Myocardial Infarction Cohort Research Articles

The impact of pre-myocardial infarction exercise frequency on prognosis in Non-ST segment elevation myocardial infarction patients

Abstract Background Non-ST segment elevation myocardial infarction (NSTEMI) presents a significant challenge in cardiovascular care, often requiring urgent management. Understanding the impact of exercise frequency prior to the onset of NSTEMI on post-event prognosis is crucial for developingmedical strategies. Purpose This study aimed to investigate the clinical characteristics and outcomes of NSTEMI patients based on their exercise frequency before experiencing NSTEMI, comparing those with regular exercise (once or more per week) versus those with infrequent or no exercise. Methods This study included acute myocardial infarction cohorts from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Inclusion criteria comprised NSTEMI patients evaluated for exercise frequency using the Community Health Questionnaire before hospitalization. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical events (NACE), and all-cause mortality, with secondary outcomes comprising the individual components of MACCE and NACE. Propensity score matching (PSM) was employed to adjust for differences in clinical characteristics between the two groups. Multivariable Cox regression and robust multivariable Cox regression were conducted before and after PSM to evaluate the impact of exercise frequency on outcomes. Results The final study population consisted of 38753 participants (42.7% in the High-frequency exercise group). The median follow-up duration was 1518 days, the mean age was 67.80±11.47 years, 61.6% were male. Compared to individuals with infrequent exercise before NSTEMI, those with regular exercise exhibited significantly lower risks of MACCE [aHR 0.93(0.90-0.96), p<0.001], NACE [aHR 0.91(0.88-0.95), p<0.001], and all-cause mortality [aHR 0.88(0.85-0.92), p<0.001]. However, regular exercise before NSTEMI was associated with an increased risk of coronary revascularization [aHR 1.14(1.06-1.23), p<0.001]. These findings remained consistent in the robust multivariate Cox regression analysis conducted after adjusting for differences between the two groups with PSM (Figure 1). After PSM, survival analysis indicated that the incidence of primary outcomes was lower in individuals with high exercise frequency before NSTEMI compared to those with low exercise frequency before NSTEMI, with all-cause mortality rates of 26.9% vs. 30.8%, MACCE rates of 37.2% vs. 38.5%, and NACE rates of 37.9% vs. 39.1%, all with log-rank p-values <0.001. Conclusion This study highlights the protective role of regular physical activity befor NSTEMI in reducing adverse post-NSTEMI outcomes. Promoting pre-NSTEMI physical activity can be a key element in preventive cardiology, potentially improving prognosis and decreasing the likelihood of cardiovascular events post-NSTEMI.Figure 1

The short-term prognosis of salvianolate use during hospitalization in patients with acute myocardial infarction

Abstract Background Salvianolate, derived from Salvia miltiorrhiza Bunge, is a traditional Chinese medicine known for its potential to promote blood circulation and eliminate blood stasis, often prescribed for cardiovascular system illnesses. This study aims to explore the impact of salvianolate treatment on the prognosis of patients with myocardial infarction during hospitalization. Methods This study included an acute myocardial infarction cohort from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Patients were divided into NSTEMI and STEMI groups. Clinical outcomes included cardiac death and major adverse cardiovascular and cerebrovascular events (MACCE, composite of cardiac death, myocardial infarction, ischemic stroke) within 30 days. Cox multivariable regression analyzed the association between salvianolate use and outcomes in STEMI/NSTEMI patients. Propensity score matching (PSM) adjusted for demographic and clinical differences between salvianolate and non-salvianolate groups. The matching factors including sex, age, Killip class, previous diseases (diabetes, hypertension, stroke, and renal insufficiency), previous percutaneous coronary intervention (PCI), in-hospital aspirin, clopidogrel, ticagrelor, lipid-lowering agents, nitrates, PCI, and thrombolytic therapy. Results A total of 76,157 STEMI patients and 74,373 NSTEMI patients were assessed. Among the STEMI group, 7,636 patients used salvianolate and 68,521 did not. Multivariate Cox regression analysis revealed that salvianolate use during hospitalization reduced cardiac death (aHR = 0.707, 95%CI = 0.623-0.803, P < 0.001) and MACCE (aHR = 0.730, 95%CI = 0.651-0.820, P < 0.001) at 30 days. These findings remained consistent in the matched population (n = 15,264) (cardiac death: aHR = 0.669, 95%CI = 0.569-0.786, P < 0.001; MACCE: aHR = 0.679, 95%CI = 0.586-0.787, P < 0.001). In the NSTEMI group, 6,461 patients used salvianolate, while67,912 did not. After matching, salvianolate use during hospitalization showed no significant difference in cardiac death and MACCE compared to not use. Conclusions Patients with STEMI treated with salvianolate exhibited improved short-term cardiovascular and cerebrovascular outcomes, while NSTEMI patients did not experience significant short-term prognosis enhancement.

The impact of pre-myocardial infarction exercise frequency on prognosis in acute myocardial infarction patients

Abstract Background Acute myocardial infarction (AMI) is a critical cardiovascular event often associated with significant morbidity and mortality. Despite the acknowledgment of regular physical activity as vital for cardiovascular health, its influence on post-AMI prognosis in patients with varying pre-AMI exercise frequencies remains to be fully explored. Purpose This study aimed to investigate the outcomes of AMI patients based on their exercise frequency prior to the occurrence of AMI, comparing those with regular exercise (once or more per week) versus those with infrequent or no exercise. Methods This study included acute myocardial infarction cohorts from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Inclusion criteria comprised AMI patients evaluated for exercise frequency using the Community Health Questionnaire before hospitalization. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical events (NACE), and all-cause mortality, with secondary outcomes comprising the individual components of MACCE and NACE. Propensity score matching (PSM) was employed to adjust for differences in clinical characteristics between the two groups. Multivariable Cox regression and robust multivariable Cox regression were conducted before and after PSM to evaluate the impact of exercise frequency on outcomes. Results The final study population consisted of 77,427 participants (42.1% in the High-frequency exercise group). The median follow-up duration was 1595 days, the mean age was 66.03±11.82 years, 65.6% were male. Compared to individuals with infrequent exercise before AMI, those with regular exercise exhibited significantly lower risks of MACCE [aHR 0.93 (0.91-0.96), p<0.001], NACE [aHR 0.91 (0.89-0.93), p<0.001], and all-cause mortality [aHR 0.90 (0.87-0.92), p<0.001]. However, regular exercise before AMI was associated with an increased risk of coronary revascularization [aHR 1.12 (1.07-1.17), p<0.001]. These findings remained consistent in the robust multivariate Cox regression analysis conducted after adjusting for differences between the two groups with PSM (Figure 1). After PSM, survival analysis indicated that the incidence of primary outcomes was lower in individuals with high exercise frequency before AMI compared to those with low exercise frequency before AMI, with all-cause mortality rates of 23.1% vs. 35.4%, MACCE rates of 26.4% vs. 36.2%, and NACE rates of 36.9% vs. 36.2%, all with log-rank p-values <0.001. Conclusions This study underscores the protective role of regular physical activity prior to AMI in reducing adverse post-AMI outcomes. Promoting pre-AMI physical activity can be a key element in preventive cardiology, potentially improving prognosis and decreasing the likelihood of cardiovascular events post-AMI.Figure 1

Pericardial Fluid Accumulates microRNAs That Regulate Heart Fibrosis after Myocardial Infarction.

Pericardial fluid (PF) has been suggested as a reservoir of molecular targets that can be modulated for efficient repair after myocardial infarction (MI). Here, we set out to address the content of this biofluid after MI, namely in terms of microRNAs (miRs) that are important modulators of the cardiac pathological response. PF was collected during coronary artery bypass grafting (CABG) from two MI cohorts, patients with non-ST-segment elevation MI (NSTEMI) and patients with ST-segment elevation MI (STEMI), and a control group composed of patients with stable angina and without previous history of MI. The PF miR content was analyzed by small RNA sequencing, and its biological effect was assessed on human cardiac fibroblasts. PF accumulates fibrotic and inflammatory molecules in STEMI patients, namely causing the soluble suppression of tumorigenicity 2 (ST-2), which inversely correlates with the left ventricle ejection fraction. Although the PF of the three patient groups induce similar levels of fibroblast-to-myofibroblast activation in vitro, RNA sequencing revealed that PF from STEMI patients is particularly enriched not only in pro-fibrotic miRs but also anti-fibrotic miRs. Among those, miR-22-3p was herein found to inhibit TGF-β-induced human cardiac fibroblast activation in vitro. PF constitutes an attractive source for screening diagnostic/prognostic miRs and for unveiling novel therapeutic targets in cardiac fibrosis.

THE COMPLEX WORLD OF NON CRITICAL CORONARY ARTERIES DISEASE

Abstract Background and Aim Acute coronary syndrome (ACS) with non–critical coronary arteries represents a major diagnostic, therapeutic and prognostic challenge for clinicians. The aim was to compare clinical–anamnestic characteristics and assess the prognosis of three cohorts with ACS with non–critical coronary arteries i.e. Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), type 2 myocardial infarction (MI) and Takotsubo syndrome (TTS). Methods In this single center observational study, 18223 patients who underwent coronary angiography between 2005 and 2022 were retrospectively analyzed. The final cohort included 676 patients with initial presentation as NSTEMI (301 MINOCA, 237 type 2 MI and 138 TTS). Results The median age was 68±11, with the TTS population being the oldest (72±10, p<0.01), presenting greater hypotension (p<0.01), tachycardia (p<0.01), and fewer cardiovascular risk factors, such as diabetes (p<0.01) and hypertension (p<0.01). The TTS cohort had worse LVEF on admission (p<0.01) and on discharge (p<0.01) (Fig. 1). At Kaplan–Meier analysis, patients with type 2 MI were more prone to the composite endpoint, while the TTS group was less likely (p<0.01) (Fig. 2). In the overall cohort, ACEi/ARB therapy on admission was an independent predictor of the composite endpoint (HR: 1.58;p=0.01), while dual antiplatelet therapy (DAPT) (HR: 0.59;p=0.01) and statin (HR: 0.71;p=0.03) at discharge were protective. After stratification according to diagnosis, ACEi/ARB therapy remained a negative predictor only in the type 2 MI cohort (HR: 2.03;p=0.01) as well as beta–blocker therapy at admission in TTS (HR: 2.97;p=0.03), while statin therapy remained protective in the MINOCA (HR: 0.51;p=0.01) and DAPT therapy in the TTS group (HR: 0.21;p=0.04) at discharge. Although a substantial number of patients with all three diagnoses achieved the endpoint, the multivariable Cox regression analysis indicated that type 2 MI, in addition to older age, male gender, worse LVEF, and anemia, is an independent factor for worse outcomes (Fig. 3). Conclusions Among all cohorts, T2 MI were associated with worse outcome. The use of DAPT in TTS and Statins in the MINOCA group showed a protective role. Since the TTS population was more compromised, BB use in the ADHF phase of TTS could predict a poorer outcome as much as ACEI/ARB use at admission could be a marker of greater early LV impairment of the T2 MI cohort, which was an independent predictor for worst outcome.

Incidence and predictors of in-hospital complications after myocardial infraction in contemporary clinical practice: Findings from the FRENCHIE myocardial infarction cohort

Incidence and predictors of in-hospital complications after myocardial infraction in contemporary clinical practice: Findings from the FRENCHIE myocardial infarction cohort

Prevalence of SELECT-eligibility and incidence of 5-year major adverse cardiovascular outcomes in non-diabetic patients with myocardial infarction

Abstract Background The ongoing Semaglutide Effects on Heart Disease and Stroke in Patients with Overweight or Obesity (SELECT) trial has randomized 17,605 non-diabetic patients with a body mass index (BMI) ≥27 kg/m2 to treatment with semaglutide versus placebo. Follow-up will be terminated on March 31, 2023. In consecutive myocardial infarction (MI) patients representing daily clinical practice, the prevalence of SELECT-eligible patients and the incidence of the three-point major adverse cardiovascular events (MACE; MI, ischemic stroke, and cardiovascular death) are not known. Purpose To assess the prevalence of SELECT-eligibility and the incidence of 5-year MACE in SELECT-eligible patients in a contemporary semi-nationwide European MI cohort representing daily clinical practice. Methods We identified 34,385 patients with a first-time MI and followed the in- and exclusion criteria for the SELECT trial as outlined in the Figure. Concordant with the SELECT trial, follow-up started on day 60 and maximum follow-up time was 5 years. We estimated adjusted hazard ratios (aHR) for the SELECT-eligible cohort using patients with a BMI from 20 to <27 kg/m2 as reference group. Moreover, we stratified the SELECT-eligible cohort by BMI ≥27 to <33 kg/m2 and ≥33 kg/m2. Results As depicted in the Figure, 10,769 patients with a BMI ≥27 kg/m2 were eligible for SELECT (SELECT-eligible cohort), which corresponds to a prevalence of 31% in the entire 34,385 MI cohort. The normoweight reference group included 11,011 patients. At baseline, the median age was 64 years for the SELECT-eligible cohort and 68 years for the reference group. Stratification of the SELECT-eligible cohort showed median age of 65 years for the BMI ≥27 to <33 kg/m2 and 63 years for the BMI ≥33 kg/m2 subgroups. The cumulative 5-year incidence of MACE was 10.7% for SELECT-eligible and 13.2% for reference patients (aHR 0.96, 95% CI 0.88-1.04). When stratifying the SELECT-eligible cohort, those with BMI ≥27 to <33 and ≥33 kg/m2 had cumulative 5-year incidence of 10.9% (aHR 0.95, 95% CI 0.87-1.04) and 9.9% (aHR 0.99, 95% CI 0.84-1.16). Conclusions In a large contemporary semi-nationwide cohort of consecutive MI patients, approximately 3 out of 10 were eligible for the SELECT trial and the estimated 5-year MACE incidence in SELECT-eligible patients was just above 10%. SELECT-eligible patients experienced the index MI up to 7 years earlier than the reference group. However, the 5-year incidence of MACE did not suggest that overweight/obese patients fulfilling SELECT eligibility criteria were associated with an excess MACE risk when compared to a normoweight reference group.

The Impact of Psychosomatic Factors on Treatment Adherence of Acute Myocardial Infarction Survivors; A Two-Year Follow-Up Study.

Because of the important role of adhering to treatment to reduce major adverse cardiovascular events and mortality, studying the factors affecting treatment adherence (TA) is warranted. This study aimed to identify the impact of psychosomatic factors on adhering to treatment among patients with acute myocardial infarction. This is a cohort study as a part of the Isfahan ST-segment-elevated Myocardial Infarction Cohort Study. Psychosomatic factors such as health anxiety, illness denial, irritable mood, and demoralization were assessed among 867 patients at the first visit. The patients were followed for 2 years; TA and major adverse cardiovascular events were checked annually in survivors. The results from binary logistic regression applied to find the association between TA and psychosomatic factors showed that the patients with health anxiety, irritable mood, and demoralization were significantly poor adherent to treatment (odds ratio [95% confidence interval]: 1.39 [1.02, 2.73], 1.51 [1.02, 2.37], and 1.66 [1.02, 2.91]), respectively. The associations remained the same when adjusted for various potential confounders. Psychosomatic factors played an essential role in adhering to treatment among patients with acute myocardial infarction. As a result, appropriate psychological interventions may help the patients adhere to their treatment better.

Cumulative incidence and risk factors of myocardial infarction during 20years of follow-up: comparing two cohorts of middle-aged men born 30years apart.

To study cumulative incidence and predictors of myocardial infarction (MI) in two random general population samples consisting of middle-aged Swedish men born 30years apart. Results from the "Study of Men Born In 1913" and the "Study of Men Born In 1943", two longitudinal cohort studies performed in the same geographic area and using the same methodology were compared. Both cohorts were followed prospectively from 50 to 70years of age. MI was defined as first myocardial infarction, fatal or non-fatal. Men born in 1943 had a 34% lower cumulative risk of first MI [HR 0.66 (0.50-0.88), p = 0.0051] during follow-up as compared to men born in 1913. Interaction analysis showed that hypertension had a significantly higher impact on risk of MI in cohort 1943 than in cohort 1913 [HR 2.33 (95% CI 1.41-3.83)] and [HR 1.10 (0.74-1.62)], p = 0.0009 respectively. The population attributable risk for hypertension was 2.5-fold higher in the cohort of men born in 1943 as compared to men born in 1913, and diabetes mellitus and sedentary lifestyle attributed more to MI risk in cohort 1943 than in cohort 1913. On the contrary, smoking and total cholesterol have less attributable risk to MI in cohort 1943 than in cohort 1913. Despite declining incident MI and improved cardiovascular prevention in general, hypertension remains an increasingly important attributable risk factor to MI together with diabetes mellitus and sedentary lifestyle over time.

Takotsubo syndrome and stroke risk: A nationwide register-based study

AimsPrevious small-scale studies have indicated a short-term stroke incidence of 1.0–1.3% following Takotsubo (syndrome). In this nationwide register-based study, we investigated the 90-day risk of ischemic stroke (IS) or transient ischemia attack (TIA) and mortality of patients with Takotsubo. Methods and resultsPatients with incident Takotsubo between January 1st 2009 to September 30th 2018 were identified from Danish nationwide registries. Takotsubo patients were age- and sex-matched with background-, atrial fibrillation/flutter- (AF) and myocardial infarction (MI) cohorts. Cumulative incidences and Cox proportional-hazard regression models were used to analyze the following outcomes: 1) composite of IS/TIA and 2) all-cause mortality. A total of 890 patients with Takotsubo were followed for 90 days. The cumulative 90-day incidence of IS/TIA in the Takotsubo-, background-, AF- and MI cohort, was 2.1% (n = 19), 0.1% (n = 4), 1.1% (n = 47) and 1.5% (n = 66), respectively. The cumulative 90-day mortality in the Takotsubo-, background-, AF- and MI cohort was 5.1% (n = 45), 0.3% (n = 13), 1.7% (n = 75) and 5.6% (n = 230), respectively.The adjusted hazard ratio (HR) for 90-day IS/TIA was when compared to the background-, AF- and MI cohort, 26.43 (95% CI: 8.82–79.24), 1.91 (95% CI: 1.09–3.35) and 2.06 (95% CI: 1.12–3.79), respectively. The adjusted HR for 90-day mortality was when compared to the background-, AF- and MI cohort, 14.19 (95% CI: 7.43–27.09), 0.73 (95% CI: 0.52–1.02) and 1.96 (95% CI: 1.25–3.07), respectively. ConclusionPatients with Takotsubo had an increased 90-day hazard for IS/TIA when compared to age- and sex-matched background-, AF- and MI cohorts.

Prevalence of Modifiable Risk Factors in First-Presentation ST Elevation Myocardial Infarction Patients in Christchurch Hospital, New Zealand, Over a 5-Year Period in Māori and Non-Māori Populations

The prevalence of modifiable risk factors is known to be changing in some first-presentation ST elevation myocardial infarction cohorts worldwide. Many studies have noted an increase in patients without modifiable risk factors. This study aimed to assess the risk factors in first-presentation ST elevation myocardial infarction patients in Christchurch, New Zealand, over a 5-year period in Māori and Non-Māori populations. Data were extracted from the ANZACS-QI database from 1 January 2017 to 1 January 2023, for patients with ST elevation myocardial infarction presenting to Christchurch Hospital. Patients with prior cardiovascular disease were excluded. Prevalence of smoking, hypertension, dyslipidaemia, diabetes, and no modifiable risk factors were analysed using a two-proportion z-test. Of 1,138 patients, 66 were Māori. There was high prevalence of modifiable risk factors present with a disproportionately high rate of smoking among Māori (z=5.7; p<0.001). A total of 6.9% of the patients had no modifiable risk factors, with no significant difference found between Māori and Non-Māori (z=–0.29; p=0.2). Modifiable risk factors were still highly prevalent in this first ST elevation myocardial infarction population. Whilst risk factors such as smoking are declining in the general population, they remain highly prevalent in this group and disproportionally higher in Māori, likely contributing to health inequities. The proportion of patients who have no modifiable risk factors is relatively small.

Medication non-adherence patterns and profiles for patients with incident myocardial infarction: Observations from a large multi-morbid US population.

Consistent adherence levels to multiple long-term medications for patients with cardiovascular conditions are typically advocated in the range of 50% or higher, although very likely to be much lower in some populations. We investigated this issue in a large cohort covering a broad age and geographical spectrum, with a wide range of socio-economic disability status. The patients were drawn from three different health plans with a varied mix of socio-economic/disability levels. Adherence patterns were examined on a monthly basis for up to 12 months past the index date for myocardial infarction (MI) using longitudinal analyses of group-based trajectory modelling. Each of the non-adherent patterns was profiled from comorbid history, demographic and health plan factors using main effect logistic regression modelling. Four medication classes were examined for MI: betablockers, statin, ACE inhibitors and anti-platelets. The participant population for the MI/non-MI cohorts was 1,987,605 (MI cohort: mean age 62 years, 45.9% female; non-MI cohort: mean age 45 years, 55.3% females). Cohorts characterized by medication non-adherence dominated the majority of MI population with values ranging from 74% to 82%. There were four types of consistent non-adherence patterns as a function of time for each medication class: fast decline, slow decline, occasional users and early gap followed by increased adherence. The characteristics of non-adherence profiles eligible for improvement included patients with a prior history of hypertension, diabetes mellitus and stroke as co-morbidities, and Medicare plan. We found consistent patterns of intermediate non-adherence for each of four drug classes for MI cohorts in the order of 56% who are eligible for interventions aimed at improving cardiovascular medication adherence levels. These insights may help improve cardiovascular medication adherence using large medication non-adherence improvement programs.

A novel approach to attribute responsible physicians using inpatient claims.

More robust attribution methods are necessary to understand physician-level variation in quality of care across risk-adjusted inpatient measures. We address a gap in the literature involving attribution of physicians to inpatient stays using administrative claims data, in which rule-based methods often inadequately attribute physicians. Methodology comparison study using a cross-section of inpatient stays. A novel approach is proposed in which physicians' relative degrees of responsibility for inpatient stays are expressed through physician-specific attribution ratios informed by existing patient characteristics and comorbidities. Attribution results are compared with the rule-based benchmark method for 7 CMS-defined clinical cohorts, including a COVID-19 cohort. Using 6,835,460 unique patient encounters during 2020 (n = 136,339 in out-of-sample cohort), the proposed approach favored specialists generally considered responsible for primary clinical conditions when compared with the benchmark. The most salient shift within the acute myocardial infarction (+17.0%), heart failure (+20.2%), and coronary artery bypass graft (+4.0%) cohorts was toward the cardiovascular diseases specialty, and the chronic obstructive pulmonary disease (+24.0%) and pneumonia (+16.2%) cohorts resulted in a shift toward the pulmonary diseases specialty. The COVID-19 cohort resulted in considerable shifts toward infectious diseases and pulmonary diseases specialties (+17.4% and +14.1%, respectively). The stroke cohort experienced a considerable shift toward the neurology specialty (+42.2%). We provide a robust method to attribute physicians to patients, which is a necessary tool to understand physician-level variation in quality of care within the inpatient acute care setting. The proposed method provides consistency across facilities and eliminates unattributed patients resulting from unsatisfied business rules.

The impact of readiness to discharge from hospital on adherence to treatment in patients after myocardial infarction

BackgroundThe healthcare professionals involved in in-hospital treatment of myocardial infarction (MI) are also responsible to patients for their education before leaving the hospital. This education aims to modify patient behaviour in order to reduce relevant risk factors and improve self-control and adherence to medications. The aim of the study was to analyse the relationship between readiness for discharge from hospital and adherence to treatment at follow-up in MI patients.MethodsAn observational, single-center, MI cohort study with 6-month follow-up was conducted between May 2015 and July 2016. The Readiness for Hospital Discharge after Myocardial Infarction Scale (RHD-MIS) and the Adherence in Chronic Diseases Scale (ACDS) were applied.ResultsTwo hundred and thirteen patients aged 30–91 years (62.91 ± 11.26) were enrolled in the study. The RHD-MIS general score ranged from 29 to 69 points (51.16 ± 9.87). A high level of readiness was found in 66 (31%) patients, intermediate in 92 (43.2%), and low in 55 (25.8%) of patients. Adherence level assessed with the ACDS 6-months after discharge from hospital ranged from 7 to 28 points (23.34 ± 4.06). An increase in objective assessment of patient knowledge according to RHD-MIS subscale resulted in significantly higher level of adherence at the follow-up visit (p = 0.0154); R Spearman = 0.16671, p = 0.015; p for trend = 0.005. During the 6-month follow-up 3 (1.41%) patients died and 17 (7.98%) were hospitalized for a subsequent acute coronary syndrome.ConclusionsThis study provided preliminary evidence of a long-term association between the results of assessment of readiness for discharge from hospital and adherence to treatment in patients after MI.

Temporal trends in myocardial infarction case fatality: methodological challenges and prevention targets

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council of AustraliaHealy Medical Research Foundation Background Case fatality is an important indicator of severity and quality of care for myocardial infarction (MI). Most studies focus on hospitalised case fatality, which does not capture the total burden of MI deaths. Additionally, changes in diagnostic criteria and acute clinical care, and evidence that identifying all coronary heart disease (CHD) events better captures this patient group,1 have led to suggestions that a different definition of case fatality is required. Purpose The aim of the study was to determine the impact of different definitions of case fatality on the composition of fatal cases, and to measure trends in case fatality across a range of case definitions. Methods A whole-state linked hospital/death dataset was used to identify all MI, acute coronary syndromes (ACS) and CHD events (fatal + nonfatal) from 1997-2015. The traditional MI case fatality definition included all MI deaths as the numerator, stratified as MI hospitalisation with death ≤28 days, non-MI hospitalisation with MI death ≤28 days, or pre-hospital MI deaths. The denominator was all MIs (fatal plus nonfatal MI). ACS and a broader CHD definition were trialled, with ACS or CHD deaths as the numerator respectively, stratified in a similar manner as MI. Case fatality was age-standardised by 5-year age group using the internal age distribution of each definition as the standard. Results From 1997 to 2015, there were 76,928 MI events, 126,470 ACS events, and 235,100 CHD events. Of the MI cohort, 64.1% were men, and 13.0% had a prior MI, with a similar pattern in the ACS and CHD cohorts. For the traditional definition of MI case fatality, 10,819 deaths (53.9%) occurred pre-hospital, 4990 deaths in those hospitalised for MI and dying ≤28 days (24.8%), and 4271 MI deaths (21.3%) ≤28 days of a non-MI hospitalisation (Figure). Using the broadest CHD definition of case fatality, there was a similar proportion of pre-hospital deaths, but a higher proportion of CHD deaths in those with a non-CHD hospitalisation. In men, age-standardised MI case fatality declined from 40.0% in 1997 to 17.3% by 2015; in women, the decline was from 41.9% to 18.2%. In contrast, using the ACS and broad CHD definitions, age-standardised case fatality was lower than for MI throughout the study period, with a smaller temporal decline (ACS: men 22.2% to 13.1%, women 20.5% to 13.0%; CHD: men 20.6% to 12.4%, women 19.3% to 12.3%). Conclusion Despite substantial falls in MI case fatality, the fatal burden remains high. Regardless of the case fatality definition, pre-hospital deaths from acute or all CHD have remained high over time, highlighting the need to target the pre-hospital setting. Caution is needed when using different definitions of case fatality to ensure relevant statistics are used, particularly for temporal trends. Figure Legend. Proportion of MI deaths occurring ≤28 days after MI hospitalisation (2), ≤28 days after non-MI hospitalisation (3), and pre-hospital (4).

Risk of Parkinson Disease and Secondary Parkinsonism in Myocardial Infarction Survivors.

BackgroundIn addition to primary neurodegenerative processes, vascular disorders, such as stroke, can lead to parkinsonism. However, some cardiovascular risk factors, such as smoking and elevated cholesterol levels, are associated with reduced risk of Parkinson disease. We examined the risk of Parkinson disease and secondary parkinsonism in 1‐year survivors of myocardial infarction (MI).Methods and ResultsWe conducted a nationwide population‐based matched cohort study using Danish medical registries from 1995 to 2016. We identified all patients with a first‐time MI diagnosis and sampled a sex‐, age‐, and calendar year–matched general population comparison cohort without MI. Cox regression analysis was used to compute adjusted hazard ratios (aHRs) for Parkinson disease and secondary parkinsonism, controlled for matching factors and adjusted for relevant comorbidities and socioeconomic factors. We identified 181 994 patients with MI and 909 970 matched comparison cohort members (median age, 71 years; 62% men). After 21 years of follow‐up, the cumulative incidence was 0.9% for Parkinson disease and 0.1% for secondary parkinsonism in the MI cohort. Compared with the general population cohort, MI was associated with a decreased risk of Parkinson disease (aHR, 0.80; 95% CI, 0.73–0.87) and secondary parkinsonism (aHR, 0.72; 95% CI, 0.54–0.94).ConclusionsMI was associated with a 20% decreased risk of Parkinson disease and 28% decreased risk of secondary parkinsonism. Reduced risk may reflect an inverse relationship between cardiovascular risk factors and Parkinson disease.

Predictors of Mortality for Patients with ST-Elevation Myocardial Infraction after 2-Year Follow-Up: A ST-Elevation Myocardial Infarction Cohort in Isfahan Study.

Mortality of ST-elevation myocardial infarction (STEMI) patients is increasing in world. This study defines predictors of mortality in patients who have STEMI. This study was a part of the ST-elevated myocardial infarction cohort study in Isfahan conducted on 876 acute myocardial infarction (MI) followed for 2 years that 781 patient entered. The effect of predictors of mortality includes demographic, physiological, and clinical characterizes compared in two groups alive and died patients. MACE was defined as nonfatal MI, nonfatal stroke, and atherosclerosis cardiovascular disease-related death was recorded. Univariate and multiple logistic regression analyses were performed. All analyses performed using SPSS 20.0. P < 0.05 considered statistically significant. A total 781 patients, 117 (13%) that 72 (8.5%) was in-hospital died. The mean (standard deviation) age of the patients was 60.92 (12.77) years and 705 (81.3%) patients were males. Significant factors that affected mortality on analysis of demographic and physiological parameters were age (P < 0.001), sex (P = 0.004), transfusion (P = 0.010), STEMI type (P < 0.001), number epicardial territories >50% (P = 0.001), ventilation options (P < 0.001), smoker (P = 0.003), and diabetes (P = 0.026). Significant clinical factors affected mortality were ejection fraction (EF) (P < 0.001), creatinine (P < 0.001), hemoglobin (P < 0.001), low-density lipoprotein-cholesterol (LDL-C) (P = 0.019), and systolic blood pressure (P < 0.001). Multiple logistics regression model definition significant predictors for mortality were age (P < 0.001), heart rate (HR) (P = 0.007), EF (0.039), LDL-C (P = 0.002), and preangia (P = 0.022). The set of factors can increase or decrease mortality in these patients. Significant predictors of mortality STEMI patients by 2-year follow up were age, HR, EF, LDL-C, and preangia. It seems that more articles need to be done in different parts of Iran to confirm the results.

Risk-associated management disparities in acute myocardial infarction

Despite improvements in the treatment of myocardial infarction (MI), risk-associated management disparities may exist. We investigated this issue including temporal trends in a large MI cohort (n = 179,291) registered 2005–2017 in SWEDEHEART. Multivariable models were used to study the associations between risk categories according to the GRACE 2.0 score and coronary procedures (timely reperfusion, invasive assessment ≤ 3 days, in-hospital coronary revascularization), pharmacological treatments (P2Y12-blockers, betablockers, renin–angiotensin–aldosterone-system [RAAS]-inhibitors, statins), structured follow-up and secondary prevention (smoking cessation, physical exercise training). High-risk patients (n = 76,295 [42.6%]) experienced less frequent medical interventions compared to low/intermediate-risk patients apart from betablocker treatment. Overall, intervention rates increased over time with more pronounced increases seen in high-risk patients compared to lower-risk patients for in-hospital coronary revascularization (+ 23.6% vs. + 12.5% in patients < 80 years) and medication with P2Y12-blockers (+ 22.2% vs. + 7.8%). However, less pronounced temporal increases were noted in high-risk patients for medication with RAAS-blockers (+ 8.5% vs. + 13.0%) and structured follow-up (+ 31.6% vs. + 36.3%); pinteraction < 0.001 for all. In conclusion, management of high-risk patients with MI is improving. However, the lower rates of follow-up and of RAAS-inhibitor prescription are a concern. Our data emphasize the need of continuous quality improvement initiatives.

Abstract 9952: Periodontal Inflammation, Periodontal Bacterial Load and Virulence Genes Expression Are Risk Factors for Myocardial Infarction

Background: A causal relationship between periodontitis and Myocardial Infarction (MI) is stipulated but remains incompletely characterised. Methods: Prospectively recruited 160 acute MI patients underwent periodontal exam to quantify periodontal inflamed surface area (PISA), probing pocket depths (PPD) and clinical attachment loss (CAL). Porphyromonas gingivalis, Tannerella forsythia, Aggregatibacter actinomycetemcomitans and Prevotella intermedia loads were assessed in subgingival plaque, venous blood, aspirated intra-coronary thrombi and deployment balloons using quantitative polymerase chain reaction. Expression of periodontal bacterial virulence genes (n=13) was quantified with reverse transcription PCR. Myocardial injury was estimated by 12-hour troponin (TnI) and severity of coronary artery disease (CAD) burden by SYNTAX-I scores. CAD-symptom free controls (n=50) of similar age/gender distribution were used for comparison. Results: Compared to controls, MI patients had worse periodontitis and higher bacterial loads (all p &lt;0.05). In MI cohort, after adjusting established risk factors, hierarchical linear regression showed that PISA (5%), mean PPD (3%), mean CAL (2%), P. gingivalis load (4%) and upregulated expression of bioF-3 , fimA , prtH , prtP , ltxA , cdtB virulence genes (4-9%) were associated with an increase in Tnl release, all p &lt;0.05. Similarly, mean PPD (5%), mean CAL (4%), P. gingivalis load (5%) and upregulated expression of bioF-3 , fimA , prtP and ltxA virulence genes (4-9%) were associated with higher SYNTAX-I score, all p &lt;0.05. Every 200 mm 2 PISA, 1mm mean PPD, 1mm mean CAL and 10 9 P. gingivalis copies/ng DNA was responsible for 19,000, 32,000, 38,000 and 10,000 ng/L increase in TnI release, respectively. The SYNTAX-I score increased by 3, 4 and 1 unit with every 1mm mean PPD, 1mm mean CAL and 10 9 P. gingivalis copies/ng DNA, respectively. Periodontal bacterial DNA was detected in coronary thrombi and subgingival plaque sampled from the same patients, with a strong correlation for P. gingivalis and T. forsythia bacterial loads (Spearman's rho=0.6 for both, p &lt;0.05). Conclusions: These findings enable further recognition of periodontitis as a risk factor for MI; a new candidate for primary and secondary prevention.

Impact of the Look-Back Period on Identifying Recurrent Myocardial Infarctions in the Danish National Patient Registry.

PurposeStudies examining myocardial infarction (MI) often seek to include only incident MIs by excluding recurrent MIs. When based on historical data, identification of previous MI depends on the length of the look-back period. However, international registries often cover a short time period, consequently containing left-censored data, making it impossible to determine if a first MI in a period is truly an incident MI. We evaluated whether the proportion of MIs identified as recurrent MIs depends on the look-back period, and how including recurrent MIs in a planned incident MI cohort impacts survival estimates.Patients and MethodsWe used the Danish National Patient Registry, covering all Danish hospitals since 1977 to identify first MIs during 2010–2016 (index events). The hospital registry history preceding the index event was then searched for previous MIs. We plotted the proportion of index events identified as recurrent MIs as a function of the look-back period. Moreover, we calculated 5-year all-cause mortality and confidence intervals (CIs) using the 1-Kaplan–Meier method for five cohorts based on the index events and defined by look-back periods of 0, 5, 10, 20, and up to 39 years.ResultsAmong 63,885 index events, 3.4% were identified as recurrent MIs with 5 years of look-back, 7.9% with 10 years, 14% with 24 years, and 15% with up to 39 years. All-cause mortality risk was 36% (95% CI: 36–37%) with 0 years of look-back, 35% (95% CI: 35–36%) with 5 years, 35% (95% CI: 35–36%) with 10 years, 34% (95% CI: 34–35%) with 20 years, and 34% (95% CI: 33–34%) with up to 39 years.ConclusionMost recurrent MIs were identified with a look-back period of 24 years. Including recurrent MIs in a planned incident MI cohort, due to shorter look-back periods, overestimated the mortality risk.