Comparison of factors associated with ST-segment elevation myocardial infarction (STEMI) complications in young versus older adults: A post hoc analysis of a single-centre registry

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Acute ST-Elevation Myocardial Infarction in the Young Compared With Older Patients in the Tamil Nadu STEMI Program

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Background The best treatment option for elderly patients with acute myocardial infarction (MI) remains unclear. Purpose We aimed to determine clinical practice and outcomes of PCI with a new generation DES in patients with ST-elevated MI (STEMI), aged ≥80 years included in a one of the largest real-world PCI registries. Methods e-Ultimaster is a prospective, world-wide, multi-centre registry that enrolled 36,671 patients with coronary artery disease, treated with a thin strut sirolimus-eluting stent with abluminal bioresorbable polymer coating, across 50 countries. 34,538 patients who completed 1-year follow-up or who died were included in the analysis. The primary endpoint was 1-year target lesion failure (TLF: cardiac death, target vessel (TV) MI, clinically driven (CD) target lesion revascularization (TLR)). An Clinical Event Committee adjudicated all endpoint-related adverse events. Results 6863 presented with STEMI at baseline (19.9%). Mean age of STEMI patients was 61.0±11.7 years, with 78.8% males. Diabetes was present in 20.9% and hypertension in 52.4%. Of 6863 STEMI patients, 430 patients (6.2%) were aged ≥80 years, with 46.5% females compared to 19.5% females in the younger group. Patients in the older group had more comorbidities (hypertension and renal impairment) and more often took oral anticoagulant medication (9.2% vs 3.9%; p&amp;lt;0.001). At discharge 94.9% of older STEMI patients were on dual antiplatelet therapy (DAPT) as compared to 97.6% of younger STEMI patients (p=0.002). Older STEMI patients more often took clopidogrel as second antiplatelet agent (54.7% vs 39.8%; p&amp;lt;0.001) and were less often on prasurgrel (2.3%vs 10.9%; p&amp;lt;0.001) and ticagrelor (41.2% vs 48.1%; p=0.005). STEMI patients in the older group more often had multivessel disease (52.1 vs 45.8%; p=0.01), treatment of the left main artery (4.7 vs 1.4%; p&amp;lt;0.001) and more calcified lesions (18.8 vs 11.2%; p&amp;lt;0.001). Other lesion characteristics were similar between the two groups. Preferred access approach was radial and was alike in the two groups (87.0 vs 84.0%; p=0.10) In-hospital mortality was more frequent in older STEMI patients (2.3% vs 0.8%; p=0.003). More bleedings were observed in older vs younger STEMI patients at discharge. One-year TLF was significantly higher in older age group (7.0% vs 3.0%; p&amp;lt;0.01), mainly driven by increased rates of cardiac death. All-cause mortality and bleedings were also more frequent in older STEMI patients. No differences were observed in revascularization or ST rates (1.4 vs 1.1%; p=0.48). Conclusions In elderly patients with STEMI, in-hospital mortality rates as well as bleeding rates were higher as compared to younger patients, while 1-year rates of revascularization and ST did not differ between the groups. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Terumo Europe

Background: Morphine is commonly used for analgesia in the setting of chest discomfort associated with acute coronary syndromes (ACS). However, a retrospective analysis in non-ST elevation acute coronary syndrome (NSTE-ACS) patients suggesting increased mortality with morphine administration and further studies suggesting morphine may delay and inhibit the absorption of the oral anti-platelet agents has placed its utility in ACS under closer scrutiny. In a large single center retrospective study, we analyzed the association between morphine and in-hospital outcomes in ST elevation myocardial infarction (STEMI) and NST-ACS patients undergoing coronary angiogram +/- percutaneous coronary intervention (PCI). Methods: All STEMI and NSTE-ACS patients undergoing PCI between January 2009 and July 2016 in Massachusetts General Hospital were included in our study. Following institutional board review approval, baseline patient characteristics (demographics, risk factors and medical history) was obtained. In-hospital outcomes included mortality, post-procedure cardiogenic shock, length of hospital stay and infarct size as measured by troponin level. Results: Overall, 3027 patients were examined. Of those, 1287/3027 (42.52%) had STEMI, of which 359/1287 patients received morphine (27.89%). STEMI patients who received morphine were younger, had a higher prevalence of prior MI, PCI, and angina, were more likely to be on oxygen therapy, and had a longer time to PCI. 1740/3027 (57.48%) of study patients had NST-ACS, of which 424 (24.37%) received morphine. NSTE-ACS patients who received morphine were younger, had a higher prevalence of cerebrovascular disease, peripheral vascular disease, prior PCI, MI, congestive heart failure and valvular surgery. In unadjusted outcomes, STEMI patients who received morphine had a lower in-hospital mortality [4.18% versus 7.54%, odds ratio (OR): 0.53, p=0.03] and smaller infarct size (mean troponin level 0.75 ng/ml versus 1.29 ng/ml, p=0.02). There was no significant difference in post procedure cardiogenic shock or length of hospital stay (p= 0.26 and p=0.29 respectively). After adjusting for basic characteristics no outcomes remained significant in the STEMI cohort. In the NST-ACS cohort, patients who received morphine had a longer hospital stay (mean 6.58 days versus 4.78 days, p&lt;0.0001) and larger infarct size (mean troponin 1.16 ng/ml versus 0.90 ng/ml, p= 0.05). There was no statistical difference in in-hospital mortality or cardiogenic shock (p=0.17 and p=0.80 respectively). After adjusting for basic characteristics, length of hospital stay (p &lt;0.0001) and infarct size (p=0.02) remained significant. Conclusion: In a large retrospective study, morphine was associated with larger infarct size and a longer hospital admission in NSTE-ACS patients but had no effect on outcomes in STEMI patients.

Objective To investigate the clinical characteristics and risk factors of non-premature STEMI patients underwentprimaryPCI with multivessel disease. Methods Data of clinic and coronary angiographic features were retrospectively compared between group of 371 younger STEMI patients (male age <55 years, female <65 years)and group of 662 older STEMI patients. All patients were admitted to hospital from January 2005 to January 2015 and treated with primary PCI. The patients’ gender, smoking history, family history of coronary heart disease (CHD), hypertension, type 2 diabetes mellitus, previous myocardial infarction and revascularization, stroke history, serum uric acid, lipids etc. were documented. The comparison of coronary artery disease characteristics and the incidence of adverse events during hospitalization were also carried out between two groups. Results (1) Prevalence of males(88.4% vs.76.9%), smokers(74.9% vs.51.5%), family history of CHD(21.0% vs.9.7%)and levels of diastolic blood pressure, total cholesterol, low density lipoprotein cholesterol (LDL-c), triglycerides, and low cholesterol were significantly higher in the non-prematuregroup than in the premature group (all P<0.01), while high density lipoprotein cholesterol (HDL-c)was lower in non-prematuregroup (P<0.01). (2) The incidence of in-hospital events in both groups were low. There was less ventricular tachycardia in the non-premature group (1.5% vs.0.3%)(P<0.05). (3) There were no statistically significant differences in the number of infarct vessels, site ofinfarctbetween two groups.(4) Logistic regression analysis showed that smoking(OR=2.22, 95%CI: 1.588-3.108)(P<0.05), family history of CHD(OR=2.12, 95%CI: 1.431-3.140)(P<0.05), triglyceride concentration(OR=1.971, 95%CI: 1.475-2.635)(P<0.05), LDL-c(OR=1.193, 95%CI: 1.008-1.413)(P=0.04)were independent risk factors fornon-premature STEMI withmultivessel disease. Conclusion Smoking, family history of CHD, triglyceride concentration, LDL are main risk factors of younger age STEMI patients with multiple vessel disease; Compared with younger age patients, older age patients during hospitalization are more likely to occur ventricular tachycardia. Regardless of age difference, the characteristics of coronary artery lesions show no significant difference. Key words: ST-segment elevation myocardial infarction; Multivessel disease; Non-premature; Risk factors; Clinical features; Primary percutaneous coronaryintervention; Smoking; Family history; Dyslipidemia

BALLOON OR NEEDLE: SEX DIFFERENCES IN STEMI TREATMENT

Introduction Acute clinical presentations of coronary artery disease include ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). Whereas STEMI presentations tend to be due to persistent thrombotic coronary artery occlusion requiring immediate revascularisation, NSTEMI presentations tend to be associated with transient thrombotic occlusion and critical stenosis of the culprit vessel which may initially be managed with aggressive anti-platelet and anti-ischaemic therapy. Aims The aim of this study was to compare the annual incidence, demographic characteristics, in-hospital mortality rates, 3-year mortality rates and independent predictors of death in patients presenting with STEMI vs NSTEMI acute coronary syndromes. Methods We performed a retrospective study of patients admitted via our casualty department between January and December 2006, with a confirmed diagnosis of STEMI or NSTEMI. All patients had prolonged cardiac chest pain or equivalent ischaemic symptoms associated with a serum troponin T rise. Categorisation into STEMI or NSTEMI was based on typical ECG changes. The variables analysed included age, gender, ethnicity, hypertension, diabetes, hyperlipidaemia, smoking, previous ischaemic heart disease and chronic renal impairment. The rates of coronary angiography, revascularisation, in-hospital death and 3-year death were also assessed. Results The study cohort consisted of 111 STEMI and 322 NSTEMI patients with a follow-up period of 3 years. Comparative data are given below in Abstract 124 Tables 1 and 2: The STEMI group were younger and had a higher proportion of men and smokers, whereas the NSTEMI group had a higher prevalence of diabetes, hypertension, previous IHD and chronic renal disease. Although STEMI patients had higher coronary angiographic and revascularisation rates than NSTEMI patients, in-hospital death rates in the two groups were similar. However, the 3-year death rate was more than twofold higher in the NSTEMI compared to STEMI group. Age (p=0.007) was the only independent predictor of 3-year mortality in STEMI patients, whereas age (p Conclusion In conclusion, our study demonstrates a significant difference in comorbidities, revascularisation rates and 3-year mortality rates among STEMI and NSTEMI patients. NSTEMI patients were older, had more comorbidities and higher death rates than STEMI patients. Age was the most robust independent predictor of death in both groups and chronic renal disease, when present, also asserted an adverse prognostic outcome.

Since the initial scientific statement on Secondary Prevention of Coronary Heart Disease (CHD) in the Elderly was published in 2002,1 several trends have continued that make an update highly appropriate. First, the graying of the US population and those of other industrialized countries has progressed unabated because more adults are surviving into their senior years. The number of Americans aged ≥75 years was estimated at 18.6 million in 2010, representing ≈6% of the population,2 and it is expected to double by 2050. The population aged ≥85 years is growing the most rapidly, with numbers expected to reach 19.5 million by 2040. In 2008, 67% of the 811 940 cardiovascular deaths in the United States occurred in people aged ≥75 years.3 In parallel to this increase in the older adult demographic, the number of Americans with CHD has increased to an estimated 16.3 million, more than half of whom are >65 years of age.3 Similarly, 7 million have had a stroke, the incidence of which approximately doubles with successive age decades after 45 to 54 years.3 Peripheral artery disease (PAD) affects 8 to 10 million Americans, the majority of whom are >65 years of age. Between 2015 and 2030, annual US costs related to atherosclerotic cardiovascular disease (ASCVD) are projected to increase from $84.8 billion to $202 billion.3 Moreover, given that ASCVD often undermines functional capacity and independence and increases reliance on long-term care, indirect expenses related to ASCVD are also expected to increase. Thus, the need for effective secondary prevention measures in the older adult population with known ASCVD has never been greater. Notably, the 2011 American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) updated guidelines for secondary prevention of CHD broadened …

Objectives The objectives of this study were to compare primary percutaneous coronary intervention (PCI) with the strategy of fibrinolysis combined with coronary angiography within 6–24 h in ST-segment elevation myocardial infarction (STEMI) patients who presented within 3 h of symptom onset. Background Guidelines for acute STEMI patients recommend primary PCI as the favorable reperfusion strategy. This approach is contingent on performing PCI in a timely manner. Most patients do not attend PCI-capable hospitals; this factor has led to major challenge in many regions. Patients and methods This was a prospective, single-center study that included 100 consecutive STEMI patients admitted to the ER Unit at the National Heart Institute between June 2013 and December 2015. Cases were divided into the following groups: group A included 50 STEMI patients with onset of symptoms within 3 h and received fibrinolysis with streptokinase followed by timely coronary artery with or without PCI using the left redial approach, and group B included 50 patients who underwent primary PCI. In-hospital outcomes were reviewed and reported after 30 days. Results No statistically significant differences among groups were found with respect to mean age, sex, pulse, blood pressure, prevalence of previous stroke, peripheral arterial disease, previous myocardial infarction, previous PCI or previous coronary artery bypass graft, the duration from onset of symptoms to emergency department (ED) arrival, number of vessels treated, maximum inflation pressure, use of drug eluting stents, number of stents at target lesion, stent length, total stent length, mean nominal stent diameter, and incidence of cardiac deaths. In contrast, highly significant differences were observed in both groups regarding the prevalence of visible thrombus (P = 0.00), initial diameter stenosis (P = 0.031), total occlusion (P = 0.00), and baseline TIMI flow grade (P = 0.00) as the incidence was significantly higher in group B compared with group A. Highly significant differences were observed among group A and group B regarding severe bleeding, heart failure, and overall complications (P = 0.00 for all). Conclusion Left radial strategy for primary/delayed PCI in acute elevation of ST patients with previous myocardial infarction is feasible, safe, and successful with low incidence of complications. Early fibrinolytic therapy combined with early percutaneous intervention is a favorable choice for management of acute STEMI patients.

Purpose: Acute Kidney Injury (AKI) is mostly defined as an increase in serum creatinine and is observed in up to 19% of ST-Elevation Myocardial Infarction (STEMI) patients. Important mechanisms of AKI in STEMI patients are renal hypoperfusion due to a large infarcts, the use of nephrotoxic agents in particular during Primary Percutaneous Coronary Intervention (PPCI), activation of sympathetic and renin-angiotensin-aldosteron system, inflammation, etc. Our purpose was to evaluate the incidence of AKI in STEMI patients, the impact of AKI upon survival in STEMI patients and predictors of AKI in STEMI patients. Methods: We retrospectively evaluated 681 STEMI patients, admitted in 2008-2010 (68,9% men, mean age 63.6±12.6 years). Reperfusion strategy was PPCI combined with antithrombotic therapy. AKI was defined as an increase of serum creatinine of more than 50% within 24-48 hours. We registered 30-day and six-month mortality in all STEMI patients, survival in AKI-STEMI subpopulation and predictors of AKI such as reperfusion strategy (PPCI), markers of ischemic necrosis (admission and peak troponin I), of inflammation (admission CRP) and of in-hospital heart failure (in-hospital EF and NT-proBNP). Results: PPCI was performed in 89.7% of all STEMI patients. AKI was observed in 12.3%. 30-day mortality of all STEMI patients was 12.5%, six-month mortality 15.4%. In STEMI patients with AKI survival was less likely than in non-AKI patients within 30 days (41.7% vs 94%, p<0.001) and within six months (34.6% vs 91.7%, p<0.001). AKI-STEMI patients in comparison to non-AKI ones were significantly older (69.6±11 vs 62.7±12.5 years, p<0.001) with significantly increased mean admission troponin I (20.7±30.5 μg/l vs 10.6±22.3 μg/l, p<0.001) and peak troponin I (64.6±37.7 μg/l vs 47.2±35.2 μg/l, p<0.001), admission CRP (26.9±54 mg/l vs 14.3±32.3 mg/l, p<0.003) and in-hospital NT-proBNP (1642±1275 vs 528.4±843.7 pmol/l, p<0.001), but significatly decreased in-hospital EF (32.3±15.9% vs 45.4±13.0%, p<0.001), less likely performed PPCI (76.1% vs 91.6%, p<0.001) in particularly within 12 hours of chest pain (63% vs 77.5%, p<0.04). Most significant independent predictor of AKI in STEMI patients was in-hospital NT-proBNP (c2 13.433, OR 1.002, 95% CI 1.001 to 1.003, p<0.001) as demonstrated by logistic regression. Conclusions: AKI was present in more than 10% of STEMI patients and associated with less frequent and later performance of PPCI, increased NT-proBNP and decreased survival. Increased NT-proBNP, being a marker of heart failure seemed most significant predictor of AKI in STEMI patients.

Background: Coronary artery disease is the leading cause of death in the world. Advancing age is a well-recognized risk factor for acute myocardial infarction (AMI). Myocardial infarction is less common in young adults. Prevalence of acute coronary syndrome in young individuals is increasing progressively. These patients have different risk profile, presentation and prognosis. Early recognition and risk factor modification in this population sub-set is of key importance. Objectives: The purpose of the present study was to determine the differences in risk factors and coronary angiographic profile of young patients with ST-segment elevated myocardial infarction (STEMI) vs. those with non-ST-segment elevated myocardial infarction (NSTEMI). Methods: In this cross sectional analytical study total 135 patients (70 STEMI and 65 NSTEMI) aged ≤45 years were enrolled to see the differences of risk factors and angiographic profile. Results: The mean age of the study population was 39.39±5.12 years and the study showed male predominance (90.40 % was male and 9.60 % was female). Smoking/tobacco consumption was significantly higher in STEMI patients, whereas diabetes mellitus and hypertension were more prevalent in NSTEMI patients. The frequency of single vessel disease and involvement of left anterior descending artery was significantly higher in young STEMI patients. In case of young NSTEMI patients frequency of triple vessel disease, noncritical coronary artery disease and involvement of left circumflex coronary was significantly higher. The frequency of double vessel disease and involvement of left main coronary artery was also nonsignificantly higher in young NSTEMI patients. There was no significant difference regarding involvement of right coronary artery. Conclusion: There are significant differences between young STEMI and young NSTEMI patients in respect to risk factors and angiographic profile. Key words: Young patient, STEMI, NSTEMI, Risk factors, Coronary angiographic profile. Bangladesh Heart Journal 2021; 36(2): 124-132

Characteristics, management, and prognosis of patients under 35 years old with ST-segment elevation myocardial infarction: Insights from the multicenter prospective ORBI registry

Background: Reports from large studies using administrative datasets and event registries have characterized recent temporal trends and treatment patterns for AMI. However, few are population based and fewer have examined differences in patterns of treatment for patients presenting with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). We examined 21-year trends in the use of 10 medical therapies and procedures by STEMI and NSTEMI classification in the ARIC Community Surveillance Study. Methods: We analyzed data from an estimated 30,986 definite or probable MIs between 1987 and 2008 among residents 35-74 years of age in the four geographically defined US communities of the ARIC Study. Data on medical therapies was obtained through detailed abstraction of the medical records. Classification of STEMI and NSTEMI was based on independent Minnesota coding of electrocardiograms. We used weighted Poisson regression to estimate annual proportions of patients receiving each medication or procedure and age-standardized these estimates to the 2000 U.S. Census population. We then used weighted multivariable Poisson regression controlling for sex, race/center classification, age, and PREDICT mortality risk score to estimate average annual percent changes in medical therapy use over the study period. Results: From 1987 – 2008, 6106 (19.7%) hospitalized events were classified as STEMI, and 20302 (65.5%) were classified as NSTEMI. Among STEMI patients, increases (%; 95% CI) were noted in the use of ACE inhibitors (6.4; 5.7, 7.2), non-aspirin anti-platelets (5.0; 4.0, 6.0), lipid-lowering medications (4.5; 3.1, 5.8), beta blockers (2.7; 2.4, 3.0), aspirin (1.2; 1.0, 1.3), and heparin (0.8; 0.4, 1.3). Among NSTEMI patients, the use of ACE inhibitors (5.5; 5.0, 6.1), non-aspirin anti-platelets (3.7; 2.7, 4.7), lipid-lowering medications (3.0; 1.9, 4.1), beta blockers (4.2; 3.9, 4.4), aspirin (1.9, 1.6; 2.1), and heparin (1.7; 1.3, 2.1) increased. Calcium channel blocker use decreased for both STEMI (−8.8%;−9.6,−8.0) and NSTEMI (−5.6; −6.1,−5.1) patients over the study period. Among STEMI patients, we observed decreases in the use of thrombolytics (−7.2; −7.9, −6.6) and CABG (−2.4%; −3.6, −1.2). We noted similar decreases in the use of thrombolytics (−9.8; −10.7, −8.8) and CABG (−2.5; −3.3, −1.6) among NSTEMI patients. PCI use increased for both STEMI (6.4; 5.8, 7.0) and NSTEMI (5.1; 4.5, 5.7) patients. Increases in the use of stents were documented for both STEMI (4.5; 2.7, 6.2) and NSTEMI patients (1.3; −0.5, 3.2). Conclusion: We found trends of increasing use of evidence-based medicine for both STEMI and NSTEMI patients over the past 21 years. Future research should examine the broader public health impact of increasing adherence to clinical therapy guidelines.

Funding Acknowledgements Type of funding sources: None. Acute myocardial injury and infarction is vastly described in patients over 45 years of age. However, the higher incidence of coronary artery disease (CAD) in young patients in recent decades has led to a concomitant increase in the importance of excluding coronary artery disease in this group. The aim of this study was to analyse the prognosis in young patients with acute myocardial injury and infarction. Additionally, we intend to evaluate the clinical features and angiographic profile. We retrospectively analysed all patients under 45 years of age with acute chest pain and elevated troponin who underwent coronary angiography in our department from January 2017 to April 2021. Patient selection and information collection were obtained through medical records. The patients were categorized into three groups, based on discharge diagnosis: group 1 for ST-segment elevation myocardial infarction (STEMI) patients, group 2 for non-ST-segment elevation myocardial infarction (NSTEMI) patients and group 3 for patients with angiographically normal coronary arteries. Outcomes were left ventricular dysfunction, assessed by left ventricular ejection fraction (LVEF) in transthoracic echocardiography; the occurrence of electrical complication during hospitalization, including sustained ventricular tachycardia, ventricular fibrillation or cardiorespiratory arrest; and in-hospital mortality. Group comparisons were performed. A p-value less than 0.05 was considered significant. Statistical analysis was performed using SPSS software v.25.0. One hundred twenty-one patients were analysed: 59 (48.8%) in group 1, 28 (23.1%) in group 2 and 34 (28.1%) in group 3. Table 1 describes the main baseline characteristics. There was a significant difference between the groups for smoking (p-value = 0.03), more prevalent in group 1 and less prevalent in group 3. Regarding outcomes, there was a significant difference for left ventricular dysfunction at discharge, with a mean LVEF of 50% in group 1, 53% in group 2, and 58% in group 3 (p-value &amp;lt; 0.01). The existence of electrical complications was similar for the three groups (p-value = 0.99), and all patients were discharged alive. In conclusion, young patients with acute myocardial injury and infarction have a similar clinical history, with the exception of smoking in STEMI patients. There was a higher prevalence of left ventricular dysfunction in patients with STEMI, similar to that observed in older patients. A multicentric analysis, as well as a long-term follow-up, would be interesting to confirm these results.