Myocardial Oxygen Supply Research Articles

Numerical Analysis on Effect of Coronary Supply-Demand Equilibrium on Varying Coronary Blockage and Stress Conditions.

In this paper, we present a computational fluid dynamic (CFD) analysis to capture the effect of physical stress and stenosis severity in coronary arteries leading to changes in coronary supply demand oxygen equilibrium. We propose a coupled Od-3d coronary vessel model to predict the variation in flow dynamics of coronary as well as arterial system, modeled using an in-silico model replicating cardiovascular hemodynamics. CFD simulation were solved using subject specific CT scan for coronary and arterial flow and pressure along with metrics related to arterial wall shear stress. Simulations were performed for three heart rates (75, 90 and 120 bpm) and four stenosis states representing different stages of Coronary artery disease (CAD) namely healthy, 50%, 75%, 90% blockage in left anterior descending artery (LAD). Myocardial oxygen supply demand equilibrium were calculated for each cases using hemodynamic surrogate markers naming Diastolic pressure time index for supply and Tension time index for demand. The proposed 0d-3d coupled hemodynamic model of the coronary vessel bed along with supply-demand equilibrium estimated for different stress level and stenosis severity may provide useful insights on the dynamics of CAD manifestation and predict vulnerable regions in coronary bed for early screening and interventions.

Features of the pathogenesis and course of myocardial infarction in COVID-19 patients: a descriptive review

The coronavirus disease 2019 (COVID-19) pandemic remains one of the most urgent problems for healthcare professionals due to the variety of non-pulmonary manifestations. Along with the respiratory syndrome in a significant proportion of patients, the disease course is accompanied by pronounced systemic inflammatory response and hemostasis changes. This is associated with a high risk of complications, especially in patients with concomitant cardiovascular pathology. The aim of the study was to analyze and systematize the literature data on the pathogenesis, clinical course, and outcomes of myocardial infarction (MI) in patients with COVID-19. For review, publications indexed in the PubMed, Google Scholar, Web of Science, and Cyberleninka databases were used. The search depth was 2 years, starting from 2020. The review is based on summarized data from the most relevant clinical studies, reports and systematic reviews. The literature analysis made it possible to conclude that the published data on MI in patients with COVID-19 are currently contradictory. Multiple thrombosis, sepsis, macrophage activation, increasing hypoxemia, imbalance between myocardial oxygen supply and demand in patients with severe COVID-19 have led to a high incidence of type 1 and type 2 MI. It should be especially noted that in a number of cases, MI with COVID-19 occurs in patients with intact coronary arteries, and its course is associated with a high incidence of complications, which, in turn, leads to a significant increase in short- and mid-term mortality.

VALIDATION OF A NONINVASIVE METHOD TO ESTIMATE SUBENDOCARDIAL OXYGEN SUPPLY AND DEMAND BALANCE

Objective: Evaluation of balance between subendocardial oxygen supply and demand is useful in order to assess the risk of myocardial ischemia. The subendocardial viability ratio (SEVR, also known as Buckberg index) evaluated by invasive recordings of left ventricular and aortic pressure curves represents a valid method to estimate the degree of myocardial perfusion relative to left ventricular workload. However, routine clinical use of this parameter requires a noninvasive estimation and the demonstration of its reliability. Design and method: Arterial applanation tonometry allows a noninvasive estimation of SEVR as the ratio of the areas directly beneath the central aortic pressure curves obtained during diastole (myocardial oxygen supply) and during systole (myocardial oxygen demand). However, this traditional method does not account for the intraventricular diastolic pressure and proper allocation to systole and diastole of left ventricular isometric contraction and relaxation, respectively, resulting in an overestimation of the SEVR values. These issues are considered in a novel method for SEVR assessment tested in this study. SEVR values were estimated with carotid tonometry by traditional and new method and compared with those evaluated invasively in 51 undergoing an cardiac catheterization for coronary angiography. Results: The traditional method provided significantly higher SEVR values than the reference invasive SEVR: average of differences ± SD = 44 ± 11%. The noninvasive new method showed a much better agreement with the invasive determination of SEVR: average of differences ± SD = 0 ± 8%. The new method for SEVR estimation showed a good repeatability between consecutive assessments (coefficient of variation 7.8%). Conclusions: A noninvasive estimation of SEVR by carotid applanation tonometry is feasible. All the main factors determining myocardial supply and demand flow should be considered in order to provide a valid estimate, in particular intraventricular diastolic pressure, left ventricular isometric contraction and relaxation.

Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients.

At present, we have entered an aging society. Many diseases suffered by the elderly, such as malignant tumors, cardiovascular diseases, fractures, surgical emergencies and so on, need surgical intervention. With the improvement of Geriatrics, surgical minimally invasive technology and anesthesia level, more and more elderly patients can safely undergo surgery. Elderly surgical patients are often complicated with a variety of chronic diseases, and the risk of postoperative myocardial injury/infarction (PMI) is high. PMI is considered to be the increase of cardiac troponin caused by perioperative ischemia, which mostly occurs during operation or within 30 days after operation, which can increase the risk of short-term and long-term death. Therefore, it is suggested to screen troponin in elderly patients during perioperative period, timely identify patients with postoperative myocardial injury and give appropriate treatment, so as to improve the prognosis. The pathophysiological mechanism of PMI is mainly due to the increase of myocardial oxygen consumption and / the decrease of myocardial oxygen supply. Preoperative and postoperative risk factors of myocardial injury can be induced by mismatch of preoperative and postoperative oxygen supply. The treatment strategy should first control the risk factors and use the drugs recommended in the guidelines for treatment. Application of cardiovascular drugs, such as antiplatelet β- Receptor blockers, statins and angiotensin converting enzyme inhibitors can effectively improve postoperative myocardial ischemia. However, the risk of perioperative bleeding should be fully considered before using antiplatelet and anticoagulant drugs. This review is intended to describe the epidemiology, diagnosis, pathophysiology, risk factors, prognosis and treatment of postoperative myocardial infarction /injury.

Nationwide frequency, risk and outcomes of type-2 myocardial infarction in patients with versus without previously revascularized myocardial infarction (type 1)

Abstract Funding Acknowledgements Type of funding sources: None. Background Type 2 myocardial infarction (T2MI), due to a mismatch between myocardial oxygen demand and supply, is being increasingly recognized with improved diagnostics. The upsetting concern of developing T2MI in patients with prior revascularized occlusive acute myocardial infarction (AMI) or type 1 MI (T1MI) makes it crucial to define the clinical profile and outcomes of T2MI in revascularized patients of ACS. Purpose To determine the risk and prognosis of T2MI in patients who had previously had coronary revascularization (PCI or CABG) Methods We used the National Inpatient Sample (2018) dataset from the United States to identify T2MI adult hospitalizations using ICD-10 codes and define our study arm as T2MI excluding secondary T1MI diagnoses but having prior revascularized (with percutaneous coronary intervention or coronary artery bypass grafting) AMI. We then compared demographics and comorbidities in T2MI cohort with vs without personal history of revascularized AMI. We used multivariate analysis to study the odds of T2MI hospitalizations with prior revascularized AMI and in-hospital outcomes (all-cause mortality, cardiogenic shock and resource utilization) adjusting for confounders. Results There were 33155 T2MI adult hospitalizations after excluding AMI (median age 71 years, 50.6% male, 67.3% white); 1435 (4.3%) had previously revascularized AMI. T2MI in the study arm had higher chances of hospitalization with prior revascularized AMI when adjusted for socio-demographics (aOR 6.92, 95% CI:6.50-7.36, p<0.001) and socio-demographics with comorbidities (aOR 5.70, 95%CI: 5.48-5.94, p<0.001) (Table 1). Study arm often had elderly (≥65 years old, 78.4% vs 65.8%), male (66.6% vs 49.9%), white (76.7% vs 66.9%), upper socio-economic class (20.2 vs 16.8%), patients who were often admitted to non-electively (99.3 vs 97.1%) and to rural (10.5 vs 9.3%) hospitalizations compared to control arm. The study arm had a significantly higher prevalence of diabetes mellitus, hyperlipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, deficiency anemias, prior TIA/stroke, depression and smoking. T2MI cohort with prior revascularized AMI did not show any significant association with in-hospital all-cause mortality (1.7 vs 3.0%, aOR 0.49, 95%CI 0.18-1.34, p=0.164) and cardiogenic shock (1.7% vs 2.1%, p=0.399) however, had lower hospital expenditure (median USD 31273 vs 36567) and fewer transfers to other facilities (19.5 vs 22.1%) than those without prior revascularized AMI (Table 2). Conclusion Population-based analysis of this nationally representative sample revealed up to six times higher risk of developing T2MI in patients with prior history of AMI (revascularized) but without any significant impact on all-cause in-hospital mortality or cardiogenic shock. Future studies are warranted to assess the short-term/long-term outcomes of T2MI in high risk patient population with previously revascularized AMI.

Comparison of haemodynamic response to induction with propofol versus etomidate in patients scheduled for elective surgery

Introduction: Laryngoscopy and endotracheal intubation are harmful stimuli that can produce adverse response in the cardiovascular, respiratory and other physiological systems. These changes are reflected in haemodynamic parameters which can be fatal for patients with low cardiac reserve and may alter the balance between myocardial oxygen supply and demand and as a result, myocardial ischemia can be precipitated. This observational comparative study was conducted to compare the haemodynamic effects of Propofol and Etomidate during induction of general anaesthesia in patients scheduled for elective surgery. Materials and Methods: 58 patients of American Society of Anaesthesiologists (ASA) physical status I and II of age group 18-60 years scheduled for elective surgeries under general anaesthesia were randomly assigned in two groups (n=28). Group P received injection Propofol (2.5mg/kg) and group E received injection Etomidate (0.3mg/kg) during induction. Hemodynamic parameters were recorded at various time intervals. Statistical analysis was done using software (MedCalc Version 20.014). P value was considered significant if p £ 0.05. Results: Demographic profile was comparable in both the groups. Hemodynamic parameters at baseline and after premedication were comparable.

New horizons in Type 2 myocardial infarction: pathogenesis, assessment and management of an emerging geriatric disease.

Type 2 myocardial infarction (MI) is characterised by a functional imbalance between myocardial oxygen supply and demand in the absence of a thrombotic process, leading to myocardial necrosis. This type of MI was relatively unknown among clinicians until the third universal definition of MI was published in 2017, differentiating Type 2 from Type 1 MI, which follows an acute atherothrombotic event. The pathogenesis, diagnostic and therapeutic aspects of Type 2 MI are described in the present review. Type 2 MI is a condition that is strongly linked to age because of vascular ageing concerning both epicardic vessels and microcirculation, age-related atherosclerosis and stress maladaptation. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extra-cardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying etiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of Type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older co-morbid patients with Type 2 MI, geriatricians and cardiologists need to work together to optimise etiological investigations, treatment and prevention of predisposing conditions and precipitating factors.

Ventricular Unloading Using the ImpellaTM Device in Cardiogenic Shock.

Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.

Correlation between Traditional Chinese Medicine Syndromes and Type 2 Myocardial Infarction in Critically Ill Patients with Pulmonary Disease.

Background Treatment based on syndrome differentiation under the traditional Chinese medicine (TCM) framework has been shown to be helpful in patients with coronary artery disease. We hypothesized that syndrome types could predict the risk of type 2 myocardial infarction (T2MI) caused by imbalance between myocardial oxygen supply and demand in critically ill patients with pulmonary disease. Methods This retrospective study included consecutive critically ill patients with pulmonary disease admitted to the ICU at Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences from January 1, 2017, to July 1, 2019. Diagnosis of T2MI was based on the fourth universal definition of myocardial infarction. Risk factors associated with T2MI were identified using multivariate regression analysis. Results A total of 244 patients were included in the study: 78 who developed T2MI and the remaining 166 who did not develop T2MI during hospitalization. The incidence of phlegm syndrome and deficiency syndrome was 61.9% and 38.1%, respectively. In comparison with the patients with phlegm syndrome, the incidence of T2MI in patients with deficiency syndrome is significantly higher (40.9% vs. 26.5%, P=0.019). In multivariate logistic regression, T2MI was independently associated with the baseline troponin level (OR 12.682, 95% CI 1.397∼115.121; P=0.024), hemoglobin < 55 g/L (OR 12.76, 95% CI 2.359∼69.021; P=0.003), mechanical ventilation (OR 2.244, 95% CI 1.029∼4.892; P=0.042), and TCM deficiency syndrome (OR 2.214, 95% CI 1.032∼4.749; P=0.041). After adjusting for confounding factors in Cox regression models, the hazard ratio (95% confidence interval) of qi deficiency syndrome groups was 1.183 (95% CI 1.053∼3.123, P=0.032). Conclusions Patients with deficiency syndrome are at high risk of T2MI, especially those combined with qi deficiency syndrome.

Sodium-Glucose Cotransporter 2 Inhibitors and Cardiac Remodeling.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have evident cardiovascular benefits in patients with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction (only empagliflozin and dapagliflozin have been investigated in this group so far), and chronic kidney disease. Prevention and reversal of adverse cardiac remodeling is one of the mechanisms by which SGLT2 inhibitors may exert cardiovascular benefits, especially heart failure-related outcomes. Cardiac remodeling encompasses molecular, cellular, and interstitial changes that result in favorable changes in the mass, geometry, size, and function of the heart. The pathophysiological mechanisms of adverse cardiac remodeling are related to increased apoptosis and necrosis, decreased autophagy, impairments of myocardial oxygen supply and demand, and altered energy metabolism. Herein, the accumulating evidence from animal and human studies is reviewed investigating the effects of SGLT2 inhibitors on these mechanisms of cardiac remodeling.

Type 2 myocardial infarction: a diagnostic and therapeutic challenge in contemporary cardiology.

In the expanding world of cardiovascular diseases, rapidly reaching pandemic proportions, the main focus is still on coronary atherosclerosis and its clinical consequences. However, at least in the Western world, middle-aged male patients with acute myocardial infarction are no more the rule. Due to a higher life expectancy and major medical advances, physicians are to treat older and frailer individuals, usually with multiple comorbidities. In this context, myocardial ischaemia and infarction frequently result from an imbalance between myocardial oxygen supply and demand—i.e., type 2 myocardial infarction (T2MI), according to the current universal definition—rather than coronary atherothrombosis. Moreover, the increasing use of high-sensitivity cardiac troponin assays has led to a heightened detection of T2MI—often causing relatively little myocardial injury—, which seems to have doubled its numbers in recent years. Nevertheless, owing to its multifaceted pathophysiology and clinical presentation, T2MI is still underdiagnosed. Perhaps more importantly, T2MI is also victim of undertreatment, as drugs that constitute the cornerstone of therapy in most cardiovascular diseases are much more unlikely to be prescribed in T2MI than in coronary atherothrombosis. In this paper, we review the recent literature on the classification, pathophysiology, epidemiology, and management of T2MI, trying to summarise the state-of-the-art knowledge about this increasingly important pathologic condition. Finally, based on the current scientific evidence, we also propose an algorithm that may be easily utilised in clinical practice, in order to improve T2MI diagnosis and risk stratification.

English

BACKGROUND Acute myocardial infarction is a form of ischemic heart disease in which there is an inadequate supply of blood and oxygen to a portion of the myocardium. It typically occurs when there is an imbalance between myocardial oxygen supply &amp; demand. In this study, we wanted to determine the prognostic significance of serum uric acid concentration in acute myocardial infarction. METHODS This is a cross-sectional comparative study conducted among 100 acute myocardial infarction patients admitted at VIMSAR, Burla during the study period from November 2017 to October 2019 and also 50 age and gender-matched healthy controls person who presented to the hospital OPD with other reasons. All patients were diagnosed with ST-segment elevation acute myocardial infarction based on clinical history, examination, ECG changes, and biochemical markers. Detailed general examination and detailed systemic examination of cardiovascular, neuromuscular, gastrointestinal, respiratory &amp; genitourinary system were done with routine tests: Hb%, TLC, DC, ESR, S. Urea, S. Creatinine, Fasting/RBS, Blood Sugar, Urine, R/M, Serum uric acid, Troponin I &amp; CPK-MB and ECG in all leads. Evaluation of patient was done to access the Killip class on the day of admission and once among 50 age and gender-matched healthy controls. RESULTS The mean serum uric acid level was higher in patients with acute myocardial infarction than the healthy controls. There was no significant difference in the mean serum uric acid level between males &amp; females and the mean serum uric acid level between diabetic &amp; non-diabetic patients. Patients in the higher Killip class had higher serum uric acid levels. All patients who died in the study were in the higher Killip class and had higher S.uric acid levels. CONCLUSIONS A combination of Killip class &amp; serum uric acid level after acute myocardial infarction is a good predictor of mortality. KEY WORDS Myocardial Infarction, ST Segment Elevation, CPK-MB, Serum Uric Acid.

Patterns and outcomes of invasive management of type 2 myocardial infarction in the United States.

Type 2 myocardial infarction (MI) occurs due to a mismatch in myocardial oxygen supply and demand without unstable coronary artery disease. We sought to identify patterns, predictors and outcomes of invasive management of type 2 MI in the USA. Adults aged ≥18 years hospitalized with type 2 MI were identified in a cross-sectional study from the 2018 National Inpatient Sample. Invasive management was defined as invasive coronary angiography or revascularization. Patient, hospital and geographic characteristics associated with invasive management were identified by multivariable logistic regression. Propensity-matched cohorts were generated to evaluate associations between invasive vs. conservative management and mortality. We identified 268 850 admissions with type 2 MI in 2018. Type 2 MI patients had a high burden of comorbidities and were commonly admitted with diagnoses of circulatory (39.7%), infectious (23.1%) or respiratory (10.8%) illness. Only 11.2% of type 2 MI were managed invasively, of which 17.9% underwent coronary revascularization. Odds of invasive management were higher with commercial insurance [adjusted OR (aOR) 1.39; 95% confidence interval (CI), 1.27-1.52] and lower with Medicaid (aOR 0.86; 95% CI, 0.76-0.96) vs. Medicare. Significant heterogeneity in invasive management of type 2 MI was observed by geographic region (range 7.2-13.8%), independent of patient and hospital factors. Invasive management was associated with lower in-hospital mortality than conservative management overall (3.9 vs. 9.1%; P < 0.001) and in propensity-matched analyses (OR, 0.70; 95% CI, 0.59-0.84). Invasive management of type 2 MI varies by insurance status and geography, highlighting uncertainty regarding optimal management and potential disparities in clinical care.

Sequelae and Comorbidities of COVID-19 Manifestations on the Cardiac and the Vascular Systems.

COVID-19 patients with pre-existing cardiovascular conditions are at greater risk of severe illness due to the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) virus. This review evaluates the highest risk factors for these patients, not limited to pre-existing hypertension, cardiac arrhythmias, hypercoagulation, ischemic heart disease, and a history of underlying heart conditions. SARS-CoV-2 may also precipitate de novo cardiac complications. The interplay between existing cardiac conditions and de novo cardiac complications is the focus of this review. In particular, SARS-CoV-2 patients present with hypercoagulation conditions, cardiac arrhythmias, as significant complications. Also, cardiac arrhythmias are another well-known cardiovascular-related complication seen in COVID-19 infections and merit discussion in this review. Amid the pandemic, myocardial infarction (MI) has been reported to a high degree in SARS-CoV-2 patients. Currently, the specific causative mechanism of the increased incidence of MI is unclear. However, studies suggest several links to high angiotensin-converting enzyme 2 (ACE2) expression in myocardial and endothelial cells, systemic hyper-inflammation, an imbalance between myocardial oxygen supply and demand, and loss of ACE2-mediated cardio-protection. Furthermore, hypertension and SARS-CoV-2 infection patients’ prognosis has shown mixed results across current studies. For this reason, an in-depth analysis of the interactions between SARS-CoV2 and the ACE2 cardio-protective mechanism is warranted. Similarly, ACE2 receptors are also expressed in the cerebral cortex tissue, both in neurons and glia. Therefore, it seems very possible for both cardiovascular and cerebrovascular systems to be damaged leading to further dysregulation and increased risk of mortality risk. This review aims to discuss the current literature related to potential complications of COVID-19 infection with hypertension and the vasculature, including the cervical one. Finally, age is a significant prognostic indicator among COVID-19 patients. For a mean age group of 70 years, the main presenting symptoms include fever, shortness of breath, and a persistent cough. Elderly patients with cardiovascular comorbidities, particularly hypertension and diabetes, represent a significant group of critical cases with increased case fatality rates. With the current understanding of COVID-19, it is essential to explore the mechanisms by which SARS-CoV-2 operates to improve clinical outcomes for patients suffering from underlying cardiovascular diseases and reduce the risk of such conditions de novo.

Development of a multi-scale CVS model for assessment of myocardial oxygen supply and demand

Development of a multi-scale CVS model for assessment of myocardial oxygen supply and demand

Abstract 11969: Endocardial Viability Ratio is Associated With Survival in Advanced Heart Failure Patients

Introduction: Myocardial oxygen supply is an important determinant of cardiac function. The Endocardial Viability Ratio (EVR), a measure of myocardial oxygen supply-demand balance, is calculated as a ratio of the diastolic pressure time index [(diastolic blood pressure - left ventricular end diastolic pressure) x (60 sec/heart rate - 0.2 sec)] and tension time index [systolic pressure x 0.2 sec]. We hypothesized that low EVR would be associated with adverse events in patients with heart failure (HF). Methods: EVR was calculated in the invasive arm of the ESCAPE trial in patients with available discharge blood pressure, pulmonary arterial wedge pressure, and heart rate as the ratio of the diastolic pressure time index (a measure of coronary blood supply) and tension time index (a measure of myocardial oxygen demand). Kaplan-Meier analysis and Cox proportional hazards regression was used to assess associations with EVR and a composite death endpoint including cardiac transplantation and left ventricular assist device implantation. Results: Among 143 patients (56.9 ± 13.3 years, 30.1% female), the median EVR was 1.168 (IQR 0.923-1.398). Survival during 180 days of follow-up was worse in patients with EVR below the median (p=0.0004) (Figure panel 1A). Among the 10 patients with EVR &lt; 0.7, considered to represent subendocardial ischemia, 50% reached this endpoint within 100 days (p=0.01 versus remaining patients) (Figure 1B). An increase of 0.1 in EVR was associated with an 18% relative risk reduction for this endpoint (HR 0.82, 95% CI 0.74-0.91, p=0.0002), while an increase of 0.5 in EVR was associated with a 62% relative risk reduction (HR 0.38, 95% CI 0.22-0.64, p=0.002). Conclusion: Decreased EVR, a marker of myocardial oxygen supply, is associated with adverse events in advanced HF patients. Further studies on the prognostic utility of EVR in HF are needed.

Relation of Type 2 Myocardial Infarction and Readmission With Type 1 Myocardial Infarction in Hypertensive Crises (from a Nationwide Analysis)

Type 2 myocardial infarction (T2MI) is an ischemic injury that occurs due to a mismatch between myocardial oxygen supply and demand. T2MI can occur with hypertensive crisis. Nevertheless, the impact of T2MI on hypertensive crisis outcome is poorly understood due to limited data. This study was a retrospective analysis of the National Readmission Database year 2018. Patients were included if the primary diagnosis was hypertensive crisis, hypertensive urgency, or hypertensive emergency. Patients were excluded if they had type 1 myocardial infarction (T1MI), severe sepsis, septic shock, gastrointestinal bleeding, or hemorrhagic anemia at index admission. The primary outcome was 90-day readmission with T1MI. Secondary outcomes were in-hospital mortality, length of stay, resource utilization, and all-cause 90-day readmission. Subgroup analysis was done according to urgency and emergency presentation. A total of 101,211 index hospitalizations were included in our cohort, of whom 3,644 (3.6%) received a diagnosis of T2MI. A total of 912 patients were readmitted within 90 days with T1MI. T2MI was an independent predictor of 90-day readmission with T1MI (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] 1.90 to 3.66, p <0.01). Subgroup analysis including only hypertensive urgency and hypertensive emergency yielded similar results (aOR 2.80, 95% CI 1.56 to 5.01, p <0.01 and aOR 2.28, 95% CI 1.59 to 3.27, p <0.01, respectively). In conclusion, T2MI was an independent predictor of poor outcome in patients presenting with hypertensive crisis. Further studies are needed to guide the management of T2MI in this population.

Impaired subendocardial perfusion in patients with metabolic syndrome.

BackgroundMetabolic Syndrome (MS) is associated to vascular damage, increased arterial stiffness, and impaired myocardial perfusion. Subendocardial viability ratio (SEVR) is a noninvasive estimation of myocardial workload, oxygen supply, and perfusion. The aim of the study was to describe the relation between arterial stiffness, SEVR, and cardio-metabolic risk factors.MethodsA cohort of 55 patients, aged 59.9 ± 10.8 years, was studied; 28 subjects (50.9%) had metabolic syndrome. All patients underwent a clinical evaluation and blood venous sampling, to assess glico-lipid profile. Applanation tonometry was performed, to obtain pulse wave analysis and SEVR values.ResultsIn the overall study population, SEVR showed negative associations with mean (r = −0.301; p = 0.026) and systolic (borderline relation, r = −0.257; p = 0.058) arterial pressure. Metabolic syndrome patients presented lower level of SEVR (p = 0.012), even after adjusting for age, sex, and mean arterial pressure (p = 0.040). Subdividing the study population by the number of metabolic syndrome components, SEVR significantly decreased as the number of Metabolic Syndrome components increased (p for trend 0.005). In a logistic backward regression analysis, both metabolic syndrome and mean arterial pressure resulted significant predictors of SEVR, accounting for 18% of variance.ConclusionThe reduced SEVR in metabolic syndrome patients could be an important pathophysiological determinant of the increased cardiovascular risk.

Coronary artery disease and cardiovascular outcomes in patients with type 2 myocardial infarction

Abstract Purpose To evaluate the role of coronary disease in predicting adverse cardiovascular events in patients with type 2 myocardial infarction. Background Type 2 myocardial infarction occurs due to imbalance in myocardial oxygen supply or demand without atherothrombosis. There is currently no consensus on how patients with type 2 myocardial infarction should be investigated or treated. Although non-cardiovascular mortality is common in this population, the incidence of future cardiovascular events is similar to those with myocardial infarction due to plaque rupture. Observational data suggest patients with type 2 myocardial infarction and underlying coronary artery disease may be at higher risk of cardiovascular events, but to date, most findings have been observed in selected rather than consecutive patient cohorts. Methods We conducted a secondary analysis of a multi-centre randomised controlled trial of 48,282 consecutive patients attending hospital with suspected acute coronary syndrome. In 9,115 patients, high-sensitivity cardiac troponin concentrations were &amp;gt;99th centile, and the diagnosis was adjudicated in line with the Fourth Universal Definition. Patients with type 2 myocardial infarction were stratified by the presence of previous coronary artery disease and evaluated for a primary outcome of cardiovascular death or Type 1 or 4b myocardial infarction at one year. Competing risk cox regression models were used to evaluate predictors of the primary outcome selected a priori on the basis of clinical importance, with adjustment for the competing risk of non-cardiovascular death. Results The diagnosis of type 1 and type 2 myocardial infarction was made in 55% (4,981) and 12% (1,121) of patients, respectively. Compared to patients without a previous diagnosis of coronary artery disease, those with coronary disease were older (78 vs 71) and more likely to be female (54% vs 46%). The incidence of future cardiovascular death or myocardial infarction was highest in patients with type 2 myocardial infarction and previous coronary disease (20%, 91/454), compared to those with type 2 myocardial infarction without known coronary disease (10%, 69/667, P&amp;lt;0.001), and was similar to patients with type 1 myocardial infarction (17%, 863/4981, Figure 1). After adjusting for cardiovascular risk factors, the presence of known coronary disease remained an important predictor for future cardiovascular death or myocardial infarction (adjusted Hazard Ratio 1.45, 95% confidence interval 1.03 to 2.03; Figure 2). Conclusion Coronary artery disease is an independent predictor of cardiovascular outcomes in patients with type 2 myocardial infarction. Further research is required to evaluate whether systematic investigation for coronary artery disease and targeted secondary prevention could improve outcomes in patients with type 2 myocardial infarction. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Figure 1Figure 2

Correlation of Coronary Artery Disease and Left Ventricular Hypertrophy.

Ischemic heart disease (IHD) is the leading cause of death worldwide, and it is defined as an imbalance between myocardial oxygen supply and demand. Coronary artery disease (CAD) and left ventricular hypertrophy (LVH) are two common causes of IHD that independently result in myocardial ischemia. CAD decreases myocardial blood and oxygen supply whereas LVH increases myocardial oxygen demand. The coexistence of both CAD and LVH results in a significant increase in oxygen demand while simultaneously lowering oxygen supply.Since hypertension is a shared predisposing condition for both CAD and LVH, the left ventricular (LV) mass on noninvasive echocardiography can reflect on the severity of coronary artery stenosis. In clinical practice, it can help physicians decide whether to perform invasive cardiac catheterization to visualize the extent of the coronary block. Although, both CAD and LVH are directly proportional to mortality risk, the addition of eccentric LVH can further increase morbidity and mortality due to myocardial infarction. Therefore, the latest management of both the acute and chronic phases of CAD places an increased emphasis on controlling the predisposing factors to prevent or reverse LVH. For example, angiotensin-converting enzyme inhibitors and diuretics reduce LV mass by lowering the cardiac preload and afterload. This article aims to investigate the deleterious effects of the collaboration between CAD and LVH, establish a causal relationship, and explore the new prevention and management strategies.