Acute Myocardial Infarction Cohort Research Articles

Exposure to Road Traffic Noise and Incidence of Acute Myocardial Infarction and Congestive Heart Failure: A Population-Based Cohort Study in Toronto, Canada.

Background:Epidemiological evidence for the association between traffic-related noise and the incidence of major cardiovascular events such as acute myocardial infarction (AMI) and congestive heart failure (CHF) is inconclusive, especially in North America.Objectives:We evaluated the associations between long-term exposure to road traffic noise and the incidence of AMI and CHF.Methods:Our study population comprised people 30–100 years of age who lived in Toronto, Canada, from 2001 to 2015 and were free of AMI (referred to as the AMI cohort) or CHF (the CHF cohort) at baseline. Outcomes were ascertained from health administrative databases using validated algorithms. Annual average noise levels were estimated as the A-weighted equivalent sound pressure level over the 24-h period (LAeq24) and during nighttime (LAeqNight), respectively, using propagation modeling, and assigned to participants’ annual six-digit postal code addresses during follow-up. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for incident AMI and CHF in relation to LAeq24 and LAeqNight using random-effects Cox proportional hazards models adjusting for individual- and census tract–level covariates, including traffic-related air pollutants [e.g., ultrafine particles (UFPs) and nitrogen dioxide].Results:During follow-up, there were 37,441 AMI incident cases and 95,138 CHF incident cases. Each interquartile range change in LAeq24 was associated with an increased risk of incident AMI (; 95% CI: 1.06, 1.08) and CHF (; 95% CI: 1.06, 1.09). Similarly, LAeqNight was associated with incident AMI (; 95% CI: 1.05, 1.08) and CHF (; 95% CI: 1.05, 1.07). These results were robust to various sensitivity analyses and remained elevated after controlling for long-term exposure to UFPs and nitrogen dioxide. We found near-linear relationships between noise and the incidence of AMI and CHF with no evidence of threshold values.Conclusion:In this large cohort study in Toronto, Canada, chronic exposure to road traffic noise was associated with elevated risks for AMI and CHF incidence. https://doi.org/10.1289/EHP5809

Understanding the large heterogeneity in hospital readmissions and mortality for acute myocardial infarction

This study aims to investigate the variation in two acute myocardial infarction (AMI) outcomes across public hospitals in Portugal. In-hospital mortality and 30-day unplanned readmissions were studied using two distinct AMI cohorts of adults discharged from all acute care public hospital centers in Portugal from 2012−2015. Hierarchical generalized linear models were used to assess the association between patient and hospital characteristics and hospital variability in the two outcomes.Our findings indicate that hospitals are not performing homogeneously—the risk of adverse events tends to be consistently larger in some hospitals and consistently lower in other hospitals. While patient characteristics accounted for a larger share of the explained between-hospital variance, hospital characteristics explain an additional 8% and 10% of hospital heterogeneity in the mortality and the readmission cohorts respectively. Admissions to hospitals with low AMI caseloads or located in Alentejo/Algarve and Lisbon had a higher risk of mortality. Discharges from larger-sized hospitals were associated with increased risk of readmissions. Future health policies should incorporate these findings in order to incentivize more consistent health care outcomes across hospitals. Further investigation addressing geographical disparities, hospital caseload and practices is needed to direct actions of improvement to specific hospitals.

Abstract 204: Impact of Global Budgets on Hospital Cardiovascular Care in Maryland

Background: Global budgets (GB), an innovative method of hospital payment, have been considered effective in containing expenditures. In January 2014, the state of Maryland introduced Global Budget Revenues (GBR), transitioning from per case to capitated, population-based payments (PBP). Under this model, hospitals are provided yearly funds, thus being financially incentivized to improve efficiency of services. Prices are set by the Health Services Cost Review Commission (HSCRC), which collects data and monitors hospitals’ quality of care. Potential adverse incentives of GB would include underprovision of necessary services or avoiding sicker, high cost patients (cream skimming). This study aimed to evaluate the effects of GBR on the care of hospitalized patients with important CV conditions. Methods: We analyzed HSCRC inpatient claim databases containing anonymized information on statewide hospital admissions between fiscal years 2013 and 2018. Using ICD codes, we identified patients with a principal diagnosis of heart failure (CHF), acute myocardial infarction (AMI), and acute ischemic stroke (AIS) from a pool of 1,959,237 inpatient admissions. Outcome measures were: hospitalizations, length of stay (LOS), inpatient PCI and CABG procedure rates, casemix adjusted 30-day readmission rates (CARR), risk standardized in-hospital mortality, and hospitalization charges. Trends in outcome measures before and after GBR implementation were compared using segmented regression analysis, with p values indicating trend change. Results: With introduction of GBR, CHF and AMI hospitalization trends did not change significantly, whereas AIS admissions stabilized downward (p<0.0001). There was an increase in mean LOS for CHF (p=0.059). CARR followed pre-policy declining trends, with more consistent improvements noted for the AMI cohort (p=0.005). In-hospital mortality continued to decrease, although at slower rates for CHF and AMI cohorts (p=0.03; p=0.019). CABG procedure rates declined significantly (p<0.0001). Mean hospitalization charges increased for all three CV conditions, faster for CHF (p=0.03) and AIS (p<0.0001), slower for AMI (p=0.0003). Conclusions: Adoption of GBR in Maryland had no harmful effects on in-hospital outcomes and quality measures. There was a modest improvement in potentially avoidable hospitalizations and mildly reduced utilization offset by significant rise in charges. Some observations could result from care shifts to the outpatient setting. Quality of CV care was not affected by GBR suggesting that efficiency improvements might have occurred in other areas of the healthcare system. Additionally, combining GB with pay for performance programs and assiduous quality monitoring might have mitigated adverse incentives. As GBR transitions to Maryland Total Cost of Care, long-term effects of PBP on CV outcomes will require further investigation.

Outcomes of Acute Myocardial Infarction in Patients with Rheumatoid Arthritis

BackgroundThere is a paucity of data on the outcomes of acute myocardial infarction in patients with rheumatoid arthritis in the contemporary era. MethodsWe queried the National Inpatient Sample database (2002–2016) for hospitalizations with acute myocardial infarction. We described the trends and outcomes of acute myocardial infarction-rheumatoid arthritis compared with acute myocardial infarction-no rheumatoid arthritis. ResultsThe analysis included 9,359,546 hospitalizations with acute myocardial infarction, of whom 123,783 (1.3%) had rheumatoid arthritis. There was an increase in the number of hospitalizations with acute myocardial infarction-rheumatoid arthritis (Ptrend < .001). There was an observed downtrend in mortality rates for acute myocardial infarction-rheumatoid arthritis (5.8% in 2002 vs 5.2% in 2016, Ptrend = .01) corresponding to an increase in the utilization of percutaneous coronary intervention (Ptrend < .001). In the overall cohort of acute myocardial infarction, rheumatoid arthritis was independently associated with lower rate of in-hospital mortality (adjusted odds ratio 0.90; 95% confidence interval, 0.81-0.99, P = .03). Compared with ST-elevation myocardial infarction (STEMI)-no rheumatoid arthritis, STEMI-rheumatoid arthritis was associated with lower in-hospital mortality and cardiac arrest, while it was associated with higher discharges to nursing facilities. No difference in mortality was observed among non-ST-elevation myocardial infarction (NSTEMI)-rheumatoid arthritis and NSTEMI-no rheumatoid arthritis, while NSTEMI-rheumatoid arthritis was associated with lower cardiac arrest, cardiogenic shock, and hemodialysis, at the expense of higher bleeding events and discharges to nursing facilities. ConclusionIn this nationwide analysis, we found an increase in hospitalizations for acute myocardial infarction-rheumatoid arthritis. Among patients with acute myocardial infarction, rheumatoid arthritis was independently associated with lower in-hospital mortality, particularly in cases of STEMI.

Association between hyperlipidemia and mortality after incident acute myocardial infarction or acute decompensated heart failure: a propensity score matched cohort study and a meta-analysis

ObjectiveTo examine the effect of HLP, defined as having a pre-existing or a new in-hospital diagnosis based on low density lipoprotein cholesterol (LDL-C) level ≥100 mg/dL during index hospitalisation or...

Extracorporeal Membrane Oxygenation Use in Acute Myocardial Infarction in the United States, 2000 to 2014.

Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data. Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization. In ≈9 million AMI admissions, ECMO was used in 2962 (<0.01%) and implanted a median of 1 day after admission. ECMO was used in 0.5% and 0.3% AMI admissions complicated by cardiogenic shock and cardiac arrest, respectively. ECMO was used more commonly in admissions that were younger, nonwhite, and with less comorbidity. ECMO use was 11× higher in 2014 as compared with 2000 (odds ratio, 11.37 [95% CI, 7.20-17.97]). Same-day percutaneous coronary intervention was performed in 23.1%; intra-aortic balloon pump/percutaneous LVAD was used in 57.9%, of which 30.3% were placed concomitantly. In-hospital mortality with ECMO was 59.2% overall but decreased from 100% (2000) to 45.1% (2014). Durable LVAD and cardiac transplantation were performed in 11.7% as an exit strategy. Of the hospital survivors, 40.8% were discharged to skilled nursing facilities. Older age, male sex, nonwhite race, and lower socioeconomic status were independently associated with higher in-hospital mortality with ECMO use. In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO.

Cannabis Use Is an Independent Predictor for Acute Myocardial Infarction Related Hospitalization in Younger Population

PurposeThis study aimed to evaluate the risk of various substances in young acute myocardial infarction (AMI) inpatients and analyze patient demographics and hospital outcomes for significant substance use risk factors. MethodsWe conducted a retrospective analysis of the Nationwide Inpatient Sample data (2010–2014). Patients (aged 15–22 years) with a primary diagnosis for AMI (N = 1,694) were compared with non-AMI (N = 9,465,255) inpatients for odds ratio (OR) of substance use by logistic regression model, adjusted for demographics, medical risk factors, and comorbid substance use. ResultsTobacco (28.4%) and cannabis (14.9%) use were most prevalent in AMI inpatients. Cocaine (OR = 3.9), amphetamine (OR = 2.3), and cannabis (OR = 1.3) users were at higher risk of AMI hospitalizations. Higher proportion of cannabis users (14.7%) had major severity of illness at admission and higher mean total charge ($53,608) compared with that seen in cocaine and amphetamine users. Angioplasty was used more in cannabis users (19.4%) than others. The in-hospital mortalities were 2.7% and 2% in overall AMI cohort and cannabis users, respectively, and none in cocaine and amphetamine users. ConclusionsOur study demonstrates a higher prevalence and significant odds of AMI inpatients with cannabis use, along with the potential cost burdens because of severe morbidity and higher use of treatment modalities. Physicians need to familiarize themselves with rising use of cannabis and other substances in adolescent and younger population and the typical presentations of cannabis-induced myocardial infarction.

P5621Diagnostic accuracy of resting full-cycle ratio in the non-culprit artery of acute patients

Abstract Introduction Resting full-cycle ratio (RFR) is a novel non-hyperemic index of coronary stenosis severity, independent of the timing within the cardiac cycle. Recent data has demonstrated good correlation between RFR and Fractional Flow Reserve (FFR) in stable coronary disease (SCD). However, there are no data regarding the reliability of RFR in non-culprit arteries of patients presenting with acute myocardial infarction (AMI). Purpose To study the diagnostic accuracy of RFR versus FFR in the non-culprit artery in AMI compared to stable lesions. Methods RFR, FFR, Coronary Flow Reserve (CFR), Index of Microcirculatory Resistance (IMR), and Resistance Reserve Ratio (RRR) were calculated in 67 patients with AMI and an intermediate lesion in a non-culprit artery (median time from primary PCI to study: 48 hours). Data were compared with those of a retrospective group of 66 patients with SCD. Results There was a higher proportion of males among patients of the AMI group (85% vs 62%, p=0.0026). Mean age was 64.5±11 years, being AMI cohort younger at presentation [62±11 vs 67±12 years in SCD cohort (p=0.04)]. Patients with AMI had a significantly lower prevalence of hypertension (52% vs 75%, p=0.006), diabetes (10% vs 32%), p=0.002) and hyperlipemia (37% vs 79%, p=0.002). Coronary physiology parameters showed a non-normal distribution, and are expressed as median [IQR] (Table 1). In patients with AMI, FFR was lower than in patients with SCD. In contrast, RFR showed no significant difference. Both CFR and RRR were higher in the AMI group. No significant differences in IMR were found between cohorts. Importantly, in the AMI group the correlation between RFR and FFR was 0.84 and the overall agreement 82%, with rates of false positive and negative of 15% and 3%, respectively. In SCD the correlation was 0.81 with a lower overall agreement of 69%, due mostly to a higher rate of false positive RFR (28%) (Figure 1). Table 1. Microcirculatory parameters in non-culprit artery (AMI) and stable coronary disease (SCD) AMI (N=66) Stable (N=67) p value FFR 0.84 [0.76–0.9] 0.84 [0.76–0.9] 0.006 RFR 0.89 [0.82–0.94] 0,9 [0.84–0.94] 0.24 CFR 2.2 [1.7–3.1] 1.8 [1.1–2.6] 0.011 IMR 17 [14–27] 25 [14–38] 0.051 RRR 2.7 [2.17 - 3.9] 2.1 [1.4–3.1] 0.005 Median [IQR]. Figure 1. Correlation between RFR and FFR valueS Conclusions RFR shows a good correlation with FFR in AMI. Surprisingly, overall agreement is higher in the non-culprit artery in an acute setting, with a lower percentage of false positive results. Acknowledgement/Funding None

Utilization trends in traditional Chinese medicine for acute myocardial infarction

Ethnopharmacological relevanceAmong heart diseases, acute myocardial infarction (AMI) is the most serious and life-threatening emergency. In Taiwan, heart disease has consistently ranked second among the top 10 leading causes of death since 2007, second only to malignant tumors; however, population-based studies on the use of traditional Chinese medicine (TCM) in AMI cases are limited.Aim of the study: This study investigated the characteristics of TCM users and prescriptions of TCM, and their differences between two cohorts of patients with AMI, identified 10 years apart. Materials and methodsA cross-sectional study was conducted using the Taiwan National Health Insurance claims database. From among two random sample of 1 million beneficiaries selected from the claims database, we identified two cohorts of patients with first hospitalization for AMI in between 2000–2001 and 2010–2011. Patients who had received TCM therapy within one year after hospital discharge were defined as TCM users, whereas, all the other patients with AMI were considered non-users of TCM. We compared the characteristics of TCM use and the patterns of prescriptions between the two cohorts. ResultsThe proportion of patients receiving TCM care was similar between the two AMI cohorts; 20% (85/418) of the patients were diagnosed in 2000–2001 and 21% (169/817) in 2010–2011. In the 2010–2011 AMI cohort, the proportion of men was smaller among TCM users than non-users, and TCM users were less likely to have hyperlipidemia. Among TCM users, the most frequently prescribed herb was Dan-shen (Salvia miltiorrhiza Bunge, Salvia root) in both cohorts. The most commonly used Chinese herbal formulations were Xue-Fu-Zhu-Yu-Tang (Blood Mansion Dispel Stasis) for the 2000–2001 cohort and Zhi-Gan-Cao-Tang (Honey-Fried Licorice Decoction) for the 2010–2011 cohort. ConclusionsThis study revealed the differences in the prescription frequency of Chinese herbal formulation among the two cohort of patients with AMI, suggesting that the practice of prescribing TCM has evolved from post-antique formula to classical remedies during the 10 years evaluated. Further investigations are needed to evaluate if the change in the utilization of Chinese herbal formulations impacts the effectiveness of the treatment.

Acute Kidney Injury Among Older Patients Undergoing Coronary Angiography for Acute Myocardial Infarction: The SILVER-AMI Study

BackgroundAmong older adults (age ≥75 years) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts. MethodsWe analyzed data from 2212 participants age ≥75 years in the Comprehensive Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study who underwent coronary angiography. Acute kidney injury was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria (serum Cr increase ≥0.3 mg/dL from baseline or ≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (activities of daily living impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors. ResultsParticipants’ mean age was 81.3 years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (odds ratio [OR] 1.91; 95% confidence interval [CI], 1.41-2.59), body mass index [BMI] >30 (vs BMI 18-25: OR 1.75; 95% CI, 1.27-2.42), and nonwhite race (OR 1.65; 95% CI, 1.16-2.33). The final model achieved an area under the receiver operating characteristic curve of 0.72 and was well calibrated (Hosmer-Lemeshow P = .50). Acute kidney injury was independently associated with 6-month mortality (OR 1.98; 95% CI, 1.36-2.88) but not readmission (OR 1.26; 95% CI, 0.98-1.61). ConclusionsAcute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors.

Abstract 243: ICD-10, DRG and ACTION: Poor Agreement Between Diagnoses of Acute Myocardial Infarction Results in Significant Differences in Process and Outcome Measures

Background: In the Unites States, there are three major approaches to identify patients diagnosed with Acute Myocardial Infarction (AMI). The Center for Medicare and Medicaid Services uses ICD-10 codes (1) for the Value-Based Payments program whereas it uses DRG codes (2) for the Inpatient Prospective Payment System. Hospital administrators, meanwhile, often use the NCDR® ACTION Registry® (3) to examine process and outcome measures for their AMI patients. Understanding which patients are captured by these different classification systems, and whether there is agreement between them, has important implications for hospitals’ efforts to optimize performance measures and payments for AMI. Methods: In a retrospective cohort analysis, we examined 730 hospitalizations at the University of Colorado Hospital between January 1, 2017 and October 6, 2018 that were captured by one of the three methods for identifying AMI patients: 1) ICD-10, 2) DRG, or 3) ACTION. Categories were not mutually exclusive. Agreement between DRG, ICD-10 and ACTION diagnoses of AMI was assessed by percentage agreement with the total AMI cohort and dual-comparison kappa statistics. AMI cohorts defined by ICD-10 vs. DRG vs. ACTION were then compared according to the primary outcome of 100-day mortality, as well as secondary outcomes of 30-day readmission, length of stay (LOS), P2Y12 inhibition and rates of inpatient echocardiography. Results: Among 730 hospitalizations with at least one diagnosis of AMI, 617 (84.5%) were assigned a primary ICD-10 code for AMI, 227 (31.1%) were assigned a DRG code for AMI, and 479 (65.6%) carried a diagnosis of AMI in ACTION. Only 112 (15.3%) were captured by all 3 diagnosis groups (ICD-10, DRG and ACTION). 159 (21.7%) hospitalizations were captured by both ICD-10 and DRG diagnoses (Kappa -0.143); 425 (58.2%) were included in ICD-10 and ACTION groups (Kappa 0.141); 121 (16.6%) were included in DRG and ACTION groups (Kappa -0.137). Outcomes and process measures as a function of diagnosis category are presented in Figure 1. Conclusion: Only about 15% of patients with a diagnosis of AMI were included in all three diagnosis groups (ICD-10, DRG and ACTION). There may be significant between-group differences in outcomes and process measures. These data emphasize the need to harmonize administrative definitions for AMI.

Hemodynamic Support with Intra Aortic Balloon Pump Differs by Etiology of Cardiogenic Shock

Purpose While intra-aortic balloon pump (IABP) counterpulsation has not been shown to be of benefit in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS), emerging data suggest that patients with acute decompensated heart failure (ADHF) might be more likely to stabilize with this device. Methods Patients with hemodynamic evidence of CS related to either AMI or ADHF who received IABP support were studied retrospectively. Cardiac outputs (CO) and indices (CI) were calculated using the Fick method. Hemodynamics were compared before and after IABP insertion and between the AMI and ADHF cohorts. Results During the study period, 77 patients were supported with IABP for AMI related CS while 132 were supported for ADHF related CS. The mean age was 64.7±13.6 years and 75.1% were men. Mean arterial blood pressure was 75.6±10.6mmHg and 78.4±14.6mmHg among ADHF and AMI patients, respectively (p=0.12). Mean pulmonary artery pressure was higher among those with ADHF (37.9±9.3mmHg vs 33.6±8.9mmHg, p=0.002). Left ventricular ejection fraction was 18.0±8.9% among those with ADHF and 28.9±12.0% among those with AMI (p Conclusion While the degree of hemodynamic compromise was similar between those with CS related to AMI and ADHF, the response to IABP counterpulsation differed significantly between these cohorts suggesting that the device's efficacy may differ between etiologies of CS.

Examining the Utility of 30-day Readmission Rates and Hospital Profiling in the Veterans Health Administration.

The Veterans Health Administration (VA) reports hospital-specific 30-day risk-standardized readmission rates (RSRRs) using CMS-derived models. The aim of this study was to examine and describe the interfacility variability of 30-day RSRRs for acute myocardial infarction (AMI), heart failure (HF), and pneumonia as a means to assess its utility for VA quality improvement and hospital comparison. A retrospective analysis of VA and Medicare claims data using one-year (2012) and three-year (2010-2012) data given their use for quality improvement or for hospital comparison, respectively. This study included 3,571 patients hospitalized for AMI at 56 hospitals, 10,609 patients hospitalized for HF at 102 hospitals, and 10,191 patients hospitalized for pneumonia at 106 hospitals. Hospital-specific 30-day RSRRs for AMI, HF, and pneumonia hospitalizations were calculated using hierarchical generalized linear models. Of 164 qualifying VA hospitals, 56 (34%), 102 (62%), and 106 (64%) qualified for analysis based on CMS criteria for AMI, HF, and pneumonia cohorts, respectively. Using 2012 data, we found that two hospitals (2%) had CHF RSRRs worse than the national average (+95% CI), whereas no hospital demonstrated worse-than-average risk-stratified readmission Rate (RSRR; +95% CI) for AMI or pneumonia. After increasing the number of facility admissions by combining three years of data, we found that four (range: 3.5%-5.3%) hospitals had RSRRs worse than the national average (+95% CI) for all three conditions. The Centers for Medicare and Medicaid Services-derived 30-day readmission measure may not be a useful measure to distinguish VA interfacility performance or drive quality improvement given the low facility-level volume of such readmissions.

Incidence, Risk Factors, and Outcomes Associated With In-Hospital Acute Myocardial Infarction

Studies of acute myocardial infarction (AMI) occurring outside the hospital have informed approaches to addressing risk, treatment, and patient outcomes. Similar insights for in-hospital AMI are lacking. To determine the incidence, risk factors, and outcomes associated with in-hospital AMI. Cohort, nested case-control, and matched cohort study of patients hospitalized in US Veterans Health Administration facilities between July 2007 and September 2009. The incidence of in-hospital AMI was determined from a complete cohort of in-hospital AMI relative to the total number of inpatient admissions. From the in-hospital AMI cohort, detailed medical record review was performed on 687 cases and 687 individually matched controls. Risk factors and outcomes associated with in-hospital AMI were determined from matched comparison of in-hospital AMI cases to hospitalized controls. Candidate risk factors for in-hospital AMI included characteristics at the time of admission and in-hospital variables prior to the index date. In the determination of the incidence and risk factors associated with in-hospital AMI, the outcome of interest was in-hospital AMI. All-cause mortality was the main outcome of interest following in-hospital AMI. A total of 5556 patients with in-hospital AMI (mean [SD] age, 73 [10] years; 5456 [98.2%] male) were identified among 1.3 million admissions, with an incidence of 4.27 in-hospital AMI events per 1000 admissions. Independent risk factors associated with in-hospital AMI included intensive care unit setting, history of coronary artery disease, heart rate greater than 100 beats/min, hemoglobin level less than 8 g/dL, and white blood cell count 14 000/μL or greater. Compared with the matched control group, mortality was significantly higher for patients with in-hospital AMI (in-hospital mortality, 26.4% vs 4.2%; 30-day mortality, 33.0% vs 10.0%; 1-year mortality, 59.2% vs 34.4%). In-hospital AMI was common and associated with common cardiovascular risk factors and markers of acute illness. Patient outcomes following in-hospital AMI were poor, with 1-year mortality approaching 60%. Further study of in-hospital AMI may yield opportunities to reduce in-hospital AMI risk and improve patient outcomes.

Platelet Toll-Like Receptor Expression and Toll-Like Receptor-Mediated Platelet Responses in Healthy and Acute Myocardial Infarction Subjects

Background: Platelets are important regulators of vascular thrombosis and inflammation, and are known to express toll-like receptors (TLRs). The functional significance of these platelet-TLR pathways in acute myocardial infarction (AMI) has not been fully examined but may contribute to persistent thrombo-inflammatory responses after AMI. This study examined platelet-TLR expression and TLR-mediated platelet activation in healthy and AMI subjects, and also examined TLR-mediated platelet inflammatory responses in healthy subjects. Methods and Results: When examined by western blotting, platelets from AMI patients exhibited significant upregulation of TLR1 and TLR4 and slight, but non-significant, upregulation of TLR2. When examined by flow cytometry, platelets from healthy and AMI subjects became similarly activated in response to TLR2, TLR1 and TLR4 stimulation. This was despite treatment with antiplatelet therapy in the AMI cohort. To demonstrate the effect of antiplatelet therapy on TLR-mediated platelet activation, a randomised trial was conducted on healthy subjects and activation was measured by flow cytometry. It showed that 1-week treatment with dual antiplatelet therapy (aspirin and ticagrelor) only moderately inhibited TLR2-mediated, TLR1-mediated, and TLR4-mediated platelet activation. In vitro co-culture experiments demonstrated that platelets regulate leukocyte pro-inflammatory responses to TLR stimulation in a TLR agonist-specific manner. Specifically, platelets attenuated leukocyte activation (measured by flow cytometry) and cytokine and chemokine production (by multiplex enzyme-linked immunosorbent assay (ELISA)) in response to TLR stimulation. Conclusion: These platelet-TLR pathways differentially regulated a number of thrombotic and inflammatory responses in both healthy and AMI subjects. Importantly, platelet-TLRs remained functional in AMI patients, despite treatment with antiplatelet therapy.

Acute-Phase Plasma PCSK9 Levels and Recurrent Cardiovascular Events in a Chinese Acute Myocardial Infarction Cohort

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a promising target for lowering plasma low-density lipoprotein cholesterol and preventing cardiovascular (CV) disease. Whether plasma PCSK9 measured during the acute phase predicts recurrent CV events in patients with acute myocardial infarction (AMI) remains unresolved. Methods and Results: Plasma PCSK9 levels were measured in 1,646 patients with AMI from the China PEACE-Prospective AMI Study at the acute phase. Additionally, 248 patients were resampled and measured at 1 month post-AMI. Associations of acute-phase PCSK9 tertiles with clinical characteristics and recurrent CV events within 1 year were assessed. Female gender (OR 1.94, 95% CI 1.24–3.03), premature coronary heart disease (CHD; OR 2.12, 95% CI 1.37–3.26), higher high-sensitivity C-reactive protein (OR 1.67, 95% CI 1.44–1.95), and higher triglycerides (OR 1.46, 95% CI 1.03–2.09) were associated with higher baseline PCSK9. Plasma PCSK9 levels in the highest tertile (versus lowest) did not have an increased risk of 1-year recurrent CV events in the AMI cohort (HR 0.78, 95% CI 0.52–1.16) or any subgroup. There was also no association between percentage changes in PCSK9 over the first month and 1-year recurrent events, although there was a trend of differences between patients in the upper versus lower tertiles. Conclusion: Plasma PCSK9 levels measured during the acute phase were associated with high-sensitivity C-reactive protein, triglycerides, premature CHD, and gender in patients with AMI but did not predict recurrent CV events within 1 year. Dynamic changes in PCSK9 suggested a trend yet no significance value in predicting recurrent CV events.

Abstract 17023: Early Incidence of First Myocardial Infarction in Adult Attention Deficit Hyperactivity Disorder Patients in the United States

Background: Behavioral patterns and pharmaceutical interventions in patients with attention deficit hyperactivity disorder(ADHD) might increase the risk of cardiovascular disease. Studies evaluating the differences in risk profiles and outcomes during first myocardial infarction in ADHD patients compared to the general population in the US are lacking. Methods: We performed a retrospective cohort analysis of the US National Inpatient Sample years 2005 - 2015 using appropriate ICD-9 codes to identify a weighted sample of hospitalizations for a first acute myocardial infarction (AMI) in adults. In this AMI cohort, patients with ADHD were identified. Differences in demographics, comorbidities, and outcomes were compared between patients with and without ADHD. Results: Of 4,285,185 first AMI cases, ADHD was present in 5379 (~1 in 1000). At the time of first AMI, patients with ADHD were 15 years younger (mean age 52 vs 67 years, p&lt;.001) and were more likely to be men (72% vs 58%, p&lt;.001) than those without. More patients with ADHD had private insurance and were in higher income categories; TABLE. Patients with ADHD had higher prevalence of substance abuse, smoking, obesity, dyslipidemia and depression whereas patients without ADHD had a higher prevalence of hypertension and diabetes mellitus. While the type of AMI was similar in both the groups, mechanical revascularization was more frequently performed in ADHD patients (69.4% vs 59.1%, p&lt;.001). All-cause inhospital mortality during the first AMI was significantly lower in ADHD patients (1.3% vs 6.1%, p&lt;.001). Conclusion: In the US, patients with ADHD had first AMI at a much younger age and had substantial differences in risk factor profile and outcomes compared to the general population. The influence of behavior patterns, underlying ADHD pathophysiology, and medical interventions in ADHD patients leading to the earlier AMI onset should be further explored.

Concomitant Intra-Aortic Balloon Pump Use in Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation.

There are contrasting reports on the effectiveness of a concomitant intra-aortic balloon pump (IABP) in cardiogenic shock patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This study sought to compare short-term mortality in patients with cardiogenic shock treated with VA-ECMO with and without IABP. We reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring VA-ECMO for cardiogenic shock with concomitant IABP. Studies reporting short-term mortality were included. Meta-analysis of the association of IABP with mortality was performed using Mantel-Haenszel models. Subgroup analyses were performed in patients with cardiogenic shock complicating acute myocardial infarction (AMI) and postcardiotomy cardiogenic shock. Twenty-two observational studies with 4653 patients were included. These studies showed high heterogeneity for the total and postcardiotomy cardiogenic shock cohorts and low heterogeneity for the AMI cohort. Short-term mortality was not significantly different in patients with and without IABP 42.1% versus 57.8%; risk ratio, 0.80; 95% CI, 0.52-1.22; P=0.30. However, concomitant IABP with VA-ECMO was associated with lower mortality in patients with AMI (50.8% versus 62.4%; risk ratio, 0.56; 95% CI, 0.46-0.67; P<0.001). There was no difference in mortality in postcardiotomy cardiogenic shock and mixed causes for cardiogenic shock. In cardiogenic shock patients requiring VA-ECMO support, the use of IABP did not influence mortality in the total cohort. In patients with AMI, use of IABP with VA-ECMO was associated with 18.5% lower mortality in comparison to patients on VA-ECMO alone. Further randomized studies are warranted to corroborate these observational data.

P4619Accelerated accrural of ischaemic events after stopping dual antiplatelet therapy at 12 months in a real-world acute myocardial infarction cohort

P4619Accelerated accrural of ischaemic events after stopping dual antiplatelet therapy at 12 months in a real-world acute myocardial infarction cohort

Deiodinases, Organic Anion Transporter Polypeptide Polymorphisms, and Thyroid Hormones in Patients with Myocardial Infarction.

To investigate the association among deiodinases (DIO), organic anion-transporting polypeptide 1C1 (OATP1C1) gene polymorphisms, and thyroid hormones (THs) in patients with acute myocardial infarction (AMI). In summary, 290 patients with AMI were evaluated for sociodemographic and clinical characteristics, coronary artery disease (CAD) risk factors, and comorbidities, as well as circulating thyroid-stimulating hormone and TH (triiodothyronine [T3], thyroxine [T4], free T3, free T4, and reverse T3) levels. Ten single nucleotide polymorphisms for thyroid axis related genes: DIO1 (rs11206244-C/T, rs12095080-A/G, rs2235544-A/C), DIO2 (rs225014-T/C, rs225015-G/A), DIO3 (rs945006-T/G), and OATP1C1 (rs10444412-T/C, rs10770704-C/T, rs1515777-A/G, rs974453-G/A) were genotyped. Marginal associations were observed between the DIO1, DIO2, and OATP1C1 gene polymorphisms and almost all analyzed THs (p's < 0.05). After controlling for potential confounders, the OATP1C1 rs1515777-A/G minor allele homozygous genotype (G/G) was associated with a decrease in circulating free T3 and free T3/free T4. In the AMI cohort, associations between: DIO1 rs12095080 and hypertension; DIO2 rs225015 and diabetes mellitus; and the OATP1C1 rs974453 genotype, and AMI type were established. DIO1 and DIO2 gene polymorphisms are mainly associated with T3, free T4, free T3/free T4, and [natural-log transformed (ln)] reverse T3 levels, while the OATP1C1 minor allele homozygous genotype is associated with free T3 and free T3/free T4 in CAD patients after AMI.