Myocardial Infarction Guidelines Research Articles

The impact of clinical pharmacists on adherence to acute myocardial infarction guidelines: A controlled before-after Interventional study

In this controlled before-and-after interventional study, the clinical pharmacist evaluated the application of performance measures (PMs) and quality measures (QMs) in the control group and the intervention group in Al-Gurayat General Hospital (GGH) in Saudi Arabia. The total number of PMs applied in the intervention group (n = 445) was significantly higher than that in the control group (n = 407) (P-value =0.006). Considering individual PMs, only PM-4 (high-intensity statin prescription) was applied at a significantly higher frequency in the intervention group (n = 41, 82%) as compared to the control group (n = 29, 58%) (P-value = 0.009). After acceptance of 60 out of the 75 recommendations made by the clinical pharmacist for the intervention group (80% acceptance rate), the number of treatment-related problems (TRPs) left on discharge of the intervention group was significantly reduced to 15 as compared to 61 TRPs left on discharge of the control group (p <0.001). The clinical pharmacist-led interventions have a significant impact on ensuring adherence to PMs during the management of acute myocardial infarction (AMI) in GGH.

Application of European Society of Cardiology guidelines for evaluating acute coronary syndrome risk in low-risk patients with cocaine-associated chest pain: Findings from the RISK study – An observational analysis

BackgroundCocaine was the drug of choice in 4.7 % of all recreational drug-related emergency department visits. Of these patients, 40 % present with cocaine-associated chest pain, of whom 4.7 % develop an acute coronary syndrome. The American Heart Association recommends a 12-hour observation period for these patients. ObjectiveThis study primarily aimed to ascertain whether the European Society of Cardiology non-ST-elevation myocardial infarction guidelines can be safely applied to rule-out acute coronary syndrome in low-risk patients with cocaine-associated chest pain. MethodsFor this prospective observational cohort study, patients, aged 18–45 years old, who presented with cocaine-associated chest pain and were risk stratified as low risk according to the European Society of Cardiology non-ST-elevation myocardial infarction guidelines and therefore discharged home without prolonged observation period, were included. They were followed to assess major adverse cardiac events four weeks after presentation to the emergency department or chest pain unit. Cocaine use was confirmed with urine toxicology screening. ResultsA total of 107 patients were included and analysed. The accuracy of the self-reported history of recent cocaine use was 94 %. Post-discharge cocaine use persisted among 32 % of patients. None of the included 107 patients died and major adverse cardiac event within four weeks did not occur among 97 patients with available data regarding MACE. ConclusionRuling out an acute coronary syndrome using the European Society of Cardiology non-ST-elevation myocardial infarction guidelines is likely to be safe for patients with cocaine-associated chest pain, however this study was underpowered to reach definitive conclusions.

Impact of the guidelines recommendations in the management of non-ST-segment elevation myocardial infarction according to gender. Analysis of 30-day mortality

Abstract Funding Acknowledgements None. Background Current non-ST-segment elevation myocardial infarction (NSTEMI) guidelines recommend early invasive treatment (<24h) and simple antithrombotic treatment with aspirin (ASA). Classic studies describe a gender bias in the infarct treatment. Purpose To evaluate the impact of the guidelines recommendations in real-life management of NSTEMI in regards to invasive strategy and dual antiplatelet pretreatment (DAPT), and to analyze 30-day mortality according to gender. Methods A prospective unicentric registry of NSTEMI patients admitted to an Acute Cardiac Care Unit was conducted from January 2017 and December 2022. We analyzed the rates of early angiography (<24h) and pretreatment according to the guideline publication (01/09/2020). Patients were classified in two groups, depending on the time of admission in pre-guidelines (preCG) group (from January 2017 to September 1st 2020) and post-guidelines (postCG, admitted after September 1st 2020). We also analyzed the differences in management and 30-day mortality according to gender. Results A total of 787 consecutive NSTEMI patients were included, 24.9% women, mean age 65.3 years. Pretreatment with DAPT was routinely used in 90,2% of the cases, irrespective of gender or the new guidelines recommendation. Early angiography (<24 hours) was performed more frequently in men than women (61.6% vs 53.1%, p=0,035), although since the new guideline publication the early invasive management has increased in both genders (51.3% vs 72.6% in men, p<0,001; and 43.3% vs 64.1% in women, p=0,003). 30-day mortality tends to be higher in men, although the difference was not significant (4.6% in men vs 2.6% in women, p=0,212) and was not affected by the guideline publication (preCG 4.6% vs postCG 4.6% in men, p=0,994, preCG 2.9% vs post CG 2.2% in women, p=0,752). Conclusions In our NSTEMI registry there was an increase in the rates of early angiography, both in men and women, since the guideline publication, but there’s still a gender bias in the invasive treatment. Most NSTEMI patients still received DAPT pretreatment, without differences after the guideline publication. Despite the increase in early invasive management, 30-day mortality rates remain unchanged in both groups.

Derivation and validation of a novel 3hour-pathway for the observe-zone of the ESC 0/1h-hs-cTnI algorithm

Abstract Background The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3-hour cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-hs-cTnI algorithm; however, no specific cut-off for further triage is endorsed. Purpose To derive and internally validate a novel 3h-pathway for the observe-zone of the ESC 0/1h-hs-cTnI (Architect) algorithm. Methods In an multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial hs-cTnI sampling and 90-day follow-up information. High sensitivity-cTnI (Architect) concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. Internal validation was assessed with a bootstrapping procedure. Results Among 2481 eligible patients, application of the ESC 0/1h-algorithm triaged 1725 patients (69.5%) to either rule-out or rule-in of NSTEMI, remaining 756 patients (30.5%) in the observe-zone (adjudicated NSTEMI prevalence 65/756 patients, 13.7%). A novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnI concentration <8 ng/L and a 0/3h-hs-cTnI absolute change <3 ng/L, triaging 241 patients (32%) towards rule-out, resulting in a sensitivity of 100% (95%CI 94.4-100) and a NPV of 100% (95%CI 98.4-100). A 0/3h-hs-cTnI absolute change ≥8 ng/L ruled-in 69 patients (9.1%), resulting in a specificity of 95.8% (95%CI 94.0-97.1) and a PPV of 58.0% (95%CI 46.2-68.9), Figure. The novel 3h-pathway reduced the number of patients remaining in the observe zone from 756 (30.5%) to 446 (18%), resulting in a relative reduction of 41%, while the number of NSTEMI was reduced from 65 to 25, resulting in a relative reduction of 62%. Findings were confirmed in the optimism-corrected bootstrap internal validation. Conclusions A novel derived pathway combining a 3h hs-cTnI concentration <8 ng/L and a 0/3h absolute change <3 ng/L allowed to safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-hs-cTnI (Architect) algorithm.Performance of the novel derived cutoffs

Time Trends of Etiology, Treatment, and Long-Term Outcomes Among Patients with Left Ventricular Thrombus.

Recommendations for drug treatment of left ventricular thrombus (LVT) are based on the ST-segment elevation myocardial infarction (STEMI) guidelines; however, the etiology of LVT has changed. Due to the lack of evidence regarding LVT treatment in the heart failure population, current heart failure guidelines do not cover LVT treatment. We sought to review the etiology of LVT and changes in antithrombotic therapy over the previous 12 years and explore the impact of anticoagulation treatment from a single center's experience. From January 2009 to June 2021, we studied 1675 patients with a discharge diagnosis of LVT at a single center to investigate the clinical characteristics, incidence of all-cause death, cardiovascular death, ischemic stroke, major adverse cardiac and cerebrovascular events (MACCE), systemic embolism (SE), and major bleeding events. Patients were divided into an anticoagulant group and a non-anticoagulant group according to whether they received oral anticoagulant therapy at discharge. The study included 909 patients (anticoagulation, 510; no anticoagulation, 399). While overall antiplatelet therapy dramatically decreased, more patients with LVT received oral anticoagulation in 2021 (74.0%) than in 2009 (29.6%). In addition, more than half of the patients had heart failure with reduced ejection fraction (HFrEF) each year. The all-cause mortality was 17.3% during 3.8 years of follow-up. The incidences of cardiovascular death, stroke, MACCE, SE, and major bleeding were 16.0%, 3.3%, 19.8%, 5.1%, and 1.7%, respectively. The anticoagulation group had a significantly higher proportion of dilated cardiomyopathy than the non-anticoagulation group (24.7% vs. 5.5%, p 0.001), and a lower LVEF (34.0 vs. 41.0, p 0.001). The anticoagulation group also had a higher probability of adverse events on long-term follow-up (p 0.05). A multivariable competing risk regression model found no significant difference in all six endpoints between the groups (all p 0.05). Similar results were found by matched and weighted data analysis. Diabetes mellitus (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.04-1.93; p = 0.027), renal insufficiency (HR, 2.36; 95% CI, 1.60-3.50; p 0.001), history of previous stroke (HR, 1.60; 95% CI, 1.13-2.29; p = 0.009), and HFrEF (HR, 2.54; 95% CI, 1.78-3.64; p 0.001) were predictors of increased risk of MACCE. Heart failure, rather than acute myocardial infarction, is currently the primary cause of LVT. A trend towards better prognosis in the no anticoagulation group was noted. Multivariable, matching and weighting analysis showed no improvement in prognosis with anticoagulant therapy. Our study does not negate the efficacy of anticoagulation but suggests the need to strengthen the management of anticoagulation in order to achieve better efficacy.

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.

Missing occlusions: Quality gaps for ED patients with occlusion MI

BackgroundST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. MethodsThis retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0–2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of “STEMI”, and admission/discharge diagnoses were compared. ResultsAmong 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had “STEMI” on ECG, and median door-to-cath time was 103 min (IQR 71–149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had “STEMI” on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043–3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as “Non-STEMI.” ConclusionsSTEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.

Clinical Study of a New Modified Early Warning Scoring System for Rapidly Evaluating Shock in Adults.

Shock is one of the most common severe syndromes requiring emergency treatment. Acute myocardial infarction guidelines, the surviving sepsis campaign, and low blood volume resuscitation guidelines indicate the prioritization ofearly identification of shock. APACHE II(Acute Physiology and Chronic Health Evaluation II), SOFA (Sequential Organ Failure Assessment), and MEWS (Modified Early Warning System) scores are used to predict mortality in ICU (intensive care unit) patients. However, similar to APACHE II, SOFA cannot be used forrapid assessment. Hence the need for a new scoring system that is simple, faster, and efficacious in predicting and preventing mortality among shock patients. The present study was conducted to evaluate a new MEWS scoring system for early identification and estimate mortality risk in patients with shock. A total of 170 patients with shock meeting the inclusion criteria who presented to the ICU of Ramaiah Hospitals from November 2019 to August 2021 were included in the study. Baseline variables, laboratory parameters, APACHE II score, SOFA score, MEWS score, and new MEWS score were compared between the two groups. Patients were followed up till mortality or discharge from ICU. Among the 170 patients included in the studyseptic shock (69.4%) was the most common type of shock followed by cardiogenic(7.64%) and hypovolemic shock (7.64%). The requirement of inotropic support and mechanical ventilation was associated with significantly higher mortality (55.6% and 52.6% respectively). The AUROC (area under the curve) for SOFA in predicting mortality was 0.738 (p<0.001). The AUROCfor APACHE II score in predicting mortality was 0.758 (p<0.001). The AUROC for MEWS score in predicting mortality was 0.655 (p=0.0002). The AUROC for the new MEWS score in predicting mortality was 0.684 which is more than that of the conventional MEWS score (p <0.001). New MEWS score is better than the MEWS score in predicting mortality. The new MEWS score is a simple, entirely clinical, inexpensive scoring system that can be done within a short time as a patient contact in an emergency. Hence, the new MEWS score can help in the quick identification of patients who are at high risk for developing shock and can be used as a better predictor of mortality.

Fallacy of Median Door-to-ECG Time: Hidden Opportunities for STEMI Screening Improvement.

BackgroundST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes.Methods and ResultsThis 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non‐English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%.ConclusionsExamining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.

Derivation and validation of a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm

Abstract Background The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed. Purpose To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm. Methods In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study. Results Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration &amp;lt;15 ng/L and a 0/3h-hs-cTnT absolute change &amp;lt;4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95% CI 96.0–99.9) and a NPV of 99.3% (95% CI 95.4–99.9). A 0/3h-hs-cTnT absolute change ≥6 ng/L ruled-in 63 patients (11.2%), resulting in a specificity of 98% (95% CI 96.2–98.9) and a PPV of 85.7% (95% CI75.0–92.3). The novel 3h-pathway reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50% (Figure 1). Findings were confirmed in both internal and external validation. Conclusions A novel derived pathway combining a 3h hs-cTnT concentration &amp;lt;15 ng/L and a 0/3h absolute change &amp;lt;4 ng/L allowed to very safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-algorithm. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1

Novel Criteria for the Observe-Zone of the ESC 0/1h-hs-cTnT Algorithm.

The non-ST-segment-elevation myocardial infarction (NSTEMI) guidelines of the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cutoff for further triage is endorsed. Recently, a specific cutoff for 0/3h high-sensitivity cardiac troponin T (hs-cTnT) change (7 ng/L) was proposed, warranting external validation. Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by 2 independent cardiologists applying the fourth universal definition of myocardial infarction, on the basis of complete cardiac workup, cardiac imaging, and serial hs-cTnT. Hs-cTnT concentrations were measured at presentation, after 1 hour, and after 3 hours. The objective was to externally validate the proposed cutoff, and if necessary, derive and internally as well as externally validate novel 0/3h-criteria for the observe-zone of the ESC 0/1h-hs-cTnT-algorithm in an independent multicenter cohort. Among 2076 eligible patients, application of the ESC 0/1h-hs-cTnT-algorithm triaged 1512 patients (72.8%) to either rule out or rule in NSTEMI, leaving 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence, 120/564 patients, 21.3%). The suggested 0/3h-hs-cTnT-change of <7 ng/L triaged 517 patients (91.7%) toward rule-out, resulting in a sensitivity of 33.3% (95% CI, 25.5-42.2), missing 80 patients with NSTEMI, and ≥7 ng/L triaged 47 patients toward rule-in (8.3%), resulting in a specificity of 98.4% (95% CI, 96.8-99.2). Novel derived 0/3h-criteria for the observe-zone patients ruled out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) toward rule-out, resulting in a sensitivity of 99.2% (95% CI, 96.0-99.9), missing 1 patient with NSTEMI. A 0/3h-hs-cTnT absolute change ≥6 ng/L triaged 63 patients (11.2%) toward rule-in, resulting in a specificity of 98% (95% CI, 96.2-98.9) Thereby, the novel 0/3h-criteria reduced the number of patients in the observe zone by 36%s and the number of type 1 myocardial infarction by 50%. Findings were confirmed in both internal and external validation. A combination of a 3h-hs-cTnT concentration (<15 ng/L) and a 0/3h absolute change (<4 ng/L) is necessary to safely rule out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-hs-cTnT-algorithm. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT00470587.

Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction.

Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.

Individual trends in LDL-C control in patients with previous myocardial infarction

Introduction and objectivesIn patients with previous myocardial infarction (MI) guidelines recommend a low-density lipoprotein cholesterol (LDL-C) < 70mg/dL (ACC/AHA) or < 55mg/dL (European Society of Cardiology). Current data on individual variation of LDL-C in this population is limited. We aimed to assess the percentage of patients who achieved an LDL-C below target, the variation from 2013 to 2018 and to evaluate clinical predictors of good LDL-C control. MethodsA retrospective cohort study was conducted. All Cardiology outpatients with previous MI with available LDL-C measurements after MI in 2013, 2016 and 2018 were included. We estimated the prevalence of patients with LDL-C below target for each year, individual trends and performed multivariate analysis for assessing clinical predictors. ResultsOf 650 patients, an LDL-C < 70mg/dL was attained in 24.8% and 34.0% in 2013 and 2018, respectively, with a median reduction in LDL-C of 6mg/dL (P<.001). LDL-C < 55mg/dL was observed in 8.0% and 11.7% in the same years. Only 10.0% and 1.4% of patients presented 3 LDL-C measurements < 70mg/dL and 55mg/dL, respectively, whereas 78.8% and 47.4% did not have any LDL-C < 55mg/dL or < 70mg/dL. Male sex and diabetes were constant predictors of achieving an LDL-C below target. ConclusionsThere has been an improvement in LDL-C control in recent years, but only one-third of the outpatients with previous MI are currently on LDL-C < 70mg/dL and even less on LDL-C < 55mg/dL. Male sex and diabetes predicted better LDL-C control.

Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a pharmaco-invasive strategy in ST-segment elevation myocardial infarction: the FAST-MI programme.

ST-segment elevation myocardial infarction (STEMI) guidelines recommend primary percutaneous coronary intervention (pPCI) as the default reperfusion strategy when feasible ≤120 min of diagnostic ECG, and a pharmaco-invasive strategy otherwise. There is, however, a lack of direct evidence to support the guidelines, and in real-world situations, pPCI is often performed beyond recommended timelines. To assess 5-year outcomes according to timing of pPCI (timely vs. late) compared with a pharmaco-invasive strategy (fibrinolysis with referral to PCI centre). The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme consists of nationwide observational surveys consecutively recruiting patients admitted for acute myocardial infarction every 5 years. Among the 4250 STEMI patients in the 2005 and 2010 cohorts, those with reperfusion therapy and onset-to-first call time <12 h (n = 2942) were included. Outcomes at 5 years were compared according to type of reperfusion strategy and timing of pPCI, using Cox multivariable analyses and propensity score matching. Among those, 1288 (54%) patients had timely pPCI (≤120 min from ECG), 830 (28%) late pPCI (>120 min), and 824 (28%) intravenous fibrinolysis. Five-year survival was higher with a pharmaco-invasive strategy (89.8%) compared with late pPCI [79.5%; adjusted hazard ratio (HR) 1.51; 1.13-2.02] and similar to timely pPCI (88.2%, adjusted HR 1.02; 0.75-1.38). Concordant results were observed in propensity score-matched cohorts and for event-free survival. A substantial proportion of patients have pPCI beyond recommended timelines. As foreseen by the guidelines, these patients have poorer 5-year outcomes, compared with a pharmaco-invasive strategy.

Abstract P210: Long-Term Outcomes After ST-Elevation Myocardial Infraction After Reducing Fibrinolytic Use in a Rural Cohort

Background: ST-elevation myocardial infarction (STEMI) guidelines recommend lytic therapy if unable to receive primary percutaneous coronary intervention (PPCI) within 120 min. from first medical contact (FMC). Sparse data exists from rural areas; we aimed to evaluate outcomes in rural population after implementing STEMI protocol. Methods: Retrospective chart review of NCDR ACTION and internal STEMI registries presenting to 2 PCI-capable hospitals (Essentia Health in Duluth, MN and Fargo, ND) between 5/2009-12/2017. Only patients with rural rural-urban commuting area (RUCA) codes were included. Analysis included using standard STEMI metrics with Cox regression and Kaplan-Meier survival curves for survival analysis, and logistic regression for 30-day and 1-year mortality and 30-day readmission. Results were adjusted for age and sex. Results: There were 1229 STEMI activations with 1033 true STEMI events (28.3% female, mean age 63.6 years). Among true STEMIs, 73.3% presented to a non-PCI capable hospital and were transferred to PCI-capable hospital. Only 9.9% were field activated and transported directly to PCI-capable hospital. FMC to device time was &lt;120 min. 33.2% of the time with a median FMC to device time of 135 min. (IQR 111-174 min.). Positive ECG to device time was &lt;120 min. 53.9% of the time with a median ECG to device time of 116 min. (IQR 99-144 min). Lytic use decreased over time from 30.2% in 2009-10 to 6.8% in 2016-17. Survival was not different comparing PPCI vs. lytic therapy (hazard ratio 1.21; 95% CI: 0.83, 1.75, p=0.32). For PPCI, 30-day and 1-year mortality were 8.6% (CI:6.8%-10.4%) and 12.8% (CI:10.6%-15.0%), respectively, while for lytics, 30-day and 1-year mortality were 7.2% (CI:4.6%-9.8%) and 10.8% (CI:7.1%-14.3%), respectively. The 30-day readmission for PPCI was not significantly different compared to lytics (7.6%, CI:6.7%-8.7% for PPCI vs. 12.0% CI:9.8%-14.6% for lytic, p=0.056). Conclusion: PPCI in rural areas was associated with similar outcomes compared to lytic therapy for STEMI patients.

Biomarkers enhance the long-term predictive ability of the KAMIR risk score in Chinese patients with ST-elevation myocardial infarction.

Background:The Global Registry of Acute Coronary Events (GRACE) score is recommended by current ST-elevation myocardial infarction (STEMI) guidelines. But it has inherent defects. The present study aimed to investigate the more compatible risk stratification for Chinese patients with STEMI and to determine whether the addition of biomarkers to the Korea Acute Myocardial Infarction Registry (KAMIR) score could enhance its predictive value for long-term outcomes.Methods:A total of 1093 consecutive STEMI patients were included and followed up 48.2 months. Homocysteine, hypersensitive C-reactive protein (hs-CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were detected. The KAMIR score and the GRACE score were calculated. The performance between the KAMIR and the GRACE was compared. The predictive power of the KAMIR alone and combined with biomarkers were assessed by the receiver-operating characteristic (ROC) curve.Results:The KAMIR demonstrated a better risk stratification and predictive ability than the GRACE (death: AUC = 0.802 vs. 0.721, P < 0.001; major adverse cardiovascular events (MACE): AUC = 0.683 vs. 0.656, P < 0.001). It showed that the biomarkers could independently predict death [homocysteine: HR = 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR = 1.052 (1.000–1.104), P = 0.018; NT-pro BNP: HR = 1.142 (1.004–1.280), P = 0.021] and MACE [homocysteine: HR = 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR = 1.012 (1.003–1.021), P = 0.020; NT-pro BNP: HR = 1.136 (1.104–1.168), P = 0.006]. When they were used in combination with the KAMIR, the area under the ROC curve (AUC) significantly increased for death [homocysteine: AUC = 0.802 vs. 0.890, Z = 5.982, P < 0.001; hs-CRP: AUC = 0.802 vs. 0.873, Z = 3.721, P < 0.001; NT-pro BNP: AUC = 0.802 vs. 0.871, Z = 2.187, P = 0.047; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.802 vs. 0.940, Z = 6.177, P < 0.001] and MACE [homocysteine: AUC = 0.683 vs. 0.771, Z = 6.818, P < 0.001; hs-CRP: AUC = 0.683 vs. 0.712, Z = 2.022, P = 0.031; NT-pro BNP: AUC = 0.683 vs. 0.720, Z = 2.974, P = 0.003; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.683 vs. 0.789, Z = 6.900, P < 0.001].Conclusion:The KAMIR is better than the GRACE in risk stratification and prognosis prediction in Chinese STEMI patients. A combination of above-mentioned biomarkers can develop a more predominant prediction for long-term outcomes.

Right bundle branch block in patients with suspected myocardial infarction.

The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. We aimed to evaluate this novel recommendation in two prospective studies of patients with suspected myocardial infarction. We included 4067 patients presenting to the emergency department with suspected myocardial infarction. All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB), bifascicular block (BFB) or no bundle branch block. All patients were followed for up to two years to assess mortality. In the overall population 125 (3.1%) patients had RBBB, 281 (6.9%) LBBB and 60 (1.5%) BFB. The final diagnosis of myocardial infarction was adjudicated in 20.8% (RBBB), 28.5% (LBBB), 23.3% (BFB) and 21.6% (no complete block) of patients. The mortality rate after one year was 10.7% (RBBB), 7% (LBBB), 17.5% (BFB) and 3.2% (no complete block). The adjusted hazard ratios were 1.29 (95% confidence interval (CI) 0.71-2.34; P=0.40) for RBBB, 1.71 (95% CI 1.17-2.50; P=0.006) for LBBB and 2.27 (95% CI 1.28-4.05; P=0.005) for BFB. Our results support the new European Society of Cardiology ST-segment elevation myocardial infarction guideline describing RBBB as a high risk for mortality in patients with suspected myocardial infarction. However, the data challenge the concept of RBBB as a trigger of acute angiography because the likelihood of myocardial infarction in a chest pain unit setting is equally frequent in patients without bundle branch block.

Integrating the results of the CULPRIT-SHOCK trial in the 2017 ESC ST-elevation myocardial infarction guidelines: viewpoint of the task force.

Holger Thiele was the PI of the CULPRIT-SHOCK trial, which was funded the European Union 7th Framework Program (FP7/2007-2013) and by the German Heart Research Foundation and the German Cardiac Society.

CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock): Implications on Guideline Recommendations.

Mortality of cardiogenic shock complicating myocardial infarction can be reduced by an early invasive strategy with percutaneous coronary intervention (PCI) of the infarct-related artery. Up to 80% of patients with cardiogenic shock present with multivessel coronary artery disease, and their mortality is higher compared with patients with single-vessel disease. Until recently, there were no randomized data on how to deal with nonculprit lesions in the setting of cardiogenic shock. This lack of evidence is also reflected by divergent recommendations in current international guidelines. The European ST-segment–elevation acute myocardial infarction (STEMI) guidelines, published in 2017, recommend immediate PCI of nonculprit lesions in patients with cardiogenic shock (Class IIb, Level of Evidence C),1 whereas the American STEMI guidelines give no specific recommendation.2 However, American appropriate use criteria, also published in 2017, consider immediate revascularization of a nonculprit artery during the same procedure appropriate if cardiogenic shock persists after treatment of the culprit artery.3 After publication of the randomized, multicenter CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), guidelines and appropriate use criteria need to be reconsidered. To briefly recap, CULPRIT-SHOCK showed a significant clinical benefit of a culprit-lesion-only strategy with a reduction in the primary end point of 30-day mortality or severe renal failure requiring renal replacement therapy (45.9% culprit-lesion-only PCI versus 55.4% immediate multivessel PCI group; relative risk, 0.83; 95% confidence interval, 0.71–0.96; P =0.01), which was driven mainly by an absolute 8.2% reduction in 30-day mortality (43.3% versus 51.5%; relative risk, 0.84; 95% confidence interval, 0.72–0.98; P =0.03).4 With the application of current guideline criteria, the results …

Background and design of the ACCA-EAPCI registry on ST-segment elevation myocardial infarction of the European Society of Cardiology.

Treatment of patients with acute ST-segment elevation myocardial infarction has improved over past decades, with reperfusion therapy being the cornerstone in the acute phase. Based on the results of large randomised trials the current ST-segment elevation myocardial infarction guidelines of the European Society of Cardiology (ESC) recommend acute treatments and secondary prevention therapies. However, there are large variations between ESC countries in the treatment of patients presenting with ST-segment elevation myocardial infarction. Therefore the ESC has initiated a prospective registry to evaluate the current treatments and outcomes of these patients with a special focus on adherence to the ESC guidelines and on differences between countries and regions. This paper describes the methodology and design of the ST-segment elevation myocardial infarction registry conducted in collaboration of the Acute Cardiac Care Association and the European Association of Percutaneous Coronary Intervention.