD before and after age 65 years.

METHODS

In the Women's Health Study (median follow-up 21.5 years), women were grouped by age and timing of incident CHD: baseline age <65 years with premature CHD by age 65 years (25 042 women; 447 events) and baseline age ≥65 years with nonpremature CHD (2982 women; 351 events). Associations of 44 baseline plasma biomarkers measured using standard assays and a nuclear magnetic resonance (NMR)-metabolomics assay were analyzed using Cox models adjusted for clinical risk factors.

RESULTS

Twelve biomarkers showed associations only with premature CHD and included lipoprotein(a), which was associated with premature CHD [adjusted hazard ratio (HR) per SD: 1.29 (95% CI 1.17-1.42)] but not with nonpremature CHD [1.09(0.98-1.22)](Pinteraction = 0.02). NMR-measured lipoprotein insulin resistance was associated with the highest risk of premature CHD [1.92 (1.52-2.42)] but was not associated with nonpremature CHD (Pinteraction <0.001). Eleven biomarkers showed stronger associations with premature vs nonpremature CHD, including apolipoprotein B. Nine NMR biomarkers showed no association with premature or nonpremature CHD, whereas 12 biomarkers showed similar significant associations with premature and nonpremature CHD, respectively, including low-density lipoprotein (LDL) cholesterol [1.30(1.20-1.45) and 1.22(1.10-1.35)] and C-reactive protein [1.34(1.19-1.50) and 1.25(1.08-1.44)].

CONCLUSIONS

In women, a profile of 12 biomarkers was selectively associated with premature CHD, driven by lipoprotein(a) and insulin-resistant atherogenic dyslipoproteinemia. This has implications for the development of biomarker panels to screen for premature CHD.

Biomimetic nanomaterials in myocardial infarction treatment: Harnessing bionic strategies for advanced therapeutics

Myocardial infarction (MI) and its associated poor prognosis pose significant risks to human health. Nanomaterials hold great potential for the treatment of MI due to their targeted and controlled release properties, particularly biomimetic nanomaterials. The utilization of biomimetic strategies based on extracellular vesicles (EVs) and cell membranes will serve as the guiding principle for the development of nanomaterial therapy in the future. In this review, we present an overview of research progress on various exosomes derived from mesenchymal stem cells, cardiomyocytes, or induced pluripotent stem cells in the context of myocardial infarction (MI) therapy. These exosomes, utilized as cell-free therapies, have demonstrated the ability to enhance the efficacy of reducing the size of the infarcted area and preventing ischaemic reperfusion through mechanisms such as oxidative stress reduction, polarization modulation, fibrosis inhibition, and angiogenesis promotion. Moreover, EVs can exert cardioprotective effects by encapsulating therapeutic agents and can be engineered to specifically target the infarcted myocardium. Furthermore, we discuss the use of cell membranes derived from erythrocytes, stem cells, immune cells and platelets to encapsulate nanomaterials. This approach allows the nanomaterials to camouflage themselves as endogenous substances targeting the region affected by MI, thereby minimizing toxicity and improving biocompatibility. In conclusion, biomimetic nano-delivery systems hold promise as a potentially beneficial technology for MI treatment. This review serves as a valuable reference for the application of biomimetic nanomaterials in MI therapy and aims to expedite the translation of NPs-based MI therapeutic strategies into practical clinical applications.

Cardiovascular hospitalizations and mortality among adults aged 25-64 years in the USA

BACKGROUND AND AIMS

Declines in cardiovascular mortality have stagnated in the USA since 2011. There is growing concern that these patterns reflect worsening cardiovascular health in younger adults. However, little is known about how the burden of acute cardiovascular hospitalizations and mortality has changed in this population. Changes in cardiovascular hospitalizations and mortality among adults aged 25-64 years were evaluated, overall and by community-level income.

METHODS

Using the National Inpatient Sample, age-standardized annual hospitalization and in-hospital mortality rates for acute myocardial infarction (AMI), heart failure, and ischaemic stroke were determined among adults aged 25-64 years. Quasi-Poisson and quasi-binominal regression models were fitted to compare outcomes between individuals residing in low- and higher-income communities.

RESULTS

Between 2008 and 2019, age-standardized hospitalization rates for AMI increased among younger adults from 155.0 (95% confidence interval: 154.6, 155.4) per 100 000 to 160.7 (160.3, 161.1) per 100 000 (absolute change +5.7 [5.0, 6.3], P < .001). Heart failure hospitalizations also increased (165.3 [164.8, 165.7] to 225.3 [224.8, 225.8], absolute change +60.0 (59.3, 60.6), P < .001), as ischaemic stroke hospitalizations (76.3 [76.1, 76.7] to 108.1 [107.8, 108.5], absolute change +31.7 (31.2, 32.2), P < .001). Across all conditions, hospitalizations rates were significantly higher among younger adults residing in low-income compared with higher-income communities, and disparities did not narrow between groups. In-hospital mortality decreased for all conditions over the study period.

CONCLUSIONS

There was an alarming increase in cardiovascular hospitalizations among younger adults in the USA from 2008 to 2019, and disparities between those residing in low- and higher-income communities did not narrow.

MiRNA-miRNA interaction network in peripheral blood of patients with myocardial infarction: a gene expression meta-analysis

In recent years, investigations have revealed that microRNAs (miRNAs) can bind together and form a miRNA-miRNA-mRNA regulatory network that alters the consequence of miRNA-mRNA interaction. If we consider the miRNA that binds to mRNA as the primary miRNA and the miRNA that binds to the primary miRNA as the secondary one, secondry miRNAs can act as master regulators upstream of primary miRNAs and their target mRNAs. One of the distinguishing characteristics of secondary miRNAs as master regulators within a diverse set of differentially expressed genes is the absence of direct target mRNA for them. Instead, these master regulators exclusively govern the regulation of miRNAs that target specific mRNAs. Through in silico analysis, we identified 18 miRNAs among 385 differentially expressed miRNAs (DEmiRNAs) with no direct target mRNAs among 58 differentially expressed mRNAs (DEmRNAs) in peripheral blood of patients with myocardial infarction (MI). Instead, these secondary miRNAs targeted 9 primary miRNAs that had 36 direct targets among 58 DEmRNAs. We found that one primary miRNA might be regulated by more than one secondary miRNAs and each secondary miRNA can target more than one primary miRNAs. Among identified miRNA-miRNA-mRNA networks miR-188-5p/miR-299-3p/natural killer cell granule protein (NKG7), miR-200a-3p/miR-199b-5p/granzyme B (GZMB), and miR-377-3p/miR-581/oviductal glycoprotein 1 (OVGP1) exhibited higher scors in terms of expression levels (>2-fold increase or decrease) and strengh of interactions (ΔG < -5). Given the extensive network of miRNA interactions, focusing on master regulators opens up avenues for identifying key regulatory nodes for more effective therapeutic strategies.

Trends in Premature Mortality from Acute Myocardial Infarction in American Indians/Alaska Natives in the United States from 1999 to 2020

Cardiovascular disease is the leading cause of mortality in American Indian and Alaska Native (AI/AN) groups. They are disproportionately found to have a higher rate of premature myocardial infarction (MI). The Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research were queried to identify premature MI deaths (female <65 years and male <55 years) occurring within the United States between 1999 and 2020. We investigated proportionate mortality trends related to premature MI in AI/ANs stratified by gender. Deaths attributed to acute MI (AMI) were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes I21 to I22. We compared the proportional mortality rate because of premature MI with that of a non-AI/AN racial group, which comprised all other races (Blacks, Whites, and Asian/Pacific Islander populations). In AI/ANs, we analyzed a total of 14,055 AMI deaths, of which 3,211 were premature MI deaths corresponding to a proportionate mortality rate of 22.8% (male 20.8%, female 26.2%). The non-AI/AN population had a lower proportionate mortality of 14.8% (male 13.7%, female 16%), p <0.01). On trend analysis, there was no significant improvement over time in the proportionate mortality of AI/ANs (19.8% in 1999 to 21.7% in 2020, p = 0.09). Upon comparison of gender, proportionate mortality of premature MI in women showed a statistically nonsignificant increase from 21.6% in 1999 to 27.3% in 2020 [average annual percent change of 0.7, p = 0.06)]. However, men had a statistically significant decrease in proportionate mortality of premature MI from 18.5% in 1999 to 18.2% in 2020 [average annual percent change of -0.8, p = 0.01)]. AI/ANs have an alarmingly higher rate of proportionate mortality of premature MI than that of other races, with no improvement in the proportionate mortality rates over 20 years, despite an overall downtrend in AMI mortality. Further research to address the reasons for the lack of improvement in premature MI is needed to improve outcomes in this patient population.

Circulating GDF11 exacerbates myocardial injury in mice and associates with increased infarct size in humans

AIMS

The heart rejuvenating effects of circulating growth differentiation factor 11 (GDF11), a transforming growth factor-β superfamily member that shares 90% homology with myostatin (MSTN), remains controversial. Here, we aimed to probe the role of GDF11 in acute myocardial infarction (MI), a frequent cause of heart failure and premature death during ageing.

METHODS AND RESULTS

In contrast to endogenous Mstn, myocardial Gdf11 declined during the course of ageing and was particularly reduced following ischaemia/reperfusion (I/R) injury, suggesting a therapeutic potential of GDF11 signalling in MI. Unexpectedly, boosting systemic Gdf11 by recombinant GDF11 delivery (0.1 mg/kg body weight over 30 days) prior to myocardial I/R augmented myocardial infarct size in C57BL/6 mice irrespective of their age, predominantly by accelerating pro-apoptotic signalling. While intrinsic cardioprotective signalling pathways remained unaffected by high circulating GDF11, targeted transcriptomics and immunomapping studies focusing on GDF11-associated downstream targets revealed attenuated Nkx2-5 expression confined to CD105-expressing cells, with pro-apoptotic activity, as assessed by caspase-3 levels, being particularly pronounced in adjacent cells, suggesting an indirect effect. By harnessing a highly specific and validated liquid chromatography-tandem mass spectrometry-based assay, we show that in prospectively recruited patients with MI circulating GDF11 but not MSTN levels incline with age. Moreover, GDF11 levels were particularly elevated in those at high risk for adverse outcomes following the acute event, with circulating GDF11 emerging as an independent predictor of myocardial infarct size, as estimated by standardized peak creatine kinase-MB levels.

CONCLUSION

Our data challenge the initially reported heart rejuvenating effects of circulating GDF11 and suggest that high levels of systemic GDF11 exacerbate myocardial injury in mice and humans alike. Persistently high GDF11 levels during ageing may contribute to the age-dependent loss of cardioprotective mechanisms and thus poor outcomes of elderly patients following acute MI.

Ambient particulate matter and in-hospital case fatality of acute myocardial infarction: A multi-province cross-sectional study in China

The acute myocardial infarction (AMI) outcomes have been extensively linked with ambient particulate matter (PM). However, whether a smaller particle has greater impact and the consequent attributable burden associated with PM of different sizes remain unclear. We conducted a multi-province cross-sectional study among AMI patients using the inpatient discharge datasets from four Chinese provinces (Shanxi, Sichuan, Guangxi, and Guangdong) from 2014 to 2019. Ambient PM exposure for each patient was assessed using the ChinaHighAirPollutants dataset. We employed the mixed-effects logistic regression models to evaluate the association of PM of different sizes (PM1, PM2.5, PM10) on in-hospital case fatality. The potential reducible fractions in in-hospital case fatality were estimated through counterfactual analyses. Of 177,749 participants, 125,501 (70.6 %) were male and the in-hospital case fatality rate was 4.9%. For short-term (7-day average) exposure, the odds ratios (ORs) for PM1, PM2.5, and PM10 (per 10 µg/m3) were 1.052 (95 % confidence interval [CI], 1.032-1.071), 1.026 (95 % CI, 1.014-1.037), and 1.016 (95% CI, 1.008-1.024), respectively. The estimated ORs for long-term exposure (annual average) were 1.303 (95 % CI, 1.252-1.356) for PM1, 1.209 (95 % CI, 1.178-1.241) for PM2.5, 1.157 (95 % CI, 1.134-1.181) for PM10. Short-term exposure to PM1 showed the highest potential reducible fraction (8.5 %, 95 % CI, 5.0-11.7 %), followed by PM2.5 and PM10, while the greatest potential reducible fraction of long-term exposure was observed in PM10 (30.9 %, 95 % CI, 27.2-34.4%), followed by PM2.5 and PM1. In summary, PM with smaller size had a more pronounced impact on in-hospital AMI case fatality, with PM1 exhibiting greater effects than PM2.5 and PM10. Substantial health benefits for AMI patients could be achieved by mitigating ambient PM exposure.

Association of Coronary Collaterals and Myocardial Salvage Measured by Serial Cardiac Magnetic Resonance Imaging after Acute Myocardial Infarction

BACKGROUND

Coronary collateral flow in angiography has been linked with lower mortality rates in patients with coronary artery disease. However, the relevance of the underlying mechanism is sparse. Therefore, we tested the hypothesis that in patients with acute myocardial infarction (AMI), relevant coronary collateral flow is associated with more salvaged myocardium and lower risk of developing heart failure.

METHODS AND RESULTS

Patients with first AMI who received a percutaneous coronary intervention within 24 h after symptom onset were classified visually by assigning a Cohen-Rentrop Score (CRS) ranging between 0 (no collaterals) and 3 (complete retrograde filling of the occluded vessel). All 36 patients included in the analysis underwent cardiac magnetic resonance examination within 3 to 5 days after myocardial infarction and after 12 weeks. Patients with relevant collateral flow (CRS 2-3) to the infarct-related artery had significantly smaller final infarct size compared to those without (7 ± 4% vs. 20 ± 12%, p < 0.001). In addition, both groups showed improvement in left ventricular ejection fraction early after AMI, whereas the recovery was greater in CRS 2-3 (+8 ± 5% vs. +3 ± 5%, p = 0.015).

CONCLUSION

In patients with first AMI, relevant collateral flow to the infarct-related artery was associated with more salvaged myocardium at 12 weeks, translating into greater improvement of systolic left ventricular function. The protective effect of coronary collaterals and the variance of infarct location should be further investigated in larger studies.

Trends in incidence and clinical outcome of non-ST elevation myocardial infarction in patients with amyloidosis in the United States, 2010-2020

Study objective

To assess temporal changes in clinical profile and in-hospital outcome of patients with amyloidosis presenting with non-ST elevation myocardial infarction, NSTEMI.

Design/setting

We conducted a retrospective observational study using the National Inpatient Sample (NIS) database from January 1, 2010, to December 31, 2020.

Main outcomes

Primary outcome of interest was trend in adjusted in-hospital mortality in patients with amyloidosis presenting with NSTEMI from 2010 to 2020. Our secondary outcomes were trend in rate of coronary revascularization, and trend in duration of hospitalization.

Results

We identified 272,896 hospitalizations for amyloidosis. There was a temporal increase in incidence of NSTEMI among patients aged 18-44 years from 15.5 % to 28.0 %, a reverse trend was observed in 45-64 years: 22.1 % to 17.7 %, p = 0.043. There was no statistically significant difference in rate of coronary revascularization from 2010 to 2020; 16.3 % to 14.2 %, p = 0.86. We observed an increased odds of all-cause in-hospital mortality in patients with NSTEMI compared to those without NSTEMI (aOR = 2.2, 95 % CI: 1.9-2.6, p < 0.001) but there was a decrease trend in mortality from 21.5 % to 11.3 %, p = 0.013 for trend. Hospitalization duration was also observed to decreased from 14.1 days to 10.9 days during the study period (p = 0.055 for trend).

Conclusion

In patients with amyloidosis presenting with NSTEMI, there was increased incidence of NSTEMI among young adults, a steady trend in coronary revascularization, and a decreasing trend of adjusted all-cause in-hospital mortality and length of hospitalization from 2010 to 2020 in the United States.

Association Between Social Vulnerability Index and Mortality Following Acute Myocardial Infarction in the US Counties

Social determinants of health (SDOH) play a major role in cardiovascular outcomes. The social vulnerability index (SVI) is a tool designed by the Center for Disease Control (CDC) to measure a community's vulnerability to respond and recover from disasters. The parameters of SVI can be used to gauge social disparities amongst different US counties and its association with acute myocardial infarction (AMI) related to age- adjusted mortality rate (AAMR) by using the multiple causes of death database from CDC, Prevention's Wide-Ranging Online Data for Epidemiological Research (WONDER 2016-2020) and Agency for Toxic Substances and Disease Registry (ATSDR). We used segmented regression models to evaluate the association between quintiles of SVI scores and AAMR using STATA. A total of 2908 of 3289 US counties were used in the analysis. The mean AAMR was 89.3 per 100,000 (95% CI: 87.1-91.5) from 2016 to 2020. US counties with higher SVI were associated with higher AMI-related age-adjusted mortality when compared to counties with lower SVI. Counties with the highest SVI and AAMR were in the mid-western and southern states The findings of our study can guide focused care for a uniform upliftment of CV health across the nation by identifying the distribution of socio-economically disadvantaged counties.

The Efficacy of Angiotensin Receptor-Neprilysin Inhibitor Versus Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Post Myocardial Infarction: A Meta-Analysis

Acute myocardial infarction (MI) is one of the leading global healthcare emergencies, contributing to over three million global deaths. The purpose of this study is to investigate further the efficacy of sacubitril/valsartan over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in reducing the risk of heart failure (HF) in post-MI patients and providing a clear evidence-based medicine guideline for future use. An electronic database search was conducted on English databases. Eight articles were included, fulfilling our inclusion criteria, i.e., adult patients of ≥18 years with a recent diagnosis of acute MI. Pooled analysis was done using Review Manager version 5.4.1 (Cochrane Collaboration, London, England), and the data for each outcome were analyzed as dichotomous variables. A total of eight clinical trials were included in the meta-analysis. Six studies analyzed the sacubitril/valsartan and ACEI combination. The pooled analysis reported a significant increase in the risk of hypotension (relative risk {RR}: 1.29 {1.18, 1.41}) in the sacubitril/valsartan compared to the ACEI alone group. In addition, a significant increase was observed in the left ventricle ejection fraction (LVEF) after using the sacubitril/valsartan combination compared to using ACEI alone (RR: 3.08 {2.68, 4.48}). Furthermore, no significant difference was observed between the groups in terms of mortality rate (RR: 0.86 {0.73, 1.02}), the risk of heart failure (RR: 0.62 {0.39, 1.00}), the frequency of recurrent MI (RR: 0.86 {0.27, 2.76}), and the mean difference of N-terminal pro-B-type natriuretic peptide (NT-proBNP) (weighted mean difference {WMD}: -174.36 {-414.18, 65.46}) between both the groups. However, the sacubitril/valsartan combination proved to be beneficial in significantly reducing the risk of major adverse cardiac events (MACE) (RR: 0.64 {0.48, 0.84}) and rehospitalizations (RR: 0.53 {0.39, 0.71}) as compared to ACEI post MI. Additionally, sacubitril/valsartan and ARB's combination was reported in two studies. This led to a significant decrease in NT-proBNP concentration (WMD: -71.91 {-138.43, -5.39}) post MI in the sacubitril/valsartan combination group compared to the ARB usage alone. However, no significant difference was observed in the improvement of LVEF (WMD: 0.88 {-5.11, 6.87}) between both groups. Although the sacubitril/valsartan combination has no difference in mortality and outcomes compared to ACEI, there is evidence that using it proves to be more beneficial post MI compared to ACEI and ARB usage alone.

What Are the Causes of Death among Patients Admitted to a Contemporary Tertiary-Level Cardiology Department? An Analysis of 10 Years of Morbidity and Mortality Meetings

Despite the efforts to deliver the best evidence-based care, in-hospital death is an inevitable event among some patients hospitalized in cardiology departments. We conducted a retrospective evaluation of mortality events from inpatient admissions to the cardiology department between 2010 and 2019. Data were collected from morbidity and mortality meeting presentations that evaluated comorbidities, medical history, treatments, and causes of death for the overall cohort and according to age group and sex. There were 1182 registered deaths. The most common causes of death among patients were acute myocardial infarction (AMI, 53.0%), heart failure (HF, 11.7%), cardiac arrest (CA, 6.6%), HF with complication/defined cardiomyopathy (6.3%), and sepsis (4.4%). We observed a decline in deaths from AMI from 61.9% in 2010 to 46.7% in 2019, while there was a clear increase in deaths from HF (11.1% in 2010 to 25.9% in 2019). Compared to patients ≥65 years, younger patients were more likely to have died from CA (15.7% vs. 4.3%, p < 0.001) and other cardiac reasons (3.0% vs. 0.4%, p < 0.001). The majority of deaths were due to AMI, HF, and CA. We observed a significant declining trend in the proportion of deaths due to AMI in recent years, with an increase in deaths due to HF.

Trends in Psychotropic Drug-Implicated Cardiovascular Mortality: Patterns in U.S. Mortality, 1999-2020

INTRODUCTION

Psychotropic drug-implicated (PDI) mortality-deaths in which psychotropic drugs were a contributing but not underlying cause of death-increased over two decades, with circulatory mortality as the primary cause leading to such deaths. Trends in PDI circulatory mortality over a 22-year period and its patterning in U.S. deaths are described.

METHODS

Deaths extracted from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research Multiple Causes of Death database from 1999 to 2020 were analyzed to generate annual counts and rates for drug-implicated deaths due to diseases of the circulatory system, including by specific drug, sex, race/ethnicity, age, and state.

RESULTS

During a period when overall age-adjusted circulatory mortality rates declined, PDI circulatory mortality more than doubled, from 0.22 per 100,000 in 1999 to 0.57 per 100,000 by 2020, now representing 1 in 444 circulatory deaths. Although PDI deaths from ischemic heart diseases are proportionally aligned with overall circulatory deaths (50.0% vs 48.5%), PDI deaths from hypertensive diseases represent a larger proportion (19.8% vs 8.0%). Psychostimulants generated the greatest escalation for PDI circulatory deaths (0.029-0.332 per 100,000). The sex gap in PDI mortality rates widened (0.291 females, 0.861 males). PDI circulatory mortality is particularly notable for Black Americans and midlife Americans, with considerable geographic variability.

CONCLUSIONS

Circulatory mortality with psychotropic drugs as a contributing cause escalated over 2 decades. Trends in PDI mortality are not evenly distributed across the population. Greater engagement with patients about their substance use is needed to intervene in cardiovascular deaths. Prevention and clinical intervention could contribute to reinvigorating previous trends of declining cardiovascular mortality.

The global estimate of premature cardiovascular mortality: a systematic review and meta-analysis of age-standardized mortality rate

BACKGROUND

Cardiovascular disease (CVD) is a significant cause of premature mortality worldwide, with a growing burden in recent years. Despite this, there is a lack of comprehensive meta-analyses that quantify the extent of premature CVD mortality. Study addressed this gap by estimating the pooled age-standardized mortality rate (ASMR) of premature CVD mortality.

METHODS

We conducted a systematic review of published CVD mortality studies that reported ASMR as an indicator for premature mortality measurement. All English articles published as of October 2022 were searched in four electronic databases: PubMed, Scopus, Web of Science (WoS), and the Cochrane Central Register of Controlled Trials (CENTRAL). We computed pooled estimates of ASMR using random-effects meta-analysis. We assessed heterogeneity from the selected studies using the I2 statistic. Subgroup analyses and meta regression analysis was performed based on sex, main CVD types, income country level, study time and age group. The analysis was performed using R software with the "meta" and "metafor" packages.

RESULTS

A total of 15 studies met the inclusion criteria. The estimated global ASMR for premature mortality from total CVD was 96.04 per 100,000 people (95% CI: 67.18, 137.31). Subgroup analysis by specific CVD types revealed a higher ASMR for ischemic heart disease (ASMR = 15.57, 95% CI: 11.27, 21.5) compared to stroke (ASMR = 12.36, 95% CI: 8.09, 18.91). Sex-specific differences were also observed, with higher ASMRs for males (37.50, 95% CI: 23.69, 59.37) than females (15.75, 95% CI: 9.61, 25.81). Middle-income countries had a significantly higher ASMR (90.58, 95% CI: 56.40, 145.48) compared to high-income countries (21.42, 95% CI: 15.63, 29.37). Stratifying by age group indicated that the age groups of 20-64 years and 30-74 years had a higher ASMR than the age group of 0-74 years. Our multivariable meta-regression model suggested significant differences in the adjusted ASMR estimates for all covariates except study time.

CONCLUSIONS

This meta-analysis synthesized a comprehensive estimate of the worldwide burden of premature CVD mortality. Our findings underscore the continued burden of premature CVD mortality, particularly in middle-income countries. Addressing this issue requires targeted interventions to mitigate the high risk of premature CVD mortality in these vulnerable populations.

Trends in Cardiogenic Shock-Related Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019

Data on mortality trends in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) are scant. This study aimed to assess the trends in CS-AMI-related mortality in United States (US) subjects over the latest 21 years. Mortality data of US subjects with AMI listed as the underlying cause of death and CS as contributing cause were obtained from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) dataset from January 1999 to December 2019. CS-AMI-related age-adjusted mortality rates (AAMRs) per 100,000 US population were stratified by gender, race and ethnicity, geographic areas, and urbanicity. Nationwide annual trends were assessed as annual percent change (APC) and average APC with relative 95% confidence intervals (CIs). Between 1999 and 2019, CS-AMI was listed as the underlying cause of death in 209,642 patients, (AAMR of 3.01 per 100,000 people [95% CI 2.99 to 3.02]). AAMR from CS-AMI remained stable from 1999 to 2007 (APC -0.2%, [95% CI -2.0 to 0.5], p = 0.22) and then significantly increased (APC 3.1% [95% CI 2.6 to 3.6], p <0.0001), especially in male patients. Starting in 2009, the AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. The higher AAMRs were clustered in the South (average APC 4.5%, [95% CI 4.4 to 4.6]) of the country. In conclusion, CS-AMI-related mortality in US patients increased from 2009 to 2019. Targeted health policy measures are needed to address the rising burden of CS-AMI in US subjects.

Using wastewater to overcome health disparities among rural residents

The SARS-CoV-2 pandemic highlighted the need for novel tools to promote health equity. There has been a historical legacy around the location and allocation of public facilities (such as health care) focused on efficiency, which is not attainable in rural, low-density, United States areas. Differences in the spread of the disease and outcomes of infections have been observed between urban and rural populations throughout the COVID-19 pandemic. The purpose of this article was to review rural health disparities related to the SARS-CoV-2 pandemic while using evidence to support wastewater surveillance as a potentially innovative tool to address these disparities more widely. The successful implementation of wastewater surveillance in resource-limited settings in South Africa demonstrates the ability to monitor disease in underserved areas. A better surveillance model of disease detection among rural residents will overcome issues around the interactions of a disease and social determinants of health. Wastewater surveillance can be used to promote health equity, particularly in rural and resource-limited areas, and has the potential to identify future global outbreaks of endemic and pandemic viruses.

The ratio of QRS/RV6-V1: a new electrocardiographic predictor of short- and long-term adverse clinical outcomes in patients with acute myocardial infarction combined with new-onset right bundle branch block

Background

A few studies have focused on electrocardiography (ECG) parameters correlating with clinical prognosis in patients with acute myocardial infarction (AMI) combined with new-onset right bundle branch block (RBBB).

Objective

To assess the prognostic value of a new ECG parameter, namely, the ratio of QRS duration/RV₆-V₁ interval (QRS/RV₆-V₁), in patients with AMI combined with new-onset RBBB.

Materials and methods

A total of 272 AMI patients combined with new-onset RBBB who received primary percutaneous coronary intervention (P-PCI) were retrospectively enrolled in the study. First, the patients were divided into survival group and non-survival group. Demographic, angiographic, and ECG characteristics were compared between the two groups. Receiver operating characteristic (ROC) curve was used to screen the best ECG parameter for predicting 1-year mortality. Second, the ratio of QRS/RV₆-V₁, a continuous variable, was converted to the high ratio group and low ratio group according to the optimal cutoff value point determined by the X-tile software. We compared the patient's demographic, angiographic, and ECG characteristics, in-hospital major adverse cardiovascular events (MACE), and 1-year mortality between the two groups. Multivariate logistic and Cox regressions were used to evaluate whether the ratio of QRS/RV₆-V₁ was an independent prognostic factor of in-hospital MACE and 1-year mortality.

Results

The ROC curve showed that the ratio of QRS/RV₆-V₁ had a higher value for predicting in-hospital MACE and 1-year mortality than the QRS duration, RV₆-V₁ interval, and RV₁ interval. The patients in the high ratio group had significantly higher CK-MB peak and Killip class, lower ejection fraction (EF%), higher ratio of the left anterior (LAD) descending artery as infarct-related artery (IRA), and longer total ischemia time (TIT) than those in the low ratio group. The QRS duration was wider in the high ratio group than that in the low ratio group, whereas RV₆-V₁ was narrower in the high ratio group compared with that in the low ratio group. The in-hospital MACE rate (93.3% vs. 31.0%, p < 0.001) and 1-year mortality rate (86.7% vs. 13.2%, p < 0.001) in the high ratio group were higher than those in the low ratio group. The higher ratio of QRS/RV₆-V₁ was an independent predictor of in-hospital MACE (odds ratio, 8.55; 95% CI, 1.40-52.37; p = 0.02) after adjusting other confounders. Cox regression showed that the higher ratio of QRS/RV₆-V₁ predicted higher 1-year mortality of the patients with AMI combined with new-onset RBBB [hazard ratios (HR), 12.4; 95% CI, 7.26-21.22); p < 0.001] than the lower ratio of QRS/RV₆-V₁, and the HR still stayed at 2.21 even after a multivariable adjustment (HR, 2.21; 95% CI, 1.05-4.64); p = 0.037).

Conclusion

According to the results of our study, the high ratio of QRS/RV₆-V₁ (>3.0) was a valuable predictor of short- and long-term adverse clinical outcomes in AMI patients combined with new-onset RBBB. The implications of the high ratio of QRS/RV₆-V₁ were severe ischemia and pseudo synchronization between bi-ventricle.

Declining trends of premature mortality from ischemic heart disease and regional differences in Italy from 2011 to 2017

AIMS

Data regarding the premature mortality (<65 years of age) due to ischemic heart disease (IHD) in Italy are scant. We sought to analyze the incidence of premature death due to IHD in Italy and its time trend between years 2011 and 2017.

METHODS AND RESULTS

We used the free publicly available EUROSTAT death certificate database to examine premature age-adjusted IHD mortality rates (per 100.000) and relative average annual percentage change (AAPC) in Italy from 2011 to 2017 using ICD-codes I20-I25. Over the study period, the proportional IHD-related mortality rates decline from 8.09% to 7.1% in the entire population (p for trend 0.012), showing a significant reduction in women (from 4.06% to 3.40%, p for trend: 0.02) but not in men (from 10.3% to 9.3%, p for trend 0.062). The age-adjusted IHD mortality rate decreased with an AAPC of -4.1 per year [(95% CI, -5.1 to -3.0), p < 0.001], resulting more pronounced in women [AAPC: -4.4 per year (95% CI: -6.4 to -2.3,), p = 0.001)] than in men [AAPC: -3.7 per year (95% CI: -5.4 to -2.0, p = 0.003)]. Age-adjusted IHD premature death rates above the 90th percentile were distributed in Italian southern regions and islands of Italy while premature death rates below the 10th percentile were clustered in the western and northeastern regions of the country.

CONCLUSIONS

In Italy, premature IHD-related mortality remains an important contributor to overall mortality. Age-adjusted mortality declined in the last decade, especially in the northern regions and among women. Moreover, a marked region-level variations were observed.

Temporal trends in major cardiovascular events following first-time myocardial infarction in the reperfusion era - a Danish nationwide cohort study from 2000 to 2017

AIM

We investigated temporal trends in major cardiovascular events following first-time myocardial infarction (MI) and trends in revascularization and pharmacotherapy from 2000 to 2017.

METHODS AND RESULTS

Using nationwide registries, we identified 120 833 Danish patients with a first-time MI between 2000 and 2017. We investigated 30-day and 1-year mortality and the 1-year risk of first-time admission for heart failure (HF) and recurrent MI. Patients were younger with a higher prevalence of hypertension and diabetes in 2015-2017 compared with 2000-2002. The patients were predominantly male (65.6%), and the median age declined by 3 years through the periods. Percutaneous coronary interventions within 7 days after first-time MI increased significantly (2000: 11.4% vs. 2017: 68.6%; Ptrend < 0.001). Cardiovascular medication after first-time MI changed significantly in the same period. Absolute risks and adjusted rates of outcomes were significantly lower in 2015-2017 compared with 2000-2002: 30-day mortality: 6.5% vs. 14.1% [hazard ratio (HR) 0.52, 95% confidence interval (CI): 0.48-0.55); 1-year mortality 10.7% vs. 21.8% (HR 0.52, 95% CI: 0.50-0.55); recurrent MI: 4.0% vs. 7.8% (HR 0.56, 95% CI: 0.51-0.62); and first-time admission for HF: 2.9% vs. 3.7% (HR 0.82, 95% CI: 0.73-0.92). The rates of 30-day/1-year mortality and recurrent MI showed significantly decreasing trends (Ptrend < 0.001). The rates of first-time admission for HF were borderline significant (Ptrend = 0.045).

CONCLUSION

From 2000 to 2017, we observed a decreasing risk of recurrent MI, first-time admission for HF, and all-cause mortality in patients with a first-time MI. In the same period, we observed a high rate of guideline-recommended pharmacological treatment after first-time MI as well as increasing rate of early revascularization in Denmark.

TRANSLATIONAL PERSPECTIVES

The results from the current study portrait the risk of all-cause mortality, recurrent MI, and first-time admission for HF in a real-life setting with a very high utilization of early revascularization and guideline-recommended pharmacological therapy. We observed a temporal trend of improved survival, reduced risk of recurrent MI, as well as reduced risk of first-time admission for HF after first-time MI from 2000 through 2017. We observed an increase in the overall use of revascularization, as well as early revascularization and use of guideline-recommended pharmacotherapy. Our study reveals important results from real-life, nationwide data, showing a reduced risk of cardiovascular outcomes after first-time MI during the past 20 years. Current guidelines are based on results from clinical trials. Our real-life results add additionally important knowledge on patients' prognosis after first-time MI and underline the importance of treating MI according to guideline recommendations.

Association of APOE (rs429358 and rs7412) and PON1 (Q192R and L55M) Variants with Myocardial Infarction in the Pashtun Ethnic Population of Khyber Pakhtunkhwa, Pakistan

Coronary Artery Diseases (CAD) remains the top among Non-communicable Diseases (NCDs). Variations in Apolipoprotein E (APOE) and Paroxonase 1 (PON1) have been associated with Myocardial Infarction (MI) in several populations. However, despite the high prevalence of CAD, no such study has been reported in the Pashtun ethnic population of Pakistan. We have conducted a two-stage (i.e., screening and validation) case-control study in which 200 cases and 100 control subjects have been recruited. In the first stage, Whole Exome Sequencing (WES) was used to screen forpathogenic variants of Myocardial Infarction (MI). In the second stage, selected variants of both APOE and PON1 genes (rs7412, rs429358, rs854560, and rs662) were analyzed through MassARRAY genotyping. Risk Allele Frequencies (RAFs) distribution and association of the selected SNPs with MI were determined using the Chi-square test and logistic regression analysis. WES identified a total of 12 sequence variants in APOE and 16 in PON1. Genotyping results revealed that APOE variant rs429358 (ɛ4 allele and ɛ3/ɛ4 genotype) showed significant association in MI patients (OR = 2.11, p value = 0.03; 95% CI = 1.25–2.43); whereas no significant difference (p˃ 0.05) was observed for rs7412. Similarly, the R allele of PON1 Q192R (rs662) was significantly associated with cases (OR = 1.353, p value = 0.048; 95% CI = 0.959–1.91), with particular mention of RR genotype (OR = 1.523, p value = 0.006; 95% CI = 1.087–2.132). Multiple logistic regression analysis showed that rs429358 (C allele) and rs662 (R allele) have a significantly higher risk of MI after adjustment for the conventional risk factors. Our study findings suggested that the rs429358 variant of APOE and PON1 Q192R are associated with MI susceptibility in the Pashtun ethnic population of Pakistan.

Racial disparities in ventricular tachycardia in young adults: analysis of national trends

BACKGROUND

In the last two decades, risk factors, prevalence, and mortality due to coronary artery disease in young adults are on the rise. We sought to assess the prevalence, trends, and economic burden of ventricular tachycardia (VT) hospitalizations in young adults (< 45 years), further stratified by race and gender.

METHODS

The Nationwide Inpatient Sample was explored for hospitalizations with VT in patients (< 45 years) between 2005 and 2018 and divided among 3 groups of the quadrennial period using validated International Classification of Diseases (ICD) 9^th and 10^th revision Clinical Modification (CM) codes. The Pearson chi-square test and Wilcoxon rank-sum were used for categorical and continuous variables, respectively. We assessed the temporal trends of mortality in VT hospitalizations and trends of VT hospitalization stratified by age, sex, and race by using Joinpoint regression analysis. The primary outcome was in-hospital mortality trends. Secondary outcomes were trends of hospital stay in days, cost of care in US dollars, cardiac arrest, and discharge disposition.

RESULTS

Out of 5,156,326 patients admitted with VT between 2005 and 2018, 309,636 were young adults. Among them, 102,433 were admitted between 2005 and 2009 (mean age 36.1 ± 6.99; 61% male, 58.5% White), 109,591 between 2010 and 2014 (mean age 35.5 ± 7.16; 59% male, 54.2% White), and 97,495 between 2015 and 2018 (mean age 35.4 ± 7.00; 60% male, 52.3% White) (p < 0.07). In the young adults with VT, all-cause mortality was 7.37% from 2005 to 2009, 7.85% from 2010 to 2014 (6.5% relative increase from 2005 to 2009), and 8.98% from 2015 to 2018 (relative increase of 14.4% from 2010 to 2014) (p < 0.0001). Similarly, risk of cardiac arrest was on the rise (6.15% from 2005 to 2009 to 7.77% in 2010-2014 and 9.97% in 2015-2018). Inflation-adjusted cost increased over the years [$12,177 in 2005-2009; $13,249 in 2010-2014; $15,807 in 2015-2018; p < 0.0001)].

CONCLUSIONS

VT hospitalizations and related all-cause mortality, and healthcare utilization costs in young adults are on the rise in the study period. Hospitalization burden related to VT and poor outcomes were more notable for Black adults. Further studies are required for targeted screening and preventative measures in young adults.

The Role of microRNA in the Development, Diagnosis, and Treatment of Cardiovascular Disease: Recent Developments

Since their discovery in 1993, microRNAs (miRNAs) have emerged as important regulators of many crucial cellular processes, and their dysregulation have been shown to contribute to multiple pathologic conditions, including cardiovascular disease (CVD). miRNAs have been found to regulate the expression of various genes involved in cardiac development and function and in the development and progression of CVD. Many miRNAs are master regulators fine-tuning the expression of multiple, often interrelated, genes involved in inflammation, apoptosis, fibrosis, senescence, and other processes crucial for the development of different forms of CVD. This article presents a review of recent developments in our understanding of the role of miRNAs in the development of CVD and surveys their potential applicability as therapeutic targets and biomarkers to facilitate CVD diagnosis, prognosis, and treatment. There are currently multiple potential miRNA-based therapeutic agents in different stages of development, which can be grouped into two classes: miRNA mimics (replicating the sequence and activity of their corresponding miRNAs) and antagomiRs (antisense inhibitors of specific miRNAs). However, in spite of promising preliminary data and our ever-increasing knowledge about the mechanisms of action of specific miRNAs, miRNA-based therapeutics and biomarkers have yet to be approved for clinical applications. SIGNIFICANCE STATEMENT: Over the last few years microRNAs have emerged as crucial, specific regulators of the cardiovascular system and in the development of cardiovascular disease, by posttranscriptional regulation of their target genes. The minireview presents the most recent developments in this area of research, including the progress in diagnostic and therapeutic applications of microRNAs. microRNAs seem very promising candidates for biomarkers and therapeutic agents, although some challenges, such as efficient delivery and unwanted effects, need to be resolved.

Dynamic Involvement of Telocytes in Modulating Multiple Signaling Pathways in Cardiac Cytoarchitecture

Cardiac interstitium is a complex and dynamic environment, vital for normal cardiac structure and function. Telocytes are active cellular players in regulating main events that feature myocardial homeostasis and orchestrating its involvement in heart pathology. Despite the great amount of data suggesting (microscopically, proteomically, genetically, etc.) the implications of telocytes in the different physiological and reparatory/regenerative processes of the heart, understanding their involvement in realizing the heart's mature cytoarchitecture is still at its dawn. Our scrutiny of the recent literature gave clearer insights into the implications of telocytes in the WNT signaling pathway, but also TGFB and PI3K/AKT pathways that, inter alia, conduct cardiomyocytes differentiation, maturation and final integration into heart adult architecture. These data also strengthen evidence for telocytes as promising candidates for cellular therapies in various heart pathologies.

Nanocarrier-Based Targeted Therapies for Myocardial Infarction

Myocardial infarction is a major cause of morbidity and mortality worldwide. Due to poor inherent regeneration of the adult mammalian myocardium and challenges with effective drug delivery, there has been little progress in regenerative therapies. Nanocarriers, including liposomes, nanoparticles, and exosomes, offer many potential advantages for the therapy of myocardial infarction, including improved delivery, retention, and prolonged activity of therapeutics. However, there are many challenges that have prevented the widespread clinical use of these technologies. This review aims to summarize significant principles and developments in the field, with a focus on nanocarriers using ligand-based or cell mimicry-based targeting. Lastly, a discussion of limitations and potential future direction is provided.