AMI Patients Research Articles

P1524Women are from venus and face barriers for AMI treatment

Abstract Background The Latin American Telemedicine Infarct Network (LATIN), a program for managing population-based AMI care, has utilized an innovative hub-spoke strategy and remote guidance to expand medical access in remote parts of Brazil, Colombia, Mexico, and Argentina. Based on the Global Lumen Organization for Women (GLOW) project, that has previously demonstrated gender inequalities and worse outcomes for women who undergo Primary PCI, our research explored the management of female patients in our network. Purpose To demonstrate gender disparities in a telemedicine-guided, population based AMI program. Methods Meta-analysis of >750,000 patients within LATIN. Telemedicine was employed as a screening tool to accurately diagnose AMI. According to the duration of chest pain and transfer time, AMI patients were triaged into guidelines-based pathways of thrombolysis, pharmaco-invasive management or Primary PCI. Resource allocation was identical for men and women. Results Data from 784,395 screened patients reveals broad gender disparities. The critical results yielded that female patients have a lower prevalence of STEMI diagnosis and treatment regardless of the technique – PCI, pharmaco-invasive or CABG (p<0.01). These findings assume more significance given the fact that more women than men, were screened through the Telemedicine pathway. Conclusions LATIN gender data signals the urgency to demand better AMI care for women.

5234KAND567, the first selective small molecule CX3CR1 antagonist in clinical development, mediates anti-inflammatory cardioprotective effects in rodent models of atherosclerosis and myocardial infarction

Abstract Background Fractalkine is a chemokine that mediates recruitment and extravasation of CX3CR1-expressing subsets of leukocytes and monocytes and has been implicated in the inflammation-driven pathology of cardiovascular disease. More specifically, fractalkine signaling has been proposed to contribute to increased infarct size and enhanced atherosclerotic plaque vulnerability in patients and experimental models. Blocking fractalkine/CX3CR1 signaling is suggested as a promising anti-inflammatory strategy for the treatment of both acute and chronic cardiovascular disease. KAND567 is a small molecule, selective, non-competitive, allosteric antagonist of the fractalkine receptor CX3CR1, that is under preparation for a clinical phase IIa study in AMI patients. Purpose To explore the therapeutic effects of the short and long term administration of KAND567 in experimental rodent models of acute myocardial infarction and atherosclerosis, respectively. Methods Myocardial infarction was induced in Wistar rats (N=6–8 per group) by ligation of the left anterior descending (LAD) coronary artery for 30 minutes followed by 2 h of reperfusion. The drug or vehicle infusion started either 5 min before or 30 min after start of reperfusion and continued during the remainder of the experiment. Hearts were collected and subjected to triphenyl tetrazolium chlorine (TTC) staining and the infarction area/area at risk of the left ventricle was determined by planimetry and compared against vehicle group. Atherosclerosis-prone LDL-receptor deficient mice on a high-cholesterol diet, (N=15–25 per group) were treated with KAND567 for 15–23 weeks. Atherosclerotic plaque development in the thoracic arch was determined by ultrasound imaging and histology. Immunohistochemistry was used to follow changes in the cellular composition in the atherosclerotic lesions. Results In the acute myocardial infarction study, the infusion of KAND567 before the start of reperfusion significantly reduced infarcted/risk area (by up to 50%) as compared to the vehicle group. However, the infusion had no effect on the infarct size when administration was initiated 30 min after start of reperfusion. In the atherogenesis study, oral treatment with KAND567 significantly reduced vascular macrophage infiltration by 50% and reduced intima media thickness. Furthermore, reduced plaque volume and a more stable plaque phenotype was noted following treatment with KAND567. KAND567 experimental results Conclusion Specific inhibition of fractalkine-driven inflammation by KAND567 provides cardioprotective, anti-atherosclerotic and plaque stabilizing effects via mechanisms related to immune cell infiltration, in rodent models. Further studies should be initiated to test if KAND567 is a potential candidate drug, targeting the excessive inflammatory injury associated with ischemia/reperfusion in myocardial infarction and providing plaque stabilization by reducing inflammatory risk for recurrent coronary events.

P3392Potential of imaging-guided PCI for event suppression in Japanese acute myocardial infarction patients: J-MINUET substudy

Abstract Background Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) has been widely used in clinical settings. Although favorable results of imaging-guided percutaneous coronary intervention (PCI) compared with angio-guided PCI were observed in several studies, impacts of institutional-based usage frequency, about imaging-guided PCI, have not been well elucidated. Methods To elucidate the impact of imaging-guided PCI and the effects of frequency of its usage, we analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48 hours of onset from July 2012 to March 2014. Clinical follow-up data was obtained for 3 years. In this sub-study, a total of 2,788 patients who underwent urgent PCI having detailed procedural information were enrolled. We analyzed the differences of utilization rates of imaging-guided PCI among the participating institutions and the impacts for the clinical events. The participating institutions were divided into 3 groups by the frequency of IVUS usage: low frequency institutions: under 50%; moderate frequency institutions: 50% to 90%; and, high frequency institutions: over 90%. Results In this cohort registry, patients were enrolled from 28 institutions. The utilization rate of coronary imaging varied widely depending on each institution from 15.4% to 100% (mean 85.7%±24.3, median 97.4%). When the institutions were divided into 3 groups by the frequency of intravascular imaging usage, four low frequency institutions enrolled 295 patients, five moderate frequency institutions enrolled 624 patients, and 19 high frequency institutions enrolled 1,491 patients. Although the incidence of MACE (death, MI, stroke, cardiac failure, or revascularization for unstable angina) decreased stepwise (33.2%, 23.7%, and 19.7%) (gray bar in the Figure), the event rates of the imaging-guided PCI cases among the 3 groups were comparable (21.6%, 21.9%, and 19.6%) (white bar in the Figure). On the other hand, a gradual event reduction between the 3 groups was observed in the angio-guided PCI cases (black bar in the Figure). In comparison of MACE rate between imaging-guided and angio-guided PCI, there were statistically significant differences in the low frequency and moderate frequency institutions (p=0.001 and p=0.012, respectively). In contrast, comparable event rates were observed in the high frequency institutions (p=0.441). MACE rate by imaging usage frequency Conclusions In Japanese ACS patients treated with imaging-guided PCI, better suppression of clinical events during 3-year was found in the institutions with the more frequent use of intravascular imaging, mainly due to stepwise event suppression in the cases of angio-guided PCI. On the other hand, the clinical benefit of coronary imaging was obtained independently of the frequency of use and its experience.

P5012Ten-year trends and outcomes in cardiogenic shock related to first-time acute myocardial infarction: a nationwide population-based cohort study

Abstract Introduction Despite declining incidence and mortality for acute myocardial infarction, cardiogenic shock remains a severe complication with poor in-hospital prognosis. Little is known about the temporal trends in hospitalization with acute myocardial infarction-related cardiogenic shock (AMI-CS) and the long-term prognosis. Purpose We aimed to investigate the hospitalization with first-time AMI-CS and subsequent 1-year mortality. Methods In this nationwide Danish cohort study we identified from 2005 through 2015 patients with first-time acute myocardial infarction and compared those with and without cardiogenic shock (defined by either an ICD-10 diagnosis code with cardiogenic shock and/or procedure code with inotropes or vasopressors). Patient characteristics and 1-year mortality were compared between groups using Kaplan-Meier plots and multivariable Cox regression analysis. Results We included 96,030 patients with acute myocardial infarction of whom 5.4% had cardiogenic shock. Median age was 69.7 years (IQR 59.0–80.1) and 37.5% were female among those without cardiogenic shock and 70.2 years (IQR 61.4–78.1) and 33.0% were female in those with cardiogenic shock. We observed no change in hospitalization with cardiogenic shock during the study period (5.45% in 2006 vs 5.54% for 2016, P for difference 0.6). One-year mortality was higher among those with cardiogenic shock relative those without (See Figure). Crude 1-year mortality risk associated with AMI decreased over time from 23.4% in 2006 vs 11.5% in 2016 (p for difference <0.0001) and this was consistent for AMI patients without CS (21.4% in 2006 vs 9.4% in 2016, p<0.0001) and patients with AMI-CS (58.1% in 2006 vs 46.2% in 2016, p<0.0001). When comparing patients with AMI-CS to those without in multivariable analysis, AMI-CS was associated with a 1-year mortality hazard ratio of 5.38 (95% CI 5.17–6.61)). Cumulative 1-year mortality among patien Conclusion In a large population-based setting, this study suggests that the hospitalization for first-time AMI-CS was stable from 2005 through 2015, while mortality improved with time. However, the grave outcome related to AMI-CS remains with a 5-times higher mortality compared to AMI patients without CS. Acknowledgement/Funding Rigshospitalets Research Fund

P1717The clinical impact of intra-aortic balloon pumping for acute coronary syndrome from Mie ACS registry

Abstract Background Intra-Aortic Balloon Pumping (IABP) was widespread used in cases of Acute Coronary Syndrome (ACS) at daily clinical situation in Japan, even though the efficacy of IABP in AMI patients with cardiogenic shock was not proved. The aim of this study was to investigate the efficacy of IABP use in ACS patients in Japan. Methods We investigated 2-year all-cause-mortality of 2,660 enrolled ACS patients including 358 patients with IABP and 2,302 patients without IABP from Mie ACS registry. Results We compared a 1:1 propensity score-matched cohort of 426 ACS patients with or without IABP (n=213, respectively). 2-year mortality was significantly higher in patients with IABP than without IABP (p=0.02, Figure A). In addition, IABP usage was independent predictor of mortality with hazard ratio of 1.6 by multivariate analysis. However, 2-year mortality was not statistically different between 2 groups only when analyzed patients with shock (p=0.60, Figure B). Figure 1 Conclusion IABP was not commonly recommended in ACS patients. However, IABP was might as well used in some situation especially in shock.

P575Merging technologies to provide Mexico an innovative nationwide AMI management network

Abstract Background “Cόdigo Infarto”, the vast patient-centric, app-based, educational crusade of the Mexican Society of Interventional Cardiology (SOCIME) has been combined with the Latin America Telemedicine Infarct Network (LATIN) to create a comprehensive, national AMI program for Mexico. Purpose To demonstrate the benefits of amalgamating educational initiatives of national cardiology societies with a global telemedicine program for improving AMI management. Methods “Cόdigo Infarto” App connects patients to a network of several hundred cardiologists and 250 Primary PCI-capable labs. LATIN provides the partnership with its robust telemedicine platform, a hub-spoke strategy that supports patient's access to appropriate medical management. Remotely located experts, in Colombia, provide urgent EKG diagnosis via tele-consultation to the entire LATIN Mexico network. They activate ambulance dispatch and implement guideline-based protocols. Results Numerous “Cόdigo Infarto” sites have incorporated LATIN to provide a simple and accelerated management of AMI patients. Currently, the partnership (7 hubs, 78 spokes) has screened 19,886 patients. A total of 359 STEMI cases (1.8%) have been diagnosed; 118 patients (33%) were urgently reperfused, Primary PCI was performed in 74% of the latter cases. D2B time was 41 min. Reasons for the lack of treatment include delayed presentation, lack of ICU beds and insurance denials. Currently, these constraints are being methodically probed. Updated results will be available at time of presentation. Conclusions The synergy of the AMI initiative for Mexico provides a template for similar initiatives in developing countries.

2349Selatogrel, a novel P2Y12 inhibitor for emergency use, achieves rapid, consistent and sustained platelet inhibition following single-dose subcutaneous administration in stable CAD patients

Abstract Background In the setting of AMI, rapid platelet inhibition is desirable but the onset of pharmacodynamic (PD) effect of oral platelet P2Y12 inhibitors is delayed, sometimes for hours. Subcutaneous (s.c) administration of a rapidly-acting P2Y12 inhibitor would overcome many of the limitations of available therapies. Patients with stable CAD were investigated initially. Purpose To characterise the inhibition of platelet aggregation and pharmacokinetics (PK) of a single dose of selatogrel, a novel s.c P2Y12 inhibitor, in patients with stable CAD. Methods Patients with stable CAD receiving oral antiplatelet therapy (aspirin and/or oral P2Y12 inhibitor) were randomized to 1 of 8 groups based on treatment (selatogrel or matching placebo), dose (8 mg or 16 mg) and s.c injection site (thigh or abdomen). Venous blood samples were collected into PPACK anticoagulant tubes. Platelet reactivity was assessed by VerifyNow PRU (P2Y12 reaction units) test before and 15 min, 30 min and 1, 2, 4, 8 and 24 h after injection. Light-transmittance aggregometry (LTA; ADP 20 uM) was also performed. PK samples were collected up to 24 h post-dose. Adverse events occurring within 30 days were recorded. Responders were defined as having PRU <100 at 30 min after injection and lasting ≥3 h. Results 345 patients (mean age 65 y; 20% female; 31% diabetes) received selatogrel 8 mg (n=114), selatogrel 16 mg (n=115) or placebo (n=116). 97% were on background therapy with aspirin (or its derivative carbasalate) and 35% with oral P2Y12 inhibitor (clopidogrel 23%, prasugrel 4%, ticagrelor 8%). 89% of subjects were responders to selatogrel 8 mg, 90% to selatogrel 16 mg and 16% to placebo (P<0.0001). At 15 min post-dose, PRU values (mean±SD) were 10±25 with selatogrel 8 mg, 5±10 with selatogrel 16 mg and 163±73 with placebo (Figure). PRU levels were maintained at 2 and 4 h for both doses and gradually returned to pre-dose levels by 24 h post-dose (Figure). LTA results were consistent with the VerifyNow results. PD responses were similar for thigh and abdomen injection sites. Selatogrel was well tolerated: mild dyspnoea (or moderate dyspnoea, n=1, with 16 mg) occurred in 5% and 9% with selatogrel 8 mg and 16 mg, respectively, vs 0% with placebo; dizziness occurred in 4% and 4% vs 1%, respectively, without significant haemodynamic or ECG changes. Bleeding events occurred in 9.6% and 4.3% with selatogrel 8 mg and 16 mg, respectively, vs 6.9% with placebo. Pharmacokinetic data will be presented. Conclusions Selatogrel has a rapid PD effect following s.c injection in patients with stable CAD, within 15 min in most patients. The consistent and high levels of P2Y12 inhibition with a single 8 mg or 16 mg dose are sustained for over 4 hours, following which platelet reactivity progressively recovers over 24 h. Selatogrel was well tolerated, with mostly mild, transient dyspnoea observed in <10% patients. These data support further studies of selatogrel for emergency treatment of AMI patients. Acknowledgement/Funding Fully funded by Idorsia Pharmaceuticals Ltd

A clinical study of hemodynamically significant arrhythmias and QTc interval associated with thrombolysed and non thrombolysed acute myocardial infarction patients

Background: Arrhythmias are a common occurrence in acute myocardial infarction. Objectives of this study the hemodynamically significant arrhythmias and QTc interval in thrombolysed and non thrombolysed acute myocardial infarction patients.Methods: Two hundred patients of AMI were enrolled. ECG and cardiac parameters were examined. Arrhythmias and its various parameters like its incidence, type, frequency associated with site of infarction were recorded in thrombolysed and non thrombolysed patients of AMI.Results: AMI was more prevalent in the males (63.3%) and those with 41-50 years of age. Hypertension (35.7%), smoking (34.2%), and diabetes (23.1%) were the major risk factor. Incidence of AWMI (30.7%) is higher than IWMI (25.1%). Out of 200 subjects 130 were thrombolysed. Arrhythmias was observed in total 164 patients while 36 patients has no documentation of arrhythmias. Mean QTc was prolonged (546.88ms vs 404.33ms) in patients documented with arrhythmia compared with those who has no arrhythmia. Out of all arrhythmias, ventricular tachycardia was seen in 38% cases with 50% mortality and preponderance to antero lateral MI. Sinus Tachycardia was seen in 22% of cases with preponderance to Antero Lateral MI and persistence of Sinus Tachycardia was a prognostic sign, mortality being 12%. Complete Heart Block were seen with IWMI, incidence being 26%. Bundle Branch Block was common in AWMI (31%) than IWMI (10%).Conclusion: Tachyarrhythmias are common with AWMI and bradyarrhythmia’s in IWMI. Reperfusion arrhythmias are a benign phenomenon and good indicator of successful reperfusion.

A comparative study of serum uric acid level in various acute coronary syndromes and its short term prognostic significance using KILLIP classification

Background: Serum uric acid is increased in ischemic conditions and is significantly higher in patients with acute myocardial infarction. The aim of study was to correlate serum uric acid level with KILLIP class in respect of mortality and morbidity profile of patients with acute coronary syndromes..Methods: 100 patients fulfilling the standard diagnostic criteria for acute coronary syndromes on the basis of classical history, clinical signs, ECG changes and biomarkers were included in the study. Age and sex matched 50 normal healthy subjects were also included as control group after obtaining informed consent. Serum uric acid level was measured on day 0, 3 and 7 of various ACS.Results: There was statistically significant higher level of serum uric acid concentration in patients of AMI on day of admission as compared to controls and unstable angina patients. On all three days of serum uric acid estimation, the serum uric acid levels were higher in AMI patients who were in higher KILLIP class as compared to lower KILLIP class group. Smokers had significantly higher baseline serum uric acid but age, sex, dyslipidemia, hypertension and diabetes mellitus did not significantly affect serum uric acid level at any stage in various ACS patients. Five patients who died during hospital stay, had serum uric acid level more than 7.0 mg/dL and all of them were in KILLIP class III and IV.Conclusions: serum uric acid level is a strong and independent risk factor in predicting mortality and morbidity profile of patients of acute myocardial infarction. Also, serum uric acid level correlates well with KILLIP class.

THE PROGNOSTIC IMPACT OF INITIAL PULSE PRESSURE IN HYPERTENSIVE OCTOGENARIAN PATIENTS PRESENTING ACUTE MYOCARDIAL INFARCTION TREATED WITH PERCUTANEOUS CORONARY INTERVENTION

Objective: Limited data was available on the effect of initial blood pressure (BP) index on outcomes in hypertensive octogenarian patients presenting acute myocardial infarction (MI) (AMI) treated with percutaneous coronary intervention (PCI). We aimed to evaluate if initial BP index was predictive for outcomes in hypertensive octogenarian patients treated with PCI for AMI. Design and method: Among 13104 AMI patients who underwent PCI in a nationwide, prospective, and real-world registry (November 2011 - December 2015), 901 hypertensive octogenarian (defined as >80 years) patients without cardiogenic shock were analyzed. The study endpoints were the composite events (cardiac death, non-fatal MI, any revascularization, stroke, or heart failure re-admission) and their components during follow-up. Results: Composite events, all-cause death, and cardiac death occurred in 263 (29.2%), 137 (15.2%), and 101 patients (11.2%), respectively, during a median follow-up of 359 days. The patients in the higher pulse pressure (PP) quartiles had lower rates of composite events, all-cause death, and cardiac death compared with those in the lower PP quartiles. Cox proportional model showed that high initial PP was associated with lower risk of composite events (hazard ratio [HR] 0.987, 95% confidence interval [CI] 0.977–0.998, p = 0.015), all-cause death (HR 0.989, 95% CI 0.978–1.000, p = 0.044), cardiac death (HR 0.981, 95% CI 0.968–0.994, p = 0.004), and non-fatal MI (HR 0.968, 95% CI 0.937–1.000, p = 0.048). In all population and men, compared with the patients with lowest quartiles of PP, those with highest quartiles of PP were independently predictive for fewer composite events. Additionally, on receiver operating characteristic curve analysis, the optimal cutoff value of PP for composite events was 42 mmHg (sensitivity 0.42; specificity 0.70; area under the curve 0.568). Compared to the patients with PP < 42mmHg, those with PP more than 42mmHg had fewer composite events (29.3% vs. 20.4%, HR 0.662, 95% CI 0.503–0.872, p = 0.003). However, systolic BP, diastolic BP, and mean arterial pressure at admission were not associated with any study endpoints. Conclusions: In this study, high initial PP was associated with improved clinical outcomes in hypertensive octogenarian patients with AMI undergoing PCI.

Correlation between serum cathepsin S level and severity of coronary heart disease in elderly patients

Objective To study the expression level of cathepsin S in elderly patients with different degree of coronary heart disease(CHD), and to evaluate the correlation between cathepsin S level and the severity of CHD. Methods A total of 126 elderly patients with CHD were enrolled, including 36 cases with acute myocardial infarction(group AMI), 48 cases with unstable angina(group UAP), and 42 cases with stable angina(group SAP). During the same period, 40 healthy subjects were selected as controls.Venous blood was collected immediately after admission.Arterial blood was taken through radial/femoral artery sheath in AMI patients who underwent primary percutaneous coronary intervention, and coronary arterial blood was taken in AMI patients undergoing intracoronary thrombus aspiration.SYNTAX score was assessed in patients undergoing coronary angiography.Serum levels of high sensitivity C-reactive protein(hs-CRP), matrix metalloproteinase-9(MMP-9)and cathepsin S were determined in all specimens and compared between groups. Results Serum levels of cathepsin S, MMP-9 and hs-CRP were higher in CHD patients than in the control group(P<0.05). Among CHD patients, group AMI had the highest serum levels of cathepsin S, MMP-9 and hs-CRP, followed by group UAP and group SAP(F=106.830, 197.035 and 310.442, all P=0.000). Spearman's rank correlation test suggested that cathepsin S level was positively correlated with serum levels of MMP-9(r=0.816, P=0.000)and hs-CRP(r=0.827, P=0.000). SYNTAX score was positively correlated with serum levels of cathepsin S(r=0.581, P=0.000), MMP-9(r=0.511, P=0.000), and hs-CRP(r=0.557, P=0.000). Among the 24 patients with AMI who underwent intracoronary thrombus aspiration, the levels of cathepsin S, MMP-9 and hs-CRP were higher in coronary artery blood than in peripheral artery blood(t=217.288, 3.177 and 681.479, all P=0.000). Cathepsin S and hs-CRP levels in peripheral arterial blood had positive correlations with those in coronary arterial blood respectively(r=0.962 and 0.494, P=0.000 and 0.014), but such correlation between in peripheral arterial blood versus in coronary artery blood was not found in MMP-9 levels(r=-0.188, P=0.380). Conclusions Serum cathepsin S level is higher in elderly CHD patients than in healthy people, increases along with the increased severity of CHD, and positively correlates with the degree of coronary stenosis. Key words: Coronary disease; Cathepsins

Studies MicroRNA 208 as a Novel Cardiac Marker in Acute Coronary Syndrome in Egyptian Patients

AbstractBackground: Acute coronary syndrome ACS patients presented to Emergency Department ED require rapid differ-ential diagnosis. Although troponin is the gold marker for ACS, there still undiagnosed patients. MicroRNAs circulate in human plasma and affected by varying cardiac pathologies. miRNA-208 was found to be elevated with ACS specially AMI.Aim of Study: The aim of this study was to investigate cTnI levels, correlated to miRNA-208 levels in ACS patients to evaluate rapid, accurate and final diagnosis in ED.Subjects and Methods: One hundred consecutive patients with ACS presenting to the Emergency Department of the National Heart Institute, Giza (Egypt) between March and June 2018, were recruited for the study, stratified into four groups according to the final diagnosis as AMI (including twenty five patients) and unstable angina UA (including twenty three patients), other cardiac patients (eighteen patients) and non cardiac (fourteen patients) twenty control subjects. Were included their cardiac markers and miRNA-208 levels were assayed and compared to the control healthy group on admis-sion.Results: Results revealed significant difference between cardiac levels on admission compared to that obtained for miRNA-208. Only miRNA-208 levels were diagnosed on admission compared to that of cTnI. MiRNA-208 was found to be increased up to 38.6 folds without differential cut off.Conclusion: Early measurement of both troponin I and miRNA-208 may revolutionize the diagnostic accuracy and therapeutic decision-making in patients with symptoms sug-gestive of ACS; differentiate between UA or AMI patients on admission. Cardiac troponin 1 cTnI alone require more time to be controlled as diagnostic while high sensitive cTn may lead to false positive results. MiRNA-208 can be used as a novel marker for early diagnosis of ACS although RT-PCR still time consuming, requires time improved techniques.

Planarity of the spatial QRS loop of vectorcardiogram is a crucial diagnostic and prognostic parameter in acute myocardial infarction

Vectorcardiogram (VCG) is a recurring, near-periodic pattern of cardiac dynamics that graphically represents the trajectory of the tip of cardiac vectors in three dimensional space with varying time. VCG is constructed by drawing the instantaneous vectors from a zero reference point according to direction, magnitude and polarity in the space. It is more informative and sensitive than conventional ECG as an evaluation tool of the physiology of cardiac dynamics.Each heart cycle consists of three loops corresponding to P, QRS, and T wave activities in VCG. The morphological assessment of the QRS loop was carried out in order to analyze the spatial vectors of the ventricles and their patho-physiological correlation in various cardiac diseases. It was found that, the three dimensional QRS loop in healthy individuals lies in a plane. It is rather surprising that the normal spatial QRS loop lies in a single plane, considering the complex structure of the ventricular musculature together with the numerous possible pathways along which the depolarization impulse passes. The highly curious phenomenon of planarity of the spatial QRS loop was explained by uniform double layer (UDL) theory, which postulates the phenomenon of activation wave-fronts that propagate with a constant & uniform rate throughout the myocardium.Acute myocardial infarction results in loss of structural and functional integrity of the different layers of heart, perturbation of the uniformity in wave propagation due to the disturbance in directional symmetry, development of nonlinear relationships among the concerned variables, loss of homogeneity and complete loss of planarity of the 3D-QRS loop.The planarity of the 3D-QRS loop is a highly restricted and sensitive parameter and a characteristic feature of normal heart and can be utilized as a test for diagnostic screening of cardiac normalcy and the loss of planarity may be a conspicuous feature of AMI. It will be reasonable to study the morphology of the spatial QRS loop in patients of AMI throughout the course of disease and also in a regular interval through the long-term follow up period. It is expected that with the reperfusion, recovery and salvage of the diseased myocardium; the homogeneity and the intensity of the line density of the membrane current of the UDL would gradually recover with retrieval of the planarity of the spatial QRS loop. The temporal pattern of characteristics alteration of the QRS loop planarity with the natural course of the disease requires intensive evaluation.We propose that, the planarity of the spatial QRS loop, its loss, involution and reversal is a temporal series of events in AMI and also a crucial diagnostic and prognostic parameter.

Circulating miR-26a-1, miR-146a and miR-199a-1 are potential candidate biomarkers for acute myocardial infarction

BackgroundAcute myocardial infarction (AMI) was considered to be one of the major causes of morbidity and mortality worldwide. In order to manage the acute myocardial infarction outbreaks, accurate biomarkers for risk prediction are needed. Circulating microRNAs (miRNAs) may act as diagnostic and prognostic biomarkers for cardiovascular events.MethodsThis study aimed to determine the possibility of circulating miRNAs used as biomarkers for AMI and their dynamic expression levels before and after percutaneous coronary intervention (PCI) in patients. Circulating miR-26a-1, miR-27a, miR-30d, miR-146a, miR-199a-1 and miR-423 were selected and validated in 31 AMI patients and 27 matched controls by quantitative real-time PCR (qPCR).ResultsThe expression levels of plasma miR-26a-1, miR-146a and miR-199a-1 were significantly increased in AMI patients. Receiver operating characteristic (ROC) analysis indicated that miR-26a-1, miR-146a and miR-199a-1 showed considerable diagnostic efficiency for predicting AMI. Furthermore, we demonstrated that the combination of miR-26a-1, miR-146a and miR-199a-1 facilitated AMI diagnosis.ConclusionsOur findings suggest that circulating miR-26a-1, miR-146a and miR-199a-1 have the potential to be used as biomarkers for AMI diagnosis.

ANALYSIS OF SOLUBLE FIBRIN MONOMER AS DIAGNOSTIC MARKER FOR ACUTE MYOCARDIAL INFARCTION AND ITS CORRELATION WITH CARDIAC TROPONIN I

Background. The diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) is required early and accurate to avoid missing diagnosis and improve the rule out of AMI patients. There is a relationship between AMI and the state of hypercoagulation and/or thrombosis process. sFM is a protrombotic marker that is found to be associated with early AMI incidence compared to cTnI that increases after mionecrosis. The aim of this study is to determine that sFM can be used as biomarker for AMI and the correlation between sFM and cTnI.Methods. A cross-sectional analytic observational study was conducted among 23 AMI patients and 27 healthy controls. AMI were established using clinical, ECG and laboratory findings. sFM levels were measured with Stago Compact Max analyzer. Statistical analysis was performed using the Spearman's correlation coefficient, ROC curve analysis, and 2x2 contingency table.Results. A significant correlation were found between the sFM and the cTnI (r=0.422, p&lt;0.05). With a sFM cutoff level of 2.56 µg/mL, AMI could be diagnosed with sensitivity and specificity of 82.6% and 40.7%, respectively (AUC=0,638).Discussion. sFM is a new biomarker for systemic thrombus events, both cardiac and non-cardiac.Conclusions and Suggestions. sFM can be considered as an parameter of AMI. Similar studies with cohort method involving large number may be needed in the future study.

Diagnostic performance of heart-type fatty acid binding protein and high sensitive-cardiac troponin in patients in an emergency department sus-pected of acute myocardial infarction

Heart-type fatty acid binding protein (H-FABP) also referred to as mammary­ derived growth inhibitor is a polypeptide structure that in humans transcribed by FABP3 gene. It is preferred to be investigated in combination with troponin to the diagnosis of myocardial infarction in patients suffering from chest pain. This study aims to evaluate the role of H­ FABP in early diagnosis of MI in comparison with new generation cardiac troponin (hs-c'Tn) and to differentiate patients with ischemic chest pain from non-ischemic ones. This case-control study was performed at the Department of Biochemistry, Medical school, University of Baghdad, during the period from December 2017 to August 2018. It involved 36 patients presented with chest pain; 18 ischemic patients (AMI) and 18 non- ischemic patients (non-AMI) who served as pathological control. Serum investigations included measurements of FABP and hs-c'I'n using enzyme-linked immunosorbent assay (ELISA) method. The mean (±SD) value of serum FABP levels at 1-3 hours did not differ significantly between ischemic and non- ischemic subjects, while it was significantly increased at 6-9 hours in ischemic patients (p&lt; 0.001). However, the mean value of serum levels of hs-c'I'n was significantly higher in AMI patients than in non- AMI ones at 1-3 hours (p&lt;O.0. 04) and 6-9 hours (u&lt;O.o. m). The results concluded that serum hs-c'Tn still the best biochemical marker in confirming the diagnosis of early acute MI and is superior of H-FABP in the rule in and rule out of MI.

THE DIAGNOSTIC VALUE OF TROPONIN I TESTING TO CORONARY ANGIOGRAPHY WITH A POINT OF CARE TESTING INSTRUMENT IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Myocardial infarction consists of STEMI and NSTEMI. Acute myocardial infarction is diagnosed by WHO criteria when at least two of the following three criteria are met: chest pain, electrocardiography (ECG) result changes, and biomarker. Troponin I is specific for cardiac muscle and has an increased level even in small cardiac muscle necrosis and not affected by the renal failure and muscle trauma but have not been standardized by WHO. This research aimed to find the effectivity of Troponin I examination with POCT to help the diagnosis and early detection of AMI. Thus each product has varied sensitivity and specificity. A cross-sectional study was conducted in the Clinical Pathology Laboratory and Cardiac Center of the Dr. Wahidin Sudirohusodo Hospital Makassar using suspected AMI patients as the subject. Troponin I level tested by POCT from August 2015 to July 2016. Data were analyzed statistically using the ROC curve with SPSS software. A total of 88 patients suspected with AMI, aged 36 to 75 years old. From the tested cut-off values (0.02, 0.03, 0.04, 0.5, 0.06, 0.07, 0.08 μg/L) the best cut-off value was 0.03 μg/L (93.9% sensitivity, 95.5% specificity, PPV 98.4%, NPV 84.0%, and 94.3% accuracy) where the cut-off value of 0.03 μg/L was the value recommended by the toolkit manual. Even if the cut-off value of 0.02 or 0.04 was used, the sensitivity and specificity value was still fairly good. Troponin I testing using POCT with a cut-off value of 0.03 μg/L can be used routinely in supporting the AMI diagnosis because it is a rapid test with a portable instrument and excellent diagnostic value.

The Intended and Unintended Consequences of the Hospital Readmission Reduction Program

The Hospital Readmission Reduction Program (HRRP) is a prominent Pay−for− Performance (P4P) program of the Centers for Medicare and Medicaid (CMS) intended to reduce hospital readmissions. In this article, I use a regression kink design to examine whether hospitals that were penalized under the HRRP changed the process of care for patients targeted and untrageted by the policy, as measured by the amount and composition of resource use (e.g. length of stay, and spending on radiology, pharmacy, and laboratory). Estimates indicate that hospitals penalized for excess heart attack (AMI) readmissions decreased AMI readmissions by 30% and increased spending on AMI patients by 20%. This additional care had no impact on mortality. Interestingly, I find that these hospitals also increased the quantity of care for patients with diagnoses not targeted by the HRRP. Hospitals penalized for excess readmissions for relatively more frequent conditions (pneumonia and heart failure) did not respond to the HRRP incentives. I show using a conceptual model of hospital behavior that as the number of patients in the targeted condition rises, the hospital’s marginal cost of reducing the penalty increases by relatively more than the marginal benefit. This intuitive result is novel and fundamental to the discussion on the relative incentive to reduce readmissions across medical diagnoses and how P4P programs can be optimized to reflect this differential cost.

Application of the VIRGO taxonomy to differentiate acute myocardial infarction in young women

BackgroundA sex-specific taxonomy was developed from the Variation in Recovery: Role of Gender Outcomes of Young AMI patients (VIRGO) study to better classify young women with AMI who received cardiac catheterization. We aim to determine whether this taxonomy is advantageous to the Universal Definition. MethodsWe conducted a single-center retrospective chart review of consecutive women aged ≤55 years presenting with AMI between 1/1/2013 to 9/1/2016 who underwent cardiac catheterization during the index admission. The proportion of women classified using the Universal Definition of MI and VIRGO classification systems were compared. ResultsAmong women with AMI who underwent cardiac catheterization (n = 177), using the Universal Definition of MI, 68.4% were classified as Type 1, 11.9% as Type 2, and 2.3% as Type 4b; 17.5% were unclassified. Using the VIRGO taxonomy, most (68.4%) were classified as Class I (thrombosis/critical stenosis). The remaining patients were stratified by the presence of obstructive coronary artery disease (CAD) with demand (Class IIa: 4.0%) and without demand (Class IIb: 2.3%) versus non-obstructive CAD with demand (Class IIIa: 6.8%) and without demand (Class IIIb: 10.2%). Alternative discreet mechanisms (Class IV) were seen in 7.3%. Only 1.1% was unclassified. ConclusionsIn a cohort of young women with AMI, 1 in 3 patients who underwent cardiac catheterization did not exhibit the classic mechanism of plaque disruption/thrombosis. By comparison, the VIRGO taxonomy classified more young women and further distinguished presentations within categories of the Universal Definition of MI. Application of this nuanced taxonomy may support the development of individualized diagnostic and treatment strategies in young women with AMI.

Abstract P209: Trends in Presenting Symptoms Among Acute Myocardial Infarction Patients in Community Surveillance: the Atherosclerosis Risk in Communities Study

Introduction: Recent research shows changing incidence rates of AMI by subtype (ST segment elevation [STEMI] and non-ST segment elevation [NSTEMI]), anatomical location, and severity. However, trends in AMI symptom presentation are less well examined. Not all AMI patients present with classic chest pain of cardiac origin. Presentation without cardiac chest pain has been associated with delayed hospital arrival, lower likelihood of receiving medical therapies and cardiac procedures, and higher mortality, as well as female sex, black race/ethnicity, and diabetes. Objective: We examined trends in symptom presentation in subsets of STEMI and NSTEMI by sex and race in the community surveillance of the ARIC Study from 2005 to 2014. Methods: Poisson regression was used to estimate sex- and race-specific event rates for AMI with and without classic chest pain of cardiac origin stratified by NSTEMI and STEMI. Events were defined as definite or probable MI with an assigned NSTEMI or STEMI subtype. Event rates were age-standardized to the US 2010 Census population. We examined average annual percent change in event rates over time, and compared comorbidities, in-hospital complications, and 28-day case-fatality of CHD death by symptom presentation, sex, and race, evaluating heterogeneity between sex and race via interaction terms. All analyses were weighted using ARIC sampling fractions. Results: Between 2005 and 2014, we observed 12,184 AMI events without classic chest pain and 39,512 events with classic chest pain. Events without chest pain were more often NSTEMI vs. STEMI (22% vs. 13%). The decline in event rates over time was similar among NSTEMI patients regardless of presentation symptoms; however, this decline was greater among STEMI patients without classic cardiac pain (-8.03, 95% CI: -10.12, -5.89) than among STEMI patients presenting with classic cardiac pain (-3.02, 95% CI: -4.83, -1.18). The average annual percent decline in event rates differed by race for STEMI but not NSTEMI. Presentation without classic cardiac chest pain was associated with comorbidities such as diabetes, as well as in-hospital complications in both NSTEMI and STEMI patients. Twenty-eight-day case fatality was greater among STEMI patients presenting without classic cardiac chest pain (9.4%, 95% CI: 5.8, 12.9) compared to those with classic cardiac chest pain (4.8%, 95% CI: 3.7, 5.9). Conclusion: AMI without classic chest pain comprised a larger percent of NSTEMI than STEMI events, and while event rates declined over 2005 to 2014, AMI without classic cardiac chest pain was associated with greater 28-day case fatality and in-hospital complications. Future research should explore care pathways and other reasons why these outcomes may differ by cardiac pain presentation.