The association between short-term PM2.5 exposure and the incidence of NSTEMI: A case-crossover study

Background: We aimed to evaluate the perfusion index (PI) level at the 10th minute of admission to the emergency department in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP). In addition, we aimed to evaluate whether PI is useful in differentiating NSTEMI and USAP patients in the emergency department in the early stage.Materials and Methods: Eighty NSTEMI (Group 1) and 50 USAP (Group 2) patients who were consecutively admitted to our emergency department between November 2017 and May 2019 and diagnosed with acute coronary syndrome were included in the study. In both patient groups, PI measured with the Massimo-SET Root 7362A RDS7 non-invasive pulse oximetry probe and other routine laboratory measurements were measured and compared.Results: The mean PI was significantly lower in NSTEMI patients (p <0.001). At 30-day patient follow-up, the PI of the reduce was significantly lower (P <0.001). The area under the curve was significantly lower for PI in NSTEMI patients (area under the curve 0.313, p = 0.016). At 30-day patient follow-up, the level of PI was significantly lower in the died patients than the survived patients (P <0.001). The area under the curve was significantly lower for PI in NSTEMI patients (area under the curve 0.313, p = 0.016).Conclusions: Although our study shows that PI may be an early marker in the distinguish of NSTEMI and USAP patients and may be useful in predicting the mortality of these patients, more extensive studies will support our hypothesis.

Background Patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) face an increased risk of cardiac events, including arrhythmias. Current guidelines therefore recommend ECG monitoring for at least 24 hours after AMI in patients with ST segment elevation myocardial infarction (STEMI) and high-risk non-ST segment elevation myocardial infarction (NSTEMI). However, in the last decades medical treatment of AMI has been substantially improved, limiting the risk of arrhythmias post-PCI. Furthermore, continuous ECG monitoring puts additional strain on healthcare personnel during an international healthcare crisis. Purpose To evaluate the contemporary burden of ventricular arrhythmias (VA) in AMI patients post-PCI. Methods This is a retrospective analysis of consecutive patients undergoing PCI for AMI between 2016 and 2020 at a secondary care centre. We defined the primary endpoint as any VA requiring intervention (electric cardioversion or pharmacologic treatment) after PCI. Baseline characteristics and outcome were compared in patients with NSTEMI vs. STEMI. Results A total of 931 patients were included in the analysis, with a mean age of 65 years and 28.6% were female. Patients with NSTEMI (47.3%) were older (median 66 vs. 63 years) and had significantly more comorbidities: hypertension (67.5% vs. 52.1 %), diabetes mellitus (25.4% vs. 15.8%), chronic obstructive pulmonary disease (11.5% vs. 6.7%), and peripheral arterial disease (11.4% vs. 5.3%, p<0.05 for all). VAs requiring intervention occurred in 3.6% vs. 7.1% (p = 0.017) before PCI and in 0% vs. 2.2% (p < 0.001) during PCI in NSTEMI vs. STEMI patients. After PCI the primary endpoint occurred in no NSTEMI patient and in 1.6% of patients with STEMI (p = 0.004). Discussion In a cohort of contemporary AMI patients, ventricular arrhythmias occurred rarely and significantly less often in NSTEMI patients compared to STEMI patients. Due to the low risk of VAs in patients with NSTEMI after PCI, the need for post-procedural rhythm monitoring in NSTEMI patients may be questioned. The identification of predictors for VA after AMI should be subject for future trials.

Clinical Outcomes According to ECG Presentations in Infarct-Related Cardiogenic Shock in the Culprit Lesion Only PCI vs Multivessel PCI in Cardiogenic Shock Trial

Objectives: Age and sex-specific differences exist in acute myocardial infarction (AMI) prevalence, morbidity and mortality. Thus, within a diverse integrated health care delivery system of over 4 million members, we examined how sex-specific temporal trends in AMI incidence may have contributed to these differences and reflect evolving changes in AMI prevention efforts. Methods: We identified all Kaiser Permanente Southern California members (aged ≥35 years) with a primary ICD-9-CM hospital discharge diagnosis of AMI between January 1, 2000 and December 31, 2014. Incident AMI hospitalization was defined as the first event documented in the electronic health record between 2000 and 2014, with no prior AMI hospitalization. Incident ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) were identified similarly. Age-standardized (using U.S. 2010 Census data) and age-specific incidence rates by sex were calculated separately for AMI, STEMI and NSTEMI events for each calendar year. Average annual percent change and 95% confidence intervals (CIs) were estimated using log-linear Poisson models. Results: A total of 45,331 AMI, 16,524 STEMI and 32,552 NSTEMI incident events were identified between 2000 and 2014. Age-standardized incidence rates (per 100,000 person years) of AMI declined an average of 4.7%/year (95% CI [4.4, 4.9]) for men from 441.9 in 2000 to 223.6 in 2014 and 3.9%/year (95% CI [3.6, 4.2]) for women from 246.5 in 2000 to 146.4 in 2014. NSTEMIs declined an average of 2.8%/year (95% CI [2.5, 3.2]) for men from 268.2 in 2000 to 170.2 in 2014 and 1.9%/year (95% CI [1.5, 2.3]) for women from 156.1 in 2000 to 121.8 in 2014. Although STEMI incidence rates declined substantially from 2000 to 2014, sex differences were minimal, with an average decline of 8.0%/year (95% CI [7.6, 8.4]) for men from 205.9 in 2000 to 67.5 in 2014 and 8.9%/year (95% CI [8.3, 9.5]) for women from 107.2 in 2000 to 32.3 in 2014. Comparing 2000 to 2014, age-specific incidence rates of AMI, NSTEMI and STEMI declined in both men and women across all age groups ( Table ). Conclusions: Despite absolute differences, both men and women have experienced similar declines in hospitalized AMI, STEMI and NSTEMI incidence rates, presumably due to increased efforts in both primary and secondary AMI prevention.

Myocardial infarction (MI), a subtype of coronary heart disease (CHD), is still a major cause of morbidity and mortality around the world. Non-ST-segment elevation MI (NSTEMI) is more common than ST-segment elevation MI (STEMI). Antithrombotic therapy, including antiplatelet and anticoagulant agents, is essential in MI management to prevent thrombus formation and reduce ischemic complications. Although international and national clinical guidelines (PERKI and ACC/AHA) provide recommendations tailored to MI type and patient factors, discrepancies in clinical practice, especially in developing countries, may impact treatment outcomes. This retrospective descriptive study aimed to evaluate the use and appropriateness of antithrombotic therapy in NSTEMI and STEMI patients at Hospital X, Kediri City, in 2018. Data were collected from medical records of hospitalized acute myocardial infarction (AMI) patients. Aspirin combined with clopidogrel was the most commonly used regimen for NSTEMI, whereas STEMI patients frequently received aspirin, clopidogrel, and enoxaparin; fibrinolytics were administered in nine STEMI cases. Dosage evaluation showed compliance with guidelines in NSTEMI patients, while 36.84% of STEMI patients, particularly those receiving enoxaparin, were given incorrect dosages. These findings highlight the need for improved adherence to clinical guidelines to optimize antithrombotic therapy outcomes in MI management

Funding Acknowledgements None Background/Introduction Left ventricular (LV) thrombus is a widely recognized complication of acute myocardial infarction (AMI). Limited data are available from South East Asian patients with this post-infarction complication nor on whether patients with non-ST segment elevation myocardial infarction (NSTEMI) or STEMI with associated LV thrombosis exhibit differing clinical characteristics and/or outcomes. Left Ventricular Ejection Fraction (LVEF) ≤ 40% is a recognized predictor of LV thrombus formation, but there is limited data on LV thrombus patients with EF > 40% or in NSTEMI patients. Purpose This study aims to investigate and compare the clinical characteristics, treatment and outcomes of post-AMI patients with LV thrombus formation, with a particular emphasis on those with EF ≤ 40% and in NSTEMI patients. Methods Among 5829 consecutive echocardiogram results containing the keyword "thrombus" from August 2006 to September 2017, we identified 289 post-AMI patients with acute LV thrombus formation. Demographics, treatment and outcome measures were analysed. Results Cardiovascular risk factors such as dyslipidaemia (54.0%) and hypertension (50.5%) were commonly present in post-AMI patients with LV thrombus. Mean LVEF was 33.0 ± 10.4%. The majority (68.0%) of patients received triple therapy and 59.5% achieved thrombus resolution. NSTEMI patients had greater number of co-morbidities including heart failure (p < 0.01), documented history of ischaemic heart disease preceding the AMI leading to thrombus formation (p < 0.01) and lower LVEF (28.3 ± 9.3% vs. 34.8 ± 10.3% , p < 0.01) compared with STEMI cases. On multivariate analysis, having a lower EF was a significant independent predictor of stroke (HR 0.96, 95% CI 0.93-1.00, p = 0.03) and all-cause mortality (HR 0.95, 95% CI 0.92-0.99, p < 0.01). The categories of STEMI and NSTEMI did not predict thrombus resolution, stroke events or all-cause mortality after adjustment. Conclusion(s) Post-AMI LV thrombus patients with NSTEMI and STEMI differed in terms of their co-morbidities in their demographics and co-morbidities but it was a lower EF that was associated with an increased risk of stroke and all-cause mortality. Further studies on this topic are required.

In Korea, the incidence of acute myocardial infarction has been increasing rapidly. Twelve-month clinical outcomes for 13,133 patients with acute myocardial infarction enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry study were analyzed according to the presence or absence of ST-segment elevation. Patients with ST-segment elevation myocardial infarction (STEMI) were younger, more likely to be men and smokers, and had poorer left ventricular function with a higher incidence of cardiac death compared to patients with non-ST-segment elevation myocardial infarction (NSTEMI). NSTEMI patients had a higher prevalence of 3-vessel and left main coronary artery disease with complex lesions, and were more likely to have co-morbidities. The in-hospital and 1-month survival rates were higher in NSTEMI patients than in STEMI patients. However, 12-month survival rates was not different between the two groups. In conclusion, NSTEMI patients have worse clinical outcomes than STEMI patients, and therefore should be treated more intensively during clinical follow-up.

BackgroundCoronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI).Methods and ResultsPatients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score.ConclusionsSurgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

The pharmacokinetics after a 180-mg loading dose (LD) of ticagrelor has not been thoroughly investigated in NSTEMI patients. We aimed to compare the ticagrelor uptake and on-treatment platelet reactivity between non-ST-segment elevation myocardial infarction (NSTEMI) patients and a control group of patients with stable coronary artery disease (SCAD) undergoing elective percutaneous coronary intervention. We performed an observational, prospective, single-center study including 40 NSTEMI patients and 20 SCAD controls. Key exclusion criteria included ongoing opioid treatment. Both groups received a 180-mg ticagrelor LD, and blood samples were taken pre-dose and 1, 2, 3, 4, 5, and 6 hours post-LD. Plasma concentrations of ticagrelor and its active metabolite AR-C124910XX were determined by validated methods. Platelet aggregation was tested using ADP-induced multiple electrode aggregometry. The primary endpoint was the time to maximal ticagrelor concentration (Tmax). Clinical trial registration identifier number: NCT02292277. None of the pharmacokinetic variables differed significantly between the groups, including the Tmax of ticagrelor (2.0h [1.0–3.0] versus 2.0h [2.0–3.0], p = 0.393) and the active metabolite AR-C124910XX (3.0 [2.0–4.0] versus 3.0 [2.5–4.0], p = 0.289). High on-treatment platelet reactivity (HPR) was defined as > 46 aggregation units and was at one hour seen in 15% of the NSTEMI patients versus 10% of the controls (p = 1.0). At two hours post the 180-mg ticagrelor LD, 3% of the NSTEMI patients had HPR compared with none of the controls (p = 1.0). In conclusion, the uptake of ticagrelor was not significantly slower in NSTEMI patients not receiving opioids compared with the SCAD controls, leading to adequate onset of platelet inhibition in both groups.

Myocardial infarction (MI), presented as ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI), is influenced by atherosclerosis risk factors. The aim of this study was to assess the patterns of presentation of patients with acute MI in Kosovo. This was a cross-sectional study conducted at the University Clinical Center of Kosovo, which included all patients hospitalized with acute MI over a period of 7 years. Among the 7353 patients admitted with acute MI (age 63 ± 12 years, 29% female), 59.4% had STEMI and 40.6% had NSTEMI. The patients with NSTEMI patients less (48.3% vs. 54%, p < 0.001), but more of them had diabetes (37.8% vs. 33.6%, p < 0.001), hypertension (69.6% vs. 63%, p < 0.001), frequently had a family history of coronary artery disease (CAD) (40% vs. 38%, p = 0.009), and had more females compared to the patients with STEMI (32% vs. 27%, p < 0.001). The patients with NSTEMI underwent less primary percutaneous interventions compared with the patients with STEMI (43.6% vs. 55.2%, p < 0.001). Smoking [1.277 (1.117-1.459), p ˂ 0.001] and high triglycerides [0.791 (0.714-0.878), p = 0.02] were independent predictors of STEMI. In Kosovo, patients with STEMI are more common than those with NSTEMI, and they were mostly males and more likely to have diabetes, hypertension, and a family history of CAD compared to those with NSTEMI. Smoking and high triglycerides proved to be the strongest predictors of acute STEMI in Kosovo, thus highlighting the urgent need for optimum atherosclerosis risk control and education strategies.

Introduction: Autoimmune hepatitis (AIH) is an inflammatory chronic liver disease disease when one’s immune system attacks the liver. Due to the widespread inflammatory response, we sought to evaluate the association between Autoimmune Hepatitis and mortality in patients hospitalized with Non-ST-Segment Elevation Myocardial Infarction (NSTEMI). Methods: Patients hospitalized for NSTEMI with and without AutoImmune Hepatitis between 2016 to 2018 were identified from the National Inpatient Sample. The primary outcome was all-cause mortality. The secondary outcomes were; Length of stay, total hospital charge and odds of requiring intra aortic balloon pump. A multivariable logistic regression analysis was used to adjust for in-hospital complications. A p-value of &lt;0.05 was considered significant. Results: There were a total of 949,984 NSTEMI patients. Out of this number, 949,659 patients had NSTEMI without AIH, while 324.9 had NSTEMI with AIH. The mean age for NSTEMI without AIH was 68.2 years while the mean age for NSTEMI with AIH was 68.7 years. The odds of in-patient mortality in NSTEMI without AIH vs NSTEMI with AIH was 3.46% vs 4.62% respectively, (aOR= 1.5 , CI = 0.505 - 4.696, p = 0.76). The length of hospital stay (LOS) in NSTEMI without AIH vs NSTEMI with AIH was 4.58 days vs 4.66 days respectively, (CI = -1.016 - 1.223, P=0.18); and total hospital charges (THC) were $86,631 vs $81,851, ( CI = -23814 - 20432, P = -0.15). The odds of requiring intra aortic balloon pump (IABP) between NSTEMI without AIH vs NSTEMI with AIH was 2.49% vs 1.54% respectively, (aOR = 0.72, CI = 0.101 - 5.177). Conclusions: Patients with AutoImmune Hepatitis in the setting of NSTEMI did not have a difference in mortality or other clinical outcomes when compared with patients without AutoImmune Hepatitis. As with most observational studies, causality may not be confirmed due to potential residual confounding.

Long-Term Prognosis of First Myocardial Infarction According to the Electrocardiographic Pattern (ST Elevation Myocardial Infarction, Non-ST Elevation Myocardial Infarction and Non-Classified Myocardial Infarction) and Revascularization Procedures

Cardiovascular diseases, particularly atherosclerosis, remain a leading cause of global mortality, presenting significant challenges with non-ST-segment elevation myocardial infarction (NSTEMI). Novel biomarkers such as cluster of differentiation 47 (CD47) and adenylate cyclase-associated protein 1(CAP1) have emerged as potential candidates for improving early diagnosis and risk stratification in NSTEMI patients. This prospective cohort study was conducted at Tianjin Chest Hospital from November 2023 to June 2024, involving a total of 270 patients categorized into NSTEMI and unstable angina (UA) groups. We used multivariable logistic regression analysis to elucidate the relationship between CD47, CAP1, and the onset of NSTEMI. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of CD47 and CAP1 as biomarkers for the early diagnosis of NSTEMI in the population.Subsequently, Cox regression models were utilized to conduct short-term (median follow-up of 146 days) assessments of patients, evaluating the role of CD47 and CAP1 in early risk stratification. In our study, CD47 and CAP1 exhibited strong correlations with NSTEMI patients. Furthermore, in ROC analysis, CAP1 (AUC = 0.827, 95% CI: 0.778-0.875, P<0.001) and CD47 (AUC = 0.807, 95% CI: 0.756-0.859, P<0.001) demonstrated robust diagnostic value. Cox regression analysis identified CD47 (HR, 1.059; 95% CI 1.010-1.110; P = 0.018) and CAP1(HR, 5.385; 95% CI 1.769-16.388; P = 0.003) as independent predictors of short-term major adverse cardiovascular events (MACE) in NSTEMI patients. After adjusting some variables, high CD47 group (HR: 4.017, 95%CI 1.320-12.224, P = 0.014) and high CAP1 group (HR: 3.893, 95% CI 1.366-11.090, P = 0.011) the risk of developing MACE was significantly increased in the lower group. CD47 and CAP1 demonstrated robust diagnostic value for early NSTEMI and great predictive power for short-term MACE in NSTEMI patients.

The clinical spectrum of acute myocardial infarction (MI) may alter from ST elevation MI (STEMI) to non-ST elevation MI (NSTEMI) or unstable angina. It has commonly been suggested that early coronary artery bypass surgery (CABG) after acute MI may be associated with increased morbidity and mortality. However, advances in technology, surgical methods and myocardial protection techniques provide a chance for cardiovascular surgeon to achieve treatment of all these clinical scenarios [1]. We read with great interest the paper by Dayan and colleagues [2]. The authors have attempted to seek the answers to an important question: Does early CABG improve survival in NSTEMI? They concluded that CABG may be safely performed in patients with NSTEMI at any time after the first 6 h of MI in patients with cTnI <0.15 ng/ml. We fully agree with their implications regarding this subject and would also like to add a short comment. Patients with NSTEMI represent a heterogeneous group and are subject to a significant risk of adverse cardiac events. Early risk stratification is essential to identify patients at highest risk. CABG for complete revascularization may be frequently put into practice as a therapeutic option in patients with NSTEMI. Therefore, cardiac surgeons are faced with the difficult decision of determining the optimal surgical timing in clinically stable patients. Various studies have been designed to inform us about the risk of CABG according to the time elapsed from the event. Practice guidelines recommend delaying CABG for a few days after index admission in STEMI patients to minimize risk. However, the optimal surgical timing after the event is not addressed in most recent guidelines for NSTEMI patients. There is no consensus as to which acute MI classification poses a greater risk after CABG. Recently, Zhang and colleagues [3] studied 2412 patients who underwent isolated CABG within 21 days after acute MI. The authors suggested that MI subtype (STEMI vs NSTEMI) did not predict in-hospital mortality or major adverse events. The GRACE (Global Registry of Acute Coronary Events) score is an easily applicable and validated tool to aid the decision-making process in patients with NSTEMI. Senanayake and colleagues [4] compared the outcomes of patients undergoing urgent CABG after 24 h of NSTEMI with the GRACE predicted in-hospital and 6-month survival. In their study, urgent CABG was associated with in-hospital mortality and 6-month survival superior to that predicted by the GRACE risk score in all risk groups. The impact of early or deferred CABG on clinical outcomes of NSTEMI has not been well established. Zhang and colleagues [5] conducted a systematic literature search. In their meta-analysis, early CABG was not superior to deferred CABG for the prevention of all-cause death in patients with NSTEMI. However, a significant decrease in refractory ischaemia was observed in the early CABG patients, and the procedure also showed a tendency toward decreasing major bleeding events. In our opinion, early CABG may be performed with favourable results when the surgical timing and selected subset of patients with NSTEMI are appropriate. Conflict of interest: none declared.

Objective To investigate the relationship between glycated albumin(GA) and extent of coronary lesions, GRACE score in patients with acute non-ST segmentelevation myocardial infarction(NSTEMI). Methods A total of 226 NSTEMI patients who successfully underwent coronary angiography(CAG) were enrolled in the study.Groups: (1)According to GA level, the patients were divided into 3 groups: GA 17.0% group.(2)According to the extent of coronary lesions, the patients were divided into 2 groups: single or double branch lesion group, three and/or left main lesion group.(3)According to the GRACE score, the patients were divided into 3 groups: Low-risk GRACE score≤108 points group, Medium-risk 108 points 140 points group.The extent of coronary lesions was evaluated by Gensini score.The clinical characteristics and Gensini score, GRACE score of each group were compared.Pearson/Spearman correlation analysis and logistic regression were used to analyze the association of GA with the severity of coronary artery disease and GRACE score. Results With glycated albumin increasing, the Gensini score(56.51±38.57, 68.30±35.57, 77.38±36.52), GRACE score(139.43±29.96, 149.77±38.33, 170.75±27.52) increased significantly, and significant differences were found between groups(F=5.587, 16.006, P=0.004, 0.000). The ejection fraction(EF) of 3 groups were significantly decrease((58.30±13.95)%, (56.45±10.79)%, (53.06±12.51)%; F=3.126, P=0.046). Proportion of severe coronary lesions of 3 groups were increase significantly(59.5%(44/74), 68.2%(60/88), 87.5%(56/64), χ2=13.528, P=0.001). The level of GA in three and/or left main lesion group was higher than that in single or double branch lesion group((13.92±3.14)% vs.(16.80±3.58)%, t=-5.693, P=0.000). The level of GA in High-risk group was higher than that in Low-risk group((14.70±1.54)% vs.(16.63±4.02)%, t=6.512, P=0.002). Correlation analysis showed that the level of GA had significant positive correlation with Gensini score and GRACE score(r=0.309, 0.265; P=0.000, 0.000), while had a negative correlation with LVEF(r=-0.149, P=0.034). Logistic regression analysis indicated that GA was independent risk factors for severity of coronary artery disease in patients with NSTEMI who successfully underwent CAG(OR=1.441, 95% CI: 1.160-1.790, P=0.001). Conclusion GA level is increase in NSTEMI patients with severe coronary artery disease and risk stratification high.GA is the independent risk factors for severity of coronary artery disease in patients with NSTEMI; GA has significant correlation with dangerous degree in patients with NSTEMI. Key words: Acute myocardial infarction; Glycated albumin; Coronary lesions; GRACE score