The predictive value of systemic immune-inflammation index for long-term cardiovascular mortality in non-ST segment elevation myocardial infarction

BACKGROUND

Increased levels of inflammatory markers have been found in association with the severity of coronary atherosclerosis. Systemic immuneinflammation index (SII), which is calculated by multiplying neutrophil and platelet counts and then dividing the result by the lymphocyte count, can also be used as a prognostic indicator in different cardiovascular diseases. In this study, we investigated SII levels and long-term mortality of patients with non-ST segment elevation myocardial infarction (NSTEMI).

METHODS

This is an observational, single-center study. Two hundred-eight patients who underwent coronary angiography for NSTEMI were included in the study. Patients were divided into 3 tertiles based on SII levels. We researched the relationship between level level and 1, 3 and 5 years mortality (NSTEMI).

RESULTS

One-year mortality of the patients was significantly higher among patients in the upper SII tertile when compared with the lower and middle SII tertile groups [11 (15.9%) vs. 2 (2.9%) and 6 (8.7%); P  = 0.008, P  = 0.195, respectively). Three-year mortality of the patients was significantly higher among patients in the upper SII tertile when compared with the lower and middle SII tertile groups [21 (30.4%) vs. 5 (7.1%) and 12 (17.4%); P  < 0.001, P  = 0.072, respectively). Five-year mortality of the patients was significantly higher among patients in the upper SII tertile when compared with the lower and middle SII tertile groups [26 (37.7%) vs. 8 (11.4%) and 15 (21.7%); P  < 0.001, P  = 0.040, respectively).

CONCLUSION

Our study showed that NSTEMI patients with higher SII had worse long-term mortality.

Impact of Preloading Strategy With Ticagrelor on Periprocedural Myocardial Injury in Patients With Non-ST Elevation Myocardial Infarction Undergoing Early Invasive Strategy

ABSTRACT

Pretreatment with an oral P2Y12 receptor blocker (before coronary angiography) versus treatment in the catheterization laboratory has been a matter of debate in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI). The primary aim of this study was to assess the impact of an immediate preloading strategy with ticagrelor on periprocedural myocardial injury in patients with NSTEMI treated with an early invasive strategy. NSTEMI patients who underwent coronary angiography and subsequent percutaneous coronary intervention (PCI) within 24 hours after hospital admission were divided into 2 groups: the first group (pretreatment group) included patients who received ticagrelor pretreatment as soon as possible after admission and the second group (no pretreatment group) included patients who received a loading dose of ticagrelor after coronary angiography. The pretreatment group included 232 patients, and the no pretreatment group included 87 patients. Male patients represented the majority of the patients. The 2 groups were similar in baseline characteristics, except for a greater incidence of hypertension ( P = 0.014) and higher hemoglobin levels ( P = 0.01) in the pretreatment group in comparison with the no pretreatment group. Patients in the ticagrelor pretreatment group had less myocardial injury until coronary angiography based on troponin measurements collected at 12 hours after admission ( P = 0.025). Patients in the ticagrelor pretreatment group also had fewer periprocedural myocardial injuries based on troponin measurements taken between 12 and 24 hours after the PCI ( P = 0.026 and P = 0.022, respectively). Our findings suggested that ticagrelor pretreatment reduces periprocedural myocardial injury in NSTEMI patients who underwent PCI within 24 hours after admission.

Influence of sex on the timing of coronary angiography and the prescription of antiplatelet therapy in patients with nonST-segment elevation myocardial infarction

OBJECTIVES

To assess differences in the clinical management of nonST-segment elevation myocardial infarction (NSTEMI), including in-hospital events, according to biological sex.

MATERIAL AND METHODS

Prospective observational multicenter study of patients diagnosed with NSTEMI and atherosclerosis who underwent coronary angiography.

RESULTS

We enrolled 1020 patients in April and May 2022; 240 (23.5%) were women. Women were older than men on average (72.6 vs 66.5 years, P .001), and more women were frail (17.1% vs 5.6%, P .001). No difference was observed in pretreatment with any P2Y12 inhibitor (prescribed in 68.8% of women vs 70.2% of men, P = .67); however, more women than men were prescribed clopidogrel (56% vs 44%, P = .009). Women prescribed clopidogrel were more often under the age of 75 years and not frail. Coronary angiography was performed within 24 hours less corooften in women (29.8% vs 36.9%, P = .03) even when high risk was recognized. Frailty was independently associated with deferring coronary angiography in the adjusted analysis; biological sex by itself was not related. The frequency and type of revascularization were the same in both sexes, and there were no differences in in-hospital cardiovascular events.

CONCLUSION

Women were more often prescribed less potent antithrombotic therapy than men. Frailty, but not sex, correlated independently with deferral of coronary angiography. However, we detected no differences in the frequency of coronary revascularization or in-hospital events according to sex.

Can prolonged P-R interval predict clinical outcomes in non-ST elevation acute coronary syndrome patients?

BACKGROUND

The present study aimed to respond to clinical question, can prolonged P-R interval predict clinical outcomes in non-ST elevation acute coronary syndrome patients?

METHODS

This descriptive-analytical study was conducted on cardiac patients. All of the non-ST elevation acute coronary syndrome (NSTEACS) including non-ST elevation myocardial infarction (NSTEMI) and unstable angina patients included in the study. Then they divided into two groups: prolonged P-R interval and normal P-R interval. The patients who had a history of digoxin and calcium channel blocker use, using antiarrhythmic drugs, known valvular or congenital heart disease and connective tissue, unreadable P-R interval and cardiac block were excluded. Data were collected using the questionnaire consisted demographic data and clinical outcomes and a follow-up part was completed by one of the researchers.

RESULTS

Finally, 248 patients completed the study. The results showed both of the two groups had significant differences in terms of the history of myocardial infarction (MI) (p = 0.018), the level of high-density lipoprotein (HDL) (p = 0.004), heart rate (p = 0.042), inverted T wave (p = 0.017), anterior ST- segment depression (p = 0.008), normal report of coronary angiography (CAG) (p = 0.003), three vessels disease (p = 0.043), left main lesion (p = 0.045) and SYNTAX score (p = 0.032) based on the CAG report. The results of six-month follow-up showed although, the frequency of ischemic stroke, coronary artery disease (CAD) and cardiovascular death were higher in prolonged P-R interval groups. The chi-square test showed this difference was statistically non-significant (p > 0.05). The multivariate logistic regression model revealed non-significant relationships between prolonged P-R interval and SYNTAX score, significant CAD, three-vessel disease, inverted T wave, anterior ST depression, heart rate and HDL.

CONCLUSIONS

Based on the results of our study the six-month follow-up showed non-significant outcomes. Further studies are recommended to assess the long-term outcomes.

Organized thrombus is a frequent underlying feature in culprit lesion morphology in non-ST-elevation myocardial infarction. A study using optical coherence tomography and magnetic resonance imaging

The concept that the culprit lesion in non-ST segment elevation myocardial infarction (NSTEMI) is caused by sudden plaque rupture with acute thrombus formation has recently been challenged. While angiography is an old gold-standard for culprit identification it merely visualizes the lumen contour. Optical coherence tomography (OCT) provides a detailed view of culprit features. Combined with myocardial edema on cardiac magnetic resonance (CMR), indicating acute ischemia and thus culprit location, we aimed to characterize culprit lesions using OCT. Patients with NSTEMI referred for angiography were prospectively enrolled. OCT was performed on angiographic stenoses ≥50% and on operator-suspected culprit lesions. Hierarchical OCT-culprit identifiers were defined in case of multiple unstable lesions, including OCT-defined thrombus age. An OCT-based definition of an organizing thrombus as corresponding to histological early healing stage was introduced. Lesions were classified as OCT-culprit or non-culprit, and characteristics compared. CMR was performed in a subset of patients. We included 65 patients with 97 lesions, of which 49 patients (75%) had 53 (54%) OCT-culprit lesions. The most common OCT-culprit identifiers were the presence of acute (66%) and organizing thrombus (19%). Plaque rupture was visible in 45% of OCT-culprit lesions. CMR performed in 38 patients revealed myocardial oedema in the corresponding territories of 67% of acute thrombi and 50% of organizing thrombi. A culprit lesion was identified by OCT in 75% patients with NSTEMI. Acute thrombus was the most frequent feature followed by organizing thrombus. Applying specific OCT-criteria to identify the culprit could prove valuable in ambiguous cases.

Updated CRUSADE score to predict in-hospital bleeding: External validation in the Thai percutaneous coronary intervention registry

BACKGROUND

The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) score has been recommended to predict in-hospital bleeding risk in non-ST segment elevation myocardial infarction (NSTEMI) patients. The evaluation of the CRUSADE risk score in Asian patients undergoing contemporary percutaneous coronary intervention (PCI) for NSTEMI is necessary.

AIMS

We aimed to validate and update the CRUSADE score to predict in-hospital major bleeding in NSTEMI patients treated with PCI.

METHOD

The Thai PCI registry is a large, prospective, multicenter PCI registry in Thailand enrolling patients between May 2018 and August 2019. The CRUSADE score was calculated based on 8 predictors including sex, diabetes, prior vascular disease (PVD), congestive heart failure (CHF), creatinine clearance (CrCl), hematocrit, systolic blood pressure, and heart rate (HR). The score was fitted to in-hospital major bleeding using the logistic regression. The original score was revised and updated for simplification.

RESULTS

Of 19,701 patients in the Thai PCI registry, 5976 patients presented with NSTEMI. The CRUSADE score was calculated in 5882 patients who had all variables of the score available. Thirty-five percent were female, with a median age of 65.1 years. The proportion of diabetes, PVD, and CHF was 46%, 7.9%, and 11.2%, respectively. The original and revised models of the CRUSADE risk score had C-statistics of 0.817 (95% CI: 0.762-0.871) and 0.839 (95% CI: 0.789-0.889) respectively. The simplified CRUSADE score which contained only four variables (hematocrit, CrCl, HR, and CHF), had C-statistics of 0.837 (0.787-0.886). The calibration of the recalibrated, revised, and simplified model was optimal.

CONCLUSIONS

The full and simplified CRUSADE scores performed well in NSTEMI treated with PCI in Thai population.

Characteristics and In-Hospital Outcomes of Patients Who Underwent Coronary Artery Bypass Grafting during Hospitalization for ST-Segment Elevation or Non-ST-Segment Elevation Myocardial Infarction

PURPOSE

Little is known about the outcomes of patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary artery bypass grafting (CABG) in the current percutaneous coronary intervention (PCI) era.

METHODS

We analyzed 25120 acute myocardial infarction (AMI) patients hospitalized between January 2011 and December 2016. In-hospital outcomes were compared between patients who underwent CABG during hospitalization and those who did not undergo CABG in the STEMI group (n = 19428) and NSTEMI group (n = 5692).

RESULTS

Overall, CABG was performed in 2.3% of patients, while 90.0% of registered patients underwent primary PCI. In both the STEMI and NSTEMI groups, patients who underwent CABG were more likely to have heart failure, cardiogenic shock, diabetes, left main trunk lesion, and multivessel disease than those who did not undergo CABG. In multivariable analysis, CABG was associated with lower all-cause mortality in both the STEMI group (adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] 0.26-0.72) and NSTEMI group (adjusted OR = 0.34, 95% CI 0.14-0.84).

CONCLUSION

AMI patients undergoing CABG were more likely to have high-risk characteristics than those who did not undergo CABG. However, after adjusting for baseline differences, CABG was associated with lower in-hospital mortality in both the STEMI and NSTEMI groups.

A patient with acute myocardial infarction with electrocardiogram Aslanger's pattern

BACKGROUND

Aslanger's pattern in electrocardiogram (ECG) indicates that patients may have acute inferior myocardial infarction(AMI) with concomitant critical stenoses on other coronary arteries, which needs to be evaluated the timing of revascularization as risk equivalents of ST elevation myocardial infarction(STEMI).

CASE PRESENTATION

The patient was a 62-year-old male with chief complaint of intermittent exertional subxiphoid pain for 20 days from 30th June. One day after the last episode (19th July), the 18-lead electrocardiogram showed ST segment elevation of 0.05-0.1mV in lead III, ST segment depression in leads I, avL, and V2-V6, T wave inversion with positive terminal vector in lead V4-V5, and positive T wave in lead V6, which indicated Aslanger's pattern. With increased Troponin I (0.162ng/mL, 0-0.02), The patient was diagnosed as acute non-ST-segment elevation myocardial infarction (NSTEMI) and admitted to coronary ward on 20th July. The coronary angiography showed 95% stenosis in the distal left main coronary artery (LM) to the ostium of the left anterior descending artery (LAD), 90% stenosis in the proximal segment of the LAD, and 80% stenosis in the middle segment of the LAD, and TIMI blood flow was graded score 2. Three drug-eluting stents were implanted at the lesions. The patient's ECG returned close to normal one month after revascularization.

CONCLUSION

We presented an acute coronary syndrome case whose ECG showed with Aslanger's pattern (i.e., isolated ST-segment elevation in lead III, associated ST-segment depression in lead V4-V6 with positive T wave/terminal vector, and greater ST-segment elevation in lead V1 than in lead V2), and was confirmed severe stenosis of the LM and the proximal segment of the LAD via coronary angiography. In clinical practice, especially in the emergency, patients with ECG presenting Aslanger's pattern should be urgently evaluated with prompt treatment, and the timing of emergency coronary angiography and revascularization should be evaluated to avoid adverse outcomes caused by delayed treatment.

Elevated uric acid/albumin ratio as a predictor of poor coronary collateral circulation development in patients with non-ST segment elevation myocardial infarction

BACKGROUND

Uric acid/albumin ratio (UAR) is a novel composite biomarker with superior predictive value for cardiovascular disease.

OBJECTIVE

To investigate the relationship between UAR and coronary collateral circulation (CCC) in patients with non-ST segment elevation myocardial infarction (NSTEMI).

METHODS

A total of 205 NSTEMI patients who underwent coronary arteriography with at least one major coronary stenosis, 95% were included. Patients were divided into two groups according to CCC development: poorly-developed CCC group (Rentrop 0-1) and well-developed CCC (Rentrop 2-3). Univariate analysis and logistic regression analysis were utilized to investigate the factors influencing adverse CCC formation in NSTEMI patients. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of UAR, C-reactive protein (CRP), uric acid, and albumin for patients with poorly developed CCC, and the area under the curve (AUC) was compared.

RESULTS

The UAR values of NSTEMI patients were significantly higher in the poorly developed CCC group than those in the well-developed CCC group (10.19 [8.80-11.74] vs. 7.79 [6.28-9.55], p < .001). In the multiple logistic regression tests, UAR (odds ratio [OR]: 1.365, 95% confidence interval [CI]: 1.195-1.560, p < .001), CRP (OR: 1.149, 95% CI: 1.072-1.231, p < .001), and diabetes (OR: 2.924, 95% CI: 1.444-5.920, p = .003) were independent predictors of poorly developed CCC. The ROC curve analysis showed that the optimal cut-off value of UAR was 8.78 in predicting poorly developed CCC with a sensitivity of 76.8% and specificity of 62.4%, with the AUC of 0.737 (95% Cl: 0.668-0.805, p < .001).

CONCLUSION

Elevated UAR may be an independent and effective biomarker for predicting poorly-developed CCC development in NSTEMI patients.

Increased triglyceride-glucose index predicts contrast-induced nephropathy in non-diabetic NSTEMI patients: A prospective study

The triglyceride-glucose (TyG) index is a new reliable marker of insulin resistance (IR) and has recently been reported to be associated with renal dysfunction and contrast-induced nephropathy (CIN). Our aim in this study is to investigate the relationship between the TyG index and CIN in non-diabetic non-ST elevation acute myocardial infarction (NSTEMI) patients. The study included 272 non-diabetic patients who applied with NSTEMI and underwent coronary angiography (CAG). Patient data were divided into quartiles according to the TyG index: Q1: TyG < 8.55; Q2: 8.55 ≤ TyG ≤ 8.87; Q3: 8.88 ≤ TyG ≤ 9.29; and Q4: TyG > 9.29. Baseline characteristics, laboratory measurements, angiography data, and the incidence of CIN were compared between the groups. CIN was observed in 18 (6.6%) patients in the study. The incidence of CIN was lowest in the Q1 group and highest in the Q4 group (1 (1.5%) in Q1; 3 (4.4%) in Q2; 5 (7.4%) in Q3; 9 (13.2%) in Q4; p = 0.040). TyG index was found to be an independent risk factor for the development of CIN in multivariate logistic regression analysis (odds ratio = 6.58; confidence interval (CI) = 2.12-20.40; p = 0.001). TyG index value of 9.17 was identified as an effective cut-off point for the prediction of CIN (Area under the curve: 0.712, CI: 0.590-0.834, p = 0.003), and it had a sensitivity of 61% and a specificity of 72%. The results of this study showed that a high TyG index increases the incidence of CIN after CAG in non-diabetic NSTEMI patients and is an independent risk factor for the development of CIN.

The association between cardiovascular risk profile and ocular microvascular changes in patients with non-ST elevation myocardial infarction

PURPOSE

We aimed to evaluate the association between ocular microvasculature (vascular density) on optical coherence tomography-angiography (OCT-A) and the cardiovascular risk profile of patients hospitalized for non-ST-elevation myocardial infarction (NSTEMI) patients.

METHODS

Patients admitted to the intensive care unit with the diagnosis of NSTEMI and undergoing coronary angiography were divided into 3 groups as low, intermediate, and high risk according to the SYNTAX score. OCT-A imaging was performed in all three groups. Right-left selective coronary angiography images of all patients were analyzed. The SYNTAX and TIMI risk scores of all patients were calculated.

RESULTS

This study included opthalmological examination of 114 NSTEMI patients. NSTEMI patients with high SYNTAX risk scores had significantly lower deep parafoveal vessel density (DPD) than patients with low-intermediate SYNTAX risk scores (p < 0.001). ROC curve analysis found that a DPD threshold below 51.65 % was moderately associated with high SYNTAX risk scores in patients with NSTEMI. In addition, NSTEMI patients with high TIMI risk scores had significantly lower DPD than patients with low-intermediate TIMI risk scores (p < 0.001).

CONCLUSIONS

OCT-A may be a non-invasive useful tool to assess the cardiovascular risk profile of NSTEMI patients with a high SYNTAX and TIMI score.

Complete surgical revascularization after NSTEMI and unstable angina in patients with multivessel coronary artery disease: Institutional experience

INTRODUCTION

The feasibility and standardization of coronary artery bypass grafting (CABG) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unstable angina (UA) remain topics of ongoing debate. In this study, feasibility and early-term outcomes of CABG in patients with NSTE-ACS and UA were discussed.

METHODS

This study enrolled 79 patients who underwent on-pump CABG with complete revascularization between January 2020 and May 2022. the survival rates analyzed using Kaplan Meier test with log rank test. The p value of statistical significance was taken as below 0.05.

RESULTS

Preoperatively, the patients had a mean age of 60.9 years and a BMI of 28.0. The medical history included hypertension (50.6%), peripheral arterial disease and atrial fibrillation (12.7%), and other comorbidities such as COPD (22.8%) and type 2 diabetes mellitus (44.3%). Intraoperatively, the mean distal anastomosis count was 3.4, with average cardiopulmonary bypass and aortic cross-clamp times of 84.0 and 49.0 min, respectively. Early-term outcomes revealed low rates of mortality (2.5%) and complications such as myocardial infarction (1.3%), acute kidney injury (5.1%) and transient ischemic attack (5.1%). Post-discharge outcomes demonstrated low cardiac and all-cause mortality rates (2.5% and 3.8%, respectively) and a high overall survival rate (93.7%) at 12-month follow-up.

CONCLUSION

This study demonstrated the feasibility and positive outcomes of complete surgical revascularization in patients with UA and NSTE-ACS. It showed no graft occlusion or stroke, low complication rates and promising survival outcomes. Further research is needed for confirmation and to establish the procedure's efficacy and safety in this patient population.

Association between Kelch-like ECH-associated protein-1 and GRACE risk score in non-ST elevation myocardial infarction

OBJECTIVE

In this study, we measured the levels of Kelch-like ECH-associated protein 1 (KEAP1), which has the potential antioxidant capacity, among non-ST elevation myocardial infarction (NSTEMI) patients compared with healthy controls. We also investigated the possible association between KEAP1 levels and the GRACE score, which is a universal risk score commonly used for patients with acute myocardial infarction.

PATIENTS AND METHODS

As the patient group, 78 patients admitted to our center with a diagnosis of NSTEMI were included in the study. As the control group, 77 individuals found to have normal coronary arteries after coronary arteriography were included (155 patients in total). GRACE risk scores and left ventricular ejection fractions (LVEFs) were calculated, KEAP1 levels were measured, and the usual blood tests were performed.

RESULTS

KEAP1 levels were significantly higher among the NSTEMI patients compared to the healthy control group (671.1 ± 120.7 vs. 262.7 ± 105.7, p < 0.001). We also found a moderate positive correlation between KEAP1 levels and GRACE risk scores among patients with NSTEMI (r = +0.521, p < 0.001). Additionally, a negative correlation between KEAP1 levels and LVEFs was detected (r = -0.264, p < 0.001).

CONCLUSIONS

Elevated KEAP1 levels have the potential to be used as a risk factor for NSTEMI in terms of clinical adverse events and poor prognosis at admission.

Clinical implication of totally occluded infarct-related coronary artery in non-ST-segment elevation myocardial infarction: the TOTAL-NSTEMI study

BACKGROUND

A subset ofpatients found to have total occlusion of the culprit artery (TOCA), present with non-ST-segment elevation myocardial infarction (NSTEMI) and elevated biomarkers. The aim of this study is to assess the effect of the TOCA in patients presenting with NSTEMI.

METHODS

This multicenter observational study was retrospectively conducted between 2015 and 2019. Thrombolysis in myocardial infarction (TIMI) flow grades 0-1 was defined as the TOCA. The primary end point included a combination of all-cause death, myocardial infarction, target vessel revascularization, stent thrombosis, and stroke.

RESULTS

Of 3272 patients, TIMI 0-1 flow in the culprit artery was present in 488 (14.9%) patients. TOCA was more likely to be of thrombotic origin (54.1% vs. 10.3%; P < 0.001) and visible collaterals (22.5% vs. 4.4%; P < 0.001). The rates of 30-day (14.3% vs. 7.2%; P < 0.001) and 2-year (25% vs. 19.1%; P = 0.003) primary end points were significantly higher in TOCA patients. Fatal arrhythmias were remarkably higher at 30-day (8.6% vs. 4%; P < 0.001) and 2-year (9% vs. 5.2%; P = 0.001) follow-ups. Mechanical complications were also higher in patients with TOCA at 30 days (0.8% vs. 0.2%; P = 0.013). Moreover, TOCA (OR, 1.379; P = 0.001) was one of the independent predictors of MACCE in NSTEMI patients.

CONCLUSION

The current data suggest that patients with TOCA in the context of NSTEMI are at higher risk of MACCE, fatal arrhythmias, and mechanical complications.

Automated tissue Doppler imaging for identification of occluded coronary artery in patients with suspected non-ST-elevation myocardial infarction

PURPOSE

Identification of regional dysfunction is important for early risk stratification in patients with suspected non-ST-elevation myocardial infarction (NSTEMI). Strain echocardiography enables quantification of segmental myocardial deformation. However, the clinical use is hampered by time-consuming manual measurements. We aimed to evaluate whether an in-house developed software for automated analysis of segmental myocardial deformation based on tissue Doppler imaging (TDI) could predict coronary occlusion in patients with suspected NSTEMI.

METHODS

Eighty-four patients with suspected NSTEMI were included in the analysis. Echocardiography was performed at admission. Strain, strain rate and post-systolic shortening index (PSI) were analyzed by the automated TDI-based tool and the ability to predict coronary occlusion was assessed. For comparison, strain measurements were performed both by manual TDI-based analyses and by semi-automatic speckle tracking echocardiography (STE). All patients underwent coronary angiography.

RESULTS

Seventeen patients had an acute coronary occlusion. Global strain and PSI by STE were able to differentiate occluded from non-occluded culprit lesions (respectively - 15.0% vs. -17.1%, and 8.1% vs. 5.1%, both p-values < 0.05) and identify patients with an acute coronary occlusion (AUC 0.66 for both strain and PSI). Measurements of strain, strain rate and PSI based on TDI were not significantly different between occluded and non-occluded territories.

CONCLUSION

Automated measurements of myocardial deformation based on TDI were not able to identify acute coronary occlusion in patients with suspected NSTEMI. However, this study confirms the potential of strain by STE for early risk stratification in patients with chest pain.

Early Invasive Strategy Based on the Time of Symptom Onset of Non-ST-Segment Elevation Myocardial Infarction

BACKGROUND

A limitation of the current guidelines regarding the timing of invasive coronary angiography for patients with non-ST-segment elevation acute coronary syndrome is the randomization time. To date, no study has reported the clinical outcomes of invasive strategy timing on the basis of the time of symptom onset.

OBJECTIVES

The aim of this study was to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS

Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, 5,856 patients with NSTE myocardial infarction were evaluated. The patients were categorized according to symptom-to-catheter (StC) time (<48 or ≥48 hours). The primary outcome was 3-year all-cause mortality.

RESULTS

Overall, 3,919 patients (66.9%) were classified into the StC time <48 hours group. This group had lower all-cause mortality than the group with StC time ≥48 hours (7.3% vs 13.4%; P < 0.001). The lower risk for all-cause mortality in the group with StC time <48 hours group was consistent in all subgroups. Notably, emergency medical service use (HR: 0.31; 95% CI: 0.19-0.52) showed a lower risk for all-cause mortality than no emergency medical service use (HR: 0.54; 95% CI: 0.46-0.65; P value for interaction = 0.008).

CONCLUSIONS

An early invasive strategy on the basis of StC time was associated with a decreased risk for all-cause mortality in patients with NSTEMI. Because the study was based on a prospective registry, the results should be considered hypothesis generating, highlighting the need for further research. (iCReaT Study No. C110016).

Association of Diastolic Dysfunction with Angiographic Severity of Coronary Artery Disease in patients with Non-ST Elevation Myocardial Infarction

In recent years, diastolic dysfunction is an evolving context. Presence of left ventricular diastolic dysfunction (LVDD) indicates a poor prognosis in patients with an ACS and chronic coronary artery diseases. This study evaluated the association of LVDD and angiographic severity of CAD in patients with non-ST elevation myocardial infarction (NSTEMI). This cross-sectional analytical study was carried out in National Institute of Cardiovascular Diseases, Dhaka, Bangladesh, during the period of April 2017 to March 2018. A total of 120 NSTEMI patients undergoing coronary angiogram (CAG) during index hospitalization were included in the study. All patients underwent transthoracic echocardiography before they underwent CAG on different days. Presence (Group I, n=65) and absence of LVDD (Group II, n=55) was established by echocardiography. Severity of CAD was assessed by Vessel score and Leaman score. Association of traditional risk factors (smoking habit, hypertension, diabetes mellitus, dyslipidemia and family history of CAD) with severity of CAD was investigated. Vessel score showed coronary artery obstruction (CAO) was present in 62(95.4%) patients in Group I and 35(63.6%) patients in Group II, single vessel was involved in 17(27.4%) patients while multi vessel in 45(72.6%) patients was found in Group I. On the contrary 27(77.1%) single vessel patients and 8(22.9%) multi vessel patients were found in Group II. Positive Leaman score was significantly higher in Group I, 62(95.4%) than that of Group II, 35(63.6%) which is statistically significant (p<0.001). This study showed a positive correlation between LVDD and CAD severity in terms of vessel score and Leamanscore. This study also demonstrates that the severity of vessel score and Leaman score was higher in the higher grade of diastolic dysfunction. The present study concludes that LVDD is associated with angiographically severe CAD in patients with NSTEMI.

Association of Race and Ethnicity on the Management of Acute Non-ST-Segment Elevation Myocardial Infarction

Background

Prior studies have reported disparities by race in the management of acute myocardial infarction (MI), with many studies having limited covariates or now dated. We examined racial and ethnic differences in the management of MI, specifically non–ST‐segment‐elevation MI (NSTEMI), in a large, socially diverse cohort of insured patients. We hypothesized that the racial and ethnic disparities in the receipt of coronary angiography or percutaneous coronary intervention would persist in contemporary data.

Methods and Results

We identified individuals presenting with incident, type I NSTEMI from 2017 to 2019 captured by a health claims database. Race and ethnicity were categorized by the database as Asian, Black, Hispanic, or White. Covariates included demographics (age, sex, race, and ethnicity); Elixhauser variables, including cardiovascular risk factors and other comorbid conditions; and social factors of estimated annual household income and educational attainment. We examined rates of coronary angiography and percutaneous coronary intervention by race and ethnicity and income categories and in multivariable‐adjusted models. We identified 87 094 individuals (age 73.8±11.6 years; 55.6% male; 2.6% Asian, 13.4% Black, 11.2% Hispanic, 72.7% White) with incident NSTEMI events from 2017 to 2019. Individuals of Black race were less likely to undergo coronary angiography (odds ratio [OR], 0.93; [95% CI, 0.89–0.98]) and percutaneous coronary intervention (OR, 0.86; [95% CI, 0.81–0.90]) than those of White race. Hispanic individuals were less likely (OR, 0.88; [95% CI, 0.84–0.93]) to undergo coronary angiography and percutaneous coronary intervention (OR, 0.85; [95% CI, 0.81–0.89]) than those of White race. Higher annual household income attenuated differences in the receipt of coronary angiography across all racial and ethnic groups.

Conclusions

We identified significant racial and ethnic differences in the management of individuals presenting with NSTEMI that were marginally attenuated by higher household income. Our findings suggest continued evidence of health inequities in contemporary NSTEMI treatment.

Intelligent Algorithm-Based Coronary Angiography Characteristics of Acute Non-ST-Segment Elevation Myocardial Infarction Patients with Different Genders

OBJECTIVE

This study was aimed at comparing the characteristics of coronary angiography based on intelligent algorithm in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) of different genders.

METHODS

Eighty patients were selected to segment the coronary angiogram using the convolutional neural network (CNN) algorithm, the input layer of the CNN was used to receive the image dataset, and three-dimensional data were input during semantic segmentation to achieve automatic segmentation of the target features. Segmentation results were quantitatively assessed by accuracy (Acc), sensitivity (Se), specificity (Sp), and Dice coefficient (Dice). The characteristics of coronary angiography were compared between the two groups.

RESULTS

The CNN algorithm had good segmentation effect, complete vessel extraction, and little noise, and Acc, Se, Sp, and Dice were 90.32%, 93.39%, 91.25%, and 89.75%, respectively. The proportion of diabetes mellitus was higher in female patients with NSTEMI (68.8%) than that in male patients (46.3%); the proportion of the left main coronary artery (LM) and left anterior descending artery (LAD) was lower in the female group (7.5%, 41.3%) than that in the male group (13.8%, 81.3%), and the difference between the two groups was statistically significant (P < 0.05).

CONCLUSION

The CNN algorithm achieves accurate extraction of vessels from coronary angiographic images, and women with diabetes and hyperlipidemia are more likely to have NSTEMI than men, especially the elderly.

Distribution Characteristics of ST-Segment Elevation Myocardial Infarction and Non-ST-Segment Elevation Myocardial Infarction Culprit Lesion in Acute Myocardial Infarction Patients Based on Coronary Angiography Diagnosis

This research was aimed at exploring the application value of coronary angiography (CAG) based on a convolutional neural network algorithm in analyzing the distribution characteristics of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) culprit lesions in acute myocardial infarction (AMI) patients. Methods. Patients with AMI treated in hospital from June 2019 to December 2020 were selected as subjects. According to the results of an echocardiogram, the patients were divided into the STEMI group (44 cases) and the NSTEMI group (36 cases). All patients received CAG. All images were denoised and edge detected by a convolutional neural network algorithm. Then, the number of diseased vessels, the location of diseased vessels, and the degree of stenosis of diseased vessels in the two groups were compared and analyzed. Results. The number of patients with complete occlusion (3 cases vs. 12 cases) and collateral circulation (5 cases vs. 20 cases) in the NSTEMI group was significantly higher than that in the STEMI group, and the difference was statistically significant, P < 0.05. There was a statistically significant difference in the number of lesions between the distal LAD (1 case vs. 10 cases) and the distal LCX (4 cases vs. 11 cases), P < 0.05. There was a statistically significant difference in the number of patients with one lesion branch (1 vs. 18) and three lesion branches (25 vs. 12) between the two groups, P < 0.05. The image quality after the convolution neural network algorithm is significantly improved, and the lesion is more prominent. Conclusion. The convolutional neural network algorithm has good performance in DSA image processing of AMI patients. STEMI and NSTEMI as the starting point of AMI disease analysis to determine the treatment plan have high clinical application value. This work provided reference and basis for the application of the convolutional neural network algorithm and CAG in the analysis of the distribution characteristics of STEMI and NSTEMI culprit lesions in AMI patients.

Feasibility of prehospital identification of non-ST-elevation myocardial infarction by ECG, troponin and echocardiography

Background

Prehospital identification and selection of treatment strategy in patients with suspected non-ST-elevation myocardial infarction (NSTEMI) is challenging. The aim of this study was to evaluate the feasibility and diagnostic accuracy of prehospital ECG, troponin T (TnT) and transthoracic echocardiography (TTE) acquired by paramedics in early identification of NSTEMI.

Methods

Consecutive patients requesting an ambulance from Sorlandet Hospital, Norway due to chest pain between November 2017 and January 2020 were screened for inclusion in the study. One ambulance was equipped with ECG recorder, point-of-care TnT test and TTE scanner, and six paramedics were given necessary training. ECG, TnT result and TTE images were acquired prehospitally and transferred to an in-hospital cardiologist. NSTEMI was suspected in patients with ischaemic ECG changes, elevated TnT or myocardial regional wall motion abnormalities (RWMA) at TTE.

Results

A total of 253 patients were included in the study. ECG was interpretable by cardiologists in 243 (96%), TnT in 238 (94%) and TTE images in 240 (95%) patients. NSTEMI was the discharge diagnosis in 22 (9%) of these patients. Four (18%) patients with NSTEMI had ischaemic ECG changes, elevated TnT and RWMA at TTE. Eight (36%) patients with NSTEMI had positive findings at two of the diagnostic methods, six (27%) patients had positive findings at one, and four (18%) patients had no positive findings in any of the diagnostic methods. In three patients (14%) with NSTEMI, RWMA was the only positive test. The negative and positive predictive values for RWMA were 42% and 96%, respectively.

Conclusions

Prehospital acquisition of ECG, TnT and interpretable TTE images by paramedics were feasible in most patients with chest pain. Based on these examinations, it was possible to identify the majority of cases with NSTEMI prehospitally and admit the patients directly to a hospital with facilities for percutaneous coronary intervention (PCI) for further treatment.

Trial registration number

NCT04223986.

ASSESSMENT OF TYPES OF MYOCARDIAL DIASTOLIC DYSFUNCTION DEPENDING ON THE DEGREE OF CORONARY ARTERY LESION IN PATIENTS WITH NSTEMI

OBJECTIVE

The aim: To evaluate the types of myocardial diastolic dysfunction depending on the degree of coronary artery lesion in patients with NSTEMI.

PATIENTS AND METHODS

Materials and methods: We examined 200 patients with NSTEMI aged 38 to 80 years, who were urgently hospitalized in the Vinnytsya Regional Clinical Center of Cardiovascular Pathology. All patients underwent echocardiography examination from 3 to 5 day of hospitalization after coronary angiography.

RESULTS

Results: We established that there were no significant gender and age differences in the types of diastolic dysfunction. However, we found that with an increase in the degree of damage to the coronary arteries and an increase in the number of affected arteries, the degree of severity of myocardial diastolic dysfunction increases and the probability of occurrence of more unfavorable types of dysfunction increases.

CONCLUSION

Conclusions: Determining the types of myocardial diastolic dysfunction in the early period of NSTEMI makes it possible to predict unfavorable variants of the course of the disease and prevent possible complications.

Comparison of quantitative flow ratio, Pd/Pa and diastolic hyperemia-free ratio versus fractional flow reserve in non-culprit lesion of patients with non ST-segment elevation myocardial infarction

OBJECTIVES

To investigate the correlation between quantitative flow ratio (QFR), Pd/Pa, diastolic hyperemia-free ratio (DFR) and fractional flow reserve (FFR, gold standard) in non-culprit lesion (NCL) of patients with non ST-segment elevation myocardial infarction (NSTEMI).

BACKGROUND

The non-hyperemic pressure ratio (NHPR) and the angiography-based indexes have been developed to overcome the limitation of the use of the FFR.

METHODS

Between January and December 2019, 184 NCL from 116 NSTEMI patients underwent physiologic assessment and were included in the study. NCLs were investigated with QFR, Pd/Pa, DFR, and FFR. Mean values of QFR, Pd/Pa, DFR and FFR were 0.85 ± 0.10, 0.92 ± 0.07, 0.93 ± 0.05 and 0.84 ± 0.07, respectively.

RESULTS

DFR and FFR showed a good correlation (r = 0.76). Bland and Altman plot showed a mean difference of 0.080. DFR Diagnostic accuracy was 88%. The area under the ROC curve (AUC) for DFR was 0.946 (95%CI 0.90-0.97, p = .0001). Similar findings were reported for Pd/Pa (r = 0.73; mean difference 0.095, diagnostic accuracy 84%, AUC 0.909 [95%CI 0.85-0.94, p = .0001]) and QFR (r = 0.68; mean difference 0.01; diagnostic accuracy 88%, AUC 0.964 [95% CI 0.91-0.98, p = .0001]). FFR, QFR, Pd/Pa and DFR identified 31%, 32%, 30% and 32% potentially flow-limiting lesions, respectively.

CONCLUSIONS

In NSTEMI patients, QFR, Pd/Pa and DFR showed equivalence as compared to gold standard FFR in the discrimination of non-culprit lesions requiring revascularization.

Total Occlusion of the Infarct-Related Artery in Non-ST-Elevation Myocardial Infarction (NSTEMI)-How Can We Identify These Patients?

Background and Objectives: Regardless of the improvement in key recommendations in non-ST-elevation myocardial infarction (NSTEMI), the prevalence of total occlusion (TO) of infarct-related artery (IRA), and the impact of TO of IRA on outcomes in patients with NSTEMI, remain unclear. Aim: The study aimed to assess the incidence and predictors of TO of IRA in patients with NSTEMI, and its clinical significance. Material and Methods: The study was a single-center retrospective cohort analysis of 399 consecutive patients with NSTEMI (293 male, mean age: 71 ± 10.1 years) undergoing percutaneous coronary intervention. The study population was categorized into patients with TO and non-TO of IRA on coronary angiography. In-hospital and one-year mortality were analyzed. Results: TO of IRA in the NSTEMI population occurred in 138 (34.6%) patients. Multivariate analysis identified the following independent predictors of TO of IRA: left ventricular ejection fraction (odds ratio (OR) 0.949, p < 0.001); family history of coronary artery disease (CAD) (OR 2.652, p < 0.001); and high-density lipoprotein (HDL) level (OR 0.972, p = 0.002). In-hospital and one-year mortality were significantly higher in the TO group than the non-TO group (2.8% vs. 1.1%, p = 0.007 and 18.1% vs. 6.5%, p < 0.001, respectively). The independent predictors of in-hospital mortality were: left ventricular ejection fraction (LVEF) at admission (OR 0.768, p = 0.004); and TO of IRA (OR 1.863, p = 0.005). Conclusions: In the population of patients with NSTEMI, TO of IRA represents a considerably frequent phenomenon, and corresponds with impaired outcomes. Therefore, the utmost caution should be paid to prevent delay of coronary angiography in NSTEMI patients with impaired left ventricular systolic function, metabolic disturbances, and a family history of CAD, who are at increased risk of TO of IRA.

Cardiovascular magnetic resonance accurately detects obstructive coronary artery disease in suspected non-ST elevation myocardial infarction: a sub-analysis of the CARMENTA Trial

BACKGROUND

Invasive coronary angiography (ICA) is still the reference test in suspected non-ST elevation myocardial infarction (NSTEMI), although a substantial number of patients do not have obstructive coronary artery disease (CAD). Early cardiovascular magnetic resonance (CMR) may be a useful gatekeeper for ICA in this setting. The main objective was to investigate the accuracy of CMR to detect obstructive CAD in NSTEMI.

METHODS

This study is a sub-analysis of a randomized controlled trial investigating whether a non-invasive imaging-first strategy safely reduced the number of ICA compared to routine clinical care in suspected NSTEMI (acute chest pain, non-diagnostic electrocardiogram, high sensitivity troponin T > 14 ng/L), and included 51 patients who underwent CMR prior to ICA. A stepwise approach was used to assess the diagnostic accuracy of CMR to detect (1) obstructive CAD (diameter stenosis ≥ 70% by ICA) and (2) an adjudicated final diagnosis of acute coronary syndrome (ACS). First, in all patients the combination of cine, T2-weighted and late gadolinium enhancement (LGE) imaging was evaluated for the presence of abnormalities consistent with a coronary etiology in any sequence. Hereafter and only when the scan was normal or equivocal, adenosine stress-perfusion CMR was added.

RESULTS

Of 51 patients included (63 ± 10 years, 51% male), 34 (67%) had obstructive CAD by ICA. The sensitivity, specificity and overall accuracy of the first step to diagnose obstructive CAD were 79%, 71% and 77%, respectively. Additional vasodilator stress-perfusion CMR was performed in 19 patients and combined with step one resulted in an overall sensitivity of 97%, specificity of 65% and accuracy of 86%. Of the remaining 17 patients with non-obstructive CAD, 4 (24%) had evidence for a myocardial infarction on LGE, explaining the modest specificity. The sensitivity, specificity and overall accuracy to diagnose ACS (n = 43) were 88%, 88% and 88%, respectively.

CONCLUSION

CMR accurately detects obstructive CAD and ACS in suspected NSTEMI. Non-obstructive CAD is common with CMR still identifying an infarction in almost one-quarter of patients. CMR should be considered as an early diagnostic approach in suspected NSTEMI.

TRIAL REGISTRATION

The CARMENTA trial has been registered at ClinicalTrials.gov with identifier NCT01559467.

Retrospective assessment of at-risk myocardium in reperfused acute myocardial infarction patients using contrast-enhanced balanced steady-state free-precession cardiovascular magnetic resonance at 3T with SPECT validation

BACKGROUND

Contrast-enhanced (CE) steady-state free precession (SSFP) CMR at 1.5T has been shown to be a valuable alternative to T2-based methods for the detection and quantifications of area-at-risk (AAR) in acute myocardial infarction (AMI) patients. However, CE-SSFP's capacity for assessment of AAR at 3T has not been investigated. We examined the clinical utility of CE-SSFP and T2-STIR for the retrospective assessment of AAR at 3T with single-photon-emission-computed tomography (SPECT) validation.

MATERIALS AND METHODS

A total of 60 AMI patients (ST-elevation AMI, n = 44;  non-ST-elevation AMI, n = 16) were recruited into the CMR study between 3 and 7 days post revascularization. All patients underwent T2-STIR, CE-bSSFP and late-gadolinium-enhancement CMR. For validation, SPECT images were acquired in a subgroup of patients (n = 30).

RESULTS

In 53 of 60 patients (88 %), T2-STIR was of diagnostic quality compared with 54 of 60 (90 %) with CE-SSFP. In a head-to-head per-slice comparison (n = 365), there was no difference in AAR quantified using T2-STIR and CE-SSFP (R2 = 0.92, p < 0.001; bias:-0.4 ± 0.8 cm2, p = 0.46). On a per-patient basis, there was good agreement between CE-SSFP (n = 29) and SPECT (R2 = 0.86, p < 0.001; bias: - 1.3 ± 7.8 %LV, p = 0.39) for AAR determination. T2-STIR also showed good agreement with SPECT for AAR measurement (R2 = 0.81, p < 0.001, bias: 0.5 ± 11.1 %LV, p = 0.81). There was also a strong agreement between CE-SSFP and T2-STIR with respect to the assessment of AAR on per-patient analysis (R2 = 0.84, p < 0.001, bias: - 2.1 ± 10.1 %LV, p = 0.31).

CONCLUSIONS

At 3T, both CE-SSFP and T2-STIR can retrospectively quantify the at-risk myocardium with high accuracy.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

OBJECTIVES

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up.

METHODS

This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24 h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140.

RESULTS

From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)].

CONCLUSIONS

An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Appropriate use criteria for cardiovascular magnetic resonance imaging (CMR): SIC-SIRM position paper part 1 (ischemic and congenital heart diseases, cardio-oncology, cardiac masses and heart transplant)

Cardiac magnetic resonance (CMR) has emerged as new mainstream technique for the evaluation of patients with cardiac diseases, providing unique information to support clinical decision-making. This document has been developed by a joined group of experts of the Italian Society of Cardiology and Italian society of Radiology and aims to produce an updated consensus statement about the current state of technology and clinical applications of CMR. The writing committee consisted of members and experts of both societies who worked jointly to develop a more integrated approach in the field of cardiac radiology. Part 1 of the document will cover ischemic heart disease, congenital heart disease, cardio-oncology, cardiac masses and heart transplant.

Diabetes, metformin and glucose lowering therapies after myocardial infarction: Insights from the SWEDEHEART registry

OBJECTIVE

To explore real-life use of glucose lowering drugs and prognosis after acute myocardial infarction (AMI) with a special focus on metformin.

METHODS

Patients (n = 70270) admitted for AMI 2012-2017 were stratified by diabetes status and glucose lowering treatment and followed for mortality and MACE+ (AMI, heart failure (HF), stroke, mortality) until end of 2017 (mean follow-up time 3.4 ± 1.4 years) through linkage with national registries and SWEDEHEART. Hazard ratios (HR) were calculated in adjusted Cox proportional hazard regression models.

RESULTS

Mean age was 68 ± 11 years and 70% were male. Of patients with diabetes (n = 16356; 23%), a majority had at least one glucose lowering drug (81%) of whom 51% had metformin (24% monotherapy), 43% insulin and a minority any SGLT2i/GLP-1 RA (5%). Adjusted HR for patients with versus without diabetes was 1.31 (95% CI 1.27-1.36) for MACE+ and 1.48 (1.41-1.56) for mortality. Adjusted HR for MACE+ for diabetes patients on metformin was 0.92 (0.85-0.997), p = 0.042 compared to diet treated diabetes.

CONCLUSION

Diabetes still implies a high complication risk after AMI. Metformin and insulin were the most common treatment used in almost half of the diabetes population. Furthermore, patients treated with metformin had a lower cardiovascular risk after AMI and needs to be confirmed in prospective controlled trials.

Thrombin generation's role in predicting coronary disease severity

BACKGROUND

Thrombin, a key enzyme of the clotting system, is involved in thrombus formation, platelet activation, and atherosclerosis, thereby possessing a central role in the pathogenesis of ischemic heart disease. Studies have shown an association between thrombin generation (TG) and cardiovascular morbidity and mortality, but results have been equivocal. Our aim was to study the predictive ability of TG assay in evaluating coronary stenosis severity.

METHODS

In this prospective study we recruited patients with acute coronary syndrome (ACS) or acute chest pain (without evidence of myocardial injury) planned for coronary angiography. Thrombin generation was evaluated by Calibrated Automated Thrombogram (CAT) prior to angiography. Primary end points were significant coronary stenosis and the Syntax I score evaluated by coronary angiography.

RESULTS

From April 2018 through September 2019, we recruited 128 patients. In the primary analysis there was no significant association between TG and significant coronary stenosis nor between TG and syntax I score, however, there was a positive correlation between peak height and troponin peak (Spearman correlation coefficient 0.194, P-value = 0.035). In sub-group analysis, the chest pain group bare no association between TG and coronary stenosis. In unstable angina group there was an association between peak height and significant coronary stenosis (P-value = 0.029), and in non ST-elevation myocardial infarction group, TG values possessed a relatively good predictive ability of significant coronary stenosis (area under the receiver operating characteristic curve of ~65%) and a positive correlation between both lag time and ttpeak with the syntax I score was noticed (Spearman correlation coefficient 0.31, P-value = 0.099 and Spearman correlation coefficient 0.37, P-value = 0.045 respectively).

CONCLUSION

In patients with acute chest pain, TG values, evaluated by CAT, do not predict severity of coronary stenosis, nor do they possess prognostic value. Yet, in ACS patients, TG may have the ability to predict coronary disease severity.

Effect of invasive strategy on long-term mortality in elderly patients presenting with acute coronary syndrome

OBJECTIVE

The elderly have the highest incidence of cardiovascular disease and frequently present with acute coronary syndrome (ACS). In this study, our aim was to evaluate the effect of an invasive strategy on long-term mortality in patients of 80 years and older presenting with ACS.

METHODS

Patients who were admitted to hospital with ACS were recruited using appropriate ICD codes in the computerised hospital data system. After exclusion of patients below 80 years old, the remaining 156 patients were involved in the final analyses. Ninety-four of 156 patients (60.3%) underwent coronary angiography and they constituted the invasive-strategy group, whereas the remaining 62 (39.7%) patients were treated medically and they constituted the conservative-strategy group.

RESULTS

Median follow-up duration of patients was 8.5 (0-61) months. Total mortality at the end of the follow-up period was 24 (25.5%) patients in the invasive-strategy group and 30 (48.4%) in the conservative-strategy group (p = 0.006). According to Cox regression analysis, the invasive strategy (OR: 0.26, 95% CI: 0.12-0.56, p = 0.001), presentation with ST-segment elevation myocardial infarction (OR: 7.76, 95% CI: 1.74-34.57, p = 0.002), low ejection fraction below 40% (OR: 3.11, 95% CI: 1.43-6.76, p = 0.004), heart rate (OR: 0.98, 95% CI: 0.96-0.99, p = 0.013) and GRACE risk score between 150 and 170 (OR: 7.76, 95% CI: 1.74-34.57, p = 0.002) were related to long-term mortality.

CONCLUSIONS

Our results show the benefit of the invasive strategy on mortality rate in elderly patients over 80 years old and presenting with ACS.

Impact of diabetes on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: insights from the ELDERLY ACS 2 trial

BACKGROUND

Despite recent improvements in percutaneous coronary revascularization and antithrombotic therapies for the treatment of acute coronary syndromes, the outcome is still unsatisfactory in high-risk patients, such as the elderly and patients with diabetes. The aim of the current study was to investigate the prognostic impact of diabetes on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study carried out at 32 centers in Italy.

METHODS

Our population is represented by 1443 patients included in the Elderly-ACS 2 trial. Diabetes was defined as known history of diabetes at admission. The primary endpoint of this analysis was cardiovascular mortality, while secondary endpoints were all-cause death, recurrent myocardial infarction, Bleeding Academic Research Consortium type 2 or 3 bleeding, and rehospitalization for cardiovascular event or stent thrombosis within 12 months after index admission.

RESULTS

Diabetes was present in 419 (29%) out of 1443 patients. Diabetic status was significantly associated with major cardiovascular risk factors and history of previous coronary disease, presentation with non-ST segment elevation myocardial infarction (P = 0.01) more extensive coronary disease (P = 0.02), more advanced Killip class at presentation (P = 0.003), use at admission of statins (P = 0.004) and diuretics at discharge (P < 0.001). Median follow-up was 367 days (interquartile range: 337-378 days). Diabetic status was associated with an absolute increase in the rate of cardiovascular mortality as compared with patients without diabetes [5.5 vs. 3.3%, hazard ratio (HR) 1.7 (0.99-2.8), P = 0.054], particularly among those treated with clopidogrel [HR (95% confidence interval (CI)) = 1.89 (0.93-3.87), P = 0.08]. However, this difference disappeared after correction for baseline differences [Adjusted HR (95% CI) 1.1(0.4-2.9), P = 0.86]. Similar findings were observed for other secondary endpoints, except for bleeding complications, significantly more frequent in diabetic patients [HR (95% CI) 2.02 (1.14-3.6), P = 0.02; adjusted HR (95% CI) = 2.1 (1.01-4.3), P = 0.05]. No significant interaction was observed between type of dual antiplatelet therapy, diabetic status and outcome.

CONCLUSION

Among elderly patients with acute coronary syndromes, diabetic status was associated with higher rates of comorbidities, more severe cardiovascular risk profile and major bleeding complications fully accounting for the absolute increase in mortality. In fact, diabetes mellitus did not emerge as an independent predictor of survival in advanced age.

Impact of body mass index on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: Insights from the ELDERLY ACS 2 trial

BACKGROUND AND AIM

Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS.

METHODS AND RESULTS

Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (<or ≥ 25.7 kg/m2). BMI was associated with hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate and hemoglobin (p < 0.001), and inversely with age (p = 0.005). Overweight patients displayed larger use of diuretics at admission (p = 0.03), aspirin pre-randomization (p = 0.01) and radial access (p = 0.04). At a median follow-up of 367 [337-378] days, BMI did not affect CV mortality in the overall population 4% vs 3.8%; adjusted HR [95%CI] = 2.3 [0.8-6.5], p = 0.12. Similar findings were observed for our secondary efficacy and safety endpoints. Results did not change when considering separately higher risk subsets of patients, (female gender, diabetics, ST-segment elevation myocardial infarction or the type of DAPT treatment allocation), with no significant interaction between these population characteristics and BMI.

CONCLUSIONS

Among elderly patients with ACS, BMI did not condition the survival or the risk of major cardiovascular and bleeding complications. The results were consistent across several patient risk categories.

A randomized controlled trial of a physiology-guided percutaneous coronary intervention optimization strategy: Rationale and design of the TARGET FFR study

Post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) ≥0.90 confers an improved cardiac prognosis. There are currently limited data available to determine how often it is possible to improve an angiographically acceptable but physiologically suboptimal result. A physiology-guided optimization strategy can achieve a clinically meaningful increase in the proportion of patients achieving a final post-PCI FFR ≥0.90 compared to standard care. Following angiographically successful PCI procedures, 260 patients will be randomized (1:1) to receive either a physiology-guided incremental optimization strategy (intervention group) or blinded post-PCI coronary physiology measurements (control group). Patients undergoing successful, standard-of-care PCI for either stable angina or non-ST-segment-elevation myocardial infarction who meet the study's inclusion and exclusion criteria will be eligible for randomization. The primary endpoint is defined as the proportion of patients with a final post-PCI FFR result ≥0.90. Secondary endpoints include change from baseline in Seattle Angina Questionnaire and EQ-5D-5L scores at 3 months and the rate of target vessel failure and its components (cardiac death, myocardial infarction, stent thrombosis, unplanned rehospitalization with target vessel revascularization) at 3 months and 1 year. 260 individual patients were successfully randomized between March 2018 and November 2019. Key baseline demographics of the study population are reported within. TARGET FFR is an investigator-initiated, prospective, single-center, randomized controlled trial of an FFR-guided PCI optimization strategy. The study has completed recruitment and is now in clinical follow-up. It is anticipated that primary results will be presented in Autumn 2020. ClinicalTrials.gov Identifier: NCT03259815. [Correction added on Apr 3 2020, after first online publication: Clinical Trials identifier added.].

Elevated Lipoprotein-Associated Phospholipase A2 is Valuable in Prediction of Coronary Slow Flow in Non-ST-Segment Elevation Myocardial Infarction Patients

Background Coronary flow is a determinative factor of non-ST-segment elevation myocardial infarction (NSTEMI) patients. Lipoprotein-Associated Phospholipase A2(Lp-PLA2) as a vascular specific inflammatory cytokine might relate to coronary slow flow in these patients. Methods 105 NSTEMI patients and 83 UAP patients were enrolled. Another group division was made by Lp-PLA2 tertile data. Corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) was adopted to represent coronary flow condition. Correlation analysis was made between CTFC and other clinical indicators. Multivariable regression analysis was used to identify the influential factors of coronary flow in NSTEMI patients. ROC curve was used to determine the diagnostic value of Lp-PLA2 with coronary slow flow (CSF). Results High sensitive C reactive protein (hsCRP, P < 0.01), Lp-PLA2(P < 0.01), N-terminal pro-brain natriuretic peptide (NT-proBNP, P < 0.05), mean platelet volume (MPV, P<0.05), CTFC(P < 0.05) was higher in NSTEMI than UAP patients. hsCRP(P < 0.01), MPV(P < 0.01), NT-proBNP(P < 0.01) CTFC(P < 0.01) was higher in high-Lp-PLA2 group. Lp-PLA2 and hsCRP (r = 0.22, P < 0.01), MPV (r = 0.21, P < 0.05), CTFC (r = 0.69, P < 0.01) had a positive correlation in NSTEMI group. Multivariable regression analysis showed that Lp-PLA2 could explain most part changes of CTFC in NSTEMI patients, CTFC = 0.55*Lp-PLA2+0.03*hsCRP+0.005*NT-proBNP+15.843. Lp-PLA2 was specific and sensitive in diagnosis of CSF in NSTEMI group, AUC = 0.851(95% confidence interval (CI): 0.771-0.924, P < 0.01), Cutoff=196.96ng/ml, sensitivity = 84%, specificity = 81%. Conclusions Lp-PLA2 is closely correlated with coronary flow in NSTEMI patients. Lp-PLA2 over 196.96ng/ml could be used to predict CSF in NSTEMI patients.

The impact of semi-automatic versus manually adjusted assessment of global longitudinal strain in post-myocardial infarction patients

There are unresolved questions related to the proper use of editing the region of interest (ROI) for measurements of global longitudinal strain (GLS). The purpose of the present study was to compare the semi-automatic default GLS value by the vendor's software with manually adjusted GLS and test the impact on GLS measures with different ROI widths. We selected 25 patients post myocardial infarction treated with PCI who had excellent echocardiographic recordings after 2-5 days and 3 months. The different GLS values were assessed from these 50 analyses in three steps. The semi-automatically GLS by default ROIs was compared with manually adjusted ROIs widths selected by an expert and then with manual adjustments, but with fixed ROIs being narrow, medium and wide. Their mean age was 64 (± 12) years, 52% had ST elevation MI and mean LVEF was 52 (± 4)%. Mean default GLS was - 15.3 (± 2.5)% with the widest ROI level selected semi-automatically in 78% of all widths. The mean expert GLS with manually adjusted ROI was - 14.7 (± 2.4)%, and the medium ROI level was selected by the expert in 85% of all examinations. The mean adjusted GLS, but with fixed ROIs widths was - 15.0 (± 2.5%)% with narrow ROI, - 14.7 (± 2.6)% with medium and - 13.5 (± 2.3)% with wide ROI width (p < 0.001 vs. default GLS). The Intra Class Coefficient Correlation between default and manually adjusted expert GLS was 0.93 (p < 0.001). The difference between the default and the manually adjusted expert GLS was neglectable. These findings may represent a simplification of the assessment of GLS that might increase its use in clinical practice. The GLS measurements with a fixed wide ROIs were significantly different from the expert measurements and indicate that a wide ROI should be avoided.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

Heparin Administration, but Not Myocardial Ischemia or Necrosis, Leads to Midkine Elevation

Midkine (MK) is a heparin-binding growth factor, whose role as a biomarker of coronary artery disease, myocardial ischaemia and necrosis has not been well measured. This study quantified serial MK levels in patients undergoing coronary angiography (CA) and identified factors associated with MK. In this single-centre, parallel cohort study, forty patients undergoing CA had arterial samples collected prior, 10 and 20 min after heparin administration. Four groups were examined: 1-stable coronary artery disease (CAD) without percutaneous coronary intervention (PCI); 2-stable CAD for elective PCI; 3-non-ST elevation myocardial infarction (NSTEMI) with or without PCI; 4-ST elevation myocardial infarction (STEMI) with primary PCI. Groups 1, 2 and 4 were heparin naïve, allowing assessment of the effects of myocardial necrosis between baseline levels; group 3 had received low-molecular-weight heparin. MK levels were analysed by ELISA. Median MK at baseline did not differ between groups, demonstrating that myocardial ischaemia or necrosis does not affect MK levels. Heparin administration had an immediate effect on median MK at 10 min, showing an average 500-fold increase that is dose-dependent (R² = 0.35, p = 0.001). Median MK levels remained elevated at 20 min following heparin administration. Multivariate analysis showed that the estimated glomerular filtration rate (eGFR) was the only predictor of elevated baseline MK (p = 0.02). Baseline MK did not correlate with high-sensitivity troponin-I (HsTnI) taken just before CA (p = 0.97), or peak HsTnI during admission (p = 0.74). MK is not a reliable marker of myocardial ischaemia or necrosis. MK increased significantly in all patients following heparin administration in a dose-dependent manner.

Endothelial Microvesicles Circulating in Peripheral and Coronary Circulation Are Associated With Central Blood Pressure in Coronary Artery Disease

BACKGROUND

Endothelial microvesicles (EMVs) have emerged as markers of endothelial injury. However, little is known about their levels in the coronary circulation of acute coronary syndrome (ACS) and stable coronary artery disease (CAD). We hypothesized that ACS patients exhibit a more pronounced increase of EMVs both in the peripheral and coronary circulation when compared with CAD. We also investigated possible associations of EMVs with markers preclinical target organ damage.

METHODS

We enrolled consecutive eligible patients undergoing coronary angiography. Blood samples were collected from the stem of the left coronary artery and the femoral artery. ΕMVs were measured by a standardized flow cytometry protocol. Central systolic blood pressure (cSBP) was measured invasively and patients' history was recorded.

RESULTS

CAD patients exhibited increased levels of EMVs compared with controls. When patients with ACS and stable CAD were compared, the former had significantly increased EMVs in both coronary and peripheral circulation. Importantly, both ACS and CAD patients exhibited increased levels of EMVs in the coronary circulation compared with periphery. In addition, EMVs were associated with cSBP.

CONCLUSIONS

EMVs emerge as novel markers of ongoing underlying vascular damage, further augmenting the vicious cycle of inflammation and thrombosis mainly in ACS but also in stable CAD.

Left Atrial Function with MRI Enables Prediction of Cardiovascular Events after Myocardial Infarction: Insights from the AIDA STEMI and TATORT NSTEMI Trials

Background The role of left atrial (LA) performance in acute myocardial infarction (AMI) remains controversial. Cardiac MRI myocardial feature tracking (hereafter, MRI-FT) is a method used to quantify myocardial function that enables reliable assessment of atrial function. Purpose To assess the relationship between LA function assessed with MRI-FT and major adverse cardiovascular events (MACE) after AMI. Materials and Methods This secondary analysis of two prospective multicenter cardiac MRI studies (AIDA STEMI [NCT00712101] and TATORT NSTEMI [NCT01612312]) included 1235 study participants with ST-elevation myocardial infarction (n = 795) or non-ST-elevation myocardial infarction (n = 440) between July 2008 and June 2013. All study participants underwent primary percutaneous coronary intervention. MRI-FT analyses were performed in a core laboratory by researchers blinded to clinical status to determine LA performance using LA reservoir function peak systolic strain (εs), LA conduit strain (εe), and LA booster pump function active strain (εa). The relationship of LA performance to a MACE within 12 months after AMI was evaluated by using Cox proportional hazards models and area under the receiver operating characteristic curve (AUC). Results Study participants with MACE had worse LA performance parameters compared with study participants without MACE (εs = 21.2% vs 16.2%, εe = 8.8% vs 6.9%, εa = 11.8% vs 10%; P < .001 for all). All atrial parameters were strongly associated with MACE (hazard ratio [HR], εs = 0.9, εe = 0.88, εa = 0.89; P < .001 for all). For εs, a cutoff of 18.8% was identified as the only independent atrial parameter with which to predict MACE after accounting for confounders and established prognostic markers in adjusted analysis (HR, 0.95; P = .02). The εs yielded incremental prognostic value above left ventricular ejection fraction, global longitudinal strain, microvascular obstruction, and infarct size (AUC comparisons, P < .04 for all). Conclusion Feature tracking of cardiac MRI to derive left atrial peak reservoir strain provided incremental prognostic value for major adverse cardiovascular events prediction versus established cardiac risk factors after acute myocardial infarction. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Almeida in this issue.

Non-ST-Elevation Myocardial Infarction with Non-significant Coronary Artery Disease as a Symptom of Occult or New Malignancy

BACKGROUND

Malignancy is a known risk factor for venous thromboembolism; however, the association with arterial thromboembolic events remains unclear.

OBJECTIVES

To examine the association between non-ST-elevation myocardial infarction (NSTEMI) and non-significant coronary artery disease (CAD) and the presence of new or occult malignancy.

METHODS

An observational cohort, single-center study was performed 2010-2015. Adult patients with NSTEMI, who underwent coronary angiography and had no significant coronary lesion, were included. Using propensity score matching, we created a 2:1 matched control group of adults with NSTEMI, and significant coronary artery disease. Risk factors for new or occult malignancy were assessed using multivariate backward stepwise logistic regression analysis. The primary outcome was new or occult malignancy, defined as any malignancy diagnosed in the 3 months prior and 6 months following the myocardial infarction (MI).

RESULTS

During the study period, 174 patients who presented with MI with non-obstructive coronary arteries were identified. The matched control group included 348 patients. There was no significant difference in the group demographics, past medical history, or clinical presentation. The incidence of new or occult malignancy in the study group was significantly higher (7/174, 4% vs. 3/348, 0.9%, P = 0.019). NSTEMI with non-significant CAD was an independent risk factor for occult malignancy (odds ratio [OR] 4.6, 95% confidence interval [95%CI] 1.1-18.7). Other risk factors included active smoking (OR 11.2, 95%CI 2.5-49.1) and age (OR 1.1, 95%CI 1.03-1.17).

CONCLUSIONS

NSTEMI with non-significant CAD may be a presenting or early marker of malignancy and warrants further investigation.

Association Between Blood Glucose Variability and the Characteristics of Vulnerable Plaque in Elderly Non-ST Segment Elevation Acute Coronary Syndrome Patients

Blood glucose variability is considered to be one of the risk factors for coronary heart disease, and there is growing evidence that blood glucose fluctuation is closely related to the characteristics of plaques. The aim of the study was to investigate the influence of blood glucose variability on the vulnerability of culprit plaques in elderly non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients.Coronary angiography and VH-IVUS were applied to evaluate the components of culprit plaque in NSTE-ACS patients. CGMS monitoring was performed for 72 hours and blood glucose variability was assessed by glycemic excursions (MAGE), absolute means of daily differences (MODD), postprandial glycemic excursions (PPGE), and the largest amplitude of glycemic excursions (LAGE). An oxidative stress indicator (urinary 8-iso-PGF_2α) was also tested.Eighty two elderly NSTE-ACS patients were enrolled in this study. Higher glucose variability was associated with the increased culprit plaque instability. MODD was positively correlated with urinary 8-iso-PGF_2α. PPGE and urinary 8-iso-PGF_2α were independent risk factors for percent fibrous and necrotic volume in culprit plaques (PPGE: β = -0.340, P = 0.024; urinary 8-iso-PGF_2α: β = -0.294, P = 0.013).Blood glucose variability is positively related to oxidative stress. With an increase in blood glucose variability, the instability of criminal plaques in elderly NSTE-ACS patients increased.

Optical coherence tomography guided successful treatment without stent implantation in a patient with non-ST-segment elevation myocardial infarction caused by plaque rapture: A case report

RATIONALE

Primary percutaneous coronary intervention (PPCI) with immediate stenting provides effective revascularization. While the risks of no-reflow, stent thrombosis, stent undersizing, and malapposition reduced the benefits in patients with high burden thrombosis. Intravascular imaging, especially optical coherence tomography (OCT), offers potential in optimization of percutaneous coronary intervention.

PATIENT CONCERNS

A 51-year-old male underwent coronary angiography (CAG) due to chest pain with minimal ST-segment depression of the electrocardiogram.

DIAGNOSES

Urgent CAG revealed burden thrombus in the mid left anterior descending coronary artery (LAD) with TIMI grade I distal flow.

INTERVENTIONS

After aspiration thrombectomy, OCT was used to evaluate the target lesion of non-ST-segment elevation myocardial infarction (NSTEMI) and conservative treatment without stent implantation was selected.

OUTCOMES

CAG repeated 1 month after PPCI revealed TIMI grade III blood flow in LAD and only minimal stenosis in the target lesion. OCT showed a cavity formation due to plaque rupture and MLA increased after thrombus dissolution. Follow-up was uneventful at 6 months.

LESSONS

OCT may be useful imaging modality to identify the characteristic of culprit lesion of acute myocardial infarction and subsequently guide individual treatment.

Presentation, Clinical Profile, and Prognosis of Young Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Results From the VIRGO Study

BACKGROUND

We compared the clinical characteristics and outcomes of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) versus obstructive disease (myocardial infarction due to coronary artery disease [MI-CAD]) and among patients with MINOCA by sex and subtype.

METHODS AND RESULTS

Between 2008 and 2012, VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) prospectively enrolled acute myocardial infarction patients aged 18 to 55 years in 103 hospitals at a 2:1 ratio of women to men. Using an angiographically driven taxonomy, we defined patients as having MI-CAD if there was revascularization or plaque ≥50% and as having MINOCA if there was <50% obstruction or a nonplaque mechanism. Patients who did not have an angiogram or who received thrombolytics before an angiogram were excluded. Outcomes included 1- and 12-month mortality and functional (Seattle Angina Questionnaire [SAQ]) and psychosocial status. Of 2690 patients undergoing angiography, 2374 (88.4%) had MI-CAD, 299 (11.1%) had MINOCA, and 17 (0.6%) remained unclassified. Women had 5 times higher odds of having MINOCA than men (14.9% versus 3.5%; odds ratio: 4.84; 95% confidence interval, 3.29-7.13). MINOCA patients were more likely to be without traditional cardiac risk factors (8.7% versus 1.3%; P<0.001) but more predisposed to hypercoaguable states than MI-CAD patients (3.0% versus 1.3%; P=0.036). Women with MI-CAD were more likely than those with MINOCA to be menopausal (55.2% versus 41.2%; P<0.001) or to have a history of gestational diabetes mellitus (16.8% versus 11.0%; P=0.028). The MINOCA mechanisms varied: a nonplaque mechanism was identified for 75 patients (25.1%), and their clinical profiles and management also varied. One- and 12-month mortality with MINOCA and MI-CAD was similar (1-month: 1.1% and 1.7% [P=0.43]; 12-month: 0.6% and 2.3% [P=0.68], respectively), as was adjusted 12-month SAQ quality of life (76.5 versus 73.5, respectively; P=0.06).

CONCLUSIONS

Young patients with MINOCA were more likely women, had a heterogeneous mechanistic profile, and had clinical outcomes that were comparable to those of MI-CAD patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.

Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction

BACKGROUND

Low health literacy is common in the United States and may affect outcomes after myocardial infarction (MI). How often hospitals screen for low health literacy is unknown.

METHODS

We surveyed 122 hospitals in the TRANSLATE-ACS study and divided them into those that reported routinely (>75% of patients), selectively (1%-75%), or never (0%) screening MI patients for low health literacy prior to discharge. We performed logistic regression with random intercepts to compare 6-week and 6-month patient-reported medication adherence and multivariable Cox regression to compare 1-year major adverse cardiovascular events and all-cause readmission risks between hospital groups.

RESULTS

Overall, 25 (20.5%), 47 (38.5%), and 50 (41.0%) hospitals reported routinely, selectively, or never screening patients for low health literacy, respectively. Patients discharged from hospitals that routinely screened were more likely to report 6-week medication adherence [routinely: adjusted odds ratio (OR) 1.26, 95% CI 1.01-1.57; selectively: adjusted OR 1.19, 95% CI 1.00-1.43, both referenced to those discharged from hospitals that never screened]. Compared with hospitals that never screened health literacy, 1-year major adverse cardiovascular events were similar for hospitals that reported routinely screening (adjusted HR 0.92, 95% CI 0.75-1.14) or selectively screening (adjusted HR 1.01, 95% CI 0.84-1.21). Hospitals that reported selectively screening health literacy were associated with a lower adjusted risk of 1-year all-cause readmission (adjusted HR 0.89, 95% CI 0.79-1.00, P=.041).

CONCLUSION

Only a minority of US hospitals routinely screen MI patients for low health literacy. Hospital screening was associated with higher medication adherence and lower readmission risk. Further investigation is needed to understand how inpatient screening can be implemented to improve longitudinal post-MI care.