Prior Acute Myocardial Infarction Research Articles

Incidence and Long-Term Outcomes of Acute Myocardial Infarction Among Survivors of Out-of-Hospital Cardiac Arrest.

Despite the increasing long-term survival after out-of-hospital cardiac arrest (OHCA), the risk of subsequent acute myocardial infarction (AMI) remains poorly understood. We aimed to determine the incidence, predictors, and long-term outcomes of AMI among survivors of OHCA. We assembled a retrospective cohort of 882 patients with OHCA who survived to 30 days or discharge from the hospital between 2010 and 2019. Survivors of OHCA had an increased risk of subsequent AMI, defined as AMI occurring 30 days after index OHCA or following discharge from the hospital after OHCA, compared with the general population when matched for age and sex (standardized incidence ratio, 4.64 [95% CI, 3.52-6.01]). Age-specific risks of subsequent AMI for men (standardized incidence ratio, 3.29 [95% CI, 2.39-4.42]) and women (standardized incidence ratio, 6.15 [95% CI, 3.27-10.52]) were significantly increased. A total of 7.2%, 8.3%, and 14.3% of survivors of OHCA had a subsequent AMI at 3 years, 5 years, and end of follow-up, respectively. Age at OHCA (hazard ratio [HR], 1.04 [95% CI, 1.02-1.06]) and past medical history of prior AMI, defined as any AMI preceding or during the index OHCA event (HR, 1.84 [95% CI, 1.05-3.22]), were associated with subsequent AMI, while an initial shockable rhythm was not (HR, 1.00 [95% CI, 0.52-1.94]). Survivors of OHCA with subsequent AMI had a higher risk of death (HR, 1.58 [95% CI, 1.12-2.22]) than those without. Survivors of OHCA are at an increased risk of subsequent AMI compared with the general population. Prior AMI, but not an initial shockable rhythm, increases this risk, while subsequent AMI predicts death. Preventive measures for AMI including cardiovascular risk factor control and revascularization may thus improve outcomes in selected patients with cardiac pathogenesis.

Survival benefit of kidney transplantation in patients with end-stage kidney disease and prior acute myocardial infarction

Survival benefit of kidney transplantation in patients with end-stage kidney disease and prior acute myocardial infarction

Bystander defibrillation increases 30-day survival even with short emergency medical service response time

Abstract Background Rates of bystander initiated defibrillation are increasing in many areas of the world (1-4), but the effect of defibrillation at different time points after recognition of out-of-hospital cardiac arrest (OHCA) remains largely unknown. Purpose To assess the effect on 30-day survival of bystander defibrillation at different intervals of emergency medical service (EMS) response time. Methods We included OHCAs from 2016 through 2020 from the Danish Cardiac Arrest Registry. Cases were included if they were ≥18 years of age, bystander witnessed, received bystander cardiopulmonary resuscitation (CPR), had EMS response time of 25 minutes or less and only the first OHCA for each subject was considered. We excluded cases witnessed by EMS or if they had missing values of OHCA-related variables. Crude survival proportions were calculated for each minute of EMS response time. Relative risks (RR) and corresponding 95 % confidence intervals (95 % CI) of the outcome (30-day survival) for eight different intervals of EMS response time were estimated using a causal inference framework utilizing Targeted Maximum Likelihood Estimation (TMLE) with ensemble Super Learning, adjusting for age, sex, place of arrest (public/private), initial cardiac rhythm (shockable/not shockable), and comorbidities (prior acute myocardial infarction, ischemic heart disease, heart failure, chronic obstructive pulmonary disease, stroke, cancer). Results We included 7,471 cases of bystander witnessed OHCA receiving CPR before EMS arrival. Of these, 14.7 % (1,098/7,471) received bystander defibrillation before arrival of EMS. Overall, 44.5 % (489/1,098) survived to 30 days when bystander defibrillation was performed versus 18.8 % (1,200/6,373) when no bystander defibrillation was performed. When examining the crude survival proportion for each minute of EMS response time, we found that 30-day survival was consistently higher in the group receiving bystander defibrillation for the first 20 minutes after which the survival was approximately the same for the two groups (Figure 1). When adjusting for confounders, we found statistically significantly increased relative risks of 30-day survival for patients receiving bystander defibrillation, compared to patients not bystander defibrillated, for all intervals of EMS response time, except for response times of 0-2 min., where the increase did not reach statistical significance (0-2 min: RR; 1.34 [95 % CI: 0.88-2.05], 2-4 min: RR; 1.37 [95 % CI: 1.10-1.70], 4-6 min: RR; 1.55 [95 % CI: 1.33-1.80], 6-8 min: RR; 2.23 [95 % CI: 1.86-2.67], 8-10 min: RR; 1.99 [95 % CI: 1.55-2.55], 10-12 min: RR; 1.89 [95 % CI: 1.34-2.68], 12-15 min: RR; 1.86 [95 CI: 1.22-2.84], >15 min: RR; 1.98 [95 % CI: 1.16-3.38]) (Figure 2). Conclusion For all intervals of EMS response time, bystander defibrillation increased 30-day survival of OHCA. The effect was significant for EMS response times as short as 2-4 minutes.

Abstract 15063: Incidence and Risk Factors for Heart Failure in 20 000 Newly Diagnosed Diabetes Patients

Introduction: Heart Failure (HF) is a diabetes complication causing high mortality and morbidity but has received relatively limited attention compared to other complications such as acute myocardial infarction (AMI). Substantial residual HF risk remains after achieving current treatment targets, suggesting important additional pathophysiological mechanisms beyond conventional risk factors. Aim: to study the incidence and risk factors for HF in newly diagnosed diabetes patients. Methods: We used a contemporary, regional inception cohort (n=19,938) from Scania County in Sweden, to study the incidence and risk factors for HF from initial diabetes diagnosis. Biochemical and questionnaire data were collected within 1 year from initial diagnosis in newly diagnosed diabetes patients (>90% participation rate). We combined baseline data with information on incident HF and AMI diagnoses from a nationwide patient register, and applied Cox-regression models for analysis. Results: A total of 819 patients (4%) had been diagnosed with HF before diabetes diagnosis (median 3 years earlier) and 1245 (6%) with AMI. The cumulative incidence of HF in patients free from HF at diabetes diagnosis was 5%, similar to AMI (3%), during up to 13 years follow-up (median 5 years). Of patients with incident HF, 27% had a prior AMI. No type 1 diabetes (T1D) patient had incident HF, while HF risk was similar in type 2 diabetes, latent autoimmune diabetes in adults (LADA) and secondary diabetes. In non-T1D diabetes patients, male sex (HR 1.52) and higher age at onset (HR 1.08), BMI (HR 1.04), and insulin resistance (HR 1.17) were independently associated with higher incidence of all-cause HF and HF without prior AMI (p<0.05). Baseline fasting glucose, HbA1c and autoantibodies were not associated with HF. Conclusions: Our findings demonstrate high incidence of HF over the decade after initial diabetes diagnosis, comparable to AMI. We further identify insulin resistance, but not hyperglycemia or autoantibodies, as risk factor for HF.

Abstract 156: Incidence and Long-Term Outcomes of Acute Myocardial Infarction Among Survivors of Out-of-Hospital Cardiac Arrest

Introduction: Despite the increasing long-term survival after out-of-hospital cardiac arrest (OHCA), the risk of subsequent acute myocardial infarction (AMI) remains poorly understood. We aimed to determine the incidence, predictors, and long-term outcomes of AMI among OHCA survivors. Methods: We assembled a retrospective cohort of patients with OHCA who survived to 30 days or discharge from hospital regardless of time from index event between 2010-2019 by linking the Pan-Asian Resuscitation Outcomes Study (Singapore participants), Singapore Myocardial Infarction Registry, and the Singapore Registry of Births and Deaths. We calculated the risk of subsequent AMI defined as AMI occurring 30 days after index OHCA or following discharge from hospital post-OHCA, among OHCA survivors compared to the general population using age- and sex-specific standardised incidence ratios (SIR) and the cumulative incidence of subsequent AMI among OHCA survivors. We investigated predictors of subsequent AMI among OHCA survivors and whether AMI predicted mortality using Cox regression hazard ratios for time-to-event analyses. Results: In total, 882 OHCA survivors were analysed. OHCA survivors had an increased risk of subsequent AMI compared to the general population when matched for age and sex (SIR 4.64, 95% CI: 3.52-6.01). Age-specific risks of subsequent AMI for males (SIR 3.29, 95%CI: 2.39-4.42) and females (SIR 6.15, 95%CI: 3.27-10.52) were significantly increased. 7.2%, 8.3%, and 14.3% of OHCA survivors had subsequent AMI at 3 years, 5 years, and end of follow-up respectively. Age at OHCA (HR 1.04, 95%CI: 1.02-1.06) and past medical history of prior AMI, defined as any AMI preceding or during the index OHCA event (HR 1.84, 95%CI: 1.05-3.22), were associated with subsequent AMI. OHCA survivors with subsequent AMI had a higher risk of mortality (HR 1.58, 95%CI: 1.12-2.22) than those without. Conclusion: Long-term OHCA survivors have an increased risk of subsequent AMI, compared to the general population. Prior AMI significantly increases this risk and subsequent AMI predicts mortality. Intensive cardiovascular risk factor control and revascularisation may improve outcomes in selected patients with a cardiac etiology.

IL-1 blockade in cardiovascular disease: an appraisal of the evidence across different inflammatory paradigms.

Pre-clinical and clinical studies suggest a role for inflammation in the pathophysiology of cardiovascular (CV) diseases. The NLRP3 (NACHT, leucine-rich repeat, and pyrin domain-containing protein 3) inflammasome is activated during tissue injury and releases interleukin-1β (IL-1β). We describe three paradigms in which the NLRP3 inflammasome and IL-1β contribute to CV diseases. During acute myocardial infarction (AMI), necrotic cell debris, including IL-1α, induce NLRP3 inflammasome activation and further damage the myocardium contributing to heart failure (HF) (acute injury paradigm). In chronic HF, IL-1β is induced by persistent myocardial overload and injury, neurohumoral activation and systemic comorbidities favoring infiltration and activation of immune cells into the myocardium, microvascular inflammation, and a pro-fibrotic response (chronic inflammation paradigm). In recurrent pericarditis, an autoinflammatory response triggered by cell injury and maintained by the NLRP3 inflammasome/IL-1β axis is present (autoinflammatory disease paradigm). Anakinra, recombinant IL-1 receptor antagonist, inhibits the acute inflammatory response in patients with ST elevation myocardial infarction (STEMI) and acute HF. Canakinumab, IL-1β antibody, blunts systemic inflammation and prevents complications of atherosclerosis in stable patients with prior AMI. In chronic HF, anakinra reduces systemic inflammation and improves cardiorespiratory fitness. In recurrent pericarditis, anakinra and rilonacept, a soluble IL-1 receptor chimeric fusion protein blocking IL-1α and IL-1β, treat and prevent acute flares. In conclusion, the NLRP3 inflammasome and IL-1 contribute to the pathophysiology of CV diseases, and IL-1 blockade is beneficial with different roles in the acute injury, chronic inflammation and autoinflammatory disease paradigms. Further research is needed to guide the optimal use of IL-1 blockers in clinical practice.

Survival Benefit of Kidney Transplantation in Patients With End-Stage Kidney Disease and Prior Acute Myocardial Infarction.

Patients with end stage kidney disease (ESKD) and a previous acute myocardial infarction (AMI) have less access to KT. Data on ESKD patients with an AMI history who underwent first KT or dialysis between January 2007 and December 2018 were extracted from the Korean National Health Insurance Service. Patients who underwent KT (n = 423) were chronologically matched in a 1:3 ratio with those maintained on dialysis (n = 1,269) at the corresponding dates, based on time-conditional propensity scores. The 1, 5, and 10years cumulative incidences for all-cause mortality were 12.6%, 39.1%, and 60.1% in the dialysis group and 3.1%, 7.2%, and 14.5% in the KT group. Adjusted hazard ratios (HRs) of KT versus dialysis were 0.17 (95% confidence interval [CI], 0.12-0.24; p < 0.001) for mortality and 0.38 (95% CI, 0.23-0.51; p < 0.001) for major adverse cardiovascular events (MACE). Of the MACE components, KT was most protective against cardiovascular death (HR, 0.23; 95% CI, 0.12-0.42; p < 0.001). Protective effects of KT for all-cause mortality and MACE were consistent across various subgroups, including patients at higher risk (e.g., age >65years, recent AMI [<6months], congestive heart failure). KT is associated with lower all-cause mortality and MACE than maintenance dialysis patients with a prior AMI.

Long-Term Exposure to Road Traffic Noise and Incident Heart Failure: Evidence From UK Biobank

BackgroundEvidence on road traffic noise and heart failure (HF) is limited, and little is known on the potential mediation roles of acute myocardial infarction (AMI), hypertension, or diabetes. ObjectivesThe purpose of this study was to evaluate the impacts of long-term road traffic noise exposure on the risk of incident HF considering air pollution, and explore the mediations of the previously mentioned diseases. MethodsThis prospective study included 424,767 participants without HF at baseline in UK Biobank. The residential-level noise and air pollution exposure was estimated, and the incident HF was identified through linkages with medical records. Cox proportional hazard models were used to estimate HRs. Furthermore, time-dependent mediation was performed. ResultsDuring a median 12.5 years of follow-up, 12,817 incident HF were ascertained. The HRs were 1.08 (95% CI: 1.00-1.16) per 10 dB[A] increase in weighted average 24-hour road traffic noise level (Lden), and 1.15 (95% CI: 1.02-1.31) for exposure to Lden >65 dB[A] compared with the reference category (Lden ≤55 dB[A]), respectively. Furthermore, the strongest combined effects were found in those with both high exposures to road traffic noise and air pollution including fine particles and nitrogen dioxide. Prior AMI before HF within 2 years’ time interval mediated 12.5% of the association of road traffic noise with HF. ConclusionsMore attention should be paid and a preventive strategy should be considered to alleviate the disease burden of HF related to road traffic noise exposure, especially in participants who survived AMI and developed HF within 2 years.

Long-term risk of major adverse cardiovascular events following ischemic stroke or TIA

Data are scarce on long-term outcomes after ischemic stroke (IS) or transient ischemic attack (TIA). In this prospective cohort study, we examined the cumulative incidence of major adverse cardiovascular events (MACE) after IS and TIA using a competing risk model and factors associated with new events using a Cox-proportional hazard regression model. All patients discharged alive from Östersund Hospital with IS or TIA between 2010 and 2013 (n = 1535) were followed until 31 December 2017. The primary endpoint was a composite of IS, type 1 acute myocardial infarction (AMI), and cardiovascular (CV) death. Secondary endpoints were the individual components of the primary endpoint, in all patients and separated in IS and TIA subgroups. The cumulative incidence of MACE (median follow-up: 4.4 years) was 12.8% (95% CI: 11.2–14.6) within 1 year after discharge and 35.6% (95% CI: 31.8–39.4) by the end of follow-up. The risk of MACE and CV death was significantly increased in IS compared to TIA (p-values < 0.05), but not the risk of IS or type 1 AMI. Age, kidney failure, prior IS, prior AMI, congestive heart failure, atrial fibrillation, and impaired functional status, were associated with an increased risk of MACE. The risk of recurring events after IS and TIA is high. IS patients have a higher risk of MACE and CV death than TIA patients.

Preoperative management of ophthalmic patients taking oral anticoagulants

Surgical treatment is often accompanied by such complication as bleeding, and ophthalmic surgery is not an exception. The bleeding risk depends on many factors, the most significant are age, arterial hypertension, hepatic and renal impairment, prior stroke or treatment with oral anticoagulants.The aim. To evaluate the structure of patients taking novel oral anticoagulants (NOACs) with an assessment of activated partial thromboplastin time before ophthalmosurgical treatment.Materials and methods. 54 patients taking oral anticoagulants were included in the study. A retrospective analysis of medical histories of patients who had surgery for ocular pathology was carried out. The patients were divided into two groups: group 1 – 28 patients whose activated partial thromboplastin time (APTT) did not exceed 45 seconds; group 2 – 26 patients with APTT more than 45 seconds. The criterion for the numerical expression of APTT is the safety of performing regional anesthesia against the background of taking anticoagulant drugs. Statistical processing was performed using the Mann – Whitney test (p &lt; 0.05).Results. A comparative analysis of the results showed that the patients of the group 2 had higher rates of APTT. At the same time, they were less likely to have acute cerebrovascular accident (11.5 % compared to 21 % of patients in the group 2) and prior acute myocardial infarction (19 % and 28 %, respectively). Among all the patients, women and slightly older patients prevailed.Conclusion. Patients with atrial fibrillation make up the majority of patients undergoing ophthalmosurgical treatment and taking NOACs. Surgical treatment method was phacoemulsification with intraocular lens implantation. Studying APTT before the surgery allowed us to identify a category of patients with high APTT, to prescribe the withdrawal of the drug before the surgery in order to create optimal conditions for surgical treatment.

Long-Term Predictors of Hospitalized Reinfarction after an Incident Acute Myocardial Infarction.

The aim of this study was to compare characteristics of incident acute myocardial infarction (AMI) and first and second time reinfarctions in terms of sociodemographic characteristics, comorbidities, symptoms, treatment, clinical characteristics, medication and outcome. A further aim was to identify predictors for an increased risk of hospitalized reinfarction. Between 2000 and 2017, a total of 13,276 AMI cases were recorded by a population-based registry in the area of Augsburg, Germany, and were included in this study (11,871 incident events, 1217 cases of first-time reinfarction and 202 cases of second-time reinfarction). Median follow-up time was 5.3 years. For differences in baseline characteristics, Chi-square tests and analysis of variance (ANOVA) were calculated. To determine factors that are associated with an increased risk of hospitalized reinfarction COX regression models were fitted. Myocardial reinfarctions differ from incident events in some major characteristics such as the frequency of comorbidities, laboratory values, ECG presentation and therapy, but not regarding 28-day mortality. Moreover, typical comorbidities and risk factors (diabetes, hypertension, hyperlipidemia, smoking, impaired renal function) are associated with an increased risk of hospitalized reinfarction. Conversely, STEMI ECG, being married, German nationality and bypass surgery are predictors for a lower risk of hospitalized reinfarction. Incident AMI and reinfarction are distinctly different in many characteristics, which physicians should have in mind when treating patients with prior AMI. Typical comorbidities are risk factors for hospitalized reinfarction. This underlines the importance of comprehensive treatment of these comorbidities including education of patients and encouragement towards lifestyle adjustments.

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease-Results from the KidDiCo.

Chronic kidney disease (CKD) is a known risk factor for cardiovascular disease, including acute myocardial infarction. However, whether this risk is only associated with severe kidney disease or is also related to mildly impaired kidney function is still under debate. The incidence rate and risk factors of incident acute myocardial infarction (AMI) in patients with CKD are sparse. Potential differences in risk factor profiles between CKD patients with incident AMI and CKD patients with a prior AMI have not been sufficiently investigated. Furthermore, important factors such as albuminuria and socio-economic factors are often not included. The primary aim of this study was to establish the incidence rate of AMI after CKD debut. Secondly, to evaluate the importance of different CKD stages and the risk of having an AMI. Finally, to identify individuals at risk for AMI after CKD debut adjusted for prevalent AMI. Based on data from the kidney disease cohort of Southern Denmark (KidDiCo), including 66,486 CKD patients, we established incidence rates and characteristics of incident AMI among patients within a 5-year follow-up period after CKD debut. A Cox regression was performed to compute the cause-specific hazard ratios for the different risk factors. The incidence rate for CKD stage G3-5 patients suffering acute myocardial infarction is 2.5 cases/1000 people/year. In patients without a previous myocardial infarction, the risk of suffering a myocardial infarction after CKD debut was only significant in CKD stage G4 (HR = 1.402; (95% CI: 1.08-1.81); p-value = 0.010) and stage G5 (HR = 1.491; (95% CI: 1.01-2.19); p-value = 0.042). This was not the case in patients who had suffered an acute myocardial infarction prior to their CKD debut. In this group, a previous myocardial infarction was the most critical risk factor for an additional myocardial infarction after CKD debut (HR = 2.615; (95% CI: 2.241-3.05); p-value &lt; 0.001). Irrespective of a previous myocardial infarction, age, male sex, hypertension, and a low educational level were significant risk factors associated with an acute myocardial infarction after CKD debut. The incidence rate of AMI in patients with CKD stage G3-5 was 2.5 cases/1000 people/year. Risk factors associated with incident AMI in CKD stage G3-5 patients were CKD stage, age, and hypertension. Female sex and higher educational levels were associated with a lower risk for AMI. Prior AMI was the most significant risk factor in patients with and without previous AMI before fulfilling CKD stage G3-5 criteria. Only age, sex, and a medium-long educational level were significant risk factors in this group.

Abstract 11986: In-Hospital Outcomes in Patients With Peripheral Artery Disease Hospitalized for Acute Myocardial Infarction: From the NCDR Chest Pain Mi Registry

Introduction: Patients with peripheral artery disease (PAD) are at high risk for adverse cardiovascular events, including acute myocardial infarction (AMI). Though AMI care has improved, in-hospital outcomes for patients experiencing an AMI with comorbid PAD are not well described in recent practice. We hypothesized that patients with PAD would have higher rates of bleeding and mortality during AMI hospitalization. Methods: We assessed clinical characteristics and in-hospital major bleeding and mortality rates of patients admitted with AMI and comorbid PAD at 646 hospitals in the NCDR Chest Pain MI Registry from 1/2019 to 9/2021. Major bleeding and mortality were compared for patients with vs. without PAD using multivariable logistic regression. Results: Compared with patients admitted for AMI without PAD (n = 307,550), those with PAD (n = 24,585) were older, had more comorbidities including tobacco use, diabetes, prior AMI and heart failure, and more frequently presented with NSTEMI vs. STEMI. Patients with PAD had higher crude rates of in-hospital major bleeding (9.7% vs. 6.3%) and mortality (8.1% vs. 4.7%); in exploratory analyses, rates of other adverse in-hospital events were also higher ( Figure ). After multivariable adjustment, PAD was associated with an increased risk of major bleeding (adjusted OR [aOR] 1.23 [95% CI 1.17-1.30]). PAD was also associated with greater risk of in-hospital mortality (aOR 1.28 [95% CI 1.21-1.37]), particularly among patients over age 65 (aOR 1.32 [95% CI 1.23-1.42] for ≥65 years vs. 1.06 [95% CI 0.96-1.18] for patients &lt;65 years; interaction p = 0.02). Conclusions: Among patients hospitalized with AMI, those with PAD have greater comorbidity burden and increased risk of major bleeding. Patients with PAD, particularly those who are ≥65 years, also have increased risk of in-hospital death. These findings highlight a need for improved preventive efforts, tailored care pathways, and greater focus on AMI management in PAD patients.

Multimorbidity, functional impairment, and mortality in older patients stable after prior acute myocardial infarction: Insights from the TIGRISregistry.

Data on the association of multimorbidity and functional impairment with cardiovascular (CV) and non-CV outcomes among older myocardial infarction (MI) patients are limited. Multimorbidity and functional impairment among older MI patients are associated with CV and non-CV mortality. Patients aged ≥65 years, 1-3 years post-MI, and enrolled between June2013 and Novemeber 2014 from 349 sites in 25 countries in the global TIGRIS registry were categorized by age, number of comorbidities, and presence and degree of functional impairment. Functional impairment was calculated using five-dimension EuroQol based on three domains-mobility, self-care, and usual activities. The association between age, number of comorbid conditions, and degree of functional impairment with 2-year incidence of CV and non-CV death was evaluated using Poisson regression analysis. Older age was associated with higher number of comorbidities and functional impairment; after adjustment, increasing age was significantly associated with non-CV mortality (p = .03) but not CV mortality (p = .38). Greater functional impairment was associated with a higher rate and relatively equal magnitude risk of CV (rate ratios[RR] 1.52, 95%confidence intervals[CI]: 1.29-1.79, per one-step increase)and non-CV mortality (RR 1.42, 95%CI: 1.17-1.73). Multimorbidity was more strongly associated with CV mortality (RR 1.52, 95%CI: 1.38-1.67, per additional comorbidity) versus non-CV mortality (RR 1.29, 95%CI: 1.14-1.47, per additional comorbidity). Multimorbidity and functional impairment are prevalent among older post-MI patients and are associated with increased CV and non-CV mortality. These findings highlight the importance of considering comorbid conditions and functional impairment as predictors of risk for adverse outcomes and aspects of medical decision making.Clinical Trial Registration: NCT01866904.

Impact of ischaemic aetiology on the efficacy of intravenous ferric carboxymaltose in patients with iron deficiency and acute heart failure: insights from the AFFIRM-AHF trial.

In AFFIRM-AHF, intravenous ferric carboxymaltose (FCM) reduced heart failure (HF) hospitalisations and improved quality of life versus placebo in iron-deficient patients stabilised after an acute HF episode. This analysis explored the effects of FCM versus placebo in patients with ischaemic and non-ischaemic HF aetiology. We included 1082 patients from AFFIRM-AHF: 590 with ischaemic HF (defined as investigator-reported ischaemic HF aetiology and/or prior acute myocardial infarction and/or prior coronary revascularisation) and 492 with non-ischaemic HF. The prevalences of male sex, comorbidities, and history of HF were higher in the ischaemic versus non-ischaemic HF subgroup. Annualised event rates for the primary composite outcome of total HF hospitalisations and cardiovascular death with FCM versus placebo were 65.3 versus 100.6 per 100 patient-years in the ischaemic HF subgroup (rate ratio [RR] 0.65, 95% confidence interval [CI] 0.47-0.89, p=0.007) and 58.3 versus 52.5 in the non-ischaemic HF subgroup (RR 1.11, 95% CI 0.75-1.66, p=0.60) (pinteraction =0.039). An interaction between HF aetiology and treatment effect was also observed for the secondary outcome of total HF hospitalisations (pinteraction =0.038). A nominal increase in quality of life, assessed using the 12-item Kansas City Cardiomyopathy Questionnaire, was observed with FCM versus placebo, within each subgroup. Heart failure hospitalisations and cardiovascular deaths occurred at a higher rate in patients with ishaemic versus those with non-ischaemic HF and were reduced by FCM versus placebo only in ischaemic patients. Further studies are needed to assess the role of aetiology in FCM efficacy.

Nationwide frequency, risk and outcomes of type-2 myocardial infarction in patients with versus without previously revascularized myocardial infarction (type 1)

Abstract Funding Acknowledgements Type of funding sources: None. Background Type 2 myocardial infarction (T2MI), due to a mismatch between myocardial oxygen demand and supply, is being increasingly recognized with improved diagnostics. The upsetting concern of developing T2MI in patients with prior revascularized occlusive acute myocardial infarction (AMI) or type 1 MI (T1MI) makes it crucial to define the clinical profile and outcomes of T2MI in revascularized patients of ACS. Purpose To determine the risk and prognosis of T2MI in patients who had previously had coronary revascularization (PCI or CABG) Methods We used the National Inpatient Sample (2018) dataset from the United States to identify T2MI adult hospitalizations using ICD-10 codes and define our study arm as T2MI excluding secondary T1MI diagnoses but having prior revascularized (with percutaneous coronary intervention or coronary artery bypass grafting) AMI. We then compared demographics and comorbidities in T2MI cohort with vs without personal history of revascularized AMI. We used multivariate analysis to study the odds of T2MI hospitalizations with prior revascularized AMI and in-hospital outcomes (all-cause mortality, cardiogenic shock and resource utilization) adjusting for confounders. Results There were 33155 T2MI adult hospitalizations after excluding AMI (median age 71 years, 50.6% male, 67.3% white); 1435 (4.3%) had previously revascularized AMI. T2MI in the study arm had higher chances of hospitalization with prior revascularized AMI when adjusted for socio-demographics (aOR 6.92, 95% CI:6.50-7.36, p&amp;lt;0.001) and socio-demographics with comorbidities (aOR 5.70, 95%CI: 5.48-5.94, p&amp;lt;0.001) (Table 1). Study arm often had elderly (≥65 years old, 78.4% vs 65.8%), male (66.6% vs 49.9%), white (76.7% vs 66.9%), upper socio-economic class (20.2 vs 16.8%), patients who were often admitted to non-electively (99.3 vs 97.1%) and to rural (10.5 vs 9.3%) hospitalizations compared to control arm. The study arm had a significantly higher prevalence of diabetes mellitus, hyperlipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, deficiency anemias, prior TIA/stroke, depression and smoking. T2MI cohort with prior revascularized AMI did not show any significant association with in-hospital all-cause mortality (1.7 vs 3.0%, aOR 0.49, 95%CI 0.18-1.34, p=0.164) and cardiogenic shock (1.7% vs 2.1%, p=0.399) however, had lower hospital expenditure (median USD 31273 vs 36567) and fewer transfers to other facilities (19.5 vs 22.1%) than those without prior revascularized AMI (Table 2). Conclusion Population-based analysis of this nationally representative sample revealed up to six times higher risk of developing T2MI in patients with prior history of AMI (revascularized) but without any significant impact on all-cause in-hospital mortality or cardiogenic shock. Future studies are warranted to assess the short-term/long-term outcomes of T2MI in high risk patient population with previously revascularized AMI.

Abstract 161: Trends In Time-Incremental Mortality After Hospitalization For Incident Acute Myocardial Infarction Among Medicare Beneficiaries, 2008-2017

Background: New medical technologies and advancements in care quality have transformed care of patients hospitalized with incident acute myocardial infarction (AMI). While some advances may impact short-term mortality (e.g., mechanical circulatory support), others may take much longer to impact mortality (e.g., cardiac rehabilitation). Little is known about trends in time-incremental AMI mortality rates. Methods: We identified all patients hospitalized with incident AMI using a 5% sample of Medicare fee-for-service beneficiaries from 2008 to 2017. We used a three-year look back to exclude patients with a prior AMI hospitalization. We calculated unadjusted in-hospital, 30-day, 1-year, 2-year, and 3-year mortality rates by dividing the total number of all-cause deaths during each period by the corresponding number of patients who were hospitalized. We used logistic regression models to adjust mortality rates for patient demographics (age, sex, race/ethnicity) and a variety of comorbid conditions. Using 2008 as the baseline, we calculated annual incremental mortality rates for each time period. We performed subgroup analyses among AMI patients with ST-segment and non-ST-segment elevation. Results: From 2008 to 2017, we identified 42,567 patients hospitalized with incident AMI (mean age 81 years, 44% male, 86% white). The largest incremental declines in mortality rates were observed for the in-hospital (2.9% [CI 2.7 to 3.1%]), 30-day (2.1% [CI 1.9 to 2.3%], and 1-year (2.9% [CI 2.6 to 3.2%] time periods. Mortality declines were smaller but persisted for the 2-year (1.5% [CI 1.2 to 1.8%]), and 3-year (0.5% [CI 0.2 to 0.8%]; Figure) time periods. Similar patterns were observed among both ST-segment and non-ST-segment elevation AMI patients. Conclusions: For patients hospitalized with incident AMI, advances in care have led to incremental declines in mortality across time periods spanning the hospital stay through 3 years after discharge.

Implications of Payment for Acute Myocardial Infarctions as a 90-Day Bundled Single Episode of Care: A Cost of Illness Analysis.

ObjectivesEvaluate the cost of illness associated with the 90-day period following acute myocardial infarction (AMI) and the implication of care pathway (percutaneous coronary intervention [PCI] vs medical management [MM]), in order to assess the potential financial risk incurred by providers for AMI as an episode of care.PerspectiveReimbursement payment systems for acute care episodes are shifting from 30-day to 90-day bundled payment models. Since follow-up care and readmissions beyond the early days/weeks post-AMI are common, financial risk may be transferred to providers.SettingAMI hospitalization Centers for Medicare & Medicaid Services (CMS) standard analytical files between 10/1/2015 and 9/30/2016 were reviewed.MethodsIncluded patients were Medicare beneficiaries with a primary diagnosis of AMI subsequently treated with either PCI or MM. Payments were standardized to remove geographic variation and separated into reimbursements for services during the hospitalization and from discharge to 90 days post-discharge. Results were stratified by Medicare Severity Diagnosis Related Groups (MS-DRGs) individually and grouped between patients treated with MM and PCI. Risk-adjusted likelihood of utilization of post-acute nursing care and all-cause readmission was assessed by logistic regression.ResultsA total of 96,546 patients were included in the analysis. The highest total mean payment (US$32,714) was for MS-DRG 248 (PCI with non-drug-eluting stent with major complication or comorbidity). Total payments were similar between MM and PCI patients, but MM patients incurred the majority of costs in the post-acute period after discharge, with the converse true for PCI patients. MM without catheterization was associated with a twofold increase in risk of requiring post-acute nursing care and 90-day readmission versus PCI (odds ratio [95% confidence interval]: 2.01 [1.92–2.11] and 2.17 [2.08–2.27]). Smaller hospital size, diabetes, peripheral arterial disease, prior AMI, and multivessel disease were predictors of higher healthcare utilization.ConclusionsMS-DRGs associated with the lowest reimbursements (and presumably, lowest costs of inpatient care) incur the highest post-discharge expenditures. As the CMS Bundled Payment for Care Improvement and similar programs are implemented, there will be a need to account for heterogeneous post-discharge care costs. Video abstract (MP4 274659 KB)Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00328-4.

Clinical burden of MACE in patients with multivessel disease during the early period following acute myocardial infarction

Abstract Background Despite numerous interventions that have improved outcomes in acute myocardial infarction (AMI) patients, the first 90 days after AMI remains a high-risk period for recurrent events. Due to higher disease burden and suboptimal outcomes, it is crucial to characterize the clinical burden upon patients with multivessel disease (MVD) and various comorbidities. Purpose To describe the post-AMI clinical burden of major adverse cardiovascular events (MACE) in patients with MVD at 30, 90, and 365 days. Methods This was a retrospective cohort study (1st January, 2008 to 31st December, 2018) using data from a longitudinal, representative UK population health dataset comprising primary care data from the Clinical Practice Research Datalink (CPRD). This was linked to data from the Hospital Episode Statistics (HES) and Office of National Statistics (ONS) databases to identify patients with a confirmed diagnosis code of MVD. A MACE was defined as any one of non-fatal MI, non-fatal stroke, or cardiovascular death. The prevalence of MACE among post-AMI patients with MVD and the effect of concurrent risk factors was quantified. Results 403,631 patients with MVD were identified (21.69% of the total study population), nearly one-fifth of whom (n=78,128; 19.35%) experienced an AMI after their first recorded diagnosis of MVD (MVD+). The mean and median age of MVD+ patients was 66 years, and the majority (72.9%) were male. Almost half (48.9%) had a Charlson co-morbidity score of at least 1, and 99.8% had an index of multiple deprivation recorded, distributed evenly across the quintiles. At least one of the composite MACE occurred in 9,533 (12.2%), 11,694 (14.9%), and 15,188 (19.4%) MVD+ patients within 30, 90, and 365 days, respectively. In MVD+ patients with 2 or more additional risk factors (peripheral artery disease [PAD], age &amp;gt;65, prior AMI; w/out comorbid diabetes; n=7,531), the proportion of MACE within 90 days was substantially higher (42.7%). Non-fatal MI was the most common MACE episode in MVD+ patients, occurring in 7,696, (9.8%), 8,924 (11.4%), and 10,673 (13.7%) MVD+ patients at 30, 90, and 365 days, respectively. Within 90 days of AMI, 39.1% of MVD+ patients with 2 or more risk factors experienced non-fatal MI. Conclusions MVD patients have a considerable clinically relevant burden of MACE following AMI. The majority of 1-year recurrent events occurred within 90 days of MACE, with 90-day risk almost 3-fold higher in patients with two additional risk factors. For patients with MVD and other risk factors, opportunities remain for treatments that may reduce the risk of recurrent events in the early period following AMI. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): CSL Behring

Sport-related acute myocardial infarction. Contemporary data from IMACS survey

Abstract Background Sport-related (SR) acute cardiovascular (CV) events are the main cause of sudden cardiac death in the setting of sport activities. However, data are very scarce regarding onset and follow-up of SR acute myocardial infarction (AMI). Methods From the prospective study IMACS (Infarctus du Myocarde et Arret Cardiaque au cours du Sport) patients admitted for a SR-AMI in our university hospital from April 2018 to March 2020 were included. A 12 months follow-up (FU) was achieved through telephone interview to address CV outcomes and sport practice information. Information was obtained from relatives in case of out of hospital sudden cardiac arrest (OH-SCA). Results Among the 55 patients included, all were male, with median (IQR) age at 62 (55–69) y. Most common sports were cycling (n=21), fitness (n=7), swimming (n=5) and hiking (n=5). The SR-AMI occurred during effort for 39 subjects and during recovery for 16. Most SR-AMI occurred in public area (n=24), at home (n=16), or in a specific sport location (n=14). An Automated External Defibrillator (AED) was available in the SR-AMI location in only 10, but was missing in 43 (unknown for 2). In 1 subject with OH-SCA, cardiopulmonary resuscitation (CPR), initiated by witnesses, using a public AED, was unsuccessful. The 4 other patients with OH-SCA underwent successful CPR. Among the 55 subjects, 4 were vapers, of whom 1 was a dual user, 17 were current tobacco smokers, 18 were ex-smokers and 2 experienced cannabis and cocaine use. Among the smokers, most smoked (n=10) or consumed cannabis (n=1) &amp;lt;2h before the event. Strikingly, CV history and/or recent symptoms were present in almost half (n=25). Only 10 felt symptoms exclusively during the sport session. Moreover, a medical advice for recent symptoms was found only for 3 subjects. Three patients who experienced prior AMI have neglected symptoms during the index event. Most were ST segment elevated MI (n=35). Only one patient (with OH-SCA) died &amp;lt;3 days after hospital admission. During hospitalization, most underwent revascularization with coronary stenting (n=44) (drug eluting stent in 43 patients), or coronary artery bypass graft (n=6) and no death nor significant CV event occurred. At 1-FU, most attended a rehabilitation program (n=41) and the majority of smokers quitted (14/17), with 3 persistent smokers starting to vape. Almost half patients (n=23) decreased their physical activity, and 21 increased it. A significant rate of patient (n=9) added fitness in their usual activity, and as a main sport for 4 of them. Conclusions In this on-going monocentric prospective survey in SR-AMI, a high proportion of subjects had prodromal symptoms, of whom only few led to sport cessation and medical advices, when requested, failed to prevent the AMI. Our findings highlight that public and medical education are urgently warranted for SR-AMI prevention. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon Bourgogne Franche Comté et ARS Bourgogne Franche Comté