Definition Of Myocardial Infarction Research Articles

Diagnosis of acute myocardial infarction in patients with renal failure using high-sensitivity cardiac troponin T.

Diagnosing myocardial infarction (MI) in patients with chronic kidney disease (CKD) is difficult as they often have increased high-sensitivity cardiac troponin T (hs-cTnT) concentrations. Observational U.S. cohort study of emergency department (ED) patients undergoing hs-cTnT measurement. Cases with >1 hs-cTnT increase >99th percentile were adjudicated following the Fourth Universal Definition of MI. Diagnostic performance of baseline and serial 2-hour hs-cTnT thresholds for ruling-in acute MI was compared between those without and with CKD (eGFR <60 ml/min/1.73m2). The study cohort included 1992 patients, amongst whom 501 (25%) had CKD. There were 75 (15%) and 350 (70%) patients with CKD and 80 (5%) and 351 (24%) without CKD who had acute MI and myocardial injury. In CKD patients with baseline hs-cTnT thresholds of >52, >100, >200 or >300 ng/L, PPVs for MI were 36% (95% CI 28-45), 53% (95% CI 39-67), 73% (95% CI 50-89) and 80% (95% CI 44-98), and in those without CKD, 61% (95% CI 47-73), 69% (95% CI 49-85), 59% (95% CI 33-82) and 54% (95% CI 25-81). In CKD patients with a 2-hour hs-cTnT delta of >10, >20 or >30 ng/L, PPVs were 66% (95% CI 51-79), 86% (95% CI 68-96) and 88% (95% CI 68-97), and in those without CKD, 64% (95% CI 50-76), 73% (95% CI 57-86) and 75% (95% CI 58-88). Diagnostic performance of standard baseline and serial 2-hour hs-cTnT thresholds to rule-in MI is suboptimal in CKD patients. It significantly improves when using higher baseline thresholds and delta values.

Periprocedural myocardial infarction after percutaneous coronary intervention and long-term mortality: a meta-analysis.

Conflicting data are available regarding the association between periprocedural myocardial infarction (PMI) and mortality following percutaneous coronary intervention. The purpose of this study was to evaluate the incidence and prognostic implication of PMI according to the Universal Definition of Myocardial Infarction (UDMI), the Academic Research Consortium (ARC)-2 definition, and the Society for Cardiovascular Angiography and Interventions (SCAI) definition. Studies reporting adjusted effect estimates were systematically searched. The primary outcome was all-cause death, while cardiac death was included as a secondary outcome. Studies defining PMI according to biomarker elevation without further evidence of myocardial ischaemia ('ancillary criteria') were included and reported as 'definition-like'. Data were pooled in a random-effect model. A total of 19 studies and 109 568 patients were included. The incidence of PMI was progressively lower across the UDMI, ARC-2, and SCAI definitions. All PMI definitions were independently associated with all-cause mortality [UDMI: hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.32-1.97; I2 34%; ARC-2: HR 2.07, 95% CI 1.40-3.08, I2 0%; SCAI: HR 3.24, 95% CI 2.36-4.44, I2 78%]. Including ancillary criteria in the PMI definitions were associated with an increased prognostic performance in the UDMI but not in the SCAI definition. Data were consistent after evaluation of major sources of heterogeneity. All currently available international definitions of PMI are associated with an increased risk of all-cause death after percutaneous coronary intervention. The magnitude of this latter association varies according to the sensitivity and prognostic relevance of each definition.

Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and cardiac troponin T

BackgroundThere are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI. ObjectivesThis study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina. ResultsAmong 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34 %, 2.05 %, and 4.94 % respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84 % vs. 1.91 %, p < 0.001; ARC 2: 3.15 % vs. 1.56 %, p = 0.136; and 4UDMI 5.91 % vs. 4.51 %, p = 0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31 % and 27.10 % of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29 % vs. 53.47 %, p < 0.001, Major: 49.21 % vs. 17.36 %, p < 0.001). ConclusionsAmong patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI.

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.

Post-procedural elevated cardiac troponin I and the association with 5-year mortality in patients undergoing elective PCI

BackgroundThe clinically meaningful cardiac troponin I (cTnI) threshold associated with the long-term prognosis in patients undergoing elective percutaneous coronary intervention (PCI) is still debated. ObjectiveTo assess the association between different thresholds for post-procedural cTnI and 5-year mortality. MethodsThe study included 4059 consecutive patients with normal baseline cTnI values who underwent elective PCI. The post-procedural cTnI level was measured at 8–48 h after PCI. The main study endpoints were 5-year all-cause mortality and cardiovascular mortality. ResultsA cTnI ≥5 times the upper reference limit (URL) as defined by the fourth universal definition of myocardial infarction (4th UDMI), ≥35 times as defined by the Academic Research Consortium-2 criteria, and ≥70 times as defined by the Society for Cardiovascular Angiography and Interventions (SCAI [2014]) was identified in 33%, 6.6%, and 3.3% of patients, respectively. During 5 years of follow-up, the all-cause mortality rate was 3.4% (n = 132) and the cardiovascular mortality rate was 2.0% (n = 77). Both all-cause mortality and cardiovascular mortality increased with higher peak cTnI, and were independently predicted by a cTnI ≥70 times the URL (adjusted hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.20–5.02 and adjusted HR 3.17, 95% CI 1.31–7.67, respectively; reference, cTnI <1 × URL]. The SCAI (2014) threshold was significantly associated with 5-year cardiovascular mortality (adjusted HR 2.66, 95% CI 1.20–5.89; reference, cTnI, <70 × URL) and all-cause mortality (adjusted HR 2.23, 95% CI 1.16–4.30; reference, cTnI <70 × URL). ConclusionIn patients with normal pre-procedural cTnI who underwent elective PCI, a post-procedural cTnI ≥70 times the URL independently predicted 5-year all-cause and cardiovascular mortality. Therefore, only the SCAI (2014) post-procedural cTnI threshold was independently associated with long-term mortality.

Periprocedural myocardial infarction and injury.

Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.

Abstract WMP98: Elevated Troponin With and Without Myocardial Infarction in Acute Ischemic Stroke

Introduction: Elevated cardiac troponin (cTn) in acute ischemic stroke (AIS) is common, and associated with increased risk of death. Whether this association depends on the cause of the cTn elevation is unclear. We examined whether etiology of elevated cTN after AIS modulates the risk of death using a large population-based study in the Greater Cincinnati Northern Kentucky (GCNK) region. Methods: Using well-validated methods, all hospitalized AIS cases in the GCNK region were collected and adjudicated in 2015. Cases with a positive cTN underwent retrospective review by cardiologists using the Fourth Universal Definition of Myocardial Infarction (MI). Date/cause of death were obtained from the National Death Index. Kaplan Meier estimates of 3-year cardiac and all-cause death were generated, stratified into the following three categories: Acute MI (Type I/Type II), elevated troponin without acute MI, and nonelevated troponin. Estimates were then compared with a Log Rank test. Results: There were 2096 AIS patients during the study period in which a cTN was obtained; cTN was elevated in 464 (22.1%). Among AIS patients with elevated cTN, 107 (23%) had an acute MI, and the remaining 357 (77%) had elevated cTN without MI. At 3 years, cardiac/all cause deaths were more common in patients with elevated cTN when compared with patients without elevated cTN regardless of cause (P&lt;0.01, Figure). Among patients with elevated cTN, death rates were not significantly higher in patients with acute MI (P=0.44 all cause, p=0.67 cardiac). Discussion: Elevated cTN after AIS is associated with a higher risk of death at 3 years, regardless of whether an MI occurred. Interventions targeting patients with elevated cTN could improve long-term outcome after AIS.

Association between periprocedural myocardial injury and neointimal characteristics in patients with in-stent restenosis: an optical coherence tomography study.

The relationship between neointimal characteristics of in-stent restenosis (ISR) and periprocedural myocardial injury (PMI) remains unclear. Therefore, this study aimed to investigate the relationship between PMI and neointimal characteristics of ISR by using optical coherence tomography (OCT). This was a retrospective study. We enrolled 140 patients diagnosed with ISR with normal baseline high-sensitivity troponin T (hs-cTnT) levels who underwent OCT and subsequent revascularization by means of drug-coated balloon (DCB) or drug-eluting stent (DES) between October 2018 and October 2022 in the Affiliated Hospital of Zunyi Medical University. Based on the 4th universal definition of myocardial infarction, patients whose hs-cTnT were increased five times above the upper reference limit (URL) after percutaneous coronary interventions (PCI) were deemed to PMI. The patients were subdivided into PMI (n=53) and non-PMI (n=87) groups. In the univariable analysis, variables in the baselines, angiography characteristics and OCT findings were analyzed with binary logistic regression. A P value of <0.2 was included in the multivariable model. Multivariable logistic regression analysis was used to identify the independent predictors of PMI. The prevalence of intra-intimal microvessels in patients with PMI was higher than in those without PMI (58.5% vs. 32.2%, P=0.003). The ratio of intra-stent plaque rupture (PR) was also higher in patients with PMI (60.4% vs. 40.2%, P=0.021). Multivariable logistic regression analysis showed that intra-intimal microvessels [odds ratio (OR): 3.193, 95% confidence interval (CI): 1.280-7.966; P=0.013] and intra-stent PR (OR: 2.124, 95% CI: 1.153-4.732; P=0.035) were independently associated with PMI. Intra-intimal microvessels and intra-stent PR were independently associated with PMI. Accurate identification and recognition of intra-intimal microvessels and intra-stent PR may be helpful in preventing PMI.

Predictors of periprocedural myocardial infarction after rotational atherectomy.

Rotational atherectomy (RA) presents superior efficacy over traditional balloon angioplasty in managing calcified plaques, albeit being associated with a perceived heightened aggressiveness and increased risk of periprocedural complications. To assess the frequency and predictive factors of periprocedural myocardial infarction (MI) following RA. This was a retrospective observational study, encompassing 534 patients. The definition of periprocedural MI was consistent with the 4th universal definition of MI. Periprocedural MI occurred in 45 (8%) patients. This subset tended to be older (74.6 ±8.2 vs. 72 ±9.3%; p = 0.04) with SYNTAX Score (SS) > 33 points (p = 0.01), alongside elevated rates of no/slow flow (p = 0.0003). These patients less often fulfilled the indication for RA, which is a non-dilatable lesion. The incidence of traditional risk factors was similar in both groups. Univariable logistic regression models revealed: male gender (OR = 0.54; p = 0.04), non-dilatable lesion (OR = 0.41; p = 0.01), prior coronary artery bypass grafting (CABG) (OR = 0.07; p = 0.01) as negative and SS > 33 (OR = 2.8; p = 0.02), older age (OR = 1.04; p = 0.04), no/slow flow (OR = 7.85; p = 0.002) as positive predictors. The multivariable model showed that occurrence of no/slow flow (OR = 6.7; p = 0.02), SS > 33 (OR = 2.95; p = 0.02), non-dilatable lesion (OR = 0.42; p = 0.02), and prior CABG (OR = 0.08; p = 0.02) were independent predictors of periprocedural MI. Periprocedural MI after RA was not an uncommon complication, occurring in nearly one-twelfth of patients. Our analysis implicated female gender, older age, and more severe coronary disease in its occurrence. As expected, the presence of no/slow flow amplified the risk of periprocedural MI, whereas prior CABG and non-dilatable lesions mitigated this risk.

CMR 2-43 - CMR LGE for Assessment of Accuracy of the ECG Criteria of the Fourth Universal Definition of Myocardial Infarction

CMR 2-43 - CMR LGE for Assessment of Accuracy of the ECG Criteria of the Fourth Universal Definition of Myocardial Infarction

TYPE 2 MYOCARDIAL INFARCTION: MODERN DIAGNOSTIC TECHNIQUES AND TREATMENT

HighlightsPatients with type 2 myocardial infarction have a more favorable course of the disease in the long-term postinfarction period compared with patients with type 1 myocardial infarction. We have determined the differences in clinical and anamnestic characteristics of patients with type 1 and type 2 MI. AbstractAim. To determine the prevalence of patients with type 2 myocardial infarction (MI) and their features in clinical practice.Methods. The prospective study involved 204 patients with acute coronary syndrome (ACS). The inclusion criteria were as follows: diagnosed ACS at admission followed by a confirmed MI during the inpatient period according to the Fourth Universal definition of MI. The following parameters were analyzed: anthropometric parameters, clinical and anamnestic characteristics, results of laboratory tests, biochemical markers of myocardial necrosis, results of instrumental diagnostics and coronary angiography. A follow-up telephone survey was carried out a year after ACS, noting the following endpoints: repeated coronary events, death, repeated hospitalizations, adherence to medical recommendations, medication taken by the patient.Results. Type 2 MI was diagnosed in 22 (10.8%) patients. The results of coronary angiography revealed either the absence of coronary artery (CA) stenosis or the presence of stenosis of less than 50% without indications of thrombosis in 16 (72.7%) of those patients. Chronic total occlusion of a non-infarct-related artery was found in 6 (27.3%) patients. Patients with type 2 MI were comparable in age with patients with type 1 MI. The group of patients with type 2 MI included more women (p = 0.029), fewer smokers (p = 0.037) and more cases of atrial fibrillation (AF) (p = 0.003) compared to patients with type 1 MI. The factors that were associated with type 2 MI were as follows: sinus tachycardia in 3 (13.6%) patients, paroxysmal atrial flutter or AF with ventricular tachysystole in 4 patients (18.2%).Conclusion. Patients with type 1 MI presented with a less favorable course of the disease: we noted higher number of recurrent MI and deaths one year after the index event compared with patients with type 2 MI. The group of patients with type 2 MI consisted mostly of women, fewer smokers and patients with dyslipidemia, as well as a more frequent indication of AF compared with patients with type 1 MI.

The role of psycho-emotional factors in assessing the prognosis of different types of myocardial infarction

Aim. To study the features of psycho-emotional status and its clinical and prognostic significance in patients with type 1 and 2 myocardial infarction (MI).Material and methods. Of the 1293 patients hospitalized at the District Cardiology Dispensary "Center for Diagnostics and Cardiovascular Surgery" with a diagnosis of acute coronary syndrome, 277 (21,4%) patients with confirmed MI were consecutively included in the observational study. There were 194 (15,0%) patients with type 1 MI (MI1) and 83 (6,4%) with type 2 MI (MI2). MI types were determined based on the IV Universal Definition of Myocardial Infarction (UDMI). During the hospital period, type D personality was identified using the Russian version of the Type D scale-14 (DS-14), while the presence and severity of anxiety and depression was assessed using the Hospital Anxiety and Depression Scale (HADS). Follow-up was conducted through outpatient visits, telephone or email interviews for 12 months after discharge. Patients' adherence to drug therapy was assessed using 8-item Morisky Medication Adherence Scale, and quality of life (QoL) using Short Form Medical Outcomes Study (SF-36) questionnaire.Results. During the hospital period, in the group of patients with MI2, patients with type D personality were more often identified compared with MI1 (30 (36,1%) vs 55 (28,3%), p&lt;0,05). Patients with MI2 had a significantly higher subclinical level of anxiety (34 (41,0%) vs 43 (22,2%), p=0,002), expressed level of anxiety (10 (12,1%) vs 12 (6,2%), p=0,011), as well as a significant level of depression (13 (15,7%) vs 14 (7,2%), p=0,03). At the same time, in patients with type D, regardless of MI type, subclinical levels of anxiety and depression were significantly expressed (63 (74,1%) vs 14 (7,3%) (p&lt;0,001) and 58 (68,2%) vs 25 (13,0%) (p&lt;0,001)). There were no significant differences in inhospital complications between the MI1 and MI2 groups depending on type D personality. After 12-month follow-up, patients with the distressed personality type had higher rate of all-cause death (5 (7,2%) vs 5 (1,6%), p&lt;0,05 without type D), rehospitalization for decompensated heart failure (8 (11,5%) vs 9 (4,8%), p=0,04). Patients with type D were less adherent to drug therapy compared to patients without type D (30 (43,4%) vs 9 (4,8%) p=0,001, respectively), and they had lower QoL scores.Conclusion. Type D personality, the presence of anxiety and depression, high all-cause mortality and rehospitalization rate of decompensated heart failure were more often observed in MI2 compared to MI1, as well as in patients with type D, regardless of MI type. Low adherence to drug therapy and poor quality of life, regardless of MI type, were also associated with the type D personality.

MINOCA: A Working Diagnosis.

Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA).The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities includeintravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.

A STUDY OF CLINICAL AND ETIOLOGICAL PROFILE OF PATIENTS OF MINOCA (MYOCARDIAL INFARCTION WITH ANGIOGRAPHICALLY NON OBSTRUCTIVE CORONARY ARTERIES) AMONG THE PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION

Objective: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a relatively new term that is characterized by clinical evidence of MI with normal or near-normal coronary arteries on coronary angiography. The aim of this was to document the prevalence and demographics of MINOCA in an Indian population. Methods: It is a single center study. All consecutive patients who were ≥18 years old, diagnosed with MI according to the Third Universal Definition of Myocardial Infarction, and had undergone coronary angiography were included in the study. Patients with stable coronary artery disease, unstable angina pectoris, a history of revascularization, and type 4/5 MI were excluded. Results: A total of 548 patients who were diagnosed with MI and had undergone coronary angiography were enrolled. The prevalence of MINOCA was 6.2% in the overall study population. Compared with non-MINOCA patients, those with MINOCA were younger, had a higher prevalence of the female gender, and had a history of COVID 19 infection. Also, the median left ventricular ejection fraction as seen on echocardiography and the ratio of Killip Class I status at presentation was significantly higher in MINOCA patients than in non-MINOCA patients (p&lt;0.001).

Long-term outcome of patients presenting with myocardial injury or myocardial infarction.

Patients with acute or chronic myocardial injury are frequently identified in the context of suspected myocardial infarction (MI). We aimed to investigate their long-term follow-up. We prospectively enrolled 2714 patients with suspected MI and followed them for all-cause mortality and a composite cardiovascular endpoint (CVE; cardiovascular death, MI, unplanned revascularization) for a median of 5.1years. Final diagnoses were adjudicated by two cardiologists according to the Fourth Universal Definition of MI, including 143 (5.3%) ST-elevation MI, 236 (8.7%) non-ST-elevation MI (NSTEMI) Type 1 (T1), 128 (4.7%) NSTEMI T2, 86 (3.2%) acute and 677 (24.9%) with chronic myocardial injury, and 1444 (53.2%) with other reasons for chest pain (reference). Crude event rates per 1000 patient-years for all-cause mortality were highest in patients with myocardial injury (81.6 [71.7, 92.3]), and any type of MI (55.9 [46.3, 66.7]), compared to reference (12.2 [9.8, 15.1]). Upon adjustment, all diagnoses were significantly associated with all-cause mortality. Moreover, patients with acute (adj-HR 1.92 [1.08, 3.43]) or chronic (adj-HR 1.59 [1.16, 2.18]) myocardial injury, and patients with NSTEMI T1 (adj-HR 2.62 [1.85, 3.69]) and ST-elevation MI (adj-HR 3.66 [2.41, 5.57]) were at increased risk for cardiovascular events. Patients with myocardial injury are at a similar increased risk for death and cardiovascular events compared to patients with acute MI. Further studies need to determine appropriate management strategies for patients with myocardial injury. Clinicaltrials.gov (NCT02355457).

The Effect of Atorvastatin Plus Ezetimibe Therapy Versus Atorvastatin Monotherapy on Clinical Outcome in Acute ST-Segment Elevation Myocardial Infaction(STEMI)

Introduction: An acute ST-elevation myocardial infarction (STEMI) is an event in which transmural myocardial ischemia results in myocardial injury or necrosis. The current 2018 clinical definition of myocardial infarction (MI) requires the confirmation of the myocardial ischemic injury with abnormal cardiac biomarkers. Acute coronary syndrome is the leading cause of death in the world and this is a consequence of unstable plaque due to dyslipidemia, reviewing with elevated LDL cholesterol. Reduction in LDL-c repeated clinical outcomes in patients with the acute coronary syndrome. Objective: To assess the effect of atorvastatin plus ezetimibe therapy versus atorvastatin monotherapy on clinical outcome in acute ST-Segment Elevation Myocardial Infaction(STEMI). Materials and Methods: A cross-sectional study was performed at dept. of Cardiology, Parkview Medical College, Sylhet, Bangladesh from June to December 2022. A total of 50 patients were evaluated in the study, including 42 patients with acute coronary syndrome with LDL-c levels≥70mg/dL at Can Tho Central General Hospital, we divided randomly into 2 groups: group A: control LDL-c by atorvastatin 40mg and ezetimibe 10mg; group B: control LDL-c by atorvastatin 40mg monotherapy. Then we compared the effect of control LDL-c between two groups after 10 follow-up days. Results: 50 patients with acute coronary syndrome: 60.0% male and 40.0% female, the average age was 66.03 ± 12.06 years, 82.0% LDL- c levels ≥7 mg/dL. After 10 days of treatment, the target LDL-c concentration in the group treated with atorvastatin 40mg+ ezetimibe 10mg was 48.1%, in the group treated with atorvastatin 40mg was 29.9% (p&lt;0.05). Conclusions: LDL-c ratio reaches the target in the treatment group by atorvastatin 40mg + ezetimibe 10mg was 48.1% in the treatment group with atorvastatin 40 mg was 29.9% (p&lt;0.05). From the results of our study, we recommend the combination therapy of atorvastatin and ezetimibe control LDL-c in patients with acute coronary syndrome better than atorvastatin monotherapy, thus physicians to treat patients with the acute coronary syndrome should combine early atorvastatin with ezetimibe since hospitalization. Medicine Today 2023 Vol. 35(2): 99-104

Incidence and prediction of periprocedural myocardial infarction in elective PCI: the ALPHEUS-MI sub-study

Abstract Background PCI-related myocardial infarction (MI) or injury are frequent events that have been shown to be associated with long-term ischemic outcomes and mortality. Determinants of these events with the validated definition of PCI-related myocardial infarction (MI) or injury are not well documented in contemporary elective PCI. Methods The ALPHEUS-MI study is a prespecified analysis of the ALPHEUS randomized trial conducted in 49 centers of two European countries which recruited 1910 patients with chronic coronary syndrome undergoing elective PCI. We analyzed the rate and predictors of periprocedural myocardial necrosis using the primary and secondary endpoint of the ALPHEUS trial (3rd and 4th universal definition of MI) and the ARC2/SCAI definitions. Multivariable model including patient’s demographic, angiographic and procedural characteristics were performed for each definition to determine predictors of periprocedural events. Findings : The primary endpoint of the ALPHEUS trial (type 4a MI or major myocardial injury) occurred in 35.85% of the patients (3rd universal definition of MI); the secondary endpoint of the ALPHEUS trial (type 4a MI and any myocardial injury) occurred in 77.21% of the patients (4th universal definition of MI); significant periprocedural myocardial injury occurred in 3.24% of the patients (ARC2/SCAI definition) and periprocedural MI (ARC2/SCAI definition) in 2.02% of the patients. The rate of events followed a stepwise increase according to the number of high-risk features with all definitions (figure). High risk features were characterized by patients’ characteristics, the complexity of the coronary lesion (anatomy and atheroma burden) and the complexity of the PCI procedure itself. The only common predictor of MI or myocardial injury present with the 4 definitions was the total length of stent implanted (&amp;gt;60mm) ; adjOR 3.23 (2.49-4.18) p&amp;lt;0,001 (type 4a MI/major injury 3rd UDMI ) , adjOR 3.82 (2.51-5.8) p&amp;lt;0,001 (type 4a MI/any injury 4th UDMI) , adjOR 2.2 (1.24-3.91) p=0,007 (myocardial injury ARC2/SCAI) and adjOR 6.0 (3.04-11.9) p&amp;lt;0,001 (MI ARC2/SCAI). Conclusion Whatever definition of type 4aMI and myocardial injury, the strongest predictor of myocardial necrosis seems to be the length of stent implanted which reflects both the severity of atheroma burden and the complexity of PCI.

Machine learning versus guideline recommended pathways for the diagnosis of myocardial infarction

Abstract Background CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) is a validated clinical decision-support tool that uses machine learning to calculate the probability of myocardial infarction (MI) for an individual patient. Current European guidelines recommend the use of 0/1h- and 0/2h-algorithms optimised to rule-out or rule-in MI and the High-STEACS pathway, which enables rapid discharge or admission in patients with suspected MI. However, it is unknown how CoDE-ACS performs against these guideline recommended pathways. Methods We enrolled adult patients presenting with suspected acute coronary syndromes at 12 sites in 5 European countries. Patients with ST-elevation MI and those with missing high-sensitivity (hs)-cTnI concentrations at 0h, 1h or 2h were excluded. Final diagnoses were adjudicated by two independent cardiologists according to current guidelines and the 4th universal definition of MI using all information including serial hs-cTnI measurements and imaging. We compare the diagnostic performance and effectiveness of CoDE-ACS with the 0/1h- and 0/2h-algorithms and the High-STEACS pathway. Results In 4,105 patients (median age 61 [IQR 50-74], 32% women), the prevalence of type 1 MI was 14%. At presentation, CoDE-ACS identified 56% (2,280/4,105) of patients as low-probability, with a 99.7% (99.5-99.9%) negative predictive value (NPV) and 99.0% (98.6-99.2%) sensitivity, which ruled out twice as many patients as other pathways. CoDE-ACS incorporating 1h hs-cTnI measurements identified 65% (2,671/4,105) patients as low-probability with a 99.7% (99.5-99.8%) NPV and 98.6% (98.2-98.9%) sensitivity and 19% (770/4,105) patients as high-probability with a 64.9% (63.5-66.4%) PPV and 92.4% (91.5-93.1%) specificity, with 16% classified as intermediate probability. In comparison, the 0/1h-algorithm identified 49% (2,014/4,105) patients as low-risk with a 100% (99.9-100%) NPV and 100% (99.9-100%) sensitivity and 20% (829/4,105) patients as high-risk with a 61.5% (60.0-63.0%) PPV and 91.0% (90.0-91.8%) specificity, with 31% triaged to the observe zone. Findings for CoDE-ACS incorporating hs-cTnI measurements at 2h, the 0/2h-algorithm and the High-STEACS pathway were comparable (Table). Conclusion All guideline recommended clinical pathways provide excellent performance for the diagnosis of MI. CoDE-ACS provides comparable diagnostic performance, but identifies twice as many patients as low-probability at presentation and fewer patients require further observation following serial hs-cTnI measurements. Implementation studies are warranted to determine whether CoDE-ACS can further improve the early diagnosis of MI.

Does the paradoxical effect of smoking on troponin impact the safety of the ESC 0/1h algorithm?

Abstract Introduction Paradoxically, recent population-based studies reported lower levels of high-sensitivity cardiac troponin (hs-cTn) in current smokers than in never and former smokers. This counterintuitive finding raises questions about the yet not investigated association between smoking and hs-cTn levels and its potential impact on the safety and accuracy of the ESC 0/1h algorithm in patients with suspected acute myocardial infarction (MI). Purpose We sought to investigate the impact of smoking on i) quantitative levels of hs-cTnI and T in patients with symptoms indicative of MI, and ii) the performance of the ESC 0/1h algorithm using both assays. Methods We used data from a prospective cohort study investigating patients with symptoms suggestive of an acute MI who presented to the emergency department of a German tertiary care center. Final diagnoses were adjudicated according to the 4th Universal Definition of MI. Patients with ST-elevation MI were excluded. The population was categorized into three subgroups according to self-reported smoking status, i.e. current, never, and former smokers. Diagnostic accuracies of hs-cTnI and T levels at 0h and 1h, as assessed by the area under the receiver operating curve (ROC-AUC), and the performance, i.e. safety, accuracy and efficacy, of the ESC 0/1h algorithm using both assays were compared between smokers and never/former smokers. Results Among 2,527 patients with suspected MI, 562 (22.2%) were current smokers, 1,352 (53.5%) never and 613 (24.3%) former smokers. The prevalence of MI was comparable between the three groups, while age as well as several cardiovascular risk factors differed across the smoking categories. Hs-cTn levels at baseline were quantitatively lower in current smokers (hs-cTnI 4.8 [2.3, 14.8] ng/L; hs-cTnT 7.0 [4.0, 16.0] ng/L) than in never (hs-cTnI 5.6 [2.6, 16.2] ng/L; hs-cTnT 9.0 [5.0, 21.0] ng/L) and former smokers (hs-cTnI 6.2 [2.9, 15.9] ng/L; hs-cTnT 10.0 [5.0, 23.0] ng/L). Diagnostic accuracies did not differ between current and never/former smokers regarding the ROC-AUC for non-ST-elevation MI, neither based on 0h hs-cTnI (AUC 0.89 [0.85-0.93] vs. 0.88 [0.86-0.90], p=0.72) and 1h hs-cTnI (AUC 0.94 [0.91-0.97] vs. 0.92 [0.90-0.94], p=0.22), nor on 0h hs-cTnT (AUC 0.87 [0.82-0.91] vs. 0.87 [0.85-0.89], p=0.79) and 1h hs-cTnT (AUC 0.94 [0.92-0.96] vs. 0.92 [0.90-0.94], p=0.086). Applying the ESC 0/1h algorithm using hs-cTnI provided a very high and comparable safety for ruling-out MI in current and never/former smokers. Rule-in accuracy was also similar in current and never/former smokers, while the observe zone was slightly larger in never/former smokers (Figure 1A). Similar findings were confirmed for hs-cTnT (Figure 1B). Conclusion Despite paradoxically lower hs-cTnI and T concentrations in current than in never or former smokers with suspected MI, the ESC 0/1h algorithm achieves very high and comparable safety, accuracy and efficacy irrespective of smoking status.

Long-term follow-up of patients with myocardial infarction and myocardial injury

Abstract Introduction Patients with symptoms indicative of acute myocardial infarction (MI) frequently present to the emergency department (ED) and undergo a structured diagnostic assessment. Apart from MI, other diagnoses are frequently identified, including myocardial injury. In these patients estimation of long-term risk is crucial to guide preventive strategies. Purpose To assess and compare the long-term incidence of all-cause death and cardiovascular events in patients with MI, myocardial injury and other causes of acute chest pain. Methods We conducted a prospective, observational cohort study enrolling consecutive patients presenting with suspected MI to the ED of a tertiary hospital. The final diagnoses were adjudicated by two independent cardiologists according to the 4th Universal Definition of MI using high-sensitivity cardiac troponin T (hs-cTnT). Patients were followed to assess incidental all-cause death and a composite endpoint (cardiovascular death, MI, or myocardial revascularization). We used Kaplan-Meier plots for crude and Cox regression models (providing hazard ratios [95% confidence intervals]) for adjusted (sex, age, cardiovascular risk factors, heart failure, renal function) time-to-event analyses, respectively, using patients with other causes of chest pain as reference. Results Overall, we prospectively included 2,714 patients with a median age of 64 (25th, 75th: 51, 75) years, of whom 1,745 (64.3%) were male. In total, 143 (5.3%) had ST-elevation MI (STEMI), 128 (4.7%) Type 1 Non-ST-elevation MI (NSTEMI), 236 (8.7%) Type 2 NSTEMI, 86 (3.2%) acute myocardial injury, 677 (24.9%) chronic myocardial injury, and 1,444 (53.2%) other diagnoses of chest pain not involving hs-cTn elevation. The median follow-up time was 4.6 (4.5, 7.3) years. The highest rates of all-cause death were observed in patients with myocardial injury (81.6 [71.7, 92.3] events/1000 patient-years) and infarction (55.9 [46.3, 66.7]), compared to other diagnoses (12.2 (9.8, 15.1). Figure 1 provides the Kaplain-Meier estimates for the final diagnoses. In adjusted Cox regression analyses, all patients with MI or myocardial injury were at significantly higher risk for all-cause death, compared to patients with other causes of chest pain (Figure 2A). Additionally, the risk for the secondary composite endpoint (cardiovascular death, MI, revascularization) was significantly increased in those with acute or chronic myocardial injury, and patients with Type 1 NSTEMI or STEMI, but not Type 2 NSTEMI (Figure 2B). Conclusion Patients with acute myocardial infarction and acute or chronic myocardial injury are at high long-term risk for death and incident cardiovascular events. Importantly, those patients with acute myocardial injury showed the highest mortality rate. Further studies need to determine appropriate management strategies for patients with myocardial injury.Kaplan-Meier plot for final diagnosesForest plot of adjusted outcome analysis