Noncardiac Conditions Research Articles

ATYPICAL PRESENTATION OF ARVC

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) has a variety of presentations, some of which can masquerade as non-cardiac conditions. Herein, we present a patient who was initially thought to have had a seizure. A 32-year-old otherwise healthy male experienced loss of consciousness after

STEMI IN THE BELLY: ABDOMINAL COMPARTMENT SYNDROME MIMICKING ST ELEVATION MYOCARDIAL INFARCTION

A variety of non-cardiac conditions can mimic electrocardiogram (ECG) changes seen in acute coronary syndrome. Abdominal compartment syndrome (AbdCS) is a rare entity that can cause cardiac effects mimicking an ST-segment elevation myocardial infarction (STEMI) on ECG. A 40 year old man with stage

High-sensitivity cardiac troponin assays for cardiovascular risk stratification in the general population.

Cardiac troponins (cTns) I and T have long been the most successful cardiac-specific circulating biomarkers in cardiovascular (CV) medicine, having changed dramatically the diagnosis of acute myocardial infarction, while being independent predictors of outcome in several cardiac conditions and non-cardiac conditions. The latest-generation high-sensitivity (hs) cTn assays demonstrate both enhanced diagnostic performance and improved analytical performance, with the ability to measure detectable concentrations in a substantial proportion of the asymptomatic and presumably healthy populations. Given this unique analytical feature, recent evidence suggests that hs-cTn can be used for the stratification of CV risk in the general population. High-sensitivity cTn predicts future CV events, are responsive to preventive pharmacological or lifestyle interventions, change in parallel to risk modifications, and offer incremental risk prediction when added to well-established prognosticators. The implementation of CV risk stratification and prevention strategies incorporating hs-cTn requires further investigation to define the optimal target populations, timing of measurement, and preventive interventions.

Evaluation of the Relationship between Early Troponin Clearance and Short-Term Mortality in Patients with Chronic Renal Failure

Objective In patients with CKD, cTn concentrations may be elevated in the absence of AMI, which is a predicted finding caused by chronic structural heart disease rather than acute injury. The increase in troponin level observed in noncardiac conditions provides conflicting results when predicting mortality. Low lactate clearance was associated with increased mortality. Lactate clearance is calculated as follows: (early lactate − late lactate/early lactate) ∗ 100. We aimed to investigate whether troponin clearance calculated according to this formula had an effect on short-term mortality. Methods The study included 300 patients with chronic renal failure who had a sepsis-related organ failure assessment (SOFA) score ≥3. By taking the baseline troponin at the time of emergency presentation as reference and comparing them with the fourth-hour troponin values, troponin clearance was investigated in the evaluation of mortality among hospitalized patients with CKD within the first month after discharge. The data obtained were analyzed using the SPSS data analysis software version 20.0. Student's t-test was used for the parametric data, and the Chi-squared test for the nonparametric data. Results Of the 300 patients evaluated, 189 patients survived (mean age 66.20 ± 14.597 years), and 111 died (mean age 74.81 ± 12.916 years). Troponin clearance was detected in 40 of the 111 patients in the mortality group and 119 of the 189 patients in the survival group. Troponin clearance was significantly more frequent in surviving patients (P=0.0000083). Conclusion Troponin clearance can be considered as a valuable leading indicator of survival, but higher levels of troponin clearance did not lead to higher survival rates.

A031 Non-ACS Diagnosis in Suspected Acute Coronary Syndrome and Regional Variations - An ANZACS-QI Study

Rate of invasive coronary angiography (ICA) has risen over past two decades. Many non-coronary and non-cardiac conditions can mimic acute coronary syndrome (ACS), with less than 30% of chest pain presentations being ACS. There is a potential for inappropriate and unnecessary procedural risks. This study reviews New Zealand regional variation in non-ACS diagnosis in patients suspected of ACS. Consecutive patients ≥18y presenting with their first suspected ACS and underwent coronary angiography in 2015-2019 were identified from the ANZACS-QI registry. Two cohorts were compared: 1) suspected STEMI and 2) suspected NSTEACS. Patient demographics, investigations and discharge diagnosis were obtained from the registry. 30,317 patients were identified. 6059 (20%) suspected STEMI among which the rate of false-positive diagnosis across all district health boards (DHB) was <12% and appears independent of patient volume. In comparison, a wider variation exists for suspected NSTEACS, up to 27.3%, and demonstrates a general trend of higher non-ACS diagnosis in higher volume centres. The non-ACS condition most likely to raise suspicion for ACS on presentation and undergo ICA includes stress cardiomyopathy (11.9%), arrhythmia (10.4%), stable angina (9.3%) and myocarditis (7.9%). Low rates of false-positive diagnosis for patients presenting with suspected STEMI across the nation. Comparatively, non-ACS diagnoses rate is higher particularly in higher volume centres for suspected NSTEACS. However, ICA appears to be appropriately performed as diagnostic tools for common non-ACS conditions that can mimic potentially life-threatening ACS.

Noncardiac-Related Morbidity, Mobility Limitation, and Outcomes in Older Adults With Heart Failure.

To examine the individual and combined associations of noncardiac-related conditions and mobility limitation with morbidity and mortality in adults with heart failure (HF). We conducted a retrospective cohort study in a large, diverse group of adults with HF from five U.S. integrated healthcare delivery systems. We characterized patients with respect to the presence of noncardiac conditions (<3 vs ≥3) and/or mobility impairment (defined by the use/nonuse of a wheelchair, cane, or walker), categorizing them into four subgroups. Outcomes included all-cause death and hospitalizations for HF or any cause. Among 114,553 adults diagnosed with HF (mean age: 73 years old, 46% women), compared with <3 noncardiac conditions/no mobility limitation, adjusted hazard ratios (HR) for all-cause death among those with <3 noncardiac conditions/mobility limitation, ≥3 noncardiac conditions/no mobility limitation, ≥3 noncardiac conditions/mobility limitation (vs) were 1.40 (95% CI, 1.31-1.51), 1.72 (95% CI, 1.69-1.75), and 1.93 (95% CI, 1.85-2.01), respectively. We did not observe an increased risk of any-cause or HF-related hospitalization related to the presence of mobility limitation among those with a greater burden of noncardiac multimorbidity. Consistent findings regarding mortality were observed within groups defined according to age, gender, and HF type (preserved, reduced, mid-range ejection fraction), with the most prominent impact of mobility limitation in those <65 years of age. There is an additive association of mobility limitation, beyond the burden of noncardiac multimorbidity, on mortality for patients with HF, and especially prominent in younger patients.

Age-specific differences in non-cardiac comorbidities among elderly patients hospitalized with heart failure: a special focus on young-old, old-old, and oldest-old.

Despite the growing epidemic of heart failure (HF), there is limited data available to systematically compare non-cardiac comorbidities in the young-old, old-old, and oldest-old patients hospitalized for HF. The precise differences will add valuable information for better management of HF in elderly patients. A total of 1053 patients aged 65 years or older hospitalized with HF were included in this study. Patients were compared among three age groups: (1) young-old: 65 to 74 years, (2) old-old: 75 to 84 years, and (3) oldest-old: ≥85 years. Clinical details of presentation, comorbidities, and prescribed medications were recorded. The mean age was 76.7 years and 12.7% were 85 years or older. Most elderly patients with HF (97.5%) had at least one of the non-cardiac comorbidities. The patterns of common non-cardiac comorbidities were different between the young-old and oldest-old group. The three most common non-cardiac comorbidities were anemia (53.6%), hyperlipidemia (45.9%), and diabetes (42.4%) in the young-old group, while anemia (73.1%), infection (58.2%), and chronic kidney disease (44.0%) in the oldest-old group. Polypharmacy was observed in 93.0% elderly patients with HF. Additionally, 29.2% patients were diagnosed with infection, and 67.0% patients were prescribed antibiotics. However, 60.4% patients were diagnosed with anemia with only 8.9% of them receiving iron repletion. Non-cardiac comorbidities are nearly universal in three groups but obviously differ by age, and inappropriate medications are very common in elderly patients with HF. Further treatment strategies should be focused on providing optimal medications for age-specific non-cardiac conditions.

P.853 Characterization of a mGlu4 positive allosteric modulator by telemetric EEG/ECG recordings and sociability assessment in freely moving rats

ST elevation myocardial infarction (STEMI) occurring in patients hospitalized for a noncardiac condition is associated with a high mortality rate and thus we sought to determine the mechanisms underlying STEMI in this patient population. This is a single center retrospective study of 70 patients who had STEMI while hospitalized on a noncardiac service and underwent coronary angiography. Thrombotic in-hospital STEMI was defined by angiographic or intravascular imaging evidence of intracoronary thrombus, plaque rupture, or stent thrombosis. Thirty-six (51%) inpatient STEMIs developed in the operating room or various postoperative stages and 6 (9%) after endoscopy or a percutaneous procedure. Thrombotic etiologies were found in 39 (56%) patients. Nonthrombotic etiologies included vasospasm, supply-demand mismatch, and takotsubo cardiomyopathy. Patients in the thrombotic group were more likely to have antiplatelet medications discontinued on admission, had higher peak troponin levels and were more likely to undergo percutaneous coronary intervention than patients in the nonthrombotic group. Exposure to vasopressors, time from ECG to angiography, post-STEMI ejection fraction, length of stay, and in-hospital mortality were similar in both groups. There was no difference in the use of percutaneous coronary intervention in patients but longer ECG to coronary angiography times and fivefold higher in-hospital mortality in thrombotic inpatient STEMI compared with 643 patients who presented with an out-of-hospital STEMI during the same time period. In conclusion, thrombotic and nonthrombotic mechanisms cause STEMI in hospitalized patients and are associated with a high mortality.

P814Analysis of patients with tako-tsubo syndrome in terms of the triggering mechanism

Abstract Introduction Tako-tsubo syndrome (TTS) might be caused by two different trigger mechanisms. There is very little data available on patient characteristics and prognosis regarding the trigger mechanisms. Purpose Comparison of patients with TTS in terms of different trigger factor – emotional stress vs. psychical stress caused by severe non-cardiac condition. Method Data were obtained from the Tako-tsubo registry of patients hospitalized in Cardiocenter University Hospital from 2013 to 2018, in total 86 patients were diagnosed with TTS. The patients were divided into 2 groups according to the triggering cause, that we thoroughly examined in each case. In the first group, there were patients with TTS triggered by emotional stress (such as death in the family or anxiety disorders) and in the second group there were patients whose TTS was caused primarily by non-cardiac conditions of various etiology, such as neurological, infectious or postoperative issues. Results Out of 86 patients, there were 20 (23,3%) patients excluded, for we weren't able to establish the triggering cause. In 26 (30,2%) patients, the trigger was psychological and 40 (46,5%) patients suffered from non-cardiac condition. According to the collected data there were no significant differences amongst basic demographic facts. Women represented the majority in both groups – 92% vs 95%, age of 70,6±0,8 vs 71,9±0,7 years (p=0,650). There were no significant differences in the hs-TnT 624ng/l ± 49,9 vs 610,2±17,3ng/l (p=0,959). There were significant differences discovered in the average NT-proBNP level – 2691±220,5pg/ml vs 10610±599pg/ml (p&lt;0,05). The patients with non-cardiac conditions developed acute complications more frequently, especially a respiratory failure requiring mechanical ventilation 20% vs 3,8% (p&lt;0,05). In total, 8 (9,3%) patients with TTS died, of whom all had a physical stress factor of p&lt;0,05. Conclusion Physical stress in patients with severe non-cardiac conditions is a more frequent trigger for TTS than emotional stress. Patients with TTS induced by physical stress have a significantly worse prognosis.

DIABETIC KETOACIDOSIS: A RARE CAUSE OF UNUSUALLY HIGH TROPONIN I LEVEL

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Troponin elevation is typically seen in acute coronary syndrome (ACS), but it can be seen in patients with non-cardiac conditions like diabetic ketoacidosis (DKA). We present an interesting case of DKA with more than thousand fold increase in troponin I in the absence of ACS. CASE PRESENTATION: A 65-year-old female presented to emergency room with non-bloody vomiting and diarrhea for one day and confusion which started two hours before presentation. She reportedly had an insulin pump malfunction and had multiple readings of high blood glucose values at home. Medical history included type 1 diabetes mellitus (A1c-8.4%, N: 40.0 (N:0.0-0.05 ng/ml) and CK-MB of 80.9 (n=1.0-3.6 ng/ml). There was a concern for ACS. Echocardiogram showed worsening diastolic heart failure. Patient underwent left heart catheterization which revealed normal coronary arteries and elevated left and right sided pressures. With treatment and resolution of the DKA, her troponin levels gradually decreased, and patient improved significantly. She was discharged to in-patient rehabilitation facility for therapy. Insulin pump was re-calibrated before discharge. DISCUSSION: Diabetes is a major risk factor for obstructive CAD. In DKA, insulin deficiency and high concentration of counter-regulatory hormones alter myocardial cell metabolism leading to necrosis, stunning and elevated troponin, even in the absence of CAD. CONCLUSIONS: Nonspecific myocardial injury may occur in severe DKA and such patients are at an increased risk of major adverse cardiac events and mortality. The presence of bio-marker elevation does not necessarily signify ACS and metabolic abnormalities should be corrected before evaluating for the CAD. Reference #1: Manikkan, A.T., Elevated Troponin I Levels in Diabetic Ketoacidosis Without Obstructive Coronary Artery Disease. J Endocr Soc, 2018. 2(9): p. 1020-1023 Reference #2: Abdo, A.S. and S.A. Geraci, Significance of elevated cardiac troponin I in patients with diabetic ketoacidosis. J Miss State Med Assoc, 2013. 54(5): p. 127-30. Reference #3: Al-Mallah, M., et al., Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events. Clin Cardiol, 2008. 31(2): p. 67-71. DISCLOSURES: No relevant relationships by Shujaa Faryad, source=Web Response No relevant relationships by Pallavi Pradeep, source=Web Response No relevant relationships by Usama Talib, source=Web Response

General pediatric care for a patient after heart transplant: what the practitioner needs to know.

The scope of this review is to discuss aspects of general pediatric care which significantly impact the outcome of children after heart transplant. The general practitioner (GP) often serves as the frontline for prevention and early detection of common problems after heart transplant. Multiple studies in the literature show the negative impact of preventable illness in immune compromised patients, including the appropriateness of vaccine administration. Except for live vaccines, pediatric heart transplant recipients generally follow standard childhood vaccine schedules. In addition, diagnosis of cardiac and noncardiac conditions by the practitioner can lead to earlier treatment by subspecialists. While rejection and infection are such conditions the practitioner may identify, psychological and neurocognitive conditions are common and impact both adherence to medications and quality of life. These issues are addressed in this review of the recent literature. Through knowledge, detection, and collaboration of care, the practitioner can greatly improve the well being of pediatric heart transplant recipients.

P1963The determinants of functional significance of coronary bifurcation lesions and its implications on clinical follow up to 48 months (insights from FIESTA registry)

Abstract Background There is no study up-to-now to determine the rate of functionally significant coronary bifurcation lesions, which have to be intervened and what are the clinical consequences of the FFR case selection strategy. Methods We analyzed patients from FIESTA registry, which was continuation of FIESTA study (Ffr vs. IcEcgSTA, ClinicalTrials.gov Identifier: NCT01724957). Patients with stable angina were included (if there were other coronary stenoses they were threated first after checking by FFR for functional significance). The inclusion criterions were angiographic bifurcation lesions in a native coronary artery with diameter ≥2.5 mm and ≤4.5 mm and SB diameter ≥2.0 mm. We excluded patients with ST-segment elevation myocardial infarction, left main, hemodynamic instability and those with non-cardiac co-morbidity conditions with a life expectancy of less than one year. PCI was performed according to the current guidelines. Provisional stenting was the default strategy in all patients. Two guidewires were inserted into both distal MB and SB. Initial FFR was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). For all FFR measurements, intracoronary adenosine was given in increasing doses of 60 mcg, 120 mcg, and 240 mcg. The minimum value of FFR measurements was taken for analysis. All patients received double antiplatelet therapy with ADP-antagonist and aspirin for at least 12 months. Results A 130 consecutive patients with coronary bifurcation stenoses were included – 57 had positive FFR&lt;.80 in main vessel of bifurcation lesion (44% functionally significant lesions). The mean age was 67±10 years, 66% males, 96% hypertensive, 39% diabetic, 96% dyslipidemic (or on treatment with statin), 55% smokers, 22% with previous myocardial infarction, 51% with previous PCI. The residual SYNTAX score before FFR bifurcation assessment was 13±4 (FFR&lt;.80) vs. 8±3 (FFR≥0.80), p&lt;0.001. Univariate predictors of bifurcation FFR&lt;.80 were: proximal (MV%DS) or distal (MB%DS) main vessel stenosis ≥85% (derived from ROC analysis with overall accuracy 77% and 72%, accordingly), lesion length, SYNTAX score, triglyceride concentration, previous MI on lateral wall and carotid artery disease. On multivariate logistic analysis only MV%DS&gt;85% (OR=8.929, CI 2.887–27.619, p&lt;0.001), MB%DS&gt;85% (OR=3.831, CI 1.349–10.883, p=0.012) and SYNTAX score≥12 (OR=16.466, CI 5.225–15.889, p&lt;0.001). At median follow-up of 26 months (IQR 17–35) the all-cause mortality was 17.5% in FFR positive bifurcations vs. 4.1% in FFR negative lesions (log-rank =.067). Conclusions Less than a half of angiographically significant coronary bifurcation lesions are functionally significant and require stent implantation. The functional significance was related with higher degree stenosis in main vessel and overall disease severity estimated with SYNTAX score. A trend to lower mortality was noted in group with non-significant FFRs.

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Specific Causes of 30-Day and 1-Year Readmissions in Heart Failure Patients

Background Readmission rates are a major metric used in evaluating the quality of hospital care for heart failure patients, but the specific causes of readmission are uncertain. Much of the existing data focuses on all-cause readmissions or uses ICD classification coding to determine causes for readmission. In this study, we retrospectively review heart failure cases to identify the specific causes of 30-day and 1-year readmission. Methods We identified heart failure patients from the University of Maryland Medical Center with an index hospitalization between January 2017 - March 2017. All charts were reviewed to determine if the index hospitalization was for heart failure. The charts were then reviewed to determine causes of subsequent readmissions. 30-day and 1-year readmissions were recorded. Readmissions were categorized as due to heart failure exacerbation, other cardiac causes, non-cardiac chest pain, infections, GI disorders, neurological disorders, renal disorders, pulmonary disorders, or trauma and surgical conditions. Planned readmissions were excluded. Results A total of 232 patients were identified to have an index heart failure hospitalization in the specified time frame. 21% of patients were readmitted within 30 days. Heart failure exacerbation, other cardiac causes, and infections were the leading causes of 30-day readmission, representing 53%, 16%, and 14% of 30-day readmissions respectively. 53% of the cohort had at least 1 readmission over 1 year. There was a total of 330 readmissions over 1 year. Heart failure exacerbation, infections, and non-cardiac chest pain were the leading causes of 1-year readmission, representing 40%, 16%, and 8% of 1-year readmissions. Discussion Heart failure exacerbation was the leading cause of both 30-day and 1-year readmissions, but infections, other cardiac causes, and non-cardiac chest pain were also significant contributors to readmissions after an index heart failure hospitalization. Prevention of readmissions necessitates addressing non-cardiac causes as well as heart failure status.

Fully-Automated Diagnosis of Aortic Stenosis Using Phonocardiogram-Based Features.

The irreversible damage and eventual heart failure caused by untreated aortic stenosis (AS) can be prevented by early detection and timely intervention. Prior work in the field of phonocardiogram (PCG) signal analysis has provided proof of concept for using heart-sound data in AS diagnosis. However, such systems either require operation by trained technicians, fail to address a diverse subject set, or involve unwieldy configuration procedures that challenge real-world application. This paper presents an end-to-end, fully-automated system that uses noise-subtraction, heartbeat-segmentation and quality-assurance algorithms to extract physiologically-motivated features from PCG signals to diagnose AS. When tested on n=96 patients showing a diverse set of cardiac and non-cardiac conditions, the system was able to diagnose AS with 92% sensitivity and 95% specificity.

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals.

Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children's hospitals. All adults (≥18years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO-free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes. Tertiary care children's hospitals. A total of 4665 adult patients underwent ACHD surgery in 39 children's hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO. There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.

Mechanisms of ST Elevation Myocardial Infarction in Patients Hospitalized for Noncardiac Conditions

ST elevation myocardial infarction (STEMI) occurring in patients hospitalized for a noncardiac condition is associated with a high mortality rate and thus we sought to determine the mechanisms underlying STEMI in this patient population. This is a single center retrospective study of 70 patients who had STEMI while hospitalized on a noncardiac service and underwent coronary angiography. Thrombotic in-hospital STEMI was defined by angiographic or intravascular imaging evidence of intracoronary thrombus, plaque rupture, or stent thrombosis. Thirty-six (51%) inpatient STEMIs developed in the operating room or various postoperative stages and 6 (9%) after endoscopy or a percutaneous procedure. Thrombotic etiologies were found in 39 (56%) patients. Nonthrombotic etiologies included vasospasm, supply-demand mismatch, and takotsubo cardiomyopathy. Patients in the thrombotic group were more likely to have antiplatelet medications discontinued on admission, had higher peak troponin levels and were more likely to undergo percutaneous coronary intervention than patients in the nonthrombotic group. Exposure to vasopressors, time from ECG to angiography, post-STEMI ejection fraction, length of stay, and in-hospital mortality were similar in both groups. There was no difference in the use of percutaneous coronary intervention in patients but longer ECG to coronary angiography times and fivefold higher in-hospital mortality in thrombotic inpatient STEMI compared with 643 patients who presented with an out-of-hospital STEMI during the same time period. In conclusion, thrombotic and nonthrombotic mechanisms cause STEMI in hospitalized patients and are associated with a high mortality.

Impact of cardiac- and noncardiac-related conditions on adverse outcomes in patients hospitalized with acute myocardial infarction.

Background:To examine the impact of cardiac- and noncardiac-related conditions on the risk of hospital complications and 7- and 30-day rehospitalizations in older adult patients with an acute myocardial infarction (AMI).Methods and Results:The study population consisted of 3863 adults aged 65 years and older hospitalized with AMI in Worcester, Massachusetts, during six annual periods between 2001 and 2011. Individuals were categorized into four groups based on the presence of 11 previously diagnosed cardiac and noncardiac conditions. The median age of the study population was 79 years and 49% were men. Twenty-eight percent of patients had two or less cardiac- and no noncardiac-related conditions, 21% had two or less cardiac and one or more noncardiac conditions, 20% had three or more cardiac and no noncardiac conditions, and 31% had three or more cardiac and one or more noncardiac conditions. Individuals who presented with one or more noncardiac-related conditions were less likely to have been prescribed evidence-based medications and/or to have undergone coronary revascularization procedures than patients without any noncardiac condition. After multivariable adjustment, individuals with three or more cardiac and one or more noncardiac conditions were at greatest risk for all adverse outcomes.Conclusions:Older patients hospitalized with AMI carry a significant burden of cardiac- and noncardiac-related conditions. Older adults who presented with multiple cardiac and noncardiac conditions experienced the worse short-term outcomes and treatment strategies should be developed to improve their in-hospital and post-discharge care and outcomes.

Identification of Carditis in Acute Rheumatic Fever with Myocardial T1 Mapping

Background: The pathogenesis of acute rheumatic fever (ARF) is incompletely understood. Valvulitis is used as part of the diagnostic criteria, while pancarditis has only been demonstrated at autopsy. Purpose: To identify carditis in patients with ARF using T1 mapping on cardiac magnetic resonance (CMR) imaging and echocardiographic global longitudinal strain (GLS). We hypothesised that prolonged native T1 time, consistent with myocardial inflammation, would be present in ARF patients compared to controls. Methods: We prospectively recruited 36 patients; 15 fulfilling the Australian modified Jones Criteria for the diagnosis of ARF, 12 controls with an inflammatory condition without major criteria for ARF and 9 healthy controls. All patients underwent CMR with assessment of non-contrast myocardial T1 mapping as well as echocardiography for GLS. The primary outcome was differences in T1 time between the groups. Results: Patients with ARF had evidence of carditis demonstrated by markedly elevated T1 times [976 (± 167 ms)] compared to those with non-cardiac inflammatory conditions [841 (±50 ms)] and healthy controls [811 (±54 ms)], P = 0.002 (Fig. 1). There was no difference in global longitudinal strain between the groups (−19.4% vs −19.5% vs −20.4%, P = 0.66). Conclusions: Patients with ARF have markedly elevated myocardial T1 times on CMR, consistent with active inflammation from carditis. In contrast, GLS was normal in ARF patients. Incorporating CMR T1 mapping into the diagnostic algorithm for ARF may improve diagnostic certainty and lead to more effective delivery of secondary penicillin prophylaxis.

Identifying Carditis in Acute Rheumatic Fever With Myocardial T1 Mapping

Background: The pathogenesis of acute rheumatic fever (ARF) is incompletely understood. Valvulitis is used as part of the diagnostic criteria, while pancarditis has only been demonstrated at autopsy. Purpose: To identify carditis in patients with ARF using T1 mapping on cardiac magnetic resonance (CMR) imaging and echocardiographic global longitudinal strain (GLS). We hypothesised that prolonged native T1 time, consistent with myocardial inflammation, would be present in ARF patients compared to controls. Methods: We prospectively recruited 36 patients; 15 fulfilling the Australian modified Jones Criteria for the diagnosis of ARF, 12 controls with an inflammatory condition without major criteria for ARF and 9 healthy controls. All patients underwent CMR with assessment of non-contrast myocardial T1 mapping as well as echocardiography for GLS. The primary outcome was differences in T1 time between the groups. Results: Patients with ARF had evidence of carditis demonstrated by markedly elevated T1 times [976(±167 ms)] compared to those with non-cardiac inflammatory conditions [841(±50 ms)] and healthy controls [811(±54 ms)], P = 0.002 (Figure 1). There was no difference in global longitudinal strain between the groups (−19.4% vs −19.5% vs −20.4%, P = 0.66). Conclusions: Patients with ARF have markedly elevated myocardial T1 times on CMR, consistent with active inflammation from carditis. In contrast, GLS was normal in ARF patients. Incorporating CMR T1 mapping into the diagnostic algorithm for ARF may improve diagnostic certainty and lead to more effective delivery of secondary penicillin prophylaxis.