Incidence Of Acute Cardiac Events Research Articles

P320 AN UNUSUAL CASE SYNCOPE DUE TO SILENT CORONARY VASOSPASM

Abstract Background Variant angina is a condition due to a transient vasospasm of the epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. A non–negligible subset of patients can also experience silent myocardial ischemia, defined as objective documentation of myocardial ischemia in the absence of angina or equivalents. This condition is associated with increased cardiac mortality and incidence of acute cardiac events. Description of the case. A 65–years–old man was admitted to our Emergency Department for syncope. He reported palpitations before the event without chest pain. ECG showed biphasic T waves in V2–V6 (Fig 1A), troponin values were normal. Immediately after admission in our coronary care unit for monitoring, he developed dynamic ST segment elevation with signs of inferior and posterior transmural ischemia (Fig 1B) and non–sustained polymorphic ventricular tachycardias (Fig 2), being symptomatic only for palpitations. ECG abnormalities and symptoms quickly resolved after intra–venous nitrates administration. Coronary angiography was performed showing a critical non–occlusive (85%) fixed stenosis at the proximal right coronary artery (Fig 3 A). The lesion was treated by angioplasty and stenting (Fig 3 B) and the patients was discharged on dual anti–platelet therapy, statins and oral high–dose calcium–channel antagonist. Discussion This case underlines first the importance of searching for high–risk features in patients with syncope of non–obvious origin: our patient reported palpitations and ECG changes consistent with myocardial ischemia (even with normal troponin values and echocardiographic findings). A peculiarity of our case is that the patient did not complaint any chest pain despite the presence of ST elevation, a condition known as silent ischemia. The transient nature of ECG modification and ventricular arrhythmias, their dramatic response to nitrates and coronary angiography findings were suggestive of silent vasospasm. Coronary vasospasm induces transient myocardial ischemia and may cause ventricular arrhythmias which in turn can cause syncope due to transient cerebral hypoperfusion or, when sustained, even cardiac arrest and sudden death. We did not perform provocative test with acetylcholine or ergonovine due to the likely vasospastic origin of myocardial ischemia and to their potential risks, especially in the presence of non–sustained plymorphic ventricular tachycardias.

Short-Term Exposure to Sulfur Dioxide and Nitrogen Monoxide and Risk of Out-of-Hospital Cardiac Arrest.

Over the past decades, particulate matter (PM), especially fine PM <2.5 μm in aerodynamic diameter (PM2.5) has been a major research focus. However, the air pollutant is a mixture of gases or vapour-phase compounds, such as carbon monoxide (C), nitrogen oxides (NOx), photochemical oxidants (Ox), and sulfur dioxide (SO2). Little is known about their cardiovascular effect, individually or in combination with PM. Thus, we aimed to determine the associations between the incidence of acute cardiac events and both gaseous and PM using a case-crossover design. Cardiovascular cases were identified through the Gunma Prefectural Ambulance Activity Database in Japan in 2015 (1,512 out-of-hospital cardiac arrest [OHCA] and 1,002 heart failures from 53,006 ambulance cases). Air quality data from the nearest station was for day of the arrest (lag0) and 1-2 days before the arrest (lag1, lag2) and the moving average across days 0-1 (lag0-1). Conditional logistic regression was used for unadjusted and adjusted analysis for temperature and humidity. Independent associations of OHCA were daily concentrations of SO2 at lag1 (OR 1.173, 95%CI 1.004, 1.370; p=0.044) and lag0-1 (OR 1.203, 95%CI 1.015, 1.425; p=0.033); and daily NO concentrations at lag2 (OR 1.039, 95%CI 1.007, 1.072; p=0.016). The incidence of heart failure was significantly associated with daily concentrations of Ox on the day of the event in univariable model but not after adjustment for temperature and humidity. No associations were found for other pollutants. Short-term exposure to SO2 and NO are associated with an increased risk of OHCA.

Unusual syncope due to silent coronary vasospasm: a case description and an overview of coronary vasospasm

Variant angina is a condition triggered by the transient vasospasm of epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. Among patients with coronary artery vasospasm, a non-negligible subset experiences silent myocardial ischemia, defined as the objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. This condition is associated with the increased cardiac mortality and incidence of acute cardiac events. Herein, we described the case of a 65-year-old man who was admitted to our Emergency Department (ED) for syncope. He reported palpitations before the event but did not complain of chest pain. Baseline electrocardiogram (ECG) showed that troponin values of biphasic T waves in V2-V6 were normal. The patient was admitted to our coronary care unit (CCU) for monitoring. Immediately after hospital admission, he developed dynamic ST segment elevation and non-sustained polymorphic ventricular tachycardia, being symptomatic only for palpitations. Both ECG abnormalities and symptoms quickly resolved after the administration of intravenous nitrates and oral calcium channel blockers. Coronary angiography showed a critical non-occlusive fixed stenosis at the proximal right coronary artery (RCA). The lesion was treated by angioplasty and stenting, and the patient was discharged on dual antiplatelet therapy, statins and oral high-dose calcium-channel antagonist.

Chronic Stress, Exercise and Cardiovascular Disease: Placing the Benefits and Risks of Physical Activity into Perspective.

Chronic stress, which has been exacerbated worldwide by the lingering COVID pandemic, has been strongly linked to cardiovascular disease (CVD). In addition, autonomic dysregulation via sustained sympathetic activity has been shown to increase the risk of arrhythmias, platelet aggregation, acute coronary syndromes and heart failure. Fortunately, effective coping strategies have been shown to attenuate the magnitude of hyperarousal associated with the stress response, including moderate-to-vigorous lifestyle activity and/or structured exercise. A good-to-excellent level of cardiorespiratory fitness also appears to be highly cardioprotective. These beneficial effects have been substantiated by numerous studies that have evaluated the levels of stress reactivity and stress recovery in physically active individuals versus matched sedentary controls, as well as before and after exercise interventions. On the other hand, unaccustomed strenuous exercise in habitually sedentary persons with underlying CVD is associated with a disproportionate incidence of acute cardiac events. Moreover, extreme exercise regimens appear to increase coronary calcification and the likelihood of developing atrial fibrillation. This review summarizes these relations and more, with specific reference to placing the benefits and risks of physical activity into perspective.

Opioid Drug Use and Acute Cardiac Events Among Pregnant Women in the United States

BackgroundCardiovascular disease remains a leading cause of pregnancy-associated deaths in the United States. The extent to which increasing opioid use among pregnant women contributes to fatal cardiovascular events is unknown. We examined trends in opioid use among pregnant women over the previous decade and the association between changes in temporal trends in opioid drug use and the incidence of acute cardiac events among mothers. MethodsIn this retrospective analysis of the Healthcare and Cost Utilization Project, we used a 2-stage stratified cluster sampling of all inpatient hospital discharges from nonfederal hospitals from January 1, 2002 through December 31, 2014. The study population comprised pregnant women aged 13-49 years and related hospitalizations, including delivery. The primary exposure of interest was opioid use during pregnancy. The primary outcome was the occurrence of acute myocardial infarction or cardiac arrest during pregnancy or childbirth. ResultsAmong the estimated 57.4 million pregnancy-related inpatient hospitalizations, 511,469 (approximately 1%) had documented use of opioids, cocaine, and/or amphetamines. There was a 300% increase in the use of opioids during pregnancy over the study period, whereas cocaine consumption significantly decreased and that of amphetamine remained stable. Over the 13-year period, the rise in opioid use paralleled a 50% increase in the incidence of acute cardiac events among mothers. ConclusionOver the previous decade opioid use during pregnancy increased significantly, in parallel with the rise in the incidence of acute cardiac events in pregnancy and childbirth. An effective national policy is needed to address this emerging public health challenge.

Mental stress-induced myocardial ischaemia

### Learning objectives The management of angina is determined by symptoms and cardiovascular risk, together guiding further assessment in order to detect significant underlying coronary artery disease (CAD). The current...

Abstract P4-12-17: Pathological responses and heart safety analysis of trastuzumab and paclitaxel based regimen plus carboplatin or epirubicin as neoadjuvant therapy in clinical stage II-III, HER2-positive breast cancer patients: A phase 2, open-label, multicentre, randomised trial

Abstract Purpose: Neoadjuvant chemotherapy may provide early indication of treatment response. Pathologic complete response (pCR) rate is a surrogate measure of disease-free and overall survival. Anthracycline remain an important component of chemotherapy regimen for breast cancer (BC), while adding taxane confers additional pCR rate. However the combination of anthracycline and trastuzumab remain controversial due to potential increased risk of cardiac event. This trial was designed to compare the efficacy and safety between epirubicin(E) and carboplatin(C) in combination with paclitaxel(P) and trastuzumab(H). Methods: In 13 medical centers, 100 Patients with HER-2/neu immunohistochemistry (IHC) 3+ or FISH-amplified untreated breast cancer, baseline left ventricular ejection fraction (LVEF) of ≥ 55%, ECOG0/1, were enrolled from Sep 2011 to May 2012. Study medication was as follows: Trastuzumab (4 mg/kg loading dose followed by 2 mg/kg) and Pacitaxel (75 mg/m2) weekly combine with Carbopatin (AUC 2) weekly for PCH group or Epirubicin(75 mg/m2) every 3 weeks for PEH group. Patients were recommended to receive 4 or more cycles. The primary endpoint was pCR in the breast and axilla. Secondary endpoints included clinical response, safety. Results: By Aug 16, 2012, 50 patients were randomly assigned to receive PCH regimen and 50 to receive PEH regimen. 49 belonged to TNM stage II, 51 belonged to TNM stage III. The median age was 48 years (range 29 to 65 years). 87 patients completed at least 4 cycles neoadjuvant therapy and then received surgical treatment. pCR in the breast/axilla were found in 38 patients (43.7%; 95% confidence interval [CI]: 33.3%-54.1%). There was no statistic significant difference in PCH and PEH regimen (39.1% vs. 48.8%; p = 0.365). However, PEH regimen achieved significant higher pCR in luminal-B (HER2-poitive) subgroup compared with PCH regimen (55.0% vs. 24.0%; p = 0.033), but not in ERBB2+ subgroup (42.9% vs. 57.1%; p = 0.355). Median LVEF at baseline was 66.0% (range 56.5% to 83.0%), having was no difference between PCH and PEH group (67.0% vs. 65.0%). After 2 cycles in 82 patients, the median LVEF was 64.7% (range 55.0% to 84.0%), there was no difference of LVEF (63.0% vs.66.0%). After 4 cycles in 80 patients, the median LVEF was 66.0% (range 53.0% to 76.0%), no difference was observed between PCH and PEH group (63.0% vs. 66.2%). 8 patients had LVEF decreases of over 10% after 2 cycles, of which 5 patients in PCH group and 3 patients in PEH group. After more than 4 cycles, 3 patients in PCH group and 1 patient in PEH group had LVEF decreases of over 10.0% compared with baseline. No patient experienced LVEF of less than 50% and congestive heart failure (CHF). There was no cardiac death reported. Conclusion: Both PCH and PEH regimens as neoadjuvant chemotherapy have the similar pCR rate for breast cancer patients with HER2-overexpression. PEH might improve the possibility of eradicating invasive cancer in the breast and axilla, especially in the luminal-B (HER2-positive) subtype. PEH is feasible and is not likely to increase the incidence of acute cardiac events compared to PCH. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-17.

Acute cardiac events and deployment of emergency medical teams and automated external defibrillators in large football stadiums in the Netherlands

The incidence of acute cardiac events - including out-of-hospital cardiac arrest - may be increased in visitors of large sports stadiums when compared with the general population. This study sought to investigate the incidence of acute cardiac events inside large Dutch football stadiums, as well as the emergency response systems deployed in these stadiums and the success rate for in-stadium resuscitation. Retrospective cohort study using a questionnaire sent to the 20 Dutch stadiums that hosted professional matches during the 2006-2007 and 2007-2008 football seasons. Stadium capacity ranged from 3600 to 51 600 spectators. Nearly 13 million spectators attended 686 'Eredivisie' (Honorary Division) and European football matches. All stadiums distribute multiple emergency medical teams among the spectators. Eighty-five percent of the stadiums have an ambulance standby during matches, 95% of the stadiums were equipped with automated external defibrillators (AEDs) during the study period. On an average, one AED was available for every 7576 spectators (range 1800-29 600). Ninety-three cardiac events were reported (7.3 per 1 million spectators). An AED was used 22 times (1.7 per 1 million spectators). Resuscitation was successful in 18 cases (82%, 95% confidence interval: 61-93). The incidence of out-of-hospital cardiac arrest inside large football stadiums in the Netherlands, albeit increased when compared with the general population, is low. The success rate for in-stadium resuscitation by medical teams equipped with AEDs is high. Dutch stadiums appear vigilant in regard to acute cardiac events. This report highlights the importance of adequate emergency medical response systems (including AEDs) in large sports venues.

Atorvastatin Efficacy in the Prevention of Cardiovascular Events in Patients with Diabetes Mellitus and/or Metabolic Syndrome

Several large-scale clinical trials have assessed the efficacy of atorvastatin in the primary and secondary prevention of cardiovascular events in patients with diabetes mellitus and/or metabolic syndrome. In primary prevention, CARDS (Collaborative Atorvastatin Diabetes Study) showed that atorvastatin 10 mg/day (vs placebo) reduced relative risk of the composite primary endpoint (acute coronary heart disease [CHD] events, coronary revascularisation, or stroke) by 37% (p = 0.001). This decrease was similar to decreases in major cardiovascular events in the ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm) trial and HPS (Heart Protection Study). However, in CARDS, atorvastatin efficacy was evident as early as 6 months after starting treatment, whereas in HPS, simvastatin efficacy was noticeable only from about 15-18 months after starting treatment. In the ASCOT-LLA trial, in 2226 hypertensive diabetic patients without previous cardiovascular disease, atorvastatin (vs placebo) reduced the relative risk of all cardiovascular events and procedures by 25% (p = 0.038). In secondary prevention, substudies of the GREACE (GREek Atorvastatin and Coronary-heart-disease Evaluation), TNT (Treating to New Targets) and PROVE-IT (PRavastatin Or atorVastatin Evaluation and Infection Therapy) trials reported results for the approximately 15-25% of study participants who had diabetes. In the GREACE substudy, atorvastatin (vs physicians' standard care) significantly reduced the relative risk of total mortality by 52% (p = 0.049), coronary mortality by 62% (p = 0.042), coronary morbidity by 59% (p < 0.002) and stroke by 68% (p = 0.046). In the TNT substudy, incidence of the primary endpoint was significantly lower in diabetic patients treated with atorvastatin 80 mg/day rather than 10 mg/day (13.8% vs 17.9%; relative risk 0.75; p = 0.026). In the PROVE-IT substudy, a significantly lower incidence of acute cardiac events was reported for atorvastatin versus pravastatin recipients (21.1% vs 26.6%; p = 0.03) and, therefore, an absolute risk reduction of 5.5% was associated with atorvastatin therapy. ASPEN (Atorvastatin Study for Prevention of coronary heart disease Endpoints in Non-insulin-dependent diabetes mellitus) - a mixed primary and secondary prevention trial in diabetic patients - found that a 29% lower low-density lipoprotein-cholesterol level was seen with atorvastatin than placebo at endpoint (p < 0.0001); however, the reduction in composite primary endpoint of major cardiovascular events (cardiovascular mortality, nonfatal major cardiovascular event or stroke, and unstable angina requiring hospitalisation) with atorvastatin (13.7% vs 15.0% with placebo), and reduction in acute myocardial infarction relative risk of 27% with atorvastatin were not statistically significant. In CHD patients with metabolic syndrome (n = 5584) in a sub-analysis of the TNT trial, intensive versus lower-dosage atorvastatin therapy reduced the relative risk of major cardiovascular and cerebrovascular events by 29% (p < 0.0001). The analysis also revealed that CHD patients with, rather than those without, metabolic syndrome had a 44% greater level of absolute cardiovascular risk, thus clearly underscoring the clinical feasibility of administering intensive lipid-lowering therapy to CHD patients with metabolic syndrome. In summary, several patient populations, from definitive, large-scale studies, are now available to corroborate the integral place of atorvastatin--in line with various regional and internationally accepted disease management guidelines--in the primary and secondary prevention of cardiovascular events in patients with diabetes and/or metabolic syndrome.

Inhalation of concentrated ambient air particles exacerbates myocardial ischemia in conscious dogs.

Short-term increases in ambient air pollution have been associated with an increased incidence of acute cardiac events. We assessed the effect of inhalation exposure to concentrated ambient particles (CAPs) on myocardial ischemia in a canine model of coronary artery occlusion. Six mongrel dogs underwent thoracotomy for implantation of a vascular occluder around the left anterior descending coronary artery and tracheostomy to facilitate particulate exposure. After recovery (5-13 weeks), pairs of subjects were exposed for 6 hr/day on 3 or 4 consecutive days. Within each pair, one subject was randomly assigned to breathe CAPs on the second exposure day and filtered air at other times. The second subject breathed CAPs on the third exposure day and filtered air at other times. Immediately after each exposure, subjects underwent 5-min coronary artery occlusion. We determined ST-segment elevation, a measure of myocardial ischemia heart rate, and arrhythmia incidence during occlusion from continuous electrocardiograms. Exposure to CAPs (median, 285.7; range, 161.3-957.3 microg/m3) significantly (p = 0.007) enhanced occlusion-induced peak ST-segment elevation in precordial leads V4 (9.4 +/- 1.7 vs. 6.2 +/- 0.9 mm, CAPs vs. filtered air, respectively) and V5 (9.2 +/- 1.3 vs. 7.5 +/- 0.9 mm). ST-segment elevation was significantly correlated with the silicon concentration of the particles and other crustal elements possibly associated with urban street dust (p = 0.003 for Si). No associations were found with CAPs mass or number concentrations. Heart rate was not affected by CAPs exposure. These results suggest that exacerbation of myocardial ischemia during coronary artery occlusion may be an important mechanism of environmentally related acute cardiac events.

924-118 The January 17,1994 Los Angeles Earthquake as a Trigger for Acute Myocardial Infarction

The January 17, 1994 Los Angeles earthquake (EQ) provided a unique opportunity to examine the effect of extensive environmental disaster associated with tremendous emotional stress on the incidenCe of acute cardiac events. We surveyed 75 coronary care units (CCUs) in Southern California comparing the number of admissions for myocardial infarction (MI), unstable angina (UA), total CCU admissions and related in-hospital mortality in the week before (Jan 10–16) and after (Jan 17–23) the EQ. Five CCUs were excluded because of insufficient data. The relative risk for MI following the EQ was assessed in a subgroup of 29 CCUs that were able to provide data on the equivalent period in 1993. Total number of pts (average number ± SD per CCU): cases Week Before Week After p Value MI 147 (2.1 ± 2.7) 195 (2.9 ± 3.1) 0.01 UA 255 (3.6 ± 5.2) 273 (3.9 ± 5.2) 0.39 Total CCU pts 1096 (15.7 ± 13.2) 1174(16.8 ± 13.2) 0.18 The % of CCU admissions for Ml increased in the week following the EQ [195 of 1174 (16.6%) vs. 147 of 1096 (13.4%); P = 0.04]. The % of CCUs reporting increased number of MIs was higher in hospitals located within 15 miles of the EQ epicenter vs. hospitals located &gt; 15 miles [11 of 14 (79%) vs. 23 of 56(41%); p = 002]. In-hospital mortality (%) was similar for Ml and UA pts in the week before and after the EQ (Ml: 7% vs. 6%; UA: 1% vs. 0%, respectively). In comparison to 1993 (subgroup of 29 CCUs), there was a significant increase in the risk of developing MI in the week following the EQ vs. the week before (1994: 70 vs. 41 pts; 1993: 49 vs. 68 pts, respectively; odds ratio 2.4, 95% confidence interval 1.4 – 4.0). 1) Our data indicate a significant increase in the incidence of Ml but not UA or in hospital mortality in the week following the EQ. 2) Our observation supports the concept that a stressful event can trigger acute MI.

990-52 Long-term Prognostic Significance of Treadmill Ischemia in “Low-risk” Patients with Coronary Artery Disease

Patients with stable single or 2-vessel coronary artery disease (CAD) and normal, or mildly depressed left ventricular function have a good prognosis. We have investigated the long-term prognostic significance of a positive exercise test (ExTestl in this population to establish whether it is useful in identifying a “high-risk” subgroup within a recognised “low-risk” population. Between 1987–94, 162 patients with documented single (n = 89) or double (n = 73) vessel CAD (exclUding left main and proximal left anterior descending CAD), left ventricular ejection fraction &gt;35% (mean 51%, range 36–72%) on radionuclide ventriculography, and an interpretable ExTest were assigned to receive medical therapy. There were 123 males and 39 females (mean age 60 yrs). A positive ExTest for ischemia was present in 104 (64%) pts. Pts were followed for a mean period of 49 months (range 6–82 months), during which time 34 (21%) had cardiac events (cardiac death n = 3, myocardial infarction (AMI) n = 14, unstable angina n = 6, elective revascularisation n = 11). Similar proportion of pts with a positive ExTest and a negative ExTest suffered cardiac events (all events, including revascularization) during follow-up (21% and 20.7% respectively). Kaplan Meier survival analysis demonstrated no difference between the groups. Survival analysis also failed to demonstrate any difference in the incidence of acute cardiac events (cardiac death and AMI) between positive and negative ExTest groups; of 15 events, 6 (40%) occurred in those with a positive Extest. Pts with 2-vessel disease suffered significantly more events than those with I-vessel disease (29% vs 14.6%, P &lt; 0.05), but there was no difference in acute events (cardiac death and AMI) between the two subsets. Even in pts with 2-vessel disease, there was no difference in survival in those with and without a positive ExTest. The data indicate that although detection of ischemia by exercise testing is useful as an initial diagnostic tool, once the coronary anatomy and left ventricular function are known, the presence of ischemia on treadmill exercise is of limited prognostic value in “low-risk” pts with stable CAD. These findings are consistent with reports demonstrating that acute cardiac events often result from plaque rupture in non-significantly stenosed vessels.

Acute cardiac effects of 'SCUD' missile attacks on a civilian population.

The 'SCUD' raids on Israel during the Gulf War afforded a rare opportunity to examine the effect of mass acute fear on the cardiac health of the general population. Press reports suggested an alarming rise in cardiac deaths during the first missile raids. In order to ascertain this statement, we examined the Emergency Room records of a community hospital in the affected area and all the death certificates in the local region. The periods studied were from 1 January to 28 February 1991, and the equivalent weeks in 1990. The Emergency Room records showed that there was an increased rate of cardiac complaints throughout the war, most marked during the first week. However, this was not accompanied by an increased cardiac mortality, either in the hospital or in the region as a whole, except during the first week. A similar increase in cardiac mortality occurred during the same week the previous year. The increased incidence of acute cardiac events during the first week of the war was probably a coincidence, and not a direct consequence of mass fear. Panic, occasioned by press reports, may have led to a lower threshold of referral which persisted throughout the war.