non-ST Segment Myocardial Infarction Research Articles

QUALITY OF CARE FOR PATIENTS WITH ACUTE MYOCARDIAL INFARCTION: RESULTS OF THE FIRST 3 MONTHS OF THE QUALITY IN CARDIOLOGY (QIC) PROJECT

Abstract Background Assessing the quality of care is the first step for improve the management of patients with acute myocardial infarction (AMI). The European Society of Cardiology (ESC) and the Acute Cardiovascular Care Association (ACCA) recently defined a set of quality indicators (QI) of care for AMI. Aim To evaluate the quality of care of patients admitted to the Cardiology ward of our first level hospital for an AMI using the ESC ACCA QI. Methods QiC project is a prospective quality improvement study in real–world practice on all patients admitted to our ward for an AMI from 1.5.2023 to 30.4.25 with six–monthly audit activities. Case record forms were filled in by doctors during admission and were attached to the patient’s discharge letter. Thirty–day mortality was assessed by telephone interviews. The ESC ACCA QI include 18 main and 8 secondary QI on centre organization, reperfusion and invasive strategy, risk assessment, antithrombotic treatment, secondary prevention discharge treatments, and patient experience. For each IQ was evaluated the percentage of QI assessable and attained. Results A total of 78 patients were admitted for AMI in our Cardiology Department in the first 3 months. No one patient denied consent, one died during hospitalization, 7 patients had to be transferred to another hospital, and 3 patients did not have their record form filled in. The median age of the 67 patients discharged alive was 66 (IQR 58–75) years, 45 (67.2%) were males, 35 (52.2%) had a ST–segment elevation myocardial infarction (STEMI) and 32 (47.8%) a non–ST–segment myocardial infarction (NSTEMI). The percentages of non–assessment, non–attainment and attainment for each QI are reported in the Figure: the degree of non–assessment of the 26 QI ranged from 0 to 22% and the degree of QI attainment from 25 to 100%. Conclusions Quality of care for acute myocardial infarction can be measured in the majority of patients admitted to our Cardiology Department using the ESC ACCA quality indicators. Although most quality indicators are met in our patients, a large room for improvement is present in the reperfusion and invasive strategy (mainly in timely reperfusion of STEMI patients) and in the patient’s satisfaction (discharge letter sent to patient).

A novel case of yamaguchi syndrome in the Saudi population

Background: Apical hypertrophic cardiomyopathy (ApHCM) known as Yamaguchi syndrome, is an uncommon variant of hypertrophic cardiomyopathy, with higher incidence reported in the Asian populations. The clinical presentation of ApHCM is vague thus can mimic other conditions, which can lead to a delayed or a missed diagnosis. Only a few reports have described the incidence of Yamaguchi syndrome in other populations other than Asians. Case Presentation: A 46-year-old male, heavy smoker, with unremarkable past medical history was presented to the emergency department with severe central chest pain that radiates to the left side, exacerbated by excretion, and relived by rest not associated with shortness of breath or palpitation. Additionally, the patient reported two similar episodes that occurred the past 4 days. However, physical examination was unremarkable. Initially the patient was labeled as high-risk acute coronary syndrome (unstable angina vs non-ST segment myocardial infarction). Cardiac markers including troponin I and Creatine kinase-MB were within normal range. ECG revealed deep T wave inversion in the inferior limb leads and pericardial leads suggestive of right coronary and left anterior descending artery or left main coronary lesion. The patient underwent for urgent cardiac catheterization which revealed normal coronary arteries. Transthoracic echocardiograph (TTE) showed isolated apical hypertrophy with preserved LV function, suggestive of ApHCM. The patient was advised on smoking cessation and discharged on beta blocker. Conclusion: There is an imminent need to establish further research investigating the prevalence of Yamaguchi syndrome among the Saudi population.

Abstract 14961: Revitalizing Graft Patency: Intravascular Lithotripsy in Calcified Saphenous Vein Graft to Left Anterior Descending Artery Stenosis

A 73-year-old man with coronary artery disease (CAD), coronary artery bypass graft, heart failure [EF 25%] & hypertension presented with Non-ST Segment Myocardial Infarction. Angiography revealed multivessel CAD with chronic total occlusion (CTO) of mid-left anterior descending (LAD) after a large first diagonal branch, CTO of mid-left circumflex & distal right coronary artery. Saphenous vein graft (SVG) to obtuse marginal was patent. SVG-diagonal & SVG-ramus intermedius were occluded. Mid SVG-LAD showed severe calcified stenosis (Fig. 1A). Native LAD beyond the SVG provided left to right collaterals to right posterior descending artery. Complex high-risk coronary intervention was performed on the SVG-LAD with mechanical circulatory support (MCS; Impella CP). SVG-LAD had a balloon undilatable lesion despite high pressure inflation with 4.0 mm cutting balloon (Fig. 1B). Intravascular ultrasound (IVUS) revealed severe stenosis with extensive circumferential calcification (Fig. 1C). Subsequently, intravascular lithotripsy (IVL) with 4.0 mm Shockwave balloon followed by high pressure balloon angioplasty with 4.5 mm noncompliant (NC) balloon was performed with significant luminal gain and fractures in calcium (Fig. 1D). The lesion was treated with 5.0 mm drug eluting stents that were post dilated with 5.0 mm NC balloon with excellent angiographic and IVUS result (Figs. 1E & F). MCS was successfully removed at the end of the case.SVG grafts are associated with poor long-term patency compared to arterial grafts. PCI to SVG has a high failure rate and PCI of native vessel is often preferable. High risk SVG interventions with atherectomy have been recently reported, though data is limited. IVL has been safely used in heavily calcified native coronary arteries, however, its use in SVG disease is rare. We report the first off-label use IVL of SVG-LAD with MCS for treatment of a last-remaining conduit. Additional studies to assess IVL efficacy in vein grafts are warranted.

Troponin level at presentation as a prognostic factor among patients presenting with non-ST-segment elevation myocardial infarction.

Timely reperfusion within 120 min is strongly recommended in patients presenting with non-ST-segment myocardial infarction (NSTEMI) with very high-risk features. Evidence regarding the use of high-sensitivity cardiac troponin (hs-cTn) concentration upon admission for the risk-stratification of patients presenting with NSTEMI to expedite percutaneous coronary intervention (PCI) and thus potentially improve outcomes is limited. All patients admitted to a tertiary care center ICCU between July 2019 and July 2022 were included. Hs-cTnI levels on presentaion were recorded, dividing patients into quartiles based on baseline hs-cTnI. Association between initial hs-cTnI and all-cause mortality during up to 3 years of follow-up was studied. A total of 544 NSTEMI patients with a median age of 67 were included. Hs-cTnI levels in each quartile were: (a) ≤122, (b) 123-680, (c) 681-2877, and (d) ≥2878 ng/L. There was no difference between the initial hs-cTnI level groups regarding age and comorbidities. A higher mortality rate was observed in the highest hs-cTnI quartile as compared with the lowest hs-cTnI quartile (16.2% vs. 7.35%, p = .03) with hazard ratio (HR) for mortality of 2.6 (95% confidence interval [CI]: 1.23-5.4; p = .012) in the unadjusted model, and HR of 2.06 (95% CI: 1.01-4.79; p = .047) with adjustment for age, gender, serum creatinine, and significant comorbidities. Patients with NSTEMI and higher hs-cTnI levels upon admission faced elevated mortality risk. This underscores the need for further prospective investigations into early reperfusion strategies' impact on NSTEMI patients' mortality, based on admission troponin elevation.

Outcomes of Non–ST-Segment Myocardial Infarction During Chronic Heart Failure and End-Stage Renal Disease

Non-ST-segment myocardial infarction (NSTEMI) occurs frequently in a growing population of patients with chronic heart failure (HF) and end-stage renal disease (ESRD) but outcomes with invasive management approaches are unknown. We sought to determine in-hospital outcomes with percutaneous coronary intervention (PCI) in comparison with medical management only. The National Inpatient Sample was used to capture hospitalizations in the United States from 2006 to 2019. Admissions for NSTEMI in patients with chronic HF and ESRD were identified by International Classification of Diseases codes. The cohort was divided into those that received PCI or medical management only. In-hospital outcomes were compared by multivariable logistic regression and propensity matching. In 27,433 hospitalizations, 8,004 patients (29%) underwent PCI, and 19,429 (71%) were managed with medications only. PCI was associated with lower adjusted odds of death during hospitalization (adjusted odds ratio 0.59, 95% confidence interval 0.52 to 0.66, p<0.01). This association remained consistent after propensity matching (adjusted odds ratio 0.56, 95% confidence interval 0.49 to 0.64, p<0.01) and was apparent across all subtypes of HF. Patients with PCI had greater duration (5, 3, to 9 vs, 5, 3 to 8days, p<0.01) and cost of hospitalization ($107,942, 70,230 to $173,182 vs, $44,156, 24,409 to $80,810, p<0.01). In conclusion, patients with HF and ESRD admitted for NSTEMI experienced lower in-hospital mortality with PCI in comparison with medical therapy only. Invasive percutaneous revascularization may be reasonable for appropriately selected patients with HF and ESRD but randomized controlled trials are needed to determine its safety and efficacy in this high-risk population.

Abstract 15703: Outcomes of Non-ST Segment Myocardial Infarction in Patients With Heart Failure and End Stage Renal Disease

Introduction: Non-ST Segment Myocardial Infarction (NSTEMI) occurs frequently in patients with pre-existing Heart Failure (HF) and End Stage Renal Disease (ESRD). However, outcomes with invasive approaches such as percutaneous coronary intervention (PCI) or medical management remain uncertain. Hypothesis: Given severe comorbidity burden, patients with HF and ESRD admitted for NSTEMI may experience higher in-hospital mortality with an invasive strategy of PCI. Methods: We utilized the National Inpatient Sample to capture hospitalizations in the United States from 2006-2014. Admissions for NSTEMI were identified by the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code 401.7x. The sample was further narrowed by coexisting diagnoses of HF (ICD-9-CM: 428.xx) and ESRD (ICD-9-CM 585.6). The cohort was divided into those that received PCI or medical management only. Multivariable logistic regression was used to compare the primary outcome of in-hospital mortality between invasive and medical management only groups. Results: During the study period, 14,333 hospitalizations were identified for NSTEMI in patients with coexisting HF and ESRD. Within this cohort, 3,549 (25%) underwent PCI (age: 66±11 years,42% female) and 10,784 (75%) were managed with medications (age: 69±12 years, 45% female) only. In-hospital mortality was 5% in the PCI group in comparison to 10% in those managed with medications only (p&lt;0.01). After adjustment for clinical covariates including age, sex and diabetes mellitus, PCI was associated with lower odds of death during hospitalization (aOR: 0.52, 95% CI: 0.44-0.61, p&lt;0.01). Conclusions: Patients with HF and ESRD admitted for NSTEMI do not incur greater in-hospital mortality with PCI, despite a high burden of comorbidities. Invasive percutaneous revascularization may be reasonable for appropriately selected patients with HF and ESRD.

Impact of pre-existing vascular disease on clinical outcomes in patients with non-ST-segment myocardial infarction: a nationwide cohort study

Abstract Aims Little is known about the outcomes and processes of care of patients with non ST-segment myocardial infarction (NSTEMI) who present with “polyvascular” disease. Methods We analysed 287,279 NSTEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed; coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral vascular disease (PVD), with comparison to a historically disease-free control group; comprising 167,947 patients (59%). Further analyses compared cumulative number of affected beds with our control. Results After adjusting for demographics and management, vascular bed disease was associated with increased likelihood of MACE (CAD OR: 1.06, 95% CI: 1.01–1.12, P=0.02) (CeVD OR: 1.19, 95% CI: 1.12–1.27, P&amp;lt;0.001) (PVD OR: 1.22, 95% CI: 1.13–1.33, P&amp;lt;0.001) and in-hospital mortality (CeVD OR: 1.24, 95% CI: 1.16–1.32, P&amp;lt;0.001) (PVD OR: 1.33, 95% CI: 1.21–1.46, P&amp;lt;0.001). Patients with no vascular disease were less likely to be discharged on statins (PVD 88%, CeVD 86%, CAD 90% and control 78%), and those with moderate (EF 30–49%) or severe left ventricular systolic dysfunction (LVSD) (EF&amp;lt;30%) were less likely to be discharged on ACE inhibitors (CAD 82%, CeVD 77%, PVD 77%, control 74%). Patients with polyvascular disease were less likely to be discharged on DAPT (PVD 78%, CeVD 77%, CAD 80%, control 87%). Conclusion Polyvascular disease patients had a higher adjusted incidence of in-hospital mortality and MACE. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT. Funding Acknowledgement Type of funding sources: None.

Impact of QRS Duration on Non–ST-Segment Elevation Myocardial Infarction (from a National Registry)

QRS duration (QRSd) is ill-defined and under-researched as a prognosticator in patients with non-ST-segment myocardial infarction (NSTEMI). We analyzed 240,866 adult (≥18 years) hospitalizations with non-ST-segment elevation myocardial infarction using data from the United Kingdom Myocardial Infarction National Audit Project. Clinical characteristics and all-cause in-hospital mortality were analyzed according to QRSd, with 38,023 patients presenting with a QRSd >120 ms and 202,842 patients with a QRSd <120 ms. Patients with a QRSd >120 ms were more frequently older (median age of 79 years vs 71 years, p <0.001), and of white ethnicity (93% vs 91%, p <0.001). Patients with a QRSd <120 ms had higher frequency of use of aspirin (97% vs 95%, p <0.001), P2Y12 inhibitor (93% vs 89%, p <0.001), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (82% vs 81%, p <0.001) and β blockers (83% vs 78%, p <0.001). Invasive management strategies were more likely to be used in patients with QRSd <120 ms including invasive coronary angiography (72% vs 54%, p <0.001), percutaneous coronary intervention (46% vs 33%, p <0.001) and coronary artery bypass graft surgery (8% vs 6%, p <0.001). In a propensity score matching analysis, there were no differences between the 2 groups in the adjusted rates of in-hospital all-cause mortality (odds ratio 0.94, 95% confidence interval 0.86 to 1.01) or major adverse cardiac events (odds ratio 0.94, 95% confidence interval 0.85 to 1.02) during the index admission. In conclusion, prolonged QRSd >120 ms in the context of non-ST-segment myocardial infarction is not associated with worse in-hospital mortality or the outcomes of major adverse cardiac events.

Sonification enables continuous surveillance of the ST segment in the electrocardiogram

IntroductionST segment elevation myocardial infarction is a common reason for out-of-hospital cardiac arrest in adult patients. The surveillance of the ST segment in the electrocardiogram is limited to visual presentation. However, the ST segment can change during the course of treatment. If ST elevation is present immediate coronary revascularization is needed, therefore detecting ST elevation changes the treatment fundamentally. Sonification of the ST segment is a new method which enables the emergency team to detect intermediate changes of the ST segment. Material and methodsWe have chosen two sonification designs which were introduced to two groups, medical students and computer science students. Twenty-one participants took part in the study. The sonification was designed for evaluation of the ST segment. The user was supposed to become empowered to distinguish between no, medium–low, medium–high or extreme ST elevation by listening to the sonification. The two groups were asked to evaluate the sounds for possible ST elevation as well as for aesthetics and usability. In a second study twenty-five medical students were taking part in a medical scenario in which sonification was played during a simulated case. The patient was suffering from a myocardial infarction, ST elevation was transient and sonification sounds were changing appropriately. The students were supposed to detect these changes and act accordingly by modifying the treatment. ResultsBoth groups were able to classify ST segment elevation by listening to the sonification samples. The higher the ST segment, the better was the detection rate overall. In all of the three categories (pleasantness, informativeness and long-term listening) the Water Ambience sonification was rated higher compared to the Polarity sonification. Moreover, in the two groups that took part in the study, we found a significant difference when comparing classification performance using both sonification designs. For the group of medical students as t(20) = 4.31, p = 3.44 × 10−4, p < 0.01 and for the computer science students as t(19) = 3.40, p = 9.39 × 10−6, p < 0.01. In the simulated medical scenario participants indicated that 96% detected the ST elevation. 60% stated that sonification played a role whereas for 32% it did not play a role for the detection of ST elevation. ConclusionsSonification has the potential to play an important role as a new supporting tool for the surveillance of the ST segment during the care of patients with suspicion of myocardial infarction. It can be helpful to differentiate between ST segment elevation myocardial infarction and non-ST segment myocardial infarction especially if ST elevation is transient. Furthermore, sonification is viewed as pleasant to listen to and might not contribute to alarm fatigue.

Impact of pre-existing vascular disease on clinical outcomes.

Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with 'polyvascular' disease. We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed-coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)-with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01-1.12; P=0.02] (CeVD OR: 1.19; 95% CI: 1.12-1.27; P<0.001) (PVD OR: 1.22; 95% CI: 1.13-1.33; P<0.001) and in-hospital mortality (CeVD OR: 1.24; 95% CI: 1.16-1.32; P<0.001) (PVD OR: 1.33; 95% CI: 1.21-1.46; P<0.001). Patients without vascular disease were less frequently discharged on statins (PVD 88%, CeVD 86%, CAD 90%, and control 78%), and those with moderate [ejection fraction (EF) 30-49%] or severe left ventricular systolic dysfunction (EF<30%) were less frequently discharged on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (CAD 82%, CeVD 77%, PVD 77%, and control 74%). Patients with polyvascular disease were less likely to be discharged on dual antiplatelet therapy (DAPT) (PVD 78%, CeVD 77%, CAD 80%, and control 87%). Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

In-Hospital Outcome and Angiographic Profile of Elderly Patients with Non-ST Segment Elevation Myocardial Infraction

Background: Non-ST Segment elevation myocardial infarction is heterogeneous in its presentation. Like ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction is life-threatening of a major cause of emergency medical care and hospitalization. Patients with non-ST segment elevation myocardial infarction are at risk for adverse cardiac events, so the initial treatment is very important. Increasing age is a strong predictor of adverse events in non-ST segment elevation myocardial infarction patients. Objective: To determine the in-hospital outcome and severity of coronary artery disease of older patients with Non-ST Segment elevation myocardial infarction. Methods: This was a descriptive cross-sectional study. The study was carried out in the cardiology department, National Heart Foundation Hospital, and Research Institute from June 2011 to May 2012. Patients of Non-ST Segment elevation myocardial infarction admitted at National Heart Foundation &amp; Research Institute who fulfill the inclusion criteria were the study population. Patients were recruited by nonrandom sampling. One hundred and thirty-four patients were recruited in this study. Data were prospectively collected in a pre-designed data collection form and analyzed using SPSS - 16 software. Results: In this study, patients had a greater prevalence of hypertension diabetes mellitus. Chest pain and shortness of breath were common presentations observed in study patients during admission. They had a lower left ventricular ejection fraction than their younger counterparts. The older group was associated with an increased risk of triple vessel disease. In-hospital complications were significantly higher in older patients. Duration of hospital stay was longer in older patients. Conclusion: Older patients with Non-ST Segment myocardial infarction strongly predict adverse in-hospital outcomes and severe coronary artery disease profiles. Older patients should alert physicians to an increased risk of morbidity and mortality, which may, in turn, support more judicious treatment, including appropriate utilization of cardiovascular diagnostic tests and therapeutics used in current cardiovascular care to optimize outcomes in these high- risk patients.

Unstable Angina Pectoris With Myocardial Injury Versus Myocardial Infarction in the Era of High-Sensitivity Cardiac Troponin

It is unknown whether outcomes in patients with unstable angina pectoris (UAP) and myocardial injury are different from outcomes in patients with non-ST-segment myocardial infarction (NSTEMI) with low peak concentrations of high-sensitivity cardiac troponin T (hs-cTnT). This study aimed to compare the prognosis in patients with UAP and evidence of myocardial injury, with prognosis in patients with NSTEMI and different peak hs-cTnT concentrations. All visits to 7 different emergency departments in Sweden from December 9, 2009 to December 31, 2016 were identified (n=5,225,075). We included all hospitalized patients with hs-cTnT >14ng/L and a diagnosis of UAP or NSTEMI, with ≥2hours-cTnT measurements. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and cardiovascular events, in patients with NSTEMI categorized according to peak hs-cTnT concentrations, compared with patients with UAP. Altogether, 11,944 patients were included, of whom 1,253 (10%) received a diagnosis of UAP. During a median follow-up of 3.0 years (interquartile [IQR] 1.6 to 4.7), 3,297 patients died. There was no difference comparing patients with NSTEMI with peak hs-cTnT of 15 to 49ng/L to patients with UAP, with regards to long-term cardiovascular mortality (HR 1.15; 95% CI, 0.85 to 1.56), but the risk of recurrent myocardial infarction was higher in patients with NSTEMI (HR, 1.61; 95% CI, 1.29 to 2.00), and the risk of heart failure hospitalization slightly lower (HR 0.80, 95% CI, 0.64 to 0.99). In conclusion, patients with UAP and myocardial injury have a similar risk of death after discharge, but a lower risk of recurrent myocardial infarction and a marginally higher risk of heart failure, compared with patients with NSTEMI with moderately elevated hs-cTnT levels.

Assessment of risk factors, clinical presentation and angiographic profile of coronary slow flow phenomenon

Background: Primary coronary slow flow phenomenon (PCSFP) is a clinical entity that causes attacks of mild to severe chest pain. It is characterized by delayed coronary vessel opacification in the absence of epicardial stenosis. This work aimed for the assessment of predictors, clinical presentation, and angiographic profile of PCSFP. Subjects and Methods: This cross-sectional case–control study was done between February 2019 and January 2020, including 150 patients who presented by ST-segment myocardial infarction, non-ST segment myocardial infarction, unstable angina, chronic coronary syndrome, or atypical chest pain. The patients were divided into two groups: group 1: consisted of 100 patients who had PCSFP and Group 2: consisted of 50 patients who had normal coronary flow (NCF). Results: PCSFP was significantly more prevalent in young male patients. Among the traditional risk factors, there was significantly more prevalence of hypertension (63.0% vs. 28.0%, P = 0.001), obesity (body mass index ≥30 kg/m2 (47.0% vs. 4.0%, P = 0.001), and history of smoking (66.0% vs. 40.0%, P < 0.002) in PCSFP patients as compared to NCF patients. Triglyceride (TG), cholesterol, low-density lipoprotein, high-sensitivity C-reactive protein (hs-CRP), and hemoglobin all were higher in patients with PCSFP. Low high-density lipoprotein levels were associated with PCSFP. In multivariable analysis, PCSFP was significantly independently associated with male sex, high TG, cholesterol, and hs-CRP. TG (odds ratio [OR]: 14.427, 95% confidence interval [CI]: 3.514–59.226) and cholesterol (OR: 11.739, 95% CI, 2.439–56.513) are the strongest independent predictors for PCSFP. Conclusion: PCSFP is more common in young smoker males, is associated with hypertension, obesity, high hs-CRP, TG, and cholesterol levels. High cholesterol and TG and male sex are the strongest risk factors for PCSFP. Furthermore, inflammation plays an important factor in the pathogenesis of PCSFP due to the association of high hs-CRP level in those patients.

Abstract 10428: Bad Fall, Good Catch: Diagnosing a Rare Condition Presenting as Acute Coronary Syndrome

A 72 year-old mountain bicyclist suffered a biking accident. The following week, he presented to the emergency room with abdominal pain, where he was treated for superior mesenteric artery thrombosis and new-onset atrial fibrillation. Two months later, he presented with intermittent left scapular pain that radiated to the chest. Pharmacologic stress testing revealed a large reversible perfusion defect in the anterior wall with an ejection fraction of 41%. Left heart catheterization showed narrowing of the distal left main coronary artery and the proximal left anterior descending (LAD) and circumflex arteries, by what appeared to be external compression. Follow-up CT angiogram demonstrated two sinus of Valsalva aneurysms (SOVA) originating from the left and right coronary cusps. A transesophageal echocardiogram confirmed these findings and showed tremendous thrombus within the larger aneurysm. The patient was admitted to cardiothoracic surgery. Troponin was elevated to 0.16 μg/L, with EKG showing 1 mm ST-segment depressions in V4-6, prompting treatment for a non-ST segment myocardial infarction. He underwent complex surgery involving thrombus extraction and closure of the SOVA with pericardial patch repair, and coronary artery bypass grafting of the LAD and obtuse marginal arteries. After a prolonged ICU course in which the patient was managed for cardiogenic shock, he was discharged to a hospital equipped with a rehabilitation facility. Unfortunately, he developed profound lactic acidosis from ischemic bowel and passed away. SOVA are rare lesions that arise from congenital or acquired etiologies, such as this patient’s biking accident. Multi-modality imaging is important for quantifying size and anatomy. Unruptured SOVA can present as embolic phenomenon from thrombus, valvular regurgitation, or chest pain from compression of the coronary arteries. Rupture is a highly morbid condition, and so urgent referral to cardiothoracic surgery is recommended.

Sars-Cov-2 Infection Associated with Aplastic Anemia and Pure Red Cell Aplasia

Introduction: Aplastic anemia (AA) is a life-threatening disorder characterized by pancytopenia and a hypocellular bone marrow. Pure red cell aplasia (PRCA) is a similar disorder with primary reduction in the red blood cell population and virtual absence of erythroid precursors in the bone marrow. While the etiology of immune mediated marrow failure is multifactorial, preceding viral infections have been associated with the disease; these include parvovirus B19, cytomegalovirus, and Epstein-Barr virus. We present four cases of immune mediated marrow failure with either preceding or simultaneous SARS-CoV-2 infection.Methods: The medical records of patients treated for AA or PRCA at the University of Texas Southwestern Medical Center, Parkland Hospital, and the National Institutes of Health (NIH) were reviewed for SARS-CoV-2 infection. Four patients without prior hematological diseases were identified who had SARS-CoV-2 infection prior to or with simultaneous the diagnosis of AA or PRCA.Results: Patient #1 was a 22-year-old white female who was diagnosed with asymptomatic COVID-19 10 days prior to her pancytopenia and AA diagnosis was confirmed by bone marrow biopsy (5% cellularity; Table 1). Her extensive work-up including HIV, hepatitis panel, immunoglobulins, B12 and folate was negative, and she underwent HLA-matched family donor hematopoietic stem cell transplant. Patient #2 was a 69-year-old Asian female who presented to her primary care physician with symptoms of fatigue and was found to be pancytopenic. CBC from a few months prior was completely normal. Further work-up was positive for COVID-19 and negative for HIV, nutritional deficiency, or hemolysis. She did not have respiratory symptoms, was eventually diagnosed with pRBC and platelet transfusion-dependent severe AA (5-10% cellularity on bone marrow), and underwent treatment with cyclosporine, equine antithymocyte globulin, and eltrombopag. She has had a partial response to this therapy. Both patients had bone marrow specimens stained for SARS-CoV-2 by immunohistochemistry that were negative. Patient #3 was a 76-year-old white male who was diagnosed with COVID-19 4 months prior to presenting with a non-ST segment myocardial infarction and found to be profoundly anemic, requiring pRBC transfusion. He re-presented with chest pain one week later and was found to be anemic again, and required transfusion. A trial of darbepoetin alfa was unsuccessful. Extensive work-up for malignancy, infection, and autoimmune etiologies were negative. He was diagnosed with PRCA based on the bone marrow biopsy and initiated treatment with cyclosporine. Patient # 4 was diagnosed with severe AA (presenting as pancytopenia) and COVID-19 infection. He had fatigue for one month and fever, chills and sore throat one-week prior seeking medical care. Testing for hepatitis, HIV, EBV, and CMV was negative. He was treated on a clinical trial (NCT04304820) at NIH with cyclosporine and eltrombopag until SARS-CoV-2 PCR was negative then received equine anti-thymocyte globulin. He has achieved a complete hematologic response at 6 months and remains well at last follow-up.Conclusion: The four patients described had minimal respiratory COVID-19 symptoms, but they presented with cytopenia and were eventually diagnosed with bone marrow failure. It is possible that this is co-incidental due to the high prevalence of SARS-CoV-2. However, there is emerging evidence that COVID-19 pneumonia is a hyperinflammatory and immune dysregulated state improved by dexamethasone therapy. Other immune mediated hematologic conditions, such as autoimmune hemolytic anemia and immune thrombocytopenia, have been reported. The onset from infection to cytopenia appears rapid, although patients often presented with symptoms for many days prior to diagnosis and thus testing may have been delayed from the onset of infection. This case series does not provide a mechanistic link between SARS-CoV-2 infection and bone marrow failure, but it raises the possibility that SARS-CoV-2 may mediate an immunologic response that contributes to marrow failure. Patients appear to respond well to standard immunosuppressive treatment. Further cases and studies are needed to determine if this is directly linked to SARS-CoV-2 and whether the natural history and response to standard therapy is different than idiopathic cases. [Display omitted] DisclosuresYoung: Novartis: Research Funding.

English

BACKGROUND Cardiovascular diseases are one of the leading causes of morbidity and mortality worldwide. High Ca levels and low Mg levels are associated with increased cardiovascular risk in the general population.1 The balance between Ca and Mg seems to play an important role in homeostasis since Mg is considered as physiologic antagonist of Ca.2 Hence Ca/Mg ratio was considered to study its association with acute coronary syndrome (ACS). METHODS This is a case control study conducted in Karnataka Institute of Medical Sciences, Hubli over a period of 2 years, February 2019 to December 2020. 200 cases and 150 controls were included in the study. The biochemical measurements including complete blood count (CBC), cardiac biomarkers, liver function tests, renal function tests (RFT), serum electrolytes and lipid profile were measured using standard laboratory methods. Student ‘t’ test was used to compare the data. Optimum cut-offs for diagnosis of acute myocardial infarction was calculated using receiver operating characteristics (ROC) analysis. The association among markers was established by calculating Pearson’s correlation. RESULTS Serum Ca/Mg ratio was significantly higher (p value &lt; 0.001) in ACS when compared to control groups. It was also found that Ca/Mg ratio was significantly lower (p value &lt; 0.001) in non-ST elevation myocardial infarction (NSTEMI) when compared to STEMI group. Serum Mg was significantly lower (p value &lt; 0.001) in ACS group when compared to control group. Significant correlation (p value &lt; 0.05) was found between serum Ca/Mg ratio and cardiac markers (CKMB, Troponin-I). ROC analysis of Ca/Mg (4.19) ratios showed optimum cut-offs in diagnosis of AMI. CONCLUSIONS Serum Ca/Mg could be useful adjuvant marker in diagnosis of AMI. The ratio is higher in ST-segment elevation myocardial infarction when compared to non-STsegment myocardial infarction, which could be due to greater decrease in Mg levels when compared Ca in ACS. KEYWORDS ST Elevation Myocardial Infarction (STEMI), Non ST Elevation Myocardial Infarction (NSTEMI), Calcium (Ca), Magnesium (Mg), Acute Coronary Syndrome (ACS), Creatine Kinase-MB (CK-MB).

Long-term clinical follow-up of the resorbable magnesium scaffolds in acute coronary syndrome patients.

Research on the resorbable magnesium scaffolds (RMSs) has shown their safety and effectiveness in stable clinical conditions. It seems that this new therapeutic option could be promising for selected acute coronary syndrome (ACS) patients. Our analysis aims to analyse the long-term performance of RMSs among ACS patients. The study population consisted of consecutive ACS patients treated with the implantation of at least one RMS. The Magmaris ACS Registry was designed as a single-arm observational registry in the 'real-world' treatment practice setting. The study population consisted of 193 patients, predominantly male (78%), at a mean (SD) age of 64 (9) years and with the typical risk factors of ACS. Unstable angina (UA) was the indication for revascularisation in 32.1%, non-ST-segment myocardial infarction (NSTEMI) in 65.8% and ST-segment elevation myocardial infarction (STEMI) only in 2.1%. During the mean 24 months of follow-up, ten cases (5.2%) of target lesion failure (TLF) were diagnosed, of which five cases (2.6%) were clinically driven target lesion failure (CD-TLR), four cases (2.1%) of asymptomatic scaffold restenosis and one case (0.5%) of target vessel myocardial infarction (TV-MI). No cardiac deaths and 2 non-cardiac deaths (2.2%, both fatal strokes) were observed. No cases of scaffold thrombosis were observed during the median 24-month follow-up. The use of the RMSs in selected ACS patients is associated with procedural safety and promising early and long-term clinical efficacy and safety outcomes. Proper lesion selection is key to the long-term success of bioresorbable technology in this patient population.

Electrical storm reveals worse prognosis compared to myocardial infarction complicated by ventricular tachyarrhythmias in ICD recipients

Both acute myocardial infarction complicated by ventricular tachyarrhythmias (AMI–VTA) and electrical storm (ES) represent life-threatening clinical conditions. However, a direct comparison of both sub-groups regarding prognostic endpoints has never been investigated. All consecutive implantable cardioverter-defibrillator (ICD) recipients were included retrospectively from 2002 to 2016. Patients with ES apart from AMI (ES) were compared to patients with AMI accompanied by ventricular tachyarrhythmias (AMI–VTA). The primary endpoint was all-cause mortality at 3 years, secondary endpoints were in-hospital mortality, rehospitalization rates and major adverse cardiac event (MACE) at 3 years. A total of 198 consecutive ICD recipients were included (AMI–VTA: 56%; ST-segment elevation myocardial infarction (STEMI): 22%; non-ST-segment myocardial infarction (NSTEMI) 78%; ES: 44%). ES patients were older and had higher rates of severely reduced left ventricular ejection fraction (LVEF) < 35%. ES was associated with increased all-cause mortality at 3 years (37% vs. 19%; p = 0.001; hazard ratio [HR] = 2.242; 95% CI 2.291–3.894; p = 0.004) and with increased risk of first cardiac rehospitalization (44% vs. 12%; p = 0.001; HR = 4.694; 95% CI 2.498–8.823; p = 0.001). This worse prognosis of ES compared to AMI–VTA was still evident after multivariable adjustment (long-term all-cause mortality: HR = 2.504; 95% CI 1.093–5.739; p = 0.030; first cardiac rehospitalization: HR = 2.887; 95% CI 1.240–6.720; p = 0.014). In contrast, the rates of MACE (40% vs. 32%; p = 0.326) were comparable in both groups. At long-term follow-up of 3 years, ES was associated with higher rates of all-cause mortality and rehospitalization compared to patients with AMI–VTA.

COVID-19 and Coronary Stent Thrombosis: A Systematic Review of Literature

Coronavirus Disease-19 (COVID-19) is a worldwide pandemic and it has created many difficulties in providing medical care due to the various multi-organ disease manifestations caused by the virus. In this paper we explore cases of stent thrombosis which occurred in patients who were infected with COVID-19 and discuss its role in potentiating this complication through the variety of mechanisms in which it creates a prothrombotic state. Stent thrombosis is described as the thrombotic occlusion of a coronary stent. The incidence of this complication has decreased considerably (from 16% to 0.7%) since the advent of antiplatelet therapy and drug eluting stents. In this systematic review, 8 papers were found which detailed 11 patients who were infected with COVID-19 and suffered a stent thrombosis. Data from these cases were tabulated and analyzed. The ages of the patient’s ranged from 49-81 years and quite interestingly the time between the time of stent placement and occurrence of stent thrombosis had great variation between patients, with some occurring within minutes of stent placement and others occurring in a stent that was placed many years ago. 91% of the patients had ST-segment elevation myocardial infarction (STEMI) for presentation of stent thrombosis and 9% had a non-ST segment myocardial infarction (NSTEMI) on presentation. Therapy mainly involved antiplatelet therapy and Percutaneous Coronary Angioplasty with new stent placement. Despite this mortality rate among the cases present was quite high at 45%, with some patients dying as a result of COVID-19 related complications. Through various literature reviews, we have found that COVID-19 contributes in creating a prothrombotic state through various inflammatory mediated mechanisms. This prothrombotic state is a major risk factor towards stent thrombosis and we recommend that physicians be aware of this potentially fatal complication in COVID-19 patients.

Abstract PS7-26: Acute myocardial infarction prevalence and trends in females with active breast cancer

Abstract Introduction:Breast cancer is among the three most common malignancies worldwide, and a better understanding of the epidemiology of the cardiovascular disease in females with breast cancer is needed Methods:Females with active breast cancer diagnosis hospitalized from January 2010 to December2017 were identified in the Nationwide Readmissions Database. Outcomes of interest were the prevalence of acute myocardial infarction (AMI), non-ST-segment myocardial infarction (NSTEMI), cardiac complications, and in-hospital mortality.Results:1,424,102 females with breast cancer were identified. Of whom, 17,578 (1.23%) were hospitalized for AMI. AMI patients were older with a mean age of 72.51 (11.73) vs. 62.22 (14.29), p&amp;lt;0.001. AMI patients had a higher prevalence of hypertension; 65.3% vs. 47.3%, p&amp;lt;0.001, known coronary artery disease; 51.1% vs. 8.2%, p&amp;lt;0.001, hyperlipidemia; 46.6% vs. 24.2%, p&amp;lt;0.001, known heart failure; 42.6% vs. 8.8%, p&amp;lt;0.001, smoking; 26.7% vs. 21.6%, p&amp;lt;0.001, history of stroke; 6.2% vs. 3.2%, p&amp;lt;0.001, history of prior AMI; 9.5% vs. 2.3%, p&amp;lt;0.001, and diabetes with chronic complications; 11.0% vs. 4.2%, p&amp;lt;0.001, and diabetes without complications; 25.2% vs. 15.8%, p&amp;lt;0.001. Over the 8 years, the prevalence of cardiovascular risk factors increased in breast cancer patients including; diabetes with chronic complications; from 2.3% in 2010 to 10.4% in 2017, p-trend&amp;lt;0.001, obesity; 7.8% in 2010 to 13.3% in 2017, p-trend&amp;lt;0.001, coronary artery disease; 8.1% in 2010 to 10.2% in 2017, p-trend&amp;lt;0.001, hyperlipidemia; 20.7% in 2010 to 29.7% in 2017, p-trend&amp;lt;0.001, and smoking; 16.8% in 2010 to 28.2% in 2017, p-trend&amp;lt;0.001. AMI increased over the study duration from 1.0% in 2010 to 1.8% in 2017, p-trend&amp;lt;0.001, and NSTEMI increased from 0.8% in 2010 to 1.5% in 2017, p-trend&amp;lt;0.001. The observed increase was persistent when patients with localized malignancies were examined with AMI inclining from 2.1% in 2010 to 2.4% in 2017, p-trend&amp;lt;0.001, and NSTEMI from 1.6% in 2010 to 2.0% in 2017, p-trend&amp;lt;0.001. Breast cancer patients with AMI had a higher hospital mortality rate; 14.7% vs. 4.2%, OR: 3.96, 95% CI (3.80-4.13), p&amp;lt;0.001, cardiac arrest; 3.9% vs. 0.5%, OR: 8.53, 95% CI (7.87-9.24), p&amp;lt;0.001, and cardiogenic shock, 5.1% vs. 0.1%, OR: 42.03, 95% CI (38.73-45.60), p&amp;lt;0.001.Conclusion:Females with breast cancer have a concerning prevalence of cardiovascular disease with stern worse outcomes, and the prevalence is shown to be increasing over the study duration. Known cardiovascular risk factors are also increasing in breast cancer patients. Further efforts should be directed to aggressively reduce the prevalence of modifiable risk factors in order to improve the outcomes of breast cancer patients. 20102011201220132014201520162017P-trendCoronary Artery Disease8.1%8.3%8.0%8.5%8.9%8.1%9.7%10.2%&amp;lt;0.001Diabetes with chronic complications2.3%2.5%2.5%2.9%3.3%3.9%7.2%10.4%&amp;lt;0.001Heart Failure7.8%7.8%7.9%8.5%9.5%9.0%11.3%12.5%&amp;lt;0.001Hyperlipidemia20.7%21.9%22.8%24.6%25.8%23.1%28.0%29.7%&amp;lt;0.001Obesity7.8%8.7%9.8%11.2%12.2%12.2%12.2%13.3%&amp;lt;0.001Smoking16.8%17.2%19.0%20.7%23.2%22.2%27.6%28.2%&amp;lt;0.001OutcomesAMIOverall1.0%1.0%1.1%1.1%1.3%1.2%1.5%1.8%&amp;lt;0.001Localized Malignancies2.1%1.9%2.0%2.0%2.1%1.8%2.0%2.4%&amp;lt;0.001Patients with History of Radiation Therapy1.2%0.7%1.1%0.7%1.2%1.2%1.6%1.6%&amp;lt;0.001History of prior AMI3.5%3.6%4.2%4.7%5.5%4.3%6.6%6.5%&amp;lt;0.001NSTEMIOverall0.8%0.8%0.9%0.9%1.0%1.0%1.3%1.5%&amp;lt;0.001Localized Malignancies1.6%1.5%1.6%1.6%1.7%1.5%1.7%2.0%&amp;lt;0.001Patients with History of Radiation Therapy0.9%0.6%0.9%0.6%0.9%1.0%1.5%1.3%&amp;lt;0.001History of prior AMI3.0%2.5%3.8%3.7%4.5%3.9%5.7%5.6%&amp;lt;0.001 Citation Format: Mohamed M Gad, Anas M Saad. Acute myocardial infarction prevalence and trends in females with active breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-26.