Myocardial Infarction Registry Research Articles

Impact of Marital Status on Management and Outcomes of Patients With Acute Myocardial Infarction: Insights From the China Acute Myocardial Infarction Registry.

Background Acute myocardial infarction (AMI) is one of the leading causes of mortality worldwide, whereas social support is a known predictor of the prognosis after AMI. As a common factor influencing social support, the impact of marital status on care quality, in-hospital mortality, and long-term prognosis of patients with AMI remains largely unknown. Methods and Results The present study analyzed data from the CAMI (China Acute Myocardial Infarction) registry involving 19 912 patients with AMI admitted at 108 hospitals in China between January 2013 and September 2014 and aimed to evaluate marital status-based differences in acute management, medical therapies, and short-term and long-term outcomes. The primary end point was 2-year all-cause death. The secondary end points included in-hospital death and 2-year major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke). After multivariable adjustment, 1210 (6.1%) unmarried patients received less reperfusion treatment in patients with both ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction (adjusted odds ratio [OR], 0.520 [95% CI, 0.437-0.618]; P<0.0001; adjusted OR, 0.489 [95% CI, 0.364-0.656]; P<0.0001). Being unmarried was not associated with poorer in-hospital outcome but with long-term all-cause mortality and major adverse cardiac and cerebrovascular events in both ST-segment-elevation myocardial infarction (adjusted hazard ratio [HR], 1.225 [95% CI, 1.031-1.456]; P=0.0209; adjusted HR, 1.277 [95% CI, 1.089-1.498]; P=0.0027) and non-ST-segment-elevation myocardial infarction (adjusted HR, 1.302 [95% CI, 1.036-1.638]; P=0.0239; adjusted HR, 1.368 [95% CI, 1.105-1.694]; P=0.0040) populations. Conclusions The present study suggests that being unmarried is independently related to less reperfusion received, but could not explain the higher in-hospital mortality rate after covariate adjustment. Being unmarried is associated with a substantially increased risk of adverse events over at least the first 24 months after AMI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01874691.

A szívinfarktus incidenciája, a betegek ellátásának és prognózisának összehasonlítása Magyarország különböző fejlettségű járásaiban

Several international studies have already confirmed the importance of the socioeconomic status of acute myocardial infarction patients in terms of patient care and prognosis. To our knowledge, a nationwide examination of this kind has not yet taken place in Hungary. The investigation of this problem field was made possible by the fact that from January 1, 2014, all healthcare providers must record the data of patients treated with a diagnosis of acute myocardial infarction in the database of the Hungarian Myocardial Infarction Registry (HUMIR). In this study, the authors searched for an answer to whether the complex development index (CDI) in Hungary's 174 districts and 23 capital districts influences the treatment and prognosis of acute myocardial infarction patients. Based on the CDI worked out by the Hungarian Central Statistical Office, the authors divided the Hungarian districts into low (CDI_L), medium (CDI_M) and high (CDI_H) CDI groups according to their values. They examined the incidence, hospital treatment and prognosis of acute myocardial infarction in these administrative-territorial units. The HUMIR included 66,253 patients treated by myocardial infarction between 2015 and 2019. Their place of residence could be identified based on the zip code and in which district it was located. In the examined population, 29,101 patients with ST-elevation (STEMI) and 37,152 without ST-elevation (NSTEMI) received treatment for acute myocardial infarction. In the population over 15 years of age, the age-standardized incidence of STEMI was 68.8 per 100,000 inhabitants a year in the CDI_L group and 52.7 per 100,000 inhabitants a year in the CDI_H group. Almost the same values were found in all three CDI subgroups of NSTEMI incidence (69.5 and 67 per 10,000 inhabitants a year). The frequency of percutaneous coronary intervention in the case of STEMI was higher than in NSTEMI, but within the groups, CDI did not influence the performance of this treatment. In the case of STEMI, the rates of patients who underwent percutaneous coronaria intervention in all three CDI subgroups (CDI_L, CDI_M, CDI_H) were 83.5%, 83.7%, 83.5%, while in the case of NSTEMI they were 57.4%, 57.7%, 57.3%. The authors applied a Cox multivariate regression analysis to examine myocardial infarction mortality. The CDI did not affect the 30-day mortality rates in the case of any myocardial infarction: the hazard ratio (HR) values were 0.906 and 0.914 (p = 0.04659; p = 0.04686) in the case of STEMI, while 1.067 and 1.001 (p = 0.16520; p = 0.98933) in the case of NSTEMI. In the case of a STEMI diagnosis, the risk of the 30-364-day and the 1-year mortality in the subgroup of CDI_H was significantly lower (HR = 0.822 and 0.816) than in the subgroup of CDI_L (p = 0.00096 and p = 0.00001). In the case of NSTEMI diagnosis, the authors found a difference in the risk of beyond 1-year mortality by comparing the districts in the subgroup of CDI_L with the districts in CDI_H: in the latter case, the HR of the mortality was 0.876, which was significantly lower (p = 0.00029) than in the subgroup of CDI_L. The CDI has independent prognostic significance in determining the late prognosis of acute myocardial infarction patients. Orv Hetil. 2022; 163(47): 1862-1871.

Abstract 9820: Heart Failure at Admission in Patients With ST-Elevation Myocardial Infarction. Registry ARGEN-IAM-ST

Introduction: Heart failure (HF) is a frequent complication of ST-elevation myocardial infarction (STEMI). Despite advances in the management of STEMI, when associated with HF, its prognosis continues to be ominous. Knowing the reality and the management of these patients is a necessity that will guide us for future strategies. Objective: To evaluate incidence, associated factors, relationship with reperfusion strategies, treatment at admission, and evolution of patients (pts) with STEMI who present HF at admission. Material and Method: Data from the National Registry of ST-Elevation Myocardial Infarction of Argentina (ARGEN-IAM-ST) were analyzed from 1/1/2016 to 9/30/2020. Based on Killip and Kimball variable at admission, the population was divided into 2 groups, those pts with Killip and Kimball equal to 1 were grouped as pts without HF (noHF) at admission and those with Killip and Kimball greater to 1 as with HF at admission. Demographic characteristics, clinical, electrocardiographic, laboratory variables, and admission treatment were compared. Hospital mortality was compared. Results: 3,174 pts were analyzed. Pts with HF were 22.31%. Mean age (noHF vs HF) was 59.80 years (SD±11.45) and 64.01 years (SD±12.14), p&lt;0.0001; predominance of women in HF (24.50% vs 18.50%, p&lt;0.001). The baselines characteristics can be seen in Table 1. Reperfusion strategy was less used in HF group [87.57% vs 92.58%, OR 0.56 (95%CI 0.43-0.74), p&lt;0.001] and its success was less frequent (Table 2). Pharmacological treatment is shown in Figures 1 and 2. Mortality was 3.00% in noHF vs 28.39% in HF, p&lt;0.001. In the multivariate analysis, the variables associated with changes in mortality are described in Table 3; HF was associated with an increase in mortality. Conclusions: Pts with STEMI associated with HF at admission are a different group with a higher risk. The reperfusion strategy and certain pharmacological treatments on admission are less frequent in these pts.

An Update on Acute Coronary Syndrome and Myocardial Infarction Registries among Member Countries of the Asian Pacific Society of Cardiology

Background: Cardiovascular disease is the leading cause of mortality globally, with most deaths occurring in low- and middle-income countries. The present study aims to provide an overview of the characteristics of the national registries managed by member societies of the Asian Pacific Society of Cardiology (APSC). Methods: The APSC website was searched to identify member countries of the society. Using a combination of keywords, PubMed and Google advanced search were trawled to identify cardiovascular registries from each member country and publications generated from these registries. The number of citations each publication received was identified and correlated with the characteristics of each registry. Results: The search found 12 of the 23 member countries (52.2%) had developed a national cardiovascular registry; seven had acute coronary syndrome (ACS) registries and five had acute myocardial infarction (AMI) registries. The registries were primarily established to assess and improve cardiovascular care, and generated a total of 318 articles, a median of 11 articles per registry. There were variations in numbers of articles produced as well as in citations received, with more publications from high-income countries than middle-income countries. Conclusion: The majority of member countries of the APSC have established national ACS and AMI registries. While there were some inherent differences between countries in terms of output, these registries provide an invaluable resource for benchmarking cardiovascular care and could help contribute to local guidelines development.

Impact of neighbourhood-level socioeconomic status, traditional coronary risk factors, and ancestry on age at myocardial infarction onset: A population-based register study

BackgroundThere is consensus that low socioeconomic status (SES) is associated with an increased risk of acute myocardial infarction (AMI), but the extent to which traditional coronary risk factors and other characteristics of low SES mediate this effect remains uncertain. This study examined AMI patients residing in neighbouring city districts with the same local hospital despite having among the most considerable differences in mean SES in Norway. Our purpose was to assess low SES as a coronary risk factor and examine whether traditional coronary risk factors or ancestry mediate this effect.MethodsSix hundred six patients (215 and 391 with a low and high neighbourhood-level SES, respectively) admitted to Diakonhjemmet Hospital with non-ST-elevation myocardial infarction (NSTEMI) between 2014 and 2017, entered analysis. Data from the Norwegian Myocardial Infarction Register were used to identify patient characteristics, and the STATA/SE 15.1 software was used to perform the statistical analyses.ResultsPatients from socioeconomically disadvantaged city-districts had a 4.9 years earlier onset of AMI (68.99 vs. 73.89 years; p < 0.001) and a higher prevalence of previous AMI, known diabetes, and current smokers (36% vs. 27%, 25% vs. 12%, and 33% vs. 17%, respectively; all p ≤ 0.05). When only comparing patients with a first time AMI, an even greater difference in the age at AMI onset was found (6.1 yrs; p < 0.001). The difference in age at AMI onset remained statistically significant when adjusting for traditional coronary risk factors (3.28 yrs; 95% confidence interval (CI) 1.11−5.44; p = 0.003), but not when adjusting for presumed non-Northwest-European ancestry (1.81 yrs; 95% CI −0.55 to 4.17; p = 0.132).ConclusionThis study supports earlier research showing an increased risk of AMI in socioeconomically disadvantaged individuals. In our population, presumed non-Northwest-European ancestry could entirely explain the increased risk, whereas traditional coronary risk factors could only partly explain the increased risk.

Determinants of Early and Late In-Hospital Mortality After Acute Myocardial Infarction: A Subanalysis of the OBTAIN Registry

BackgroundPredictors of in-hospital mortality after myocardial infarction (MI) have been reported dichotomously: survival vs death. Predictors of time from admission to death have not been reported. MethodsA total of 7335 patients were enrolled in a prospective multicentre registry of acute MI. In-hospital mortality was classified by time from admission as acute (≤ 2 days), subacute (3 to 7 days), late (8 to 14 days), and very late (≥ 15 days) to identify factors associated with time to death in patients who died before discharge. Patient and MI characteristics, in-hospital interventions, and electrocardiographic findings were screened for differences in time to in-hospital death. ResultsIn-hospital death affected 351 patients (4.8%). Mean age was 72.0 ± 12.4 years, and 40.5% were female patients. Median survival was 5 days (interquartile range: 2-12), and 41% of in-hospital deaths occurred after 1 week. Cardiac biomarkers and ejection fraction were not related to time to in-hospital death. Previous MI, systolic blood pressure, pharmacologic therapy, and interventional treatments were different among the 4 groups. The factors associated with late in-hospital death were coronary artery bypass graft surgery (CABG), new-onset atrial fibrillation or flutter, heart failure or pulmonary edema, bleeding, and lung disease. Acute and subacute in-hospital death was associated with ST-elevation MI, lower systolic blood pressure, and cardiac arrest on admission. CABG was performed in 12% of post-MI patients who died in hospital. ConclusionsClinical risk factors for in-hospital mortality evolve over time immediately after acute MI. Understanding the time-dependent risk factors may allow for the development of new approaches to curtail the “later” in-hospital mortality.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry.

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation. Consecutively hospitalised adult NSTEMI patients (n=3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin. The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Derivation and validation of a predictive model for chronic stress in patients with cardiovascular disease.

Chronic stress in patients with cardiovascular disease (CVD), including peripheral artery disease (PAD), is independently associated worse outcomes. A model that can reliably identify factors associated with risk of chronic stress in patients with CVD is needed. In a prospective myocardial infarction (MI) registry (TRIUMPH), we constructed a logistic regression model using 27 patient demographic, socioeconomic, and clinical factors, adjusting for site, to identify predictors of chronic stress over 1 year. Stress at baseline and at 1-, 6- and 12-month follow-up was measured using the 4-item Perceived Stress Scale (PSS-4) [range 0-16, scores ≥6 depicting high stress]. Chronic stress was defined as at least 2 follow-up PSS-4 scores ≥6. We identified and validated this final model in another prospective registry of patients with symptomatic PAD, the PORTRAIT study. Our derivation cohort consisted of 4,340 patients with MI (mean age 59.1 ± 12.3 years, 33% females, 30% non-white), of whom 30% had chronic stress at follow-up. Of the 27 factors examined, female sex, current smoking, socioeconomic status, and economic burden due to medical care were positively associated with chronic stress, and ENRICHD Social Support Instrument (ESSI) score and age were inversely related to chronic stress. In the validation cohort of 797 PAD patients (mean age 68.6±9.7 years, 42% females, 28% non-white, 18% chronic stress) the c-statistic for the model was 0.77 and calibration was excellent. We can reliably identify factors that are independently associated with risk of chronic stress in patients with CVD. As chronic stress is associated with worse outcomes in this population, our work identifies potential targets for interventions to as well as the patients that could benefit from these.

Inflammatory plasma proteins predict short-term mortality in patients with an acute myocardial infarction

BackgroundThe aim of this study was to investigate the association between inflammatory markers and 28-day mortality in patients with ST-elevation myocardial infarction (STEMI).MethodsIn 398 STEMI patients recorded between 2009 and 2013 by the population-based Myocardial Infarction Registry Augsburg, 92 protein biomarkers were measured in admission arterial blood samples using the OLINK inflammatory panel. In multivariable-adjusted logistic regression models, the association between each marker and 28-day mortality was investigated. The values of the biomarkers most significantly associated with mortality were standardized and summarized to obtain a prediction score for 28-day mortality. The predictive ability of this biomarker score was compared to the established GRACE score using ROC analysis. Finally, a combined total score was generated by adding the standardized biomarker score to the standardized GRACE score.ResultsThe markers IL-6, IL-8, IL-10, FGF-21, FGF-23, ST1A1, MCP-1, 4E-BP1, and CST5 were most significantly associated with 28-day mortality, each with FDR-adjusted (false discovery rate adjusted) p-values of < 0.01 in the multivariable logistic regression model. In a ROC analysis, the biomarker score and the GRACE score showed comparable predictive ability for 28-day mortality (biomarker score AUC: 0.7859 [CI: 0.6735–0.89], GRACE score AUC: 0.7961 [CI: 0.6965–0.8802]). By combining the biomarker score and the Grace score, the predictive ability improved with an AUC of 0.8305 [CI: 0.7269–0.9187]. A continuous Net Reclassification Improvement (cNRI) of 0.566 (CI: 0.192–0.94, p-value: 0.003) and an Integrated Discrimination Improvement (IDI) of 0.083 ((CI: 0.016–0.149, p-value: 0.015) confirmed the superiority of the combined score over the GARCE score.ConclusionsInflammatory biomarkers may play a significant role in the pathophysiology of acute myocardial infarction (AMI) and AMI-related mortality and might be a promising starting point for personalized medicine, which aims to provide each patient with tailored therapy.

Association of air pollutants, weather variables, and myocardial infarction incidence in Berlin. A study of the Berlin Brandenburg Myocardial Infarction Registry (B2HIR) based on 17873 cases

Abstract Background Harmful health effects of air pollutants have long been assumed. Respective associations with respiratory diseases have frequently been reported. Recently, studies also pointed at possible links between air pollution and cardiovascular disease. Currently, nitric oxide (NOx) and particulate matter are of concern in Germany. Purpose To investigate the association of NOx, particulate matter (PM10), and weather variables with the incidence of myocardial infarction (MI) in Berlin. Methods The Berlin Brandenburg myocardial infarction registry (B2HIR) is documenting symptom onset, patient characteristics, comorbidity, procedural data, and outcome of patients with acute MI (onset ≤24h before admission) in Berlin and Brandenburg. From 2008 to 2014 (study period) the stable number of enrolling cardiology departments enabled epidemiologic analyses. Daily (aggregate and variable-specific) MI incidence was assessed for the study period. The government of Berlin provides detailed regional air pollution data (BLUME network). Daily and local NOx and PM10 concentrations were assessed and grouped according to regions (downtown, main roads, suburbs). Preceding days (single and 3 day average) values were also assorted to every single day. Ambient temperature, precipitation, and sunshine duration were assessed from the Berlin-Tempelhof weather station. Bivariate correlations and Poisson regression were calculated to examine associations between air pollutants, weather parameters, and MI incidence. Results 17873 MI cases were included over 7 years. Bivariate correlations and the Poisson regression model revealed a highly significant independent association of the overall MI incidence with same day NOx concentrations (mean values across all measuring stations) and with average PM10 concentration over three preceding days. Based on regression coefficient and interquartile range of pollutant concentrations, MI incidence variation with same day NOx was 3.2% (p&amp;lt;0.001) and variation with three preceding days PM10 was 4.8% (p&amp;lt;0.001). Daily peak ambient temperature was inversely related to MI incidence (p&amp;lt;0.001), whereas for sunshine duration and precipitations no independent association could be identified. Interestingly, the MI incidence in current smokers was unaffected (p=0.145 and p=0.104, respectively) by NOx and PM10 pollution. Conclusion This study is the first to show significant associations between the air pollutants NOx (same day level) and PM10 (3 day preceding average level) and MI incidence in Berlin. MI incidence varied with these pollutants at single digit percentage points. A causal relationship appears likely, as continuously self-intoxicating smokers did not exhibit this association. Funding Acknowledgement Type of funding sources: None.

Impact of multivessel versus single-vessel disease on the association between low diastolic blood pressure and mortality after acute myocardial infarction with revascularization

Abstract Background Previous studies demonstrated a J-shaped relationship between low diastolic blood pressure (DBP) and adverse clinical outcomes in patients with acute myocardial infarction (AMI) that was sensitive to revascularization. We hypothesized that this relationship differs between patients with multivessel disease (MVD) and those with single-vessel disease due to differing degrees of myocardial ischemic burden. Methods Among 9,983 AMI patients from the Korea Acute Myocardial Infarction Registry database who underwent percutaneous coronary intervention and were followed up for a median duration of 3.2 years, average on-treatment DBP was calculated at admission, discharge, and every scheduled visit and divided into &amp;lt;70 mmHg, 70–74 mmHg, 75–79 mmHg, and ≥80 mmHg. The relationship between average on-treatment DBP and clinical outcomes including all-cause death, cardiovascular (CV) death, non-CV death, and _hospitalization for heart failure was analyzed using Cox regression models adjusted for clinical covariates. Results In patients with MVD, all-cause death (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.06–2.04) and CV death (HR: 1.59; 95% CI: 1.02–2.46) were significantly increased in patients with a DBP &amp;lt;70 mmHg, showing a J-shaped relationship. However, these findings were not significant for single-vessel disease. On a sensitivity analysis excluding subjects with a baseline SBP &amp;lt;120 mmHg, an increased risk of a low DBP &amp;lt;70 mmHg remained in MVD. Conclusions The J-shaped relationship between low DBP and adverse clinical outcomes in AMI patients who underwent revascularization persisted in MVD, which has a high ischemic burden. These high-risk patients require cautious treatment. Funding Acknowledgement Type of funding sources: None.

Added value of left atrial strain in outcome prediction after myocardial infarction. SWEDEHEART-registry based echocardiographic study

Abstract Background Left ventricular function parameters, such as ejection fraction and global longitudinal strain are widely accepted prognostic parameters after myocardial infarction. Left atrial strain has been suggested as a novel risk parameter in this population. Objective To investigate whether left atrial (LA) deformation parameters (LA reservoir strain, LARS) can improve prognostic value of traditional echo parameters in prediction of heart failure and dead in patients after myocardial infarction. Moreover, to study relationship between LARS and established LV function parameters, and test its reproducibility between the readers. Method A total of 380 patients with myocardial infarction, hospitalized at our university hospital between 2008–2014, underwent echocardiography during hospital stay. The collected images was reanalyzed with respect to left atrial strain. Patients were followed up within the Swedish myocardial infarction registry (SWEDEHEART). Results To the final analysis a total of 253 patients (64 years of age, 81% men) were included, and followed up over median of 4.9 years. Among the parameters tested in the univariate analysis, LARS was able to predict long-term risk of heart failure admissions and death in patients with myocardial infarction (HR 0.95, 95% CI 0.91–0.99 for combined end-point). LARS below 27.2% identifies patients with higher risk of combined endpoint with AUC 0.68 (p=0.001). After adjustment for background characteristics and established LV function measures, LARS has lost significance, meaning that it provides no additional information in this population. LARS correlates moderately with LV GLS (r=−0.52, p&amp;lt;0.001) and weakly with LVEF (r=0.31, p&amp;lt;0.001), to a moderate extent and to a small extent with LAVI and LVEF, respectively. LARS shows moderate to perfect agreement between reviewers. Conclusions LARS is a good prognosticator of death and heart failure hospitalizations after myocardial infarction, but not independent of the established LV function parameters. We showed a good correlation between LARS and LV strain parameters and its near perfect inter-reader reproducibility. Funding Acknowledgement Type of funding sources: None.

A COMPARATIVE ANALYSIS OF ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION BETWEEN CANADA AND THE UNITED STATES FROM THE NORTH AMERICAN COVID-19 STEMI REGISTRY

BackgroundImportant healthcare differences exist between the US and Canada. The goal of this investigation is to compare clinical characteristics, treatment strategies and clinical outcomes of STEMI patients with COVID-19 infection treated in the US versus Canada.Methods and ResultsThe North American COVID-19 Myocardial Infarction (NACMI) registry is a prospective, investigator-initiated study enrolling STEMI patients with documented COVID infection in the US and Canada. The primary end-point is in-hospital mortality. The secondary end-points include stroke, reinfarction and a composite of death, stroke or reinfarction. Of the 767 STEMI-COVID patients, 67 (9%) were from Canada and 669 (91%) from the US. Patients enrolled in Canada were more likely to present with chest pain (79% vs. 54%, p< 0.001), otherwise patients across both countries had comparable presenting demographics (Table 1). The proportion of patients not undergoing coronary angiography was significantly lower in Canada compared with the US (9% vs. 19%, p=0.039); of those who underwent angiography, no significant differences in reperfusion modalities were noted. Compared with the US, patients in Canada had a significantly lower unadjusted risk for in-hospital mortality (15% vs. 29%, p=0.016) and the risk for the composite of death, stroke or re-infarction (15% vs. 31%, p=0.006). Vaccination status was available in Canada 26 / 67 patients (unvaccinated 13, vaccinated 13) and US 328/ 669 patients (unvaccinated 282, vaccinated 46); a strong association between vaccination and adverse clinical composite is noted in both countries (Canada: 3/13, 23% (unvaccinated) vs. 0/13, 0% (vaccinated), p=0.22; and, US: 75/282, 27% (unvaccinated) vs. 6/46, 13% (vaccinated), p=0.048).Conclusion BackgroundImportant healthcare differences exist between the US and Canada. The goal of this investigation is to compare clinical characteristics, treatment strategies and clinical outcomes of STEMI patients with COVID-19 infection treated in the US versus Canada. Important healthcare differences exist between the US and Canada. The goal of this investigation is to compare clinical characteristics, treatment strategies and clinical outcomes of STEMI patients with COVID-19 infection treated in the US versus Canada. Methods and ResultsThe North American COVID-19 Myocardial Infarction (NACMI) registry is a prospective, investigator-initiated study enrolling STEMI patients with documented COVID infection in the US and Canada. The primary end-point is in-hospital mortality. The secondary end-points include stroke, reinfarction and a composite of death, stroke or reinfarction. Of the 767 STEMI-COVID patients, 67 (9%) were from Canada and 669 (91%) from the US. Patients enrolled in Canada were more likely to present with chest pain (79% vs. 54%, p< 0.001), otherwise patients across both countries had comparable presenting demographics (Table 1). The proportion of patients not undergoing coronary angiography was significantly lower in Canada compared with the US (9% vs. 19%, p=0.039); of those who underwent angiography, no significant differences in reperfusion modalities were noted. Compared with the US, patients in Canada had a significantly lower unadjusted risk for in-hospital mortality (15% vs. 29%, p=0.016) and the risk for the composite of death, stroke or re-infarction (15% vs. 31%, p=0.006). Vaccination status was available in Canada 26 / 67 patients (unvaccinated 13, vaccinated 13) and US 328/ 669 patients (unvaccinated 282, vaccinated 46); a strong association between vaccination and adverse clinical composite is noted in both countries (Canada: 3/13, 23% (unvaccinated) vs. 0/13, 0% (vaccinated), p=0.22; and, US: 75/282, 27% (unvaccinated) vs. 6/46, 13% (vaccinated), p=0.048). The North American COVID-19 Myocardial Infarction (NACMI) registry is a prospective, investigator-initiated study enrolling STEMI patients with documented COVID infection in the US and Canada. The primary end-point is in-hospital mortality. The secondary end-points include stroke, reinfarction and a composite of death, stroke or reinfarction. Of the 767 STEMI-COVID patients, 67 (9%) were from Canada and 669 (91%) from the US. Patients enrolled in Canada were more likely to present with chest pain (79% vs. 54%, p< 0.001), otherwise patients across both countries had comparable presenting demographics (Table 1). The proportion of patients not undergoing coronary angiography was significantly lower in Canada compared with the US (9% vs. 19%, p=0.039); of those who underwent angiography, no significant differences in reperfusion modalities were noted. Compared with the US, patients in Canada had a significantly lower unadjusted risk for in-hospital mortality (15% vs. 29%, p=0.016) and the risk for the composite of death, stroke or re-infarction (15% vs. 31%, p=0.006). Vaccination status was available in Canada 26 / 67 patients (unvaccinated 13, vaccinated 13) and US 328/ 669 patients (unvaccinated 282, vaccinated 46); a strong association between vaccination and adverse clinical composite is noted in both countries (Canada: 3/13, 23% (unvaccinated) vs. 0/13, 0% (vaccinated), p=0.22; and, US: 75/282, 27% (unvaccinated) vs. 6/46, 13% (vaccinated), p=0.048). Conclusion

A Closer Look at the HEART Score.

The history, electrocardiogram, age, risk factors, and troponin (HEART) score is currently a widely used tool for acute chest pain risk stratification. Relatively soon after its inception in 2008, a number of validation studies on the HEART score showed it to be superior to Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores and at least as accurate to other existing scores for predicting short-term major adverse cardiovascular events (MACEs). However, partly due to its focus on simplicity, the HEART score has some limitations. In this article we review how the HEART score has evolved and taken on various modifications to circumvent some of its limitations. We also highlight the strength of the HEART score in comparison with other risk stratification tools and the current guidelines.

Radial versus femoral access in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: A propensity-matched analysis from real-world data of the K-ACTIVE registry

BackgroundThe access site for primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) recently shifted from femoral to radial. However, few real-world data on Japanese patients exist. MethodsTo elucidate the clinical selection and impact of the access site in STEMI patients, we analyzed a Japanese observational prospective multicenter registry of acute myocardial infarction (K-ACTIVE: Kanagawa ACuTe cardIoVascular rEgistry) in 2015 to 2021. Data were analyzed in the entire population and a propensity score-matched population adjusted for confounding factors. Major adverse cardiac event (MACE) was defined as cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Bleeding Academic Research Consortium (BARC) type 3 or 5 was used to assess bleeding events. MACE plus BARC type 3 or 5 bleeding were considered composite events. Clinical outcomes were followed for 30 days. ResultsThe 6802 STEMI patients included 4786 patients with radial access (70.3 %) and 2016 with femoral access (29.7 %). Femoral access tended to be selected for more severe conditions than radial access. The median door-to-device time in the radial access group was significantly shorter than the femoral access group in the entire population (75 min versus 79 min, p < 0.01). After propensity score matching (each group, n = 1208), the incidence of MACE tended to be lower in the radial access group [risk ratio (RR) 0.83, 95 % confidence interval (CI) 0.63–1.09, p = 0.17]. The incidence of BARC 3 or 5 bleeding was significantly less in the radial access group (RR 0.47, 95%CI 0.23–0.97, p = 0.04). The incidence of composite events was significantly less in the radial access group (RR 0.74, 95%CI 0.57–0.96, p = 0.02). ConclusionIn STEMI patients undergoing primary PCI, in comparison to femoral access, radial access reduced composite events in the entire population and the matched population, through a reduction in MACE and BARC 3 or 5 bleeding.

Effect of different revascularization times on intermediate-risk non-ST-elevation acute coronary syndrome

Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a specific type of acute coronary syndrome. We applied the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification of patient prognosis. There was uncertainty about the routine revascularization time in patients with intermediate-risk NSTE-ACS. A total of 2835 patients with intermediate-risk NSTE-ACS (TIMI score 3–4) included in the China Acute Myocardial Infarction Registry from November 2014 to January 2017 were analyzed according to the time window from symptom onset to revascularization: within 24 h, Group I (814/28.7%); within 24 to 48 h, Group II (526/18.6%); within 48 to 72 h, Group III (403/14.2%); and after 72 h, Group IV (1092/38.5%). Risk factors, management and in-hospital outcomes were analyzed in the four groups. The results of the chi-square test showed that there was a significant difference in the incidence of in-hospital major adverse cardiovascular events (MACEs) when revascularization was completed within 48 h than when it was completed after 48 h (P < 0.05). The results of revascularization within 48 h were similar, and the incidence of in-hospital MACEs was lower than when revascularization was completed after 48 h. The incidence of in-hospital MACEs among patients who underwent revascularization within 48 h is lower than that of patients who underwent revascularization after 48 h.

Impact of P2Y12 inhibitors on cardiovascular outcomes of Korean acute myocardial infarction patients with baseline thrombocytopenia.

BackgroundAntiplatelet therapy is crucial for managing acute myocardial infarction (AMI) and reducing adverse ischemic events after percutaneous coronary intervention (PCI) with drug-eluting stents. However, the ideal P2Y12 inhibitor for patients—particularly East Asians—with AMI and low platelet levels remains unknown. We evaluated the impact of various potencies of P2Y12 receptors on major cardiovascular outcomes of AMI patients with thrombocytopenia in Korea.MethodsWe analyzed the clinical and outcome data of 800 AMI patients with baseline platelet counts <150 × 103/μL who underwent PCI between November 2011 and June 2015. All patient data were obtained from the Korea Acute Myocardial Infarction Registry–National Institutes of Health registry. Subjects were allocated to group A (n = 244; treated with potent P2Y12 inhibitors) or group B (n = 556; treated with clopidogrel). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs).ResultsAt the 3-year follow-up, clinical outcomes appeared better in group A than in Group B. However, after propensity score weighting-adjusted analysis, these findings were statistically attenuated, showing a similar incidence of MACCEs between the two groups.ConclusionsClopidogrel may be reasonable for patients with low platelet counts and is associated with comparable outcomes to potent P2Y12 inhibitors for Korean AMI patients.

Comparison of the Korean Activity Status Index with cardiopulmonary exercise test in patients with acute myocardial infarction

This study aimed to compare the Korean Activity Status Index (KASI) with the cardiopulmonary exercise test (CPET) among patients with acute myocardial infarction. A total of 2,268 patients (85.4% male; mean age, 59.3±10.2 years; range, 23-90 years) diagnosed with acute myocardial infarction were enrolled in the Regional Center Myocardial Infarction Registry between July 2016 and June 2019. The KASI is a tool used to measure functional capacity by asking patients about their ability to perform specific activities and then scoring their responses. In contrast, CPET is the gold standard for assessing the objective functional capacity in patients undergoing cardiac rehabilitation. Peak oxygen uptake (VO&lt;sub&gt;2peak&lt;/sub&gt;) was used to analyze the correlation. Patients who completed two consecutive KASI and CPET evaluations during their first (KASI_1, VO&lt;sub&gt;2peak&lt;/sub&gt;_1) and second visits (KASI_2, VO&lt;sub&gt;2peak&lt;/sub&gt;_2) for cardiac rehabilitation were included in the study. The mean KASI_1 and KASI_2 scores were 43.3±14.3 and 49.8±13.9, respectively, and the mean VO&lt;sub&gt;2peak&lt;/sub&gt;_1 and VO&lt;sub&gt;2peak&lt;/sub&gt;_2 scores were 25.9±8.0 and 28.5±8.3, respectively. Both the KASI scores were significantly correlated with the measured VO&lt;sub&gt;2peak&lt;/sub&gt; during each visit, with correlation coefficients of 0.385 (&lt;i&gt;P&lt;/i&gt;&lt;0.001) and 0.346 (&lt;i&gt;P&lt;/i&gt;&lt;0.001), respectively. Moreover, the KASI score and VO&lt;sub&gt;2peak&lt;/sub&gt; had a linear relationship (VO&lt;sub&gt;2peak&lt;/sub&gt;_1=0.22×KASI_1+16.5, &lt;i&gt;P&lt;/i&gt;&lt;0.001; VO&lt;sub&gt;2peak&lt;/sub&gt;_2=0.21×KASI_2+18.2, &lt;i&gt;P&lt;/i&gt;&lt;0.001). This study revealed that the KASI is a valid measure for the follow-up evaluation of the functional capacity of patients. These findings suggest that VO&lt;sub&gt;2peak&lt;/sub&gt; can be predicted using the KASI score in patients who do not undergo CPET.

Comparison of the modified Singapore myocardial infarction registry risk score with GRACE 2.0 in predicting 1-year acute myocardial infarction outcomes

Risk stratification plays a key role in identifying acute myocardial infarction (AMI) patients at higher risk of mortality. However, current AMI risk scores such as the Global Registry of Acute Coronary Events (GRACE) score were derived from predominantly Caucasian populations and may not be applicable to Asian populations. We previously developed an AMI risk score from the national-level Singapore Myocardial Infarction Registry (SMIR) confined to ST-segment elevation myocardial infarction (STEMI) patients and did not include non-STEMI (NSTEMI) patients. Here, we derived a modified SMIR risk score for both STEMI and NSTEMI patients and compared its performance to the GRACE 2.0 score for predicting 1-year all-cause mortality in our multi-ethnic population. The most significant predictor of 1-year all-cause mortality in our population using the GRACE 2.0 score was cardiopulmonary resuscitation on admission (adjusted hazards ratio [HR] 6.50), while the most significant predictor using the SMIR score was age 80–89 years (adjusted HR 7.78). Although the variables used in the GRACE 2.0 score and SMIR score were not exactly the same, the c-statistics for 1-year all-cause mortality were similar between the two scores (GRACE 2.0 0.841 and SMIR 0.865). In conclusion, we have shown that in a multi-ethnic Asian AMI population undergoing PCI, the SMIR score performed as well as the GRACE 2.0 score.

Prevalence and prognostic implications of reduced left ventricular ejection fraction among patients with STEMI in India.

To describe clinical characteristics and outcomes for those with STEMI and reduced left ventricular ejection fraction (LVEF) in low-income and middle-income countries (LMICs). Adults presenting with STEMI to two government-owned tertiary care centres in Delhi, India were prospectively enrolled in the North India ST-elevation myocardial infarction (NORIN-STEMI) registry. LVEF was evaluated at presentation and clinical characteristics were compared across LVEF categories. Overall, 3597 patients were included, of whom 468 (13%) had LVEF >50%, 1482 (41%) had mildly reduced LVEF (40-49%), 1357 (38%) had moderately reduced LVEF (30-39%), and 290 (8%) had severely reduced LVEF (<30%). Presentation delay >24h, prior MI, and hyperlipidaemia were associated with decreasing LVEF category. Although most patients with reduced LVEF were discharged on appropriate guideline-directed therapies, adherence at 1year was low (ACE inhibitor/ARB 91% to 41%, beta blocker 98% to 78%, aldosterone receptor antagonist 69% to 6%). After multivariable adjustment, a Cox regression model showed moderately reduced LVEF (HR 1.77, 95% CI 1.20, 2.60) and severely reduced LVEF (HR 3.63, 95% CI 2.41, 5.48) were associated with increased risk of all-cause mortality compared with LVEF ≥50%. On presentation for STEMI, almost 90% of NORIN-STEMI participants had at least mildly reduced LVEF and almost half had LVEF <40%. Patients with LVEF <40% had significantly higher risk of mortality at 1year, and adherence to guideline-directed therapies at 1year was poor. Systematic initiatives to improve access to timely revascularization and guideline-directed therapies are essential in advancing STEMI care in LMICs.