Previous After Acute Myocardial Infarction Research Articles

The prognostic value of global longitudinal strain in patients with myocardial infarction and preserved ejection fraction - a prespecified substudy of the REDUCE-AMI trial

Abstract Aims The REDUCE-AMI trial showed that beta-blockers in patients with preserved left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI) had no effect on mortality or cardiovascular outcomes. The aim of this substudy was to evaluate whether global longitudinal strain (GLS) is a better prognostic marker than LVEF, and if beta-blockers have a beneficial effect in patients with decreased GLS. Methods and Results REDUCE-AMI was a registry-based randomized clinical trial. Conventional echocardiographic parameters and GLS were obtained and a likelihood ratio test between models adjusted for age, sex, hypertension, smoking, diabetes, previous AMI, and multi-vessel disease was used to compare LVEF and GLS as prognostic methods. A Cox regression model evaluated the impact of beta-blocker treatment on the composite endpoint of death from any cause or new AMI. Results 1436 patients (28.6% of total population) were included in this substudy. Due to poor image quality or incompatible equipment, 324 (22.6%) patients were excluded from analysis of GLS. Median GLS was 17.3%. The likelihood ratio test resulted in no difference (P = 0.56) when comparing the combination of GLS to LVEF. The results were robust when adding beta-blocker randomization status as an independent variable. Conclusions In patients after AMI with preserved LVEF, GLS did not add prognostic value regarding death from any cause or new AMI. In addition, beta-blocker treatment did not alter the prognostic information obtained from GLS. Consequently, this study does not support an additive value of GLS compared to standard echocardiographic measurement in this patient population.

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.

The relative impact of components of high residual risk on the long-term prognosis after AMI

BackgroundThe reduction in long-term mortality after acute myocardial infarction (AMI) is less pronounced than that of in-hospital mortality among patients with AMI complicated by heart failure (HF) and/or in those with a high residual thrombotic risk (HTR). AimTo investigate the relative prognostic significance of HTR and HF in AMI survivors. MethodsThis retrospective cohort study enrolled patients admitted for AMI in 2014–2015 in all Italian hospitals. HTR was defined as at least one of the following conditions: previous AMI, ischemic stroke or other vascular disease, type 2 diabetes, renal failure. Patients were classified into four categories: uncomplicated AMI; AMI with HTR; AMI with HF and AMI with both HTR and HF (HTR + HF). Cox proportional hazard model was used to evaluate the impact of HTR, HF and HTR + HF on the 5-year prognosis. A time-varying coefficient analysis was performed to estimate the 5-year trend of HR for major averse cardiac and cerebrovascular events (MACCE). Resultsa total of 174.869 AMI events were identified. The adjusted 5-year HR for MACCE was 1.74 (p < 0.0001) and 1.75 (p < 0.0001) in HTR and HF patients vs uncomplicated patients, respectively. The coexistence of HTR and HF furtherly increased the risk of MACCE (HR = 2.43, p < 0.0001) over the first 3 years after AMI. ConclusionEither HRT and HF confer an increased 5-year hazard of MACCE after AMI. The coexistence of HTR and HF doubled the overall 5-year risk of MACCE after AMI.

AMI causing cardiogenic shock in patients with severely depressed left ventricular function

Abstract Introduction Left ventricular function is assumed to be the main predictor of cardiogenic shock (CS), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction. Purpose Characterize population of patients (Pts) with CS after acute myocardial infarction (AMI) and with severe left ventricular dysfunction (defined as ejection fraction (EF) &amp;lt;30%). Methods From a national multicenter registry, we evaluated 729ptswith CS after AMI.We considered 2 groups: Group 1 – pts with CS and EF &amp;lt;30% and Group 2 – pts with CS and EF &amp;gt;30%. We registered age, gender, cardiovascular and non-cardiovascular comorbidities, electrocardiographic presentation, vital signs at admission, reperfusion strategy and coronary anatomy. We also evaluated in-hospital complications, such as re-infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT), atrial fibrillation (AF) and stroke. We compared in-hospital mortality and multivariate analysis was performed to assess the impact of EF in in-hospital mortality and to identify predictors of severe left ventricular function. Results Severe dysfunction in Cardiogenic shock due to AMI was present in 28.9% (n=211) of pts (68% male, mean age of 72±12 years old). Group 1 had higher incidence of previous heart disease, such as AMI, previous PCI and congestive heart failure (27% vs 14%, p&amp;lt;0.001; 17.7% vs 9.6% p=0.002 and 16% vs 10%, p=0.022, respectively). STEMI pts were 71% (n=149), and timing from symptoms until first contact was longer (185 min (90; 437) vs 123 (60; 300), p&amp;lt;0.001). Undetermined location AMI was more often in group 1 (8% vs 2%, p&amp;lt;0.001), particularly due to left or right bundle brunch block (13% vs 4.7%, p&amp;lt;0.001, and 15% vs 10%, p=0.041 respectively). Anterior STEMI was also more prevalent in this groups (81% vs 46%, p&amp;lt;0.001). No differences were observed on coronariography rate, rate or type of reperfusion nor multivessel disease. Group 1 pts presented more with left main (LM) (25% vs 12%, p&amp;lt;0.001) and anterior descending (AD) (9.4% vs 2.4%, p&amp;lt;0.001) arteries lesions (88% vs 72.4%, p&amp;lt;0.001) or occlusion (65.5% vs 33.7%, p&amp;lt;0.001). Group 1 presented more with in-hospital VT (16% vs 10.8%, p=0.048). In-hospital mortality was also higher (56.5% vs 29.5%, p&amp;lt;0.001). After multivariate analysis we found that severe left ventricular dysfunction was a mortality predictor (OR 3.37; 95% CI 2.05–5.54, p&amp;lt;0.001). LM (OR 3.41; 95% CI 1.86–6.26, p&amp;lt;0.001) and AD (OR 2.74; 95% CI 1.51–4.96, p=0.001) arteries disease and previous AMI (OR 2.36; 95% CI 1.28–4.37, p=0.006) were predictors of severe LV dysfunction. Conclusions Severely depressed EF is a predictor of in-hospital mortality. Left main and anterior descending artery disease and previous AMI were identified as predictors of an EF &amp;lt;30%. Funding Acknowledgement Type of funding sources: None.

Long-term survival benefit of ramipril in patients with acute myocardial infarction complicated by heart failure

AimsACE inhibition reduces mortality and morbidity in patients with heart failure after acute myocardial infarction (AMI). However, there are limited randomised data about the long-term survival benefits of ACE inhibition...

Determinants of persistent smoking after acute myocardial infarction: an observational study

BackgroundSmoking cessation is one of the most effective secondary prevention measures after acute myocardial infarction (AMI). However, around 50% of smokers do not quit smoking after AMI. The aim of the present study is to estimate the proportion of patients quitting smoking and to identify determinants of persistent smoking after AMI in a region with increased cardiovascular mortality. We also assessed the time of smoking cessation after AMI.MethodsWe used follow-up data of patients registered with the Regional Myocardial Infarction Registry in Saxony-Anhalt (RHESA) in Germany. We assessed smoking status and determinants of persistent smoking six weeks after discharge from hospital after AMI. Information on smoking, sociodemographic characteristics, risk factors for AMI, experienced symptoms of AMI, and clinical care were gathered in a computer-assisted telephone interview and questionnaires filled out by study subjects and physicians or study nurses.ResultsOut of 372 smokers at the time of AMI, 191 (51.3%) reported that they quit smoking within six weeks after discharge from hospital after AMI. Strongest determinant of persistent smoking was a previous AMI before the current one (OR = 2.19, 95%CI 1.10–4.38) and strongest determinants of smoking cessation were experiencing complications in the hospital (0.37, 95%CI 0.12–1.12) and having a life partner (0.56, 95%CI 0.34–0.95). Most individuals who stopped smoking did so during the initial stay in the hospital, before the cardiac rehabilitation (CR).ConclusionsPersistent smoking after AMI and its determinants were similar in our region to previous studies. CR cannot be viewed as determinant of smoking cessation – more likely the same teachable moment induces behavioural change with regard to smoking and participation in CR.

P1720Survival analysis in a population of patients with cardiogenic shock after acute myocardial infarction: characterization of the population and identification of mortality predictors

Abstract Introduction The presence of cardiogenic shock (CC) after acute myocardial infarction (AMI) is associated with high mortality. Purpose To compare the clinical characteristics, cardiac and non-cardiac complications among survivors and non-survivors of CC after AMI in order to identify predictors of in-hospital mortality. Population and methods An observational study involving 467 patients (P) with CC after AMI included in a national multicenter registry. Considered 2 groups: Group 1 - P with CC who died (n=190) and Group 2 - P with CC who survived (n=277). We recorded age, gender, personal history, coronary angiography and angioplasty performed, in-hospital therapy and ejection fraction, cardiac complications (Re-infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia) and non-cardiac complications [acute renal injury (ARI), major bleeding and stroke]. Multivariate analysis was performed to identify predictors of in-hospital mortality. Results Mortality in patients with CC after AMI was 40.6%. Group 1 P were older (77±10 vs 68±13 years, p&lt;0.001), presented higher prevalence of diabetes mellitus (41.8% vs 28.2%, p=0.003), previous AMI (23.8% vs. 12%, p&lt;0.001) 7%, p=0.002), previous angor (31.9% vs 14.1%, p=0.001), heart failure (18.6% vs 8.7%, p=0.002) and peripheral arterial disease (11.8% vs 6.2%, p=0.03). There were fewer coronary angiographies (64.2% vs 87.7%, p&lt;0.001), with no difference in the number or type of vessels with lesions in both groups, as well as inotropic therapy. With the exception of mechanical complications, more prevalent in group 1 (12.6% vs 5.4%, p=0.006), there were no differences in the prevalence of the remaining cardiac complications. Among the non-cardiac complications considered, only the presence of ARI was more prevalent in Group 1 (72.1% vs 37.5%, p&lt;0.001). After multivariate analysis the presence of age&gt;75 years [OR: 2.21 (CI: 1.39–3.51)], previous angor [OR: 1.91 (CI: 1.09–2.92)], LRA [OR: 3.14 (CI: 4.0–7.04)] and mechanical complications [OR: 3.82 (CI: 2.39–6.10] were independent predictors of in-hospital mortality of P with CC post-AMI. Conclusions Mortality in patients with CC after AMI remains high. Age&gt;75 years, prior angor, ARI and mechanical complications are independent predictors of in-hospital mortality in P with CC post-AMI.

Abstract P371: Twenty-Five-Year (1986-2011) Trends in the Incidence and In-Hospital Case-fatality Rates of Stroke Complicating Acute Myocardial Infarction

Introduction: Stroke after acute myocardial infarction (AMI) is an important complication resulting in increased morbidity and mortality. However, limited long-term trends data are available about the incidence and death rates associated with this serious complication. Objective: The aim of this study is to examine the 25-year trends in the incidence rates and outcomes of initial episodes of stroke complicating AMI. Hypothesis: We hypothesize that the incidence and outcomes of stroke complicating AMI would decrease over time with recent advances in the management of both diseases. Methods: The study population consisted of 11,433 adults hospitalized with validated AMI at all 11 medical centers in central Massachusetts on a biennial basis between 1986-2011. Results: Of 11,436 patients (mean age = 69 years; 42% female) without a history of stroke hospitalized with confirmed AMI, 159 patients (1.4%) experienced an acute stroke during their index hospitalization. The proportion of patients with AMI who developed a stroke increased through the 1990s but declined slightly thereafter (Figure 1). Patients who experienced an acute stroke were significantly older, more likely to be female, had a previous AMI, had a significant burden of comorbidities, and were more likely to have developed atrial fibrillation, heart failure, and have died (32.1% versus 10.8%; p&lt;0.001) during their index hospitalization compared with patients who did not develop a stroke. Patients developing a stroke in the most recent years (2003-2011) were 5 times more likely to have died during hospitalization compared to those who did not develop a stroke (OR, 5.05; 95% CI, 2.34-10.90). Conclusions: In conclusion, the incidence rates of acute stroke complicating AMI remained relatively stable during the years under study but with an increased likelihood of dying during hospitalization. Better characterization of factors associated with the risk of stroke remains important for the more optimal care of this vulnerable population.

Depressive symptoms are associated with in-hospital complications following acute myocardial infarction

AimTo examine the effect of depressive symptoms on in-hospital complication rates after Acute Myocardial Infarction (AMI). BackgroundCoronary Heart Disease (CHD) is the primary cause of death worldwide. AMI is the most common consequence of CHD. Depressive symptoms are an important risk factor for CHD and increased risk of AMI. Understanding the relationship between depressive symptoms and short term complications for patients with AMI is important for determining their needs, developing interventions, and evaluating the outcomes of interventions. MethodsA prospective observational study was conducted with 175 patients who were admitted to the Intensive Care Units (ICUs) of four large hospitals in Jordan. During the interview, within 72h (mean, 38±16h) of admission to the hospital, participants completed the sociodemographic and clinical questionnaire and the Beck Depression Inventory Scale. ResultsThe mean age was 66.9±11.0years. The number of patients with mild, moderate, and severe depressive symptoms who developed complications was significantly higher than those with minimal depressive symptoms, p˂0.001. Patients with mild, moderate, and severe depressive symptoms had longer lengths of stay in the ICU and in hospital than patients with minimal depressive symptoms. Patients with mild, moderate and severe depressive symptoms were at 1.22 times higher risk for developing complications than patients with minimal depressive symptoms. Moreover, previous AMI history increased the risk for developing complication by 150%. ConclusionsDepressive symptoms were an independent predictor of complications and increased length of stay after AMI. Interventions to control depressive symptoms early after AMI are necessary.

Fifteen-year trends in the management of cardiogenic shock and associated 1-year mortality in elderly patients with acute myocardial infarction: the FAST-MI programme.

Alhough cardiogenic shock (CS) after acute myocardial infarction (AMI) is more common in elderly patients, information on the epidemiology of these patients is scarce. This study aimed to assess the trends in prevalence, characteristics, management, and outcomes of elderly patients admitted with CS complicating AMI between 1995 and 2010, using data from the FAST-MI programme. We analysed the incidence and 1-year mortality of CS in four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive AMI patients over 1-month periods. Among the 10 610 patients, 3389 were aged ≥75 years, of whom 9.9% developed CS. The prevalence of CS decreased in elderly patients from 11.6% in 1995 to 6.7% in 2010 (P = 0.02). Over the 15-year period, the characteristics of elderly patients with CS changed, with more diabetes, hypertension, and hypercholesterolaemia. The use of PCI increased markedly in elderly patients with and without CS, reaching 51% and 59%, respectively, in 2010. In addition, medical therapy also evolved, with more patients receiving antithrombotic agents, beta-blockers, and statins. Over time, 1-year mortality decreased by 32% among elderly patients with CS but remained high (59% in 2010). ST-segmet elevation myocardial infarction and previous AMI were independent correlates of increased 1-year death, while study period was associated with decreased mortality (2010 vs, 1995: hazard ratio 0.40, 95% confidence interval 0.27-0.61, P < 0.001), along with early use of PCI. Cardiogenic shock in elderly patients with AMI remains a major clinical concern. However, 1-year mortality declined in these patients, a decrease potentially mediated by broader use of PCI and the improvement of global patient management.

Abstract 12445: A Detailed Analysis of Peripheral Blood Cytokines 2-3 weeks After Acute Myocardial Infarction: IL-6-Related Impairment of Bone Marrow Function

Background: Intracoronary infusion of bone marrow (BM) mononuclear cells (BM-MNCs) late after acute myocardial infarction (AMI) has shown no improvement in global or regional left ventricular (LV) function (LateTIME and SWISS-AMI). Studies in experimental AMI models suggest a possible cytokine-related depression of progenitor cell function. Furthermore, BM cell content is correlated with the LV functional response. Accordingly, we hypothesize that inflammatory cytokines associated with the late phase of AMI may impair BM function and alter progenitor cell subsets. Method: Patients with previous AMI (n=87) were recruited in a multicenter cell therapy trial by the Cardiovascular Cell Therapy Research Network (CCTRN LateTIME, NCT00684060). BM and peripheral blood (PB) were collected 2-3 weeks after AMI and examined for cell phenotypes and progenitor capacities as well as PB inflammatory and angiogenic cytokines in a core laboratory. Multiple regression analyses were conducted and correlations between cytokine levels and cell phenotypes, cell functions, and post-MI cardiac function were determined. BM from healthy donors, handled in the same manner, was used as a reference. Result: Of 26 cytokines analyzed, IL-6 showed a negative correlation with ECFC colony maximum in BM (estimate±SE (SEE) -0.13±0.04 P=0.007, multivariableR2: 0.59) and Healthy BM showed decreased ECFC colony outgrowth in the presence of IL-6 (P &lt;0.05), in a dose-dependent manner. PDGF-BB positively correlated with CFU-EC colony maximum in BM (SEE 0.006± 0.002, P=0.023, R2: 0.22), MSC colony maximum in BM (SEE 0.006±0.002, P=0.023, R2: 0.17) and MSC colony maximum in PB (SSE 0.018±0.005, P=0.00005, R2:0.24). No significant correlations were found between cardiac function after AMI and PB cytokine levels. Conclusions: At 2-3 weeks after AMI, PB levels of the angiogenic cytokine, PDGF-BB and the pro-inflammatory cytokine, IL-6, were associated with BM cell phenotype and function. IL-6 has the potential to impair endothelial progenitor cell capacity; inhibiting IL-6 may be a target for improving the regenerative capacity of BM cells after AMI.

Appropriate Timing of Coronary Artery Bypass Grafting after Acute Myocardial Infarction

Optimal timing of coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) remains the subject of fierce debate. Therefore, the recommended deferral ranges from immediate intervention to surgery 4 weeks after infarction. Especially, the increasing cohorts of patients at old age or with poor left ventricular function, whose mortality rates are additionally enhanced, may profit from focused analyses. This study aims at clarifying the appropriate timing of CABG after AMI, with special regard to high-risk patients (Age >70 years, left ventricular ejection fraction (LVEF) <30%). Retrospective analysis was performed in 3475 patients who had undergone isolated CABG between 2005 and 2009. Those 1168 patients with previous AMI (<30 days) were categorized in groups, depending on deferral of surgery: <6 hours after AMI (A), 6 hours-1 day (B), 2-3 days (C), 4-10 days (D), 11-20 days (E), and 21-30 days (F). Furthermore, subgroups with an age >70 years or a LVEF <30% were examined. The mortality rates in groups A-F were 14.8, 10.2, 8.8, 4.2, 2.3, and 2.0%, whereas only the values of groups A-D were significantly increased versus the mortality rate of patients without previous AMI (1.9%). In patients over 70 years, we observed operative mortalities of 26.3, 14.3, 11.9, 6.1, 4.2, and 3.1% (groups A-F) versus 2.5% (no previous AMI), while 27.4, 15.4, 11.7, 6.0, 3.7, and 2.8% (groups A-F) versus 2.7% (no previous AMI) of patients with a LVEF <30% died during the first 30 days after surgery. In both subanalyses of high-risk patients, the enhanced mortalities of groups A-E reached significance. Multivariate analysis of operative risk factors revealed that CABG within 10 days after AMI and age over 60 years are independently associated with operative mortality. CABG early after AMI (<10 days) is accompanied by significantly increased mortality, especially in elderly patients or in patients with a severely impaired LVEF. At least the critical time period of 3 days should be avoided-whenever the hemodynamics is stable enough.

The Terminal Part of the QT Interval (T peak to T end): A Predictor of Mortality after Acute Myocardial Infarction

The terminal part of the QT interval (T peak to T end; Tp-e)-an index for dispersion of cardiac repolarization-is often prolonged in patients experiencing malignant ventricular arrhythmias after acute myocardial infarction (AMI). We wanted to explore whether high Tp-e might predict mortality or fatal arrhythmia post-AMI. Tp-e was measured prospectively in 1359/1384 (98.2%) consecutive patients with ST elevation (n = 525) or non-ST elevation (n = 859) myocardial infarction (STEMI or NSTEMI) admitted for coronary angiography. Tp-e was significantly correlated with age, heart rate (HR), heart failure, LVEF, creatinine, three-vessel disease, previous AMI and QRS and QT duration. During a mean follow-up of 1.3 years (range 0.4-2.3),109 patients (7.9%) died; 25, 45, and 39 from cardiac arrhythmia, nonarrhythmic cardiac causes and other causes, respectively. Long Tp-e was strongly associated with increased risk of death, and Tp-e remained a significant predictor of death in multivariable Cox analyses (RR 1.5, 95% CI[1.3-1.7]). HR-corrected Tp-e (cTp-e) was the strongest predictor of death (RR 1.6 [1.4-1.9]). Tp-e and cTp-e were particularly strong predictors of fatal cardiac arrhythmia (RR 1.6 [1.2-2.1] and RR 1.8 [1.4-2.4]). Findings were similar in STEMI and NSTEMI. When comparing two methods for measuring Tp-e, one including the tail of the T wave and one not, the former had markedly higher predictive power (P < 0.001). Tp-e, and in particular cTp-e, were strong predictors of mortality during the first year post-AMI, and should be further evaluated as prognostic factors additional to established post-AMI risk factors.

Cardiotrophin-1 Predicts Death or Heart Failure Following Acute Myocardial Infarction

Background Cardiotrophin-1 (CT-1) is an important inflammatory cytokine; its presence has been documented in patients after acute myocardial infarction (AMI). However, its role as a predictor of death or heart failure is unclear. We sought to investigate this and compared it with N terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of death or heart failure. Methods and Results We studied 291 post-AMI patients. The plasma concentration of CT-1 and NT-proBNP was determined using in-house noncompetitive immunoassays and patients followed for death or heart failure. There were 27 deaths and 19 readmissions with heart failure. CT-1 was raised in patients with death or heart failure compared with survivors (median [range] fmol/mL, 0.9 [0.1–392.2] vs. 0.67 [0–453.3], P = .019). Using a multivariate binary logistic model CT-1 (OR 1.8, 95% CI: 1.1–3.2, P = .031) and NT-proBNP (OR 2.4, 95% CI: 1.1–5.2, P = .026) predicted death or heart failure independently of age, sex, previous AMI, serum creatinine, and Killip class. The receiver-operating curve for CT-1 yielded an area under the curve (AUC) of 0.62 (95% CI: 0.53–0.70, P = .017); for NT-proBNP the AUC was 0.77 (95% CI: 0.69–0.86, P < .001); the logistic model combining the 2 markers yielded an AUC of 0.84 (95% CI: 0.78–0.91, P < .001). Conclusion After an AMI, combined levels of CT-1 and NT-proBNP are more informative at predicting death or heart failure than either marker alone.

Impact and Determinants of Left Ventricular Function in Patients Undergoing Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

We evaluated the prognostic effect of baseline left ventricular function and the determinants of its recovery after acute myocardial infarction (AMI) treated by primary angioplasty. Left ventriculography was performed during the index procedure in 1,620 of 2,082 patients (78%) who underwent primary angioplasty for AMI in the CADILLAC trial. One-year survival rate was significantly lower in patients whose baseline left ventricular ejection fraction (LVEF) was <40% than in those whose LVEF was > or =40% (89.0% vs 97.2%, respectively, p <0.0001). The effect of baseline left ventricular dysfunction on mortality was confined to the first 3 months after AMI; thereafter, survival was independent of baseline LVEF. By multivariate analysis, baseline LVEF (hazard ratio 0.93, 95% confidence interval 0.90 to 0.97, p <0.001) and infarct zone regional wall motion (hazard ratio 2.67, 95% confidence interval 1.08 to 6.63, p = 0.03) were independent predictors of 1-year mortality. Seven-month convalescent LVEF was also directly related to baseline LVEF and inversely correlated with previous AMI, multivessel coronary disease, preprocedural Thrombolysis In Myocardial Infarction grade 0 to 2 flow, larger infarct artery diameter, and infarct artery restenosis at follow-up. In conclusion, baseline left ventricular function measured during the index procedure is a strong independent predictor of early and late survival after primary angioplasty. Simple clinical and angiographic features readily available at the time of primary angioplasty also predict convalescent LVEF and are thus of prognostic utility.

High-risk clinical features predict increased post-infarction myocardial apoptosis and the benefits as a result of an open infarct-related artery.

Infarct-related artery (IRA) patency after acute myocardial infarction (AMI) is associated with a more favourable clinical course, in particular in patients with high-risk features. As it has been recently reported that IRA patency is associated with a reduced postinfarction apoptotic rate (AR), the aim of our study was to assess whether IRA status late after AMI had a different impact on AR in high- vs. low-risk patients. Co-localization of TUNEL and caspase-3 was used to calculate the AR at the site of infarction at the time of death in 30 subjects. The Norris coronary prognostic index (NI) was calculated (computing age, presence of pulmonary congestion, heart size and history of previous additional AMI) in order to define the patients' individual risk at the time of hospitalization. According to the NI (< or =7 vs. >7), subjects were divided into low and high risk, as NI >7 carries an approximate threefold higher risk of death. The NI was significantly correlated with the AR at the time of death both in infarct and remote areas. Twenty subjects had IRA occlusion at the time of death, and in these patients AR was significantly higher both in infarct and remote areas (P<0.001 and P=0.009 vs. the others, respectively). However the impact of IRA occlusion on AR was significantly different comparing high- vs. low-risk subjects. In particular, AR at the infarct site was 10-fold higher in the high-risk subjects with IRA occlusion (26.1%[20.4-28.7%]) vs. those with open IRA (2.3%[0.6-3.5%]; P=0.002) and was nonsignificantly different in the low-risk subjects vs. those without IRA occlusion (8.2%[2.5-17.5%] vs. 5.4%[1.5-7.9%]; P=0.48). Similarly, in the high-risk subjects, AR in remote areas was significantly greater in cases with occluded vs. open IRA (0.7%[0.4-0.9%] vs. 0.3%[0.3-0.32%]; P=0.009). A significantly higher AR is associated with IRA occlusion late post AMI in subjects with high-risk clinical features, and not in low-risk patients. The diverse impact of IRA occlusion on AR in subjects with different risk profiles may explain the greater benefit associated with coronary reperfusion in high-risk subjects. The overall lower AR in low-risk subjects, independently from the IRA status, may be correlated with the better long-term prognosis after AMI in this case.

Usefulness of exercise testing shortly after acute myocardial infarction for predicting 10-year mortality

Previous studies on the prognostic value of exercise test variables after acute myocardial infarction (AMI) are limited methodologically and have yielded inconsistent results. This study determined whether 6 exercise test variables (systolic blood pressure, ST-segment depression or elevation, exercise capacity, arrhythmias, and angina pectoris) after controlling for age and sex, enhance 6 clinical variables (digoxin, previous AMI, history of systemic hypertension and angina, Killip class, and stress) as predictors of cardiovascular death and act as independent predictors as well. The present study followed 258 patients for 10.6 years, each of whom had AMI between 1977 and 1980 and an exercise test before hospital discharge. By 1988, 71 of the 258 patients had died, 56 of cardiovascular causes. This study is unique because exposure and outcome variables are clearly defined and follow-up was complete and longer than in previous studies. Multivariate survival analysis using an exponential model was tested to evaluate the conditional effects of the exercise test and clinical variables and to control for confounders. The model combined the exercise test and clinical variables. Results are reported with hazard ratios (HR) and 95% confidence intervals (CI). For important clinical risk predictors, the HRs with CIs are: digoxin use, HR 4.0 (CI 1.8, 8.5); history of prior AMI, HR 2.4 (CI 1.2, 4.7); history of systemic hypertension, HR 2.5 (CI 1.3, 4.5); angina, HR 2.4 (CI 1.3, 4.5); and stress, HR 4.2 (CI 2.2, 7.9). Three exercise test variables—hypotensive blood pressure response, HR 5.1 (CI 1.9,13.6); ST-segment depression, HR 1.8 (CI 0.98, 3.6); and ST-segment elevation, HR 2.4 (CI 0.98, 5.9)—were strong independent predictors of cardiovascular death after controlling for age, sex, and clinical variables. This is the only exercise test study with a complete 10.6-year followup in the U.S., a clearly defined outcome, and showing that 3 exercise test variables—hypotensive blood pressure response, and ST-segment depression and elevation—are strong independent predictors of cardiovascular death after controlling for clinical variables. These results support the use of exercise testing after AMI for predicting long-term prognosis.

Comparison of one-, six- and 24-hour ambulatory electrocardiographic monitoring for ventricular arrhythmia as a predictor of mortality in survivors of acute myocardial infarction

To compare 1-, 6- and 24-hour ambulatory electrocardiograms for prediction of mortality after acute myocardial infarction (AMI), all patients with AMI hospitalized in Hamilton, Ontario during 1 year were identified. There were 683 patients discharged alive after AMI. One-, 6- and 24-hour ambulatory electrocardiographic results were available in 565 patients, and follow-up mortality data at 1 year was available in 560. Mean age of the patients was 64 years; 160 (29%) had previous AMI and 105 (19%) had had congestive heart failure. One hundred and fifty-two patients (27%) were receiving β blockers, and 31 (6%) were receiving antiarrhythmic drugs. Regression modeling of survival times up to 1 year showed that all 3 durations of recording were univariate predictors of mortality. Using >10 ventricular premature complexes/hour as the criterion of a positive test, neither the 6- nor 24-hour data contained statistically significant residual explanatory power after the 1-hour data were accounted for by the model. The longer durations of recording increased sensitivity at a cost of decreased specificity. The positive and negative predictive values of the 3 durations of recording were virtually identical. The presence of ventricular tachycardia was not a significant predictor of mortality in this population. There appears to be no benefit to ambulatory electrocardiographic recordings >1 hour when they are to be used for prediction of 1-year mortality after AMI.

Prognosis of late versus early ventricular fibrillation in acute myocardial infarction

To determine the prognosis of late ventricular fibrillation (VF) after acute myocardial infarction (AMI), the length of the monitoring period after AMI was extended. All patients in this series were continuously monitored in a coronary care unit to ensure observation of all VF within 18 days of AMI. From 1977 to 1985, 4,269 patients were admitted with AMI and 413 (9.6%) had in-hospital VF. Of these 281 (6.8%) had early VF (<48 hours after AMI) and 132 (3.2%) had late VF (≥48 hours after AMI). In-hospital mortality was 50 and 54% for early and late VF, respectively (p = 0.31). Kaplan-Meier survival analysis showed better survival after discharge for patients with early versus late VF (p = 0.009) but this difference was fully explained by the presence of heart failure. Survival analysis showed the same prognosis after 1, 3 and 5 years for early and late VF, when VF was not associated with heart failure. When VF was associated with heart failure (secondary VF) early VF had a greater mortality than late VF after 2 and 5 years. Logistic regression analysis showed that heart failure (relative risk 1.9 [1.1 to 3.1]) and cardiogenic shock (relative risk 3.9 [1.8 to 8.5]) were significant risk factors for in-hospital death. Late VF compared to early VF had no prognostic implication (relative risk 1.0 [0.6 to 1.6]). For patients discharged from the hospital, risk factors were heart failure (1.8 [1.1 to 2.8]) and previous AMI (1.6 [1.3 to 2.1]). Late VF showed a trend (1.2 [0.8 to 1.8]) toward poorer long-term prognosis than early VF. There is no special risk for patients with late VF compared to patients with early VF after AMI when they are monitored as described.

Effects of cigarette smoking and propranolol in survivors of acute myocardial infarction

The effect of propranolol on mortality and reinfarction after acute myocardial infarction (AMI) in cigarette smokers and nonsmokers was studied in the Beta Blocker Heart Attack Trial. Cigarette smokers (n = 2,332) were 5 years younger than nonsmokers and had a lower incidence of diabetes mellitus, systemic hypertension, previous AMI and cardiomegaly. Among cigarette smokers, the placebo group had a higher total mortality rate than the propranolol group (11.0 vs 7.4%, p < 0.0008) and more sudden cardiac deaths (7.1 vs 4.6%, p < 0.009). In nonsmokers the placebo group had a mortality (7.9 vs 7.1%, p > 0.64) similar to the propranolol group. After baseline adjustment, cigarette smokers were estimated to have 1.6 times the risk of dying as compared to nonsmokers (p < 0.0007). Adjusting for baseline differences, both treatment with propranolol and nonsmoking were predictors of survival. No detectable nonsmoking/ propranolol interaction could be identified. In survivors of AMI a beneficial effect of propranolol is observed for cigarette smokers. Nevertheless, cigarette smoking continues to be a risk factor for mortality after AMI even for those receiving propranolol.