First-time Myocardial Infarction Research Articles

Risk factors for acute myocardial infarction in patients with alcohol-related cirrhosis - a Danish nested case-control study

Background & Aims Alcohol-related cirrhosis (ALD cirrhosis) has a weaker effect on acute myocardial infarction (MI) than on other arterial or venous thromboses, and the reasons for this pattern are unclear. This study aimed to identify risk factors of MI amongst patients with ALD cirrhosis. Methods This nationwide register-based nested case-control study was conducted within a cohort of all Danish patients diagnosed with ALD cirrhosis from 2000-2019. Patients with first-time MI after diagnosis of ALD cirrhosis were identified as cases, and matching cohort members (10:1) with no history of MI, using risk-set sampling. We selected candidate risk factors a priori and used conditional logistic regression to study the association between them and the adjusted odds ratio of MI. Results and conclusions We included 373 cases and 3,730 controls. We identified the following risk factors for MI: hospitalization for infection (adjusted odds ratio 2.26 [95% CI 1.38-3.71]), recent surgery (adjusted odds ratio 1.82 [95% CI 1.18-2.81]), history of atherosclerosis (adjusted odds ratio 1.89 [95% CI 1.39-2.57]), cardiac ischemia (adjusted odds ratio 6.23 [95% CI 4.30-9.04]), heart failure (adjusted odds ratio 2.83 [95% CI 1.90-4.22]) or chronic obstructive pulmonary disease (COPD) (adjusted odds ratio 2.26 [95% CI 1.62-3.17]). Use of anticoagulants had a protective effect (adjusted odds ratio 0.47 [95% CI 0.25–0.91]). Our findings contribute to the understanding of risk factors for MI in patients with ALD cirrhosis. They may have clinical implications e.g. for the decision to offer thromboprophylaxis.

Acute myocardial infarction and chronic kidney disease: A nationwide cohort study on management and outcomes from 2010-2022.

Chronic kidney disease (CKD) is present in >30% of patients with acute myocardial infarction (MI) and has been associated with lower rates of guideline-directed management and worse prognosis. We investigated the use of guideline-directed management and mortality risk in patients with and without CKD. A nationwide cohort study based on health care registers encompassing all patients ≥18 years hospitalized with first-time MI in Denmark from 2010-2022 was conducted. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Probability of guideline-directed management and risk of all-cause mortality in patients with and without CKD were calculated from adjusted multivariable logistic and Cox regression models with probabilities and risks standardized to the distribution of confounders in the population. In total, we identified 21,009 patients who met eligibility criteria. Median age was 72 years, and 61% of patients were males; the median eGFR was 82 ml/min/1.73 m2, and 21% of patients had CKD. The 30-day probabilities of coronary angiography and revascularization were 71% (95% CI 69%-72%) and 78% (95% CI 77-79%), p<0.001; and 52% (95% CI 50%-54%) and 58% (95% CI 58%-59%), p<0.001, in patients with and without CKD, respectively. Probabilities increased during the study period (p for trend 0.05, 0.03, 0.02 and 0.03, respectively). In patients with and without CKD, probability of dual antiplatelet therapy was 67% (95% CI 65%-68%) and 70% (95% CI 69%-71%), p=0.001; while probability of lipid-lowering treatment was 76% (95% CI 75%-78%) and 82% (95% CI 81%-83%), p<0.001. Associated one-year mortality was 21% (95% CI 20%-22%) and 16.4% (95% CI 16%-17%) in patients with and without CKD, respectively. with decreasing mortality rates in both groups during the study period (p for trend 0.03 and 0.01). Although survival following MI improved for all patients, CKD continued to be associated with lower use of guideline-directed management and higher mortality.

#2551 Treatment and prognosis for myocardial infarction in patients with chronic kidney disease 2010-2022: a nationwide cohort study

Abstract Background and Aims Chronic kidney disease (CKD) is present in &amp;gt;30% of patients with acute coronary syndrome. Although prognosis following myocardial infarction (MI) has improved throughout the last decades, patients with CKD remain at considerably increased risk of recurrent cardiovascular events. We investigate use of guideline-directed cardiovascular interventions and cardioprotective medical therapy and associated cardiovascular outcomes in patients with and without CKD. Method From 2010 to 2022, all adult patients hospitalized with first-time MI (ICD10: DI21) were identified in nationwide Danish health care registers. CKD was defined by an estimated glomerular filtration rate (eGFR) &amp;lt;60 ml/min/1.73 m2. Study outcomes were evaluated in multiple logistic and cause-specific Cox regression models with computation of standardized risks/probabilities of outcomes. The probability of referral for interventional work-up was evaluated based on 30-days probability of cardiovascular interventions, i.e. coronary angiography (CAG) and/or revascularization. Guideline-directed cardioprotective medical therapy, i.e. lipid-lowering treatment, dual antiplatelet therapy, renin-angiotensin-system inhibitors, aldosterone antagonists, beta blockers, calcium channel blockers, and nitrates, was evaluated as 90-days probability of treatment in 90-days survivors. Lastly, one-year standardized risk of mortality was evaluated. All models were adjusted for age, sex, kidney transplant, congestive heart failure, hypertension, diabetes, cancer, thromboembolism, and any arrhythmia. Results In total, 21 009 patients were included; median age 72 years (IQR 63; 81), 60.8% males, median eGFR 82 ml/min/1.73 m2, 20.9% CKD. Patients with CKD were older, less likely to be male, had a longer admission time, had more comorbidities, and received more medical treatment compared with patients without CKD. The 30-days probability of CAG was 77.8% (95% CI 77.2%-78.5%) and 65.8% (95% CI 64.1%-67.3%), p &amp;lt; 0.001, and of revascularization 58.2% (95% CI 57.3%-59.0%) and 48.8% (95% CI46.9%-50.5%), p &amp;lt; 0.001, in patients without and with CKD, respectively. Development in probability of cardiovascular interventions and risk of 1-year mortality during the study period is depicted in Fig. 1. Probability of cardioprotective medical therapy in 90-days survivors is presented in Fig. 2. The 1-year risk of mortality was 16.4% (95% CI 15.7%-17.0%) and 20.9% (95% CI 19.9%-22.0%) in patients without and with CKD. Conclusion Although prognosis following first-time myocardial infarction has been improved for all patients, CKD continues to be associated with lower rates of guideline-directed cardiovascular interventions and cardioprotective medical therapy and increased 1-year mortality compared with patients without CKD.

Statin initiation after myocardial infarction in patients with alcohol-related liver disease: A nationwide population-based study.

Secondary prevention with statins improves clinical outcomes after myocardial infarction (MI). We aimed to compare odds of statin initiation after MI in patients with co-existing alcohol-related liver disease (ALD) to the general population, and the association between statin initiation and mortality in the patients with ALD. All statin-naïve patients with ALD and a first-time MI between 2006 and 2020 were identified from Swedish healthcare registers and matched for age, sex, and year of MI with up to ten ALD-free general population controls with a first-time MI. Logistic regression was used to estimate adjusted odds ratios (OR) for statin initiation within 30 days after MI for ALD patients versus controls. Cox regression was used in patients with ALD to compare mortality between statin initiators and non-initiators. Of the 276 patients with a first-time MI and ALD, 206 (74.6%) were male, the median age was 67 (interquartile range 62-72), 151 (54.7%) had cirrhosis, and 62 (22.5%) had decompensated cirrhosis. 1769 matched controls were included. Initiation of statins was less common in ALD patients (50.0%) than controls (89.2%, adjusted OR = .15, 95% confidence interval [CI] = .10-.20). Among patients with ALD, statin initiators and non-initiators were followed for a median of 3.9 (interquartile range = 1.8-7.7) and 1.9 years (interquartile range = .5-4.4), respectively. Statin initiators had lower mortality than non-initiators (adjusted hazard ratio = .41, 95%CI = .28-.59). Patients with ALD less often initiated statins after MI than the general population. Statin initiation was associated with improved survival, suggesting that patients with ALD might be undertreated following MI.

Influence of Low-Density Lipoprotein Cholesterol Levels on NSAID-Associated Cardiovascular Risks After Myocardial Infarction: A Population-Based Cohort Study.

To examine whether low-density lipoprotein cholesterol (LDL-C) levels influence the cardiovascular risk associated with non-aspirin non-steroidal anti-inflammatory drug (NSAID) use after myocardial infarction (MI). Using Danish health registries, we conducted a population-based cohort study of all adult patients with first-time MI during 2010-2020 with an LDL-C value before discharge. Based on the latest LDL-C value, we categorized patients into a low and a high LDL-C group (<3.0 vs ≥3.0 mmol/L). We used time varying Cox regression to compute hazard ratios (HRs) with 95% confidence intervals of the association between NSAID use and a major adverse cardiovascular event (MACE: recurrent MI, ischemic stroke, and all-cause death). We followed 50,573 patients for a median of 3.1 years. While exposed, 521 patients experienced a MACE: 312 in the low LDL-C group and 209 in the high LDL-C group. The HRs for MACE comparing NSAID use with non-use were 1.21 (1.11-1.32) overall, 1.19 (1.06-1.33) in the low LDL-C group, and 1.23 (1.07-1.41) in the high LDL-group. The HRs for recurrent MI and ischemic stroke were comparable between the LDL-C subgroups. The HRs for all-cause death were 1.22 (1.07-1.39) in the low LDL-C group and 1.54 (1.30-1.83) in the high LDL-C group. Changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L showed consistent results. In patients with MI, LDL-C levels did not influence the increased risk of MACE associated with NSAID use, but might influence the association between NSAID use and all-cause death.

Mortality of patients presented with acute ST-segment elevation myocardial infarction according to the status of standard modifiable cardiovascular risk factors

BackgroundStandard modifiable cardiovascular risk factors (SMuRFs) remain well-established elements of assessing cardiovascular risk scores. However, there is growing evidence that patients presented without known SMuRFs at admission demonstrate worse post-myocardial outcomes. The aim of the study was to assess the influence of the SMuRF status on short- and long-term mortality rates in patients with first-time ST-segment elevation myocardial infarction (STEMI). MethodsThis observational, cross-sectional study covered 182,726 patients admitted between 2003–2020 to the CathLabs, according to data from the Polish Registry of Acute Coronary Syndrome. Both baseline characteristics and mortality (in-hospital, 30-day, and 12-month) were examined and stratified by SMuRF status. The predictors of mortality were assessed at selected time points by multivariable analysis. ResultsThe majority of STEMI patients had at least one SMuRF (88.7%), however, mortality rates of SMuRF-less individuals were greater at selected time points of the follow-up (p < 0.001), and persisted at a higher level during each year of the follow-up period compared to the SMuRF group and general population. Furthermore, the SMuRFs status constituted an independent predictor of mortality at the 30-day (OR: 1.345; 95% CI: 1.142–1.585, p < 0.001) and 12-month (OR: 1.174; 95% CI: 1.054–1.308, p < 0.001) follow-ups. ConclusionsSMuRF-less individuals presented with STEMI are at an increased risk of all-cause mortality compared to those with at least one SMuRF. Consequently, further investigations regarding the recognition and treatment of risk factors, irrespective of SMuRF status, are indicated.

Elevated soluble LOX-1 predicts risk of first-time myocardial infarction

Background There is an unmet clinical need for novel therapies addressing the residual risk in patients receiving guideline preventive therapy for coronary heart disease. Experimental studies have identified a pro-atherogenic role of the oxidized LDL receptor LOX-1. We investigated the association between circulating soluble LOX-1 (sLOX-1) and the risk for development of myocardial infarction. Methods The study subjects (n = 4658) were part of the Malmö Diet and Cancer study. The baseline investigation was carried out 1991-1994 and the incidence of cardiovascular events monitored through national registers during a of 19.5 ± 4.9 years follow-up. sLOX-1 and other biomarkers were analyzed by proximity extension assay and ELISA in baseline plasma. Results Subjects in the highest tertile of sLOX-1 had an increased risk of myocardial infarction (hazard ratio (95% CI) 1.76 (1.40-2.21) as compared with those in the lowest tertile. The presence of cardiovascular risk factors was related to elevated sLOX-1, but the association between sLOX-1 and risk of myocardial infarction remained significant when adjusting for risk factors. Conclusions In this prospective population study we found an association between elevated sLOX-1, the presence of carotid disease and the risk for first-time myocardial infarction. Taken together with previous experimental findings of a pro-atherogenic role of LOX-1, this observation supports LOX-1 inhibition as a possible target for prevention of myocardial infarction.

Influence of cholesterol levels on NSAID-associated risks after myocardial infarction: a nationwide population-based cohort study

Abstract Introduction Non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, fever, and inflammation, but they can increase the risk of recurrent myocardial infarction (MI), ischemic stroke, atrial fibrillation, and death in patients with MI. Consequently, the European Society of Cardiology warns against using NSAIDs in patients with manifest cardiovascular disease and in high-risk individuals, such as those with dyslipidemia. However, no study has investigated whether NSAID-associated cardiovascular risks differ according to patients’ low-density lipoprotein cholesterol (LDL-C) levels. Purpose To examine whether LDL-C levels influence the cardiovascular risk associated with NSAID use after first-time MI. Methods Using Danish health registries, we conducted a population-based cohort study of all adult patients with a first-time MI hospitalization during 2010–2020 with an LDL-C value before discharge. Based on the latest LDL-C value, we categorized patients into a low and high LDL-C group (&amp;lt;3 vs. ≥3 mmol/L). We used multivariate Cox regression to compute adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between NSAID use (modelled in time-varying manner) and a major adverse cardiovascular event (MACE), defined as a composite of recurrent MI, ischemic stroke, and all-cause death. We repeated the analysis by changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L. Results We followed 50,573 patient with a first-time MI for a mean of 3.5 years (66% males, median age of 68 years. During NSAID use, 521 patients experienced a MACE: 312 in the low LDL-C group and 209 in the high LDL-C group. The HRs for MACE comparing NSAID use with non-use were 1.21 (1.11–1.32) overall, 1.19 (1.06–1.33) in the low LDL-C group, and 1.23 (1.07–1.41) in the high LDL-group. The HRs in the low and high LDL-C groups were 1.09 (0.88–1.34) vs. 0.94 (0.74–1.19) for recurrent MI, 0.97 (0.66–1.41) vs. 1.27 (0.86–1.87) for ischemic stroke, and 1.22 (1.07–1.39) vs. 1.54 (1.30–1.83) for all-cause death. Changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L showed consistent results. Conclusion In patients with a first-time MI, NSAID use was associated with an increased risk of MACE. The LDL-C level did not influence the association between NSAID use and MACE, but it might influence the association between NSAID use and all-cause death. Thus, healthcare providers should be mindful of the increased cardiovascular risk associated with NSAID use in patients with previous MI, regardless of LDL-C values.

Prevalence of SELECT-eligibility and incidence of 5-year major adverse cardiovascular outcomes in non-diabetic patients with myocardial infarction

Abstract Background The ongoing Semaglutide Effects on Heart Disease and Stroke in Patients with Overweight or Obesity (SELECT) trial has randomized 17,605 non-diabetic patients with a body mass index (BMI) ≥27 kg/m2 to treatment with semaglutide versus placebo. Follow-up will be terminated on March 31, 2023. In consecutive myocardial infarction (MI) patients representing daily clinical practice, the prevalence of SELECT-eligible patients and the incidence of the three-point major adverse cardiovascular events (MACE; MI, ischemic stroke, and cardiovascular death) are not known. Purpose To assess the prevalence of SELECT-eligibility and the incidence of 5-year MACE in SELECT-eligible patients in a contemporary semi-nationwide European MI cohort representing daily clinical practice. Methods We identified 34,385 patients with a first-time MI and followed the in- and exclusion criteria for the SELECT trial as outlined in the Figure. Concordant with the SELECT trial, follow-up started on day 60 and maximum follow-up time was 5 years. We estimated adjusted hazard ratios (aHR) for the SELECT-eligible cohort using patients with a BMI from 20 to &amp;lt;27 kg/m2 as reference group. Moreover, we stratified the SELECT-eligible cohort by BMI ≥27 to &amp;lt;33 kg/m2 and ≥33 kg/m2. Results As depicted in the Figure, 10,769 patients with a BMI ≥27 kg/m2 were eligible for SELECT (SELECT-eligible cohort), which corresponds to a prevalence of 31% in the entire 34,385 MI cohort. The normoweight reference group included 11,011 patients. At baseline, the median age was 64 years for the SELECT-eligible cohort and 68 years for the reference group. Stratification of the SELECT-eligible cohort showed median age of 65 years for the BMI ≥27 to &amp;lt;33 kg/m2 and 63 years for the BMI ≥33 kg/m2 subgroups. The cumulative 5-year incidence of MACE was 10.7% for SELECT-eligible and 13.2% for reference patients (aHR 0.96, 95% CI 0.88-1.04). When stratifying the SELECT-eligible cohort, those with BMI ≥27 to &amp;lt;33 and ≥33 kg/m2 had cumulative 5-year incidence of 10.9% (aHR 0.95, 95% CI 0.87-1.04) and 9.9% (aHR 0.99, 95% CI 0.84-1.16). Conclusions In a large contemporary semi-nationwide cohort of consecutive MI patients, approximately 3 out of 10 were eligible for the SELECT trial and the estimated 5-year MACE incidence in SELECT-eligible patients was just above 10%. SELECT-eligible patients experienced the index MI up to 7 years earlier than the reference group. However, the 5-year incidence of MACE did not suggest that overweight/obese patients fulfilling SELECT eligibility criteria were associated with an excess MACE risk when compared to a normoweight reference group.

Myocardial infarction mortality after COVID-19: a nationwide population-based cohort study

Abstract Background Coronavirus disease 2019 (COVID-19) is associated with an increased risk of myocardial infarction (MI). Small studies suggest that MI in patients with recent COVID-19 may have a distinct clinical course and a worse prognosis, compared to MI without recent COVID-19. Whether previous COVID-19 vaccination modifies the clinical course of MI after recent COVID-19 is also unknown. Purpose To compare mortality in people with MI with and without recent COVID-19, and to examine the impact of previous COVID-19 vaccination. Methods Using Danish health registries, we conducted a nationwide population-based cohort study comprising all adults (≥18 years) with a first-time MI between 26 May 2020 and 9 March 2022. We excluded patients with &amp;lt;1 year of residence in Denmark prior to their MI. The exposure was recent COVID-19 defined by a positive SARS-CoV-2 PCR test ≤90 days before MI. We followed the patients for 30 days from the date of their MI admission until death (if any), or emigration, whichever came first. We used Cox proportional-hazards regression to compute hazard ratios (HRs) for death within 30 days after MI. Using propensity-score balancing of confounders with stabilised inverse probability weighting, we adjusted for differences in age, sex, DANCAMI comorbidity burden, use of selected medications, and calendar period between MI patients with and without recent COVID-19. We stratified by COVID-19 vaccination status. Results Of 11,919 included patients with MI, 332 patients had COVID-19 within 90 days before MI. The COVID-19 exposed patients were characterised by a larger proportion of males and COVID-19 vaccinations, lower age, and a longer median time from first COVID-19 vaccination to MI compared to the COVID-19 unexposed patients. 34 of the patients with recent COVID-19 (10.2%) and 702 of the patients without recent COVID-19 (6.1%) died within 30 days after their MI, resulting in a crude HR of 1.71 with a 95% confidence interval (CI) of 1.21–2.42 for the patients with recent COVID-19. After adjusting by stabilised inverse probability weighting, this HR further increased to 2.08 (95% CI: 1.23–3.52). Previous COVID-19 vaccination modified this association with a three-fold increased mortality in unvaccinated MI patients with recent COVID-19, while the mortality HR associated with recent COVID-19 was close to one in patients who were previously COVID-19 vaccinated. Conclusion Patients with recent COVID-19 had increased short-term mortality after MI, but only if unvaccinated.

Non-invasive pressure volume loops derived by cardiovascular magnetic resonance: association between area at risk or infarct size and cardiac hemodynamics at 2-6 days after myocardial infarction

Abstract Background A novel non-invasive method for generation of pressure volume loops (PV-loops) using brachial blood pressure and cardiovascular magnetic resonance (CMR) imaging has recently been presented and validated (1). The non-invasive nature of this method enables calculation of PV-loops in large patient cohorts previously not feasible due to the need of invasive measurements. Purpose The purpose of the present study was to investigate how cardiac hemodynamics assessed by PV-loop variables such as stroke work, potential energy, contractility and ventriculoarterial coupling is related to myocardium at risk and infarct size in a cohort of patients with acute myocardial infarction (MI). Method A total of 100 patients with ST-elevation MI (STEMI) were included from the SOCCER, MITOCARE and CHILL-MI trials (2-4). The CHILL-MI cohort (n = 11) was prone to a stricter selection criterion than the SOCCER cohort, including first-time myocardial infarction and no comorbidities. All patients underwent a CMR examination at 2-6 days after MI. Non-invasive PV-loops were generated by combining volumetric CMR data and brachial sphygmomanometric pressure measurements using a recently validated method (1). Maximal elastance (Emax, translated to contractility), stroke work, potential energy and ventriculoarterial coupling (Ea/Emax) were measured from the PV-loops. Myocardium at risk and infarct size were assessed using contrast-enhanced steady state free precession and late gadolinium enhancement images, respectively. Results Contractility, ventriculoarterial coupling, stroke work and potential energy all correlated to myocardium at risk (Emax: r²=0.25, Ea/Emax: r²=0.36, stroke work: r²=0.21, potential energy: r²=0.10) and infarct size (Emax: r²=0.29, Ea/Emax: r²=0.41, stroke work: r²=0.25, potential energy: r²=0.15) as shown in Figure 1. Furthermore, contractility showed a stronger correlation to myocardium at risk (Emax: r²=0.77) than to infarct size (Emax: r²=0.37) for the CHILL-MI patients as shown in Figure 2. Conclusion Non-invasive CMR derived PV-loop parameters can be used to assess cardiac hemodynamics early after STEMI showing that increased myocardium at risk and infarct size are both associated with an increased ventriculoarterial coupling and potential energy, and a decreased contractility and stroke work. To what extent these hemodynamic parameters provide incremental prognostic information compared to conventional parameters such as ejection fraction and left ventricular dimensions after STEMI remains to be determined.Figure 1Figure 2

The effect of discontinuing long-term beta-blockers following acute myocardial infarction in optimally treated, stable patients without heart failure - a Danish, nationwide cohort study

Abstract Aims We studied the effect of discontinuing beta-blockers following myocardial infarction in optimally treated, stable patients without heart failure. Methods and results Using nationwide registers, we identified first-time myocardial infarction patients treated with beta-blockers following percutaneous coronary intervention or coronary angiography. The analysis was based on landmarks selected as 1, 2, 3, 4, and 5 years after the first redeemed beta-blocker prescription date. The outcomes included all-cause death, cardiovascular death, recurrent myocardial infarction, and a composite outcome of cardiovascular events and procedures. We used logistic regression and reported standardized absolute 5-year risks and risk differences at each landmark year. Among 21,220 first-time myocardial infarction patients, beta-blocker discontinuation was not associated with an increased risk of all-cause death, cardiovascular death, or recurrent myocardial infarction compared with patients continuing beta-blockers (landmark year 5; absolute risk difference [95% confidence interval]), correspondingly; -4.19% [-8.95%; 0.57%], -1.18% [-4.11%; 1.75%], and -0.37% [-4.56%; 3.82%]). Further, beta-blocker discontinuation within two years after myocardial infarction was associated with increased risk of the composite outcome but there was no risk difference associated with discontinuation hereafter. Conclusion Discontinuation of beta-blockers one year or later after myocardial infarction without heart failure was not associated with increased serious adverse events.

Clinical characteristics of first myocardial infarction in women by history of adverse pregnancy outcomes

Abstract Background Adverse pregnancy complications are known risk factors for future coronary artery disease in women and small studies suggest that a history of hypertensive disorders of pregnancy are associated with ST-elevation myocardial infarction (STEMI) at the time of myocardial infarction. (1) Recent evidence from a population-based study also suggests that middle aged women with a history of either hypertensive disorders of pregnancy or a small for gestational age infant have a different segmental-level pattern of coronary artery atherosclerosis as detected by coronary computed tomography angiography. (2) Purpose To study clinical characteristics of first-time myocardial infarction by adverse pregnancy outcome history (preterm delivery, hypertensive disorders of pregnancy [including preeclampsia and gestational hypertension], and small for gestational age infant). Methods In 8,320 women age ≤65 years with first myocardial infarction in Sweden 2007-2022, we used logistic regression to estimate the association between adverse pregnancy outcome history and presenting with STEMI (vs. non ST-elevation myocardial infarction [NSTEMI]), in-hospital revascularization, and peak troponin &amp;gt;75th percentile, respectively. In addition to age-adjusted results, we also considered predictors of coronary artery disease (body mass index, diabetes, hypertension, smoking status and dyslipidemia). Results In total, 1301 (15.6 %) women with a first myocardial infarction had a history of preterm delivery, 887 (10.7 %) women had a history of small for gestational age infant, 1078 (13.0 %) women had a history of hypertensive disorders of pregnancy, and 3,128 (37.6%) women presented with STEMI. The odds of presenting with STEMI were higher in women with a history of delivering a small for gestational age infant (age-adjusted odds ratio 1.40, 95% CI 1.22-1.61), as well as the odds of in-hospital revascularization (odds ratio 1.30, 95% CI 1.12-1.50), and peak troponin &amp;gt;75th percentile (odds ratio 1.23, 95% CI 1.05-1.43). Accounting for predictors of coronary artery disease did not change these estimates substantially. No consistent associations were observed between preterm delivery or hypertensive disorders of pregnancy and outcomes. Conclusion(s) Among women presenting with a first myocardial infarction, a history of small for gestational age infant was associated with clinical characteristics indicating larger myocardial injury. The extent to which this is relevant for the prevention and treatment of coronary artery disease in women warrants further studies.

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending

The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. ClinicalTrials.gov Identifier: NCT04047147.

Role of serum CAP1 protein in the diagnosis of patients with first-time acute myocardial infarction.

The dysregulation of adenylate cyclase-associated protein 1 (CAP1) is associated with a variety of inflammatory conditions. Here, we aimed to assess the role of serum CAP1 protein in predicting acute myocardial infarction (AMI), and to explore its effect and mechanism in vascular endothelial cells injury. ELISA was utilized to detected CAP1 protein expression in serum from 70 patients with first-time AMI at 0, 6, 12, 24, 48 hours and 7 days of the onset of chest pain. Receiver operating characteristic (ROC) curve analysis was administered to analyze the diagnostic power of CAP1 for AMI. The CCK-8 and 5-BrdU assays were applied to measure cell proliferation and inflammation in a model of oxidized low-density lipoprotein (ox-LDL) induced human umbilical vein endothelial cells (HUVEC). Luciferase reporter gene assay and Western blotting were used to assess the activity of NF-κB pathway. Results showed that serum CAP1 protein expression was upregulated in patients with first-time AMI, its expression was highest at 12 hours of the onset of chest pain. CAP1 protein was positively associated with the levels of cTnI and ox-LDL. CAP1 showed a relatively high diagnostic accuracy in patients with first-time AMI compared with cTnI, and CAP1 combined with cTnI had superior diagnostic value than CAP1 and cTnI alone. The expression of CAP1 protein was increased in supernatants of ox-LDL induced HUVEC in a dose- and time-dependent manner. CAP1 inhibited cell proliferation but promoted inflammation, and induced the activation of NF-κB pathway in vitro. To sum up, increased serum CAP1 expression might serve as a novel diagnostic biomarker for patients with first-time AMI, the mechanism might be related to its induction of NF-κB pathway activation causing abnormal proliferation and inflammation and thus mediating vascular endothelial cell injury.

Treated periodontitis and recurrent events after first-time myocardial infarction: A Danish nationwide cohort study.

To investigate the association between previous periodontal treatment and recurrent events after first-time myocardial infarction (MI). From the Danish nationwide registries, patients with first-time MI between 2000 and 2015 were divided into three groups according to oral health care within 1 year prior to first-time MI. A multiple logistic regression model provided adjusted odds ratios (ORs) with 95% confidence intervals (CIs) to assess the 3-year risk of major adverse cardiovascular events (MACE). A total of 103,949 patients were included. Patients with treated periodontitis (PD) prior to first-time MI had an adjusted 3-year risk of MACE similar to patients presumed periodontally healthy (OR 0.97 [95% CI 0.92-1.03]). Patients with no prior dental visits were significantly older, had more comorbidities and showed significantly increased adjusted 3-year risks of MACE (OR 1.47 [95% CI 1.42-1.52]), cardiovascular death (OR 1.71 [95% CI 1.64-1.78]) and heart failure (OR 1.13 [95% CI 1.07-1.20]) compared with patients presumed periodontally healthy. Patients with treated PD 1 year prior to first-time MI had a similar risk of recurrent cardiovascular events as patients presumed periodontally healthy. No dental visit prior to first-time MI was an independent risk factor for recurrent events.

Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study.

Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.

The impact of end-stage kidney disease on mortality in patients after acute myocardial infarction: A nationwide study.

This study aimed to evaluate the impact of end-stage kidney disease (ESKD) on mortality in patients with first-time acute myocardial infarction (AMI). This was a retrospective nationwide cohort study. Patients diagnosed with first-time AMI between January 1, 2000, and December 31, 2012, were included. All patients were followed-up until death or December 31, 2012, whichever occurred first. A one-to-one propensity score matching technique was used to match patients with ESKD to those without ESKD of similar sex, age, comorbidities, and coronary intervention (including percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]). Kaplan-Meier cumulative survival curves were constructed to compare AMI patients with and without ESKD. A total of 186 112 patients were enrolled and 8056 patients with ESKD were identified. Propensity score matched 8056 patients without ESKD were included in the comparison. Overall, the 12-year mortality rate was significantly higher in patients with ESKD than in those without ESKD (log-rank p < 0.0001), including the sex, age, and PCI and CABG subgroups. In Cox proportional-hazard regression analysis, ESKD was an independent risk factor for mortality after patients suffered from first-time AMI (hazard ratio, 1.77; 95% CI, 1.70-1.84; p < 0.0001). A forest plot for subgroup analysis revealed that in AMI patients, ESKD had a higher impact on mortality in male; younger age; without comorbidities such as hypertension, diabetes mellitus, peripheral vascular disease, heart failure, cerebrovascular accident, and chronic obstructive pulmonary disease; and receiving PCI and CABG subgroups. ESKD significantly increases the mortality risk in patients with first-time AMI, including both sexes, different ages, and whether PCI or CABG was performed. In patients with AMI, ESKD has a high impact on mortality in male, younger age, without comorbidities, and those undergoing PCI and CABG.

The effect of discontinuing beta-blockers after different treatment durations following acute myocardial infarction in optimally treated, stable patients without heart failure: a Danish, nationwide cohort study.

We studied the effect of discontinuing beta-blockers following myocardial infarction in comparison to continuous beta-blocker use in optimally treated, stable patients without heart failure. Using nationwide registers, we identified first-time myocardial infarction patients treated with beta-blockers following percutaneous coronary intervention or coronary angiography. The analysis was based on landmarks selected as 1, 2, 3, 4, and 5 years after the first redeemed beta-blocker prescription date. The outcomes included all-cause death, cardiovascular death, recurrent myocardial infarction, and a composite outcome of cardiovascular events and procedures. We used logistic regression and reported standardized absolute 5-year risks and risk differences at each landmark year. Among 21220 first-time myocardial infarction patients, beta-blocker discontinuation was not associated with an increased risk of all-cause death, cardiovascular death, or recurrent myocardial infarction compared with patients continuing beta-blockers (landmark year 5; absolute risk difference [95% confidence interval]), correspondingly; -4.19% [-8.95%; 0.57%], -1.18% [-4.11%; 1.75%], and -0.37% [-4.56%; 3.82%]). Further, beta-blocker discontinuation within 2 years after myocardial infarction was associated with an increased risk of the composite outcome (landmark year 2; absolute risk [95% confidence interval] 19.87% [17.29%; 22.46%]) compared with continued beta-blocker use (landmark year 2; absolute risk [95% confidence interval] 17.10% [16.34%; 17.87%]), which yielded an absolute risk difference [95% confidence interval] at -2.8% [-5.4%; -0.1%], however, there was no risk difference associated with discontinuation hereafter. Discontinuation of beta-blockers 1 year or later after a myocardial infarction without heart failure was not associated with increased serious adverse events.

Cardiovascular risks of continuing vs. initiating NSAIDs after first-time myocardial infarction or heart failure: a nationwide cohort study.

It is unknown whether the cardiovascular risks associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) shortly after first-time myocardial infarction (MI) or heart failure (HF) differ between patients continuing and initiating use. Using nationwide health registries, we conducted a cohort study of all patients with first-time MI or HF during 1996-2018 (n=273 682). NSAID users (n=97 966) were categorized as continuing (17%) and initiating (83%) users according to prescription fillings<60 days before index diagnosis. The primary outcome was a composite of new MI, HF admission, and all-cause death. Follow-up started 30 days after the index discharge date. We used Cox regression to compute hazard ratios (HRs) with 95% confidence intervals (CIs) comparing NSAID users vs. non-users. The most commonly filled NSAIDs were ibuprofen (50%), diclofenac (20%), etodolac (8.5%), and naproxen (4.3%). The composite outcome HR of 1.25 (CI: 1.23-1.27) was driven by initiators (HR=1.39, 1.36-1.41) and not continuing users (HR=1.03, 1.00-1.07). The lack of association among continuing users was also observed for individual NSAIDs (ibuprofen and naproxen), except diclofenac (HR=1.11, 95% CI: 1.05-1.18). Among initiators, the HR was 1.63 (CI: 1.57-1.69) for diclofenac, 1.31 (CI: 1.27-1.35) for ibuprofen, and 1.19 (CI: 1.08-1.31) for naproxen. The results were consistent for both MI and HF patients, the individual components of the composite outcome, and various sensitivity analyses. NSAID initiators were more susceptible to adverse cardiovascular outcomes after first-time MI or HF than continuing users.