Hospitalization For Infarction Research Articles

Acute myocardial infarction in the Covid-19 era: incidence, clinical characteristics and in-hospital outcomes – a multicenter registry

Abstract Background A reduction in acute myocardial infarction (AMI) hospitalizations during the coronavirus pandemic has been previously documented. We aimed to describe the characteristics and in-hospital outcomes of AMI patients during the Covid-19 era compared to a recent previous registry. Methods We conducted a prospective, multicenter, observational study involving 13 intensive cardiac care units (ICCUs) to evaluate consecutive AMI patients admitted throughout an 8-week period during the Covid-19 outbreak. Data were compared to the corresponding period in 2018 using an acute coronary syndrome survey conducted in all ICCUs in Israel. The primary end-point was defined as a composite of sustained ventricular arrhythmia, pulmonary congestion, and/or in-hospital mortality. Results The study cohort comprised 1466 patients, of whom 774 (53%) were hospitalized during the Covid-19 outbreak. Overall, 841 patients were diagnosed with ST-elevation MI (STEMI): 424 (50.4%) during the Covid-19 era and 417 (49.6%) during the parallel period in 2018. No differences were detected in the admission rate of patients between the two study periods. STEMI patients admitted during the Covid-19 period tended to have fewer co-morbidities, but a higher Killip class (p value = 0.03). The median time from symptom onset to reperfusion was extended from 180 minutes (IQR 122–292) in 2018 to 290 minutes (IQR 161–1080, p<0.001) in 2020. Hospitalization during the Covid-19 era was independently associated with an increased risk of the combined endpoint of heart failure, malignant arrhythmia, or death in the multivariable logistic regression model (OR 1.63, 95% CI 1.02–2.65, p value = 0.05). Conclusion While the admission rate of AMI and STEMI in Israel remained similar during both the Covid-19 era and the corresponding period in 2018, total ischemic time extended significantly during the Covid-19 period, which translated into a more severe disease status upon hospital admission, and a higher rate of in-hospital adverse events. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by a grant from a Fefer foundation for medical research

Long-term outcomes in patients with left bundle branch block after transcatheter aortic valve replacement

Abstract Introduction New-onset persistent left bundle branch block (NOP-LBBB) is one of the most common complications after transcatheter aortic valve replacement (TAVR). The impact that this conduction disorder may have on the cardiovascular events during the follow-up of these patients remains unclear. Objective The main goal was to assess the prognosis of TAVR recipients that develop persistent LBBB after TAVR, evaluating long-term outcomes. Methods A cohort study was conducted. Consecutive patients undergoing TAVR from January 2012 to December 2020 were included. NOP-LBBB was defined as a new LBBB occurring during the hospitalization period after the TAVR procedure that persisted at hospital discharge. Patients were divided into 2 groups according to whether they had a NOP-LBBB. Patients carrying a pacemaker before the procedure and those who already presented LBBB were excluded. MACE (major adverse cardiovascular events including cardiovascular death, myocardial infarction, cerebrovascular accident and heart failure hospitalization) as primary outcome was searched. Results A total of 254 patients were included with a median age of 81.07 years (77.73–86.22). 77% TAVR patients received self-expanding prosthesis. 21.57% of our cohort presented NOP-LBBB and 29% of this group required a pacemaker. We reported a single case of prosthesis dysfunction, in a patient of the NO-LBBB group. Global baseline characteristics and long term events at follow-up according to the occurrence of LBBB are summarized at figure 1. Patients in both groups were statistically comparable. At a median of 21.3 (8.52–38.94) months of follow-up, a higher incidence of syncope was found among the patients with NO-LBBB, reaching the statistical significance. There were no significant differences between groups regarding cardiovascular mortality (OR 1.48 95% CI: 0.36–4.00 p=0.41). NOP-LBBB group showed higher rates of heart failure hospitalization (OR 1.95 95% CI: 0.98–3.9 p=0.057) NOP-LBBB was associated with an increased risk of MACES at follow-up (27.72% vs 17.54%; adjusted HR: 1.77 95% CI 1.02–3.06, p 0.04). Survival curves are displayed in figure 2. Conclusions Developing LBBB after TAVR seems to lead to more cardiovascular events, with a significant difference in long- term survival. These data suggest an adverse clinical impact of “de novo” LBBB, highlighting the necessity of a close vigilance of these patients. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Lung comets ultrasound and prediction of one year mortality and chronic ischemic heart faillure

Abstract Background Lung ultrasound can be used to assess pulmonary congestion by imaging B-lines for patients with heart failure after acute coronary syndromes, it is a major risk marker for morbidity and mortality. Purpose The objective of the study is to determine the role of pulmonary B lines in the acute phase of acute coronary syndromes in the prediction of the risk of mortality and chronic ischemic heart failure after 1 year of discharge Methods We conducted a prospective monocentric follow-up study with a minimum follow-up of 1 year for each recruited patient. We included patients over the age of 18 with acute coronary syndromes. 304 consecutive patients underwent clinical examination, echocardiography, and lung ultrasound in the acute phase, independently of, and in addition to routine management by the attending physicians. Results We find in the general population, Killip stage ≥ II in 22.4% of patients, the median B-line count was 5 (0–16).In patients with ≥30 B-lines; we have 17.8% STEMI, 12.7% NSTEMI and 9.3% unstable angina, twelve-month event-free survival for the primary endpoint (all-cause death or heart faillure) was 31.7% in patients with ≥30 B-lines and 68.3% in those with <30 B-lines (P<0.0001), 33.5% of the general population have signs of chronic ischemic heart failure after one year of follow-up, 22.5% with HFpEF and 78.5% with HFrEF, B-lines ≥16 in 58.7% patients with HFrEF and 17.4% with HFpEF, Pulmonary ultrasound B-lines in admission are an independent risk factor for all-cause mortality and chronic ischemic heart failure after 1 year of acute coronary syndrome (HR 1.80; IC 95%=1.48–2.18, p<0.001), Pulmonary comets are also an independent predictor of chronic ischemic HFrEF risk (HR 1.62; IC 95%=1.26–2.07, p<0.001) and of chronic ischemic HFpEF (HR 1.54; IC 95%=1.01–2.37, p=0.04). Discussion With respect to B-line assessment as a prognostic tool at discharge in chronic ischemic HF patients, evidence is scarce, some studies reported that B-lines were associated with a two-fold increase in the rate of death, myocardial infarction, or HF hospitalisation at follow-up. However, in other study the B lines are part of the evaluation variables of an echocardiographic prognostic score as in the Bedetti series, their application as a simple prognostic tool for evaluation is an important contribution to guide management. Conclusion Ultrasonic pulmonary comets are a strong predictor of the residual risk of mortality and chronic ischemic heart failure and allowing a significant prognosis reclassification. Multicenter studies evaluating whether this tool could ultimately guide therapy optimization are warranted. Funding Acknowledgement Type of funding sources: None.

Killip classification and baseline heart rate can be used to predict streptokinase‑induced hypotension in acute myocardial infarction

Streptokinase is the thrombolytic therapy of choice for acute myocardial infarction in hospitals without cardiac facilities. Streptokinase‑induced hypotension is one of the common adverse drug reactions and is usually observed within 30 min of an intravenous streptokinase infusion. The present study aimed to identify predictive clinical parameters for the development of hypotension in patients with acute myocardial infarction. The present retrospective study involved data transcription from National Indicator Approach (NIA) records of acute myocardial infarction recorded between 2015 to 2018. Multivariate analysis was performed to evaluate potential predictors of streptokinase‑induced hypotension and to determine the association between selected clinical variables in patients with streptokinase‑induced hypotension. The present study included a total of 412 patients with acute myocardial infarction administered streptokinase. The majority (n=258, 62.6%) did not develop any complication from the therapy, whereas 109 (26.5%) developed hypotension at 18.5 (interquartile range, 10.00) min from the initiation of therapy. Multiple logistic regression analysis revealed that with every one‑unit increment in the baseline heart rate, the risk of hypotension was reduced by 2.6%. Additionally, patients classified as Killip class III and IV were at an increased risk (5‑fold) of developing hypotension as compared with those classified as Killip I. Therefore, as demonstrated herein, these predictive factors may assist clinicians in identifying susceptible individuals and may encourage vigilance when delivering streptokinase therapy.

Effects of Colchicine on Cardiovascular Outcomes in Patients with Coronary Artery Disease: A Systematic Review and One-Stage and Two-Stage Meta-Analysis of Randomized-Controlled Trials.

Colchicine has received emerging interest due to its cardiovascular benefits in patients with coronary artery disease (CAD). We conducted a one-stage meta-analysis of reconstructed individual patient data (IPD) from randomized-controlled trials to summarize the effects of colchicine on cardiovascular outcomes in patients with CAD. Four databases (PubMed, Embase, Cochrane, SCOPUS) were searched for articles published from inception to 30th September 2020, examining the effect of colchicine on cardiovascular outcomes in patients with CAD, yielding 10 randomized-controlled trials with a combined cohort of 12,781 patients. IPD was reconstructed from Kaplan-Meier curves published in 3 studies and analysed using the shared-frailty Cox model. Aggregate data meta-analysis of all 10 studies was performed for outcomes unsuitable for IPD reconstruction. In patients receiving colchicine compared to placebo, one-stage meta-analysis demonstrated a hazard ratio of 0.70 (95% CI 0.61-0.80) for the composite outcome of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and urgent hospitalization for angina requiring coronary revascularization. Aggregate data meta-analysis demonstrated a significant reduction in hazard rate for stroke (HR 0.45; 95% CI 0.27-0.75) and urgent revascularization (HR 0.59; 95% CI 0.38-0.91); and a relative risk reduction for myocardial infarction (RR 0.72; 95% CI of 0.52-1.00) and post-operative atrial fibrillation (RR 0.64; 95% CI 0.48-0.86). Given the significant benefits of colchicine demonstrated on IPD, and its consistent benefits when analyzed using aggregate data meta-analysis, we propose that colchicine may be considered as an additional pharmacological adjunct to the first line therapy for patients with coronary artery disease.

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.

Associação entre o tempo porta-balão e fatores clínicos com turnos hospitalare

Background: In ST-segment elevation myocardial infarction, the main therapy is early arterial reperfusion, performed by primary percutaneous coronary intervention. The recommended door-to-balloon time is &lt;90 minutes. The objective of this study was to associate the door-to-balloon time and clinical factors with hospital shifts. Methods: This was a cross-sectional observational study, part of the Catarina Heart Study. We analyzed patients diagnosed with ST-segment elevation myocardial infarction in hospitals of the metropolitan area of Florianópolis, from 2016 to 2020. The qualitative variables were analyzed using the Chi-square test, and the quantitative variables were analyzed using the Student’s t test and Mann-Whitney test. Results: A total of 318 patients were analyzed, with a mean age of 58.7±11.4 years, predominantly male (71.7%) and hypertensive (53.7%). The median door-to-balloon time was significantly lower in the group seen on weekdays compared to the group seen on weekends, respectively, 71.0 (51.0-126.0) minutes and 91.0 (71.0-123.0) minutes (p=0.028). There was no difference in the door-to-balloon time in the night shift and in off-hours. Individuals undergoing primary percutaneous coronary intervention during the night shift showed a non-significant tendency for higher mortality rates from any cause (1.9%) compared to those seen during the day shift (0.0%; p=0.057). Conclusion: Patients with ST-segment elevation myocardial infarction seen on weekdays have shorter door-to-balloon time.

Abstract 15436: Left Ventricular Ejection Fraction and MACE in Women With Signs and Symptoms of Ischemia: Data From the WISE (Women's Ischemia Syndrome Evaluation)

Background: Relatively high left ventricular ejection fraction (EF) (&gt;65%) in women was recently associated with higher all-cause mortality over 6 years follow-up in the CONFIRM study. We sought to evaluate high EF and major adverse cardiovascular events (MACE) in the Women’s Ischemia Syndrome Evaluation (WISE) study. Methods: The WISE original cohort (enrolled 1996-2000) is a multicenter prospective study of women with suspected ischemic heart disease undergoing clinically indicated invasive coronary angiography. We investigated the relationship between high (&gt;65%) and normal (55-65%) EF and MACE, defined as all-cause death, nonfatal myocardial infarction (MI), stroke and heart failure (HF) hospitalization using Kaplan Meier (KM) and regression analyses. Results: A total of 653 women were included (298 high and 355 normal EF). Mean age was 58±11 years and mean EF was 68±7%. There was no significant difference in MACE by EF group over a 10-year follow-up period (log rank p=0.54, Figure ). When patients were stratified by the presence of obstructive CAD, MACE rates remained similar between high and normal EF. High EF was not associated with stroke or HF but had a lower MI risk (log rank p=0.03, Table ). EF was not associated with MACE in a multivariable regression model. Conclusions: Among women presenting with evidence of ischemia, there was no significant difference in MACE between high and normal EF groups. High EF was associated with a lower risk of myocardial infarction as an individual component of MACE.

Abstract 13611: Prognostic Value of Shock Index in Patients Admitted With Non ST-Segment Elevation Myocardial Infarction: The ARIC Study Community Surveillance

Introduction: Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and has been reported to predict all-cause mortality in acute myocardial infarction (AMI) hospitalizations, primarily among patients with STEMI. Large-scale investigations examining the prognostic value of SI in patients with NSTEMI are lacking. Methods: Hospitalizations for acute myocardial infarction were sampled from 4 US areas by the ARIC Study and classified by physician review. HR and SBP at first presentation were abstracted from the medical record. Pulseless patients, those with unobtainable SBP, and transfer patients were excluded. An SI value ≥0.7 was considered high. The TIMI risk score for NSTE-ACS was calculated using the established algorithm. Predictions of all-cause 28-day mortality were analyzed using receiver operating characteristics (ROC). Results: From 2000-2014, 18,301 weighted hospitalizations for NSTEMI patients were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs 39%) and older (65 vs 63 years), with more prevalent chronic kidney disease (40% vs. 32%), pneumonia (16% vs 8%), and complication by acute heart failure (42% vs 30%). However, the TIMI risk score was comparable for the 2 groups (4.3 vs. 4.2). Angiography (36% vs 58%), revascularization (19% vs 41%), and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was nearly 3 times higher (13% vs 5%). Continuous values of SI were more predictive of 28-day mortality than the TIMI risk score, both overall (ROC-AUC: 0.68 vs 0.54; P &lt;0.0001) and among the subset of patients who were revascularized (ROC-AUC: 0.72 vs. 0.56; P &lt;0.0001). Conclusion: The SI outperformed the TIMI risk score for prediction of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.

Abstract 15686: Early Intervention versus Conservative Management for Asymptomatic Severe Aortic Stenosis: An Updated Systematic Review and Meta-analysis

Introduction: The management of asymptomatic severe aortic stenosis (AS) is controversial and guidelines for the management of the same is not updated based on recently available evidence. Hypothesis: The main objective is to determine the optimal strategy for the management of asymptomatic severe AS between early intervention versus conservative management. Methods: We performed a systematic electronic search of the PubMed and Cochrane databases from the inception of the database to May 31 st , 2020. We used the Mantel Haenszel method with the Paule-Mandel estimator of Tau 2 and Hartung-Knapp adjustment to calculate relative risk (RR) with a 95% confidence interval (CI) and 95% prediction interval (PI). We used P curve analysis to assess publication bias and estimate the true effect of an intervention. All analysis was carried out using R version 3.6.2. Results: A total of seven studies were included in the final analysis, consisting of 1213 patients with early intervention and 2601 patients with conservative management. Early intervention as compared to conservative management was associated with reduced risk of all-cause mortality (RR: 0.32, 95% CI: 0.21-0.48) (Panel A) , cardiac mortality (RR: 0.36, 95% CI: 0.27-0.48) (Panel B) and non-cardiac mortality (RR: 0.40, 95% CI: 0.28-0.56) (Panel C) . There was no difference in the risk of sudden cardiac death (RR: 0.46, 95% CI: 0.15-1.40), stroke (RR: 0.79, 95% CI: 0.17-3.64), myocardial infarction (RR: 0.44, 95% CI: 0.01-16.82) or heart failure hospitalization (RR: 0.18, 95% CI: 0.01-5.29) between the groups. The pooled estimate for all the outcomes was associated with low-moderate heterogeneity. Conclusions: Among asymptomatic severe AS patients, early intervention is associated with reduced mortality without increasing any procedure-related clinical outcomes. Hence, this meta-analysis supports early intervention as opposed to watchful waiting for the management of asymptomatic severe AS.

Abstract 16587: More Than Five Years After FDA Approval, There Remains Very Limited Adoption of New Evidence-Based, Highly Effective Medications for the Treatment of Patients With Heart Failure, Especially Among Those on Medicare

Background: Over the past decade, the FDA has approved several new medications that are highly effective when added to existing standard therapy in the treatment of heart failure with reduced ejection fraction (HFrEF). It is possible that, despite the presence of substantial evidence regarding the clinical effectiveness of these new medications, their high cost and the complex medical reimbursement system in America may prevent their routine adoption. Methods: We analyzed 5,824 Intermountain Healthcare patients, age ≥18 years with a new clinical diagnosis of HFrEF (LVEF ≤35%), from 1/1/2015 onward, for the use of newly-approved sacubitril/valsartan or any sodium-glucose cotransporter-2 inhibitor (SGLT2-I). We collected baseline characteristics and medication utilization data. We followed the patients for 1.7±1.4 years for future major adverse cardiovascular events (MACE), including death, myocardial infarction (MI), stroke, and heart failure hospitalization (HFH). We identified differences between groups by multivariable Cox regression analysis. Results: Baseline characteristics and incidence of MACE, according to insurance status and the use of common HFrEF medications, are shown in the Table. Overall, only 344 (5.9%) and 169 (2.9%) of patients ever received a prescription for sacubitril/valsartan or an SGLT2 inhibitor, respectively. The figures show survival curves for MACE of patients receiving or not receiving the newly-approved medications. Conclusion: In this large, modern, real-world HFrEF population, the adoption of newly-approved evidence-based HFrEF medications is minimal in all patients and especially in Medicare patients. This lack of adoption is associated with a significant worsening in patient outcomes. These findings demonstrate a critical need to resolve our present healthcare financial crisis, which is almost certainly the reason for these findings.

Cardiovascular magnetic resonance to predict clinical outcome in chronic total coronary artery occlusion

Abstract Background Chronic total coronary artery occlusions (CTOs) are present in approximately 20–30% of patients undergoing invasive angiography. Despite their prevalence, the optimum management strategy of CTOs remains uncertain. A potential limitation in published trials of CTO revascularisation is their failure to incorporate systematic assessment of ischaemia/viability in informing revascularisation decisions. Aim We sought to determine the prognostic utility of ischaemia/viability assessment by cardiovascular magnetic resonance (CMR) in a large, contemporaneous, real-world CTO population. Methods We retrospectively studied consecutive adult patients with≥1angiographically identified CTO who were referred for clinical CMR imaging during a consecutive 8-year period in our centre (2010–2018). Multi-parametric CMR comprised functional assessment, adenosine-stress perfusion and scar imaging. For perfusion assessment, images were analysed qualitatively with a concurrent examination of scar images. Myocardial segments were assigned to CTO or non-CTO territories according to standard criteria, taking into account coronary dominance. Significant ischaemia was defined as ≥10% and/or ≥2 contiguous myocardial segments with hibernation. Angiographic collateral flow to the CTO territory was graded using the Rentrop classification and the Collateral Connection (CC) Score. Significant CAD in non-CTO vessels was defined angiographically as ≥50% stenosis in any epicardial coronary artery/branch with diameter ≥2mm. The composite clinical endpoint comprised all-cause mortality, myocardial infarction and heart failure hospitalisation. Results From a total of 27,201 invasive angiograms performed during the study period, 389 patients were diagnosed with CTO and underwent CMR imaging (mean age 65.0±11.0 years, 84% male). CTO was present most frequently in the right coronary artery (59% of subjects, 229/389), with left circumflex (LCx) artery involvement in 29% (112/389) and left anterior descending (LAD) artery in 29% (111/389). Collaterals with CC grade ≥2 were identified in 186 subjects (48%), and Rentrop score ≥2 in 300 (77%). Significant ischaemia was present in 61% of patients, and infarction in 71% (median infarction 8.6% [interquartile range (IQR) 4.5–14.1]. With a median follow-up time of 3.30 years [IQR 0.04–8.64], 65 (17%) met the composite endpoint. On multivariate analysis, neither significant ischaemia nor infarction was associated with the composite endpoint. However, non-CTO territory ischaemia was independently predictive of adverse outcome (hazard ratio 1.93; 95% CI 1.16–3.21; p=0.0113). Conclusion CTO-territory ischaemia and infarction are not predictive of adverse clinical outcome, challenging the assertion that CTO revascularisation may be guided by ischaemia assessment. The finding that non-CTO territory ischaemia is associated with adverse cardiovascular events warrants further investigation. Kaplan-Meier curves_CTO Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

2-OR: Impact of N Terminal Pro B-Type Natriuretic Peptide and High Sensitivity Cardiac Troponin on the Prediction of Death and Cardiovascular Events in High-Risk Patients with Type 2 Diabetes

We assessed the relative contributions of N-terminal pro-B-type natriuretic peptide (NTBNP) and high sensitivity cardiac troponin (hsTnT) to the prediction of death and cardiovascular (CV) events in 5597 (with complete data) of 8561 patients with type 2 diabetes (T2DM) and CV disease (CVD) and/or chronic kidney disease (CKD) enrolled in the Aliskiren Trial in Type 2 Diabetes Using Cardiorenal Endpoints (ALTITUDE). We analysed Harrell’s C-statistics (Cs) to estimate Cox model performance to predict death (n= 473) and a CV composite outcome (CVCO: CV death, resuscitated cardiac arrest, nonfatal myocardial infarction, stroke or heart failure hospitalization, n= 1129) after a median follow-up of 2.6 years, using a base model (BM) of 19 clinical baseline variables. The Cs for predicting death in the BM (0.724) was augmented by adding hsTnT (0.744, p= 0.002) which was further improved by NTBNP (0.779, p &amp;lt;0.001). Similarly, the BM for predicting CVCO Cs (0.716) was improved by hsTnT (0.732, p= 0.001) and enhanced further by including NTBNP in the model (0.763, p &amp;lt;0.001). Notably, NTBNP by itself was as predictive as BM plus hsTNT for predicting death (both 0.744, p= 1.0) and the CVCO (0.732 vs. 0.721, p= 0.27). In patients with T2DM and CVD or/and CKD, NTBNP was the major prognostic factor and should be considered for risk stratification. Disclosure M.V.B. Malachias: Speaker’s Bureau; Self; Biolab Sanus Farmaceutica, Libbs Farmaceutica. P. Jhund: Advisory Panel; Self; Cytokinetics Inc. Research Support; Self; Boehringer Ingelheim International GmbH. Speaker’s Bureau; Self; Novartis AG. Other Relationship; Self; AstraZeneca. B. Claggett: None. M.O. Wijkman: None. R. Bentley-Lewis: Consultant; Self; Novo Nordisk Inc. Research Support; Self; Janssen Pharmaceuticals, Inc. P.C. Brunel: Consultant; Self; Novartis AG. N. Chaturvedi: Consultant; Self; AstraZeneca. A.S. Desai: Consultant; Self; Abbott, Alnylam Pharmaceuticals, AstraZeneca, Biofourmis, Boehringer Ingelheim Pharmaceuticals, Inc., Boston Scientific, DalCor Pharmaceuticals, Merck &amp; Co., Inc., Novartis Pharmaceuticals Corporation, Regeneron Pharmaceuticals, Relypsa, Inc. Research Support; Self; Alnylam Pharmaceuticals, AstraZeneca, Novartis Pharmaceuticals Corporation. S.M. Haffner: None. H.D. Parving: None. M.F. Prescott: Employee; Self; Novartis Pharmaceuticals Corporation. S. Solomon: Consultant; Self; AstraZeneca, Theracos, Inc. Research Support; Self; AstraZeneca, Theracos, Inc. D. de Zeeuw: Advisory Panel; Self; AbbVie Inc., Bayer AG, Boehringer Ingelheim International GmbH, Fresenius Medical Care, Janssen Pharmaceuticals, Inc., Mitsubishi Tanabe Pharma Corporation. J.J. McMurray: Other Relationship; Self; AbbVie Inc., Alnylam Pharmaceuticals, Amgen, AstraZeneca, Bayer Healthcare Pharmaceuticals Inc., Bristol-Myers Squibb, Cardurion, GlaxoSmithKline plc., Novartis Pharmaceuticals Corporation, Theracos, Inc. M.A. Pfeffer: Consultant; Self; AstraZeneca, CinCor, Correvio, Corvidia, DalCor Pharmaceuticals, GlaxoSmithKline plc., Innovative Science, Jazz Pharmaceuticals, MyoKardia, Inc., Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., PharmaScience, Sanofi US, Servier, Takeda Development Center Americas, Inc. Research Support; Self; Novartis Pharmaceuticals Corporation. Funding Novartis Pharmaceuticals (NCT00549757)

Survey on the Management of ST-Segment Elevation Myocardial Infarction in Hospitals from Rural Areas of Rio Negro, Argentina

espanolIntroduccion: Es escasa la informacion del manejo del infarto agudo de miocardio con supradesnivel del segmento ST (IAMCEST)en zonas rurales de nuestro pais.Objetivo: Conocer la disponibilidad y utilizacion de recursos diagnosticos y terapeuticos en la atencion del infarto agudo demiocardio con supradesnivel del segmento ST en centros medicos rurales de la provincia de Rio Negro.Material y metodos: Se realizo una encuesta telefonica, estructurada, de respuesta abierta, a medicos de guardia de los 8hospitales de la Linea Sur, todos de nivel entre 2 y 4 (sin areas intensivas).Resultados: Los casos con infarto agudo de miocardio con supradesnivel del segmento ST son atendidos por generalistas, queen la mitad de los casos no tienen con quien consultar los electrocardiogramas. En general, no cuentan con sistematicas niredes de derivacion. A pesar de que el 75% de los centros tienen mas de 2 horas de derivacion, la mayoria no disponen deestreptoquinasa. La mitad de las derivaciones son a ciudades que no disponen de hemodinamia para casos sin cobertura.Conclusion: Es escasa la organizacion y la disponibilidad de recursos en la atencion del infarto agudo de miocardio con supradesniveldel segmento ST en zonas rurales de la provincia de Rio Negro. EnglishIntroduction: information on the management of AMI with a ST-segment elevation (IAMCEST) in rural areas of our countryis scarce.Objective: To know about the availability and use of diagnostic and therapeutic resources in the care of IAMCEST in ruralmedical centers in Rio Negro provinceMethods: A structured, open-response, telephone survey was conducted, to on-call doctors from 8 hospitals of the South Line,all between 2 and 4 level (without intensive areas).Results: The IAMCEST patients are attended by generalists, who in half of the cases have no one to consult the ECG. Broadlythey do not have systematic systems or referral networks. Although 75% of the centers have more than 2 hours of derivation,most do not have streptokinase. Half of the referrals are cities that do not have hemodynamics for cases without coverage.Conclusion: The organization and availability of resources in IAMCEST care in rural areas of the province of Rio Negro is scarce.

P8833-year prognosis of patients with acute coronary syndromes with non-obstructive coronary arteries

Abstract Background More than 10% of patients presenting with symptoms suggestive of acute myocardial ischaemia have no significant atherosclerotic plaques in coronary angiography. The management and longer term prognosis of these patients has been a subject of debate. Material and methods The aim of the study was to assess the 3-year prognosis of patients with the diagnosis ACS (acute coronary syndrome) in Swietokrzyskie region of Poland based on data from the Polish National ORPKI Registry. Between 2014–2015, 9771 patients with ACS who underwent coronary angiography entered the registry and were included in the study. Of them, 2141 had no evidence of atherosclerosis or no significant stenosis on coronary angiography. Data on death, myocardial infarction, stroke, heart failure and cardiac hospitalization were compared between ACS patients with and without significant atherosclerotic plaques in coronary angiography. Results The results are presented in the table. Death and cardiovascular events at 3-year follow-up ACS with significant stenosis ACS without significant stenosis p-value Death 14.4% 7.8% &lt;0.001 Myocardial infarction 16.8% 11.6% 0.04 Stroke 6.8% 2.5% 0.01 Heart failure 38.0% 34.0% 0.19 Cardiac hospitalization 50.3% 22.7% &lt;0.001 Conclusion Patients who have presented with ACS and had no significant stenosis on angiography have had generally better 3-year prognosis that patients with ACS with significant stenosis. However, cardiovascular events, especially heart failure have not been uncommon in this group of patients.

Association of Hyperhomocysteinemia with Acute Myocardial Infarction in Kurdish Patients

Cardiovascular disease (CVD) is the main cause of death worldwide. Among multiple cardiovascular risk factors, such as age, blood pressure, diabetes, smoking and hyperlipidemia, hyperhomocysteinemia has recently emerged to have an important role in increasing risk of CVD by impairing oxidative stress-induced endothelial dysfunction and inducing atherothrombosis. However, the association between high circulating level of homocysteine and increasing the risk of CVD in human remains controversial and has not been consistently observed. OBJECTIVES: The aim of this study is to evaluate the association between serum total homocysteine (tHcy) concentrations with increased risk of CAD in patients with acute myocardial infarction (MI) in Kurdish population. In addition, correlations of classical risk factors including hypertension, smoking, diabetes and hyperlipidemia with hyperhomocysteinemia in MI patients were studied. Its role in in development of CVD could be pivotal. METHODS: In a case-control study, a total of 74 patients (51 male; 23 female; aged 22-80 years) who had diagnosed with acute CAD on angiography were enrolled in this study and 74 gender and age matched non-CAD individuals were included as the control group. The serum tHcy level was measured by enzymatic immunoassay. Hyperhomocysteinemia (HHcy) was defined as Hcy>15 µmol/l. RESULTS: the mean ± standard deviation (SD) of serum total homocysteine (tHcy) level in acute myocardial infarction patients was 22.8 ± 1.30 µmol/l, which was significantly higher compared to that of control group being 15.1 ± 1.33 µmol/l (P < 0.001), indicating that a high homocysteine level may promote pathogenesis of atherosclerosis. 51 (68.9%) MI cases had hyperhomocysteinemia; of these 35 MI patients (47.3%) had mild hyperhomocysteinemia (15-30µmol/L), and 16 MI patients (21.6%) had moderate levels of hyperhomocysteinemia (30-100 µmol/L). No significant correlation between tHcy levels and MI risk factors such as hypertension, hyperlipidemia, and diabetes mellitus, was observed. The tHcy levels were significantly higher in smoker patients than in non-smokers. CONCLUSIONS: These findings confirm that in patients with acute myocardial infarction, elevated homocysteine levels are associated with development of MI independent of other risk factors. A strong association between elevated levels of serum tHcy in MI patients was observed in Kurdish population. This study concludes that Hcy is considered as a strong emerging cardiovascular risk factor for development of myocardial infarction. Moreover, the measurement of Homocysteine levels might act as a surrogate laboratory marker and as one of the effective ways to diagnose patients with myocardial infarction in hospitals.

High Voltage J-Waves as a Predictor of Death in Acute ST-Segment Elevated Myocardial Infarction in Hospital

Aims: Stratification of the risk of malignant arrhythmias in patients with coronary artery disease remains a challenge. This study evaluated the potential of high voltage J-waves in patients with acute ST-segment elevated myocardial infarction (STEMI) to predict the risk of malignant arrhythmias during hospitalization. Methods: A total of 128 consecutive STEMI patients with J-waves were enrolled within 48 h after the onset of the STEMI in this prospective study. The mean age was 62.97 ± 12.1 years, and 108 patients were male. Both 12-lead electrocardiograms (ECGs) and right-sided chest lead ECGs were recorded simultaneously within 10 min of admission to the hospital. Continuous ECG monitoring was administered from admission until discharge. Clinical characteristics and ECG parameters were compared between patients who survived and those who died during hospitalization. Results: Malignant ventricular arrhythmias (MVAs) were seen with J-waves more frequently in STEMI patients who subsequently died (P < 0.05). J-wave voltage, QTDc, Tp-e, and the Tp-e/QT ratio increased significantly in patients who died (P < 0.05). Multivariate logistic regression analysis revealed that J-wave voltage (odds ratio [OR], 89.09; 95% confidence interval [CI], 2.606-3045.108; P < 0.05) and MVAs (OR, 4.296; 95% CI, 1.348–13.693; P < 0.05) were associated with the occurrence of sudden death in patients with STEMI during hospitalization. Conclusions: High voltage J-waves are a potential ECG parameter for predicting sudden death in patients with STEMI during hospitalization.

The effects of optimizing the timeliness of emergency care of patients with ST-elevation myocardial infarction in hospital

Objective To investigate the effect of optimizing rescue time for patients with acute st-elevation myocardial infarction (STEMI) in the hospital. Methods A retrospective analysis of the clinical data of 133 patients with ST-elevation myocardial infarction who were hospitalized in the first affiliated hospital of university of science and technology of china during July,2016 to June,2017 was performed. Timeline in the rescue, the result of coronary reperfusion and satisfaction degree of patients were analyzed. Results The rapid evaluation time (F=2.609, P=0.046),emergency handling time(F=7.581, P=0.032), login and logout time (F=5.667, P=0.017)and visit-ballon time (F=8.942, P=0.007) were shortened quarter by quarter. The average time of each project in the four quarters showed a statistically significant difference. The difference of TIMI classification of coronary flow reperfusion among the four quarters was statistically significant (H=8.402, P=0.038). The satisfaction degree of each quarter showed a statistically significant difference (the third quarter of 2016:94.68±2.38, the fourth quarter of 2016:96.72±5.10, the first quarter of 2017: 97.23±7.64, the second quarter of 2017:98.36±4.86; F=7.891, P=0.048). Conclusions Enhancing timeliness of emergency care can remarkably shorten rescue time, improve satisfaction degree of patients and help to improve the success rate of emergency treatment for patients with STEMI. Key words: Acute ST segment elevation myocardial infarction; Nursing process; Hospital rescue; Timeliness

IMPACT OF LEFT VENTRICULAR ASSIST DEVICES ON ACUTE MYOCARDIAL INFARCTION AND HEART FAILURE MORTALITY AND READMISSION MEASURES

Background: The Centers for Medicare and Medicaid Services penalizes hospitals for excess 30-day readmissions and mortality after acute myocardial infarction (AMI) or heart failure (HF) hospitalization. There is concern as to whether Centers for Medicare and Medicaid Services should exclude

Door in - door out assessment of patients admitted with acute ST-segment elevation myocardial infarction in hospitals without catheterization facilities

Many patients with acute ST-segment elevation myocardial infarction (STEMI) are admitted to emergency departments (EDs) of centres without percutaneous coronary intervention (PCI) facilities. The 2012 European Society of Cardiology guidelines recommend transfer to a PCI centre with a "door in - door out" (DI-DO) time≤30min. To report DI-DO times in a registry of patients with acute STEMI. The RESeau des Urgences CORonarienne (RESUCOR) is a permanent registry of patients admitted with acute STEMI in 16 hospitals in the north French Alps since 2002. In patients admitted to a non-PCI centre, the DI-DO times were split into "diagnostic time" (from admission to transfer decision) and "logistical time" (from transfer decision to discharge). Of 2081 patients included in the registry from 2012 to 2014, 493 were admitted directly into an ED (254 PCI centre and 239 non-PCI centre). Of those admitted into an ED of a non-PCI centre, 228 were immediately transferred to a PCI centre (76 treated with thrombolysis and 132 with primary PCI). The proportions of patients with DI-DO≤30min and median (interquartile range [IQR]) DI-DO times are reported in the Table 1. Median (IQR) DIDO times were 90.5 (69-118) min for patients treated with thrombolysis and 88 (62-147) min for primary PCI. DI-DO times were longer than recommended. Efforts to decrease these delays are required. Transfer with a non-PCI centre ambulance is preferable.