The Family Income Ratio of Barcelona and its impact on treatment delays and one-year mortality in 3173 cases of STEMI treated at the Codi IAM network

Introduction

STEMI networks have spread reperfusion and have decreased treatment delays.Increased treatment times have a negative impact on mortality after STEMI.The Family Income Ratio of Barcelona (FIRB) is an indicator that combines economic and socio-cultural welfare that is annually documented at the different Barcelona's neighborhoods by the Barcelona Public Health Office.

Purpose

To evaluate if FIRB has a prognostic impact on STEMI treatment times and mortality on patients of Barcelona city treated in the Codi IAM Network with primary PCI.

Methods

Analysis of all data from “Codi IAM Network” from STEMI treatment in Barcelona city from 2010 to 2016 -including treatment delays, clinical risk factors and 1-year all-cause mortality- and corresponding FIRB for each patient and episode.FIRB is divided into tertiles.Multilevel analysis is performed to obtain factors associated to EKG-opening artery time and cox-regression on 1-year all-cause mortality.

Results

3173 cases of STEMI were included with a mean age of 65±13, 25% women,21% diabetes mellitus and 42% hypertension.Characteristics of population, treatment and mortality per FIRB tertile is shown in Table 1.Multilevel analysis showed that age,diabetes mellitus,heart failure at admission,FIRB and who performed first care were associated to EKG-Opening Artery Time (all p<0.003).However,only age,heart failure at admission,who performed first care and EKG-opening artery time>120min were significantly associated to 1-year all-cause mortality (p<0.005) but not FIRB.

Conclusions

Patients at the lower FIRB treated for STEMI in Barcelona showed younger age,worse cardiovascular profile and longer treatment delays.Longer EKG-open artery time was associated to diabetes mellitus, heart failure, first assistance care and lower FIRB.One-year all-cause mortality was not associated to FIRB.

Funding Acknowledgement

Type of funding source: None

Iron deficiency is associated with larger infarcts and with adverse remodeling in STEMI patients and reduces myocardial tolerance to ischemia/reperfusion by inhibiting the eNOS/sGC/PKG pathway in mice

Background

Iron deficiency (ID) interferes with the cardioprotective pathway endothelial nitric oxide synthase/soluble guanylate cyclase/protein kinase G (eNOS/sGC/PKG), but its role in acute myocardial infarction remains unclear.

Methods

Patients (n=125) with a first anterior STEMI treated with PCI underwent magnetic resonance imaging in the acute phase and at 6 months. We assessed whether ID (ferritin level <100 μg/L or <300 μg/L if transferrin saturation was <20%) was associated with infarct size acutely or with adverse left ventricular (LV) remodeling (LV end-diastolic volume increase at 6 months >20%, n=105). C57BL6/N mice were fed with standard diet or iron-deficient diet for 4 weeks before undergoing 45-min coronary occlusion/24-h reperfusion.

Results

Patients with ID (43.2%) had larger infarcts (22.8±10.2 vs 16.8±9.8% of LV mass, P=0.002) and more frequent microvascular obstruction (70.0 vs 43.3%, P=0.004) in the initial exam than the rest. They also developed adverse LV remodeling more often (38.6 vs 14.8%, P=0.005), even after adjusting by infarct size and final TIMI flow grade (OR 3.1, 95% CI 1.1–8.6, P=0.027). In mice, ID diet reduced myocardial iron content, serum ferritin and hemoglobin levels without reaching anemic values and without inducing echocardiographic alterations. ID diet reduced myocardial eNOS protein content, its dimeric form, and nitrites/nitrates and cGMP levels. eNOS decrease was associated with reduced HSP90 levels and increased eNOS ubiquitination in correlation with oxidative and nitrosative stress. Weekly iv administration of iron sucrose effectively reverted the ID-diet effects. Infarct size was larger in the ID group than in controls (58.8±3.0 vs. 40.3±3.6%, P=0.03) but was not increased in ID-diet animals treated with iron sucrose (36.3±4.0%) or receiving the sGC activator ataciguat before ischemia (31.0±2.5%).

Conclusions

ID is associated with larger infarcts and with more frequent adverse LV remodeling in patients with STEMI and reduces myocardial tolerance to ischemia/reperfusion in mice by attenuating eNOS/sGC/PKG pathway activity. Iron sucrose treatment and sGC activation reverted these deleterious effects of ID in mice. Iron supplementation might be beneficial in STEMI patients with ID.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIBER-CV. Instituto de Salud Carlos III (PI16/00232), co-financed by the ERDF

Rebound myocardial ischaemia following abrupt interruption of intravenous nitroglycerin infusion in patients with unstable angina at rest

Isolated observations prompted a prospective study of the possible occurrence of myocardial ischaemia following abrupt discontinuation of intravenous infusion of nitroglycerin in 46 consecutive patients with unstable angina. In 26 (55%, group 1), but not the remainder (45%, group 2), cessation of nitroglycerin produced in 10.3 +/- 5.8 (mean +/- SD) minutes ECG changes comparable with those of spontaneous angina without significant changes in heart rate and blood pressure. Reproducible results were observed in 18/20 patients in whom the test was repeated. In four patients with two positive tests, a third test failed to elicit ischaemia 15 min after sublingual administration of 5 mg isosorbide dinitrate. An ergonovine test performed in four other patients with a positive test produced similar ECG changes. Thus, acute interruption of intravenous nitroglycerin infusion in patients with unstable angina is often associated with acute myocardial ischaemia. The lack of preceding changes in heart rate and blood pressure and the similarities with the spontaneous episodes and with those produced by ergonovine, strongly suggest a rebound coronary vasoconstrictive phenomenon as the underlying mechanism.