non-ST-segment Elevation Myocardial Infarction Patients Research Articles

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.

Comparison of GRACE and TIMI risk scores in the prediction of in hospital outcome among NSTEMI patients: a single centre study

Abstract Background Major component of ACS, Non-ST segment elevation myocardial infarction (NSTEMI), has more than twice the incidence compared to ST-segment elevation myocardial infarction (STEMI). GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) risk scores are the two most popular prediction models in ACS due to TIMI’s advantage in its simplicity in clinical application and GRACE’s favorable discriminating power. Nevertheless, limited evidence compared the usefulness of these two major risk scores and their association with in-hospital events. Purpose To compare between the predictive ability of GRACE & TIMI risk scores for In hospital outcomes among the NSTEMI patients . Methods This prospective observational study was carried out from 8th march 2020 to 7th March 2022. Total 2152 acute NSTEMI patients were included. Both GRACE & TIMI risk score were calculated. For GRACE score, patients who scored ≤108 points were low risk,109-139 points were medium risk, ≥140 points were high risk . For TIMI scores patients with 0-2 scores were low risk , 3-4 scores were medium risk and 5-7 score were High risk. In Hospital outcomes were defined as the in hospital composite events which includes acute left ventricular failure, cardiogenic shock, arrhythmia & mortality. Results Among the 2152 patients majority were male (73.5%) with mean age of the study population were 58.33 ± .25 years. Mean Grace score & TIMI score of the study population were 137.81±16.38& 3.29±.97 respectively. Most of the patients were categorized in to Medium risk groups by both GRACE & TIMI risk scores , 70% & 51.3% respectively. However, high risk group percentage were higher in GRACE score group(41.3%) in comparison to TIMI score group(10.3%). GRACE score showed better predictive ability than TIMI score for in-hospital outcomes as evaluated by ROC curve( AUC of GRACE vs TIMI, In hospital ALVF:0.89vs 0.59, P<0.001; Cardiogenic Shock 0.72 vs 0.57, P=0.002; Mortality: 0.75 vs 0.59, P=0.002; arrhythmia 0.72 vs0.63, P=0.003). Conclusion GRACE showed better predictive accuracy than TIMI in NSTEMI patients for in-hospital outcomes. The sequential use of TIMI and GRACE scores provide an easy and promising discriminative tool in predicting outcomes in NSTEMI patients , thus improve the identification of high-risk patients.Pic :ROC curve for prediction of ALVFPic: ROC curve for Mortality prediction

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 < 0.001), older age (77.0 [69.0, 83.0] vs. 71.0 [66.0, 78.0], p < 0.001), and a higher proportion of patients with KILLIP III and above (25.86% vs. 17.44%, p < 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 < 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 < 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 < 0.001) and cardiovascular mortality (41.8% vs. 24.8%, p < 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 < 0.001). Conclusions The decline in ADL is significantly associated with adverse clinical outcomes among NSTEMI patients.Baseline characteristics of patientsMedications of patients

Application of anticoagulants in the perioperative period of pci for patients with a history of atrial fibrillation and NSTEMI: a real-world, large multicenter retrospective clinical study

Abstract Backgrounds The optimal management for patients with atrial fibrillation (AF) and concomitant coronary artery disease (CAD) remains unclear, particularly regarding anticoagulants use and ischemia-bleeding balance risks. This study aims to investigate the impact of perioperative anticoagulant use on patients with AF and acute non-ST-segment elevation myocardial infarction (NSTEMI). Methods Data for this study were obtained from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. A total of 150,530 patients were enrolled, including 74,373 NSTEMI patients. Patients were divided into anticoagulants and non-anticoagulants groups. A total of 1,358 patients were included in the non-anticoagulant group, and 3,541 patients were included in the anticoagulant group. Patients in each group were one-to-one matched based on propensity scores using the nearest available pair matching (PSM) method with a caliper width equal to 0.01. The primary endpoints were major adverse cardiovascular and cerebrovascular adverse events (MACCE), including cardiovascular death, recurrent myocardial infarction, and stroke. Secondary endpoints included cardiovascular death, recurrent myocardial infarction, BARC type 3 bleeding, and cerebral hemorrhage. Follow-up time points were set at 1 month,3 months, and 6 months. Multivariate Cox regression models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). Results After PSM matching, each group consisted of 809 patients. The anticoagulant group had a higher proportion of males, a higher prevalence of patients with a history of Percutaneous Coronary Intervention, and hyperlipidemia, while proportions of patients with Killips classification of III/IV and history of chronic kidney disease were lower. Anticoagulant use during the perioperative period significantly reduced the occurrence of MACCE at the primary endpoint at 1 month (aHR 0.57; P < 0.001), 3 months (aHR 0.57; P = 0.023), and 6 months (aHR 0.57; P < 0.001). At the secondary endpoint, anticoagulants use was associated with a lower incidence of cardiogenic death at 1 month,3 months, and 6 months (aHR 0.55; P <0.001), (aHR 0.55; P <0.001), (aHR 0.56; P <0.001), lower risk of myocardial infarction recurrence at 3 months and 6 months (aHR 0.47; P = 0.02), (aHR 0.44; P <0.001), without increasing the risk of bleeding events, including BARC type 3 bleeding and cerebral hemorrhage. Conclusion Perioperative anticoagulant use during PCI can reduce the occurrence of cardiac death, myocardial infarction, and stroke recurrence within 6 months post-surgery without increasing bleeding events in AF and NSTEMI patients. Therefore, for patients with AF, it is recommended to consider combining anticoagulant therapy with dual antiplatelet therapy during the perioperative period, if no contraindications.

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<0.001], NACE [aHR 0.91(0.88-0.95), p<0.001], and all-cause mortality [aHR 0.88(0.85-0.92), p<0.001]. However, regular exercise before NSTEMI was associated with an increased risk of coronary revascularization [aHR 1.14(1.06-1.23), p<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 <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

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 < 0.001), predominantly male (70% vs. 63%, P < 0.001), and exhibited a higher prevalence of cardiovascular risk factors such as diabetes (52% vs. 24%, P < 0.001), hypertension (67% vs. 54%, P < 0.001), hypercholesterolemia (49% vs. 34%, P < 0.001), and chronic renal dysfunction (13% vs. 8%, P < 0.001). Ethnic minorities more frequently underwent invasive coronary angiography (80% vs. 68%, P < 0.001), percutaneous coronary intervention (53% vs. 44%, P < 0.001), and coronary artery bypass grafting (5% vs. 4%, P < 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 < 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.

Impact of symptom-to-balloon time on long-term prognosis: a 3-year follow-up study in non-st-segment elevation myocardial infarction patients with complex lesions

Abstract Background Because no data are available, we compared clinical outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI), stratified based on the presence of complex lesions, according to symptom-to-balloon time (SBT, <48 h versus ≥48 h), undergoing newer-generation drug-eluting stents. Methods From the KAMIR (Korea Acute Myocardial Infarction Registry)-NIH dataset, a total of 4373 patients diagnosed with NSTEMI were enrolled and stratified into two groups: the complex group (2106 patients; SBT <48 h, 1365; SBT ≥48 h, 741) and the non-complex group (2267 patients, SBT <48 h, 1573; SBT ≥48 h, 694). The primary outcome was the 3-year all-cause death rate, and the secondary outcome was major adverse cardiac events (MACE), including cardiac death (CD), recurrent MI, and any repeat revascularization. Results The rates of all-cause death (adjusted hazard ratio [aHR], 0.656; p = 0.009) and cardiac death (aHR, 0.633; p = 0.037) in the complex group, and the rate of all-cause death (aHR, 0.773; p = 0.036) in the total study population, were significantly lower for patients with SBT <48 h than for those with SBT ≥48 h. In the non-complex group, all clinical outcomes were not significantly different between the SBT <48 h and SBT ≥48 h groups. In the SBT ≥48 h group, the complex group exhibits higher rates of all-cause death, any repeat revascularization, and MACE than those of the non-complex group Conclusions Reducing SBT was more effective in decreasing 3-year mortality in NSTEMI patients with a complex group compared to the non-complex group.

Differences in treatment and outcome of patients with ST- Elevation Myocardial Infarction (STEMI) and Non-STEMI in Germany

Abstract Background ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are the main diagnoses of acute coronary syndrome (ACS). Although both types of infarction are classed as ACS, the treatment and overall survival rate are different. Methods Health claims data (≈26 million members) were screened for patients with STEMI and NSTEMI from 01/2010 to 12/2018. Patient demographics, hospitalization details, adherence to guideline-directed drug therapy, and survival were assessed. Results The total cohort of acute myocardial infarctions comprised 544,529 patients (mean age 74 (IQR 62 - 82), one third of whom were hospitalized with a STEMI. Patients with STEMI were more likely to be in a life-threatening situation and had higher in-hospital, 30- and 60-day mortality, but better long-term survival. Major adverse cardiac and cerebrovascular events (MACCE), infarct recurrence, chronic kidney disease, peripheral arterial disease, heart failure and cerebrovascular disease were more common in patients with NSTEMI. STEMI-patients received coronary angiography and percutaneous coronary intervention more frequently. Although there was a clear correlation between guideline-compliant therapy and overall survival, adherence to guideline-compliant therapy decreased over time, especially in NSTEMI patients. Conclusion In ACS patients, there are clear differences between STEMI and NSTEMI patients in terms of short- and long-term survival. Guideline-based therapy improved long-term survival in both, but more significantly in STEMI patients.

Favourable lifestyle changes 1 year after acute myocardial infarction

Abstract Background Acute myocardial infarction (AMI) is a life-threatening event that should be an excellent motivator to adopt a healthy lifestyle. We aimed to evaluate the proportion of patients with AMI who reported favourable lifestyle changes 1 year after AMI. Methods Harnessing a nationwide prospective cohort of patients with AMI in Switzerland, ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients enrolled in the AMIS Plus registry between 2012 and 2022 were followed-up 1 year after the event by telephone interview. Favourable lifestyle changes, often addressed in hospitals or rehabilitation programmes were defined as smoking cessation, weight reduction (for overweight patients at index presentation), dietary changes, increased physical activity and stress reduction. Self-reported lifestyle changes were stratified according to AMI type, sex, and age. Results From 7906 AMI patients, 7234 (91.5%) with follow-up data were included. Of these, 5627 (77.8%) were male, 1607 (22.2%) female, 4664 (64.5%) had a STEMI, and 2570 (35.5%) a NSTEMI. At a median follow-up of 397 (interquartile range 371 to 465) days, 861 (50.9%) smokers at the time of the AMI had quit smoking, 1297 (35.0%) overweight patients had lost weight, 2567 (44.8%) patients had implemented nutritional changes, 2415 (41.2%) had increased their physical activity, and 1729 (30.5%) had reduced their stress levels. Patients with STEMI were more likely to stop smoking (53.0% vs. 45.1%, p=0.005), change their diet (46.4% vs. 41.6%, p<0.001), increase their physical activity (43.5% vs. 36.8%, p<0.001), or reduce stress (31.4% vs. 28.7%, p=0.04) compared to NSTEMI patients. Male sex was associated with smoking cessation [52.5% vs. 44.4%; p=0.008; age-adjusted odds ratio (OR), 0.78; 95% confidence interval (CI), 0.61-0.99; p=0.043], dietary change (47.8% vs. 33.7%; p<0.001; age-adjusted OR, 0.67; 95% CI, 0.58-0.77; p<0.001), and an increase in physical activity (43.5% vs. 32.9%; p<0.001; age-adjusted OR, 0.77; 95% CI, 0.67-0.88; p<0.001). However, after adjusting for age, stress reduction was comparable between males and females (30.9% vs. 28.9%; p<0.001; age-adjusted OR, 1.09; 95% CI, 0.94-1.26; p=0.25). Conclusions A substantial proportion of patients with AMI in Switzerland reported favourable lifestyle changes within 1 year after the index event. In general, STEMI as well as male patients were more likely to report multiple favourable lifestyle changes. Nevertheless, there is still room for improvement in terms of secondary prevention measures.

Smoking cessation after acute myocardial infarction: a Swiss-wide cohort study

Abstract Background Smoking is a major cardiovascular risk factor and of great importance in terms of both primary and secondary prevention. The present study aims to identify patient characteristics associated with smoking cessation within 1 year after acute myocardial infarction (AMI) to inform physician-patient interactions, secondary prevention measures, and public health planning. Methods ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients enrolled between 2012 and 2022 in the AMIS Plus registry who were active smokers at the time of the index event were included. At the 1-year follow-up, patients were questioned about their smoking behaviour via telephone interview and were further classified into those who had quit (stoppers) or continued (continuers) smoking. Patient characteristics were collected at the time of the index event and at follow-up and then compared using descriptive statistics. Results From a total of 4523 patients with AMI, 4242 (93.8%) provided information regarding their smoking status at a median follow-up of 395 days (interquartile range 370 to 469) after the index event. Of 1691 (39.9%) active smokers at the time of AMI, 861 (50.9%) reported quitting whereas 830 (49.1%) were still smoking at the 1-year follow-up. Stoppers were younger (57 vs. 58 years, p<0.001), more likely to be male (82.8% vs. 77.7%, p=0.008) and have presented with STEMI (77.0% vs. 71.0%, p=0.005), and less likely to have had a previous AMI (6.6% vs. 13.3%, p<0.001) than continuers. Smoking cessation was more common in patients with a more severe AMI characterised by a greater extent of myocardial injury (in-hospital median peak creatine kinase level 1291 IU/L vs. 1101 IU/L, p=0.012), at least one in-hospital complication (13.9% vs. 9.9%, p=0.01), and participation in a rehabilitation programme (83.7% vs. 68.8%, p<0.001). Stoppers more frequently implemented other favourable lifestyle changes, such as dietary changes (56.2% vs. 45.2%, p<0.001) and increased physical activity (54.6% vs. 37.7%, p<0.001) than continuers. Self-reported weight gain was more prevalent among those who quit smoking (44.0% vs. 19.7%, p<0.001). Conclusions In Switzerland, half of the patients with AMI who were active smokers at the time of AMI, reported to have stopped smoking 1 year after the index event. Smoking cessation was associated with participation in a rehabilitation programme and occurred more often in patients with larger AMI sizes, higher in-hospital complication rates and more frequent implementation of other favourable lifestyle changes after AMI. The significant weight gain after smoking cessation seems to represent a major issue that should specifically be addressed.

Comparing the ability of GRACE 2.0 scores for predicting mortality in patients with and without diabetes

Abstract Background The GRACE 2.0 (G2) was an improvement on GRACE. Neither contains DM in the model. In the GRACE, DM independently predicted in-hospital but not the 6-month post-discharge mortality. Similar analysis for GRACE 2.0 score is unavailable. Purpose Assess the ability of the GRACE 2.0 score in predicting mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on non-STEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics of the population and G2 scores were recorded. Death at 1 year was recorded from hospital and general practice records. Follow up was censored at the last recorded contact of the patient with a medical professional. The discriminative power of the G2 score in patients with and without diabetes in predicting mortality was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk. Results Of 2841 patients entered, complete data was available for 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes). G2 risk was higher in DM (8.3, IQR 3.9 to 19.0 v 5.5, IQR 2.6 to 13.0; p<0.0001). 337 patients died, 156 with DM. Higher deaths occurred in DM group (17.8% vs 16.3; adjusted OR 1.81, 95% CI 1.41-2.33, p<0.0001) (fig 1D). G2 discriminated between events well in whole cohort (AUC 0.81, p<0.001) with no difference between DM and non-DM patients (AUC DM: 0.78, 95% CI 0.75 to 0.81; non-DM 0.81, 0.79 to 0.83; δAUC 0.0301, p=0.242) (fig1E). Calibration of predictions by G2 was excellent across all deciles of risk for the whole cohort (fig 1A). However, G2 underestimated mortality in DM versus non-DM (fig1B,C), especially in the higher deciles of risk (fig 1 F,G). Conclusion(s) Discrimination of the GRACE 2.0 model was excellent for mortality at 1-year with no difference between patient with and without diabetes in our cohort of NSTEMI and UA patients. However, calibration plots suggest GRACE 2.0 underestimates mortality in diabetic compare to non-diabetic patients. This may suggest that risk stratification with GRACE 2.0 in diabetic patients may have to be considered with caution.Figure 1.

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<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<0.001), dyspnea more often (18.2 vs. 9.2%, p<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>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>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.

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 (<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<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<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.

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.

Reassess Hospital Costs and Mortality Between Myocardial Infarction With and Without ST-Segment Elevation in a Modern Context.

Patients with ST-segment elevation myocardial infarction (STEMI) may have higher hospitalization costs and poorer prognosis than non-ST-segment elevation myocardial infarction (NSTEMI). A single-center retrospective study was conducted on 758 STEMI patients and 386 NSTEMI patients from January 1, 2020 to May 30, 2023 aimed to investigate the differences in cost and mortality. STEMI patients had higher maximal troponin I (15,222.5 (27.18, 40,000.00) vs. 2731.5 (10.73, 27,857.25), p < 0.001) and lower left ventricular ejection fraction (LVEF) (56% (53%, 59%) vs. 57% (55%, 59%), p < 0.001) compared to NSTEMI patients. The clinical symptoms were mainly persistent or interrupted chest pain/distress in either STEMI or NSTEMI patients. STEMI patients had a significantly higher risk of combined hypotension than NSTEMI patients (8.97% vs. 3.89%, p = 0.002), and IABP was much more frequently used in the STEMI group with a statistical difference (2.90% vs. 0.52%, p = 0.015). STEMI patients have statistically higher hospitalization costs (RMB, ¥) (31,667 (25,337.79, 39,790) vs. 30,506.91 (21,405.96, 40,233.75), p = 0.006) and longer hospitalization days (10 (8, 11) vs. 9 (8, 11), p = 0.001) compared to NSTEMI patients. Although in-hospital mortality was higher in STEMI patients, the difference was not statistically significant (3.56% vs. 2.07%, p = 0.167). Multivariable logistic regression was performed and found that systolic blood pressure and NT-proBNP were risk factors for patient death (OR ≥ 1). STEMI patients are more likely comorbid cardiogenic shock, heart failure complications with higher hospitalization costs and longer hospitalization days. And relatively more use of acute mechanical circulatory support devices such as IABP. ChiCTR2300077885.

Machine Learning Diagnostic Model for Early Stage NSTEMI: Using hs-cTnI 1/2h Changes and Multiple Cardiovascular Biomarkers.

This study demonstrates differences in the distribution of multiple cardiovascular biomarkers between non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) patients. Diagnostic machine learning predictive models measured at the time of admission and 1/2 h post-admission, achieving competitive diagnostic predictive results. This study aims to explore the diagnostic value of changes in high-sensitivity cardiac troponin I (hs-cTnI) levels in patients with suspected NSTEMI. A total of 267 patients presented with chest pain, requiring confirmation of acute coronary syndrome (ACS) subtypes (NSTEMI vs. UA). Hs-cTnI and other cardiac markers, such as creatine kinase-MB (CK-MB) and Myoglobin (Myo), were analyzed. Machine learning techniques were employed to assess the application of hs-cTnI level changes in the clinical diagnosis of NSTEMI. Levels of CK-MB, Myo, hs-cTnI measured at admission, hs-cTnI measured 1-2 h after admission, and NT-proBNP in NSTEMI patients were significantly higher than those in UA patients (p < 0.001). There was a positive correlation between hs-cTnI and CK-MB, as well as Myo (R = 0.72, R = 0.51, R = 0.60). The optimal diagnostic model, Hybiome_1/2h, demonstrated an F1-Score of 0.74, an AUROC of 0.96, and an AP of 0.89. This study confirms the significant value of hs-cTnI as a sensitive marker of myocardial injury in the diagnosis of NSTEMI. Continuous monitoring of hs-cTnI levels enhances the accuracy of distinguishing NSTEMI from UA. The models indicate that the Hybiome hs-cTnI assays perform comparably well to the Beckman assays in predicting NSTEMI. Moreover, incorporating hs-cTnI measurements taken 1-2 h post-admission significantly enhances the model's effectiveness.

Angiographic findings in patients with Non-ST-elevation myocardial infarction

Background &amp; Objective: Acute coronary syndrome (ACS) can be divided into subgroups of ST-segment elevation myocardial infarction (STEMI), Non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (USA). Patients diagnosed with NSTEMI are either treated conservatively or early invasive strategy is adopted. In NSTEMI it is believed that either one or more vessel is transiently occluded or that the blood flow is critically reduced in a patent vessel i.e. subtotal occlusion. This study was conducted to find the angiographic characteristics of NSTEMI patients undergoing coronary angiography. Methods: This study was conducted in Department of Cardiology, Lady Reading Hospital Peshawar. It was Cross Sectional Study. Data was collected from 8th November 2022 to 8th May 2023. Consecutive non-probability sampling technique was used to collect data from the patients. Results: Total of 300 patients were studied. The mean age was 56.95 years ±1.176 standard deviation. Male patients were 201 (67%) and remaining were female. It was found that 51(17%) of total NSTEMI patients were having totally obstructed coronary artery (OCA) in one or more coronary arteries. In NSTEMI, non-obstructive CAD (&lt;50%) were found in 81 (27%) of patients whereas 219 (73%) were having significant CAD. It was found that 40% were having single vessel CAD, 32% were having double vessel CAD and 28% were having triple vessel CAD. TVCAD was present significantly higher in advance age, Diabetes mellitus, hyperlipidemia and family history of CAD. Conclusion: Patients having NSTEMI are usually having multiple risk factors and having usually severe and multivessel CAD. doi: https://doi.org/10.12669/pjms.40.10.9499 How to cite this: Ikramullah, Ahmad F, Haq A, Khan SW. Angiographic findings in patients with Non-ST-elevation myocardial infarction. Pak J Med Sci. 2024;40(10):2228-2232. doi: https://doi.org/10.12669/pjms.40.10.9499 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Comparison of Regional Wall Motion Abnormalities in STEMI and NSTEMI Patients at Mardan Medical Complex

Objectives: This study aims to determine and compare regional wall motion abnormalities (RWMA) in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), along with associated common complications. Methodology: A comparative cross-sectional study was conducted in the cardiology department of Mardan Medical Complex from June to November 2023. Patients diagnosed with acute myocardial infarction (both STEMI and NSTEMI) were included. Data were collected using a convenient sampling technique. Ethical approval was obtained prior to data collection, which was performed using a predesigned questionnaire. RWMA assessments were conducted by an expert in accordance with the American Society of Echocardiography guidelines using a Toshiba Xario200 Echocardiography machine. Data were analyzed using SPSS 22. Results: Out of 274 patients, 156 (56.9%) were male and 118 (43.1%) were female, with 136 (50%) from the STEMI group and 136 (50%) from the NSTEMI group. The mean age of the respondents was 57.4 ± 13.1 years. RWMA was observed in both types of MI, with significant differences (p &lt; 0.05) found between STEMI and NSTEMI in several segments: basal anterior (5.83% vs. 1.82%), basal anteroseptal (16.23% vs. 2.55%), basal anterolateral (14.59% vs. 3.23%), basal inferior (18.61% vs. 2.91%), apical anterior (5.09% vs. 1.45%), and apical septal (5.46% vs. 1.82%). Severe left ventricular systolic dysfunction was observed in only 2 (0.73%) STEMI patients, while severe pulmonary hypertension was more common in NSTEMI patients. Conclusion: RWMA is a common finding in STEMI patients. Echocardiography plays a crucial role in the early detection of RWMA, which can improve prognosis and reduce the risk of complications.

Aslanger's pattern with acute lesion in the left coronary system: A case report

Acute Coronary Syndrome (ACS) is characterized by the suspicion or confirmation of acute ischemia or acute myocardial infarction (MI). The presence of ST segment elevation (STE) consists in the main criterion for indication of immediate reperfusion therapy due to acute coronary occlusion, although significant part of the acute coronary occlusion cases do not fit the ST-segment elevation myocardial infarction (STEMI) criteria.A case report of a 50 year-old male presenting typical anginal pain, whose electrocardiogram (EKG) presented Aslanger's pattern. The patient had severe lesion of the left anterior descending artery (ADA) and chronic occlusion of the right coronary artery on cardiac catheterization, with important collateral flow from branches of the left coronary artery to the right coronary artery.The dichotomy between STEMI and Non-ST segment elevation myocardial infarction (NSTEMI) must be contested, owing to the evidence that one third of the NSTEMI patients presents a total coronary occlusion. There are other electrocardiographic patterns which must be considered to diagnose ACS. Our case report outlines a different clinical presentation of Aslanger pattern, that shows a ADA acute occlusion, instead of the lesion being in the right coronary system.There is evidence that, in addition to the STEMI vs NSTEMI criteria, the Aslanger pattern and other electrocardiographic patterns characterize occlusive ACS. Recognizing those patterns in clinical practice is essential to improve the diagnosis and early treatment of patients with ACS.