non-ST Elevation Myocardial Infarction Research Articles

Systemic immune inflammatory response index (SIIRI) in acute myocardial infarction.

Different treatment approaches exist for non-ST elevation acute coronary syndrome (ACS) patients. This study assessed the systemic immune inflammatory response index (SIIRI) for its prognostic value and incremental clinical utility in determining optimal timing for percutaneous coronary intervention (PCI) in non-ST elevation myocardial infarction (NSTEMI) patients, particularly when troponin levels are initially negative. This study included 1270 ACS patients: 437 STEMI, 422 NSTEMI, and 411 unstable angina. Patients were stratified by SIIRI levels measured at admission, and coronary artery disease severity was evaluated using the SYNTAX score. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, stroke, and revascularization. Secondary endpoints encompassed individual MACE components and heart failure hospitalisations. The mean age was 54.93 years (83% male). SIIRI levels were significantly higher in STEMI patients (6.83 ± 6.43 × 105) compared to NSTEMI (4.5 ± 5.39 × 105) and unstable angina (3.48 ± 2.83 × 105) (P < 0.001). Area under the curve for SIIRI distinguished NSTEMI and unstable angina from STEMI (0.81 and 0.80), with optimal cut-off points of 4.80 × 105 and 4.25 × 105. In NSTEMI, 24.6% presented within 2 h of symptom onset, were troponin-negative, yet had elevated SIIRI. Post-PCI, SIIRI > 4.93 × 105 correlated with increased MACE at 1 year (17.2% vs 5%). NSTEMI and unstable angina patients with SIIRI values >4.80 × 105 and 4.25 × 105 respectively, may require urgent intervention (<2 h). SIIRI can be of significant utility in patients of NSTEMI who present earlier with negative troponins. SIIRI can also aid in identifying high-risk individuals post-PCI, providing a valuable tool for early and accurate assessment.

The Impact of Different Revascularization Strategies Implemented in Acute Myocardial Infarction on the Recovery of Left Ventricular Functional and Deformational Parameters

Background: Despite well-established therapeutic techniques, such as direct revascularization through percutaneous coronary intervention (PCI), acute myocardial infarction (AMI) remains a leading cause of mortality and morbidity. Objectives: To determine if two-dimensional speckle tracking echocardiography (STE) deformation parameters and the early recovery of left ventricular (LV) functions are affected by the timing of PCI in AMI. Methods: A total of 200 cases with newly-onset acute myocardial infarction (AMI) who had a baseline left ventricular ejection fraction (LVEF) higher than 40% and received effective therapy with percutaneous coronary intervention (PCI) were included in this investigation. cases were categorized as either ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). cases were grouped into four groups according to the time between presentation and PCI. Using standard echocardiography and two-dimensional (2D) ST-elevation STE, individuals were re-evaluated three months later to find out if remodeling had taken place or if the LV function had returned. Results: Of the 200 AMI patients, including 140 males (70%), improvement in global longitudinal strain (GLS) and harmed longitudinal strain (HLS) were better in STEMI and NSTEMI patients received urgent revascularization with PCI (groups I and III) versus patients with pharmacoinvasive strategy or routine invasive strategy (Groups II and IV) (P &lt; 0.05) while there was an insignificant difference between group I and III (P = 0.79). Of the 200 patients, 47 patients (23.5%) presented signs of LV remodeling at 3 months follow up. Age, smoking history, hypertension, dyslipidemia, Killip class, peak creatine phosphokinase - MB level, baseline left ventricular end diastolic volume (LVEDV), HLS, and harmed longitudinal strain rate (HLSR) were all factors that were found to be significantly associated with left ventricular remodeling (P&lt;0.05) in the univariate logistic regression analysis. The following factors were identified as independent predictors of left ventricular remodeling in multivariate logistic regression analysis: damaged left ventricular ejection fraction (EF) and end-systolic volume, peak troponin I, Killip class, culprit left anterior descending (LAD), 2 and 3-vessel coronary artery disease (CAD), and wall motion score index (WMSI). Conclusion: Earlier PCI in AMI helps earlier improvement in myocardial strain parameters. HLS and HLSR are excellent predictors for LV remodeling and may do better than global parameters.

The Impact of Neutrophil-to-High-Density Lipoprotein Ratio and Serum 25-Hydroxyvitamin D on Ischemic Heart Disease

Background: This study describes the complex association between the neutrophil-to-high-density lipoprotein cholesterol ratio (NHR), 25-hydroxyvitamin D (25(OH)D) levels, and cardiovascular disease (CVD), such as stable ischemic heart disease (IHD), ST elevation myocardial infarction (STEMI), non–ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Methods: The serum 25(OH)D concentration and NHR values were analyzed in groups of patients with chronic coronary syndrome (CCS) and acute coronary syndrome (ACS). The severity of coronary artery atherosclerosis was determined using the Coronary Artery Surgery Study (CASS) scale. Results: Significant differences in 25(OH)D and NHR concentrations were observed between CCS and (ACS)/STEMI patients (p &lt; 0.01). Higher 25(OH)D concentrations were associated with the diagnosis of CCS, and higher NHR values with the diagnosis of ACS/STEMI. The NHR threshold for ACS was set at 0.10 (p &lt; 0.001). Patients without significant coronary artery stenosis showed significantly higher 25(OH)D levels and lower NHR values (p &lt; 0.01). Conclusions: The significant correlation between 25(OH)D, HDL, and the NHR suggests that vitamin D, through its influence on inflammatory processes and lipid metabolism, may play a role in the pathogenesis of chronic and acute coronary syndromes. The suggested bidirectional relationship between the NHR and 25(OH)D and the role of the NHR as a predictor of vitamin D levels require further well-designed studies.

Acute renal failure requiring renal replacement therapy secondary to rhabdomyolysis due to rosuvastatin

Introduction and importance: Statins are the group of medicines that lower the level of low-density lipoprotein cholesterol. One of the life-threatening complications is rhabdomyolysis as the use of these drugs. Case presentation: Here, we report a case of a 69-year-old female who was diagnosed with non-ST elevation myocardial infarction one month and was on regular medication before presentation with generalized weakness and decreased urine output. Proximal muscle weakness was greater than distal muscle on the bilateral lower limb, and power at the hip, knee, and ankle was 3/5 in the bilateral area, with absent reflex at the knee and ankle bilateral area. Clinical discussion: A total of four hemodialysis sessions were performed; the first three sessions were performed at an interval of 24 h, then the last maintenance hemodialysis after 48 h of three sessions. The patient’s weakness in the bilateral lower limb returns to normal condition. Conclusion: Physicians need to be aware of the potential of developing severe rhabdomyolysis in patients taking rosuvastatin to prevent morbidity, extended hospital stay, and financial loss.

Morphological Characterization of Coronary Plaques in Young Indian Patients With Acute Coronary Syndrome: A Multicentric Study.

The prevalence of atherosclerosis and acute coronary syndrome (ACS) is increasing in young Indians (18-50 years of age). However, the characteristics of atherosclerotic plaques in such individuals are poorly understood, presenting distinct challenges for the management of ACS. This study aims to analyze plaque characteristics in young Indian patients with ACS who underwent percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) imaging. This was a prospective, multicentric, non-interventional study on patients aged 18-50 years presenting with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction, or unstable angina, and were scheduled to undergo OCT-guided PCI. Major adverse cardiac events (MACE) were assessed post-procedure and at the 6-month and 12-month follow-ups. The study included 100 ACS patients (mean age=43.6±5.2 years), with 51% presenting with STEMI. Pre-PCI OCT assessment showed that fibrous plaques (75%) were most common followed by plaques containing macrophages (27%), microchannels (20%), and calcified nodules (14%). In addition, plaque rupture, plaque erosion, and lipid-rich plaques, along with red, white, and mixed thrombi, were observed in 31%, 25%, 24%, 21%, 14%, and 17% (total thrombus occurrence=52%) of the patients, respectively. At 12 months, the MACE coronary artery bypass graft (CABG) rate was 1%. Young Indian patients with ACS displayed a range of plaque morphologies identified through pre-PCI OCT. Among these, fibrous plaques were the most prominent type, followed by plaques containing macrophages. Additionally, plaque rupture, plaque erosion, and lipid-rich plaques were also observed in this population.

The role of systemic immune-inflammatory index in predicting contrast-induced nephropathy in non-ST-segment elevation myocardial infarction cases.

Aim: Systemic immune-inflammation index (SII) is obtained by multiplying the platelets by the ratio of neutrophils to lymphocytes. We aimed to examine the relationship between contrast induced nephropathy (CIN) development and SII in non-ST-segment elevation myocardial infarction (NSTEMI) patients.Methods: 1124 NSTEMI patients included and divided into two groups according to the development of CIN. The relationship between SII and CIN development was examined.Results: Among two groups, significant differences were observed in terms of age, chronic renal failure, presence of critical stenoses in the LAD, SII and C-reactive protein (CRP). It was calculated that a value of 709 and above for SII had a predictive power with 74% sensitivity and 74% specificity for CIN.Conclusion: SII has the potential to predict the development of CIN in NSTEMI patients.

Elevated Circulatory Levels of UL16 Binding Protein 1 Positive Microparticles Are Associated With Acute Myocardial Infarction and its Severity.

Atherosclerosis is a vascular inflammatory disease characterized by the activation and stress of various inflammatory cells, leading to the development of coronary artery disease and subsequently acute myocardial infarction (AMI). Among AMI cases, ST-segment elevation myocardial infarction (STEMI) is typically more severe than non-STEMI (NSTEMI). UL16-binding proteins (ULBPs), which are NKG2D ligands, can be expressed on the surface of stressed and activated cells, prompting these cells to generate microparticles (MPs). Consequently, MPs carrying ULBPs, particularly ULBP1 (ULBP1+ MPs), may be released into the bloodstream. This study aimed to investigate the association between ULBP1+ MPs and the presence of AMI and its severity. We recruited 58 AMI patients and 45 age-matched control subjects. Levels of ULBP1+ MPs and ULBP1+ MPs originating from T lymphocytes (ULBP1+ TMPs) were measured using flow cytometry. Both ULBP1+ MP and ULBP1+ TMP levels were significantly elevated in AMI patients compared to controls. Elevated levels of these MPs were independent risk factors for AMI with odds ratios (OR) of 4.3 (95%CI=1.5-12.3) for ULBP1+ MPs and 5.8 (95%CI=2.0-17.0) for ULBP1+ TMPs. Additionally, ULBP1+ TMP levels were significantly higher in STEMI patients compared to NSTEMI patients, with an independent association observed between ULBP1+ TMPs and STEMI (OR=3.9; 95%CI=1.2-12.8). Elevated levels of ULBP1+ MPs and ULBP1+ TMPs are associated with AMI and its severity. These biomarkers could serve as indicators of vulnerable plaques that lead to AMI.

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

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

Prognostic implications of N-terminal pro-brain natriuretic peptide in patients with Non-ST segment elevation myocardial infarction

Abstract Background Limited data exist regarding prognostic implications of N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) in patients with non-ST segment elevation myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI). Objectives The current study sought to evaluate the prognostic implications of NT-proBNP in patients with NSTEMI who underwent PCI. Methods Among a total of 13,104 patients from a nationwide, multicenter, and prospective registry of the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH), a total of 3,083 patients with NSTEMI who underwent PCI were selected. The selected patients were classified according to the initial NT-proBNP value (cut-off value of NT-proBNP, 700 pg/ml). Primary endpoint was major adverse cardiovascular events (MACE) at 3 years, a composite of all-cause death, recurrent myocardial infarction (MI), unplanned repeat revascularization, and admission for heart failure. Results Among the study population, 1,813 patients (58.8%) were in the low NT-proBNP group (&amp;lt;700 pg/ml) and 1,270 patients (41.2%) were in the high NT-proBNP group (≥700 pg/ml). The high NT-proBNP group showed significantly higher risk of MACE than the low NT-proBNP group (29.5% vs 12.3%; adjusted hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.39-2.07; P&amp;lt;0.001), mainly driven by higher risk of cardiac death or admission for heart failure (15.6% vs. 2.2%; adjusted HR, 2.98; 95% CI, 2.03-4.40; P&amp;lt;0.001). These results were consistent after confounder adjustment by propensity score matching (HR, 1.56; 95% CI, 1.21-2.02; P=0.001) and inverse probability weighting analysis (HR, 1.54; 95% CI, 1.19-2.00; P=0.001). Conclusion In patients with NSTEMI who underwent PCI, elevated initial NT-proBNP level was associated with higher risk of MACE at 3 years, mainly driven by the higher risk of cardiac death or admission for heart failure. The current results suggest that the initial NT-proBNP level may have a clinically significant prognostic value in NSTEMI patients undergoing PCI.

Effects of short-term exposures to lower air temperature and cold spells on myocardial infarction hospital admissions: a nationwide study in Sweden

Abstract Background Exposures to lower air temperature and cold spells have been associated with an increased risk of various diseases. However, the short-term effect of lower air temperature and cold spells on myocardial infarction (MI) remains incompletely understood. Purpose We aimed to evaluate the short-term effects of lower air temperature and cold spells on MI hospital admissions within the nationwide SWEDEHEART registry. Methods This population-based nationwide study included 120,380 MI cases admitted to hospitals in Sweden during the cold season (October to March) from 2005 to 2019. Daily mean air temperature was estimated at 1 km2 spatial resolution across Sweden using a three-stage machine learning approach and percentiles of daily temperatures experienced by individuals in the same municipality were employed as individual exposure indicators to account for potential geographic adaptation. Cold spells were defined as periods of at least two consecutive days with a daily mean temperature below the 10th percentile of the temperature distribution for each municipality. A time-stratified case-crossover design incorporating a conditional logistic regression model with distributed lag non-linear model using lag 0-1 and lag 2-6 days was employed to evaluate the short-term effects of lower air temperature and cold spells on total MI, non-ST-segment elevation MI (NSTEMI) and ST-segment elevation MI (STEMI). Results We found significant increases in risk for total MI, NSTEMI, and STEMI in association with a decrease of one percentile in temperature at a lag of 2-6 days, indicated by ORs (95% CI) of 1.099 (1.057-1.142), 1.110 (1.06-1.164), and 1.076 (1.004-1.153), respectively. Additionally, we found that cold spells were significantly associated with increased risks for total MI, NSTEMI, and STEMI at a lag of 2-6 days, with ORs (95% CI) of 1.077 (1.037-1.12), 1.069 (1.02-1.119), and 1.095 (1.023-1.172), respectively. Moreover, independent effects of lower air temperature and cold spells on MI occurrence were found after adjusting for each other. Conversely, we observed that lower air temperature and cold spells were associated with decreased risks for MI at a lag of 0-1 days. Conclusions This nationwide case-crossover study demonstrated a novel biphasic pattern in MI risk following exposure to lower air temperatures and cold spells, characterized by an initial transient reduction in risk at lags 0-1 day, followed by a significant increase in risk at lags 2-6 days. As climate change continues to induce complex shifts in regional weather patterns, enhancing protections to reduce future cold-related cardiac hospitalizations is crucial.

The clinical characteristics and prognosis of patients with acute non-ST-segment elevation myocardial infarction complicated with impaired activity daily living

Abstract Background Impaired activities of daily living (ADL) have been identified as an independent risk factor for cardiovascular diseases. This study aims to describe the clinical characteristics, treatment modalities, and prognosis of acute non-ST-segment elevation myocardial infarction (NSTEMI) patients with impaired ADL. Methods The data for this study were derived from a Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. The inclusion criteria encompassed patients with a discharge diagnosis of NSTEMI.ADL prior to NSTEMI was evaluated using the Barthel index(BI),a widely used assessment tool for evaluating ADL.The patients' BI were obtained from patients’ resident health records, and patients were categorized into two groups: ADL normal and ADL impaired group. A comparative analysis was conducted between the two groups regarding clinical characteristics, treatment regimens, and prognosis. Results The study included 28,227 NSTEMI patients with normal ADL and 1,576 NSTEMI patients with impaired ADL. Baseline data revealed that the ADL impaired group had a higher proportion of females (49.4% vs. 43.2%, p &amp;lt; 0.001), older age (77.0 [69.0, 83.0] vs. 71.0 [66.0, 78.0], p &amp;lt; 0.001), and a higher proportion of patients with KILLIP III and above (25.86% vs. 17.44%, p &amp;lt; 0.001). Additionally, the ADL impaired group had a greater number of pre-existing comorbidities. Regarding treatment, the proportion of patients undergoing percutaneous coronary intervention (PCI) was significantly lower in the ADL impaired group (16.5% vs. 65.3%, p &amp;lt; 0.001). Moreover, the ADL impaired group showed lower utilization rates of antiplatelet agents, ACEI/ARBs, beta-blockers, ARNI, statins, and nitrates, while the utilization rates of diuretics and cardiac glycosides were higher. In terms of prognosis, the ADL impaired group exhibited a higher in-hospital mortality rate (6.03% vs. 3.35%, p &amp;lt; 0.001). During a median follow-up period of 876 days, the ADL impaired group had significantly higher rates of all-cause mortality (61.2% vs. 35.9%, p &amp;lt; 0.001) and cardiovascular mortality (41.8% vs. 24.8%, p &amp;lt; 0.001), while the rate of revascularization (6.69% vs. 9.20%, p = 0.008) was lower. There were no significant differences in the risks of recurrent non-fatal myocardial infarction (10.7% vs. 10.8%, p = 0.935), recurrent stroke (10.90% vs. 9.48%, p = 0.08), and hemorrhagic stroke (0.82% vs. 0.74%, p = 0.806). Following adjustment for age, gender, KILLIP classification, medical history, and treatment strategies in a multivariable Cox regression analysis, impaired ADL remained an independent risk factor for increased all-cause mortality (aHR 1.167, 95%CI: 1.091-1.249, p &amp;lt; 0.001). Conclusions The decline in ADL is significantly associated with adverse clinical outcomes among NSTEMI patients.Baseline characteristics of patientsMedications of patients

Association between completeness of revascularization and cardiovascular outcomes in patients with diabetes and non-ST elevation myocardial infarction: a population-based registry analysis

Abstract Introduction Approximately one-third of the patients presenting with non-ST elevation myocardial infarction (NSTEMI) have diabetes. From these, two-thirds have multivessel coronary disease. The impact of completeness of revascularization in this population remains unclear. Purpose To evaluate the contemporary patterns of coronary revascularization among patients with diabetes and NSTEMI, and the clinical outcomes stratified by anatomic completeness of revascularization. Methods All patients with diabetes and multivessel disease admitted for NSTEMI between April 2009 and March 2020 in Ontario, Canada were included. Patients with previous coronary artery bypass graft surgery (CABG) at any time, percutaneous coronary intervention (PCI) in the previous 90 days, or shock were excluded. Patients were classified in four groups, from the most to the least complete revascularization strategy: CABG, complete revascularization with PCI, incomplete revascularization with PCI, or no revascularization. Outcomes included all-cause death and the composite of all-cause death, myocardial infarction, and stroke. Multivariable Cox regression was used to account for confounding (demographics, comorbidities, left ventricular function, coronary anatomy, laboratory tests, and diabetes treatment). Results We included 14,511 patients (mean age: 68.7±11.5y; 69.6% males). A total of 4,525 (31.2%) patients were treated with CABG, 3,008 (20.7%) with complete PCI, 3,624 (25.0%) with incomplete PCI and 3,354 (23.1%) were not revascularized. Patients with more complex coronary disease were more frequently treated with CABG, while PCI was more common in those with less complex disease (p&amp;lt;0.001; Fig 1). The mean number of grafts in the CABG group was 3.4±1.0. The mean number of stents in the complete and incomplete PCI groups was 2.4±1.3 and 1.7±0.9, respectively. Adjusted 5-y risks of all-cause death following CABG, complete PCI, incomplete PCI and no revascularization were, respectively, 25.9%, 29.8%, 32.2%, and 39.4%. Over a median follow-up of 5.8ys, CABG was associated with reduced all-cause death compared with complete PCI (HR 0.82; 95%CI 0.75 - 0.90), incomplete PCI (HR 0.73; 95%CI 0.67 - 0.80), or no revascularization (HR 0.54; 95%CI 0.50 - 0.58); p&amp;lt;0.001 for all (Fig 2). Adjusted 5-y risks of the composite endpoint following CABG, complete PCI, incomplete PCI and no revascularization were, respectively, 34.0%, 41.5%, 44.6%, and 52.9%. CABG was associated with reduced rates of the composite endpoint compared with complete PCI (HR 0.75; 95%CI 0.69 - 0.81), incomplete PCI (HR 0.67; 95%CI 0.62 - 0.72), or no revascularization (HR 0.50; 95%CI 0.47 - 0.54); p&amp;lt;0.001 for all. Conclusion In this contemporary real-world cohort study, almost a quarter of the patients with diabetes and NSTEMI did not receive any revascularization procedure. Cardiovascular outcomes were incrementally improved with CABG or complete revascularization with PCI, compared to no revascularization.Figure 1Figure 2

Levosimendan improves the early prognosis of patients with Non ST-segment elevation myocardial infarction and Killip class &amp;gt; II

Abstract Background Levosimendan is an inotropic agent known for its calcium-sensitizing myofilament effect and ATP-dependent potassium channel opening mechanism, which enhances myocardial contractility without increasing oxygen consumption. Despite its potential benefits, the impact of levosimendan on the prognosis of patients with myocardial infarction remains uncertain and requires further investigation through larger-scale studies. Purpose This study aimed to investigate the effect of levosimendan on the short-term prognosis of patients with Non-ST-segment elevation myocardial infarction (NSTEMI) and Killip&amp;gt; II. Methods The data for this study were derived from the Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals in the City from 2010 to 2023. A total of 12472 patients with NSTEMI and Killip &amp;gt; II were included. Patients were divided into the levosimendan group and the non-leosimendan group based on whether levosimendan was used during hospitalization. Propensity score matching (PSM) was employed to balance covariates between the two groups. Multivariate Cox regression was used to evaluate the relationship between levosimendan and clinical outcomes. Covariates adjusted in PSM included age, sex, Killip class, early PCI, previous PCI, previous medical conditions (diabetes, hypertension, ischemic stroke, and chronic kidney disease), and medications during hospitalization (aspirin, clopidogrel, indobufen, ticagrelor, statins, cedilanid, recombinant human brain natriuretic peptide [rhBNP], milrinone, dopamine, dobutamine, and angiotensin converting enzyme inhibitor/angiotensin receptor blockers [ACEI/ARB]). The primary endpoint was major cardiovascular and cerebrovascular adverse events (MACCE), defined as the composite endpoint of cardiac death, myocardial infarction, and ischemic stroke within 3 months. Results The levosimendan group comprised 782 patients, while the non-leosimendan group included 11690 patients. After PSM, the covariates were balanced, resulting in 756 well-matched pairs. In PSM patients, the levosimendan group exhibited a significantly lower incidence of MACCE (aHR, 0.573; 95%CI, 0.466–0.704; p &amp;lt; 0.001) and cardiac death (aHR, 0.500; 95%CI, 0.399-0.626; p &amp;lt; 0.001). However, there was no significant difference in the incidence of myocardial infarction and ischemic stroke. Conclusions Levosimendan was associated with a lower incidence of MACCE within 3 months in patients with NSTEMI and Killip&amp;gt; II, mainly driven by lower incidence of cardiac death. However, these findings are based on observational data and require confirmation through adequately powered, randomized, controlled trials.

Short-term effects of ambient temperature variability on myocardial infarction hospitalizations in Sweden: A nationwide case-crossover study

Abstract Background Climate change threatens human health and general welfare via multiple dimensions. However, the short-term effect of temperature variability, a crucial aspect of climate change, on myocardial infarction (MI) remains largely unexplored. Purpose We aimed to assess the short-term effects of temperature variability on MI hospitalizations within the nationwide SWEDEHEART registry. Methods This population-based nationwide study involved 228,897 MI patients from the SWEDEHEART registry in Sweden from 2005 to 2019. High-resolution (1 km × 1 km) daily mean ambient temperature was estimated using a spatiotemporal machine learning methodology and assigned to patients’ home addresses. Temperature variability was calculated as the difference between the same-day (as the MI event) ambient temperature and the average temperature recorded over the preceding seven days. Specifically, an upward temperature shift represents a rise in the current day’s temperature relative to the seven-day average, while a downward temperature shift indicates a corresponding decrease. A time-stratified case-crossover design incorporating a conditional logistic regression model with distributed lag non-linear model was applied to estimate the association between ambient temperature variability and total MI, ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). Moreover, we assessed potential effect modification by sex and medication intake. The results were expressed as odds ratio (OR, with their 95% confidence intervals [CIs]) per 1°C increase in temperature variability. Results Our study found that a 1°C increase in upward temperature shift was significantly associated with increased risks for total MI, STEMI, and NSTEMI (OR [95% CI]: 1.010 [1.006-1.015], 1.014 [1.006-1.022], and 1.009 [1.004-1.014], respectively). Furthermore, a 1°C greater in downward temperature shift was significantly associated with decreased risks for total MI and NSTEMI (OR [95% CI]: 0.995 [0.991-0.999], and 0.993 [0.988-0.998], respectively). Moreover, we found that males and patients who were on any heart medication, particularly digitalis, were at a higher risk of MI associated with exposure to higher upward temperature shifts compared to females and their counterparts not taking these medications. Conclusions This nationwide case-crossover study provides novel evidence that short-term exposure to increasing upward temperature shift is associated with an increased risk of MI hospitalization. Our finding highlights the cardiovascular health threats posed by upward temperature shifts, which are anticipated to increase in frequency and intensity due to climate change.

Predictors of periprocedural myocardial infarction following percutaneous coronary intervenction in NSTEMI

Abstract Background Percutaneous coronary intervention (PCI) has demonstrated a significant positive prognostic impact on outcomes in patients with Non-ST-elevation myocardial infarction (NSTEMI). However, PCI is associated with an increased risk of periprocedural complications, among which periprocedural myocardial infarction (PMI). Although risk factors of periprocedural events are only well established in patients undergoing PCI for chronic coronary syndrome with normal baseline cardiac troponin (cTn) levels, evidence on predictors of additional post-PCI myocardial infarction in patients with acute coronary syndrome who present elevated cTn levels at baseline (pre-PCI) is missing. Purpose To identify the predictors of PMI in patients affected by NSTEMI undergoing PCI. Methods We prospectively evaluated all NSTEMI patients admitted to our coronary care unit from 2017 to 2022 who underwent PCI. NSTEMI patients were managed according to the current European guidelines criteria. The diagnosis of PMI (type 4a myocardial infarction) was based on the Fourth Universal Definition of Myocardial Infarction. We only enrolled patients with stable (≤ 20% variation) or falling pre-procedure baseline cTn values. A multivariable logistic regression analysis was performed to investigate the factors independently associated with the occurrence of PMI after PCI. For the analysis, we selected the main known predictors of PMI after elective PCI, specifically age, serum creatinine, GRACE score &amp;gt; 140, multivessel disease, coronary bifurcation PCI, left main or proximal left anterior descending PCI, multivessel PCI and stent length ≥ 60 mm. Results The final court of the study included 1412 patients. PMI was recognized in 240 patients (17.0%). Although the patients who developed PMI had a higher risk profile as documented by a higher mean age, a higher complexity of atherosclerotic disease, and thus a significant technical difficulty of PCI compared to other patients, according to the multivariable model, only age [OR: 1.02 (95% CI: 1.01-1.04); p=0.006], coronary bifurcation PCI [OR: 3.71 (95% CI: 2.70-5.10); p&amp;lt;0.001], and stent length ≥ 60 mm [OR: 1.87 (95% CI: 1.30-2.68); p=0.001] were independent predictors of PMI. Interestingly, despite previous studies have demonstrated a predictive role of procedural complexity features, this was not completely confirmed by our analysis, in which left main or proximal left anterior descending PCI [OR: 0.92 (95% CI: 0.66-1.26); p=0.596] and multivessel PCI [OR: 0.83 (95% CI: 0.56-1.23); p=0.357] were not associated with an increased risk of periprocedural ischemic complications. Conclusions Among NSTEMI patients undergoing PCI, age, coronary bifurcation PCI and stent length ≥ 60 mm represent independent predictive factors of type 4a MI. This finding may have important clinical implications for clinical practice, providing valuable insights for the identification of higher-risk patients that can benefit from a more aggressive treatment.

Derivation and external validation of new ESC 0/1-h algorithm cut-offs for high-sensitivity troponin T and I in the cancer population

Abstract Background The diagnostic performance of high-sensitivity cardiac troponin T/I (hs-cTnT/I) and the efficacy of the European Society of Cardiology (ESC) 0/1h-hs-cTnT/I-algorithms for the early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is reduced in cancer patients presenting to the emergency department (ED) with chest pain.[1] Purpose This study aimed to derive and externally validate new cut-offs for the ESC 0/1h-hs-cTnT/I-algorithms in chest pain patients with active or past cancer. Methods Patients presenting with acute chest discomfort to the ED were prospectively enrolled in an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by 2 independent cardiologists applying the fourth universal definition of myocardial infarction using all available medical records, cardiac imaging, and serial hs-cTnT/I. Hs-cTn concentrations were measured at presentation and after 1 hour. New assay-specific cutoffs for the ESC 0/1h-hs-cTnT/I-algorithm were derived and externally validated in two independent cohorts. Results Among 541 and 516 eligible patients with 0h and 1h hs-cTnT and hs-cTnI values, respectively, application of the current ESC 0/1h-hs-cTnT/I algorithm triaged 317 (58.6%) and 306 (59.3%) patients to either rule-out or rule-in, leaving 224 (41.4%) and 210 (40.7%) patients in the observe-zone of the ESC 0/1h-hs-cTnT/I algorithm, respectively. The novel ESC 0/1h-hs-cTnT cut-offs ruled out NSTEMI with a cut-off &amp;lt;8 ng/L at presentation (if chest pain onset &amp;gt;3 hours) or &amp;lt;14 ng/L together with a 0/1-hour delta &amp;lt;3 ng/L, ruling-out 241 patients (44.5%) with a sensitivity and negative predictive value (NPV) of 99.2% and 99.6%, respectively. The novel ESC 0/1h-hs-cTnI cutoffs ruled out NSTEMI with a cut-off &amp;lt;7 ng/L at presentation (if chest pain onset &amp;gt;3 hours) or &amp;lt;10 ng/L together with a 0/1-hour delta &amp;lt;3 ng/L, ruling-out 281 patients (54.5%) with a sensitivity and NPV of 99.1% and 99.6, respectively. Findings were confirmed in both internal and external validation (Figure 1). A total of 167 (32.8%) patients died at 5-years, of whom 61 died of cardiovascular causes, and 30 (5.9%) patients had an MI at 5 years. 5-year all-cause mortality for the rule-out group was similar for both the current and the novel ESC 0/1-h algorithm, although the novel one identified patients in the observe zone group as having the highest mortality (Figure 2). Incidence of 5-year cardiovascular mortality or AMI provided by the current ESC 0/1h-algorithm was similar for the rule-in and observe zone groups for both hs-cTnT and hs-cTnI. Conclusions In chest pain patients with a history of cancer, new derived assay-specific cutoffs for the ESC 0/1h-hs-cTnT/I-algorithm achieved a higher proportion of patients triaged to either rule-out or rule-in without decreasing safety. The low mortality rate of the rule-out group identified by the new algorithm further reassures on the safety of the new derived cut-offs.Sensitivity analysis in the APACE cohort5-year all-cause mortality

Impact of sex, age, comorbidities, and culprit lesion location on symptoms in patients with non-ST-segment elevation myocardial infarction

Abstract Background Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) about 80% present with chest discomfort. Others have less obvious symptoms, but early diagnosis is crucial. Sex differences in symptoms have been reported to delay diagnosis in about half of women. This study aims to analyze the symptoms and its disparities caused by sex, age, comorbidities, and culprit lesion location. Methods Patients presenting with troponin elevation and at least one angiographically confirmed atherosclerotic lesion causing the myocardial ischemia (culprit lesion) between February 2018 and July 2023 were prospectively included in a single-center, all-comers, real-world registry. Results Information regarding symptoms was available for 842 NSTEMI patients with an identifiable culprit lesion. Chest discomfort was reported by 684 patients (81.2%), dyspnea by 361 (42.9%) with it being the primary symptom in 102 (12.1%), and atypical symptoms by 317 (37.6%) with it being the primary symptom in 56 (6.7%). Concretely, dizziness or syncope was reported by 82 patients (9.7%), nausea, vomiting or any other gastrointestinal symptoms by 73 (8.7%), epigastric, shoulder, arm, back, neck or jaw pain by 57 (6.8%), diaphoresis by 66 (7.8%), other vegetative symptoms like palpitations or anxiety by 56 (6.7%), fatigue by 37 (4.4%), and neurologic symptoms like sensory or motor impairments by 28 (3.3%). In women, the primary complaint was less often chest discomfort (76.3 vs. 82.9%, p=0.040), more often atypical symptoms (9.8 vs. 5.6%, p=0.049) and equally often dyspnea (14.0 vs. 11.5%, p=0.403). Gastrointestinal symptoms were more often reported by women (13.5 vs. 7.0%, p=0.006). Elderly, i.e., age ≥80 years, reported chest discomfort less often (75.4 vs. 83.0%, p=0.023), dyspnea more often (19.5 vs. 9.9%, p&amp;lt;0.001) and atypical symptoms equally often (5.1 vs. 7.1%, p=0.418). Likewise, diabetic had chest discomfort less often (74.3 vs. 84.5%, p&amp;lt;0.001), dyspnea more often (18.2 vs. 9.2%, p&amp;lt;0.001), and atypical symptoms equally often (7.4 vs. 6.3%, p=0.633). No differences regarding primary symptoms were observed for dyslipidemia (82.1 vs. 78.9% for chest discomfort, 12.1 vs. 12.1% for dyspnea, 5.8 vs. 9.0% for atypical symptoms, p&amp;gt;0.05 for all) and obesity (84.5 vs. 81.2% for chest discomfort, 9.8 vs. 12.5% for dyspnea, 5.7 vs. 6.3% for atypical symptoms, p&amp;gt;0.05 for all). For LM culprit lesions, dyspnea was more often the primary symptom compared to LAD, LCX, and RCA culprit lesions (17.4% for LM vs. 13.6% for LAD, 5.7% for LCX, and 13.2% for RCA, p=0.023), while no differences were observed for chest pain (73.9% for LM, 80.6% for LAD, 86.1% for LCX, and 80.2% for RCA, p=0.235) and atypical symptoms (8.7% for LM, 5.9% for LAD, 8.1% for LCX, and 6.6% for RCA, p=0.758). Conclusions Chest discomfort is significantly less often the primary symptom of NSTEMI in women, elderly and diabetic making these groups more vulnerable for delayed diagnosis or misdiagnosis.

The long-term clinical benefit of early versus delayed invasive strategies in elderly patients with non-ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention

Abstract Background The data regarding long-term outcomes of early versus delayed invasive strategies in elderly patients who have undergone percutaneous coronary intervention (PCI) for non-ST-segment elevation myocardial infarction (NSTEMI) is limited. Purpose We aimed to investigate the long-term clinical benefit of early versus delayed invasive strategies in elderly patients who underwent PCI for NSTEMI. Methods From a nationwide, prospective, real-world registry of 13,104 patients with acute myocardial infarction (MI) who underwent PCI, 2818 elderly patients (aged ≥70 years) who underwent PCI for NSTEMI were included. Of these, 2299 patients were treated with an early invasive strategy (early invasive group), and 519 were treated later (delayed invasive group). The incidence of major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, readmission due to heart failure [HF], or definite/probable stent thrombosis [ST]) and the components of MACE were compared using multivariable Cox regression, propensity score (PS) matched, and PS-adjusted analyses. Results During a median follow-up of 1047 days, MACE, all-cause death, and cardiac death occurred in 1018 (36.1%), 660 (23.4%), and 423 patients (15.0%), respectively. The early invasive group showed significantly lower risks of MACE (entire: 35.0% vs. 41.2%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.66-0.90, p=0.001; PS-matched: n=984, 33.3% vs. 40.8%, HR 0.75, 95% CI 0.62-0.91, p=0.005), all-cause death (entire: 22.5% vs. 27.4%, HR 0.76, 95% CI 0.63-0.92, p=0.004; PS-matched: 21.8% vs. 27.2%, HR 0.75, 95% CI 0.58-0.90, p=0.005), cardiac death (entire: 13.8% vs. 20.2%, HR 0.64, 95% CI 0.51-0.79, p&amp;lt;0.001; PS-matched: 13.1% vs. 19.4%, HR 0.67, 95% CI 0.55-0.86, p=0.011), and readmission due to HF (entire: 6.5% vs. 9.2%, HR 0.64, 95% CI 0.46-0.89, p=0.007; PS-matched: 6.7% vs. 9.4%, HR 0.68, 95% CI 0.51-0.96, p=0.017) than the delayed invasive group. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, and definite/probable ST between the groups. Furthermore, in patients aged ≥80 years, the early invasive group had significantly reduced rates of MACE (42.9% vs. 49.5%, HR 0.71, 95% CI 0.55-0.91, p=0.039), all-cause death (31.7% vs. 39.0%, HR 0.71, 95% CI 0.55-0.92, p=0.010), and cardiac death (20.9% vs. 31.0%, HR 0.59, 95% CI 0.44-0.80, p=0.001) compared to the delayed invasive group. Conclusions In elderly patients with NSTEMI, an early invasive intervention strategy was associated with favorable long-term clinical outcomes compared to a delayed invasive intervention strategy.

Ethnic disparity in the care and management of non-ST-segment elevation myocardial infarction and its impact on short-term and long-term survival: a long-term study of a national registry

Abstract Background Previous examination of data from the United Kingdom indicates no apparent ethnic disparity in the treatment of patients hospitalised with non-ST-segment elevation myocardial infarction (NSTEMI). However, it remains uncertain whether this lack of disparity results in similar long-term survival outcomes among ethnic minority groups, particularly those with multiple underlying risk factors for coronary artery disease, when compared to White patients. Purpose To assess the impact of quality of care on short-term and long-term survival among NSTEMI patients while examining disparities based on ethnicity. Methods We analysed records of 252,964 individuals diagnosed with NSTEMI from the Myocardial Ischaemia National Audit Project database spanning 2005 to 2019, alongside Office of National Statistics data for mortality. Among them, 233,158 were identified as White patients, while 19,806 were categorised as belonging to ethnic minority groups (Asian, Black, and mixed ethnicity). Propensity score matching was used to compare average treatment effects between cohorts while survival was compared using Cox regression model. Results Ethnic minorities were younger (median age in years) (66 vs. 73, P &amp;lt; 0.001), predominantly male (70% vs. 63%, P &amp;lt; 0.001), and exhibited a higher prevalence of cardiovascular risk factors such as diabetes (52% vs. 24%, P &amp;lt; 0.001), hypertension (67% vs. 54%, P &amp;lt; 0.001), hypercholesterolemia (49% vs. 34%, P &amp;lt; 0.001), and chronic renal dysfunction (13% vs. 8%, P &amp;lt; 0.001). Ethnic minorities more frequently underwent invasive coronary angiography (80% vs. 68%, P &amp;lt; 0.001), percutaneous coronary intervention (53% vs. 44%, P &amp;lt; 0.001), and coronary artery bypass grafting (5% vs. 4%, P &amp;lt; 0.001). After conducting propensity score matching, both cohorts had no significant differences in in-hospital all-cause mortality [odds ratio (OR) 1.13, confidence interval (CI) 0.89 – 1.43; P = 0.268], cardiac mortality (OR 1.20, CI 0.89 – 1.54; P = 0.209), one-year mortality (OR 1.01, CI 0.89 – 1.13; P = 0.893) and major adverse cardiovascular events (OR 1.21, CI 0.95 – 1.48; P = 0.108). However, upon conducting a five-year survival analysis, ethnic minorities had better survival rates than their White counterparts (Hazard ratio (HR) 0.89, CI 0.86-0.92; P &amp;lt; 0.001). Conclusions Despite ethnic minorities being at a higher risk for coronary artery disease, our findings indicate that they experience better five-year survival rates than White patients. This suggests equitable access to care and potentially a more aggressive treatment approach in this relatively young patient cohort.

Mortality related to left ventricular ejection fraction and obstructive coronary artery disease in non-ST-segment elevation myocardial infarction

Abstract Background Extent of coronary artery disease (CAD) and the severity of reduced left ventricular ejection fraction (LVEF) have both been associated with the prognosis after non-ST-segment elevation myocardial infarction (NSTEMI). However, the contemporary mortality associated with the extent of obstructive CAD over a range of LVEF remains uncertain. Purpose The aim of this study was to assess the impact of CAD and LVEF on all-cause death following a first-time NSTEMI. Methods We included consecutive first-time NSTEMI patients undergoing coronary angiography from 2010 to 2021 in Western Denmark. Patients were stratified by extent of obstructive vessel disease (VD; 1, 2, or 3VD) and LVEF (≥51%, 41-50%, or 10-40%). Patients with previous myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting were excluded. The primary outcome was all-cause death. We calculated 5-year cumulative incidence proportions (CIP) as a measure of absolute risk and adjusted hazard ratios (HR). Results A total of 8,770 patients with first-time NSTEMI and obstructive CAD were examined with coronary angiography. Two-thirds were male and median age was 68 years (Q1-Q3: 58-78). The increase in mortality associated with decreasing LVEF was greater than observed by extent of CAD (Table). Thus, the 5-year mortality increased stepwise by extent of CAD from 14% for 1VD to 31% for 3VD (adjusted HR 1.35, 95% CI:1.19-1.54), but from 12% for LVEF ≥51% to 40% for LVEF 10-40% (adjusted HR 2.32, 95% CI: 2.04-2.65). When combining LVEF and extent of CAD, an increase in 5-year mortality was found from 9% for 1VD and LVEF ≥51% to 46% for 3VD and LVEF 10-40% (risk difference of 37.1%; Figure). Correspondingly, using 1VD and LVEF ≥51% as reference, the adjusted HRs increased gradually with extent of CAD and decline in LVEF to 3.05 (95% CI: 2.51-3.70) for patients with 3VD and LVEF 10-40% (Table). Conclusion In a contemporary all-comers cohort of first-time NSTEMI patients, increasing extent of CAD and declining LVEF are both associated with a gradual increase in 5-year mortality. Our data suggest that the level of LVEF reduction was more strongly associated with 5-year mortality than CAD extent.