History Of Previous MI Research Articles

Abstract P196: Outcomes in Cocaine Chest Pain Patients Treated with β-Blockers

Introduction: Cocaine is the second most commonly used illicit drug in the US, and the most frequent illicit substance to precipitate an emergency room visit. Cocaine is associated with acute and chronic complications affecting the cardiovascular system. Although Beta blockers (BB) have been shown to improve outcomes in patients with ACS, current ACC/AHA guidelines call for avoidance of BB in patients presenting with chest pain and suspected MI with recent cocaine use due to concern for precipitating coronary vasoconstriction. Recently new data has emerged on beta blockade following cocaine intoxication, demonstrating improved cardiovascular hemodynamics and patient outcomes. In this study we looked at clinical outcomes of patients with cocaine chest pain that received BB therapy. Methods: All patients presenting to the Thomas Jefferson University Hospital Emergency Department (ED) with a chief complaint of chest pain from April 2007 to September 2008 were included (n=5432). Retrospective chart review was conducted on 37 individuals with cocaine positive urine drug screen that received BB. Data was collected on gender, previous history of MI, outpatient BB therapy, and cardiovascular outcomes (hypertensive emergency, MI, stroke, cardiac arrest or death). Results: Of the 37 patients that were cocaine positive and received BB therapy, 33 were male, 18 had a prior MI, and 24 were on outpatient BB therapy. There were no reports of hypertensive emergency, stroke, cardiac arrest or death following BB therapy. Four patients were diagnosed with MI, but in all cases the troponin assay was positive prior to BB administration. When compared with cocaine positive patients who did not receive a BB, there was no significant increase in negative cardiovascular outcomes following BB therapy. Conclusions: We found no increase in adverse events or negative cardiovascular outcomes following Beta blocker therapy in patients with cocaine associated chest pain. This study adds to the body of evidence showing BB may not be harmful in patients with cocaine associated chest pain and myocardial ischemia. Given the strong evidence supporting BB use in ACS, further study is warranted to investigate whether BB therapy may be beneficial in certain cocaine chest pain patients.

Abstract P80: Lack of English Comprehension is Associated with Delays in Hospital Presentation in Patients with ST-Segment Elevation Myocardial Infarction

Background: Prior studies have demonstrated an association between ethnicity and symptom onset to presentation time (S2PT) among patients presenting with ST elevation MI (STEMI) in the USA, with a shorter S2PT among Caucasians when compared with other ethnicities. However, little is known regarding whether or not a patient's ability to comprehend English impacts the S2PT. Methods: Consecutive patients presenting to 4 hospitals in NYC with STEMI referred for primary angioplasty were included in the analysis. S2PT was recorded on the day of the infarct based on the patient's account of the onset of symptoms. We assessed a patient's ability to comprehend English through telephone interviews conducted during routine follow-up. Results: Among 210 patients, 83.8% (176 of 210) had either some English comprehension or were fluent in English (E) and 16.2% (34 of 210) reported no English comprehension (non-E). Of the non-E patients, 65% (22 of 34) spoke Spanish, 6% (2 of 34) spoke Russian, 6% (2 of 34) spoke Chinese and 23% (8 of 34) spoke another language. The baseline variables and mean S2PT are depicted in the table. Non-E patients had a significantly higher S2PT compared to E patients even after adjusting for differences in baseline variables. Increased odds were also observed among non-E patients with a longer S2PT (adjusted odds ratio for S2PT > 120 minutes 2.17; 95% CI 01.03-4.54; p=0.04). This association remained constant even after adjusting for confounders like age, sex, ethnicity, level of education and comorbidities (diabetes, previous history of MI and PCI). Conclusions: S2PT is strongly influenced by a patient's ability to comprehend English. This information emphasizes the need for more aggressive “multi-lingual” educational outreach and the use of multi-lingual emergency lines in an effort to decrease total ischemic time during STEMI. English Comprehension Fair or Good (N=176) No English Comprehension (N=34) P Age Mean (SD) 62 (14.2) 65 (11) 0.22 Male sex n (%) 129 (73) 26 (76) 0.70 Diabetes n (%) 25 (14) 9 (27) 0.09 Hypertension n (%) 107 (66) 20 (62.5) 0.70 Prior MI n (%) 21 (12) 2 (6) 0.284 Prior PCI or CABG n (%) 12 (6.8) 2 (6) 0.960 Education: n (%) 40 (23) 12 (35) 0.09 Less than HS 62 (35) 8 (23) HS Diploma 8 (4) 0 (0) College Diploma Unknown 66 (38) 14 (42) Mean S2P time (SD) 225 (315) 387 (820.6) 0.05 S2P time > 120 minutes n (%) 70 (40) 20 (62.5) 0.04

436 Prevalence, characterization and clinical impact of chronic total occlusion in patients with acute ST-elevation myocardial infarction

Little is known about the prevalence and clinical impact of chronic total occlusion (CTO) in patients with acute ST-elevation myocardial infarction with (STEMI) undergoing primary percutaneous coronary intervention (PCI). Our objective was to evaluate the prevalence and impact on 1-year mortality of CTO in non-infarct related coronary artery (IRA) in patients with STEMI referred for primary PCI. Consecutive patients referred for primary PCI were identified from our data-base and were categorized into NO CTO, 1 CTO and > 1 CTO groups. All angiograms were prospectively analyzed. The primary end-point was mortality at 1 year. Fom 5/2006 to 5/2009, we identified 1094 patients. The prevalence of NO CTO, 1 CTO and > 1CTO was 91.8%, 7.2% and 1%, respectively. Patients with CTO were older (P = 0.0058) but there was no significant difference in other traditional risk factors between groups. Patients with CTO had more frequently a previous history of MI (P < 0.0001), unstable angina (P < 0.0001) and stable angina (P = 0.0002). Patients with CTO presented more often in Killip class IV (P < 0.0001) and with decreased renal function (P = 0.026). The prevalence of 3-vessel disease was higher in patients with 1 CTO (32%), and with > 1CTO (90%) compared to NO CTO (4.1%) (P < 0.0001). After adjustment for differences in clinical and angiographic characteristics, the presence of CTO remained an independent predictor of 1-year mortality (HR: 1.75 95% CI, 1.00-3.05, P = 0.048). The prevalence of CTO in non-IRA in STEMI patients referred for primary PCI was 8.2%. Compared to patients with NO CTO, mortality at 1 year was higher in patients with 1 CTO and exceedingly high in patients with > 1CTO. After adjustment, the presence of CTO remained a strong independent predictor of 1-year mortality. Therapeutic options in these STEMI patients with CTO in non-IRA need to be further defined.

Prognostic value of adenosine stress perfusion cardiac magnetic resonance with late gadolinium enhancement

Objective To determine the prognostic value of a normal adenosine stress perfusion CMR in combination with late gadolinium enhancement in intermediate risk patients with suspected ischaemic heart disease (IHD). Background Adenosine stress CMR is a non invasive test with high sensitivity for the detection of IHD, and is now frequently combined with late gadolinium enhancement (LGE) imaging. This may augment its prognostic accuracy for predicting cardiovascular events. Previous studies have failed to appraise the combination of adenosine stress perfusion CMR with LGE for this purpose, and generally populations at low risk for cardiovascular events have been assessed. We sought to determine the clinical utility of stress perfusion CMR with LGE in the evaluation of intermediate risk patients. Methods Retrospective study of 362 consecutive patients referred to at ertiary cardiology centre for as tress perfusion CMR. Perfusion imaging was obtained at stress (adenosine 140 µg/kg/min) and rest on a 1.5T machine. Late enhancement was assessed with dual pass gadolinium (0.2mmol/kg total dose). A negative test, assessed qualitatively, was defined as the absence of both reversible ischaemia and LGE. Patient records, hospital databases and national death index were reviewed. MACE - death, myocardial infarction, revascularisation or ischaemic hospitalisation - were evaluated over a median follow up of 22 months (IQR 18-25). Results The cohort of 362 patients had a mean age of 62.6 years ±11.9 (mean ±SD), 152 (53.1%) male and 94 (32.8%) had a history of previous MI or PCI. Of the 362, 96 (27%) had a stress perfusion CMR positive for ischaemia, 266 (73%) were negative. Of the 266 negative CMR, MACE was encountered in only 6 (2%) patients (5 PCI and 1 death due to heart failure). Accordingly a negative stress CMR afforded a freedom from MACE of 98%. Conclusion In patients at intermediate risk for cardiovascular events, a negative stress perfusion CMR is associated with an excellent prognosis. This is consistent with the approximate 1% annualised cardiovascular event rate seen in negative stress imaging with other modalities.

Stress perfusion CMR reliably risk stratifies patients with prior exercise treadmill testing

Seventy patients (50% male, age 58.4 years ±11.2; mean ±SD) were identified. Twelve (17%) had a history of previous MI or revascularisation. Seventeen had an objectively positive ETT, of which 7 (41%) had a positive stress CMR. Thirty one had an equivocal ETT, of which 8 (26%) had a positive stress CMR. Twenty two had a negative ETT, of which 3 (14%) had a positive CMR. All positive CMRs had stenoses ≥50% at angiography, except for two patients (11%), both from the equivocal ETT group. A negative CMR, irrespective of ETT status, resulted in a 0% MACE rate at median 23 months (IQR 20-27) follow up. No positive CMRs were seen in negative or equivocal ETTs where ≥ 10 metabolic equivalents (METS) were attained. Conclusions Adenosine stress perfusion CMR can reliably risk stratify patients independent of previous ETT result. A negative CMR is associated with an excellent prognosis at a median of 23 months follow up.

Health Related Quality of Life After Percutaneous Coronary Revascularisation in Patients with Previous Coronary Artery Bypass Grafts: A Two-Year Follow Up Study

Percutaneous coronary revascularisation [PCR] improves angina and health related quality of life [HRQOL] compared to standard medical therapy. It is unknown whether PCR has the same benefits for patients with a history of CABG. Over a period of 5 years, we assessed HRQOL of patients undergoing PCR using Part 1 of the Nottingham Health Profile [NHP] at baseline 3, 12 and 24 months. We compared HRQOL after PCR in 255 patients with CABG to 2680 without. There were more males [81.1% v 69.6% p = 0.002] and older patients [mean age 60.1 years v. 58.0 p = 0.03] in CABG group. Perceived HRQOL improved at 24 months for pain, energy and emotional reaction but the improvement was less in the CABG group. However, mean NHP scores at 24 months for those with CABG had returned to baseline levels for sleep [34.9] and for physical function was worse than at baseline [22.0 vs 30.7]. This relationship persisted after adjustment for male sex, history of previous MI and coronary stent usage. Patients with previous CABG had less improvement in HRQOL after PCR. Further work is needed to assess the benefits and cost effectiveness of PCR in these patients.

Disturbed Sleep, Fatigue, Anxiety and Depression in Myocardial Infarction Patients

Disturbed sleep has been linked to increased morbidity, mortality and depression and worsened health-related quality of life in patients with chronic illness. Few studies of readjustment after coronary artery disease have explicitly focused on sleep disturbance. To explore associations between disturbed sleep, fatigue, anxiety and depression, and to assess to what extent fatigue four months post-MI could be explained. The sample included 204 consecutive patients, <or=80 years of age who answered questionnaires about disturbed sleep, fatigue, anxiety and depression four months after MI. The variables anxiety, depression and disturbed sleep were all associated with fatigue. The regression model accounted for 46% of the variance in fatigue with depression and disturbed sleep as predictors. Infarct size measured by conventional biochemical markers, left ventricle ejection fraction and history of previous MI were not correlated with disturbed sleep, fatigue, anxiety or depression. From knowledge about associations between disturbed sleep, fatigue, anxiety and depression after MI, cardiac nurses could be trained to observe such symptoms. Optimal care for sleep disturbance may include actions to reduce anxiety and depression as well as self-care advices about sleep hygiene in order to improve sleep quality and reduce fatigue.

Long-Term Clinical Outcome of Chronic Total Occlusive Lesions Treated With Drug-Eluting Stents: - Comparison of Sirolimus-Eluting and Paclitaxel-Eluting Stents -

There are few studies comparing the efficacy of different drug-eluting stents and their long-term clinical outcomes in percutaneous coronary intervention (PCI) of chronic total occlusive (CTO) lesions. To compare the efficacy of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) for CTO, and to identify predictors of outcome after PCI, 200 patients with at least 1 successfully revascularized CTO were enrolled into either a SES (n=132) or PES (n=71) group. At 6-9-month angiographic follow-up, SES was superior to PES (late loss 0.27+/-0.60 vs 0.53+/-0.62 mm, P=0.04). During mean follow-up of 2 years, the SES group had a significantly lower cumulative target vessel failure (TVF) rate than the PES group (14.9% vs 28.4%, P=0.01), as a consequence of lower target vessel revascularization (9.7% vs 23.9%, P=0.01) and also a partially lower rate of myocardial infarction (MI: 3.1% vs 7.6%, P=0.04). SES was also superior to PES in both early (<or=9 months) and late (>9 months) TVF (P=0.02 for log-rank test, respectively). Predictors for TVF were use of PES (hazard ratio (HR) 3.81, P<0.01), previous history of MI (HR 4.06, P<0.01), diabetes (HR 2.07, P=0.04) and chronic kidney disease (CKD; HR 3.56, P=0.05). CTO lesions treated with SES showed better angiographic and long-term clinical outcomes than those treated with PES. Factors such as stent type, infarct-related CTO, diabetes and CKD affect the outcome of CTO intervention.

Risk stratification for arrhythmic death in an emergency department cohort: a new method of nonlinear PD2i analysis of the ECG

Heart rate variability (HRV) reflects both cardiac autonomic function and risk of sudden arrhythmic death (AD). Indices of HRV based on linear stochastic models are independent risk factors for AD in postmyocardial infarction (MI) cohorts. Indices based on nonlinear deterministic models have a higher sensitivity and specificity for predicting AD in retrospective data. A new nonlinear deterministic model, the automated Point Correlation Dimension (PD2i), was prospectively evaluated for prediction of AD. Patients were enrolled (N = 918) in 6 emergency departments (EDs) upon presentation with chest pain and being determined to be at risk of acute MI (AMI) >7%. Brief digital ECGs (>1000 heartbeats, approximately 15 min) were recorded and automated PD2i results obtained. Out-of-hospital AD was determined by modified Hinkle-Thaler criteria. All-cause mortality at 1 year was 6.2%, with 3.5% being ADs. Of the AD fatalities, 34% were without previous history of MI or diagnosis of AMI. The PD2i prediction of AD had sensitivity = 96%, specificity = 85%, negative predictive value = 99%, and relative risk >24.2 (p ≤ 0.001). HRV analysis by the time-dependent nonlinear PD2i algorithm can accurately predict risk of AD in an ED cohort and may have both life-saving and resource-saving implications for individual risk assessment.

Association of pulse wave velocity with vascular and valvular calcification in hemodialysis patients

The recent Kidney Disease: Improving Quality Outcomes (KDIGO) recommendations called for an investigation of the relationship between various radiological methods to assess cardiovascular calcification and measures of arterial stiffness. Accordingly, in 131 adult maintenance hemodialysis patients, we investigated the association of aortic pulse wave velocity (PWV) with calcification of cardiac valves on echocardiography, coronary artery, and thoracic aorta calcium on computed tomography and a calcification score of the abdominal aorta obtained on a plain abdominal X-ray. All tests were performed within a week. Mean PWV increased as the severity of coronary artery, thoracic, and abdominal aorta calcium scores increased (each P<0.05). No trend was present for number of valves with calcification. After multivariable adjustment, abdominal aorta X-ray calcium scores remained associated with PWV (P=0.004), whereas the association of PWV with thoracic aorta and coronary artery calcium scores became marginal (P=0.308 and P=0.083, respectively). No association was found between number of calcified valves and PWV. This study demonstrates a strong association between abdominal aorta calcification on plain X-ray and PWV and a borderline association with thoracic aorta and coronary artery calcification. Sudden death and congestive heart failure, two frequent causes of death in hemodialysis, are likely caused by increased arterial stiffness that can be closely predicted by the presence of aortic calcification on plain X-rays.

External validity of ST elevation myocardial infarction trials: The Zwolle studies

Guidelines are mainly based upon results of randomised controlled clinical trials. However, due to low external validity of these trials, their results can not reasonably be applied to all patients in routine practice. In our hospital, all patients with ST-elevation myocardial infarction (STEMI) are eligible for inclusion in one of our ongoing trials or registries. To asses differences between patients enrolled versus not-enrolled in a trial or registry, we evaluated all patients with a discharge diagnose of STEMI during the study period. Retrospectively, individual patient data from all patients with a discharge diagnosis of STEMI between Jan 2001 and Dec 2001 were evaluated. Follow-up data were obtained until Dec 2004. A total of 583 patients were discharged with a diagnosis of STEMI. About 455 (78%) patients were enrolled in one of the ongoing clinical trials or registry and 128 were not. Not-enrolled patients were significantly older; more often had a history of previous MI and had higher risk profiles. Multivariate analysis revealed that higher age was the only independent predictor for non enrollment. Not-enrolled patients were more often treated conservatively and had a higher mortality rate (36% vs. 6%, P << 0.001). After multivariate analysis, non-enrollment (OR: 95% CI) 4.02 (1.98-8.16), age 1.07 (1.04-1.12), and diabetes 2.39 (1.17-4.89) were the only independent predictors of long term mortality. This study shows important differences in baseline characteristics, treatment, and prognosis between patients with STEMI who were enrolled or not in a trial. To better reflect daily clinical practice, guidelines should also consider results of observational studies of unselected patients.

Is diabetes an independent risk factor for mortality after myocardial infarction? The ARIC (Atherosclerosis Risk in Communities) Surveillance Study.

We investigated the age-, gender- and race-specific 1-year case fatality rates of diabetic and non-diabetic individuals with a myocardial infarction. Data were obtained from the Atherosclerosis Risk in Communities (ARIC) Surveillance Study, which monitors both hospitalized myocardial infarction and coronary heart disease (CHD) deaths in residents aged 35-74 years in four communities in the USA. The study population comprised 3242 hospitalized myocardial infarctions (HMIs) in diabetic subjects and 9826 HMIs in non-diabetic individuals between 1987 and 1997. Age-adjusted and gender- and race-specific odds ratios (OR) for 1-year case fatality comparing diabetic to non-diabetic patients were 2.0 (95% CI, 1.6-2.4) for white men and 1.4 (95% CI, 1.1-1.8) for white women. Further adjustment for severity of HMI, history of previous MI, stroke and hypertension, and therapy variables showed significantly higher case fatality in white diabetic men than in non-diabetic white men (OR=1.5; 95% CI, 1.2-1.9), but no significant association in the other race-gender groups. The age-adjusted odds of out of hospital death was significantly higher among white diabetic men (OR=1.7; 95% CI, 1.2-2.3), white women (OR=2.3; 95% CI, 1.4-3.8), and African-American women (OR=2.9; 95% CI, 1.5-5.9) as compared to their non-diabetic counterparts. In conclusion, diabetes is an independent factor for mortality within one year following a myocardial infarction among white men, and following out-of hospital coronary death in white men and women and in African-American women. It is possible that these differences could be explained, at least in part, by a less than optimal medical management of the high cardiovascular risk profile of these patients after hospital discharge.

Coronary artery bypass grafting in patients over 70 years old: the influence of age and surgical technique on early and mid-term clinical outcomes.

To investigate the influence of age and modern techniques of coronary artery bypass grafting with or without cardiopulmonary bypass on early and mid-term mortality and morbidity in a consecutive series of elderly patients. From April 1996 to December 2000, data of 3842 patients undergoing coronary revascularisation were prospectively entered into a database. Data were extracted for 990 patients older than 70 years: (A) 70-74 years, (n=659); (B) 75 or more years, (n=331). A total of 990 elderly patients (> or = 70 years) underwent coronary revascularisation, 219 (22.1%) with off-pump surgery. Elderly patients were more likely to have higher CCS, NYHA and EuroScores, history of previous MI, unstable angina, renal dysfunction, left main stem disease > or = 50%, and to be urgent. However, they were less likely to be overweight. In-hospital mortality, occurrence of re-intubation, renal dysfunction, and hospital stay were significantly higher in this elderly group. Overall, the distribution of mortality was doubled in the female gender although this was not statistically significant. Patients undergoing on-pump surgery had lower EuroScore, were less likely to be >75 years of age, likely to have obesity or hypercholesterolaemia, or to have suffered a previous cerebro-vascular accident. However, they had more extensive coronary disease, were more likely to have unstable angina, and received more grafts than those undergoing off-pump surgery. After adjustment for prognostic variables, off-pump surgery was found to be associated with reduced inotropic use, intra-operative arrhythmias, blood loss and transfusion requirement when compared to on-pump coronary surgery (point estimates of odd ratios, 0.26-0.87) (all P<0.05). Mid-term mortality or cardiac-related events were similar in the two groups. Early but not mid-term mortality is higher in patients aged 75 or more years when compared with those aged 70-74 years. Off-pump coronary artery bypass surgery is safe and effective in the elderly population.

The impact of coronary artery disease on carotid endarterectomy.

In a series of 531 CENDX, preoperative cardiac risk was categorized by clinical criteria. Patients with CAD (history of previous MI, angina, congestive heart failure, and/or electrocardiographic evidence of CAD were selected for more invasive studies based on clinical criteria. The overall incidence of postoperative myocardial infarction was 2.5% and increased slightly to 4% in patients with symptomatic cardiac disease. More importantly, the overall mortality was 0.9% and only 3 of 13 (23%) postoperative myocardial infarctions were fatal. Neurologic complications averaged 1.4% and approximately 70% were related to preceding cardiac events. Twenty-two patients or 4% of the entire series underwent carotid endarterectomy combined with coronary artery bypass graft and this approach was associated with one death and one stroke. Therefore, we conclude that a selective approach to coronary arteriography and subsequent CABG based on clinical criteria is associated with an acceptably low mortality and cardiac morbidity.