MI Survivors Research Articles

Electrocardiographic changes during sustained normobaric hypoxia in patients after myocardial infarction

The safety of prolonged high-altitude stays and exercise for physically fit post-myocardial infarction (MI) patients is unclear. Myocardial tissue hypoxia and pulmonary hypertension can affect cardiac function and electrophysiology, possibly contributing to arrhythmias. We included four non-professional male athletes, clinically stable after left ventricular MI (three with ST-segment elevation MI and one with non-ST-segment elevation MI) treated with drug-eluting stents for single-vessel coronary artery disease. Oxygen levels were reduced to a minimum of 11.8%, then restored to 20.9%. We conducted electrocardiography (ECG), ergometry, and echocardiography assessments in normoxic and hypoxic conditions. With an average age of 57.8 ± 3.3 years and MI history 37 to 104 months prior, participants experienced a significant increase in QTc intervals during hypoxia using Bazett’s (from 402 ± 13 to 417 ± 25 ms), Fridericia’s (from 409 ± 12 to 419 ± 19 ms), and Holzmann's formulas (from 103 ± 4 to 107 ± 6%) compared to normoxia. This effect partially reversed during recovery. Echocardiographic signs of pulmonary hypertension during normobaric hypoxia correlated significantly with altered QTc intervals (p < 0.001). Despite good health and complete revascularization following MI, susceptibility to hypoxia-induced QTc prolongation and ventricular ectopic beats persists, especially during physical activity. MI survivors planning high-altitude activities should consult cardiovascular specialists with high-altitude medicine expertise.

THE IMPACT OF AGE-RELATED SARCOPENIA ON SURVIVAL AND MORTALITY IN PATIENTS WITH CHRONIC HEART FAILURE

There is an increasing HF population resulting from the higher number of MI survivors and the widespread presence of diabetes, hypertension, CHD (Chronic Heart Filure), obesity and other chronic conditions. Cardiac dysfunction is the main factor that leads to reduced physical activity in patients with HF. The alternations in skeletal musculature often are present in the background of HF and can contribute to fatigue and dyspnea. Sarcopenia is a reduction in muscle mass and force, and it is right to say that it is one of the signs of “getting old”.The modern views on sarcopenia are that it is an outcome of many medical, behavioral and ecological factors, which are common in older people. Together with a sedentary lifestyle, it can be the main reason for disability in the late stages of human life. In our study, we examined the significance of reduced skeletal muscle tissue on mortality and survival of patients with diagnosed HF. The results showed that sarcopenia is a significant contributing factor for increased mortality [p = 0,022] and reduced survival rates [p = 0,033] in patients with HF II – IV class by NYHA. As a secondary goal we found there is significant correlation between age and sarcopenia [R²Linear = 0,057].

Abstract 15663: Prediction of 5-year Cardiovascular and All-cause Mortality After Myocardial Infarction in United States Veterans

Objective: This is a large prospective study aimed to develop risk prediction models of CVD and all-cause mortality in patients who survived MI. Methods: Using 2002-2012 national electronic health record data from the Veterans Health Administration, sex-specific risk prediction models for CVD and all-cause death were developed from the 5-year follow-up data of 100,601 first MI survivors aged &gt;30 years. Model performance was evaluated using a 5-fold cross-validation approach. Results: We followed 98,657 male and 1,944 female MI survivors up to 5 years (407,199 person-years). There were 31,622 deaths (men 31,147, women 475) and 12,901 CVD deaths (men 12,752, women 149) observed during follow up. Among men, greater age, current smoking, diabetes, atrial fibrillation, heart failure, peripheral artery disease, geographic region, and lower BMI (&lt;20kg/m 2 ) were associated with increased risk of subsequent CVD and all-cause-mortality, while statin treatment, hypertension medication, beta-blocker, eGFR level, and high BMI (≥25 kg/m 2 ) were significantly associated with reduced risk of CVD and all-cause-mortality. Similar associations were generally observed among women. We observed U-shaped relations between total cholesterol and outcomes, and HDL cholesterol and outcomes. The prediction models demonstrated good discrimination and calibration. The estimated Harrell’s C-statistics of the final models versus the cross-validation estimates were similar, ranging from 0.75 to 0.81. The predicted risk of death was well-calibrated compared to observed risk. Conclusions: We developed and validated risk prediction models of 5-year risk for CVD and all-cause death for patients following MI. Traditional risk factors, co-morbidity, lack of blood pressure or lipid treatment, and geographic region were all associated with greater risk of CVD and all-cause mortality.

Managed care improves prognosis in AMI patients irrespectively of the hospital setting. Data from the MAnaged Care for Acute Myocardial Infarction Survivors (MACAMIS) Programme

Abstract Background In 2017 a nation-wide system of managed care for MI survivors comprising acute treatment of MI, cardiac rehabilitation and cardiac ambulatory care within one year following MI was implemented in Poland. The managed care programme (MCP) was proved to be related to lower risk of all-cause death. The goal of the analysis was to assess the effectiveness of MCP in patients discharged from university, district, municipal and non-public hospitals. Methods The database of survivors of acute MI discharged from hospital from October 1, 2017 to December 31, 2018 was analyzed. Patients who died within 10 days after discharge were excluded from the analysis. The primary end-point was defined as death from any cause. Propensity-Score Matching using nearest neighbor matching was used to form comparable groups of patients participating and not participating in the MCP. The Cox proportional hazard regression analysis was used to assess the relation between MCP and the overall mortality. Results MCP was implemented in the first stage in 48 hospitals spread around the country (about 34% of all hospitals treating acute MI patients in Poland). Among them 14 were university, 20 district, 8 municipal and 6 nonpublic hospitals. Out of 34064 patients discharged from hospitals with MCP implemented 10404 patients (30.5%) participated in MCP. They were matched with 10404 patients not participating in the MCP. About 24% of the analyzed patients were discharged from university hospitals, 42% from district hospitals, 20% from nonpublic, 14% from municipal and other hospitals. During 326.3±134.8 days of follow-up 1062 patients died (4.4% vs. 6.5% of patients participating and not participating in the MCP; p&amp;lt;0.001). Hazard ratios related to MCP of patients hospitalized in each hospital categories are presented in the table. Conclusion The implemented in Poland nation-wide system of managed care for MI survivors is related to improved survival in all hospital settings. Funding Acknowledgement Type of funding source: None

Post-load glucose spike is a determinant of post-MI prognosis in patients without known or newly diagnosed diabetes

Abstract Background Post-prandial plasma glucose spikes contribute to the progression of atherosclerosis. Glycaemic variability may predict post-ACS prognosis. A third to two-thirds of these patients had diabetes mellitus (DM). Post-ACS prognosis is worse in DM than in those without. This has not been tested in patients without DM. Purpose To test whether post-load spike in plasma glucose in patients without known or newly diagnosed DM adversely affects prognosis. Methods Retrospective cohort analysis of 847 MI survivors without known or newly diagnosed DM who were followed up for MACE (death and non-fatal MI). The median post-glucose spike (PGS, defined as the difference between the 2h-PG and FPG) was 2.4 mmol/l for the whole cohort and 1.5 mmol/l for the patients with normal glucose tolerance (NGT). Group 1: PGS ≤2.4 mmol/l and Group 2: PGS &amp;gt;2.4 mmom/l were compared using Mann-Whitney test for continuous variables and chi-squared test for categorical variables. Event free survival in the two groups was estimated from the Kaplan–Meier curves and compared using log-rank test. Cox proportional hazard regression identified predictors of MACE. Continuous net reclassification improvement (NRI&amp;gt;0) and integrated discrimination improvement (IDI) and c-statistics determined the added predictive value of glycaemic matrices Results MACE was higher in group 2 (OR 1.99, 95% CI 1.36 to 2.91, p=0.0004) compared to group 1. In patients with NGT, MACE was higher in patients with PGS ≥1.5 mmol/l vs those below (OR 2.37, 95% CI 1.31 to 4.26, p=0.0041). Event free survival was worse in pre-diabetes than in the NGT groups (HR 1.57, 95% CI 1.17 to 2.12, p=0.003). and in group 2 than 1 (HR 2.01, 95% CI 1.49 to 2.71, p&amp;lt;0.001). Amongst the patients with NGT, event free survival was worse in patients with PGS ≥1.5 mmol/l (HR 2.09, 95% CI 1.35 to 3.25, p&amp;lt;0.001). PGS independently predicted MACE in the whole cohort (HR 1.16, 95% CI 1.06 to 1.26, p=0.002) and NGT group (HR 2.06, 95% 1.51 to 2.79, p&amp;lt;0.000). Group 2 independently predicted MACE in the whole cohort (HR 1.75, 95% CI 1.26 to 2.42, p&amp;lt;0.001). In the NGT group, PGS &amp;gt;median, independently predicted of MACE (HR 2.67, 95% CI 1.54 to 4.61, p&amp;lt;0.001). The c-statistic a model containing GRS only increased on addition of PGS (δAUC 0.0134, p=0.046) but not on addition of FPG. Within the whole cohort, PGS improved the net reclassification by 28% when added to the model containing GRS only. NGT cohort had higher net improvement at 46.6%. Addition of PGS to the model containing GRS and FPG resulted in NRI&amp;gt;0 of 25.5% in the whole cohort and 56.3% in the NGT cohort. Similar changes were seen in the IDI. Conclusion(s) PGS predicts post MI prognosis in patients without known or newly diagnosed DM including in patients with NGT. This suggests that PGS is a more powerful indicator of post-MI prognosis than FPG Funding Acknowledgement Type of funding source: None

Does high-normal 2-hour post load plasma glucose after myocardial infarction in patients with normal glucose tolerance adversely affect prognosis?

Abstract Background Type 2 diabetes mellitus (DM) and pre-DM, newly diagnosed after MI in patients without known DM adversely affects prognosis. 2-hour post-load glucose (2h-PG) predicts post-MI prognosis better than fasting plasma glucose (FPG). Plasma glucose below the conventional threshold for the diagnosis of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), affects post-MI prognosis. Purpose To test whether high-normal post-load plasma glucose in patients with normal glucose tolerance (NGT) would affect post-MI prognosis and whether FPG or 2h-PG increases this risk. Methods Retrospective cohort analysis of 425 MI survivors without known DM and with NGT followed up for (death and non-fatal MI) as MACE. MACE in patients with 2h-PG &amp;gt; median for the whole cohort (Group 2), was compared with those at or below (Group 1). Event free survival in the two groups was estimated from the Kaplan–Meier curves and compared using log-rank test. Cox proportional hazard regression identified predictors of MACE. Continuous net reclassification improvement (NRI&amp;gt;0) and integrated discrimination improvement (IDI) and c-statistics determined the added predictive value of glycaemic matrices. Results Median 2h-PG was 6.3 mmol/l. 219 patients in Group 1 and 206 in Group 2. Group 2 had higher age, prevalence of hypertension, hypercholesterolaemia, ST-segment depression and higher heart rate and GRACE scores. Median follow-up was 40.6 months. MACE was more frequent in Group 2 than Group 1 (OR 2.82, 95% CI 1.55 to 5.16, p&amp;lt;0.001). MACE-free survival was higher in Group 1 (HR 2.43, 95% CI 1.53 to 3.85, p&amp;lt;0.001). Group 2 (HR 2.42, 95% CI 1.44 to 4.04, p&amp;lt;0.001) predicted the MACE-free survival. 2h-PG, but not the FPG independently predicted of MACE (HR 1.73, 95% CI 1.31 to 2.30, p&amp;lt;0.001). Addition of 2h-PG to models containing FPG and other variables improved their predictive performance (NRI&amp;gt;0 0.5062, p&amp;lt;0.001; IDI 0.0376, p=0.003). The c-statistic increased when 2h-PG was added to the GRACE score only model (δAUC 0.037, 95% CI 0.012 to 0.081, p=0.046). Conclusion(s) This study suggests that “high-normal” 2h-PG is an independent predictor of post-MI prognosis. Normoglycaemic patients with 2h-PG ≥6.4 mmol/l, had worse post-MI prognosis compared to those with 2h-PG ≤6.3 mmol/l. The risk of MACE increased with increasing 2h-PG within the normal range. FPG had no effect on prognosis. Funding Acknowledgement Type of funding source: None

Economic valuation of informal care provided to people after a myocardial infarction in France

BackgroundThe aim of this study was to estimate the mean cost per caregiver of informal care during the first year after myocardial infarction event in France.MethodsWe used the Handicap-Santé French survey carried out in 2008 to obtain data about MI survivors and their caregivers. After obtaining the total number of informal care hours provided by caregiver during the first year after MI event, we estimated the value of informal care using the proxy good method and the contingent valuation method.ResultsFor MI people receiving informal care, an annual mean cost was estimated at €12,404 (SD = 13,012) with the proxy good method and €12,798 (SD = 13,425) with the contingent valuation method per caregiver during the first year after myocardial infarction event.ConclusionsThe present study suggests that informal care should be included more widely in economic evaluations in order not to underestimate the cost of diseases which induce disability.

P6217Managed Care after Acute Myocardial Infarction (MC-AMI) reduces MACE by 45% in 3-month follow-up - results form Poland's National Health Fund program of post-MI care. A single center analysis

Abstract Background Despite progress in the medical and interventional treatment of acute myocardial infarction (AMI) and low in-hospital mortality related to AMI, a post-discharge prognosis in MI survivors is still unacceptable. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is a program introduced by Poland's National Health Fund aiming at comprehensive care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD. Aims To assess the effect of MC-AMI on major adverse cardiovascular events (MACE) in a 3-month follow-up. Methods In this single-center, retrospective observational study we enrolled 1211 patients, and compared them to 1130 subjects in the control group. After 1:1 propensity score matching two groups of 529 subjects each were compared. Cox regression was performed to assess the effect of MC-AMI and other variables on MACE. Results MC-AMI has been proved to reduce MACE rate by 45% in a 3-month observation. Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with the occurrence MACE at 3 months (HR 0.476, 95% CI 0.283–0.799, p&lt;0.005). Besides, older age, male sex (HR 2.0), history of unstable angina (HR 3.15), peripheral artery disease (HR 2.17), peri-MI atrial fibrillation (HR 1.87) and diabetes (HR 1.5), were significantly associated with the primary endpoint. Comparison of study endpoints between KO Total, n (%) MC-AMI group, n (%) Control Group, n (%) RR 95% CI NNT P n=1058 n=529 n=529 All-cause mortality 19 (1.8%) 7 (1.3%) 12 (2.3%) 0.583 0.232–1.470 105.8 0.247 Hospitalization for HF 31 (2.9%) 12 (2.3%) 19 (3.6%) 0.632 0.310–1.288 75.6 0.202 Myocardial infarction 25 (2.4%) 9 (1.7%) 16 (3.0%) 0.563 0.251–1.262 75.6 0.157 MACE 73 (6.9%) 26 (4.9%)# 47 (8.9%) 0.553 0.348–0.879 25.2 0.012 *Two-tailed Pearson's Chi-square test; MACE, Major Adverse Cardiovascular Events. #Number of patients with at least one MACE; in 2 patients 2 endpoints occurred. This explains why the total number of MACE is lower than the sum of all endpoints. MC-AMI vs. control - MACE in 3 months up Conclusions MC-AMI is the first program of a comprehensive. Participation in MC-AMI – a first comprehensive in-hospital and post-discharge care for AMI patients for AMI patients improves prognosis and reduces MACE rate by 45% as soon as in 3 months.

P6211Efficacy of comprehensive Managed Care after Acute Myocardial Infarction (MC-AMI) in a long-term follow-up - preliminary experience of a single high-volume center

Abstract Introduction Despite substantial progress in the medical and interventional treatment of acute myocardial infarction (AMI), a long-term prognosis in MI survivors remains unsatisfactory. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is the first program of a comprehensive, supervised care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD. Purpose To assess the effect of MC-AMI on major adverse cardiovascular and cerebrovascular events (MACCE) in 12 months follow-up. Methods In this single-center, retrospective observational study we enrolled 1211 patients, out of which 719 consented for participation in MC-AMI and compared them to 1130 subjects in the control group. After propensity score matching two groups of 529 subjects each were compared. Cox regression was performed to assess the effect of MC-AMI on clinical endpoints. Results Primarily, MC-AMI has been proved to reduce MACCE rate by 40% in a 12-month observation. Participants of MC-AMI had a higher adherence to cardiac rehabilitation (98 vs. 14%) higher rate of scheduled revascularisation (coronary artery bypass grafting: 9.8% vs. 4.9%, p&lt;0.001; elective percutaneous coronary intervention: 3.0% vs 2.1%, p&lt;0.05) and ICD implantation (2.8% vs. 0.6%, p&lt;0.05) compared to control. Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with the occurrence MACCE at 12 months (HR=0.500, 95%Cl 0.349–0.718, p&lt;0.001). Besides, older age, diabetes mellitus, hyperlipidemia, prior PAD, previous UA, and lower LVEF were significantly associated with the primary endpoint. 12-month FU - freedom from MACCE Conclusions MC-AMI is the first program of a comprehensive in-hospital and post-discharge care for AMI patients. MC-AMI improves prognosis by increasing the rate of patients undergoing CR, complete revascularization and ICD implantation, thus reducing MACCE rate by 40% in 12 months. Participation in MC-AMI is inversely related to mortality rate, recurrent MI and heart failure related hospitalization during 12 months.

Lipid levels achieved after a first myocardial infarction and the prediction of recurrent atherosclerotic cardiovascular disease

BackgroundLow density lipoprotein cholesterol (LDL-C) goals post-myocardial infarction (MI) are debated, and the significance of achieved blood lipid levels for predicting a first recurrent atherosclerotic cardiovascular disease (rASCVD) event post-MI is unclear. MethodsThis was a cohort study on first-ever MI survivors aged ≤76 years attending 4–14 week revisits throughout Sweden 2005–2013. Personal-level data was collected from SWEDEHEART and linked national registries. Exposures were quintiles of LDL-C, high density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglycerides (TGs) at the revisit. Group level associations with rASCVD (nonfatal MI or coronary heart disease death or fatal or nonfatal ischemic stroke) were estimated in Cox regression models. Predictive capacity was estimated by differences in C-statistic, integrated discriminatory improvement, and net reclassification improvement when adding each blood lipid to a validated risk prediction model. Results25,643 patients, 96.9% on statin therapy, were followed during a mean of 4.1 years. rASCVD occurred in 2173 patients (8.5%). For LDL-C and TC, moderate associations with rASCVD were observed only in the 5th vs. the lowest (referent) quintiles. For TGs and HDL-C increased risks were observed in quintiles 3–5 vs. the lowest. Minor predictive improvements were observed when lipid fractions were added to the risk model but the discrimination overall was poor (C-statistics <0.6). ConclusionsOur data question the importance of LDL-C levels achieved at first revisit post-MI for decisions on continued treatment intensity considering the weak association with rASCVD observed in this post-MI cohort.

Managed Care after Acute Myocardial Infarction (MC-AMI) – a Poland’s nationwide program of comprehensive post-MI care - improves prognosis in 12-month follow-up. Preliminary experience from a single high-volume center

BackgroundDespite progress in the treatment of acute myocardial infarction (AMI), long-term prognosis in MI survivors remains a challenge. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is the first program of a comprehensive, supervised care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD. Our aim was to assess the relation between participation in MC-AMI and major adverse cardiovascular and cerebrovascular events (MACCE) in 12-month follow-up. Methods and resultsIn this single-center, retrospective analysis we compared 719 patients participating in MC-AMI and compared them to 1130 subjects in the control group. After propensity score matching, two groups of 529 subjects each were compared.MC-AMI was related with MACCE reduction by 40% in a 12-month observation. Participants of MC-AMI had a higher adherence to cardiac rehabilitation (98 vs. 14%), higher rate of scheduled revascularisation (coronary artery bypass grafting: 9.8% vs. 4.9%, p ≪ 0.001; elective percutaneous coronary intervention: 3.0% vs 2.1%, p ≪ 0.05) and ICD implantation (2.8% vs. 0.6%, p ≪ 0.05) compared to control.Multivariable Cox regression analysis revealed MC-AMI to be inversely associated with the occurrence of MACCE (HR = 0.500, 95% Cl 0.349–0.718, p ≪ 0.001). Besides, older age, diabetes mellitus, hyperlipidemia, prior PAD, previous UA, and lower LVEF were significantly associated with the primary endpoint. ConclusionsMC-AMI is the first program of comprehensive care for AMI patients. MC-AMI improves prognosis by increasing the rate of patients undergoing CR, complete revascularization and ICD implantation, thus reducing MACCE.

Managed Care after Acute Myocardial Infarction (KOS-zawał) reduces major adverse cardiovascular events by 45% in 3-month follow-up - single-center results of Poland's National Health Fund program of comprehensive post-myocardial infarction care.

IntroductionDespite progress in medical and interventional treatment of acute myocardial infarction (AMI) resulting in low in-hospital mortality, the post-discharge prognosis in MI survivors is still unacceptable. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawał) is a program introduced by Poland’s National Health Fund aiming at comprehensive care for patients with AMI to improve prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), scheduled outpatient follow-up, and prevention of sudden cardiac death. The aim of the study was to assess the effect of MC-AMI on major adverse cardiovascular events (MACE) in 3-month follow-up.Material and methodsIn this single-center, retrospective observational study we enrolled 1211 patients, and compared them to 1130 subjects in the control group. After 1 : 1 propensity score matching two groups of 529 subjects each were compared. Cox regression was performed to assess the effect of MC-AMI and other variables on MACE.ResultsMC-AMI participation is related to reduced MACE rate by 45% in a 3-month observation. Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with the occurrence MACE at 3 months (HR = 0.476, 95% CI: 0.283–0.799, p < 0.005). Also, older age, male sex (HR = 2.0), history of unstable angina (HR = 3.15), peripheral artery disease (HR = 2.17), peri-MI atrial fibrillation (HR = 1.87) and diabetes (HR = 1.5) were significantly associated with MACE.ConclusionsParticipation in MC-AMI – the first comprehensive in-hospital and post-discharge care for AMI patients – improves prognosis and is related to a MACE rate reduction by 45% as soon as in 3 months.

Plasma Pentraxin 3 Levels Do Not Predict Coronary Events but Reflect Metabolic Disorders in Patients with Coronary Artery Disease in the CARE Trial

Chronic inflammation closely associates with obesity, metabolic syndrome, diabetes mellitus, and atherosclerosis. Evidence indicates that the immunomodulator pentraxin 3 (PTX3) may serve as a biomarker of these cardiometabolic disorders, but whether PTX3 predicts cardiovascular complications is unknown. We examined the association of plasma PTX3 levels with recurrent coronary events via a prospective, nested, case-control design in the CARE trial. Among 4159 patients who had a prior myocardial infarction 3 to 20 months before enrollment and also had total cholesterol levels <240 mg/dL and LDL cholesterol levels between 115 and 175 mg/dL, we measured plasma PTX3 levels at baseline by high-sensitivity ELISA in 413 cases with recurrent myocardial infarction or coronary death during a 5-year follow-up period, and in 366 sex- and age-matched controls. Cases with recurrent coronary events and controls had similar PTX3 levels, and PTX3 did not predict recurrent coronary events — a finding that contrasts with that of C-reactive protein (CRP) and serum amyloid A (SAA) in this cohort. We then associated PTX3 levels with metabolic disorders. Low plasma PTX3 levels correlated with high body-mass index, waist circumference, and triglycerides; and with low HDL cholesterol. Overall, PTX3 levels correlated inversely with the number of metabolic syndrome components. PTX3 levels also correlated inversely with apoCIII and tissue plasminogen activator, but did not associate with CRP. Although the study further links low PTX3 levels with various features associated with metabolic syndrome, the results do not indicate that PTX3 can predict recurrent coronary events among MI survivors.

Impact of Cardiovascular Events on Change in Quality of Life and Utilities in Patients After Myocardial Infarction: A VALIANT Study (Valsartan In Acute Myocardial Infarction)

The objective of this study was to determine the impact of nonfatal cardiovascular (CV) events on changes in health-related quality of life (HRQL). There is limited understanding of the impact of nonfatal CV events on long-term changes in HRQL in survivors ofmyocardial infarction (MI). The VALIANT (Valsartan In Acute Myocardial Infarction) trial enrolled 14,703 patients post-MI complicated by Killip class II or higher (scale measuring heart failure severity post-MI ranging from class I to IV) and/or reduced ejection fraction. The HRQL substudy included 2,556 (17.4%) patients who completed the EQ-5D with 5 questions, with responses mapped to utility weight on a scale of 0 to 1 and a visual analog scale (VAS) ranging from 0 (worst) to 100 (best) imaginable health state. EQ-5D was administered at baseline and 6, 12, 20, and 24 months. The trajectory of EQ-5D scores was developed by using linear mixed effects regression models with calculation of deviation from this trajectory after nonfatal CV events. Patients who died before the next EQ-5D assessment were excluded. Over a 2-year period, 597 patients experienced a nonfatal CV event and survived to have another EQ-5D assessment. Their baseline EQ-5D scores were lower than patients without a subsequent nonfatal CV event (VAS 61.0 ± 19 vs 68.2 ± 18 [p< 0.001] and US-based utility score 0.76 ± 0.22 vs 0.83 ± 0.17 [p< 0.001]). These patients with CVevents experienced a trajectory-adjusted 6.6 point decrease (p< 0.001) in VAS scores and a 0.07 decrease (p<0.001) in utility score after the nonfatal CV event. MI survivors suffering a CV event experienced significantly worse HRQL than their previous trajectory, suggesting that generic instruments can be responsive to nonfatal events. Reduction in nonfatal CV events may affect longitudinal changes in HRQL.

Identifying susceptible populations for public health action. Results from the PHASE project.

Background and aims: Extreme weather events (EWEs) have been increasing as a result of climate change. An objective of the European funded PHASE project, is to define subgroups of the population susceptible to EWEs such as heat waves, cold spells, floods, forest fires and air pollutants. Methods: Case-study analyses among PHASE cities were carried out to estimate the effects of EWEs and identify susceptible subgroups using different methodologies (time series, case cross over analysis and cohort approach). Where primary studies were not yet performed, a literature review was carried out to summarize susceptibility factors to EWEs. Results: Analyses from PHASE show: Heat. In the last decades, the effect of heat in the 65-74 age group is increasing while among the very old (75+ years) the effect is declining and there has also been a reduction in the harvesting effect. An effect of high temperatures among children was also observed, especially for respiratory diseases. Exposure to high temperatures increases the risk of preterm births (+2% for every 1°C increase). Among cohorts of adult patients within chronic diseases (Diabetes, COPD, MI survivors, CHF, Psychiatric disease) an increase in deaths during extreme heat days was observed. Floods. The indirect health effects of floods include respiratory disease, mental health, gastroenteritis; children and persons with chronic-related conditions are most at risk. Specific case studies within PHASE are ongoing. Air pollutionForest Fires. Through the use of satellite data, a EU map of the areas at-risk to fires was defined and an emissions inventory will allow to estimate the health effects of wild fires in selected case studies. The health effects of urban air pollution seem to be exacerbated during extreme temperatures, especially for respiratory and cardiovascular causes. Conclusions: Specific public health measures should be focused on subgroups that will suffer the greatest health burden through life as a consequence of exposure to EWEs. Results from the PHASE project on subgroups susceptible to EWEs need to be integrated in public health guidelines.

Abstract P264: Meeting 2008 Physical Activity Guidelines for Americans Reduces Risk of Recurrent CVD Events in MI Survivors: The Western New York Acute MI Study (1996–2006)

Introduction: The 2008 Physical Activity Guidelines for Americans (PAG) recommend adults perform at least 150 minutes/week of moderate intensity physical activity or 75 minutes/week of vigorous intensity activity or an equivalent combination of both in order to obtain important health benefits, including lower CHD risk. Despite advances in clinical medicine, survivors of MI remain at substantial risk of recurrent cardiovascular events and death. The aim of our prospective study was to examine whether meeting the PAG reduced risk of recurrent CVD events in MI patients. Hypothesis: We hypothesized that MI survivors who met the current PAG had a more favorable prognosis than those who did not meet the guidelines. Methods: Incident MI cases (933 men, 354 women, 35–69 years old) recruited from 12 of 15 Western NY hospitals completed an interviewer-administered survey and clinic exam. Physical activity (PA) in the previous seven days was assessed using the Stanford 7-day PA recall. Minutes reported in moderate and vigorous intensity recreational, household and occupational activity (MVPA) were summed and participants were categorized as follows (min/week): inactive (0), insufficiently active (&gt;0–&lt;150), met (150–300), and exceeded the guideline goal (&gt;300). Participant surveys, medical records and a search of the National Death Index Plus were used to determine fatal and non-fatal recurrent CVD (ICD9 390–450) events. Cox regression analysis adjusting for age (in years), gender, education (in years), race, BMI, smoking status, hypertension and use of diabetes and lipid medication was conducted to examine the association between PA and recurrent events. Results: During a mean follow up of 4.1 years, 301 recurrent CVD events occurred. At baseline, 174 (13.5%) participants reported no MVPA, 216 (16.8%) were insufficiently active, whereas 259 (20.1%) met and 638 (49.6%) exceeded the PAG, respectively. Multivariate adjusted hazard ratios (95% CI) for recurrent CVD events were Inactive [Ref (1.00)], insufficiently active [0.68 (0.46–1.01)], met [0.63 (0.43–0.92)], and exceeded the guideline goal [0.63 (0.45–0.87)], p-trend =0.019. Conclusion: In this prospective population-based study, there is evidence to support that meeting the 2008 Physical Activity Guidelines for Americans has significant benefits on fatal and non-fatal recurrent CVD events in men and women following myocardial infarction.

Sudden death risk in type 2 diabetic patients post-myocardial infarction: A “sweet” opportunity?

Sudden death risk in type 2 diabetic patients post-myocardial infarction: A “sweet” opportunity?

Sulfonylureas May Elevate Risk in MI Survivors

Sulfonylureas May Elevate Risk in MI Survivors

Vitality and recurrent event risk in acute myocardial infarction survivors

Low vitality, characterized by fatigue and lack of energy, is common among survivors of acute myocardial infarction (AMI) and has been shown to be associated with increased risk of primary and secondary cardiac events. The goal of this study was to determine whether an association between vitality and recurrent cardiac events (nonfatal MI, cardiac death) among acute MI survivors persists after controlling for possible physiological and psychological confounders. Incident AMI survivors (n = 1328) from Erie and Niagara (New York) county hospitals were enrolled and followed up to 9 years. Vitality was measured by the Short Form-36 on a 0-100 scale approximately 4 months post-AMI. Cox proportional hazards models were developed to assess the vitality-recurrent event association controlling for traditional cardiovascular disease risk factors, index MI severity, and psychological correlates of vitality. Low-vitality individuals at baseline were more likely females, of higher BMI, smoking, diabetic, less physically active, and to have worse depression scores. Vitality was not strongly associated with MI severity markers. Lower vitality scores were associated with increased risk of recurrent cardiac events: adjusted hazard ratios (95% CI) for vitality scores 51-79, 21-50, and < or =20 (compared with > or =80) were 1.2 (0.8, 1.8), 1.4 (0.9, 2.2), and 2.9 (1.5, 5.4), respectively (Ptrend = 0.005). Low vitality was associated with increased risk of recurrent cardiac events among AMI survivors after controlling for physiological and psychological confounders. Mechanistic links with vitality should be sought as interventional targets.

Depressive Symptoms Do Not Reduce The Benefits Of Physical Activity On Recurrent Cardiovascular Disease Events

PURPOSE: To examine prospectively whether depressive symptoms attenuate the benefits recreational physical activity on the risk of recurrent CVD in a population based sample of primary incident MI survivors. METHODS: Cases (1063 men, 430 women) 35-69 yrs old were recruited from 12 of 15 Western New York hospitals and completed an interviewer-administered survey and clinic exam (mean 4 months post-MI). Recreational physical activity (RPA) was assessed using the Stanford 7-day physical activity recall and depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). A score of ≥16 on the CES-D was used to define depression. Recurrent events (RE) included non-fatal and fatal CVD (ICD9 390-450) and revascularizations (ICD9 36-39). Age and sex-adjusted Cox regression models were used to examine the effect of depression on the association between RPA and RE. RESULTS: During a mean follow-up period of 2.4 yrs a total of 314 RE occurred. Depression was associated with an increased risk of recurrent events (HR 1.34 95%CI 1.02-1.75), whereas RPA had a protective effect on RE (HR 0.63 95%CI 0.50-0.79). The protective effect of RPA on RE remained after adjustment for age and sex (HR 0.66 95% CI: 0.52-0.83). Further adjustment for the presence of depressive symptoms did not change the association between RPA and RE (HR = 0.66, 95% CI: 0.52-0.83). CONCLUSIONS: Depressive symptoms did not reduce the protective effect of RPA on recurrent events in this population-based prospective study of MI survivors. These findings have important implications for MI survivors since depression is common in CHD patients.