Impact of educational attainment on preventive efforts after myocardial infarction: results of the IPP and NET-IPP trials

AIMS

Educational attainment might impact secondary prevention after myocardial infarction (MI). The purpose of the present study was to compare the rate of risk factors and the efficacy of an intensive prevention program (IPP), performed by prevention assistants and supervised by physicians, in patients with MI and different levels of education.

METHODS

In this post hoc analysis of the multicenter IPP and NET-IPP trials, patients with MI were stratified into two groups according to educational attainment: no "Abitur" (no A) vs. "Abitur" or university degree (AUD). The groups were compared at the time of index MI and after 12-month IPP vs. usual care.

RESULTS

Out of n = 462 patients with MI, 76.0% had no A and 24.0% had AUD. At the time of index, MI rates of obesity (OR 2.4; 95%CI 1.4-4.0), smoking (OR 2.2, 95%CI 1.4-3.6), and physical inactivity (OR 1.6; 95%CI 1.0-2.5) were significantly elevated in patients with no A. At 12 months after index MI, larger improvements of the risk factors smoking and physical inactivity were observed in patients with IPP and no A than in patients with IPP and AUD or with usual care. LDL cholesterol levels were reduced by IPP compared to usual care, with no difference between no A vs. AUD. A matched-pair analysis revealed that high baseline risk was an important reason for the large risk factor reductions in patients with IPP and no A.

CONCLUSION

The study demonstrates that patients with MI and lower educational level have an increased rate of lifestyle-related risk factors and a 12-month IPP, which is primarily performed by non-physician prevention assistants, is effective to improve prevention in this high-risk cohort.

Lifestyle and metabolic risk factors in patients with early-onset myocardial infarction: a case-control study

AIMS

Family history is a known risk factor for early-onset myocardial infarction (EOMI). However, the role of modifiable lifestyle and metabolic factors in EOMI risk is unclear and may differ from that of older adults.

METHODS

This case-control study included myocardial infarction (MI) patients aged ≤45 years from the Bremen ST-elevation MI Registry and matched controls randomly selected from the general population (German National Cohort) at the same geographical region. Multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the individual and combined associations of lifestyle and metabolic factors with EOMI risk, overall and according to family history for premature MI.

RESULTS

A total of 522 cases and 1191 controls were included. Hypertension, current smoking, elevated waist-to-hip ratio, and diabetes mellitus were strongly associated with the occurrence of EOMI. By contrast, higher frequency of alcohol consumption was associated with decreased EOMI risk. In a combined analysis of the risk factors hypertension, current smoking, body mass index ≥25.0 kg/sqm, and diabetes mellitus, participants having one (OR = 5.4, 95%CI = 2.9-10.1) and two or more risk factors (OR = 42.3, 95%CI = 22.3-80.4) had substantially higher odds of EOMI compared to those with none of these risk factors, regardless of their family history.

CONCLUSION

This study demonstrates a strong association of smoking and metabolic risk factors with the occurrence of EOMI. The data suggest that the risk of EOMI goes beyond family history and underlines the importance of primary prevention efforts to reduce smoking and metabolic syndrome in young persons.

Temporal trends in treatment strategies and clinical outcomes among patients with advanced chronic kidney disease and ST-elevation myocardial infarctions: results from the Bremen STEMI registry

Background

Although the detrimental effects of advanced chronic kidney disease (CKD) on prognosis in coronary artery disease is known, there are few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD, because this special patient cohort is often excluded or underrepresented in randomized trials.

Methods

In the present study all patients admitted with ST-elevation myocardial infarctions (STEMI) from the region of Bremen/Germany treated between 2006 and 2019 were analyzed. Advanced CKD was defined as glomerular filtration rate < 45 ml/min.

Results

Of 9605 STEMI-patients, 1018 (10.6%) had advanced CKD with a serum creatinine of 2.22 ± 4.2 mg/dl at admission and with lower rates of primary percutaneous coronary intervention (pPCI) (84.1 vs. 94.1%, p < 0.01) and higher all-cause-mortality (44.4 vs. 3.6%, p < 0.01). Over time, advanced CKD-patients were more likely to be treated with pPCI (2015–2019: 90.3% vs. 2006–2010:75.8%, p < 0.01) and with ticagrelor/prasugrel (59.6% vs. 1.7%, p < 0.01) and drug eluting stents (90.7% vs. 1.3%, p < 0.01). During the study period a decline in adverse ischemic events (OR 0.3, 95% CI 0.1–0.7) and an increase in bleedings (OR 2.2, 95% CI 1.3–3.8) within 1 year after the index event could be observed in patients with advanced CKD while 1-year-mortality (OR 1.0, 95% CI 0.7–1.4) and rates of acute kidney injury (OR 1.2, 95% CI 0.8–1.7) did not change in a multivariate model. Both, ticagrelor/prasugrel (OR 0.48, 95% CI 0.2–0.98) and DES (OR 0.38, 95% CI 0.2–0.8) were associated with a decrease in ischemic events at 1 year.

Conclusions

During the observed time period STEMI-patients with advanced CKD were more likely to be treated with primary PCI, ticagrelor or prasugrel and DE-stents. These changes probably have contributed to the decline in ischemic events and the increase in bleedings within 1 year after STEMI while overall mortality at 1-year remained unchanged for this high-risk patient group.

Risk factors in young patients with myocardial infarction: what is different from the general population?

Introduction

Patients that suffer from myocardial infarction (MI) at a younger age are of special medical and socioeconomic interest. Data on risk factors for MI in this patient group are however scarce.

Methods

In this case–control study, clinical characteristics of consecutive patients admitted to hospital with MI at age of ≤45 years were compared to a randomly selected cohort from the general population in the same geographic region in Germany. After 3:1 matching on age and gender and multivariable analyses, independent risk factors for the occurrence of MI at a younger age were analyzed.

Results

522 patients with MI ≤45 years were compared to 1191 matched controls from the general population. The proportion of active smokers was more than 3-fold higher in younger MI-patients compared to the general population (82.4% vs. 24.1%, p&lt;0.01), while the proportion of persons consuming alcohol at least 2 times a week was higher in the general population (19.9% vs. 36.6%, p&lt;0.01). Younger patients with MI were more often obese (median body mass index 28.4 vs. 25.5 kg/m2, p&lt;0.01), had a higher proportion of hypertension (25.1% vs. 0.5%, p&lt;0.01) or diabetes mellitus (11.7% vs. 1.7%, p&lt;0.01) and had more often a family history of the father (22.4% vs. 7.1%, p&lt;0.01) or the mother (7.5% vs. 1.3%, p&lt;0.01) for premature coronary artery disease.

In multivariable analysis, hypertension or diabetes, active smoking, family history and body mass index ≥30 kg/m2 were strong predictors for the occurrence of MI at a younger age, while alcohol consumption was a protective factor (Figure).

Conclusions

This case-control study demonstrates a very strong association of active smoking, metabolic syndrome and family history with the occurrence of MI at a younger age. The contrary is found regarding alcohol consumption.

These data suggest that the risk of young-onset MI goes beyond family history and underline the importance of primary prevention efforts to reduce smoking and metabolic syndrome in children, adolescents and young adults in order to reduce the burden of cardiovascular diseases.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Bremen Heart FoundationLeibniz Institute for Prevention Research and Epidemiology

Association of bleeding events and acute kidney failure in patients with ST-Elevation myocardial infarcation undergoing emergency percutaenous coronary intervention

Background

Acute kidney injury (AKI) is associated with a worse overall prognosis in patients with ST-elevation myocardial infarctions (STEMI). At the same time bleeding complications during emergency percutaneous interventions (PCI) in STEMI-patients are often associated with hemodynamic impairement, which might contribute to renal tissue damage. Aim of the present study was to investigate an association between bleeding complications and AKI and the interaction between bleedings events and other possible contributors to AKI.

Methods

All patients with STEMI admitted to a German heart center between 2006 and 2020 were analysed. AKI was defined as KDIGO stage ≥1. Bleedings were characterised by BARC criteria or by decrease in total hemoglobin (ΔHb = Hb(admission) − Hb(minimal).

Results

Of a total of 7381 patients, 6805 (92%) showed no or only minmal bleedings (BARC 0/1), in 300 (4%) a BARC 2 bleeding, in 200 (3%) a BARC 3a and in 76 (1%) a BARC 3b/c or 5-major-bleeding event was documented. In patients with bleeding events, higher age, female gender (BARC 0/1: 25%, BARC 3b/c+5: 41%) and cardiogenic shock (BARC 0/1: 11%, BARC 3b/c and 5: 38%) were more prevalent. Furthermore BARC was associated with higher rates of AKI (BARC 0/1: 13%, BARC 2: 24%, BARC 3a: 43%, BARC 3b/c+5: 57%, p (for trend) &lt;0.01). Of the significant bleedings (≥BARC 2) 51% were femoral/retroperitoneal, 21% gastrointestinal, 2% intracerebral and 26% various. When estimating AKI-rates by decrease in Hemoglobin (ΔHb = Hb(admission) − Hb(minimal during the hospital stay in the PCI-center)), an association between any decrease in hemoglobin and AKI-rate was evident: ΔHb &lt;1 g/dL: AKI-rate: 7%, ΔHb 3 to 3.9 g/dl: 29%, ΔHb ≥6 g/dl: 57%, p (for trend) &lt;0.01. For every 1 g/dl decrease in hemoglobin, AKI-rates increased by on average the factor 1.44. When comparing the impact of the amount of contrast media (CM) used during emergency-PCI and Hb-decrease on AKI-rates it became evident that while higher CM-doses were associated with a modest rise in AKI-rates, the effect of an Hb-decrease on AKI-rates was more pronounced. A major decrease in Hemoglobin (≥4 g/dl) was associated with an at least 3.5 fold higher risk for AKI irrespective of amount of contrast media applied (Figure).

Conlusions

This registry data shows that bleeding events in STEMI-patients, classified by BARC-criteria or alternatively stratified by decrease in hemoglobin-levels are closely associated with incidence-rates of AKI. This indicates the importance of bleeding complications and its hemodynamic alterations in STEMI, which most likely contribute to renal tissue damage. Less access site complications might therefore result in renal protection.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): State of BremenStiftung Bremer Herzen Predictors of AKI in STEMI

Temporal trends in adverse ischemic events, bleedings, kidney injury and overall mortality for patients with ST-elevation myocardial infarctions and advanced kidney disease

Background

Although the negative effects of advanced chronic kidney disease (CKD) on the pathogenesis and prognosis of coronary artery disease (CAD) has been shown in prior studies, there is few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD. Aim of the present study was to analyse temporal trends in patients with ST-elevation myocardial infarctions (STEMI) and advanced CKD during the last 15 years.

Methods

All STEMI-Patients admitted to a German heart center between 2006–2019 were analysed. Advanced CKD, estimated with the CKD-EPI-equation, was defined as stage ≥G3b (glomerular filtration rate (GFR) &lt;45 ml/min). Cumulative ischemic events at 1 year were defined as a combination of in-stent-thrombosis, myocardial re-infarction and repeat target-lesion-revascularisation

Results

Of a total of 9605 patients, 1013 (10.6%) showed a moderately or severely (G3b-G5) reduced renal function with a mean baseline Serum creatinine of 2.2±4.2 mg/dl and a GFR of 32.3±10 ml/min/1.73 m2. CKD-Patients were less likely to be treated with a primary percutaneous coronary interention (PCI): 84.1 vs. 94.1% (p&lt;0.01) and showed higher all-cause-mortality (44.4 vs. 3.6%, p&lt;0.01) and bleeding-rates (9.4 vs 3.7%, p&lt;0.01) compared to non-CKD-patients at 1 year, while cumulative ischemic events did not differ (6.5 vs. 5.1%, p=0.12). Over time however, patients with advanced CKD were also more likely to be treated with primary PCI (2006–10: 75.8 to 2015–19: 90.1%, p&lt;0.01), ticagrelor/prasugrel (1.7 to 59.6%, p&lt;0.01) and drug eluting stents (DES: 1.3 to 90.7%, p&lt;0.01). After adjustment for confounders (multivariate analysis of outcomes adjusted for age, gender, diabetes and cardiogenic shock) patients with advanced CKD showed a decline in ischemic events at 1 year, however offset by an increase in bleedings (table). Neither overall mortality nor rates of acute kidney injury changed over time (table), despite an increase in amount of contrast media used (132±62 ml to 152±73 ml, p&lt;0.01). In patients with advanced CKD both ticagrelor/prasugrel (OR 0.48, 95% CI 0.2–0.98) and DES (OR 0.38, 95% CI 0.2–0.8) were associated with a decrease in ischemic-events.

Conclusions

This registry data shows, that during the last 15 years STEMI-patients with advanced CKD were more likely to be treated with primary PCI and are in their majority now treated with ticagrelor, prasugrel and modern DES. These changes in therapeutic strategies probably have contributed to the decline in adverse ischemic events, while overall mortality was not affected.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): State of BremenStiftung Bremer Herzen Multivariate outcome analysis over time

Long-Term Effects of an Intensive Prevention Program After Acute Myocardial Infarction

Effective long-term prevention after myocardial infarction (MI) is crucial to reduce recurrent events. In this study the effects of a 12-months intensive prevention program (IPP), based on repetitive contacts between non-physician "prevention assistants" and patients, were evaluated. Patients after MI were randomly assigned to the IPP versus usual care (UC). Effects of IPP on risk factor control, clinical events and costs were investigated after 24 months. In a substudy efficacy of short reinterventions after more than 24 months ("Prevention Boosts") was analyzed. IPP was associated with a significantly better risk factor control compared to UC after 24 months and a trend towards less serious clinical events (12.5% vs 20.9%, log-rank p = 0.06). Economic analyses revealed that already after 24 months cost savings due to event reduction outweighted the costs of the prevention program (costs per patient 1,070 € in IPP vs 1,170 € in UC). Short reinterventions ("Prevention Boosts") more than 24 months after MI further improved risk factor control, such as LDL cholesterol and blood pressure lowering. In conclusion, IPP was associated with numerous beneficial effects on risk factor control, clinical events and costs. The study thereby demonstrates the efficacy of preventive long-term concepts after MI, based on repetitive contacts between non-physician coworkers and patients.

Efficacy of Drug-Eluting Stents in Diabetic Patients Admitted with ST-Elevation Myocardial Infarctions Treated with Primary Percutaneous Coronary Intervention

Background: Diabetic patients show higher adverse ischemic event rates and mortality when undergoing percutaneous coronary intervention (PCI) in acute myocardial infarctions. Therefore, diabetic patients might benefit even more from modern-generation drug-eluting stents (DES). The aim of the present study was to compare adverse ischemic events and mortality rates between bare-metal stents (BMS) and DES in diabetic patients admitted with ST-elevation-myocardial infarction (STEMI) with non-diabetic patients as the control group. Methods: All STEMI patients undergoing emergency PCI and stent implantation documented between 2006 and 2019 in the Bremen STEMI registry entered the analysis. Efficacy was defined as a combination of in-stent thrombosis, myocardial re-infarction or additional target lesion revascularization at one year. Results: Of 8356 patients which entered analysis, 1554 (19%) were diabetics, while 6802 (81%) were not. 879 (57%) of the diabetics received a DES. In a multivariate model, DES implantation in diabetics compared to BMS was associated with lower rates of in-stent thrombosis (OR 0.16, 95% CI 0.05–0.6), myocardial re-infarctions (OR 0.35, 95%CI, 0.2–0.7, p < 0.01) and of the combined endpoint at 1 year ((ST + MI + TLR): OR 0.31, 95% CI 0.2–0.6, p < 0.01), with a trend towards lower 5-year mortality (OR 0.56, 95% CI 0.3–1.0, p = 0.058). When comparing diabetic to non-diabetic patients, an elevation in event rates for diabetics was only detectable in BMS (OR 1.78, 95% CI 0.5–0.7, p < 0.01); however, this did not persist when treated with a DES (OR 1.03 95% CI 0.7–1.6, p = 0.9). Conclusions: In STEMI patients with diabetes, the use of DES significantly reduced ischemic event rates and, unlike with BMS, adverse ischemic event rates became similar to non-diabetic patients.

Impact of COVID-19 Pandemic on Presentation and Outcome of Consecutive Patients Admitted to Hospital Due to ST-Elevation Myocardial Infarction

Impact of COVID-19 pandemic and pandemic-related social restrictions on clinical course of patients treated for acute ST-elevation myocardial infarction (STEMI) is unclear. In the present study presentation and outcome of patients with STEMI in the year 2020 were compared with the years before in a German registry that includes all patients hospitalized for acute STEMI in a region with approximately 1 million inhabitants. In the year 2020 726 patients with STEMI were registered compared with 10.226 patients in the years 2006 to 2019 (730 ± 57 patients per year). No significant differences were observed between the groups regarding age, gender and medical history of patients. However, in the year 2020 a significantly higher rate of patients admitted with cardiogenic shock (21.9% vs 14.2%, p <0.01) and out-of-hospital cardiac arrest (OHCA) (14.3% vs 11.1%, p <0.01) was observed. The rate of patients with subacute myocardial infarction (14.3% vs 11.6%, p <0.05) was elevated in 2020. Hospital mortality increased by 52% from the years 2006 to 2019 (8.4%) to the year 2020 (12.8%, p <0.01). Only 4 patients (0.6%) with STEMI in the year 2020 had SARS-CoV-2 infection, none of those died in-hospital. In conclusion, in the year 2020 a highly significant increase of STEMI-patients admitted to hospital with advanced infarction and poor prognosis was observed. As the structure of the emergency network to treat patients with STEMI was unchanged during the study period, the most obvious reason for these changes was COVID-19 pandemic-related lockdown and the fear of many people to contact medical staff during the pandemic.

Long-term effects of an intensive prevention program (IPP) after acute myocardial infarction – the IPP Follow-up and Prevention Boost Trial

Background

The effects of an intensive prevention program (IPP) for 12 months following 3-week rehabilitation after myocardial infarction (MI) have been proven by the randomized IPP trial. The present study investigates if the effects of IPP persist one year after termination of the program and if a reintervention after &gt;24 months (“prevention boost”) is effective.

Methods

In the IPP trial patients were recruited during hospitalization for acute MI and randomly assigned to IPP versus usual care (UC) one month after discharge (after 3-week rehabilitation). IPP was coordinated by non-physician prevention assistants and included intensive group education sessions, telephone calls, telemetric and clinical control of risk factors. Primary study endpoint was the IPP Prevention Score, a sum score evaluating six major risk factors. The score ranges from 0 to 15 points, with a score of 15 points indicating best risk factor control.

In the present study the effects of IPP were investigated after 24 months – one year after termination of the program. Thereafter, patients of the IPP study arm with at least one insufficiently controlled risk factor were randomly assigned to a 2-months reintervention (“prevention boost”) vs. no reintervention.

Results

At long-term follow-up after 24 months, 129 patients of the IPP study arm were compared to 136 patients of the UC study arm. IPP was associated with a significantly better risk factor control compared to UC at 24 months (IPP Prevention Score 10.9±2.3 points in the IPP group vs. 9.4±2.3 points in the UC group, p&lt;0.01). However, in the IPP group a decrease of risk factor control was observed at the 24-months visit compared to the 12-months visit at the end of the prevention program (IPP Prevention Score 10.9±2.3 points at 24 months vs. 11.6±2.2 points at 12 months, p&lt;0.05, Figure 1).

A 2-months reintervention (“prevention boost”) was effective to improve risk factor control during long-term course: IPP Prevention Score increased from 10.5±2.1 points to 10.7±1.9 points in the reintervention group, while it decreased from 10.5±2.1 points to 9.7±2.1 points in the group without reintervention (p&lt;0.05 between the groups, Figure 1).

Conclusions

IPP was associated with a better risk factor control compared to UC during 24 months; however, a deterioration of risk factors after termination of IPP suggests that even a 12-months prevention program is not long enough. The effects of a short reintervention after &gt;24 months (“prevention boost”) indicate the need for prevention concepts that are based on repetitive personal contacts during long-term course after coronary events.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Stiftung Bremer Herzen (Bremen Heart Foundation)

Development of 1- and 5-year outcomes between 2006 and 2018 in patients with uncomplicated ST-elevation myocardial infarctions and successful percutaneous coronary intervention

Introduction

While modern P2Y12-inhibitors and drug eluting stents (DES) have changed therapeutic options in patients with ST-elevation mycoardial infarctions (STEMI) during the last decade, there is few data on their impact in real world registries. Aim of the present study was to analyze changes in mortality and major adverse cardiac and cererobrovascular event rates (MACCE: death, reinfarction,stroke) during the last 13 years in patients with uncomplicated STEMI after successful percutaneous coronary intervention (PCI).

Methods

All consecutive STEMI-patients, admitted between 2006 and 2018 and successfully treated with PCI (TIMI flow ≥2) in a large German heart center entered analysis. To reduce confounding pts. with STEMI complicated by heart failure and pts. &gt;70 yrs. of age were excluded.

Results

A STEMI-cohort of 5016 pts. was analysed, with a mean age of 55.9±8 yrs., 19% females, 16% diabetics and 59% smokers. At the beginning of the study period (2006) no patient was treated with ticagrelor/prasugrel and only 5% had a DES implanted. In 2018 92% were treated with prasugrel or ticagrelor and 96% with a DES. The reduction in 1-year-mortality during the study period was not significant: 2006–11: 3.4%, 2012–19: 3.1%, p=0.4, however the reduction in 1-year-MACCE was: 2006–11: 8.3%, 2012–18: 5.7%, p&lt;0.01. This could mainly be attributed to a reduction in reinfarctions: 2006–11: 4.9%, 2012–18: 2.8%, p&lt;0.01. Subgroup analysis revealed that with the exception of diabetics all subgroups showed a significant decline in MACCE-rates during the study period. It was more pronounced in women, non-smokers and patients with a high socioeconomic status (SES) (Table). Analysis of 5-year-data revealed a significant reduction in both 5-year-mortality (2006–09: 9.1%, 2010–13: 6.8%, p&lt;0.01) and 5-year-MACCE-rates: 2006–09: 19.3%, 2010–13: 14.5%, p&lt;0.01.

Conclusions

This analysis of registry data over a study period of 13 years reveals, that for patients with uncomplicated STEMI and successful PCI a significantly better 1- and 5-year-outcome could be achieved during the last years. This improvement of prognosis was more pronounced in specific subgroups, such as women, non-diabetics and patients with higher SES.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Bremer Herzen, Gesundheit Nord

P6214How to improve long-term prevention in young patients after myocardial infarction - the IPP-Y study

Background

Patients who experienced myocardial infarction (MI) at a young age are of special medical and socioeconomic interest; cardiovascular risk factor control to prevent recurrent events is crucial in this specific cohort.

Objectives

The purpose of the study was to evaluate long-term risk factor control in young MI-patients in clinical practice and investigate the effects of a modern intensive prevention program in a prospective randomized trial. In a genetic substudy it was analyzed if prevention effects were depending on individual genetic risk.

Methods

Patients who had MI at age of ≤45 years were revisited after a mean period of 5.7±4.0 years to evaluate long-term risk factor control. Furthermore a 12-months intensive prevention program in young MI-patients (IPP-Y), coordinated by non-physician prevention assistants and including personal teachings, telephone contacts, clinical and telemetric control of risk factors, was compared to usual care in a randomized trial. Primary endpoint of the randomized trial was prevention success, defined as improvement of one of the risk factors smoking, LDL cholesterol or physical inactivity without deterioration of the others. As the opposite prevention failure was defined as deterioration of one of the risk factors without improvement of the others. Genetic risk was assessed by polygenetic risk scores, based on 163 SNPs.

Results

Only a minority of the 277 young patients after MI achieved guideline-recommended risk factor targets at long-term follow-up visits: mean body mass index was 29.9±5.1 kg/m2, just 14.8% had a body mass index <25 kg/m2. More than one third (38.3%) were persistent or recurrent smokers. Mean LDL cholesterol level was 94±38 mg/dl, only 27.1% of the patients achieved LDL cholesterol levels <70 mg/dl.

However, the long-term prevention program IPP-Y led to a higher rate of the primary endpoint prevention success (IPP-Y: 49% vs. UC: 27%, p<0.05) and a lower rate of prevention failure (IPP-Y: 15% vs. UC: 38%, p<0.05) compared to usual care after 12 months (see figure). Telemetric control of risk factors as part of the prevention program was used by 71.4% of the patients.

In the genetic subanalysis prevention effects were found in both, patients with high genetic risk as well as patients with low genetic risk assessed by polygenetic risk scores (p=0.79 high vs. low genetic risk).

Effects of IPP-Y during 12 months

Conclusions

To our knowledge this is the first study on young patients with MI that demonstrates insufficient long-term risk factor control in clinical practice and significant effects of an intensive prevention program. Prevention effects were independent from individual genetic risk.

Acknowledgement/Funding

This work was supported by the Stiftung Bremer Herzen, Bremen, Germany and the Stiftung Bremer Wertpapierbörse, Bremen, Germany

P2660Definition of clinically relevant thresholds of acute kidney injury in patients with ST-elevation myocardial infarctions undergoing primary percutaneous coronary interventions

Background

Although the clinical importance of deteriorating kidney function in patients with ST-elevation-myocardial infarctions (STEMI) on overall prognosis is generally accepted, there is conflicting evidence on the importance of small changes in renal function. Aim of the present study was to calculate clincially relevant thresholds for deterioration of renal function after STEMI.

Methods

From a large registry of patients with STEMI renal function was estimated calculating the glomerular filtration rate (GFR in ml/min/1.73 m2) with the CKD-EPI-equation. To assess acute kidney injury the ratio GFR (at peak creatinine))/ GFR (at admission) was calculated for each patient (with 1 representing no change). Patients were graded by GFR-reduction and assigned to 11 groups (G1 to G11) each representing 5% intervals.

Results

Of 6583 patients admitted with STEMI between 2006–2017 3518 (53%) had no change or a change <5% during hospital stay (G1) while 161 (3%) showed a decrease in GFR of ≥50% (G11). The rest of the patients could be attributed to G2- G10 (table). There was a pronounced correlation between extent of GFR-reduction and peak creatine kinase (indicating size of STEMI, r2=0.785; G1: 1521±1684 U/l vs. G11: 2885±2943 U/l, p<0.01) as well as left-ventricular ejection fraction (LVEF) (r2=0.79; G1: 50.9±9% vs. G11: 41.4±10%, p<0.01). However, no such correlation could be detected between GFR-reduction and amount of contrast media (CM) applied (r2=0.05, G1: 141±60 ml vs. G11: 139±61 ml, p=0.5). Analysis of outcome-data (1-year-mortality and major adverse cardiovascular and cerebrovascular events (MACCE: death, stroke, re-infarction)) revealed, that beneath a threshold of 25% deterioration of renal function did not significantly impact prognosis, while higher degrees of deterioration led to a 7-fold increase in mortality and a 5-fold increase in MACCE-rates (table).

Impact of GFR-reduction on outcome Group G1 G2 G3 G4 G5 G6 G7 G8 G9 G10 G11 GFR-reduction (in %) 0–4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 ≥50 Patients, n (%) 3518 (53) 881 (13) 717 (11) 492 (7) 327 (5) 196 (3) 119 (2) 88 (1) 48 (1) 36 (1) 161 (3) 1 year mortality (%) 7 4 5 8 7 15 20 22 39 43 50 1-year-MACCE (%) 12 8 8 12 10 19 27 27 49 49 52

Conclusions

These data from a large STEMI-registry show that small changes (less than 25%) in GFR did not significantly impact long-term outcome, while the impact was pronounced for all patients beyond that threshold. The degree of renal deterioration furthermore correlated with size of STEMI as well as reduction of LV-function after STEMI while no correlation to amount of contrast media could be found.

465Benefit of modern P2Y12-inhibitors on long-term prognosis in patients with ST-elevation myocardial infarction with and without advanced chronic kidney disease

Background

Current guidelines on the management of patients with ST-elevation myocardial infarction (STEMI) recommend the preferred use of the modern P2Y12-inhibitors ticagrelor or prasugrel regardless of the presence of chronic kidney disease (CKD), although patients with advanced stages of CKD were excluded from randomized trials. Aim of the present study was therefore to evaluate the potential benefit of modern P2Y12-inhibitors in patients with and without advanced renal disease at admission.

Methods

All patients admitted with STEMI between 2006–2017 from a large german heart center treated with primary percutaneous coronary intervention (PCI) entered analysis. Initial CKD was estimated with the initial glomerular filtration rate (GFR), calculated with the CKD-EPI-equation, assigning them to the groups G1-G5.

Results

Of 7227 patients with STEMI and primary PCI 2669 (37%) showed no relevant reduction in GFR at admission (≥90 ml/min/1.73 m2, G1), 2976 pts. (41%), a slight reduction (GFR 60–89 ml/min/1.73 m2, G2), 880 pts. (12%) a moderate reduction (GFR 45–59 ml/min/1.73 m2, G3a) and 702 pts. (10%) a moderate to severe reduction (GFR<45 ml/min 1.73 m2, G3b-G5). Pts. with more advanced stages of CKD were on average older (G1: 55±11 years, G2: 66±12 years, G3a: 72±12 years, G3b-G5: 75±11 years, p<0.01) and more likely to be female (G1: 19%, G2: 26%, G3a: 40%, G3b-G5: 48%, p<0.01). Prasugrel/ticagrelor were less often given instead of clopidogrel in patients with advanced CKD (G1: 70%, G2: 45%, G3a: 31%, G3b-G5: 32%, p<0.01). The use of ticagrelor/prasugrel was associated with a reduction in 1-year-MACCE (major adverse cardio- and cerebrovascular events)-rates in patients with no/low-grade-CKD (G1-G2), while no significant reduction in MACCE could be observed for patients with moderate to severe CKD (table). Furthermore, CKD was associated with an elevation in severe bleeding events within 1 year (G1: 1%, G2: 3%, G3a: 5%, G3b-G5: 6%, p<0.01).

Impact of CKD-stage on outcome CKD-stage G1 CKD-stage G2 CKD-stage G3a CKD-stage G3b-G5 1-year-MACCE-rate (%) Ticagrelor/prasugrel 4.5 11.0 27.4 47.3 Clopidogrel 9.9 15.6 26.6 50.4 Significance <0.01 <0.01 0.6 0.7

Conclusions

These data from a large STEMI-registry demonstrate, that modern P2Y12-inhibitors were less often used in patients with CKD and their benefit regarding MACCE disappeared in advanced stages of CKD while bleeding rates increased. These results underline the special role of patients with advanced stage-CKD in STEMI and the necessity of specialized randomized trials for these patients.

Efficacy and Safety of Ticagrelor in Comparison to Clopidogrel in Elderly Patients With ST-Segment-Elevation Myocardial Infarctions

Background Current guidelines recommend the new-generation P2Y12-inhibitor ticagrelor for patients with acute ST-segment-elevation myocardial infarctions (STEMIs). The aim of the present study was to assess efficacy and safety of ticagrelor for elderly patients with STEMI (≥75 years) in an all-comers STEMI registry. Methods and Results Patients with STEMI, aged ≥75 years, treated with primary percutaneous coronary intervention and documented in the Bremen STEMI Registry between 2006 and 2017 entered analysis. The primary efficacy outcome, major adverse cardiac and cerebrovascular events, was defined as a composite of death, myocardial reinfarction, and stroke. The safety outcome was defined as any significant bleeding event within 1 year. To estimate benefit/risk ratio, net adverse clinical events (major adverse cardiac and cerebrovascular events+bleedings) were calculated. Outcomes were estimated in propensity score-matched cohorts to adjust for possible confounders. Of a total of 7466 patients with STEMI, 1087, aged ≥75 years, were selected, of which 552 (51%) received clopidogrel and 535 (49%) received ticagrelor, with similar age (80.9±4.6 versus 80.9±4.6 years) and sex (51% versus 50% female) distributions between treatment arms. The primary efficacy outcome occurred in 32.4% of patients treated with clopidogrel versus 25.5% treated with ticagrelor (P=0.015), with the 1-year mortality rate at 26.8% versus 21.1% (P=0.035). Because there was no difference in the safety outcome (clopidogrel versus ticagrelor, 4.9% versus 5.1%; not significant), net adverse clinical events were higher for clopidogrel than for ticagrelor: 37.3% versus 30.6% (P=0.028). In a propensity score-matched model, the advantage for ticagrelor on major adverse cardiac and cerebrovascular events remained significant (hazard ratio, 0.69; 95% CI, 0.49-0.97; P=0.03), whereas 1-year-mortality (hazard ratio, 0.89; 95% CI, 0.67-1.27; P=0.5) and 1-year bleeding events (hazard ratio, 1.1; 95% CI, 0.4-2.3; P=0.8) did not differ. Conclusions These results from propensity score-matched registry data show that for elderly patients with STEMI, ticagrelor compared with clopidogrel was associated with a reduction in major adverse cardiac and cerebrovascular events without a significant increase in bleeding events within 1 year.