History Of ST-elevation Myocardial Infarction Research Articles

Heart rate variability in patients with acute ST-segment elevation myocardial infarction after COVID-19

Aim. To compare heart rate variability parameters in patients after a coronavirus disease 2019 (COVID-19) with acute ST elevation myocardial infarction (STEMI) during the inhospital and post-hospital periods.Material and methods. A total of 140 patients with STEMI were divided into 2 groups: I — patients with STEMI who had COVID-19 (n=52) in the period of 1,5-6 months before acute coronary syndrome, II — comparison group (n=88), which included patients with STEMI without prior COVID-19. All patients underwent infarct-related artery stenting within the first 24 hours from the onset. Heart rate variability (HRV) parameters were determined for all patients on days 2-3 and days 9-11 and 6 months after the hospitalization for STEMI.Results. Patients in group I showed more pronounced changes in HRV indicators on days 2-3 of STEMI: RMSSD (root square of successive RR intervals) by 21% (p=0,026), variations (Var) (the difference between the minimum and maximum RR intervals) by 33% (p=0,013), VLF (total very low-frequency HRV) by 7% (p=0,009) were higher, and HF (highfrequency HRV) by 40% (p=0,003), pNN50% (ratio of the number of consecutive RR interval pairs differing by >50 ms to the total number of RR intervals) by 66% (p=0,038) were lower than in the control group, respectively. On days 9-11 of the disease in patients with a history of STEMI and COVID-19, in contrast to the control group, there was a more pronounced increase in the SDNN (standard deviation of RR intervals) by 46% (p=0,005), VLF by 42% (p=0,031), whereas in the control group there were an increase of only 22% (p=0,004) and 11% (p=0,022), respectively. The HF value in the main group increased by 25% (p=0,007), while in the control group it decreased by 19% (p=0,030). Six months after STEMI in the main group, the RMSSD decreased by 19% (p=0,009), Var by 16% (p=0,041), VLF by 30% (p=0,025), LF (low-frequency component HRV) by 11% (p=0,005), while the control group these parameters decreased by 20% (p=0,006), 21% (p=0,001), 9% (p=0,011), and 7% (p=0,016), respectively.Conclusion. In patients with STEMI and prior COVID-19, the initial HRV values differ from similar HRV parameters in patients with STEMI without prior COVID-19. In the hospital and post-hospital periods, the changes of HRV in patients with and without COVID-19 are multidirectional as follows: pronounced sympathetic hyperactivity predominates, and slower recovery of HRV in patients after COVID-19 predominates.

A comprehensive secondary prevention benchmark (2PBM) score identifying differences in secondary prevention care in patients after acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grands from AstraZeneca, Boehringer Ingelheim and Sanofi Background Reaching secondary prevention targets improves long-term prognosis in patients after acute coronary syndrome (ACS). Although prevention targets are defined by guidelines, their achievement rates are insufficiently documented. Suitable benchmarking tools are lacking. Purpose We aimed to determine the degree of secondary prevention care by creating a secondary prevention benchmark score (2PBM) and using it in patients undergoing ambulatory cardiac rehabilitation (CR) after an acute coronary syndrome. Methods In this observational cohort study, 472 consecutive ACS patients who completed the local ambulatory CR programme between 2017-2019 were included. Benchmarks for secondary prevention medication, clinical and lifestyle targets were predefined and combined in the complete 2PBM with maximum 10 points. The association of patient characteristics and achievement rates of individual components and the complete 2PBM were assessed using multivariable logistic regression analysis. Results Patients were on average 62 ± 11 years old and predominantly male (n = 406; 86%). Type of ACS was ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for individual components of the 2PBM were 71% for medication, 35% for clinical and 61% for lifestyle benchmarks. Achievement of medication benchmark was associated with younger age [odds ratio (OR): 0.979, 95% confidence interval (CI) 0.959-0.996, p = 0.021] and history of STEMI [OR: 2.05, 95% CI 1.35-3.12, p = 0.001]. Achievement of clinical benchmark was associated with medication benchmark [OR: 1.66, 95% CI 1.03-2.71, p = 0.042]. The complete 2PBM was achieved by 74 patients (16%), while 362 patients (77%) reached ≥8 points. Achievement of complete 2PBM was independently associated with a history of STEMI [OR: 1.79, 95 CI 1.06-3.08 p = 0.032]. Conclusion Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. A history of STEMI was associated with the highest 2PBM score, suggesting best secondary prevention care in patients after STEMI. 2PBM may be used for internal quality control, comparison of cohorts and future correlation studies between CR targets and outcomes. Abstract Figure.

Prognostic implications of 2018 ESC/EACTS guideline-endorsed high ischaemic risk features on clinical outcomes after PCI with drug-eluting stents

Abstract Background Recently, the 2018 ESC/EACTS guidelines on myocardial revascularization have been proposed to standardize the definition of high ischemic events risk (HIR) features. However, the prevalence and the expected ischemic event rate of HIR patients defined by ESC/EACTS-endorsed criteria are currently unknown in the real-world percutaneous coronary intervention practice. We sought to investigate the impact of HIR features on clinical outcomes after drug-eluting stents implantation and whether this effect is influenced by high bleeding risk (HBR). Methods Between January 2013 and December 2013, a total of 10,167 consecutive patients undergoing PCI were prospectively enrolled in Fuwai PCI Registry. The primary ischemic endpoint was target lesion failure (TLF) (comprising cardiac death, target vessel myocardial infarction, and target lesion revascularization] and the primary bleeding endpoint was clinically relevant bleeding defined as Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. Guideline-endorsed HIR features were in the present study and definitions were as follows: diffuse (defined as lesion length ≥20 mm) multivessel disease in patients with diabetes, CKD (defined as estimated glomerular filtration rate <60 ml/min/1.73 m2), ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, and treatment of CTO, and history of ST-elevation myocardial infarction. HBR was defined based on the highest quartile of PARIS bleeding score (≥6 or <6). Results Median follow-up was 29 months. 5149 patients had at least 1 HIR feature (50.6%), who experienced significantly increased risks of TLF (adjusted hazard ratio [HR]: 1.59, 95% confidence interval [CI]: 1.32–1.93; P<0.001), compared to those with non-HIR features. In contrast, the risk of clinically relevant bleeding was statistically similar between the 2 groups (HRadjust: 0.85 [0.66–1.09]; P=0.200). By including ESC/EACTS-endorsed HIR criteria as a continuous variable within the same multivariable models, the risk of adverse ischemic events tended to be greater as the number of high-risk procedural characteristics increased (per number of high-risk features increase: for TLF, HRadjust: 1.15, 95% CI: 1.07–1.23; P trend<0.001; for MACE, HRadjust: 1.33, 95% CI: 1.22–1.46; P trend<0.001). There was no statistical interaction between HBR and HIR features in regard to TLF (adjusted Pinteraction=0.855) and clinically relevant bleeding (adjusted Pinteraction=0.269), suggesting a consistent effect within ESC/EACTS-endorsed HIR features. Results were consistent when categorizing patients into HBR according to PARIS bleeding risk score ≥8 points. Conclusions ESC/EACTS-endorsed HIR criteria were associated with a substantial risk of ischemic events, with no increase in clinically relevant bleeding in routine clinical practice; and theses associations did not seem to be modified by HBR status. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences

Impact of recurrent mitral regurgitation after mitral valve repair for functional mitral regurgitation: long-term analysis of competing outcomes.

Recurrent mitral regurgitation (MR) has been reported after mitral valve repair for functional MR. However, the impact of recurrent MR on long-term survival remains poorly defined. In the present study, mortality-adjusted recurrent MR rates, the clinical impact of recurrent MR and its determinants were studied in patients after mitral valve repair with revascularization for functional MR in the setting of ischaemic heart disease. Long-term clinical and echocardiographic outcome was evaluated in 261 consecutive patients after restrictive mitral annuloplasty and revascularization for moderate to severe functional MR, between 2000 and 2014. The cumulative incidence of recurrent MR ≥ Grade 2, assessed by competing risk analysis, was 9.6 ± 1.8% at 1-year, 20.3 ± 2.5% at 5-year, and 27.6 ± 2.9% at 10-year follow-up. Cumulative survival was 85.8% [95% confidence interval (CI) 81.0-90.0] at 1-year, 67.3% (95% CI 61.1-72.6%) at 5-year, and 46.1% (95% CI 39.4-52.6%) at 10-year follow-up. Age, preoperative New York Heart Association Class III or IV, a history of renal failure, and recurrence of MR expressed as a time-dependent variable [HR 3.28 (1.87-5.75), P < 0.001], were independently associated with an increased mortality risk. Female gender, a history of ST-elevation myocardial infarction, a preoperative QRS duration ≥120 ms, a higher preoperative MR grade, and a higher indexed left ventricular end-systolic volume were independently associated with an increased likelihood of recurrent MR. Mitral valve repair for functional ischaemic MR resulted in a low incidence of recurrent MR with favourable clinical outcome up to 10 years after surgery. Presence of recurrent MR at any moment after surgery proved to be independently associated with an increased risk for mortality.

Morphine delays the onset of action of prasugrel in patients with prior history of ST-elevation myocardial infarction.

Delays in the onset of action of prasugrel during primary percutaneous coronary intervention (PPCI) have been reported and could be related to the effects of morphine on gastric emptying and subsequent intestinal absorption. The study objective was to determine whether morphine delays the onset of action of prasugrel in patients with a prior history of ST-elevation myocardial infarction (STEMI) treated with PPCI. This was a crossover study of 11 aspirin-treated patients with prior history of STEMI treated with PPCI, for which prasugrel and morphine had been previously administered. Patients were randomised to receive either morphine (5 mg) or saline intravenously followed by 60 mg prasugrel. Blood samples were collected before randomised treatment and over 24 hours after prasugrel administration. The inhibitory effects of prasugrel on platelets were determined using the VerifyNow P2Y12 assay and light transmission aggregometry. Plasma levels of prasugrel and prasugrel active metabolite were measured. Platelet reactivity determined by VerifyNow PRU, VerifyNow % Inhibition and LTA was significantly higher at 30-120 minutes (min) when morphine had been co-administered compared to when saline had been co-administered. Morphine, compared to saline, significantly delayed adequate platelet inhibition after prasugrel administration (158 vs 68 min; p = 0.006). Patients with delayed onset of platelet inhibition also had evidence of delayed absorption of prasugrel. In conclusion, prior administration of intravenous morphine significantly delays the onset of action of prasugrel. Intravenous drugs may be necessary to reduce the risk of acute stent thrombosis in morphine-treated STEMI patients undergoing PPCI.

Pathophysiology of myocardial remodeling in survivors of ST-elevation myocardial infarction revealed by native T1 mapping: inflammation, remote myocardium and prognostic significance

Background: The pathophysiology and prognostic significance of remote myocardium in the natural history of STEMI is uncertain. Cardiac magnetic resonance (CMR) provides a non-invasive assessment of myocardial pathology that is spatially and temporally coordinated. Native T1 quantified by CMR (T1 relaxation time, milliseconds) is a fundamental tissue property determined by water content and cellularity. We aimed to investigate the clinical significance of remote myocardium in survivors of acute ST-elevation myocardial infarction (STEMI) using native T1 mapping. Methods: We performed a prospective single center cohort study in reperfused STEMI patients who underwent CMR 2 days and 6 months post-MI and long term follow-up (18 months minimum). Native T1 CMR (MOLLI investigational prototype sequence: 3 (3) 3 (3) 5) was measured in regions-of-interest in remote and injured myocardium. Infarction was depicted on late gadolinium contrast enhancement imaging. Adverse remodeling was defined as an increase in left ventricular end-diastolic volume ≥ 20% at 6 months. Major adverse cardiac events (MACE) were defined as cardiac death or hospitalization for non-fatal MI or heart failure. Results are mean±SD unless specified. Results: 300 STEMI patients (mean age 59 years, 74% male) gave informed consent (14 July 2011 - 21 November 2012). Of these, 288 STEMI patients had evaluable native T1 CMR and follow-up data (median duration 845 days). Infarct size was 18±14% of left ventricular mass. Two days post-STEMI, native T1 in remote myocardium was lower than native T1 in the infarct zone (961±25 ms vs. 1097±52 ms; p<0.01). In multivariable linear regression, remote zone native T1 was independently associated with incomplete ST-segment resolution (9.42 (2.37 to 16.47); p=0.009), the log of the initial CRP concentration (regression coefficient 3.01 (95% CI 0.016 to 5.55); p=0.038) and the peak monocyte count within 2 days of admission (10.20 (0.74, 19.67); p=0.035). At 6 months, left ventricular end-diastolic volume increased by 5 (25) ml (n=262 patients with evaluable data) overall, and adverse remodeling occurred in 30 (12%) patients. Remote zone native T1 was a multivariable predictor of the change in left ventricular end-diastolic volume from baseline (0.13 (0.01, 0.24); p=0.035). 39 (13.5%) patients experienced a MACE including 20 (6.9%) patients with a post-discharge MACE. Remote zone native T1 was an independent predictor of post-discharge MACE (hazard ratio 1.016, 95% CI 1.000, 1.032; p=0.048) including after adjustment for changes in LVEF (p=0.032), LV end-diastolic volume (p=0.053), and monocyte count (p=0.036). Conclusions: Remote zone tissue characteristics early post-MI are temporally linked with reperfusion injury and inflammation and independently predict left ventricular remodeling and MACE in STEMI survivors.

Elevated Liver Transaminase Levels: A Biomarker for Severe Coronary Atherosclerosis?

Figure: Liver transaminase levels and coronary atherosclerosis.Purpose: Elevated liver transaminase levels in serum have been associated with components of metabolic syndrome and non-alcoholic fatty liver disease (NAFLD), both of which are positively correlated with coronary artery disease (CAD). The objective of this study is to evaluate the relationship between liver transaminase levels (ALT, AST) and angiographically documented coronary atherosclerosis in a cohort of elderly (>65 years) patients. Methods: This was an IRB-approved retrospective study. Of the 1,808 elderly patients who underwent elective cardiac catheterization from 2008 to 2012, 1,222 had ALT/AST levels checked prior to cardiac catheterization, lacked a history of significant alcohol consumption (as per AGA definition), and lacked a history of ST-elevation myocardial infarction (STEMI), were included. Patients were subdivided into two cohorts, based on normal (n=925) and elevated transaminase levels (n=297), (ALT>50 U/L, AST>40 U/L). Baseline characteristics and coronary angiographic findings were recorded. Significant CAD was defined as >50% stenosis. CAD was subdivided into 1-, 2-, and 3-vessel CAD. Cohorts were compared with chi-square and unpaired t-tests, using STATA IC 12.1 statistical software. Results: Both cohorts were similar in terms of traditional cardiovascular risk factors: sex, BMI, diabetes, hypertension, hyperlipidemia and smoking, except age (1.5 years higher in the elevated AST/ALT cohort, compared to normal cohort). Elevated transaminase levels were associated with: a) Greater prevalence of 3-vessel CAD (29.0% vs. 22.3% in normal cohort, p=0.019) b) Higher mean number of vessels involved (1.59 vs 1.33 in normal cohort, p=0.004). Cohorts were similar in terms of 1-vessel, 2-vessel, and left main disease. Conclusion: NAFLD manifested as elevated ALT/AST levels may predict presence of severe coronary artery disease. Further prospective studies are needed to test the feasibility of using serum ALT/AST levels as biomarkers for coronary atherosclerosis.

Quantitation of the Mitral Tetrahedron in Patients With Ischemic Heart Disease Using Real‐Time Three‐Dimensional Echocardiography to Evaluate the Geometric Determinants of Ischemic Mitral Regurgitation

Ischemic mitral regurgitation (IMR) is common in ischemic heart disease and results in poor prognosis. However, the exact mechanism of IMR has not been fully elucidated. Quantitation of the mitral tetrahedron using three-dimentianl (3D) echocardiography is capable of evaluating the geometric determinants and mechanisms of IMR. Forty patients with a history of ST-elevation myocardial infarction at least 6 months earlier were studied. Parameters of mitral deformation and global left ventricular (LV) function and shape were evaluated by 2-dimensional echocardiography. The effective regurgitant orifice (ERO) of IMR was obtained by the quantitative continuous-wave Doppler technique. Three-dimensional (3D) echocardiography was applied to assess the mitral tetrahedron. Mitral valvular tenting area (P < 0.001), mitral annular area (P = 0.032), dilation of the LV in diastole, impairment of the LV ejection fraction, and volume of the spherically shaped LV in systole were greater in patients with an ERO ≥20 mm(2) than in those with an ERO <20 mm(2). In the mitral tetrahedron, only the interpapillary muscle roots distance showed a significant difference (P = 0.004). Multivariate analysis with the logistic regression model showed the systolic mitral tenting area (odds ratio [OR]: 280.49, 95% confidence interval [CI]: 4.59-1.72 × 10(4), P = 0.007) and interpapillary muscle distance (OR: 1.50, 95% CI: 1.03-2.19, P = 0.036) to be independent factors in predicting significant IMR (ERO ≥20 mm(2)). 3D echocardiography can be effectively applied in measuring the mitral tetrahedron and evaluating the mechanism of IMR. Mitral valvular tenting and interpapillary muscle distance are 2 independent factors of significant IMR.

Midregional pro-atrial natriuretic peptide is a useful indicator for the detection of impaired left ventricular function in patients with coronary artery disease

Aims We compared the diagnostic performance of N-terminal pro-brain natriuretic peptide (NT-proBNP) with a newly developed assay for the midregional part of pro-atrial natriuretic peptide (MR-proANP) concerning the detection of impaired left ventricular ejection function (LVEF) among patients with coronary artery disease (CAD). Methods and results Plasma levels of MR-proANP and NT-proBNP were determined in 102 consecutive patients with a history of ST-elevation myocardial infarction. Plasma levels of both markers were measured during a mean follow-up period of 687 days after acute myocardial infarction. Univariate analyses revealed inverse correlations between MR-proANP levels and LVEF ( r = − 0.39; p < 0.001), NT-proBNP levels and LVEF ( r = − 0.39; p < 0.001) and a positive correlation between MR-proANP and NT-proBNP ( r = 0.75; p < 0.001). After adjustment for traditional risk factors, MR-proANP was the strongest predictor for LVEF ( p = 0.001) in multivariate analysis, being even superior to NT-proBNP. The area under the ROC curve (AUC) indicated moderate performance (AUC = 0.73; p < 0.01) of MR-proANP regarding the detection of a reduced LVEF < 50%. The AUC of NT-proBNP for detection of impaired LVEF < 50% was 0.68 ( p = 0.019). The negative predictive values of both markers were 86% for MR-proANP at a cut-off > 135 pmol/L and NT-proBNP at a cut-off > 560 pmol/L. At these cut-offs, the specificity of MR-proANP was 90%, and the specificity of NT-proBNP was 84%. Conclusions MR-proANP is a useful indicator for the exclusion of a preserved left ventricular function in patients with coronary artery disease. The study demonstrates that the diagnostic performance of MR-proANP is comparable to the “gold standard” NT-proBNP.