Higher Killip Class Research Articles

Renal insufficiency impacts on early and late mortality after acute coronary syndrome after adjustment for comorbidities and management. Insights from the FAST MI 2005 registry

Background: There is excess mortality in patients (pts) with renal insufficiency (RI) and acute coronary syndrome (ACS) due to comorbidities, increased hemorrhagic & thrombotic risks and suboptimal management. We investigated the impact of RI itself on acute and long term outcomes after MI, after adjustment for comorbidities and management. Methods: FAST-MI is a nationwide French registry that included consecutive pts with AMI in 223 centres in 2005. Baseline characteristics and management were compared between groups according to RI status at inclusion. All-cause mortality at 30 days and 5 years were compared between RI groups by Cox multivariate analysis and paired comparison (matched on a propensity score to have RI). Results: Of 3670 AMI pts included, 1537 (41.9%) had RI (creatinine clearance≤60 ml/min). RI pts were older, more often diabetic and smokers, more often had a history of hypertension, heart failure, stroke, peripheral arterial disease and anemia, had longer time to treatment and higher Killip class. RI pts less frequently received aspirin, thienopyridines, ACEI/ARB and less often underwent revascularisation. In-hospital death was 3 times higher in RI pts (10.8 vs 3%, p<0.0001), and 5 year mortality was more than twice as high (51% vs 18%, p<0.0001). After adjustment for baseline characteristics, comorbidities and management, RI was associated with higher 30-day (hazard ratio, HR 1.8 [1.2; 2.7]) and 5 year mortality (HR 1.45 [1.18; 1.8]) and higher 5 year mortality among survivors at 30 days (HR 1.47 [1.2; 1.8]). After matching on a propensity score, in-hospital and 5 year mortality remained higher in RI pts (figure). ![Figure][1] Conclusions: Pts with RI are at increased risk of early and late death, independently of comorbidities and management. [1]: pending:yes

Predictors of mineralocorticoid receptor antagonist utilization in patients with left ventricular dysfunction following acute myocardial infarction: real world data from the acute coronary syndrome IS

Background: Following the EPHESUS trial, published in 2003, mineralocorticoid receptor antagonist (MRA) therapy among acute MI patients with left ventricular dysfunction and heart failure or diabetes mellitus received a class I indication in this high risk population. We sought to assess predictors for the implementation of this indication in a real world setting following the trial. Methods: The study population comprised 955 patients enrolled in the Acute Coronary Syndrome Israeli Surveys (ACSIS) 2004-2010 who met the guideline criteria for treatment with MRA including serum creatinine I or diabetes mellitus. Results: Among 7,696 patients enrolled in the ACSIS surveys from 2004, 955 (12%) were eligible for MRA treatment. In this population MRA therapy has increased from 20.6% to 25.4% over the six-year period, whereas utilization of other guideline recommended drugs, including ACE-I/ARBs and beta-blockers, was >3-fold higher. In a multivariate-adjusted logistic regression analysis, independent predictors of MRA prescription included a higher degree of left ventricular dysfunction (and a higher Killip class on admission, whereas there was no significant difference in creatinine level between patients with and without MRA treatment (Figure). ![Figure][1] Conclusions: In a real world setting, approximately one quarter of acute MI patients eligible for treatment with an MRA received this mode of medical therapy. MRA prescription in this population was associated with lower risk clinical characteristics, suggesting underutilization of MRAs in higher risk eligible patients. [1]: pending:yes

Serum Uric Acid as a prognostic biomarker &amp; its correlation with Killip Class in Acute Myocardial Infarction

Introduction: Uric acid has been proven to be a negative prognostic indicator in patients with acute myocardial infarction and heart failure. There is a need to find a simple, less expensive but accurate marker that could be use in rural areas where fibrinolytic treatment is the first choice of acute reperfusion therapy. Materials and Methods: 80 patients presenting with acute myocardial infarction were included in the study and serum uric acid levels and Killip Class was assessed on Day 0,3 and 7. Results: Serum uric acid levels were raised in patients who presented with higher Killip Class on admission and all the 6 patients who succumbed belonged to either Killip Class 3 or 4 at presentation with a serum uric acid level of more than or equal to 7mg/dL. Conclusion: Serum uric levels are raised during an episode of myocardial infarction and more so when the patient is in heart failure. There is a positive correlation between rising serum uric acid levels with higher Killip Class at the time of admission. Thus uric acid can be used as a prognostic indicator in patients presenting with myocardial infarction more so if they are in heart failure.

Pre-Hospital Cardiac Arrest in Acute Coronary Syndromes: Insights from the Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events

Objectives: Cardiac arrest in acute coronary syndromes (ACS) is associated with high morbidity and mortality. We examined the clinical characteristics, contemporary management patterns and outcomes of ACS patients with pre-hospital cardiac arrest. Methods: The Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events enrolled 14,010 ACS patients in 1999-2008. We compared the clinical characteristics, in-hospital treatment and outcomes between patients with and without pre-hospital cardiac arrest. Results: Overall, 206 (1.4%) patients had cardiac arrest prior to hospital presentation. ACS patients with pre-hospital cardiac arrest were less frequently treated with aspirin, β-blocker, angiotensin-converting enzyme inhibitors, and statins within the first 24 h of presentation, but the use of cardiac procedures was similar compared to the group without cardiac arrest. Patients with pre-hospital cardiac arrest had significantly higher rates of in-hospital adverse events. Factors independently associated with pre-hospital cardiac arrest included male gender, current smoker status, tachycardia, higher Killip class and ST-segment deviation. Conclusion: ACS patients with pre-hospital cardiac arrest continue to have more in-hospital complications and higher mortality. Their use of evidence-based medical therapies was lower but the use of cardiac procedures was similar compared to the group without cardiac arrest. Better utilization of evidence-based therapies in these patients may translate into improved outcomes.

An optimal cardiothoracic ratio cut-off to predict clinical outcomes in patients with acute myocardial infarction

The traditional cut-off for the cardiothoracic ratio (CTR) by chest X-ray was not originally proposed as a prognostic variable. We investigated an optimal CTR cut-off that could predict clinical outcomes in patients with acute myocardial infarction (AMI). A total of 3,083 AMI patients (65.2 ± 12.0 years, 2,091 males) who underwent successful percutaneous coronary intervention were divided into two groups by use of a CTR of 0.42 as determined by receiver-operating characteristic curve analysis (group I: CTR ≤ 0.42, group II: CTR > 0.42). We compared the incidences of in-hospital death and major adverse cardiac events (MACEs), including cardiac death, reinfarction, coronary artery bypass grafting, and target lesion revascularization, during 12 months between the groups. The patients in group II were older than those in group I and included more women. The patients in group II were more likely to have hypertension and multivessel disease and had a higher Killip class, higher troponin, higher N-terminal pro-brain natriuretic peptide, and lower ejection fraction than did those in group I. The in-hospital death rate was higher in group II (1.9 vs. 4.8%, p < 0.001). The incidences of cardiac death and composite of MACEs during 12 months of follow-up were significantly higher in group II than in group I (2.4 vs. 5.7%, p < 0.001, and 16.0 vs. 19.8%, p = 0.007, respectively). Multivariable logistic regression analysis revealed that CTR greater than 0.42 was an independent predictor of MACEs (relative risk: 1.361, 95% CI 1.014-1.827, p = 0.040). A CTR greater than 0.42, although within the traditional normal range, was associated with worse in-hospital and long-term clinical outcome in AMI patients.

Comparative prognostic value of T-wave inversion and ST-segment depression on the admission electrocardiogram in non–ST-segment elevation acute coronary syndromes

ST-segment depression (STD) is predictive of adverse outcomes in non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but there are conflicting data on the incremental prognostic value of T-wave inversions (TWIs) on the admission electrocardiogram. Admission electrocardiograms of 7,343 patients with NSTE-ACS from the Global Registry of Acute Coronary Events (GRACE) and ACS I registry were independently analyzed at a core laboratory and stratified by TWI and STD status. We performed multivariable analyses to determine the independent prognostic significance of TWI and tested for interaction between TWI and STD for adverse outcomes. Patients with TWI and/or STD had a higher prevalence of cardiovascular risk factors, higher Killip class, and higher GRACE risk scores. Among the 2,708 patients with available angiographic data, rates of 3-vessel or left main disease were similar between patients with TWI and those without TWI/STD. After adjusting for other established prognosticators, TWI did not independently predict in-hospital (adjusted odds ratio 1.03, 95% CI 0.75-1.42, P = .85) or 6-month mortality (adjusted odds ratio 1.02, 95% CI 0.80-1.30, P = .88); STD remained a strong independent predictor. There was no interaction between TWI and STD for these outcomes. No contiguous lead groups or cumulative number of leads with TWI provided independent prognostic information. TWI is associated with other high-risk clinical features but is not an independent predictor of adverse short- and long-term mortality in NSTE-ACS. T-wave inversion does not provide additional prognostication beyond the GRACE risk model, and its concomitant presence does not alter the prognostic value of STD.

Statins modulate feedback regulation mechanisms between advanced glycation end-products and C-reactive protein: Evidence in patients with acute myocardial infarction

ObjectiveHigh sensitivity C-reactive protein (hsCRP) and advanced glycation end-products (AGEs) have been proposed as mediators in inflammation and atherosclerosis. Therefore, we studied the relation between AGE and hsCRP in patients with acute myocardial infarction (AMI). MethodsPatients with AMI diagnosis and satisfying our inclusion criteria were included during 2009–2011 in an unicentre registry of AMI patients for a cross-sectional study. The final cohort was composed of 156 patients (46.2% STEMI and 27.6% with type-2 diabetes). AGE and hsCRP were measured in plasma. ResultsDiabetic patients were older than non-diabetics (68.6±10.6 vs. 60.4±13.9years; p<0.05), presented more incidence of hypertension (62.8 vs. 36.3%; p<0.05) and were in a higher Killip class (p<0.05). The mean values of fluorescent AGE and hsCRP levels were 61.3±49.8 AU and 2.4±4.0mg/L, respectively, and there were no differences in these parameters between diabetic and non-diabetic patients. A direct association between AGE and hsCRP levels was observed, mainly in diabetic patients (r=0.258; p=0.018). Importantly, this association disappeared in patients who had been treated with statins before their AMI (r=−0.055; p=0.845), but it was maintained in non-diabetic patients naïve for statins treatment (r=0.634; p<0.001), independently of other treatments and confounding parameters. ConclusionsThis is the first evidence in humans of a feedback regulation mechanism between CRP and the AGE–RAGE axis modulated by statins.

Predictors and clinical implications of stent thrombosis in patients with ST-segment elevation myocardial infarction

Few data are available about safety of second generation drug eluting stents in an all-comer ST elevation myocardial infarction (STEMI) population. We sought to investigate the predictors and clinical implications of 1-year stent thrombosis (ST) in patients with STEMI, included in the EXAMINATION trial. The EXAMINATION trial is an all-comer prospective, randomized 1:1 controlled trial, testing everolimus-eluting stent (EES) vs. cobalt chromium bare metal stent (BMS) in STEMI patients. It included 1498 patients, randomized to EES (n = 751) or BMS (n = 747). At 1 year, definite/probable stent thrombosis, defined according to ARC criteria, occurred in 26 patients (1.73%), including 18 definite and 8 probable events. The incidence of ST was lower in patients treated with EES than in those treated with BMS (HR 0.16, 95% CI 0.03-0.29, p = 0.017). Patients with ST have higher 1-year rates of cardiac death (30.8% vs. 2.5%, p<0.001), myocardial infarction (30.8% vs. 0.5%, p<0.001) and target vessel revascularization (65.4% vs. 4.2%, p<0.001) compared with those without. Independent predictors of 1-year definite/probable ST were BMS implantation at the index procedure (HR 3.41, 95% CI 1.35-8.60), ST segment resolution of at least 70% in the EKG post-PCI (HR 0.30, 95% CI 0.13-0.70) and Killip class on admission (HR 2.57, 95% CI 1.70-3.90). ST had low frequency in the first year after implantation of EES/BMS in STEMI patients, but it is associated with adverse events. BMS implantation, lack of ST-segment resolution and high Killip class on admission were independent predictors of 1-year ST.

Determinants of Angiographic Thrombus Burden in Patients With ST-Segment Elevation Myocardial Infarction

We aimed to investigate the determinants of angiographic thrombus burden in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI). The study population consisted of 662 patients with nonanemic STEMI who underwent pPCI. Clinical, laboratory, and demographic properties of the patients were recorded. Baseline hematologic indices were measured at the time of admission. Angiographic coronary thrombus burden was scored based on thrombolysis in myocardial infarction (TIMI) thrombus grades. After wiring and/or small balloon dilation, patients with thrombus burden grades 4 and 5 were defined as high thrombus burden, and patients with thrombus burden <grade 4 was defined as low thrombus burden. Patients with high thrombus burden had more family history of coronary artery disease, longer pain to balloon time, higher Killip class (≥II), higher neutrophil to lymphocyte ratio, red cell distribution width (RDW), baseline creatine kinase-MB fraction (CK-MB) and baseline troponin, higher peak CK-MB, and peak troponinbut lower triglycerides. Angiographically, patients with high thrombus burden had longer lesion in the infarct-related artery, less frequent direct stenting, lower epicardial and myocardial perfusion, more frequent distal embolization, and more frequent electrocardiographic and angiographic no reflow. In multivariate logistic regression analysis, only RDW (odds ratio: 1.29, 95% confidence interval 1.19-1.39, P < .001) was determined as independent predictor. The area under the receiver-operating characteristic curve of the RDW was 0.733 (0.690-0.776, P < .001) to predict high TIMI thrombus burden. Present study results demonstrated that high thrombus burden in patients with STEMI was associated with impaired postprocedural epicardial and myocardial perfusion and higher no reflow and distal embolization; and increased RDW values were independent predictors of coronary thrombus burden.

Initial culprit-only versus initial multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: results from the Ibaraki Cardiovascular Assessment Study registry

We investigated clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) treated for initial culprit-only or by initial simultaneous treatment of nonculprit lesion with culprit lesion. Optimal management of multivessel disease in STEMI patients treated by primary percutaneous coronary intervention (PCI) is still unclear in the drug-eluting stent era. We compared clinical outcomes of 274 STEMI patients (69.3 ± 11.8 years, 77 % men) in the Ibaraki Cardiovascular Assessment Study registry who underwent initial culprit-only (OCL, n=220) or initial multivessel PCI of nonculprit lesion with culprit lesion (NCL, n=54) from April 2007 to August 2010. Major adverse cardiac and cerebrovascular events (MACCE) included all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), and cerebrovascular accident (CVA). Patients in the NCL group were older and had higher Killip class and lower estimated glomerular filtration rate than those in the OCL group. MI, TVR, CVA, and stent thrombosis were not significantly different between the two groups. Incidences of all-cause death and MACCE were lower in the OCL than in the NCL group (all-cause death: 10.9 % vs 31.5 %, P < 0.05; MACCE: 27.7 % vs 46.2 %, P < 0.05). After adjusting for patient characteristics, NCL remained at significantly higher risk compared with OCL for in-hospital and all-cause death (P=0.001, respectively), and MACCE were not significantly different (odds ratio 1.95, 95 % confidence interval 0.94-4.08; P=0.07) between groups. Initial multivessel PCI was associated with significantly increased risk of in-hospital death, all-cause death, and MACCE, which was somewhat attenuated in a multivariable model, but the numerically excessive risk with NCL still persisted.

Estimated Glomerular Filtration Rate as a Useful Predictor of Mortality in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BackgroundThis study evaluated the impact of estimated glomerular filtration rate (eGFR) on 30-day and 1-year mortalities in patients with an acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). MethodsBetween January 2002 and November 2009, 1432 consecutive patients who had experienced STEMI with an onset of chest pain <12hours of undergoing primary PCI were prospectively enrolled. Patients were categorized into group 1 (eGFR <30mL/min/1.73m2), group 2 (eGFR=30–60mL/min/1.73m2) and group 3 (eGFR >60mL/min/1.73m2). ResultsThe incidence of a high Killip class (defined as class ≥3) upon presentation, a requirement for mechanical ventilatory support for respiratory failure and intra-aortic balloon pump support for hemodynamic instability, and duration of hospitalization were substantially higher in group 1 than in groups 2 and 3, and notably higher in group 2 compared with group 3 (all P<0.001). Conversely, the procedural success of primary PCI was remarkably lower in group 1 compared with groups 2 and 3, and it was also notably lower in group 2 than in group 3 (all P<0.001). Additionally, both 30-day and 1-year mortalities were markedly increased in group 1 than in groups 2 and 3, and significantly higher in group 2 than in group 3 (all P<0.001). Multivariate analysis showed that eGFR <30mL/min/1.73m2 was a significantly independent predictor of 30-day and 1-year mortalities (all P<0.001). ConclusionseGFR <30mL/min/1.73m2 was strongly and independently predictive of poor short-term and long-term prognostic outcomes in patients with STEMI undergoing primary PCI.

Relation of Gender to Infarct Size in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty

Previous reports have shown that female gender is associated with impaired outcomes among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, mainly owing to a worst risk profile (more diabetes, more advanced age, and higher Killip class at presentation) compared to men. Still contrasting are data on the effect of gender on the outcome in patients with STEMI undergoing primary angioplasty. In particular, it is still unclear whether a larger infarct size might contribute to the explanation of the worse outcome in women. Therefore, the aim of the present study was to investigate gender-related differences in infarct size as evaluated by myocardial scintigraphy in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We included 830 patients with STEMI undergoing primary percutaneous coronary intervention. The infarct size was evaluated at 30 days using technetium-99m-sestamibi. A logistic regression analysis was performed to determine the relation between gender and infarct size (as percentage of patients above the median) after correction for baseline confounding factors. We also evaluated the presence of a potential age-gender interaction. A total of 183 patients (20.8%) were women. Female gender was associated with more advanced age and a greater prevalence of hypertension; previous infarction and smoking were more frequently observed in men. Female gender was associated with a smaller infarct size (p <0.001) that was confirmed after correction for baseline confounding factors (adjusted odds ratio 0.48, 95% confidence interval 0.33-0.7, p <0.001). No age-gender interaction was observed (p = 0.13). In conclusion, the results of the present study have shown that despite the presence of high-risk features at presentation, female gender was associated with a smaller infarct size than that in men, without any interaction between age and gender.

Prognosis of different types of atrial fibrillation in the primary angioplasty era

Atrial fibrillation (AF) has been associated with a poor prognosis in patients with ST-segment elevation myocardial infarction. There is considerable controversy regarding the prognostic implications of different types of AF. We analyzed 913 patients consecutively admitted to our center with ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention. Clinical, ECG, and angiographic data were collected. We carried out univariate and multivariate analysis, using a combined endpoint of death, reinfarction, stroke, and clinically relevant bleeding. AF was documented in 117 patients. Among them, 25 presented AF at admission (previous AF) and 92 developed new-onset AF (66% transient, 13% persistent). Patients with AF were older, more frequently men, and had a worse Killip class, and a poorer left-ventricular ejection fraction. When analyzing the different types of AF, patients with new-onset AF (persistent and transient) had a higher Killip class and a worse left-ventricular ejection fraction. AF was associated with significantly higher in-hospital mortality and with a greater incidence of in-hospital adverse events. An increase in in-hospital mortality was recorded both for previous and for new-persistent AF, but after adjusting for confounding factors, only persistent AF was found to carry a worse short-term prognosis. In patients undergoing primary angioplasty in the stent era, AF is associated with a poor prognosis. This risk appears to be particularly high among patients with persistent AF.

Early and late clinical outcome in elderly patients after revascularization with Primary Percutaneous Coronary Intervention presenting with acute ST-elevation myocardial infarction: Results from Qassim Primary Angioplasty Services (QAPAS) registry

We sought to investigate the procedural success rates, in hospital and 2 years clinical outcomes of Primary Percutaneous Coronary Intervention in patients older than 75 years presenting with acute myocardial infarction. Total of 50 patients, 75 years or older were enrolled in the retrospective data analysis. Primary end-points were procedural success, in hospital, short-term (1 month) and long-term (2 years) all cause mortality. Secondary end-points were recurrent MI, stroke, new revascularization. Mean age was 80.5 ± 5.75 years (range 75–96), 82% males, 18% females, 28 (56%) patients presented with anterior wall MI, 19 (38%) with inferior wall MI and 2 (4%) had posterior wall MI. All underwent PPCI achieving a door to balloon time of 140 ± 50 min (range 52–227 min) and CAG revealed SVD 16.5%, 2VD 29%, 3VD 54% and involvement of left main in 14.5% of cases. A total of 68 stents were deployed, mean stent length of 33.29 mm using DES in 42 patients (85.5%) and BMS in 2 patients (4%). Thirty (60%) patients received Glycoprotein IIbIIIa inhibitors. Successful recanalization of IRA was achieved in 90% of patients with 82% achieving TIMI III flow while no reflow occurred in 2 patients. Procedure related coronary artery dissection occurred in 2 patients. Mechanical complications like severe MR and severe LV dysfunction were observed in 4% and 16% of the cases, respectively. One patient had a massive fatal haemoptysis. In-hospital mortality was 18%. One-month and 2 years mortality were 2.5% (n = 1) and 11% (n = 4), respectively. Older age, Gp IIb IIIa use and higher Killip Class were associated with higher overall mortality. The incidence of recurrent MI and repeat revascularization was 4% and 7%, respectively. Our data reveal that in elderly patients primary PCI is a feasible revascularization strategy and such patients have a high in-hospital mortality and complication rates.

121 Cardiac Arrest in Acute Coronary Syndromes: Insights From the Canadian Global Registry of Acute Coronary Events

121 Cardiac Arrest in Acute Coronary Syndromes: Insights From the Canadian Global Registry of Acute Coronary Events

263 The Forgotten Lead: Does aVR ST-Deviation Add Insight Into STEMI Patients?

Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction (STEMI) patients (pts) treated with fibrinolysis. However, its prognostic value in patients undergoing primary percutaneous coronary intervention (PCI) is unknown. We examined this question in nearly 5700 high-risk STEMI pts presenting within 6 hours of symptom onset in the Assessment of PEXelizumab in Acute Myocardial Infarction (APEX-AMI) trial. A core laboratory examined the 12-lead baseline electrocardiogram (ECG) in 5683 pts, and readers were blinded to study treatment and clinical outcomes. The association between aVR ST-elevation or depression (≥1mm at the J-point) versus no ST-deviation and 90-day mortality was examined via Cox regression (adjusted Hazard Ratio (HR) and 95% confidence intervals (CI) reported), and the interaction with MI location was tested. Six percent (n=352) had ST-elevation in lead aVR and 27% (n=1512) had ST-depression in lead aVR. The pts with aVR ST-elevation were older, higher heart rate, higher Killip class, and more prior MI compared to pts with no aVR ST-deviation (Table). They were also more likely to have a non-inferior MI. Mortality within 90 days was highest among those with aVR ST-elevation, particularly among pts with inferior MI (Table). After adjustment for age, systolic blood pressure, heart rate, creatinine, Killip class and MI location, both ST-depression and ST-elevation in aVR were associated with increased hazard of 90-day mortality (Table). The interaction with MI location was also significant (p<0.001) such that ST-depression was associated with higher risk in non-inferior MI pts; ST-elevation in aVR in inferior MI pts.Tabled 1 aVR ST deviation, occurring in one third of STEMI pts, was associated with a similar increase in 90-day mortality after multivariable adjustment. aVR ST-depression was most strongly associated in non-inferior MI whereas aVR ST-elevation was in those with inferior MI. When assessing risk from baseline ECG, the evaluation of ST-deviation in lead aVR provides valuable prognostic insight into STEMI pts treated with PCI.

Thirty-Day Rehospitalizations After Acute Myocardial Infarction

Rehospitalization is a quality-of-care indicator, yet little is known about its occurrence and predictors after myocardial infarction (MI) in the community. To examine 30-day rehospitalizations after incident MI. Retrospective cohort study. Population-based registry in Olmsted County, Minnesota. 3010 patients who were hospitalized in Olmsted County with first-ever MI from 1987 to 2010 and survived to hospital discharge. Diagnoses, therapies, and complications during incident and subsequent hospitalizations were identified. Manual chart review was performed to determine the cause of all rehospitalizations. The hazard ratios and cumulative incidence of 30-day rehospitalizations were determined by using Cox proportional hazards regression models. Among 3010 patients (mean age, 67 years; 40.5% female) with incident MI (31.2% ST-segment elevation), 643 rehospitalizations occurred within 30 days in 561 (18.6%) patients. Overall, 30.2% of rehospitalizations were unrelated to the incident MI and 42.6% were related; the relationship was unclear in 27.2% of rehospitalizations. Angiography was performed in 153 (23.8%) rehospitalizations. Revascularization was performed in 103 (16.0%) rehospitalizations, of which 46 (44.7%) had no revascularization during the index hospitalization. After adjustment for potential confounders, diabetes, chronic obstructive pulmonary disease, anemia, higher Killip class, longer length of stay during the index hospitalization, and a complication of angiography or reperfusion or revascularization were associated with increased rehospitalization risk. The 30-day incidence of rehospitalization was 35.3% in patients who experienced a complication of angiography during the index MI hospitalization and 31.6% in those who experienced a complication of reperfusion or revascularization during the index MI hospitalization, compared with 16.8% in patients who had reperfusion or revascularization without complications. This study represents the experiences of a single community. Comorbid conditions, longer length of stay, and complications of angiography and revascularization or reperfusion are associated with increased 30-day rehospitalization risk after MI. Many rehospitalizations seem to be unrelated to the incident MI. National Institutes of Health.

Risk-Prediction Model for Ischemic Stroke in Patients Hospitalized With an Acute Coronary Syndrome (from the Global Registry of Acute Coronary Events [GRACE

The risk of stroke in patients hospitalized with an acute coronary syndrome (ACS) ranges from <1% to ≥ 2.5%. The aim of this study was to develop a simple predictive tool for bedside risk estimation of in-hospital ischemic stroke in patients with ACS to help guide clinicians in the acute management of these high-risk patients. Data were obtained from 63,118 patients enrolled from April 1999 to December 2007 in the Global Registry of Acute Coronary Events (GRACE), a multinational registry involving 126 hospitals in 14 countries. A regression model was developed to predict the occurrence of in-hospital ischemic stroke in patients hospitalized with an ACS. The main study outcome was the development of ischemic stroke during the index hospitalization for an ACS. Eight risk factors for stroke were identified: older age, atrial fibrillation on index electrocardiogram, positive initial cardiac biomarkers, presenting systolic blood pressure ≥ 160 mm Hg, ST-segment change on index electrocardiogram, no history of smoking, higher Killip class, and lower body weight (c-statistic 0.7). The addition of coronary artery bypass graft surgery and percutaneous coronary intervention into the model increased the prediction of stroke risk. In conclusion, the GRACE stroke risk score is a simple tool for predicting in-hospital ischemic stroke risk in patients admitted for the entire spectrum of ACS, which is widely applicable to patients in various hospital settings and will assist in the management of high-risk patients with ACS.

Statin therapy to reduce stent thrombosis in acute myocardial infarction patients with elevated high-sensitivity C-reactive protein

ObjectiveWe investigated whether statin therapy and high-sensitivity C-reactive protein (hs-CRP) levels were associated with the risk of stent thrombosis (ST) in acute myocardial infarction (AMI) patients. MethodsA total of 9,162 AMI patients who underwent coronary stent implantation were analyzed in the Korean Acute Myocardial Infarction Registry. The study population was divided into four groups according to level of hs-CRP and peri-procedural statin treatment: low hs-CRP (≤2.0mg/L) and high hs-CRP (>2mg/L) with or without statin therapy. We compared the incidence of early ST among the groups. ResultsStatin therapy did not significantly affect the development of early ST in the low hs-CRP group. In the high hs-CRP group, however, the incidence of early ST was significantly decreased with statin treatment. In a subgroup analysis of the high hs-CRP group, patients aged less than 65years, without diabetes, with a high body mass index, and with a high Killip class seemed to benefit more from statin therapy. In a multivariable Cox regression analysis of the high hs-CRP group, lack of statin therapy was a significant predictor of ST incidence. ConclusionsPeri-procedural statin treatment had an effect on reduced incidence of early ST in AMI patients with high levels of hs-CRP.

Thrombolytic effect of streptokinase infusion assessed by ST-segment resolution between diabetic and non-diabetic myocardial infarction patients

Recently, it has been hypothesized that type 2 diabetes might interfere with acute intravenous thrombolysis effectiveness as estimated by angiographic or electrocardiographic criteria. In our study, we compared the thrombolytic effect of streptokinase infusion between diabetic and non-diabetic myocardial infarction (MI) patients. In a prospective interventional study, 240 consecutive patients who were admitted to the emergency ward and diagnosed with ST-elevation MI (STEMI) were enroled and classified into diabetics (n = 85) and non-diabetics (n = 155). Streptokinase was given to each patient at a dose of 1.5 million units in 1 h. Twelve-lead ECG was recorded immediately before the start of thrombolytic therapy and at 180 min afterwards for the patients with STEMI. The ST-segment elevation resolution was calculated and stratified as complete resolution ( > 70% ST-resolution), partial resolution (30-70% ST-resolution), or failed resolution ( < 30% ST-resolution). Complete ST-resolution occurred in 31.6% of diabetic and 51.0% of non-diabetic patients, respectively (p < 0.001). The incidence of partial ST-resolution in diabetic and non-diabetic patients was 40.5% and 40.0%, whereas 27.8% of patients in the diabetic group and 9.0% of patients in the non-diabetic group showed failed ST resolution. ST-resolution was independent of the location of MI. Multivariate analysis showed that diabetes mellitus, as well as higher Killip class and lower ejection fraction, could effectively predict ST-resolution failure. Failure of ST-segment resolution 180 min after streptokinase infusion is notably higher in diabetic vs non-diabetic patients. This failure rate is correlated with higher Killip class and lower ejection fraction.