Hospitalization For MI Research Articles

Cardiovascular Hospitalizations Among Older Adults in the US and Denmark.

Cardiovascular disease is the leading cause of death in the US. However, it remains unclear how the burden of cardiovascular events in the US compares with that of other high-income countries with distinct health care systems like Denmark, both overall and by income. To compare cardiovascular hospitalization rates (acute myocardial infarction [MI], heart failure [HF], ischemic stroke) and associated outcomes among adults 65 years or older, overall and by income, between the US and Denmark. This population-based cross-sectional study used national data from the US and Denmark from January 1, 2021, to January 1, 2022. The study population included all Medicare beneficiaries 65 years or older in the US and all adults 65 years or older in Denmark. The primary outcome was age- and sex-standardized hospitalization rates for MI, HF, and ischemic stroke, as well as 30-day all-cause mortality rates. The US study population included 58 614 110 adults 65 years or older (mean [SE] age, 74.6 [7.7] years; 32 179 146 female [54.9%]) of whom 1 171 058 (2.0%) were hospitalized for a cardiovascular event. The Danish study population included 1 176 542 adults 65 years or older (mean [SE] age, 75.3 [7.1] years; 634 217 female [53.9%]) of whom 16 305 (1.4%) were hospitalized with a cardiovascular event. The overall age- and sex-standardized cardiovascular hospitalization rate was significantly higher in the US compared with Denmark (risk ratio [RR], 1.50; 95% CI, 1.47-1.52), as were associated 30-day all-cause mortality rates (RR, 1.12; 95% CI, 1.06-1.17). Across conditions, the risk of hospitalization for MI (RR, 1.56; 95% CI, 1.51-1.61) and HF (RR, 2.37; 95% CI, 2.31-2.43) was significantly higher in the US compared with Denmark, whereas hospitalizations for ischemic stroke were lower (RR, 0.90; 95% CI, 0.88-0.93). Overall cardiovascular hospitalization rates in the US were more than 2-fold higher among low-income adults compared with higher-income adults (RR, 2.38; 95% CI, 2.25-2.47), whereas the magnitude of income-based disparities was smaller in Denmark (RR, 1.45; 95% CI, 1.39-1.50). In this international cross-sectional study, cardiovascular hospitalization rates were significantly higher in the US compared with Denmark. There were income-based differences in the burden of cardiovascular hospitalizations in both countries, although the magnitude of these disparities was much greater in the US.

In asymptomatic severe AS, early surgery vs. conservative therapy reduced a composite of death, MI, stroke, or HF hospitalization at 63 mo.

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Optimization of the therapeutic follow-up of patients after hospitalization for an acute MI through an e-health application: Preliminary findings from ASTERIA

Optimization of the therapeutic follow-up of patients after hospitalization for an acute MI through an e-health application: Preliminary findings from ASTERIA

Abstract 4138246: Differences in Major Adverse Cardiovascular and Lower Limb Events and Guideline-Directed Medical Therapy Among Males and Females Within an Integrated Healthcare System

Background: Health disparities based on gender have been recognized as having a detrimental impact on care delivery and early identification of disease processes. Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic disease mortality. It is unclear what role, if any, gender plays in the diagnosis, treatment, and outcomes of PAD. Hypotheses: Females are less likely to have guideline-directed medical therapy (GDMT) and more likely to have major adverse cardiovascular events (MACE) and major adverse lower limb events (MALE) than males. Methods: The Intermountain Health electronic database was queried for patients meeting the following criteria: ≥18-years of age, PAD diagnosis between Jan 2006 to Dec 2021, seen at least once within the 18-months following initial PAD diagnosis, and had a symptom of PAD (see table). Follow-up GDMT, based on the 2016 AHA/ACC PAD guidelines, was determined by medication and procedures. Time to outcomes of MACE (all-cause death, MI, stroke, or unstable angina hospitalization) and MALE (limb ischemia, limb revascularization, or limb amputation) were examined using Cox-proportional hazard adjusted for GDMT, age, and prior CAD. Results: A total of 7522 patients had a symptomatic PAD diagnosis, with 38% female and 62% male. Females tended to be older (70.1±13.0 vs 68.6±11.7), more likely to be obese (25% v 21%), and less likely to have Afib (21% v. 24%), CAD (30% v 41%), MI (11% v 16%), renal failure (19% v 22%) but more likely to have a bleeding history (30% v 26%) (all p<0.01). Females were slightly less likely to have all the GDMT and yet had similar rates of referrals to specialists but higher rates to primary care providers (Table). After adjustment, females were less likely to have MACE (HR=0.94; 95% CI: 0.88, 0.99) and MALE (HR=0.85; 95% CI: 0.80, 0.92). Conclusion: Females had lower rates of MALE, driven by lower limb revascularization or amputation rates, and slightly lower rates, after adjustment, for MACE. This was observed despite the high rates of GDMT for both females and males (~80% in any category), with females having slightly less GDMT.

Type 1 Kounis syndrome: recurrent myocardial infarctions in a patient with aspirin-exacerbated respiratory disease: a case report

Introduction. We present a case of type 1 Kounis syndrome in a patient with recurrent myocardial infarction with non-obstructive coronary arteries (MINOCA) due to allergic coronary vasospasm. Awareness of doctors about this pathology will allow identifying the MINOCA causes and prescribing pathogenetic treatment.Brief description. A 51-year-old woman with aspirin-exacerbated respiratory disease (asthma, rhinosinusitis with nasal polyposis, aspirin hypersensitivity, eosinophilia) without cardiovascular risk factors developed three recurrent myocardial infarctions against the background of vasospastic angina over a 6-month period. Despite the typical clinical performance, stable ST segment elevation, unchanged coronary arteries on coronary angiography, the vasospastic MI was not immediately established. The patient received long-term treatment for type 1 MI, including beta-blockers. Recurrent MI occurred against the background of an asthma attack. During the second and third hospitalization for MI, coronary angiography revealed a spasm of the right coronary artery, which completely resolved with the nitroglycerin administration. Intracoronary ultrasound made it possible to rule out atherosclerotic involvement of the infarct-related artery. Subsequently, microvascular angina developed, which was confirmed by positron emission tomography. Vasospastic angina in combination with microvascular angina, MIBOCA with asthma attacks, were regarded as type 1 Kounis syndrome. Over the next 2 years, the patient received pathogenetic treatment, and no recurrent cardiovascular events were observed.Discussion. Lack of awareness about Kounis syndrome led to incomplete examination of the patient with MIBOCA and the prescription of pathogenetically unreasonable tehrapy, which could contribute to recurrent MI within 6 months.

Impact of SGLT2 Inhibitors on Left Ventricular Remodeling in Diabetic Patients with Acute Myocardial Infarction.

To assess the effect of sodium-glucose cotransporter 2 inhibitors (SGLT2-I) on cardiac remodeling and prognosis in type 2 diabetes mellitus (T2DM) patients presenting with acute myocardial infarction (AMI). In this single-center retrospective active-comparator study, consecutive diabetic AMI patients undergoing percutaneous coronary intervention (PCI) between 2021 and 2023 were enrolled. Patients were divided into SGLT2-I users and non-SGLT2-I users based on discharge medications. The primary endpoint was the left ventricular remodeling index (LVRI), defined as the relative change in LV end-diastolic volume after six months. The secondary outcomes included major adverse cardiovascular events (MACE), comprising all-cause mortality, hospitalization for heart failure, nonfatal MI, and nonfatal stroke. The study comprised 423 T2DM AMI patients(with or without ST-segment elevation), with 239 SGLT2-I users and 184 non-SGLT2-I users. At six months, LVRI was significantly lower in the SGLT2-I users compared to the non-SGLT2-I users (3.49 ± 19.71 vs 7.06 ± 15.15, P = .042). The non-SGLT2-I users exhibited a higher prevalence of positive LVR (LVRI > 0%) (64.67% vs 50.63%, P = .004) and pathological LVR (LVRI > 20%) (19.57% vs 12.13%, P = .036). Multivariate logistic regression indicated that SGLT2-I was associated with a reduced risk of LVR (OR 0.6; 95%CI 0.38-0.97; P = .035). During a mean follow-up of 25 ± 8 months, Kaplan-Meier analysis demonstrated a lower rate of MACE-free survival in the non-SGLT2-I users (P = .005). SGLT2-I protects against LVR and lowers the risk of adverse cardiovascular outcomes in T2DM AMI patients.

Blood pressure variability as a prognostic factor in patients with acute myocardial infarction. Data from the ACS-BP study

Abstract Background Blood pressure variability (BPV) is considered a modern cardiovascular risk factor. There are many data relating BPV to mortality, risk of stroke and target organs damage mainly in hypertensive patients. Purpose The purpose of the present study is to investigate whether BPV in patients with acute myocardial infarction (AMI) who all underwent percutaneous coronary intervention (PCI) was associated with short and and/or long-term cardiovascular mortality. Methods A total of 402 patients (67.2% male, mean age: 62.7 years, 70.1% hypertensive, 46.9% STEMI) underwent 24-ambulatory blood pressure monitoring (ABPM) during hospitalization for MI. Both during their hospitalization and in a period of 6 and 12 months, they were reviewed to assess cardiovascular mortality. BPV extracted from the ABPM recordings using the coefficient of variation (CV) of systolic (SBP) and diastolic (DBP) blood pressure. Patients were classified into 4 quartile-intervals based on CV. Results After full adjustment of data (age, sex, type of ACS, BP, Diabetes, Chronic Kidney Disease <3rd stage) patients in the quartile with the highest CV of SBP (Q4 n= 92) have a higher in-hospital (OR = 2, 07, 95% CI: 1.02-2.99, p=0.001), 6-month (OR = 1.94, 95% CI: 1.22– 3.170, p<0.001) and long-term (1-year follow-up) mortality (OR = 1.81, 95% CI: 1.08-2.77, p=0.03) compared to patients presenting lower BPV and classified in the corresponding quartiles (Q1-Q3, n=310). Corresponding results were obtained from the control of the CV of DBP. Conclusions In the context of patients admitted for AMI and underwent PCI, higher post-infarction BPV of both SBP and DBP expose these patients to a higher risk of short - and long-term mortality. Consequently, monitoring of BPV in patients with AMI may identify patients with potential hemodynamic instability and contribute to early clinical decision-making.

Abstract 15190: Association of Initiating SGLT2i and GLP1Ra Therapeutics on Insulin Utilization and MACE Outcomes Among Patients With Diabetes in an Integrated Healthcare System

Background: Nearly 10% of US adults diagnosed with diabetes (DM) begin using insulin within 1 year (yr) of the diagnosis. A third of all patients (pts) with DM experience an atherosclerotic cardiovascular (CV) event. SGLT2is and GLP1Ras, have been shown to reduce major adverse CV events (MACE). Meta-analyses show a reduction in insulin utilization when these medications are initiated individually or concurrently. This study evaluated the real-world impact on MACE and insulin usage among pts with DM initiating SGLT2is and GLP1Ras. Methods: Intermountain pts (n=6,476) ≥18 years of age with ≥3 encounters and on insulin at time of initiation of SGLT2i, GLP1-RA, or combined therapy from January 1, 2012 to November 30, 2021 were studied. Pts were stratified by whether they stopped-insulin (st-in) within 90 days of having started SGLT2i, GLP1Ra, or both or continued-insulin (co-in). MACE was defined as death, MI, CVA, or HF hospitalization and was assessed at 1- and 3-yrs. Results: Of 6,476 pts, 93.3% (n=6,039) st-in and 6.7% (n=437) co-in. St-in pts had less comorbidities, but were older (58.2 vs. 55.0 years), male (55% vs. 48.5%), weighed less (105.5 vs. 110.7 kg), and included fewer pts with DM I (18.5% vs 38.4%). Renal function and hemoglobin A1C were similar. Compared to co-in, pts with st-in were prescribed SGLT2i (30.0% vs 20.4%) or combination (SGLT2i/GLP1Ra) (16.2% vs 11.2%) more often. St-in vs co-in had a higher frequency of MACE, which persisted after adjustment by risk factors, comorbidities, and medications (Table). Conclusion: In pts with DM on insulin, adding SGLT2i, GLP1Ra, or both led to a change in insulin utilization, with >90% of pts stopping insulin entirely. However, we observed an increase in 1-yr and 3-yr MACE for st-in vs co-in pts. This suggests a need for caution when initiating these medications in those already on insulin with regards to insulin management, including a decision to discontinue insulin. More data are needed to further understand our observations.

The role of insurance status in the association between short-term temperature exposure and myocardial infarction hospitalizations in New York State.

To evaluate effect modification of the relationship between short-term ambient temperature and MI, by individual-level insurance status (insured vs. uninsured). We identified MI hospitalizations and insurance status across New York State (NYS) hospitals from 1995 to 2015 in the New York Department of Health Statewide Planning and Research Cooperative System database, using International Classification of Diseases codes. We linked short-term ambient temperature (averaging the 6 hours preceding the event [MI hospitalization]) or nonevent control period in patient residential zip codes. We employed a time-stratified case-crossover study design for both insured and uninsured strata, and then compared the group-specific rate ratios. Over the study period, there were 1,095,051 primary MI admissions, 966,475 (88%) among insured patients. During extremely cold temperatures (<5.8 °C) insured patients experienced reduced rates of MI; this was not observed among the uninsured counterparts. At warmer temperatures starting at the 65th percentile (15.7 °C), uninsured patients had higher rates than insured patients (e.g., for a 6-hour pre-event average temperature increase from the median to the 75th percentile, the rate of MI increased was 2.0% [0.0%-4.0%] higher in uninsured group). Uninsured individuals may face disproportionate rates of MI hospitalization during extreme temperatures.

Cardiovascular Outcomes of ST-Elevation Myocardial Infarction (STEMI) Patients without Standard Modifiable Risk Factors (SMuRF-Less): The Intermountain Healthcare Experience

Studies primarily outside the United States have reported that SMuRF-less STEMI patients are surprisingly common (14-27%) and have a worse in-hospital/short-term prognosis. Given potential demographic and management differences over time and in the US, we aimed to identify the proportion and outcomes of SMuRF-less STEMI patients in a large US healthcare population. Patients with a first STEMI presenting to Intermountain Healthcare catheterization laboratories between 2001-2021 were included. SMuRF included a clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and smoking. Follow-up MACE were defined as death, MI, and heart failure hospitalization (HFH) by 60 days and long-term. Qualifying STEMI patients totaled 3510, 26.2% (919) with no SMuRF. SMuRF-less patients were younger, more frequently male, and had fewer comorbidities. Neither total MACE (adj HR 0.95, p = 0.72) nor death (adj HR 1.06, p = 0.69) differed by SMuRF status at 60 days. Long-term outcomes were more frequent in SMuRF patients, which remained significant for total MACE (adj HR 0.83, p = 0.02) and HFH (HR 0.36, p = 0.0005) after adjustment for baseline differences other than SMuRF. Results were consistent through subgroup and sensitivity analyses. In this moderately large US healthcare population, SMuRF-less STEMI presentation was confirmed to be common (26.2%). However, unlike earlier, mostly non-US reports, adjusted short-term outcomes were similar, and long-term outcomes were more favorable. Further studies to increase understanding, recognition, and treatment of risk factors in SMuRF-less subjects and to optimize STEMI management are indicated.

Abstract 10291: Elevated C-Reactive Protein Level Amplifies the Association of Lipoprotein(a) With Cardiovascular Risk and Risk Reduction With Alirocumab After Acute Coronary Syndrome

Background: In the ODYSSEY OUTCOMES trial (NCT01663402) the PCSK9 inhibitor alirocumab [ALI] reduced the risk of cardiovascular events [CVE] after acute coronary syndrome [ACS] in patients [pts] with elevated atherogenic lipoproteins despite optimized statin treatment, an effect modified by baseline levels of lipoprotein [Lp](a). Levels of the inflammatory biomarker high-sensitivity C-reactive protein [hsCRP] are associated with risk after ACS. In this post hoc analysis, we determined whether Lp(a)-associated risk of CVE after ACS and reduction in that risk with ALI are modified by concurrent hsCRP levels. Methods: 18,924 pts were randomized to ALI or placebo [PBO] 1-12 months after ACS and followed for median 2.8 years. Baseline Lp(a) and hsCRP were available in 18,290 pts. CVE [CV death, non-fatal MI, stroke, unstable angina or heart failure hospitalization, ischemia-driven coronary revascularization, peripheral artery events, and venous thromboembolism] were evaluated by baseline quartile of Lp(a) and by hsCRP dichotomized at 0.2 mg/dL. Results: Median (Q1-Q3) baseline Lp(a) was 21.3 (6.7-59.6) mg/dL. In 10,323 pts with baseline hsCRP&lt;0.2 mg/dL ( Fig top ) risk of CVE in the PBO group increased modestly in Lp(a) Q4 (P trend =0.0592). Overall treatment hazard ratio [HR] was 0.91 without significant trend across Lp(a) quartiles. In 7967 pts with baseline hsCRP≥0.2 mg/dL ( Fig bottom ) risk of CVE in the PBO group was elevated and increased across Lp(a) quartiles (P trend &lt;0.0001). Overall treatment HR was 0.82 and decreased across Lp(a) quartiles (P trend =0.0003). Conclusion: Elevated hsCRP amplifies the relationship of Lp(a) with risk of CVE after ACS and the reduction in that risk with alirocumab. Funding: Sanofi, Regeneron Pharmaceuticals

Abdominal Obesity Is Associated with an Increased Risk of All-Cause Mortality in Males but Not in Females with HFpEF.

Background Association between abdominal obesity and development of heart failure (HF) with preserved ejection fraction (HFpEF) between the sexes is not completely understood. Objectives This study evaluated the association between abdominal obesity and the risk of all-cause mortality in patients with HFpEF while performing a gender outcome comparison. Methods A post hoc analysis was undertaken from the American cohort of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT). The primary outcome (all-cause mortality) and the secondary outcomes (cardiovascular mortality, hospitalization for HF, stroke, and MI) were evaluated via Cox proportional hazards models to compare the hazard ratios (HRs) between sexes in HFpEF patients. Abdominal obesity was defined as a waist circumference of ≥102 cm in men and ≥88 cm in women. Results A total of 3320 HFpEF patients (1620 men [48.80%] and 1700 women [51.20%]) were included in the analysis. The mean follow-up period was 3.4 ± 1.7 years, with 503 patients dying during that time. After multivariable adjustment, abdominal obesity was significantly associated with an increased risk of all-cause mortality in males (adjusted HR: 1.32; 95% confidence interval [CI]: 1.02 to 1.71; p = 0.038). Abdominal obesity was associated with hospitalization for HF in both male (adjusted HR: 1.39; 95% CI: 1.01 to 1.93; p = 0.045) and female patients (adjusted HR: 1.15; 95% CI: 1.18 to 3.28; p = 0.010). Conclusions Abdominal obesity is associated with increased risks of all-cause mortality in the male but not the female HFpEF population and is associated with increased risks of hospitalization for HF in both sexes.

The cardiovascular effects and safety of colchicine

Colchicine is an alkaloid obtained from the bulb and seed of the Crocus (Colchicum autumnale L. (Liliaceae), Autumn Crocus) plant with a history of 2000 years and is currently prescribed for the treatment of rheumatic diseases. In 2015, the European Society of Cardiology supported and recommended colchicine as a first-choice treatment agent that can be added to traditional anti-inflammatory treatments to improve response to treatment, increase remission rates and reduce relapses in acute and recurrent pericarditis in the diagnosis and treatment guidelines of pericardial diseases. In addition, the use of colchicine in the Secondary Prevention of Atherosclerosis is recommended with evidence level A in the European Society of Cardiology Guidelines published in 2021. It was concluded that colchicine is a safe and effective treatment modality to prevent AF recurrence after catheter ablation. It has been noted that colchicine, used secondary to the currently used preventive drugs against CHD, has lower rates of cardiovascular death, MI, stroke, or emergency hospitalization due to angina requiring coronary revascularization, and the risk of acute cardiovascular events compared to placebo. In addition, it has been reported that the use of colchicine in patients with MI reduces the risk of ischemic cardiovascular events. Colchicine is an effective and safe option as a first-choice treatment agent that can be added to conventional anti-inflammatory treatments in patients with recurrent cardiovascular events despite optimal medical therapy and in the secondary prevention of atherosclerotic cardiovascular diseases where other risk factors cannot be adequately controlled.

Abstract 9809: Mortality, Hospitalization, and Cardiac Interventions in Atrial Fibrillation Patients Younger Than 65 Years

Introduction: The risk factor burden, and long-term outcome among atrial fibrillation (AF) patients under 65 years of age is unclear. Methods: The study population included 67,221 (mean age 72.4 ± 12.3, 45% female) adult patients with AF evaluated at the University of Pittsburgh Medical Center between 1/2010 and 12/2019. Hospital system wide electronic health records and administrative data using International Classification of Disease 9 and 10 revisions was utilized to ascertain risk factors, comorbidities, and subsequent mortality and hospitalization stratified according to age at initial evaluation. Association of AF with all-cause mortality among those &lt; 65 years was analyzed using an internal contemporary cohort of patients without AF (n=918,073). Results: 17,335 patients (26%) were less than 65 years of age (32% female, 92% white) with considerable cardiovascular risk factors (current smoker 16%, BMI 33.0 ± 8.3, hypertension 55%, Diabetes Mellitus 21%, congestive heart failure 20%, Coronary artery disease 19%, prior ischemic stroke 6%) and comorbidity burden (COPD 11%, Obstructive sleep apnea 18%, CKD 1.3 %). Over mean follow up of &gt; 5 years, 2084 (6.7% &lt;50 years; 13% 50-65 years) patients died. Proportion of patients with &gt;1 hospitalization for MI, HF and Ischemic stroke was 1.25%, 4.8%, and 1.05% for those &lt;50 years and 2.2%,7.4%, and 1.1% for the 50-65 years subgroup respectively. Multiple cardiac and non-cardiac risk factors were associated with increased mortality in younger AF patients with HF and hypertension demonstrating significant age-related interaction (p=0.007 and p=0.013 respectively). AF patients experienced significantly worse survival when compared to comorbidity adjusted patients without AF (Males &lt;50y HR 1.49 (1.24-1.79), 50-65y HR 1.34 (1.26-1.43); Females &lt;50y HR 2.4 (1.82-3.16), 50-65y HR 1.75 (1.6-1.92)). Conclusions: AF patient &lt;65 years of age have significant comorbidity burden and considerable long-term mortality. They are also at a significant increased risk of hospitalization for HF, stroke, and myocardial infarction. Cardiac and non-cardiac comorbidities are independently associated with worse outcome in these patients and warrant aggressive risk factor and comorbidity evaluation and management.

Abstract 13154: Association of Serial Health Status Measurements With Clinical Events: Insights From the ISCHEMIA Trial

Introduction: The Seattle Angina Questionnaire (SAQ), a disease-specific health status measure, has been shown to predict future clinical outcomes in patients with chronic coronary disease (CCD) at a single point in time. The prognostic value of serial SAQ scores in patients with CCD is unknown. Methods: Serial assessments of the 7-item SAQ were obtained in the ISCHEMIA trial of patients with CCD and moderate/severe ischemia. Using Cox regression, we examined the association of baseline and 3-month SAQ-7 Summary Scores (SAQ7-SS) with CV death, MI or unstable angina hospitalization over a 12 month period (between 3 and 15 months after randomization) in patients randomized to conservative treatment. We fit several models including: (a) baseline score only; (b) 3-month score only; (c) 3-month change only; (d) baseline and 3-month score; (e) 3-month change and score. Results: The mean age was 64.3 years in 2095 patients randomized to conservative care with SAQ scores at 1 and 3 months; 78% were men. Twelve-month event rates were 3.3% overall; 2.9% with a 3-month SAQ7-SS ≥75, and 6.9% in those with 3-month scores &lt;50. In unadjusted analyses, higher scores at baseline, 3 months, and greater 3-month improvement were associated with fewer clinical events (Figure 1a). In landmark analyses combining serial scores, neither baseline nor change were significant after adjustment for 3-month score (Figures 1b and 1c). Conclusions: We found that the most recent SAQ score was more predictive of subsequent clinical events than prior scores or changes. Following patients’ health status not only provides an assessment of their current angina control, but also a continuously updatable insight into their risk for subsequent cardiac events.

Abstract 11355: Contemporary Patterns of Lipoprotein(a) Testing and Associated Clinical Care and Outcomes

Introduction: Elevated lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular disease (ASCVD), yet little is known about Lp(a) testing patterns in real-world practice. We hypothesized that Lp(a) testing occurs in a different population than calculated low density lipoprotein (LDL-C) testing alone, and that elevated Lp(a) is associated with greater lipid-lowering therapy (LLT) initiation and cardiovascular (CV) events. Methods: We used data from 11 health systems participating in the National Patient-Centered Clinical Research Network. We created two cohorts based on lab tests from Jan 1, 2015 to Dec 31, 2019: 1) the Lp(a) cohort, of adults with an Lp(a) test and 2) the LDL-C cohort, of 4:1 date- and site-matched adults with an LDL-C test, but no Lp(a) test. We used logistic regression to assess the relationship between Lp(a) levels (&lt; 50, 50-100, and &gt; 100mg/dL) and initiation of LLT within 3 months; and cox proportional hazards to evaluate Lp(a) levels and time to all-cause hospitalization and the composite of MI, revascularization and ischemic stroke hospitalization. Results: Overall, 20,551 patients (0.06% per year) had Lp(a) tests, with median Lp(a) value 17.5mg/dL (Q1, Q3: 7.0, 56.0). Compared with the LDL-C cohort (N=82,204), the Lp(a) cohort more frequently had ASCVD (24.3% vs. 8.5%) or multiple prior CV events (8.6% vs. 2.6%). Elevated Lp(a) was associated with greater odds of LLT initiation (Figure 1). Elevated Lp(a) was not significantly associated with all-cause hospitalization; however, Lp(a) &gt; 100mg/dL was correlated with composite CV hospitalization compared with Lp(a) &lt; 50mg/dL [adj HR (95% CI): 1.24 (1.06-1.44), p=0.006]. Conclusions: Lp(a) testing occurs more often in adults with ASCVD and multiple CV events, but testing is infrequent. Elevated Lp(a) was associated with LLT initiation, including niacin, despite lack of evidence of CV benefit. There was an association between elevated Lp(a) and CV hospitalization outcomes.

Serum cortisol as a predictor for posttraumatic stress disorder symptoms in post-myocardial infarction patients

BackgroundAfter an acute myocardial infarction (MI22MI: myocardial infarction), patients may develop posttraumatic stress disorder (PTSD33PTSD: posttraumatic stress disorder). There is evidence for alterations in the hypothalamic–pituitary–adrenal axis in PTSD. An association between patients` cortisol level after experiencing an MI and subsequent PTSD symptoms has not been investigated yet. Therefore, the aim of this study was to examine whether serum cortisol measured in patients admitted to hospital for acute coronary care after MI is predictive of PTSD symptoms at three and 12 months post-MI, respectively. MethodsPatients (N=106) with a verified MI and high risk for the development of MI-induced PTSD symptoms were included in the study within 48 hours of hospital admission for acute coronary intervention. Serum cortisol was measured from fasting venous blood samples the next morning. Hierarchical regression analysis was used to test for an independent contribution of cortisol levels from admission to the Clinician-Administered PTSD Scale sum score three and 12 months after discharge from the coronary care unit. ResultsHierarchical regression analysis showed that lower serum cortisol levels were significantly associated with more severe PTSD symptoms three months (B=-0.002, p=0.042) and 12 months (B=-0.002, p=0.043) post-MI. LimitationsThe generalizability of the findings is limited to patients with high acute peri-traumatic distress and without an acute severe depressive episode. The study does not provide any information about the diurnal cortisol pattern. ConclusionLower serum cortisol measured during MI hospitalization may predict more severe MI-induced PTSD symptoms three and 12 months after hospital discharge.

Applicability of the REDUCE-IT trial to the FAST-MI registry. Are the results of randomized trials relevant in routine clinical practice?

The REDUCE-IT data revealed robust CVD reduction with a strategy comprising of high dose omega-3 icosapent ethyl. In order to evaluate the applicability of REDUCE-IT, we applied the inclusion and exclusion criteria in the French Registry on Acute ST- elevation and non-ST-elevation Myocardial Infarction (FAST-MI). We included patients over 45 years, who had detailed lipid values 11.1 months after hospitalization for MI. We compared the applicability of REDUCE-IT [TG between 150 and 500 mg/dl and an LDL-C between 40 and 100 mg/dl while treated with statin therapy] in the FAST-MI registry. 12.5% of the patients met the eligibility criteria for REDUCE-IT. The differences between the REDUCE-IT like and REDUCE-IT excluded samples were related to age, male gender, body mass index, current smoking, hypertension, and the percentage of diabetic patients. In the REDUCE-IT like sample, the mean values of total cholesterol, TG (median) and the HDL-C were respectively 159, 192, 43 and the LDL-C value was 72 mg/dl. The distribution of the statin regimens in the REDUCE-IT like sample was as follows: 65.3%, 32.4% and 2.3% had high, moderate and low intensity statin therapy. The distribution of TG categories in the REDUCE-IT like sample was as follows: 55.3% (150-199), 36.0% (200-299) and 8.7% (300-500 mg/dl). The subgroup with TGs greater than 200 mg/dl and HDL-C less than 35 mg/dl was 16.1% in the REDUCE-IT like group and 2.1% in the REDUCE-IT excluded group ( P < 0.001). The cardiovascular event rate (death, nonfatal MI, nonfatal stroke) was respectively 36.7 for the FAST-MI REDUCE-IT like group and 36.9 per 1000 persons-years (CVD death, nonfatal MI, nonfatal stroke) for the REDUCE-IT trial. If the results of REDUCE-IT are applied to patients hospitalized for a myocardial infarction in France, on top of statins, 12.5% of these patients could benefit from a strategy of high dose omega-3 icosapent ethyl.

Abstract 16428: An On-Treatment Comparative Effectiveness Analysis of Ticagrelor vs Clopidogrel in US Real-world Setting

Background: Current guidelines recommend ticagrelor over clopidogrel as part of DAPT regimen for ACS treatment. However, real-world head-to-head assessment of ticagrelor and clopidogrel has been methodologically challenging due to prescribing patterns and adherence. Thus, we conducted an on-treatment comparative analysis utilizing a large national payer data within US. Methods: A retrospective cohort study of ACS patients discharged on ticagrelor or clopidogrel between January 1, 2012 to September 30, 2019 was conducted utilizing the Optum TM Clinformatics TM data. Patients were required to have twelve months of continuous enrollment prior to the ACS event and a fill of their index prescription within 30 days of discharge. Hospitalization for MI and major bleeding were evaluated pre and post propensity score matching on demographic and clinical covariates (Table 1). Study outcomes were ascertained from day 31 until outcome of interest, switch from or discontinuation of index prescription or day 365. Results: Of 339,387 ACS patients, 14,110 ticagrelor and 57,482 clopidogrel treated patients met the study criteria. Prior to matching, MI hospitalization were significantly lower in the ticagrelor compared to the clopidogrel group (2.2 vs. 4.1 per 100 patient years; 47.3% RRR, p &lt; 0.001). Similarly, in the post-matching population (12,983 ticagrelor, 27,007 clopidogrel), the MI hospitalization rates were 2.2 vs. 3.3 per 100 patient years (33.5% RRR, p &lt;0.001). Hospitalization due to bleeding was 2.1 vs. 2.0 per 100 patient years (-2.7% RRR, p= 0.75 ) in the ticagrelor and clopidogrel patients respectively. Conclusion: In this real world on-treatment analysis, patients who were optimally adherent to ticagrelor post-ACS had significantly fewer MI hospitalization as compared to the clopidogrel cohort. Study findings highlight the importance of being adherent to guideline recommended treatment for better clinical outcomes without the added risk of bleeding.

Impact of timing of randomization after an acute coronary syndrome and subsequent events in patients with type 2 diabetes mellitus: an analysis of the EXAMINE trial

Abstract Background The timing of enrolment following an acute coronary syndrome (ACS) may influence cardiovascular (CV) outcomes and potentially treatment effect in clinical trials. Using a large contemporary trial in patients with type 2 diabetes mellitus (T2DM) post-ACS, we examined the impact of timing of enrolment on subsequent CV outcomes. Methods EXAMINE was a randomized trial of alogliptin versus placebo in 5380 patients with T2DM and a recent ACS. The primary outcome was a composite of CV death, non-fatal myocardial infarction [MI], or non-fatal stroke. The median follow-up was 18 months. In this post hoc analysis, we examined the occurrence of subsequent CV events by timing of enrollment divided by tertiles of time from ACS to randomization: 8–34, 35–56, and 57–141 days. Results Patients randomized early (compared to the latest times) had less comorbidities at baseline including a history of heart failure (HF; 24.7% vs. 33.0%), prior coronary artery bypass graft (9.6% vs. 15.9%), or atrial fibrillation (5.9% vs. 9.4%). Despite the reduced comorbidity burden, the risk of the primary outcome was highest in patients randomized early compared to the latest time (adjusted hazard ratio [aHR] 1.47; 95% CI 1.21–1.74) (Figure 1). Similarly, patients randomized early had an increased risk of recurrent MI (aHR 1.51; 95% CI 1.17–1.96) and HF hospitalization (1.49; 95% CI 1.05–2.10). Conclusion In a contemporary cohort of T2DM with a recent ACS, early randomization following the ACS increases the risk of CV events including recurrent MI and HF hospitalization. This should be taken into account when designing future clinical trials. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Takeda Pharmaceutical