ST-elevation Myocardial Infarction Hospitalizations Research Articles

Outcomes of ST-Elevation Myocardial Infarction in Patients with Adrenal Insufficiency

Abstract Background Patients with adrenal insufficiency (AI) have both increased risk of cardiovascular disease and adverse outcomes with many medical emergencies. However, limited data exist specifically regarding ST elevation myocardial infarction (STEMI) in the context of AI. Methods Admissions for STEMI were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) intervention, acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS), mechanical ventilation, ventricular tachycardia (VT), hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Results Among 690,430 STEMI hospitalizations, 1,382 (0.2%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (adjusted OR [aOR] 1.51, 95% CI 1.03-2.2), lower odds of PCI (aOR 0.73, 95% CI 0.55-0.98), higher odds of CABG (aOR 2.8, 95% CI 1.89-4.2) and, AKI (aOR 2.38, 95% CI 1.72–3.3), VT (aOR 1.55, 95% CI 1.1-2.2), need for vasopressors (aOR 2.34, 95% CI 1.33-4.1), mechanical ventilation (aOR 2.11, 95% CI 1.54-2.89) and MCS (aOR 2.18, 95% CI 1.57–3.03). Patients with AI also had a longer LOS (10 days vs. 4.2 days, p<0.001) and higher charges ($258,475 vs. $115,505, p<0.001). Conclusion Patients with AI admitted for STEMI had higher in-hospital mortality, non-fatal adverse outcomes, and resource utilization compared to patients without AI.

EARLY MANIFESTATIONS OF HEART FAILURE AND ACTIVITY OF SYSTEMIC INFLAMMATION IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION DEPENDING ON RISK FACTORS

Acute myocardial infarction and heart failure (HF) resulting from this condition remain complex and not fully understood problems in cardiology. It is important to detect early manifestations of HF and optimize treatment to prevent pathological myocardial remodeling and the occurrence of adverse events. The increase in systemic inflammation activity (SIA) and the presence of comorbidities in patients contribute to the development of HF. The aim of the study- to investigate the impact of risk factors (RF) such as arterial hypertension (AH), diabetes mellitus (DM), history of COVID-19, and obesity on the occurrence of HF and SIA in patients with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention. Materials and Methods. The study involved 50 patients from the cardiology and reperfusion therapy department of St. Panteleimon Hospital in Lviv (66,00 (52,43-78,35) % men and 34,00 (21,65-47,57) % women), with an average age of 62,01±10,30 years. Blood levels of NT-proBNP (a biomarker of HF) and C-reactive protein (CRP) (a biomarker of SIA) were analyzed on the day of hospitalization for STEMI (the first day from the onset of clinical symptoms, stenting of the infarct-related coronary artery). Results were evaluated using descriptive statistical analysis methods (mean and standard deviation; median and percentile, fractions and their 95 % confidence intervals, calculated by the Wald and Fisher methods), unpaired Student's t-test, and Pearson correlation analysis. Results. The average NT-proBNP levels in the studied patients were 0,50 (0,30; 2,60) ng/ml, and CRP levels were 10,50 (6,00; 20,80) IU/ml (p<0,05, compared to normal parameters). NT-proBNP levels significantly (p<0,05) exceeded the upper reference limit in the presence of AH (0,50 (0,30; 3,30) ng/ml); DM (0,61 (0,30; 4,37) ng/ml); history of COVID-19 (0,61 (0,32; 3,36) ng/ml) (as well as without this RF – 0,49 (0,15; 1,37) ng/ml); obesity (0,31 (0,19; 380) ng/ml). The average NT-proBNP levels in patients with a history of COVID-19 were significantly (p<0,05) higher compared to those in patients without it. CRP levels in blood were significantly (p<0,05) higher than normal values in patients with AH (11,05 (5,60; 25,90) IU/ml); DM (15,20 (7,06; 25,20) IU/ml) (as well as without this RF – 9,50 (5,54; 18,20) IU/ml); history of COVID-19 (12,52 (8,20; 19,65) IU/ml) (as well as without it in history – 9,99 (5,60; 20,06) IU/ml); obesity (9,63 (6,52; 35,00) IU/ml) (as well as without this RF – 10,50 (5,81; 18,40) IU/ml). Average CRP levels in patients with DM and a history of COVID-19 were significantly (p<0,05) higher compared to those without these RFs. The correlation between NT-proBNP and CRP levels was direct – strong in the presence of DM (r=0,78; p=0,012) and history of COVID-19 (r=0,70; p=0,001), medium strength in patients with AH (r=0,55; p=0,0004). Conclusions. In patients with STEMI who underwent myocardial revascularization, early manifestations of HF and a significant increase in SIA occur within the first day of the disease, promoted by such risk factors as AH, DM, history of COVID-19, and obesity. In the presence of DM and history of COVID-19, CRP should be considered an early marker of HF occurrence alongside NT-proBNP, as indicated by a strong direct correlation between these indicators in this category of individuals.

Premature Acute Myocardial Infarction Treated With Invasive Revascularization: Comparing STEMI With NSTEMI in a Population-Based Study of Young Patients

BackgroundAcute myocardial infarction (AMI) usually presents in older populations, in which there are established demographic and outcome differences for ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). No similar comparisons for AMI in the young population exist. MethodsWe compared all index NSTEMI and STEMI hospitalizations in young (18-45 years) patients who required revascularization in Alberta, Canada. Outcomes were survival to discharge, and a composite of heart failure hospitalization, cardiac arrest hospitalization, and all-cause mortality at 1 and 5 years. ResultsThere were 1679 patients included with an index AMI who required revascularization: 655 (39.0%) NSTEMI and 1024 (61.0%) STEMI. The population was disproportionately male (86%), particularly in STEMI patients (87.3%). Marked dyslipidemia (35%) and active smoking (42%) were common, with similar rates among groups. Percutaneous coronary intervention was used in 98.7% of STEMI and 91.5% of NSTEMI patients (P < 0.001), with the remainder who underwent surgical revascularization. The in-hospital mortality rate during index AMI was higher in STEMI compared with NSTEMI patients (1.7% vs 0%; P < 0.001). The rates of the composite outcome were similar for both groups at 1 and 5 years of follow-up in patients who survived to index hospital discharge. After adjusting for sex, age, heart failure and/or cardiac arrest at index AMI, outcomes remained similar among groups at 1 and 5 years. ConclusionsIn young patients with AMI, STEMI was a disproportionately male phenomenon and associated with higher mortality at index hospitalization. One-year and 5-year outcomes were similar among STEMI and NSTEMI patients in those discharged alive at index AMI. Smoking and dyslipidemia appear to be major risk factors in the young.

Disparity in the Under-Utilization of Novel P2Y12 Inhibitors in ST-Elevation Myocardial Infarction Following Percutaneous Coronary Intervention.

The most recent guidelines (European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA)) all favor prasugrel/ticagrelor over clopidogrel in the setting of acute coronary syndrome (ACS). We therefore sought to investigate which P2Y12 inhibitors were being prescribed in our community hospital setting upon discharge among patients undergoing percutaneous coronary intervention (PCI) in the setting of ST-elevation myocardial infarction (STEMI). We identified patients presenting to two Metro Detroit Michigan hospitals with STEMI between January 1, 2018, to December 31, 2021 using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) PCI registry. The primary outcome was the choice of P2Y12 inhibitor prescribed on day of discharge following hospitalization for STEMI, and baseline characteristics were compared including race, sex and type of insurance. A total of 366 patients presented to these two Metro Detroit hospitals from January 1, 2018, to December 31, 2021. Female and non-White patients were more likely to be discharged on clopidogrel than ticagrelor or prasugrel (odds ratio (OR): 1.56, confidence interval (CI): 0.99 - 2.45, and OR: 1.43, CI: 0.91 - 2.25, respectively), however, did not reach statistical significance. Patients without private insurance presenting with STEMI were more likely to be discharged on clopidogrel (OR: 1.83, CI: 1.22 - 2.74), which did reach statistical significance in our cohort. In this retrospective single-center study evaluating BMC2 registry, we demonstrate a clinically significant disparity in prescribing patterns based on insurance, with trends for disparity based on gender and ethnicity.

Abstract 15112: Characteristics and Clinical Outcomes of Patients With Sarcoidosis Admitted for ST-Elevation Myocardial Infarction

Background: Multisystem involvement is often seen in sarcoidosis. This study aims to explore the characteristics and clinical outcomes following hospitalization for ST-elevation myocardial infarction (STEMI) in patients with sarcoidosis when compared to patients without sarcoidosis. Methods: Patients with and without sarcoidosis admitted for STEMI were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models. Results: A total of 851290 patients hospitalized with a primary diagnosis of STEMI between 1 st January 2016 to 31 st December 2020 were identified. Around 1215 (0.1%) had a diagnosis of sarcoidosis consisting of 58.4% males. When compared to patients without sarcoidosis, patients with sarcoidosis had a longer mean length of stay (LOS: 4.76 vs. 4.01 days, p&lt;0.01), a greater prevalence of diabetes (42.4% vs. 32.4%, p&lt;0.01), cirrhosis (1.6% vs. 0.5%, p&lt;0.01), depression (9.1% vs. 6.7%, p&lt;0.01), peripheral vascular disease (7.8% vs. 5.1%, p&lt;0.01), obesity (24.3% vs. 17.8%, p&lt;0.01), chronic kidney disease (25.9% vs. 13.1%, p&lt;0.01) and prior stroke (7.4% vs. 5.2%, p&lt;0.01). However, patients without sarcoidosis had a higher incidence of percutaneous coronary intervention (PCI) (79.8% vs. 75.3%, p&lt;0.01), smoking (52% vs. 35.4%, p&lt;0.01), drug abuse (2.8% vs. 1.2%, p&lt;0.01) and alcohol abuse (3.5% vs. 2.1%, p&lt;0.01) (Table 1A). Moreover, patients with sarcoidosis were less likely to have cardiogenic shock during their hospitalization (12.3% vs. 13.7%, aOR 0.768, 95% CI 0.636-0.927, p&lt;0.01). No statistically significant differences were seen for CABG or PCI use, events of Acute Kidney Injury, acute ischemic stroke and death (Table 1AB). Conclusion: Patients with sarcoidosis admitted for STEMI had a longer length of stay and fewer cardiogenic shock incidence when compared to patients without sarcoidosis. Complications and mortality was otherwise comparable.

Impact of COVID-19 Diagnosis on Mortality in Patients with ST-Elevation Myocardial Infarction Hospitalized during the National Outbreak in Italy.

We sought to assess the clinical impact of COVID-19 infection on mortality in patients with ST-elevation myocardial infarction (STEMI) admitted during the national outbreak in Italy. We analysed a nationwide, comprehensive, and universal administrative database of consecutive STEMI patients admitted during lockdown for COVID-19 infection (11 March-3 May 2020) and the equivalent periods of the previous 5 years in Italy. The observed rate of 30-day and 6-month all-cause mortality of STEMI patients with and without COVID-19 infection during the lockdown was compared with the expected rate of death, according to the trend of the previous 5 years. During the study period, 32.910 STEMI hospitalizations occurred in Italy. Among these, 4048 STEMI patients were admitted during the 2020 outbreak: 170 (4.2%) with and 3878 (95.8%) without a COVID-19 diagnosis. According to the 5-year trend, the 2020 expected rates of 30-day and 6-month all-cause mortality were 9.2% and 12.6%, while the observed incidences of death were 10.8% (p = 0.016) and 14.4% (p = 0.017), respectively. Excluding STEMI patients with a COVID-19 diagnosis, the mortality rate resulted in accordance with the prior 5-year trend. After multiple corrections, the presence of COVID-19 diagnosis was an independent predictor of all-cause mortality at 30 days [adjusted odds ratio (OR) 4.5; 95% confidence intervals (CI) 3.09-6.45; p &lt; 0.0001] and 6 months (adjusted OR 3.6; 95% CI: 2.47-5.12; p &lt; 0.0001). During the 2020 national outbreak in Italy, COVID-19 infection significantly increased the mortality trend in patients with STEMI.

19-LB: The Impact of Diabetes on 30-Day Readmission, In-Hospital Mortality, and Medical Cost in ST-Segment Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention—A Nationwide Readmissions Database Analysis

Background: ST-elevation myocardial infarction (STEMI) poses significant morbidity, mortality and economic burden in people with diabetes. We sought to determine the impact of diabetes on the short-term outcome and hospital costs post-percutaneous coronary intervention (PCI) for STEMI. Methods: STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent PCI, we examined the 30-day readmission, in-hospital mortality, and total cost according to the presence of diabetes, prior stroke, and prior MI. All statistical analyses were performed using R statistical software version 4.1.2. Results: Among 539,171 index STEMI hospitalizations for primary PCI, 10.1% were readmitted within 30 days and 4.6% died in hospital. The readmission rates were 10.2%, 12.9%, 14.4%, 17.5%, and 18.4% in the reference (i.e., no diabetes, prior MI or stroke) , diabetes-only, diabetes and MI, diabetes and stroke, diabetes, MI, and stroke groups, respectively (P&amp;lt;0.001) . The corresponding adjusted hazard ratios for 30-day readmission were 1.14 (95% CI 1.10-1.18) , 1.23 (1.12-1.35) , 1.24 (1.10-1.39) , and 1.29 (0.99-1.68) . In-hospital mortality rates during index hospitalization were 4.3%, 5.3%, 5.5%, 7.2%, and 7.4% in the reference, diabetes-only, diabetes and MI, diabetes and stroke, diabetes, MI, and stroke groups, respectively (P&amp;lt;0.001) . The corresponding adjusted odds ratios for mortality were 1.24 (95% CI 1.15-1.33) , 1.55 (1.28-1.87) , 1.51 (1.22-1.87) , and 2.03 (1.27-3.25) . The median overall cost increased by 4.5% and 11.8% in the diabetes-only group and diabetes, MI, and stroke group, respectively, compared with the reference group (P&amp;lt;0.001) . Conclusion: Within 30 days of PCI for STEMI, diabetes increases readmission rate, in-hospital mortality, and financial burden with and without prior CVD. These findings underscore the importance of aggressive optimization in STEMI patients with diabetes. Disclosure Y. Kang: None. S. Jang: None.

In-hospital mortality and readmission after ST-elevation myocardial infarction in nonagenarians: A nationwide analysis from the United States.

To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI. There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI. We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30-day readmission, readmission rates, and causes of readmissions. We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30-day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p < 0.001). However, mortality during index hospitalization and during 30-day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p < 0.001; 7.4% vs. 14.2%, p < 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30-day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12-1.39, p < 0.001)and 49% lower odds of in-hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46-0.56, p < 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction. In nonagenarians with STEMI, pPCI is associated with slightly higher 30-day readmission but significantly lower mortality during index hospitalization and during 30-day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.

A-14 | Effect of Coronary Artery Anomalies on Outcomes in STEMI Hospitalizations Undergoing Percutaneous Coronary Interventions

The presence of coronary artery anomalies (CAA) can impose technical challenges during percutaneous coronary interventions (PCI). We sought to study the impact of CAA on outcomes in hospitalizations with ST-elevation myocardial infarction (STEMI) undergoing PCI.

Abstract 10833: 30-Day Readmissions After Primary Percutaneous Coronary Intervention in Nonagenarians: A Nationwide Analysis from the United States

Objective: To assess 30-day readmission rates and mortality at readmission in nonagenarians following primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). Background: There is limited contemporary data exploring the 30-day readmission rates and mortality in nonagenarians (age greater than 90 years) with STEMI following pPCI when compared to no pPCI. Methods: We utilized the National Readmissions Database (NRD) from 2010 to 2018 to identify nonagenarians hospitalized with STEMI. We divided the total cohort into two groups based on pPCI status. We analyzed 30-day readmission rates, mortality at the time of readmission, and causes of readmissions in both study cohorts. Results: Between 2010-2018, an estimated 37,363 STEMI hospitalizations were identified in nonagenarians, of which 12,062 (32.3%) included pPCI and 25,301 (67.7%) had no pPCI. Compared to pPCI cohort, no pPCI had more women (69.8% vs 36.7%), higher elixhauser comorbidity index (13% vs 8%), palliative care consultation (12.6% vs 3.4%), and nursing home placement (48% vs 33.3%) (all p&lt;0.01). Overall, 30-day readmission rates were higher in pPCI cohort compared with no pPCI (22.1% vs 16.2%; p&lt;0.01). However, the in-hospital mortality rates at 30-day readmission were significantly lower in pPCI cohort compared with no pPCI (7.0% vs 14.3%; p&lt;0.01). Heart failure is the most common cause of 30-day readmissions in both cohorts, followed by acute myocardial infarction (MI) and gastrointestinal hemorrhage. Recurrent MI rates were significantly lower in pPCI cohort compared with no pPCI (12.3% vs 18.4%; p&lt;0.01). Conclusion: In nonagenarians with STEMI, pPCI during index hospitalization is associated with slightly higher 30-day readmissions but significantly lower mortality at the time of readmission. Given the remarkable mortality benefit with pPCI, further research is necessary to risk stratify and optimize readmission rates following STEMI in nonagenarians.

The CADILLAC risk score accurately identifies patients at low risk for in-hospital mortality and adverse cardiovascular events following ST elevation myocardial infarction

BackgroundThe CADILLAC risk score was developed to identify patients at low risk for adverse cardiovascular events following ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI).MethodsWe performed a single center retrospective review of STEMI hospitalizations treated with PPCI from 2014 to 2018. Patients were stratified using the CADILLAC risk score into low risk, intermediate risk and high risk groups. Patients presenting with cardiac arrest or cardiogenic shock were excluded from the study. The primary outcome was adverse clinical events during initial hospitalization. Secondary outcomes were adverse clinical events at 30 days and 1 year following index hospitalization.ResultsThe study included 341 patients. Compared to patients with a low CADILLAC score, adverse clinical events were similar in the intermediate risk group during hospitalization (OR 1.23, CI 0.37–4.05, p 0.733) and at 30 days (OR 2.27, CI 0.93–5.56, p 0.0733) while adverse clinical events were significantly elevated in the high risk group during hospitalization (OR 4.75, CI 1.91–11.84, p 0.0008) and at 30 days (OR 8.73, CI 4.02–18.96, p < 0.0001). At 1 year follow-up, compared to the low risk CADILLAC group (9.4% adverse clinical event rate), cumulative adverse clinical events were significantly higher in the intermediate risk group (22.9% event rate, OR 2.86, CI 1.39–5.89, p 0.0044) and in the elevated risk group (58.6% event rate, OR 13.67, CI 6.81–27.43, p < 0.0001). The mortality rate was 0% for patients defined at low risk by CADILLAC score during hospitalization, as well up to 1 year follow up. On receiver operating curve analysis, discrimination of in-hospital adverse clinical events was fair using CADILLAC (C = 0.66, odds ratio 1.18; 95% CI 1.04–1.33; p = 0.0064) with somewhat better discrimination at 30-day follow-up (C = 0.719) and 1-year follow-up (C = 0.715).ConclusionPatients defined as low risk by the CADILLAC score following a STEMI were associated with lower mortality and adverse clinical event rates during hospitalization and up to 1 year following STEMI when compared to those with an intermediate or high CADILLAC score.

Trends in Clinical Characteristics and Outcomes in ST-Elevation Myocardial Infarction Hospitalizations in the United States, 2002-2016

ST-segment Elevation Myocardial Infarction (STEMI) remains a major modern-day public health problem. We aimed to assess the demographic trends in STEMI related hospitalizations in the United States over a period of fifteen years. The nationwide inpatient sample was queried to obtain information of patients hospitalized with STEMI from January 1, 2002, to December 31, 2016. Annual hospitalization rates were calculated and annual percentage change (APC) was evaluated using regression analysis. A total of 4,121,155 eligible patients were included in this analysis. Overall, the total number of STEMI hospitalization decreased from 421,043 in 2002 to 208,510 in 2016 (P-trend <0.01). With the decreasing trend, the rate was relatively higher among males as compared to females, whites as compared to non-whites, and lower as compared to high socioeconomic status (SES). The rate of PCI in STEMI patients increased from 32.8% in 2002 to 67.8% in 2016 (APC = 5.392%, 95% CI [4.384–6.411], P < 0.001), but was higher among males as compared to females, urban as compared to rural hospitals and higher as compared to lower SES. In-hospital mortality decreased from 11% in 2002 to 10.5% in 2016 (APC = -0.771%, 95% CI [-1.230 to -0.311], P = 0.003), but remained higher among females, rural hospitals and low SES as compared to their correspondent groups. Among STEMI patients, the prevalence of individual comorbidities was noted to be increasing over the study period. Although there has been a declining trend in the number of STEMI hospitalizations, patients with modifiable risk factors presenting with STEMI has been on the rise. Females, rural communities and lower SES groups need special attention because of greater vulnerability.

Neutrophil Counts Help Predict Free Wall Rupture Following St-elevation Myocardial Infarction.

Free wall rupture (FWR) is a lethal complication after acute myocardial infarction; however, the un-derlying mechanisms of FWR are unclear. This study analyzes the relationship between neutrophil counts and FWR following ST-elevation myocardial infarction (STEMI). The case group was STEMI patients with FWR and the control group was STEMI patients without FWR (case-control ratio was 1:4). The demographic data, clinical manifestation and laboratory test results were retrospectively collected and analyzed. Of a total of 6,712 consecutive STEMI patients, 78 patients (1.2%) had FWR. Compared with STEMI patients, patients with FWR were older and more likely to be female with an anterior infarct. White blood cell (WBC) counts were significantly higher in the FWR group. Moreover, we found that the elevated neutrophil counts mainly accounted for the elevated WBC counts. There was also a correlation between the age and neu-trophil counts (P=0.0109); as patient age increased, neutrophil counts decreased (P=0.0387). We also found no correlation between neutrophil counts and the time between myocardial infarction attack and FWR; however, when dividing these patients into FWR ≤48 h after admission to hospital for STEMI and FWR >48 h, there was a significant difference in neutrophil counts (P=0.0196). Furthermore, the results of logistic regression analy-sis showed that increased neutrophil was an independent risk factor for FWR (odds ratio: 2.404, confidence interval: 1.055-5.477). Elevated neutrophil counts were found to be the main cause of differences in WBC counts be-tween FWR and STEMI. Elevated neutrophil was an independent risk factor for FWR. This study provided clues for further research and development of therapeutics for the prevention of FWR.

Outcomes of ST elevation myocardial infarction (STEMI) hospitalizations during corona virus disease 19 (COVID 19) era

Funding AcknowledgementsType of funding sources: None.Multiple studies reports a reduction of STEMI hospitalizations rates during COVID 19 pandemic outbreak. Contradictory STEMI complications rates are reported during COVID 19 pandemic regarding case fatalities rates, cardiogenic shock, life threatening arrhythmias and others.Purpose. To evaluate the impact of the COVID 19 outbreak on STEMI patient outcomes and complication rates in country with low COVID 19 incidence and mortality and without changes in Cardiology hospital services.Methods. Was conducted a retrograde study collecting data for STEMI hospitalizations, revascularization procedures and case fatalities and other complications from March 9th 2020 (first COVID 19 case in our country) to April 30th (period of total lockdown) compared with the same period of 2019 in our center. Incidence rate ratio (IRR) was used to compare STEMI admissions and revascularization procedures and risk ratio (RR) to compare case fatality rate and other complications rate.ResultsHospital admissions for STEMI declined during 2020 (COVID 19 period) from a total of 217 patients in 2019 to 155 patients hospitalization in 2020 representing IRR 0.72 (p = 0.009). Reduction were observed in the number of primary PCI from 168 procedures in 2019 to 113 in 2020 (IRR 0.67 p = 0.001). Symptom onset to our ICU (including regional transportation) was significantly higher in 2020 than in 2019 (939.97 ± 1122 versus 436.15 ± 383 minutes p <0.0001) The STEMI case fatality was importantly increased during pandemic outbreak (13.55%) compared to 2019 (8.3%) (RR= 1.63 p = 0.001), but a similar a primary PCI-STEMI case fatality 6.2% versus 5.95%. Also an increase was observed for cardiogenic shock (IRR =1.75 p = 0.003).Results; Hospitalizations and related invazive revascularization procedures for STEMI significantly reduced during COVID 19 pandemic. We identified a substantial increase of STEMI case fatalities and cardiogenic shock during pandemic outbreak. Delayed timely reperfusion by primary PCI has an important impact on infarct related mortality.

C-Reactive Protein as a Risk Marker for Post-Infarct Heart Failure over a Multi-Year Period.

Inflammatory activation during acute ST-elevation myocardial infarction (STEMI) can contribute to post-infarct heart failure (HF). This study aimed to determine prognostic value of high-sensitivity C-reactive protein concentration (CRP) for HF over a long-term follow-up in 204 patients with a first STEMI undergoing guideline-based therapies including percutaneous coronary intervention. CRP was measured at admission, 24 h (CRP24), discharge (CRPDC), and one month (CRP1M) after index hospitalization for STEMI. Within a median period of 5.6 years post-index hospitalization for STEMI, hospitalization for HF (HFH) which is a primary endpoint, occurred in 24 patients (11.8%, HF+ group). During the study, 8.3% of HF+ patients died vs. 1.7% of patients without HFH (HF- group) (p = 0.047). CRP24, CRPDC, and CRP1M were significantly higher in HF+ compared to HF- group. The median CRP1M in HF+ group was 2.57 mg/L indicating low-grade systemic inflammation, in contrast to 1.54 mg/L in HF- group. CRP1M ≥ 2 mg/L occurred in 58.3% of HF+ vs. 42.8% of HF- group (p = 0.01). Kaplan–Meier analysis showed decreased probability of survival free from HFH in patients with CRP24 (p < 0.001), CRPDC (p < 0.001), and CRP1M (p = 0.03) in quartile IV compared to lower quartiles. In multivariable analysis, CRPDC significantly improved prediction of HFH over a multi-year period post-STEMI. Persistent elevation in CRP post STEMI aids in risk stratification for long-term HF and suggests that ongoing cardiac and low-grade systemic inflammation promote HF development despite guideline-based therapies.

Is plasma concentration of coenzyme Q10 a predictive marker for left ventricular remodelling after revascularization for ST-segment elevation myocardial infarction?

Left ventricular remodelling that frequently occurs after acute myocardial infarction is associated with an increased risk of heart failure and cardiovascular death. Although several risk factors have been identified, there is still no marker in clinical use to predict left ventricular remodelling. Plasma concentration of coenzyme Q10, which plays a key role in mitochondrial energy production and as an antioxidant, seems to be negatively correlated with left ventricular function after acute myocardial infarction. The goal of our study was to determine whether the plasma coenzyme Q10 baseline concentrations at time of the ST-elevation myocardial infarction (STEMI) could predict left ventricular remodelling at six months' follow-up. Sixty-eight patients who were admitted to hospital for STEMI and successfully revascularized with primary percutaneous coronary intervention were recruited. All patients underwent a 3D-echocardiography examination within the first four days after percutaneous coronary intervention and six months later then divided into two groups based on the presence or not of left ventricular remodelling. Plasma coenzyme Q10 concentration at the time of percutaneous coronary intervention was determined using high-performance liquid chromatography-tandem mass spectrometry. While we found similar plasma coenzyme Q10 concentrations compared with other studies, no association was evidenced between coenzyme Q10 concentrations and left ventricular remodelling (P = 0.89). We found no evidence for using plasma coenzyme Q10 concentration as an early prediction marker of left ventricular remodelling after STEMI.

Effect of primary percutaneous coronary intervention on in-hospital outcomes among active cancer patients presenting with ST-elevation myocardial infarction: a propensity score matching analysis.

Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI. All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group. Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.

ST-elevation myocardial infarction in nonagenarians: A nationwide analysis of trends and outcomes in the United States.

To assess ST elevation myocardial infarction (STEMI) trends and outcomes in nonagenarians undergoing primary percutaneous coronary intervention (pPCI) compared to medical management. Although nonagenarians (age greater than 90 years) represent the fast-growing age decade of the US population, limited evidence is available regarding trends and outcomes of treatment strategies for STEMI in this population cohort. We performed a retrospective analysis using the National Inpatient Sample (NIS) database to identify nonagenarians presenting with STEMI and treated with either pPCI or medical management. In-hospital mortality, in-hospital complications, length of stay and in-hospital costs were analyzed. Between 2010-2017, 41,042 STEMI hospitalizations were identified in nonagenarians, of which 11, 155 (27.2%) included pPCI whereas 29, 887 (72.8%) included medical management. STEMI hospitalizations among nonagenarians decreased over the study period. Overall unadjusted in-hospital mortality was 21.6%, and the hospitalizations that included pPCI had significantly lower mortality compared to the medical management (13.6% vs. 24.5%, p < .001). After adjusting for baseline characteristics, hospitalizations that included pPCI had 42.1% lower odds of in-hospital mortality (adjusted OR: 0.58, 95% CI: 0.50 to 0.67, p < .001). Altogether, in-hospital cardiac, bleeding and vascular complications, length of stay and in-hospital costs were higher in pPCI hospitalizations. In nonagenarians, STEMI mortality is high, but pPCI is associated with superior outcomes compared to medical management alone. Therefore, pPCI can be considered an acceptable treatment strategy in this population.

Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients Admitted With ST-Elevation Myocardial Infarction

Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.

Agreement of 2D transthoracic echocardiography with cardiovascular magnetic resonance imaging after ST-elevation myocardial infarction

BackgroundThis study was designed to investigate the agreement of 2D transthoracic echocardiography (2D TTE) with cardiovascular magnetic resonance imaging (CMR) in a contemporary population of ST-elevation myocardial infarction (STEMI) patients. MethodsIn this subanalysis of the GIPS-III trial, a randomized controlled trial investigating the administration of metformin in STEMI patients to prevent reperfusion injury, we studied 259 patients who underwent same-day CMR and 2D TTE assessments four months after hospitalization for a first STEMI. Bland-Altman analyses were performed to assess agreement between LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and LV mass measurements. Sensitivity and specificity of 2D TTE to detect categories of LVEF (≤35%, 35–50%, ≥50%) was determined. Linear regression of absolute differences in measurements between imaging modalities was used to investigate whether patient characteristics impact measurement bias. ResultsPairwise difference (bias) and 95% limits of agreement between CMR and 2D TTE measurements were +84 (37, 147) ml for LVEDV, +39 (6, 85) ml for LVESV, -1.1 ± 13.5% for LVEF, and -75 (-154, -14) g for LV mass. Sensitivity and specificity of 2D TTE to detect subjects with moderately depressed LVEF (35–50%) as measured by CMR were 52% and 88% respectively. We observed a significant effect of enzymatic infarct size on bias between 2D TTE and CMR in measuring LVESV and LVEF (P = 0.029, P = 0.001 respectively), of age and sex on bias between 2D TTE and CMR in measuring LV mass (P = 0.027, P < 0.001) and LVEDV (P = 0.001, P = 0.039), and of heart rate on bias between 2D TTE and CMR in LV volume measurements (P = 0.004, P = 0.016). ConclusionsWide limits of agreement, underestimation of LV volumes and overestimation of LV mass was observed when comparing 2D TTE to CMR. Enzymatic infarct size, age, sex, and heart rate are potential sources of bias between imaging modalities.