Clinical Diagnosis Of Myocardial Infarction Research Articles

Application of the Universal Definition of Myocardial Infarction in Clinical Practice in Scotland and Sweden

Whether the diagnostic classifications proposed by the universal definition of myocardial infarction (MI) to identify type 1 MI due to atherothrombosis and type 2 MI due to myocardial oxygen supply-demand imbalance have been applied consistently in clinical practice is unknown. To evaluate the application of the universal definition of MI in consecutive patients with possible MI across 2 health care systems. This cohort study used data from 2 prospective cohorts enrolling consecutive patients with possible MI in Scotland (2013-2016) and Sweden (2011-2014) to assess accuracy of clinical diagnosis of MI recorded in hospital records for patients with an adjudicated diagnosis of type 1 or type 2 MI. Data were analyzed from August 2022 to February 2023. The main outcome was the proportion of patients with a clinical diagnosis of MI recorded in the hospital records who had type 1 or type 2 MI, adjudicated by an independent panel according to the universal definition. Characteristics and risk of subsequent MI or cardiovascular death at 1 year were compared. A total of 50 356 patients were assessed. The cohort from Scotland included 28 783 (15 562 men [54%]; mean [SD] age, 60 [17] years), and the cohort from Sweden included 21 573 (11 110 men [51%]; mean [SD] age, 56 [17] years) patients. In Scotland, a clinical diagnosis of MI was recorded in 2506 of 3187 patients with an adjudicated diagnosis of type 1 MI (79%) and 122 of 716 patients with an adjudicated diagnosis of type 2 MI (17%). Similar findings were observed in Sweden, with 970 of 1111 patients with adjudicated diagnosis of type 1 MI (87%) and 57 of 251 patients with adjudicated diagnosis of type 2 MI (23%) receiving a clinical diagnosis of MI. Patients with an adjudicated diagnosis of type 1 MI without a clinical diagnosis were more likely to be women (eg, 336 women [49%] vs 909 women [36%] in Scotland; P < .001) and older (mean [SD] age, 71 [14] v 67 [14] years in Scotland, P < .001) and, when adjusting for competing risk from noncardiovascular death, were at similar or increased risk of subsequent MI or cardiovascular death compared with patients with a clinical diagnosis of MI (eg, 29% vs 18% in Scotland; P < .001). In this cohort study, the universal definition of MI was not consistently applied in clinical practice, with a minority of patients with type 2 MI identified, and type 1 MI underrecognized in women and older persons, suggesting uncertainty remains regarding the diagnostic criteria or value of the classification.

Automatic detection and localisation of myocardial infarction using multi-channel dense attention neural network

Myocardial infarction (MI) is a life-threatening cardiac disease. Electrocardiogram (ECG) is crucial in the clinical diagnosis of MI, facilitating early localisation and diagnosis, guiding timely intervention, and improving patient outcomes. However, most previous studies required additional denoising operations and did not propose an effective method to reduce differences between patients. Therefore, this paper presents a multi-channel dense attention neural network (MCDANN) for MI detection and localisation using 12-lead ECG signals without denoising preprocessing. MCDANN is composed of 12 parallel channels dedicated to the automatic extraction of heartbeat features. The extracted features from all channels are then aggregated for MI detection and localisation. Each channel consists primarily of the dense layers and the squeeze-and-excitation (SE) module. The dense layers enhance the reuse of feature information within the leads, whereas the SE module weakens less critical information in the ECG classification task. We conduct inter-patient and intra-patient experiments to evaluate the MCDANN model based on the PTB diagnostic database. For MI detection, MCDANN achieved 99.94% accuracy and 99.92% F1 score in intra-patient experiments and 98.27% accuracy and 96.84% F1 score in inter-patient experiments. For MI localisation, MCDANN achieved 99.85% accuracy and 99.84% F1 score in intra-patient experiments, and 81.70% accuracy and 80.73% F1 score in inter-patient experiments. Based on the experimental findings, it is clear that the MCDANN model exhibits remarkable performance in MI detection and localisation, both for intra-patient and inter-patient cases. Notably, it substantially enhances the performance of inter-patient MI localisation compared to other existing methods.

Impact of clinical diagnosis of myocardial infarction in patients with elevated cardiac troponin

ObjectiveType 2 myocardial infarction (MI) and myocardial injury are common conditions associated with an adverse prognosis. Physicians experience uncertainty how to distinguish these conditions, as well as how to manage...

NR4A2 may be a potential diagnostic biomarker for myocardial infarction: A comprehensive bioinformatics analysis and experimental validation.

Myocardial infarction is a well-established severe consequence of coronary artery disease. However, the lack of effective early biomarkers accounts for the lag time before clinical diagnosis of myocardial infarction. The present study aimed to predict critical genes for the diagnosis of MI by immune infiltration analysis and establish a nomogram. Gene microarray data were downloaded from Gene Expression Omnibus (GEO). Differential expression analysis, single-cell sequencing, and disease ontology (DO) enrichment analysis were performed to determine the distribution of Differentially Expressed Genes (DEGs) in cell subpopulations and their correlation with MI. Next, the level of infiltration of 16 immune cells and immune functions and their hub genes were analyzed using a Single-sample Gene Set Enrichment Analysis (ssGSEA). In addition, the accuracy of critical markers for the diagnosis of MI was subsequently assessed using receiver operating characteristic curves (ROC). One datasets were used to test the accuracy of the model. Finally, the genes with the most diagnostic value for MI were screened and experimentally validated. 335 DEGs were identified in GSE66360, including 280 upregulated and 55 downregulated genes. Single-cell sequencing results demonstrated that DEGs were mainly distributed in endothelial cells. DO enrichment analysis suggested that DEGs were highly correlated with MI. In the MI population, macrophages, neutrophils, CCR, and Parainflammation were significantly upregulated compared to the average population. NR4A2 was identified as the gene with the most significant diagnostic value in the immune scoring and diagnostic model. 191 possible drugs for the treatment of myocardial infarction were identified by drug prediction analysis. Finally, our results were validated by Real-time Quantitativepolymerase chain reaction and Western Blot of animal samples. Our comprehensive in silico analysis revealed that NR4A2 has huge prospects for application in diagnosing patients with MI.

Abstract 10785: Cardiac Magnetic Resonance Imaging and Optical Coherence Tomography in Patients with a Clinical Diagnosis of Myocardial Infarction with Non-Obstructive Coronary Arteries - A Systematic Review and Meta-Analysis

Background: Myocardial Infarction with Non-Obstructive Coronary arteries (MINOCA) is defined as acute Myocardial Infarction (MI) despite the absence of severe coronary artery stenosis on angiography (i.e., stenosis severity &lt;50%) and no specific alternative diagnosis (e.g., sepsis, pulmonary embolism). MINOCA remains a serious diagnostic and therapeutic challenge given the various possible underlying etiologies. Cardiac Magnetic Resonance Imaging (CMR) can distinguish between acute myocarditis (AM), MI, and Takotsubo cardiomyopathy (TCM) which are some of the commonest causes of MINOCA. Hence, The European Society of Cardiology (ESC) recommend CMR in all MINOCA patients with an unclear etiology. Intracoronary Optical coherence tomography (OCT) is a high-resolution imaging modality that allows for assessment of the integrity of the atheroma. We aimed to study the efficacy of CMR and OCT in detecting the etiology in MINOCA patients, which has the potential to guide medical therapy. Methods: A systematic search was made in PubMed, Medline and Cochrane database. Search terms used: Myocardial infarction, Coronary angiography, Normal coronary arteries, CMR, and OCT. Inclusion criteria was fulfilled by 18 studies. Meta-analysis and meta-regression was performed with 14 studies due to increased heterogeneity. Results: A total of 2474 patients were included in the meta-analysis. The mean age of all the patients was 51.5 and 56.4% were men. CMR was able to establish diagnosis in 74% of the patients; 30.4% had AM, 21.3% had true MI and 12% had TCM. Upon meta-regression the demographic variables, cardiovascular risk factors, troponin levels and C-reactive protein levels did not have any association with AM or MI. Incorporation of OCT with CMR was better at finding the etiology than either modalities individually. Conclusion: CMR is integral in finding the cause of MINOCA. Coupling coronary OCT and CMR is better than either techniques alone at identifying the etiology.

Exacerbation of Cardiovascular Complications in case of Covid-19 Patients and their Treatments

The 2019 Corona virus Outbreak (COVID-19) is a scientific, medical and social challenge. The complexity of Severe Acute Respiratory Syndrome Corona virus 2 (SARSCoV2) focuses on the clinical course of unpredictable illnesses that can develop rapidly and cause serious complications leading to death. Systemic inflammation and lung problems can ensue, causing considerable morbidity and mortality. Acute coronary syndrome (ACS), arrhythmias, myocarditis, acute myocardial damage, heart failure, and other problems affect the cardiovascular system. Existing data about cardiovascular complications had been collected from the case study performed in China, Wuhan, and New York COVID-19 patients. In the case report of China, 16.7% out of 138 patients showed arrhythmias where heart failure was identified as a problem in 23% of patients in a retrospective study from Wuhan and 52% of non-survivors in China. On the other hand case studies on 18 COVID-19 patients with ST-elevation myocardial infarction (STEMI) on electrocardiogram (ECG) from New York were investigated; 6 patients (33%) reported chest pain, 14 patients (78%) reported ST-segment elevation, 6 patients (35%) reported regional wall motion abnormality on TTE, and 8 patients (44%) reported a clinical diagnosis of myocardial infarction and a total of 9 patients individuals (50%) had coronary angiography, with 6 patients (67%) of them showing obstructive disease. The cardiovascular consequences of COVID-19 infection are examined in this brief paper. The virus attaches to ACE2 (Angiotensin converting enzyme 2), allowing it to enter. COVID-19 therapy is currently being studied in conjunction with cardiovascular drugs. Therefore, emergency phy

Abstract 15859: Fibroblast Growth Factor 23 and Myocardial Infarction in the Boston Puerto Rican Health Study

Background: FGF-23 is an endocrine regulator of phosphate metabolism as well as also a potent biomarker that mediates cardiovascular remodeling, with markedly elevated plasma concentration associated with the occurrence of morbid cardiovascular events such as myocardial infarction. This association usually indicates risk of developing further adverse cardiovascular events in individuals that are already susceptible to repeat morbid cardiovascular outcomes. This cross-sectional epidemiological study aims at investigating the risk association between FGF-23 and individuals in the 8 th year cohort of the Boston Puerto Rican Health Study (BPRHS) that have self-reported clinical cardiovascular disease in the form of myocardial infarction. Methods: FGF-23 plasma concentration was measured by ELISA in 496 participants of the fourth wave of the Boston Puerto Rican Health Study (BPRHS). Multivariate logistic regressions were used to analyze the cross-sectional association of plasma FGF-23 quartile distribution with self-reported clinical diagnosis of myocardial infarction (MI). Results: The crude model for the association between FGF-23 and MI showed increased risk across the 2 nd , 3 rd and 4 th quartiles, OR (95% CI); 1.27 (0.48-3.34), 1.13 (0.42-3.04), and 3.13 (1.33-7.33), respectively. The relationship with the highest vs lowest quartile remained significant after adjusting for age, sex and BMI, OR (95% CI); 2.91 (1.15-7.36). With further adjustment for diabetes, smoking, plasma total cholesterol, HDL cholesterol and triglycerides, results were attenuated, and the latter comparison was no longer statistically significant, OR (95% CI); 2.15 (0.79-5.79). The test for trend across the quartiles yielded a p value of 0.03. Conclusion: Within this population of older Puerto Rican adults, FGF-23 was not significantly associated with increased likelihood of self-reported history of myocardial infarction. Longitudinal studies, using clinical parameters that objectively measure the progression of cardiovascular disease are needed to assess the prognostic value of FGF-23 for future cardiovascular outcomes.

Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.

Prevalence of Myocardial Infarction with Non-Obstructive Coronary Arteries in Western Nepal

Background and Aims: It is well known that ST segment elevation myocardial infarction results from complete occlusion of a coronary artery supplying that area. However, in up to 15% of patients with clinical diagnosis of myocardial infarction, early angiography reveal either non-obstructive or normal coronary artery. This subgroup of disease, myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA), represent a diagnostic and therapeutic challenge to clinicians. We aimed to determine prevalence and clinical profile of patients with MINOCA in current study.&#x0D; Methods: This is a retrospective, observational study conducted in cardiology department of Manipal Teaching Hospital, Pokhara, Nepal from 6th April 2014 to 5th April 2019. Patients with age ≥18 years and clinically diagnosed acute myocardial infarction who underwent coronary angiography without prior use of thrombolytic agents were selected. Data were analyzed using the software SPSS for windows version 18.&#x0D; Results: A total of 177 patients’ underwent early coronary angiography without prior use of thrombolytic agent. The prevalence of MINOCA was 13.5% (n=24) in our study population. MINOCA patients were younger (p&lt;0.001) compared to non-MINOCA. Smoking, systemic hypertension, access through femoral route and depressed left ventricular ejection fraction were significantly lower in MINOCA patients (p&lt;0.05, for all).&#x0D; Conclusion: The prevalence of MINOCA was high (13.5%) in our study. Prospective studies are needed to conclude its high prevalence and to look for other associated factors and etiology.

Interrelationships Between American Heart Association's Life's Simple 7, ECG Silent Myocardial Infarction, and Cardiovascular Mortality.

BackgroundWe examined the interrelationships among cardiovascular health (CVH), assessed by the American Heart Association's Life's Simple 7 (LS7) health metrics, silent myocardial infarction (SMI), and cardiovascular disease (CVD) mortality.Methods and ResultsThis analysis included 6766 participants without a history of coronary heart disease from the Third Report of the National Health and Nutrition Examination Survey. Poor, intermediate, and ideal CVH were defined as an LS7 score of 0 to 4, 5 to 9, and 10 to 14, respectively. SMI was defined as ECG evidence of myocardial infarction without a clinical diagnosis of myocardial infarction. Cox proportional hazard analysis was used to examine the association of baseline CVH with CVD death stratified by SMI status on follow‐up. In multivariable logistic regression models, ideal CVH was associated with 69% lower odds of SMI compared with poor CVH. During a median follow‐up of 14 years, 907 CVD deaths occurred. In patients without SMI, intermediate CVH (hazard ratio, 1.41; 95% CI, 1.14–1.74) and poor CVH (hazard ratio, 2.77; 95% CI, 2.10–3.66) were associated with increased risk of CVD mortality, compared with ideal CVH. However, in the presence of SMI, the magnitude of these associations almost doubled (hazard ratio, 2.17 [95% CI, 1.42–3.32] for intermediate CVH and hazard ratio, 6.28 [95% CI, 3.02–13.07] for poor CVH). SMI predicted a significant increased risk of CVD mortality in the intermediate and poor CVH subgroups but a nonsignificant increased risk in the ideal CVH subgroup.ConclusionsIdeal CVH is associated with a lower risk of SMI, and concomitant presence of SMI and poor CVH is associated with a worse prognosis. These novel findings underscore the potential role of maintaining ideal CVH in preventing future CVD outcomes.

A novel label-free photoelectrochemical sensor based on N,S-GQDs and CdS co-sensitized hierarchical Zn2SnO4 cube for detection of cardiac troponin I

A novel label-free photoelectrochemical (PEC) sensor based on graphene quantum dots doped with nitrogen and sulfur (N,S-GQDs) and CdS co-sensitized hierarchical Zn2SnO4 cube was fabricated to detect cardiac troponin I (cTnI). The unique hierarchical Zn2SnO4 cube was synthesized successfully by the solvothermal method, which has a large specific surface to load functional materials. N,S-GQDs nanoparticles were assembled to the surface of cubic Zn2SnO4 coated ITO electrode, which efficiently accelerated the electronic transition and improved photo-to-current conversion efficiency. Then, CdS nanoparticles further were modified by in-situ growth method to form Zn2SnO4/N,S-GQDs/CdS composite with prominent photocurrent, which was 30 times that of the Zn2SnO4 cube alone. In this work, the specific immune recognition between cTnI antigens and cTnI antibodies (anti-cTnI) reduced the intensity of the photoelectric signal. And the intensity decreased linearly with the logarithm of cTnI concentration range from 0.001 ng/mL to 50 ng/mL with a detection limit of 0.3 pg/mL. With high sensitivity, excellent selectivity, good stability and reproducibility, the fabricated PEC sensor showed promising applications in the sensor, clinical diagnosis of myocardial infarction and PEC analysis.

Utilidad del strain sistólico pico longitudinal bidimensional en pacientes con diagnóstico clínico de infarto del miocardio sin elevación del ST

ObjectivesTo evaluate the usefulness of two-dimensional longitudinal peak systolic strain to detect significant coronary disease in patients with a diagnosis of acute myocardial infarction without ST elevation, and its ability to identify the artery responsible for the coronary event. MethodsA descriptive, observational, and cross-sectional study was conducted between March and November 2015 on patients with a clinical diagnosis of acute myocardial infarction without ST elevation, and on whom the two-dimensional longitudinal peak systolic strain of the left ventricle was evaluated prior to coronary angiography. ResultsThe longitudinal strain was evaluated in 28 patients who fulfilled selection criteria. For the ROC curve analysis, a cut-off point of ≥ -18.8% for the overall strain was identified, with a sensitivity of 85% and a specificity of 75% to recognise the presence of angiographically significant coronary disease. A cut-off point of ≥ -17.8% of overall strain identified significant lesions, with a specificity of 100%. For the segmental analysis, a cut-off point of ≥ 3 segments with a strain ≥ -14% was established, finding a sensitivity of 90% and a specificity of 87.5% for the diagnosis of significant coronary disease. ConclusionsThe evaluated echocardiographic technique, when applied to patients with a clinical diagnosis of myocardial infarction without ST elevation, was shown to be useful in identifying significant coronary disease, but was unable to find the vessel responsible for the acute event.

Abstract 444: Association Between Cannabis Use and Acute Myocardial Infarction

Background: Cannabidiol (CBD)-a component of cannabis with no psychoactive or cognitive effect has been proven in animal models to have a vasodilatory, anti-oxidant and anti-inflammatory effect on the blood vessels. However, it is unclear if cannabis users - while being exposed to its CBD constituents - benefit from its vasodilatory and anti-inflammatory effect in the prevention of acute myocardial infarction (MI). Objective: To investigate if there is a difference in the odds of MI among cannabis users when compared to nonusers. Methods: We used data from the Nationwide Inpatient Sample on patients ages 45 years and older admitted between 2012 - 2014. The main study outcome was clinical diagnosis of MI, and the main exposure variable was cannabis use identified using ICD-9 codes. Cannabis use was categorized into non-use, non-dependent, and dependent use. Multivariable logistic regression models were used to estimate the odds of MI and In-hospital mortality in relation to cannabis use adjusting for demographics, comorbidities, and use of other recreational drugs. Results: Of the 7, 995,162 hospitalized patients who were &gt; 45 years, 532,112 (6.7%) had a diagnosis of MI, 56,836 (0.7%) were non-dependent cannabis user and 5,417 (0.1%) were dependent cannabis users. We observed a significant inverse association between cannabis use and MI (non-dependent OR: 0.86, 95% CI: 0.83-0.90; dependent OR 0.26, 95% CI: 0.21-0.31). After adjusting for confounding variables, the association was attenuated for non-dependent cannabis users (OR: 1.03, 95% CI: 0.99-1.06]). However, among dependent cannabis users, there was 66% decreased odds of MI when compared to nonusers. Also, cannabis use was associated with 32% decreased odds of in-hospital mortality among patients with MI when compared to nonuse. Conclusions: Using the largest national data, our study showed cannabis use was not a risk factor for MI and alternatively may point to a protective benefit in the diagnosis of MI and in-hospital mortality. Future prospective studies may aid in further exploring this association to maximize the therapeutic advantage of the cannabinoid system in MI prevention.

Echocardiographic Correlate of Subendocardial Myocardial Infarction

Nontransmural (subendocardial) myocardial infarcts produce classical discomfort. Electrocardiograms usually show localized T wave inversions. Routine echocardiography usually does not show supportive regional wall motion abnormalities. Detailed echocardiography, however, reveals endocardial sear in the affected region. This echocardiographic finding supports the clinical diagnosis of myocardial infarction. We are reporting such eleven cases.

Myocarditis or “true” infarction by cardiac magnetic resonance in patients with a clinical diagnosis of myocardial infarction without obstructive coronary disease: A meta-analysis of individual patient data

ObjectiveMyocardial Infarction with Non-Obstructed Coronary Arteries (MINOCA) is common, but the causes are to a large extent unknown. Thus, we aimed to study the prevalence of myocarditis and “true” myocardial infarction determined by cardiac magnetic resonance (CMR) imaging in MINOCA patients, and risk markers for these two conditions in this population. MethodsA search was made in the PubMed and Cochrane databases using the search terms “Myocardial infarction”, “Coronary angiography”, “Normal coronary arteries” and “MRI”. All relevant abstracts were read and seven of the studies fulfilled the inclusion criteria; studies describing case series of patients fulfilling the diagnosis of acute myocardial infarction with normal or non-obstructive coronary arteries on coronary angiography that were investigated with CMR imaging. Data from five of these studies are presented. ResultsA total of 556 patients from 5 different sites were included. Fifty-one percent were men with a mean age of 52 ± 16 years. Thirty-three per cent of the patients had myocarditis (n = 183), whereas 21% of the patients had infarction on CMR (n = 115). Young age and a high CRP were associated with myocarditis whereas male sex, treated hyperlipidemia, high troponin ratio and low CRP were associated with “true” myocardial infarction. Conclusion and relevanceThe results of this meta-analysis of individual data showed that myocarditis and “true” myocardial infarction are common in MINOCA when determined by CMR imaging. This information emphasizes the importance of performing CMR imaging in MINOCA patients and can be used clinically to guide diagnostics and treatment of MINOCA patients.

Highly Sensitive Troponin and Critical Illness Insurance: Have the Goalposts Moved Again?

An elevated cardiac troponin is a sine qua non for the clinical diagnosis of myocardial infarction. The sensitivity of troponin assays has improved repeatedly since troponin entered clinical use in the late 1990s. Its most recent iteration, "highly sensitive" troponin will shortly enter clinical use in North America. It is able to detect amounts of troponin 10 times smaller than the current assay. As a result, more myocardial infarctions will be diagnosed. This may have an impact on the number of critical illness claims for heart attack.

Abstract 173: A Comparison of Administrative Claims Discharge Diagnosis with Electronic Medical Record Problem List in the Diagnosis of Acute Myocardial Infarction

Background: Administrative claims data are commonly used for measurement of mortality and readmissions in Acute Myocardial Infarction (AMI). With advent of the Electronic Medical Record (EMR), the electronic problem list offers new ways to capture diagnosis data. However, no data comparing the accuracy of administrative claims data and the EMR problem list exists. Methods: Two years of admissions at a single, quaternary medical center were analyzed to compare the presence of AMI diagnosis in administrative claims and EMR problem list data using a 2x2 matrix. To gain insights into this novel method, 25 patient admissions were randomly selected from each group to undergo physician chart review to adjudicate a clinical diagnosis of myocardial infarction based on the universal definition. Results: A total of 105,929 admissions from January 1, 2010 to December 31, 2011 were included. Where EMR problem list and administrative claims data were in agreement for or against AMI diagnosis they were highly accurate. Where administrative claims data, but not EMR problem list, reported AMI the most common explanation was true AMI with missing EMR problem list diagnoses (60%). Less common reasons for discordance in this category include: (1) administrative coding error (20%), (2) computer algorithm error (8%), (3) patient death before EMR problem list created (4%), (4) EMR problem list not used (4%) and (5) AMI diagnosis was removed from EMR problem list (4%). Where EMR problem list, but not administrative claims data, reported AMI the most common explanation was no AMI with historical diagnosis of AMI from a previous admission (60%). Less common reasons for discordance in this category include: (1) AMI present but not the principal diagnosis (32%), (2) administrative coding error (4%) and (3) erroneous EMR problem list entry (4%). Conclusion: Compared to administrative and chart review diagnoses, we found that using the EMR problem list to identify patient admissions with a principal diagnosis of AMI will overlook a subset of patients primarily due to inadequate clinical documentation. Additionally, the EMR problem list does not discriminate the admission principal diagnosis from the secondary diagnoses.

Detection and management of asymptomatic myocardial injury after noncardiac surgery

Surgery and the subsequent recovery are serious circulatory stress tests that may result in symptomatic cardiac events in vulnerable patients. Despite efforts to prevent the occurrence of postoperative adverse events, myocardial infarction following noncardiac surgery remains common. Even more worrisome, the typical symptoms of myocardial ischaemia, such as chest pain, are easily masked by postoperative pain treatment including opioids. As a consequence, the clinical course of postoperative myocardial infarction is mainly silent. Yet, cardiac morbidity and mortality rates in patients with asymptomatic postoperative myocardial infarction reportedly are similar to those among patients with a clinical diagnosis of myocardial infarction. As postoperative myocardial infarction may go largely undetected, the available evidence further indicates significant elevations of risk in postoperative patients with increases in circulating biomarkers reflecting cardiac cell damage, such as troponin, but without a conventional clinical diagnosis of myocardial infarction. Silent myocardial injury, as documented by elevated cardiac biomarkers, may occur in 10–20% of the patients undergoing noncardiac surgery. A metaanalysis of studies in such patients showed isolated troponin elevations to be a strong independent predictor of mortality within the first year after surgery. Moreover, the VISION study, including over 15,000 noncardiac surgery patients, showed a strong association between any troponin elevation after surgery, which occurred in 11% of the patients, and 30-day mortality. After implementing routine postoperative troponin monitoring in elderly noncardiac surgery patients at our institution, we found similar results: 19% of the patients had a troponin elevation following surgery and such elevation was significantly associated with 30-day mortality. These patients go largely undetected, and if detected, clinical guidelines for the management of isolated increases in cardiac biomarkers do presently not exist. Coronary plaque rupture

Circulating cardio-enriched microRNAs are associated with long-term prognosis following myocardial infarction

BackgroundIncreased levels of cardio-enriched microRNAs (miRNAs) have been described in patients with myocardial infarction (MI). We wanted to evaluate the diagnostic and prognostic potential of cardio-enriched miRNAs in patients presenting with a suspected acute coronary syndrome (ACS).MethodsCardio-enriched miRNAs (miR-1, miR-208b and miR-499-5p) were measured using real time PCR in plasma samples from 424 patients with suspected ACS treated in a coronary care unit. miRNAs were assessed for discrimination of a clinical diagnosis of myocardial infarction and for association with 30-day mortality and diagnosis of heart failure. Correlation with left ventricular systolic dysfunction as measured by the ejection fraction (LVEF) was also assessed. To confirm myocardial origin miRNA was measured during coronary artery bypass surgery.ResultsmiRNAs were higher in MI patients and correlated with LVEF (p < 0.001). Discrimination of MI was accurate for miR-208b (AUC = 0.82) and miR-499-5p (AUC = 0.79) but considerable lower than for Troponin T (AUC = 0.95). Increased miRNA levels were strongly associated with increased risk of mortality or heart failure within 30 days for miR-208b (OR 1.79, 95% CI = 1.38-2.23, p = 1 × 10-5) and miR-499-5p (OR 1.70, 95% CI = 1.31-2.20, p = 5 × 10-5) but the association was lost when adjusting for Troponin T. During surgery miR-208b and miR-499-5p was released in the coronary sinus after cardioplegia-reperfusion to markedly higher levels than in a peripheral vein.ConclusionsOur findings confirm increased levels of cardio-enriched miRNAs in the blood of MI patients and establish association of increased miRNA levels with reduced systolic function after MI and risk of death or heart failure.

Removal of Inhibitory Effects in a Serum Cardiac Troponin I Immunoassay

The measurement of cardiac troponin I (cTnI)1 has become the gold standard for the clinical diagnosis of myocardial infarction (1). Varieties of commercial sandwich-type immunoassays are used for the measurement of cTnI concentration in human serum or plasma. Several of these assays use pairs of monoclonal antihuman cTnI antibodies with high specificities for the invariant part of the cTnI molecule (amino acid residues 30–110), in accordance with the recommended guidelines (2). These assays are often based on magnetic beads or latex particles to take advantage of the ease of bead/particle washing, which can minimize assay interference by matrix proteins. Signal amplification by means of chemiluminescence or electrochemiluminescence allows the detection of serum cTnI at concentrations <0.05 μg/L. As a part of the recent effort of the IFCC Working Group for Standardization of Troponin I to develop a cTnI reference measurement system (1), we have used various measurement techniques to investigate binding affinities between 6 monoclonal antibodies (mAbs) obtained from HyTest (each serving as either the capture or the detection antibody) and cTnI, in the form of either a reference material (NIST SRM 2921) or a cTnI-positive serum pool (PS). One of the techniques is the multiplexed bead array (3), which resembles the commercial bead- or particle-based immunoassays. The capture mAb molecules are covalently immobilized on different bead populations to capture cTnI. The bound cTnI …