Recent Acute Myocardial Infarction Research Articles

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

The impact of the 2019 ESC/EAS dyslipidaemia guidelines on real-world initial lipid-lowering therapy in patients with acute myocardial infarction.

This study aimed to investigate the impact of the latest guidelines on the real-world clinical practice of initial lipid-lowering therapy, especially on the use of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in China. All adult patients diagnosed with acute myocardial infarction in our hospital between August 31, 2018, and August 31, 2020, were divided into the following 2 groups: those patients treated before the latest guideline release, and those patients treated after the release. A propensity score-matched method was used, and logistic regression was used to assess the association with intensive statin, ezetimibe and PCSK9 inhibitor usage together with treatment results between the 2 groups. A total of 325 patients were enrolled in this study, including 141 patients who were admitted before the release of the latest guideline and 184 patients who were admitted after the release. After a median follow-up time of 8.20 months, the mean low-density lipoprotein cholesterol was 1.87 ± 0.59 mmol/L (1.87 ± 0.55 in the before group vs 1.88 ± 0.62 in the after group, P = .829). After propensity score matching, the initial usage of intensive statin therapy was decreased after guideline release without statistical significance (17.00% vs 28.00%, P = .090), whereas the usage of ezetimibe and PCSK9 inhibitors was increased (19.00% vs 8.00%, P = .039; and 10.00% vs 3.00%, P = .085, respectively). In logistic regression models, the release of the guideline was associated with a statistically significantly increased use of ezetimibe (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.21, 3.02; P = .005), a marginally decreased use of intensive statins (OR: 0.68; 95% CI: 0.45, 1.03; P = .069) and a marginally increased use of PCSK9 inhibitors (OR: 1.31; 95% CI: 0.98, 1.76; P = .068). In this single-center, real-world data analysis, after the release of the 2019 European Society of Cardiology/European Atherosclerosis Society guidelines, an increasing number of patients with a recent acute myocardial infarction were initially receiving ezetimibe and PCSK9 inhibitors.

Differences in Attitudes and Barriers Towards Advance Care Planning Amongst Ischemic Heart Disease Patients: A Cross-Sectional Study.

Perceptions towards advanced care planning (ACP) amongst individuals with Ischemic Heart Disease before or after a life-threatening Acute Myocardial Infarction event is underexamined and could impact the appropriate timing for ACP advocacy. This cross-sectional study assessed awareness and intentions regarding ACP in individuals with Ischemic Heart Disease, both before and after an Acute Myocardial Infarction, and explored the motivating effect of a near-fatal Acute Myocardial Infarction event on its engagement. This study was conducted from 24 August 2021 through 13 March 2023, whereby patients were administered a one-time questionnaire with no follow-up required. Patients with either chronic Ischemic Heart Disease (group A) or a recent Acute Myocardial Infarction event (group B) were recruited from the outpatient National University Heart Centre, Singapore. 101 patients (n = 51 for Group A, n = 50 for Group B) were recruited. Mean age (SD) was 59 (10.5) years and 84 were male (83.2%). Between both groups, patients in group B reported significantly higher scores on 'Lack of information' and 'Self-efficacy' domains, and had no ACP awareness nor plans of doing an ACP compared to group A. ACP awareness was the sole significant predictor of intentions of doing an ACP in the final regression model (P < .05). Interestingly, this study suggests that surviving a potentially life-threatening heart condition did not result in higher intention of doing an ACP. Thus, advocacy of ACP in the community should simply start by raising awareness levels widely and may not need to be focused on individuals' state of health.

Use of Sodium-Glucose Co-transporter-2 Inhibitors after Acute Myocardial Infarction

Use of Sodium-Glucose Co-transporter-2 Inhibitors after Acute Myocardial Infarction

Use of polypill to improve therapeutic adherence and outcomes in adults with recent acute myocardial infarction: is it an effective strategy?

Use of polypill to improve therapeutic adherence and outcomes in adults with recent acute myocardial infarction: is it an effective strategy?

Computed tomography plaque analysis identifies residual inflammation in recent acute myocardial infarction patients

Abstract Introduction Residual inflammatory risk (RIR) following acute myocardial infarction (AMI) patients is associated with recurrent major adverse cardiovascular events. Atherosclerotic plaque quantification using computed tomographic coronary angiography (CTCA) can specifically identify inflamed plaque characteristics. We compared plaque burden and tissue composition in AMI patients with those of stable coronary artery disease (CAD) patients to identify imaging markers of RIR. Purpose We aimed to identify signs of residual inflammation in recent AMI patients via CTCA atheroma quantification. We hypothesised that recent AMI patients have plaque characteristics suggestive of inflammation. Methods 108 patients recruited from multiple sites with AMI &amp;lt;1 month were propensity-matched via CAD risk factors (age, gender, diabetes, hypertension, hyperlipidaemia, smoking and family history of CAD) with stable CAD patients in a 1:1 ratio. Propensity matched recent AMI and stable CAD patient cohorts had similar profiles: age (60±9.7 vs 57±10.0 years), gender (91.7% vs 92.6% male), diabetes (13.9% vs 15.7%), hypertension (44.4% vs 50.9%) and hyperlipidaemia (50.9% vs 63.9%, p&amp;gt;0.05 for all). Total plaque burden (total lesion volume/total vessel volume) and plaque composition (fibrous fatty [fibrofatty, FF, 31 – 130 HU], necrotic core [NC, -30 – 30 HU], fibrous [131 – 350 HU] and calcium [&amp;gt; 350 HU]) were extracted from CTCA scans and aggregated per patient. Culprit lesions of recent AMI patients were excluded from the analysis due to the fact that coronary stents would affect plaque characterisation. Multivariate linear regression, corrected for CAD risk factors, was used to compare these parameters between the two cohorts. Results Recent AMI patients and stable CAD patients had similar total plaque burden (β=0.001±0.013, p=0.950, Figure 1a). Patients with recent AMI had higher non-calcified plaque volume ratio (β=0.071±0.026, p&amp;lt;0.05, Figure 1b) due to higher FF (β=0.094±0.019, Figure 1d) and NC (β=0.025 ± 0.005, Figure 1e) plaque volume (p&amp;lt;0.05 for all), but less fibrous plaque volume (β = -0.048±0.019, p&amp;lt;0.05, Figure 1c). Conclusions Recent AMI patients had a greater non-calcified plaque burden than stable CAD patients due to larger FF and NC plaque burden. Since FF and NC components indicate ongoing inflammation in the plaque, while fibrous content indicates resolved inflammation; increased NC and FF burden suggest increased coronary plaque inflammation in non-culprit lesions of recent AMI patients, supporting the presence of residual inflammation in recent AMI patients.Figure 1

Abstract 16764: Changes in Triglyceride Levels During Omega-3 Fatty Acid Supplementation, and Incident Cardiovascular Events: Secondary Analysis From the OMEMI Trial

Background: Elevated triglyceride levels are associated with increased cardiovascular risk. Omega-3 polyunsaturated fatty acids (n-3PUFA) are known to reduce triglyceride levels, but whether changes in triglycerides mediate any cardiovascular effects of n-3PUFA, remains unclear. Methods: In the randomized controlled OMEMI trial, 1014 elderly (70-82 years) patients with a recent acute myocardial infarction (AMI) were treated with 1.8 g/day of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or placebo (corn oil) for two years, and followed for the primary outcome of MACE (AMI, coronary revascularization, stroke, heart failure hospitalization or all-cause death). Relative changes in triglycerides from baseline to 3 months (n=920, 91%), were associated with incident MACE (N=175) using landmark Cox regression models. Results: The median (Q1-Q3) baseline triglyceride concentration was 97 (74-135) mg/dL, and higher levels were associated with higher BMI, diabetes and heart failure, in multivariable models. After 3 months of treatment, triglycerides decreased by median -10% and 0% in the n-3PUFA and placebo groups, respectively, followed by relatively stable levels at 12 and 24 months ( Figure ). Greater triglyceride reductions at 3-months were associated with a lower risk of MACE in the n-3PUFA group (HR 1.98 [95%CI 1.23-3.17] per doubling, p=0.004; Figure ), and this persisted after adjusting for baseline triglycerides, age, sex, BMI and comorbidities (HR 2.34 [1.37-3.98], p=0.002). Changes in triglycerides did not associate with MACE in the placebo group (HR 1.13 [0.63-2.02], p=0.68). Conclusion: Treatment with 1.8 g/day of EPA/DHA modestly reduced triglyceride levels and greater on-treatment triglyceride-reductions were associated with a lower risk of MACE. Although the overall OMEMI-trial was neutral, these findings suggest that n-3PUFA-related triglyceride changes may play a role with respect to cardiovascular outcomes.

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.

Temporal Changes in Coronary 18F-Fluoride Plaque Uptake in Patients with Coronary Atherosclerosis.

Coronary 18F-sodium fluoride (18F-fluoride) uptake is a marker of both atherosclerotic disease activity and disease progression. It is currently unknown whether there are rapid temporal changes in coronary 18F-fluoride uptake and whether these are more marked in those with clinically unstable coronary artery disease. This study aimed to determine the natural history of coronary 18F-fluoride uptake over 12 mo in patients with either advanced chronic coronary artery disease or a recent myocardial infarction. Methods: Patients with established multivessel coronary artery disease and either chronic disease or a recent acute myocardial infarction underwent coronary 18F-fluoride PET and CT angiography, which was repeated at 3, 6, or 12 mo. Coronary 18F-fluoride uptake was assessed in each vessel by measuring the coronary microcalcification activity (CMA). Coronary calcification was quantified by measuring calcium score, mass, and volume. Results: Fifty-nine patients had chronic coronary artery disease (median age, 68 y; 93% male), and 52 patients had a recent myocardial infarction (median age, 65 y; 83% male). Reflecting the greater burden of coronary artery disease, baseline CMA values were higher in those with chronic coronary artery disease. Coronary 18F-fluoride uptake (CMA > 0) was associated with higher baseline calcium scores (294 Agatston units [AU] [interquartile range, 116-483 AU] vs. 72 AU [interquartile range, 8-222 AU]; P < 0.001) and more rapid progression of coronary calcification scores (39 AU [interquartile range, 10-82 AU] vs. 12 AU [interquartile range, 1-36 AU]; P < 0.001) than was the absence of uptake (CMA = 0). Coronary 18F-fluoride uptake did not markedly alter over the course of 3, 6, or 12 mo in patients with either chronic coronary artery disease or a recent myocardial infarction. Conclusion: Coronary 18F-fluoride uptake is associated with the severity and progression of coronary artery disease but does not undergo a rapid dynamic change in patients with chronic or unstable coronary artery disease. This finding suggests that coronary 18F-fluoride uptake is a temporally stable marker of established and progressive disease.

High-risk Plaque Features Identify Residual Inflammation In Patients With Recent Acute Myocardial Infarction

High-risk Plaque Features Identify Residual Inflammation In Patients With Recent Acute Myocardial Infarction

Cardiac fibroblast activation after acute myocardial infarction: pilot study using technetium 99m-iFAP SPECT

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Instituto Nacional de Investigaciones Nucleares (ININ). Background/Introduction Excessive fibrosis and persistent active fibroblasts can lead to increased left ventricular stiffness and, thus, heart failure. Cardiac remodeling is an important factor in the prognosis of patients after an acute myocardial infarction (AMI), and fibroblast activation is mandatory for repair and regeneration of the damage. There's an increasing use of molecular imaging in cardiovascular processes, such as molecules targeting fibroblast activation protein (FAP). FAP inhibitors (iFAP) radiolabeled with 68Ga in PET/CT have demonstrated adequate biodistribution and high uptake by activated fibroblasts in patients with cardiovascular risk factors and after acute myocardial infarction. Unfortunately, PET is not always widely available or cost-effective. Purpose This pilot study evaluates the feasibility of imaging activated fibroblast using 99mTc-iFAP SPECT in patients after AMI and its correlation with myocardial perfusion imaging (MPI), cardiac magnetic resonance (CMR) and invasive coronary angiography (ICA). Methods A prospective study with recent first AMI and non-previous known coronary artery disease patients were included. They underwent 99mTc-MIBI MPI SPECT and 99mTc-iFAP SPECT (including whole-body scan and thorax anterior static image acquired at 20, 60, and 120 min for the iFAP) and CMR/ICA within 14 days (+-2) after AMI. Qualitative and quantitative analysis was performed using a 17 segments model using QPS (Cedars Sinai) to determine the infarct extension from MPI and the correlation with the 99mTc-iFAP uptake pattern. A visual grading scale was established to assess localized tracer uptake and segments belonging to the hypoperfused area of the culprit's vessel. CMR yielded an area of injury with late gadolinium enhancement (LGE) and correlated with MPI studies. Results Five patients with STEMI were included (mean age of 63). Localized uptake of 99mTc-iFAP was observed in all patients with according to the affected coronary territory detected by ICA in 100% of patients (four anterior STEMI, one inferior STEMI). No radiotracer uptake was observed in the non-infarcted territories. Agreement between myocardial iFAP uptake, MIBI myocardial perfusion defect, CMR LGE, and ICA findings are presented in figure 1. An agreement of mismatch in polar maps between iFAP and MPI was performed, obtaining an excellent mismatch pattern in all patients, especially in transmural infarct segments. The best quality image was obtained at 60 minutes. Conclusions We successfully carried out the first pilot study with the patented 99mTc-iFAP molecule with SPECT technique. 99mTc-iFAP is a promising novel biomarker in assessing myocardial injury in sites where PET/CT is unavailable. There is an excellent correlation between iFAP uptake with the perfusion defect, LGE, and invasive anatomical obstruction findings. It is feasible and necessary to extend the inclusion of patients to a larger sample.

New Perspectives on Treatment of Depression in Coronary Heart Disease.

It has been 35 years since we published a study in Psychosomatic Medicine showing that patients with coronary heart disease (CHD) and major depression were at twice the risk of having a cardiac event as were nondepressed patients (Carney et al. Psychosom Med. 1988;50:627-33). This small study was followed a few years later by a larger, more convincing report from Frasure-Smith et al. (JAMA. 1993;270:1819-25) showing that depression increased the rate of mortality in patients with a recent acute myocardial infarction. Since the 1990s, there have been many more studies of depression as a risk factor for cardiac events and cardiac-related mortality from all over the world, and many clinical trials designed to determine whether treating depression improves medical outcomes in these patients. Unfortunately, the effects of depression treatment in patients with CHD remain unclear. This article considers why it has been difficult to determine whether treatment of depression improves survival in these patients. It also proposes several lines of research to address this question, with the goal of definitively establishing whether treating depression can extend cardiac event-free survival and enhance quality of life in patients with CHD.

P137 STEMI IN YOUNG MAN: A "CHALLENGE" CASE OF SPONTANEOUS CORONARY DISSECTION

Abstract A 21–years old male patient presented to the emergency department complaining chest pain in the night. There was no family history of cardiovascular events; he did not have any known risk factors and denied drug abuse. Pathological history was positive for allergic asthma. On admission, he was paucisyntomatic. The physical examination was normal. Blood pressure was slightly elevated. The EKG showed sinus rhythm, ST segment elevation in high lateral leads and reciprocal ST depression in inferior leads. The echocardiogram showed anterolateral and mid–apical septal akinesia of the left ventricle with ejection fraction of 45%. The urgent coronary angiography showed suspected coronary artery dissection of the first diagonal branch with TIMI flow grade 2 and myocardial brigde of the middle segment of the left anterior descending artery (fig.1). An initial conservative management with beta–blockers, dual antiplatelet therapy, statin and ACE–inhibitors was adopted: the patient was asymptomatic and the EKG became normal during the coronary angiography. In addition the young age, the suspicion of Spontaneous Coronary Artery Dissection (SCAD) and TIMI flow grade 2 in the culpit vessel provided support of conservative treatment. The hospital stay was unremarkable. Troponin T peak value was 1542 pg/ml (n.v. &amp;lt; 13 pg/ml). Thrombophilia screening showed mild hyperhomocysteinemia and homozygous MTHFR mutation. Autoimmunity screening was negative. The subsequent echocardiogram showed mid–distal hypokinesia of the anterolateral, inferolateral and anterior wall of the left ventricle with normal ejection fraction. The CT angiography of the cerebral and abdominal vessels was normal. The cardiac magnetic resonance imaging (MRI) confirmed a recent acute myocardial infarction of the mid–apical portions of the anterior and anterolateral wall and normal global contractile function of the left ventricle (fig. 2, 3). At 30 days follow up, the echocardiogram remained unchanged; the coronary AngioCT scan confirmed the dissection of the ostium and proximal section of the first diagonal branch; the cardiac MRI showed transmural fibrosis of the anterolateral wall with normal left ventricular ejection fraction. SCAD is an under–reported pathology. It can lead to acute coronary syndromes and life–threatening consequences. Diagnosis and treatment are still under debate. The presented clinical case, effectively treated with conservative therapy, represented a "challenge" in the acute phase.

CENtral blood pressure Targeting: a pragmatic RAndomized triaL in advanced Chronic Kidney Disease (CENTRAL-CKD): A Clinical Research Protocol.

Emerging data favor central blood pressure (BP) over brachial cuff BP to predict cardiovascular and kidney events, as central BP more closely relates to the true aortic BP. Considering that patients with advanced chronic kidney disease (CKD) are at high cardiovascular risk and can have unreliable brachial cuff BP measurements (due to high arterial stiffness), this population could benefit the most from hypertension management using central BP measurements. To assess the feasibility and efficacy of targeting central BP as opposed to brachial BP in patients with CKD G4-5. Pragmatic multicentre double-blinded randomized controlled pilot trial. Seven large academic advanced kidney care clinics across Canada. A total of 116 adults with CKD G4-5 (estimated glomerular filtration rate [eGFR] < 30 mL/min) and brachial cuff systolic BP between 120 and 160 mm Hg. The key exclusion criteria are 1) ≥ 5 BP drugs, 2) recent acute kidney injury, myocardial infarction, stroke, heart failure or injurious fall, 3) previous kidney replacement therapy. Double-blind randomization to a central or a brachial cuff systolic BP target (both < 130 mm Hg) as measured by a validated central BP device. The study duration is 12 months with follow-up visits every 2 to 4 months, based on local practice. All other aspects of CKD management are at the discretion of the attending nephrologist. Primary Feasibility: Feasibility of a large-scale trial based on predefined components. Primary Efficacy: Carotid-femoral pulse wave velocity at 12 months. Others: Efficacy (eGFR decline, albuminuria, BP drugs, and quality of life); Events (major adverse cardiovascular events, CKD progression, hospitalization, mortality); Safety (low BP events and acute kidney injury). May be challenging to distinguish whether central BP is truly different from brachial BP to the point of significantly influencing treatment decisions. Therapeutic inertia may be a barrier to successfully completing a randomized trial in a population of CKD G4-5. These 2 aspects will be evaluated in the feasibility assessment of the trial. This is the first trial to evaluate the feasibility and efficacy of using central BP to manage hypertension in advanced CKD, paving the way to a future large-scale trial. clinicaltrials.gov (NCT05163158).

Abstract 11881: Association of Post-Vaccination Adverse Reactions After Influenza Vaccine With Mortality and Cardiopulmonary Outcomes in Patients With High-Risk Cardiovascular Disease: The INVESTED Trial

Introduction: Influenza vaccination is associated with reduced cardiopulmonary morbidity and mortality among patients with heart failure or recent myocardial infarction. The immune response to vaccination frequently results in mild adverse reactions (AR), which leads to vaccine hesitancy. We assessed the association between vaccine-related AR and morbidity and mortality in patients with high-risk cardiovascular disease. Methods: The INVESTED trial randomized 5260 patients with recent acute myocardial infarction or heart failure hospitalization to high-dose trivalent or standard-dose quadrivalent inactivated influenza vaccine. We examined the association between vaccine-related AR and adverse clinical outcomes in propensity-adjusted models. Results: Overall, 1968 participants (37.4%) experienced a vaccine-related AR. Compared to those without AR, post-vaccination AR, most commonly injection site pain (60.3%), were associated with lower adjusted risk for the composite of all-cause death or cardiopulmonary hospitalization, cardiopulmonary hospitalizations, all-cause death, cardiovascular hospitalizations and non-cardiopulmonary hospitalizations (Figure 1; Table 1). Conclusions: Post-vaccination reactions after influenza vaccine were associated with reduced risk of cardiopulmonary hospitalizations and all-cause mortality in patients with high-risk cardiovascular disease in propensity adjusted models, and may be a marker of a better immune response or overall health status, and should not deter future vaccinations.

Association of post-vaccination adverse reactions after influenza vaccine with mortality and cardiopulmonary outcomes in patients with high-risk cardiovascular disease: the INVESTED trial.

Influenza vaccination is associated with reduced cardiopulmonary morbidity and mortality among patients with heart failure or recent myocardial infarction. The immune response to vaccination frequently results in mild adverse reactions (AR), which leads to vaccine hesitancy. This post hoc analysis explored the association between vaccine-related AR and morbidity and mortality in patients with high-risk cardiovascular disease. The INVESTED trial randomized 5260 patients with recent heart failure hospitalization or acute myocardial infarction to high-dose trivalent or standard-dose quadrivalent inactivated influenza vaccine. We examined the association between vaccine-related AR and adverse clinical outcomes across both treatment groups in propensity-adjusted models. Among 5210 participants with available information on post-vaccination symptoms, 1968 participants (37.8%) experienced a vaccine-related AR. Compared to those without AR, post-vaccination AR, most commonly injection site pain (60.3%), were associated with lower risk for the composite of all-cause death or cardiopulmonary hospitalization (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.75-0.92, p < 0.001), cardiopulmonary hospitalizations (HR 0.85 [95% CI 0.76-0.95], p = 0.003), all-cause death (HR 0.77 [95% CI 0.62-0.96], p = 0.02), cardiovascular hospitalizations (HR 0.88 [95% CI 0.78-0.99], p = 0.03) and non-cardiopulmonary hospitalizations (HR 0.80 [95% CI 0.69-0.92], p = 0.003). While mild (76.4%) and moderate (20.6%) AR were most common and together associated with lower risk for the primary outcome (HR 0.81 [95% CI 0.74-0.90], p < 0.001), severe AR (2.9%) were related to increased risk (HR 1.68 [95% CI 1.17-2.42], p = 0.005). Mild to moderate post-vaccination reactions after influenza vaccine were associated with reduced risk of cardiopulmonary hospitalizations and all-cause mortality in patients with high-risk cardiovascular disease, while severe reactions may indicate increased risk. Mild to moderate AR to influenza vaccination may be a marker of immune response and should not deter future vaccinations.

The Correlation between the Triglyceride-Glucose Index and Coagulation Markers in Patients with Recent Acute Myocardial Infarction.

Background Metabolic abnormalities and hypercoagulability seem to have an important predictive role in patients with coronary artery disease (CAD). The triglyceride-glucose (TyG) index has emerged as a good marker for metabolic syndrome with predictive value for cardiovascular events. Overall haemostatic potential (OHP) is a reliable global haemostatic essay to identify hypercoagulability in CAD patients. The aim of our study was therefore to evaluate a possible correlation between the TyG index and haemostatic derangements in patients with CAD. Methods Consecutive patients referred for the first follow-up visit after acute myocardial infarction between December 1, 2018, and March 31, 2020, and did not meet exclusion criteria were included. We determined OHP, overall coagulation potential (OCP), overall fibrinolytic potential (OFP), fibrinogen, D-dimer, and von Willebrand factor from peripheral blood samples. The TyG index was calculated with the previously described and validated formula. Linear regression models were constructed for the multivariate analysis. Results A total of 117 patients (mean age 56 ± 10 years, 20% women) were included. A correlation was found between TyG index and OCP (r = 0.229, p = 0.026), TyG index and OHP (r = 0.202, p = 0.050), and TyG index and fibrinogen (r = 0.271, p = 0.005). In the multivariate model which accounted for sex, age, and BMI, the correlation between TyG index and OCP (R2 0.108; ANOVA for regression p = 0.035; beta 2.08 [0.79-4.01], p = 0.042) and between TyG index and fibrinogen (R2 0.11; ANOVA for regression p = 0.015; beta 0.35 [0.08-0.62], p = 0.012) emerged as statistically significant. Conclusion The TyG index, a marker of metabolic syndrome, has a strong correlation with a hypercoagulability state in CAD, as determined by the OCP and higher fibrinogen levels. Our findings suggest that metabolic syndrome may be an important driver of atherothrombotic risk in patients with CAD.

Association of ischemic and bleeding events with mortality in patients with a recent acute myocardial infarction

Abstract Background/Introduction Duration and intensity of antithrombotic treatment after myocardial infarction should be individualized based on a patient's ischemic and bleeding risk [1,2]. While such strategies are typically based on calculations that give equal weight to both types of events, uncertainty remains regarding their relative importance. Purpose To describe the incidence of ischemic and bleeding events in patients with a recent myocardial infarction, to compare the association of an ischemic vs bleeding event with mortality and to assess whether this association had changed over the past two decades. Methods Patients with acute myocardial infarction enrolled in the SWEDEHEART registry and discharged alive with antithrombotic treatment (aspirin, P2Y12 inhibitor, or oral anticoagulant) from January 2012 to December 2017 were followed from discharge until an ischemic event (recurrent myocardial infarction or ischemic stroke) or bleeding event. Cox regression adjusted for demographic factors, comedications and comorbidities, was used to estimate hazard ratios (HR) for time to death after an ischemic and bleeding event as compared with no event (in a model using time-varying exposure definition) and for an ischemic vs bleeding event in a direct comparison. We then assessed whether the adjusted HR for mortality of an ischemic vs bleeding event had changed across three time-periods (1997–2000, 2001–2011 and 2012–2017) by using an interaction term between time period and type of event. Results From January 2012 until December 2017 86, 736 patients were discharged alive with antithrombotic treatment after a myocardial infarction. Of these, 4,039 patients experienced a first ischemic event (incidence rate 5.7 events per 100 person-years), and 3,399 a first bleeding event (incidence rate 4.8 events per 100 person-years). As compared with no event, both ischemic events (adjusted HR 4.16, 95% CI 3.91 to 4.43) and bleeding events (adjusted HR 3.43, 95% CI 3.17 to 3.71) were associated with an increased risk of death. In the direct comparison, ischemic events were associated with a higher risk of death than bleeding events (adjusted HR 1.27, 95% CI 1.15 to 1.40). There was no evidence of a change in the aHR across the three time periods (aHR; 1.17, 95% CI 1.02 to 1.35 in 1997–2000 and 1.18, 95% CI, 1.11 to 1.27 in 2001–2011, p for interaction between time period and type of event ≥0.646). Conclusion In this nationwide study of patients with a recent MI, post-discharge ischemic events were more common and associated with higher mortality risk as compared with bleeding events. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung FoundationSwedish Diabetes Foundation

Pressure–flow responses to exercise in aortic stenosis, mitral regurgitation and diastolic dysfunction

BackgroundHaemodynamic exercise testing is important for evaluating patients with dyspnoea on exertion and preserved ejection fraction. Despite very different pathologies, patients with pressure (aortic stenosis (AS)) and volume (mitral regurgitation...

Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy

Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. To compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. A cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. The incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. Of 86 736 patients discharged after MI in 2012-2017 (median age, 71 [IQR, 62-80] years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event. The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant difference in the aHR of an ischemic vs bleeding event in 1997-2000, 2001-2011, and 2012-2017. In this nationwide cohort study of patients with a recent MI, postdischarge ischemic events were more common and associated with higher mortality risk compared with bleeding events.