Elevation Acute Myocardial Infarction Research Articles

Impact of medicaid expansion on disparities in revascularization in patients hospitalized with acute myocardial infarction.

IntroductionBlacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction.MethodsRetrospective analysis study using data (2010–2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion.ResultsThe analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29–3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83–11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51–3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs.ConclusionMedicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions.

Abstract 13615: Weekdays versus Weekends: Outcomes of Cardiogenic Shock in the Setting of Acute Myocardial Infarction

Introduction: Acute myocardial infarction (AMI) accounts for the majority of patients with cardiogenic shock (CS). The high case fatality justifies the need for an optimal hospital care system that is available 24 hours, 7 days a week. It is unclear whether the “weekend effect” has an impact on the outcome of CS associated with AMI. Hypothesis: Weekend CS-AMI admissions have a higher in-hospital case fatality than weekday admissions. Methods: A total of 22,632 patients with ST segment elevation AMI complicated with CS between the years 1986 to 2015 were identified in the Myocardial Infarction Data Acquisition System, a statewide database of all admissions to non-federal hospitals in NJ. Trend analysis was performed using a logistic regression model with admission year as a continuous variable. Case fatality rates between weekend vs weekday admissions were compared using the Cochran–Mantel–Haenszel test, stratifying by admission year. Results: From 1986 to 2015 there was a steady decline in the rates of in-hospital case fatality of AMI complicated with CS, from 79% to 33% (p&lt; 0.001). The overall CS death rate for admissions on weekends was 61% and for weekdays 59% (Common-Odds Ratio = 1.10 (95% CI (1.02-1.17) p= 0.006) (figure). The use of mechanical circulatory support (MCS) was lower on weekends (p&lt;0.001) and was associated with a higher case fatality rate 48 hours from admission (p&lt;0.001). Conclusion: Deaths related to CS complicating AMI have steadily declined and this applies for both, patients admitted on weekends and weekdays. There was a higher hospital death rate in patients admitted over weekends compared to weekdays. The underutilization of MCS devices during weekends likely contributes to the difference in case fatality between weekends and weekdays.

Clinical predictors and angiographic features of acute coronary syndromes caused by systemic embolism

Abstract Introduction Systemic embolism to coronary arteries is one of the mechanisms of acute myocardial infarction (AMI) of non-atherosclerotic cause. However, its clinical profile has not been properly established yet. Purpose To identify clinical predictors and angiographic characteristics of acute coronary syndromes caused by systemic embolism to a principal coronary artery (ACS-E), as well as to describe in-hospital mortality of these patients. Methods 40 patients with ACS-E, admitted between 2003 and 2018 in a tertiary hospital. Epidemiological, clinical and angiographic characteristics of these cases were compared with those from 4989 patients, attended for acute coronary syndrome of atherosclerotic cause (ACS-A) in the same hospital during the same period. Results Patients with ACS-E were younger (28% vs 10% were &amp;lt;45 years old, p&amp;lt;0.001) and had a higher proportion of women (43% vs 22%, p 0.003), atrial fibrillation (40% vs 5%, p&amp;lt;0.001) and neoplasia (18% vs 7%, p 0.009). They had also undergone previous valvular surgery more frequently than patients with ACS-A (13% vs 0.5%, p&amp;lt;0.001) and a higher proportion of them were under treatment with warfarin (15% vs 3%, p&amp;lt;0.001). Variables identified as independent predictors of ACS-E in the multivariate analysis are shown in the table. Regarding clinical presentation, ST elevation AMI was more frequent in ACS-E cases (83% vs 67%, p 0.04). Patients with ACS-E did not present any significative stenosis in other vessels apart from the culprit one (number of other vessels with at least 1 severe stenosis was 0 in the ACS-E group vs 1.33 + 1 in the ACS-A arm, p&amp;lt;0.001). PCI was attempted in 75% of the patients with ACS-E, resulting successful in 80% of the cases. On the other hand, 100% of SCA-A underwent PCI, with a success proportion of 99% (p&amp;lt;0.001). In-hospital mortality in ACS-E group was 15% and 4% in the control group (p&amp;lt;0.001). Conclusions ACS-E and ACS-A have different clinical and angiographic features. Atrial fibrillation, chronic warfarin treatment, previous valvular surgery, presence of any neoplasia and female sex are independent predictors for ACS-E. Funding Acknowledgement Type of funding source: None

Prognostic Impact of B-Type Natriuretic Peptide on Long-Term Clinical Outcomes in Patients with Non-ST-Segment Elevation Acute Myocardial Infarction Without Creatine Kinase Elevation.

Although B-type natriuretic peptide (BNP) has gradually gained recognition as an indicator in risk stratification for patients with acute myocardial infarction (AMI), the prognostic impact on long-term clinical outcomes in patients with non-ST-segment elevation acute myocardial infarction (NSTEMI) without creatine kinase (CK) elevation remains unclear.This prospective multicenter study assessed 3,283 consecutive patients with AMI admitted to 28 institutions in Japan between 2012 and 2014. We analyzed 218 patients with NSTEMI without CK elevation (NSTEMI-CK) for whom BNP was available. In the NSTEMI-CK group, patients were assigned to high- and low-BNP groups according to BNP values (cut-off BNP, 100 pg/mL). The primary endpoint was defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. Primary endpoints were observed in 60 (33.3%) events among patients with NSTEMI-CK. Kaplan-Meier analysis revealed a significantly higher event rate for primary endpoints among patients with high BNP (log-rank P < 0.001). After adjusting for covariates, a higher BNP level was significantly associated with long-term clinical outcomes in NSTEMI-CK (adjusted hazard ratio, 4.86; 95% confidence interval, 2.18-12.44; P < 0.001).The BNP concentration is associated with adverse long-term clinical outcomes among patients with NSTEMI-CK who are considered low risk. Careful clinical management may be warranted for secondary prevention in patients with NSTEMI-CK with high BNP levels.

Factores de riesgo de muerte hospitalaria en pacientes con infarto agudo de miocardio durante la pandemia de la COVID-19

Introduction and objectivesDespite advances in treatment, patients with acute myocardial infarction (AMI) still exhibit unfavorable short- and long-term prognoses. In addition, there is scant evidence about the clinical outcomes of patients with AMI and coronavirus disease 2019 (COVID-19). The objective of this study was to describe the clinical presentation, complications, and risk factors for mortality in patients admitted for AMI during the COVID-19 pandemic. MethodsThis prospective, multicenter, cohort study included all consecutive patients with AMI who underwent coronary angiography in a 30-day period corresponding chronologically with the COVID-19 outbreak (March 15 to April 15, 2020). Clinical presentations and outcomes were compared between COVID-19 and non-COVID-19 patients. The effect of COVID-19 on mortality was assessed by propensity score matching and with a multivariate logistic regression model. ResultsIn total, 187 patients were admitted for AMI, 111 with ST-segment elevation AMI and 76 with non-ST-segment elevation AMI. Of these, 32 (17%) were diagnosed with COVID-19. GRACE score, Killip-Kimball classification, and several inflammatory markers were significantly higher in COVID-19-positive patients. Total and cardiovascular mortality were also significantly higher in COVID-19-positive patients (25% vs 3.8% [P <.001] and 15.2% vs 1.8% [P=.001], respectively). GRACE score> 140 (OR, 23.45; 95%CI, 2.52–62.51; P=.005) and COVID-19 (OR, 6.61; 95%CI, 1.82-24.43; P=.02) were independent predictors of in-hospital death. ConclusionsDuring this pandemic, a high GRACE score and COVID-19 were independent risk factors associated with higher in-hospital mortality.Full English text available from:www.revespcardiol.org/en

Impact of Raised Blood Glucose Level on In-Hospital Outcome of Thrombolysed Patients with Acute Myocardial Infarction

Background: Diabetes mellitus (DM) is an established major cardiovascular risk factor associated with increased prevalence of coronary artery disease (CAD). Patients with diabetes often have numerous concomitant cardiac risk factors with a higher incidence of acute myocardial infarction (AMI) and congestive heart failure (CHF). Patients either with or without a prior history of DM may present with hyperglycemia during AMI. We analysed our population to determine whether admission hyperglycemia was a strong risk factor for in-hospital mortality and morbidity in patients with AMI and may be even stronger than a previous history of diabetes.In-hospital death risk of AMI patients without DM was about 2 to 4 times higher in patients with hyperglycemia than in those without hyperglycemia.&#x0D; Methods: This Prospective observational study was carried out at the National Institute of Cardiovascular Diseases (NICVD), Dhaka. A total number of 200 STsegment elevation AMI patients were enrolled in this study as per inclusion and exclusion criteria. They were subdivided on the basis of admission blood glucose into two groups. Group-1A and 2A were 50 patients with blood glucose &lt;200mg/dl (&lt;11.1mmol/l) and Group-1B and 2B were 50 patients with blood glucose ≥200mg/dl (11.1 ≥mmol/l). The numerical data obtained from the study were analyzed and significance of differences were estimated by using statistical methods. Computer based SPSS (Statistical Package for Social Science) were used.&#x0D; Results: In the present study mean age of the male and female were 56.10±11.86 and 57.83±13.74 years, p&gt;0.05%. There was no significant difference regarding risk factors and smoking was higher in both group. Regarding inhospital adverse outcome, death was significantly higher in hyperglycemic non diabetic group (p&lt;0.0001). It was two times (56%) higher than diabetic hyperglycemic (28%) group.Cardiogenic shock (66%) and CHF (56%) were also more common in hyperglycemic non diabetic group. Lowest patients (8%) died of AMI without DM with random blood glucose &lt;11.1 mmol/l (controlled). On the other hand highest improvement was in the controlled group (p&lt;0.0001).Multivariate analysis showed Diabetic status with normal blood sugar was a predictor of adverse outcome; but patients with hyperglycemia and no history of diabetes had a worse outcome and were independently associated with significant risk of in-hospital mortality. Age group &gt;65 years and Male sex were also associated with significant in-hospital mortality.&#x0D; Conclusion: Independent of diabetic status, the occurrence of hyperglycemia during AMI is associated with a subpopulation of patients at particularly high risk for an adverse clinical outcome. Even with the highly efficacious treatment strategies currently available, persons presenting with AMI and hyperglycemia are at increased risk for cardiogenic shock and CHF or death in hospital.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 14-19

Intracranial Hemorrhage Complicating Acute Myocardial Infarction: An 18-Year National Study of Temporal Trends, Predictors, and Outcomes.

Background: There is a paucity of contemporary data on the burden of intracranial hemorrhage (ICH) complicating acute myocardial infarction (AMI). This study sought to evaluate the temporal trends, predictors, and outcomes of ICH in AMI. Methods: The National Inpatient Sample (2000–2017) was used to identify adult (>18 years) AMI admissions with ICH. In-hospital mortality, hospitalization costs, length of stay, and measure of functional ability were the outcomes of interest. The discharge destination along with use of tracheostomy and percutaneous endoscopic gastrostomy were used to estimate functional burden. Results: Of a total 11,622,528 AMI admissions, 23,422 (0.2%) had concomitant ICH. Compared to those without, the ICH cohort was on average older, female, of non-White race, had greater comorbidities, and had higher rates of arrhythmias (all p < 0.001). Female sex, non-White race, ST-segment elevation AMI presentation, use of fibrinolytics, mechanical circulatory support, and invasive mechanical ventilation were identified as individual predictors of ICH. The AMI admissions with ICH received less frequent coronary angiography (46.9% vs. 63.8%), percutaneous coronary intervention (22.7% vs. 41.8%), and coronary artery bypass grafting (5.4% vs. 9.2%), as compared to those without (p < 0.001). ICH was associated with a significantly higher in-hospital mortality (41.4% vs. 6.1%; adjusted OR 5.65 (95% CI 5.47–5.84); p < 0.001), longer hospital length of stay, higher hospitalization costs, and greater use of percutaneous endoscopic gastrostomy (all p < 0.001). Among ICH survivors (N = 13, 689), 81.3% had a poor functional outcome at discharge. Conclusions: ICH causes a substantial burden in AMI due to associated higher in-hospital mortality and poor functional outcomes.

Clinical risk assessment of biotin interference with a high-sensitivity cardiac troponin T assay.

Objectives Biotin >20.0ng/mL (81.8nmol/L) can reduce Elecsys® Troponin T Gen 5 (TnT Gen 5; Roche Diagnostics) assay recovery, potentially leading to false-negative results in patients with suspected acute myocardial infarction (AMI). We aimed to determine the prevalence of elevated biotin and AMI misclassification risk from biotin interference with the TnT Gen 5 assay. Methods Biotin was measured using an Elecsys assay in two cohorts: (i) 797 0-h and 646 3-h samples from 850 US emergency department patients with suspected acute coronary syndrome (ACS); (ii) 2023 random samples from a US laboratory network, in which biotin distributions were extrapolated for higher values using pharmacokinetic modeling. Biotin >20.0ng/mL (81.8nmol/L) prevalence and biotin 99th percentile values were calculated. AMI misclassification risk due to biotin interference with the TnT Gen 5 assay was modeled using different assay cutoffs and test timepoints. Results ACS cohort: 1/797 (0.13%) 0-h and 1/646 (0.15%) 3-h samples had biotin >20.0ng/mL (81.8nmol/L); 99th percentile biotin was 2.62ng/mL (10.7nmol/L; 0-h) and 2.38ng/mL (9.74nmol/L; 3-h). Using conservative assumptions, the likelihood of false-negative AMI prediction due to biotin interference was 0.026% (0-h result; 19ng/L TnT Gen 5 assay cutoff). US laboratory cohort: 15/2023 (0.74%) samples had biotin >20.0ng/mL (81.8nmol/L); 99th percentile biotin was 16.6ng/mL (68.0nmol/L). Misclassification risk due to biotin interference (19ng/L TnT Gen 5 assay cutoff) was 0.025% (0-h), 0.0064% (1-h), 0.00048% (3-h), and <0.00001% (6-h). Conclusions Biotin interference has minimal impact on the TnT Gen 5 assay's clinical utility, and the likelihood of false-negative AMI prediction is extremely low.

Same-Day Versus Non-Simultaneous Extracorporeal Membrane Oxygenation Support for In-Hospital Cardiac Arrest Complicating Acute Myocardial Infarction.

Background: Although extracorporeal membrane oxygenation (ECMO) is used for hemodynamic support for in-hospital cardiac arrest (IHCA) complicating acute myocardial infarction (AMI), there are limited data on the outcomes stratified by the timing of initiation of this strategy. Methods: Adult (>18 years) AMI admissions with IHCA were identified using the National Inpatient Sample (2000–2017) and the timing of ECMO with relation to IHCA was identified. Same-day vs. non-simultaneous ECMO support for IHCA were compared. Outcomes of interest included in-hospital mortality, temporal trends, hospitalization costs, and length of stay. Results: Of the 11.6 million AMI admissions, IHCA was noted in 1.5% with 914 (<0.01%) receiving ECMO support. The cohort receiving same-day ECMO (N = 795) was on average female, with lower comorbidity, higher rates of ST-segment-elevation AMI, shockable rhythm, and higher rates of complications. Compared to non-simultaneous ECMO, the same-day ECMO cohort had higher rates of coronary angiography (67.5% vs. 51.3%; p = 0.001) and comparable rates of percutaneous coronary intervention (58.9% vs. 63.9%; p = 0.32). The same-day ECMO cohort had higher in-hospital mortality (63.1% vs. 44.5%; adjusted odds ratio 3.98 (95% confidence interval 2.34–6.77); p < 0.001), shorter length of stay, and lower hospitalization costs. Older age, minority race, non-ST-segment elevation AMI, multiorgan failure, and complications independently predicted higher in-hospital mortality in IHCA complicating AMI. Conclusions: Same-day ECMO support for IHCA was associated with higher in-hospital mortality compared to those receiving non-simultaneous ECMO support. Though ECMO-assisted CPR is being increasingly used, careful candidate selection is key to improving outcomes in this population.

Influence of seasons on the management and outcomes acute myocardial infarction: An 18-year US study.

BackgroundThere are limited data on the seasonal variation in acute myocardial infarction (AMI) in the contemporary literature.HypothesisThere would be decrease in the seasonal variation in the management and outcomes of AMI.MethodsAdult (>18 years) AMI admissions were identified using the National Inpatient Sample (2000‐2017). Seasons were classified as spring, summer, fall, and winter. Outcomes of interest included prevalence, in‐hospital mortality, use of coronary angiography, and percutaneous coronary intervention (PCI). Subgroup analyses for type of AMI and patient characteristics were performed.ResultsOf the 10 880 856 AMI admissions, 24.3%, 22.9%, 22.2%, and 24.2% were admitted in spring, summer, fall, and winter, respectively. The four cohorts had comparable age, sex, race, and comorbidities distribution. Rates of coronary angiography and PCI were slightly but significantly lower in winter (62.6% and 40.7%) in comparison to the other seasons (64‐65% and 42‐43%, respectively) (P < .001). Compared to spring, winter admissions had higher in‐hospital mortality (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.06‐1.08), whereas summer (aOR 0.97; 95% CI 0.96‐0.98) and fall (aOR 0.98; 95% CI 0.97‐0.99) had slightly lower in‐hospital mortality (P < .001). ST‐segment elevation (10.0% vs 9.1%; aOR 1.07; 95% CI 1.06‐1.08) and non‐ST‐segment elevation (4.7% vs 4.2%; aOR 1.07; 95% CI 1.06‐1.09) AMI admissions in winter had higher in‐hospital mortality compared to spring (P < .001). The primary results were consistent when stratified by age, sex, race, geographic region, and admission year.ConclusionsCompared to other seasons, winter admission was associated with higher in‐hospital mortality in AMI in the United States.

Risk factors for in-hospital mortality in patients with acute myocardial infarction during the COVID-19 outbreak

Introduction and objectivesDespite advances in treatment, patients with acute myocardial infarction (AMI) still exhibit unfavorable short- and long-term prognoses. In addition, there is scant evidence about the clinical outcomes of patients with AMI and coronavirus disease 2019 (COVID-19). The objective of this study was to describe the clinical presentation, complications, and risk factors for mortality in patients admitted for AMI during the COVID-19 pandemic. MethodsThis prospective, multicenter, cohort study included all consecutive patients with AMI who underwent coronary angiography in a 30-day period corresponding chronologically with the COVID-19 outbreak (March 15 to April 15, 2020). Clinical presentations and outcomes were compared between COVID-19 and non-COVID-19 patients. The effect of COVID-19 on mortality was assessed by propensity score matching and with a multivariate logistic regression model. ResultsIn total, 187 patients were admitted for AMI, 111 with ST-segment elevation AMI and 76 with non-ST-segment elevation AMI. Of these, 32 (17%) were diagnosed with COVID-19. GRACE score, Killip-Kimball classification, and several inflammatory markers were significantly higher in COVID-19-positive patients. Total and cardiovascular mortality were also significantly higher in COVID-19-positive patients (25% vs 3.8% [P <.001] and 15.2% vs 1.8% [P=.001], respectively). GRACE score> 140 (OR, 23.45; 95%CI, 2.52–62.51; P=.005) and COVID-19 (OR, 6.61; 95%CI, 1.82-24.43; P=.02) were independent predictors of in-hospital death. ConclusionsDuring this pandemic, a high GRACE score and COVID-19 were independent risk factors associated with higher in-hospital mortality.

Size-fractionated particulate air pollution and myocardial infarction emergency hospitalization in Shanghai, China

BackgroundFine particulate matter (PM2.5) air pollution has been associated with increased risks of acute myocardial infarction (AMI), but it remains unknown about the potentially differentiated effects of size-fractionated particulate matter on AMI risk. ObjectiveTo identify the specific size ranges that dominate the effects of particulate matter on AMI onset. MethodsWe conducted a time-series study in Shanghai, China from January 2014 to December 2018. We evaluated particle size distribution of 0.01 μm to 2.5 μm from an environmental supersite and AMI emergency hospitalizations from the largest cardiovascular hospital in Shanghai. We used over-dispersed generalized additive models to estimate the associations of size-fractionated particle number concentrations (PNC) with AMI and its types. ResultsWe identified a total of 4720 AMI emergency hospitalizations. PM2.5 was significantly associated with increased AMI risk on the concurrent day. The associations were significant only for PNC < 0.3 μm. For an IQR increase of PNCs for size ranges 0.01–0.03 μm, 0.03–0.05 μm, 0.05–0.10 μm and 0.10–0.30 μm, AMI hospitalizations increased by 6.68% (95% CI: 2.77%, 10.74%), 6.53% (95% CI: 2.08%, 11.17%), 5.78% (95% CI: 0.92%, 10.88%) and 5.92% (95% CI: 1.31%, 10.74%), respectively. The associations of PNC < 0.05 μm remained significant when adjusting for other air pollutants. There were consistently much stronger associations of particles with ST-segment elevation AMI than those with non-ST-segment elevation AMI. ConclusionsThis epidemiological investigation suggested that ultrafine particles, especially those <0.05 μm, may be mainly responsible for the acute AMI risk induced by PM2.5.

Impact of Early (≤24 h) Versus Delayed (>24 h) Intervention in Patients With Non-ST Segment Elevation Myocardial Infarction: An Observational Study of 20,882 Patients From the London Heart Attack Group

IntroductionWe aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention in non-ST-segment elevation acute myocardial infarction (NSTEMI) patients. MethodsWe examined the impact of early (≤24 h) versus delayed (>24 h) intervention in a large observational cohort of 20,882 consecutive NSTEMI patients treated with PCI between 2005 and 2015 at 8 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching. ResultsMean age was 64.5 ± 12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24 h. Patients treated within 24 h were slightly younger (62.8 ± 12.8 vs. 65.2 ± 12.6, p < 0.001), most commonly male (76% vs. 72.9%, p < 0.001) and were more frequently ventilated (2.3% vs. 1.4%, p < 0.001) and in cardiogenic shock (3.6% vs. 1.4%, p < 0.001) with dynamic changes on their ECG (84.5% vs. 76.1% p < 0.001). At a median follow up of 4.2 years (interquartile range 1.8 to 7) 17.7% of patients had died. Estimated 5-year survival in patients treated within 24 h was 84.6% vs. 81% for those treated >24 h following their presentation (p < 0.001). This survival benefit remained following adjustment for confounders; HR(delayed vs. early management) 1.11 (95%CI 1.003 to 1.23, p = 0.046). In the propensity matched cohort of 4356 patients in each group, there remained a trend for higher survival in the early intervention group (p = 0.061). ConclusionsNotwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24 h) may improve mid-term survival.

P1004Atrial fibrillation during acute myocardial infarction : a prospective multicenter study

Abstract New-onset atrial fibrillation (AF) frequently complicates acute myocardial infarction (AMI) and is associated with higher in-hospital and 1-year mortality, particularly in patients with ST-segment elevation AMI. In this clinical setting the occurrence of AF is of particular importance since irregular ventricular rates during AF may cause further impairment of the coronary circulation and left ventricular function in addition to the adverse consequences of neuro-hormonal activation. However, incidence and risk factors contributing to the occurrence of AF in AMI are still not well-known. The purpose of this study is to evaluate prospectively some risk factors contributing the incidence of AF in the setting of AMI. Methods This was a three-center prospective study, conducted in the coronary care unit of our medical center during the period of January 2017 to June 2018. This study included 976 patients with acute MI of different localization. AF was found in 82 patients of whom 68 experienced this arrhythmia anew. Onset, duration and mode of termination of AF, clinical and risk factors associated with its presentation and its relation with patient outcome were evaluated. Anamnesis, clinical and functional state of the heart (according to the results of instrumental and laboratory data) was studied in all patients. The data was analyzed for statistical significance using multivariate analyses by SPSS 16. Results The obtained results showed that in acute MI AF was registered in 9.4% of patients, among which new episodes of AF have been identified in 82.9% of patients. All the patients who developed AF after AMI were more than 60 years of age. Moreover, 68% of patients with AF have arterial hypertension, 27% - diabetes mellitus and 67% patients have higher heart rate. There is a relationship between developed AF and other supraventricular arrhythmias in the past history. In 62% of patients with AF, anterior MI was detected and accompanied by more severe hemodynamic disorders. Multivariate analyses showed that AF correlated weakly with age (r = 0.249) and strongly with left atrial diameter (r = 0.478) and left ventricular dysfunction (r = 0.419) especially with higher Killip class. Conclusions The results of the present study revealed that in the presence of identified certain risk factors in patients with acute MI, AF may develop. There is the link between identified risk factors and the occurrence of AF

Whole blood transcriptome profile at hospital admission discriminates between patients with ST-segment elevation and non-ST-segment elevation acute myocardial infarction

Whether ST-segment (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) should be regarded as distinct pathophysiological entities is a matter of debate. We tested the hypothesis that peripheral blood gene-expression profiles at presentation distinguish STEMI from NSTEMI. We performed a case-control study collecting whole-blood from 60 STEMI and 58 NSTEMI (defined according to the third universal definition of MI) consecutive patients on hospital admission. We used RNA-sequencing for the discovery phase, comparing 15 STEMI vs. 15 NSTEMI patients, matched for age, sex, and cardiovascular risk factors, and quantitative PCR in the remaining unmatched patients for validating top-significant genes. Gene-level differential expression analysis identified significant differences in the expression of 323 genes: 153 genes withstood correction for admission cardiac troponin I (cTnI), differentiating the two conditions independently of myocardial necrosis extent. Functional annotation analysis uncovered divergent modulation in leukocyte and platelet activation, cell migration, and mitochondrial respiratory processes. Linear regression analysis revealed gene expression patterns on admission predicting infarct size, as indexed by cTnI peak (R2 = 0.58–0.75). Our results unveil distinctive pathological traits for these two MI subtypes and provide insights into the early assessment of injury extent. This could translate into RNA-based disease-specific biomarkers for precision diagnosis and risk stratification.

Functional Genetic Variant in ATG5 Gene Promoter in Acute Myocardial Infarction.

Coronary artery disease (CAD) including acute myocardial infarction (AMI) is an inflammatory and metabolic disease mainly caused by atherosclerosis. Dysfunctional autophagy has been associated with abnormal lipid metabolism and inflammation. In previous studies, we have reported altered autophagic activity in AMI patients. As autophagy-related protein 5 (ATG5) is a core protein in autophagy, we speculated that altered ATG5 level may contribute to CAD and AMI development. In this study, the promoter of the ATG5 gene was genetically and functionally investigated in large groups of AMI patients (n = 378) and ethnic-matched healthy controls (n = 386). The results showed that a total of 15 genetic variants including 6 single-nucleotide polymorphisms (SNPs) in the ATG5 gene promoter were found in this study population. A novel deletion variant (g.106326168_70delTCT) and an SNP [g.106325757C > G (rs190825454)] were found in one 66-year-old male patient with non-ST-segment elevated AMI, but in none of controls. In cultured HEK-293 and H9c2 cells, the deletion variant significantly decreased the transcriptional activity of the ATG5 gene promoter (P < 0.01). In contrast, the genetic variants either identified only in controls or found in both AMI patients and controls did not affect the transcriptional activity of the ATG5 gene promoter (P > 0.05). Furthermore, an electrophoretic mobility shift assay showed that the deletion variant evidently affected the binding of a transcription factor. Therefore, the genetic variant identified in AMI may affect the activity of the ATG5 gene promoter and change the ATG5 level, contributing to AMI as a rare risk factor.

Cardiac intervention rates for older patients with acute myocardial infarction in the United States and Ontario, 2003-2013: a retrospective cohort study.

Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions. In this retrospective cohort study, we followed adults aged 66-99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality). We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%). Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI.

SHORT TERM CLINICAL OUTCOMES IN NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION PATIENTS WITH HIGH THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) RISK SCORE

Objective: To determine short-termclinical outcomes and factors related to themin non ST segment elevation myocardial infarction (NSTEMI) patients with highThrombolysis in Myocardial Infarction (TIMI) risk score. Methodology: This cross-sectional study was conducted in the in theDepartment of cardiology, Lady Reading hospital, Peshawar from1st January2016 to 30th June,2016. Patients of Non STEMI elevation acute myocardialinfarction (MI) having high TIMI score were included in the study in a consecutivemanner and followed to determine the short-term clinical outcome. Sociodemographicfactors were correlated with the outcome among the studyparticipants. Results: In this study 167 patients were included, with 65.3% males. Mean age ofthe patients was 52.8 +7.6 years. About 56.3% patients had hypertension,41.3% had diabetes mellitus and smoking was recorded in 52.7% of patients.Ventricular tachycardia was recorded in 10.2%, VF in 17.4%, AF in 9.6%,cardiopulmonary edema in 65.3%, cardiogenic shock in 49.7%, CHB in 32.3%and in hospital death was recorded in 48.5% of patients. Presence of DM andsmoking were significantly correlated with presence of various complicationsamong the study participants. Conclusion: Adverse clinical outcome were highly prevalent in our patientspresenting with NSTEMI and high TIMI score. Patients who have been cigarettesmokers and suffering from diabetes mellitus should be cautiously followed upand screened for the complications after the NSTEMI. Key Words: TIMI score, NSTEMI, Risk factors

P1722 Post myocardial infarction pericarditis or subacute left ventricular free wall rupture after acute myocardial infarction- a role of multimodality imaging

Abstract Introduction Moderate to severe pericardial effusion (PE) in patients with acute myocardial infarction (AMI) can be associated with a broad spectrum of etiologies like left ventricular free wall rupture (LVFWR) or post- myocardial infarction pericarditis (PMIP). We present a case of successful medical treatment of patient with subacute LVFWR after AMI, initially managed as PMIP. Case Presentation A 60- year- old man with a history of hypertension was admitted with persisting chest pain for 72 hours, with diagnosis of ST- segment elevation AMI of inferior wall. Patient underwent a percutaneous coronary intervention (PCI) of the right coronary artery as the AMI culprit vessel. Two days after PCI patient experienced progressive sharp chest pain, dyspnea and low- grade fever. Clinical evaluation revealed elevated inflammatory markers and pericardial rub. Transthoracic echocardiography (TTE) showed PE up to 10 mm. Patient has been diagnosed and treated as PMIP. During further observation patient had TTE performed repeatedly. Four days after PCI TTE revealed PE of 20 mm thickness and suspicion of subacute LVFWR of the lateral wall. Cardiac magnetic resonance (CMR) confirmed the diagnosis. Due to hemodynamic stability, the patient received only medical treatment. During further hospitalization TTE was performed every day. On fifteenth day both TTE and CMR didn’t reveal any rupture. Moreover patient was readmitted 6 weeks after initial hospitalization and TTE again did not show the LVFWR. Discussion Post AMI patients with PE who fulfill pericarditits diagnostic criteria should be managed as having PMIP. Nevertheless LVFWR should also be considered as frequent diagnosis of PE. Echocardiography is crucial in the prompt diagnosis of PE. In our presented case, the TTE did not show initially the LVFWR, only repeatedly performed investigation showed the increasing amount of PE and raised suspicion of subacute LVFWR, which was confirmed in CMR. CMR has become a tool providing accurate diagnosis and visualization of the localization of rupture. Moreover CMR imaging can show LVFWR revealing whether the hematoma is circumscribed to the myocardium or communicates with ventricular cavity or the pericardial sac. LVFWR is a catastrophic complication accounting for a significant proportion of in-patient deaths. It is accepted that emergent surgical repair is the cornerstone treatment for patients with LVFWR. However, similarly to ours, some cases with fairly good survival rates following isolated medical treatment have been reported. This clinical situation stands somewhere between the insidious free rupture into the pericardial cavity and the formation of the pseudoaneurysm. Conclusions Our presentation illustrates the usefulness of repeated multimodality imaging for the diagnosis and follow up of patients with PE after AMI. Our case also underscores the value of a conservative approach as a valid alternative to surgery in some patients with subacute LVFWR.

Invasive Evaluation of the Microvasculature in Acute Myocardial Infarction: Coronary Flow Reserve versus the Index of Microcirculatory Resistance.

Acute myocardial infarction (AMI) is one of the most common causes of death in both the developed and developing world. It has high associated morbidity despite prompt institution of recommended therapy. The focus over the last few decades in ST-segment elevation AMI has been on timely reperfusion of the epicardial vessel. However, microvascular consequences after reperfusion, such as microvascular obstruction (MVO), are equally reliable predictors of outcome. The attention on the microcirculation has meant that traditional angiographic/anatomic methods are insufficient. We searched PubMed and the Cochrane database for English-language studies published between January 2000 and November 2019 that investigated the use of invasive physiologic tools in AMI. Based on these results, we provide a comprehensive review regarding the role for the invasive evaluation of the microcirculation in AMI, with specific emphasis on coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR).