Recent Acute Myocardial Infarction Research Articles

Multimodality cardiac imaging of a left ventricular papillary fibroelastoma: a case report

BackgroundIn the setting of an acute myocardial infarction (AMI), although the most common etiology of a left ventricular (LV) mass identified on multimodality cardiovascular imaging is a thrombus, other possibilities including a vegetation or tumor should be entertained within the differential diagnosis.Case presentationWe describe a case of a 43-year-old Caucasian female post AMI diagnosed with a mid-cavitary mass within the LV. Although echocardiography and cardiovascular MRI (CMR) suggested that the mass was a thrombus, given the context of the recent AMI, exploration and surgical excision was completed by the surgeon due to the potential for the mass to embolize.ConclusionThe final diagnosis of a papillary fibroelastoma was unique due to its unusual location and large size within the LV cavity. This unique case demonstrates shortcomings of multimodality cardiac imaging in the diagnosis of an atypical mass and the importance of obtaining tissue when clinically safe and feasible.

Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative

ObjectivePostoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes. MethodsThe Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events. ResultsThe cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P < .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P < .0001; adjusted odds ratio, 5.85; P < .0001), and discharge to a nursing facility (57.8% vs 19.0%; P < .0001; adjusted odds ratio, 3.14; P < .0001). ConclusionsRAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery.

Depressive symptoms, functional measures and long-term outcomes of high-risk ST-elevated myocardial infarction patients treated by primary angioplasty.

The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10% of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors "per se" of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.

Rationale and design of Apo-I Event Reduction in Ischemic Syndromes I (AEGIS-I): A phase 2b, randomized, placebo-controlled, dose-ranging trial to investigate the safety and tolerability of CSL112, a reconstituted, infusible, human apoA-I, after acute myocardial infarction

Despite aggressive pharmacotherapy and stenting, there is a residual risk of major adverse cardiovascular events among patients with acute coronary syndrome. High-density lipoprotein (HDL) has been a major target for secondary acute coronary syndrome prevention; however, a better understanding of the physiologic function of HDL has demonstrated that a high cholesterol efflux capacity, rather than high HDL concentrations alone, may be critical to improving outcomes. CSL112, a reconstituted, infusible human apolipoprotein A-I, has been demonstrated to increase cholesterol efflux capacity and to have a protective effect in experimental models of atherosclerotic cardiovascular disease. The AEGIS-I trial (ClinicalTrials.govNCT02108262) is a phase 2b, multicenter, randomized, placebo-controlled, dose-ranging clinical trial to evaluate the hepatic and renal safety of multiple administrations of 2 doses of CSL112 among subjects with acute myocardial infarction (AMI). Approximately 1,200 subjects (400 per treatment group) with either normal renal function or mild renal impairment will be enrolled up to 7 days after an AMI and will be stratified by renal function and randomized in a 1:1:1 ratio to either 1 of 2 doses of CSL112 (either 2 g or 6 g) or placebo as a weekly 2-hour infusion over the course of 4 consecutive weeks. The coprimary safety endpoints will be the incidence of hepatic and renal toxicity, defined as either confirmed ALT >3 × ULN, total bilirubin >2 × ULN, serum creatinine ≥1.5×baseline value, or a new requirement for renal replacement therapy through the end of the active treatment period. The AEGIS-I trial will characterize the safety profile of CSL112, a reconstituted formulation of apolipoprotein A-I, and will assess if administration to patients with a recent AMI is associated with a clinically significant alteration in either liver or kidney function when compared with placebo.

Use of the Wearable Cardioverter Defibrillator in High-Risk Populations.

The United States Food and Drug Administration has approved the wearable cardioverter defibrillator (WCD) for use in patients who are at high risk for sudden cardiac arrest (SCA) and who do not yet have an established indication for an implantation cardioverter defibrillator (ICD) or have contraindications for device implantation for various reasons. The WCD is typically used for primary prevention in (1) high-risk patients with reduced left ventricular ejection fraction (LVEF) ≤35% after recent acute myocardial infarction (MI) during the 40-day ICD waiting period, (2) before and after coronary artery bypass graft or percutaneous coronary intervention during the 90-day ICD waiting period, (3) after recently diagnosed nonischemic dilated cardiomyopathy (NICM) during the 3- to 9-month medical therapy optimization period, or (4) for those with inherited proarrhythmic conditions such as long QT syndrome or hypertrophic cardiomyopathy. Unlike the automatic external defibrillator, the WCD does not require assistance from bystanders for therapy and conscious patients can delay or avert therapy with the use of response buttons. The WCD exhibits a small risk of inappropriate shock, mostly due to supraventricular tachycardia and/or electrical noise. Multiple non-randomized observational studies have shown high efficacy in detection and appropriate shock therapy for sustained ventricular tachyarrhythmias. This paper discusses the use of the WCD for prevention of SCA in patients with various cardiac substrates.

Inhibition Of COX‐2/PGE2/EP4 Signaling Protects Against Post‐hypoxic Apoptosis In H9C2 Cardiomyocytes

Myocardial infarction is a condition associated with significant mortality. Reperfusion therapy restores blood flow, it may also induce lethal tissue injury, known as ischemia‐reperfusion injury (IRI) in clinical practice. Thus, exploring ways to control or attenuate IRI is of clinical interest for improving post‐ischemic recovery. Cyclooxyenase‐2 (COX‐2) – which is induced during ischemia ‐ is highly expressed at the site of recent acute myocardial infarction (Heart. 2004;90:440–443). Furthermore, the presence of COX‐2 is positively correlated with progressively increased apoptosis which played a central role in the pathophysiology of IRI. However, whether there is causal link or underlying signaling cascade between ischemia‐driven COX‐2 expression and apoptosis in IRI is unclear. Thus, the present study aimed to investigate the molecular basis of potential cause‐effect link between COX‐2 expression and enhanced apoptosis during ischemia using rat origin cardiomyocytes (H9C2) subjected to hypoxia/reoxygenation (H/R, 6 hours hypoxia followed by 12 hours reoxygenation). The results showed that H/R significantly increased the protein expression of COX‐2 (P&lt;0.05 vs. Control), which was prevented by 2 hours pretreatment with Helenalin (NFkB inhibitor, at 10μM, P&lt;0.05 vs. H/R) but not by pretreatment with SC‐205346A [Hypoxia inducible factor alpha (HIF‐1α) inhibitor, at 20μM]. This suggests that NFkB but not HIF‐1α mediated the expression of COX‐2 during H/R in H9C2 cardiomyocytes. Further, under the experimental setting, H/R induced H9C2 cells damage [evidenced by increased lactic acid dehydrogenase (LDH) leakage (marker of cell injury, P&lt;0.05 vs. Control)] was concomitant with increased cleaved caspase‐3 expression (marker of cell apoptosis, P&lt;0.05 vs. Control) but no changes in the protein expressions of the anti‐apoptotic Bcl‐2 and pro‐apoptotic Bax, suggesting that H/R induced caspase‐3 dependent cell apoptosis which was independent of the intrinsic mitochondrial pathway. Pretreat the cells with NS398 (COX‐2 selective inhibitor, at 10μM, 1 hour) or L161,982 [prostaglandin E receptor subtype 4 (EP4) selective antagonist, at 100nM, 1 hour] suppressed the H/R induced increases of LDH leakage and cleaved caspase‐3 expression (P&lt;0.05 vs. H/R), indicating that both COX‐2 and EP4 mediated cell apoptosis during H/R. Given that prostaglandin E2 (PGE2) is a major metabolite of COX‐2 and an endogenous ligand of EP4 receptor, H9C2 cardiomyocytes were exposed to exogenous PGE2 (from 5nM to 50μM, 18 hours) in a concentration dependent manner. As anticipated, PGE2, at a high concentration (50μM), significantly increased cellular injury as evidenced by enhanced LDH leakage (P&lt;0.05 vs. Control). It is concluded that H/R may induce cardiomyocytes apoptosis via NFkB/COX‐2/PGE2/EP4 signaling, which may serve as a novel target for anti‐ischemic therapy.Support or Funding InformationThis study was supported by General Research Fund (17124614, and 17123915) from the Research Grants Council of Hong Kong and by National Natural Science Foundation of China (NSFC 81270899).

Delineation of QRS offset by instantaneous changes in ECG vector angle can improve detection of acute inferior myocardial infarctions

We developed an automated new method for determining QRS offset, based on angular velocity (AV) changes around the QRS loop, and compared the method's performance to that of manual and more established automated methods for determining QRS offset in both healthy subjects and patients with acute myocardial infarction (AMI). Specifically, using Frank leads reconstructed from standard 12-lead ECGs, we determined AV in the direction of change raised to the 4th power, d(t). We found that the d(t)-determined AV transition (ΔAV) nearly coincided with manually determined QRS offset in healthy subjects, and in 27 patients with anterior AMI. However, in 31 patients with inferior AMI, ΔAV typically preceded that of QRS offset determined by the established automated methods, and by more than 10ms in 32% of cases. While this “ΔAV precedence” coincided with diagnostic ST elevation in only a minority of patients with recent inferior AMI, the use of ΔAV precedence as a complement to traditional determination of ST elevation increased the sensitivity for detecting inferior AMIs from 23 to 42%.

R-COMP Regimen in B Cell Non Hodgkin Lymphoma Patients with Cardiovascular Comorbidities

Backgroung: Anthracyclines-based regimens remain the gold standard for the treatment of Lymphomas, although the associated cardiac toxicity may limit their use, especially in frail and elderly patients.Patients and Methods: From October 2008 to January 2015 we treated 51 newly diagnosed patients B cell with poor-risk non Hodgkin lymphoma and cardiovascular comorbidities using the R-COMP regimen (rituximab, cyclophosphamide, non-pegylated liposome-encapsulated doxorubicin, vincristine and prednisone). Median age was 72 years (range:46-82 yrs ; 62% ≥ 70 years). As for histology, 26/51 (50%) were Diffuse Large B-cell Lymphoma; 10/51 (20%) Follicular Lymphoma; 8/51 (16%)mantle cell lymphoma; 5/51 (10%) Nodal Marginal Zone Lymphoma; 2/51 (4%) other B-cell indolent Lymphoma. IPI and FLIPI prognostic scores were Intermediate to High in the majority (39/51 = 76%) of the patients. Stage III and IV according to Ann-Arbor staging system was present in 40/51 patients (78%). The median age adjusted Charlsons comorbidity index was 6 (range: 3 to 11). Cardiovascular risk factors were considered: hypertension (39/51pts = 76%), a history or recent acute myocardial infarction (9/51 pts = 17%) and Atrial fibrillation (4/51 = 8%). According to National Institute of Aging/National Cancer Institute (NIA/NCI index), a large portion of patients (39%) presented high-impact conditions mainly consisting of ischemic and arrhythmic diseases, under active treatment. Treatment was well tolerated and toxicities were limited grade III/IV cytopenia.RESULTS: Complete remission was achieved in 37/51 (72%) and partial response in 8/51 (15%). The remaining 12% of patients had a progressive disease . As of July 2015, after a median follow up period of 25 months (range 3-79), the OS, RD, EFS, TTF were not reached ( Figure 1, panel A,B,C respectively). In particular, at 5 years from the treatment starting, OS and RD are both 70% and EFS is 54% .Cardiac toxicity was observed in one patients who died for pulmonary edema, while two patients developed arrhythmias.Conclusions: This study confirm the efficacy and tolerability of R-COMP regimen in elderly patients with cardiovascular comorbidities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Abstract 13428: Unveiling the Predictive Mechanisms of Care-seeking Delay in Patients With Acute Myocardial Infarction

Introduction: Despite decades of research has been conducted to examine the phenomenon of care-seeking delay in patients with acute myocardial infarction (AMI), such delay remains the most significant limiting factor for effective disease management. Objectives: This study aimed to develop and test an integrative theoretical model to unveil the predictive mechanism for explaining the care-seeking behaviors of patients who experiencing an attack of AMI. Methods: Based on several major theories which explain the illness behaviors of patients with chronic diseases and the research evidence on the care-seeking behaviors of AMI patients, we hypothesized that AMI patients’ care-seeking decision was determined by two sequential perceptual-cognitive processes and the immediate context of symptom occurrence. A total of 301 patients with a recent AMI were recruited from the cardiac units of three regional hospitals in Hong Kong. Structural equation modeling was used to test the validity of the hypothesized model. Results: The results indicated the decision-making process of AMI patients was driven by two sequential perceptual-cognitive processes, by which a successful action relied on whether the patients could correctly attribute the symptoms to AMI. Such correct symptom attribution depended upon whether they were aware of their own susceptibility to this condition and had a good understanding about the nature of the disease manifestation. A perception of severe illness consequences and the associated negative emotional arousal motivated patients to seek care. The immediate context in which the symptoms occurred also played a role in influencing their decision making, with the favorable roles of lower level of perceived barriers to seek care and positive cues from others in advising care-seeking. This model explained 46% of the variance of care-seeking behaviors with a good data-model fit (χ2 = 38.48, df=30, p=0.72; RMSEA=0.03, NFI=0.96, NNFI=0.98 and CFI=0.99). Conclusions: The integrative theoretical model is valid to explain the care-seeking decisions in AMI patients. This model provides important insights to inform the development of innovative empowerment strategies to enhance appropriate care-seeking decisions and behaviors among AMI patients.

Usefulness of two-dimensional longitudinal strain pattern to predict left ventricular recovery and in-hospital complications after acute anterior myocardial infarction treated successfully by primary angioplasty.

The aim of this study was to test the usefulness of two-dimensional longitudinal strain pattern in segments with wall motion abnormalities to predict left ventricular recovery and in-hospital cardiac events as well as coronary microvascular impairment (CMI) in patients with recent acute anterior myocardial infarction. Forty-nine consecutive patients with acute myocardial infarction (mean age, 59±13years) treated successfully with primary coronary angioplasty prospectively underwent transthoracic Doppler echocardiography 24hours after angioplasty and during follow-up (6months). A two-dimensional strain analysis, including measurement of the duration of systolic lengthening expressed as a percentage of systolic duration (SL % duration), the lengthening-to-shortening ratio, the postsystolic shortening index in segments with wall motion abnormalities, and global longitudinal strain and left anterior descending coronary artery territory strain, was performed. Cardiac events were defined as a composite of death, reinfarction, and heart failure. CMI was assessed noninvasively by transthoracic Doppler left anterior descending coronary artery investigation <24h after angioplasty and was defined as coronary flow velocity reserve<1.7 and/or a no-reflow pattern (mean coronary flow velocity reserve, 1.8±0.6 in the whole group). At the segmental level, SL % duration, lengthening-to-shortening ratio, and postsystolic shortening index were correlated with recovery (defined as normalization of wall motion abnormalities), whereas in multivariate analysis, only SL % duration independently predicted recovery (threshold level, 40%; area under the curve, 0.76; P<.01). At the patient level, in univariate analysis, SL % duration, global longitudinal strain, left anterior descending coronary artery territory strain, and troponin peak were correlated with recovery (defined as an absolute improvement of left ventricular ejection fraction of >5%). In multivariate analysis, SL % duration was independently related to recovery (area under the curve, 0.78; P<.01). Furthermore, SL % duration was independently linked to cardiac events (n=13) and CMI (n=24) (P<.01 for all). In patients with AMI treated by primary angioplasty, two-dimensional strain predicts left ventricular recovery independently of more traditional parameters and is independently linked to cardiac events and CMI.

Dilemma in timing of delivery in a patient with an acute myocardial infarction.

Introduction. Acute myocardial infarction (AMI) in a pregnant woman is rare. When occurring, AMI is a major cause of maternal and neonatal death. By presenting the following case we describe the dilemma concerning the timing of delivery. Case. A 36-year-old, multiparous women, at 35 6/7 weeks of gestation, suffered from an AMI due to an acute blockage of the left anterior descending artery (LAD). This was treated by angiographic thrombosuction and biodegradable stent placement. Within 5 hours after this procedure, a cesarean section (CS) was performed because of a nonreassuring fetal condition. A healthy son with an Apgar score of 9/10 was born. The patient's postoperative course was complicated by a big wound hematoma, a hemoglobin drop, and heart failure. Discussion. In case of AMI during pregnancy, the cardiological management has absolute priority. The obstetrical management is not outlined. In a nonreassuring fetal condition, delivery is indicated after stabilization of the mother. However, delivery after recent AMI and angiography will bring new risks of cardiologic stress and bleeding complications. The limited literature available tends to an expectant obstetrical management, but this case emphasizes the difficulty of waiting in suspected fetal distress.

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes.

IntroductionThere is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients.MethodsFrom 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups.ResultsNo significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps.ConclusionsThe use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.

Su1592 The Risk of Gastrointestinal Endoscopy in the Setting of Recent Acute Myocardial Infarction

Su1592 The Risk of Gastrointestinal Endoscopy in the Setting of Recent Acute Myocardial Infarction

Multiple coronary plaque ruptures in a patient with a recent ST-elevation acute myocardial infarction causing recurrent coronary instability

Multiple plaque instability has been reported in about one-third of patients with ST elevation acute myocardial infarction (STEMI) and could be responsible for early recurrent instability after STEMI. Optical coherence tomography (OCT) is a high-resolution imaging technique that may help in detection and characterization of unstable coronary plaques. We present a case of multiple coronary instability in a patient with anterior STEMI where OCT has tailored an optimal diagnosis and treatment.

Ischaemic heart disease, influenza and influenza vaccination: a prospective case control study

BackgroundAbundant, indirect epidemiological evidence indicates that influenza contributes to all-cause mortality and cardiovascular hospitalisations with studies showing increases in acute myocardial infarction (AMI) and death during the influenza season.ObjectiveTo investigate...

Double patch repair for a double ventricular rupture

We describe the case of a 77-year-old woman with recent acute myocardial infarction complicated by ventricular septal defect and formation of a pseudoaneurysm, which were successfully treated surgically with a double patch repair. This case highlights the importance of early recognition of this serious complication, using clinical and echocardiographic examinations, and the various challenges encountered in surgical repair.

Detection of infarct size safety threshold for left ventricular ejection fraction impairment in acute myocardial infarction successfully treated with primary percutaneous coronary intervention

In acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention (PCI), there is a direct relationship between myocardial damage and consequent left ventricular (LV) functional impairment. It is however unclear whether there is a safety threshold below which infarct size does not significantly affect LV ejection fraction (EF). The aim of this study was to evaluate the relationship between infarct size and LVEF in AMI patients treated by successful PCI using a specific statistical approach to identify a possible safety threshold. Among patients with recent AMI submitted to perfusion gated single photon emission computed tomography (SPECT) to define the infarct size, the data of 427 subjects with sizable infarct size were considered. The relationship between infarct size and LVEF was analysed using a simple segmented regression (SSR) model and an iterative algorithm based on robust least squares (RLS) for parameter estimation. The RLS algorithm detected two break points in the SSR model, set at infarct size values of 11.0 and 51.5 %. Because the slope coefficients of the two extreme segments of the regression line were not significant, by constraining such segments to zero slope in the SSR model, the lower break point was identified at infarct size = 8 % and the upper one at 45 %. Using a rigorous statistical approach, it is possible to demonstrate that below a threshold of 8 % the infarct size apparently does not affect the LVEF and therefore a safety threshold could be set at this value. Furthermore, the same analysis suggests that the relationship between infarct size and LVEF impairment is lost for an infarct size > 45 %.

Behaviour of protein carbonyl groups in juvenile myocardial infarction

Acute myocardial infarction (AMI) is accompanied by oxidative stress, and protein oxidation is among the consequences of oxidative stress. We examined the plasma concentration of protein carbonyl groups (PC), a marker of protein oxidation, in a group of young subjects with AMI (45 men and 5 women; mean age 40.4 ± 4.8 yrs). We found a significant increase of PC (p < 0.001) in comparison with normal controls. No difference was observed between patients with AMI characterized by elevated ST segment and those without elevation of ST segment. There was no correlation between the ejection fraction and PC in the whole group nor in the subgroups of STEMI and non-STEMI patients. Subdividing the whole group of AMI patients according to the number of risk factors and the number of stenosed coronary vessels, the difference in PC level was not statistically significant among the subgroups. This study showed an increased protein oxidation in young subjects with recent AMI. Further investigation is needed to ascertain whether this can be a target of therapeutic intervention.

Interactive Associations of Depression and Sleep Apnea With Adverse Clinical Outcomes After Acute Myocardial Infarction

Depression and sleep apnea (SA) are common among patients with a recent acute myocardial infarction (AMI), and both are associated with increased risk for adverse outcomes. We tested the hypothesis that there is an interaction between them in relation to post-AMI prognosis. Participants were patients with a recent AMI, 337 of them were depressed and 379 were nondepressed, who participated in a substudy of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial. SA was identified from Holter electrocardiogram by an algorithm that detects cyclic variation of heart rate. During a median follow-up of 25 months, 83 (11.6%) patients either died or experienced a recurrent AMI and 43 (6.0%) patients died. Among 94 patients with both depression and SA, these end points occurred in 25 (26.6%) and 20 (21.3%) at 3.9- and 6.9-times higher prevalence than predicted probabilities by ENRICHD clinical risk scores (p <.001 for both). In the patients with depression alone, SA alone, or neither, the prevalence was similar to the predicted probability. Depression and SA showed significant interactions in prediction of these end points (p = .02 and p = .03). SA independently predicted these end points in patients with depression (p = .001 and p <.001) but not in those without depression (p = .84 and p = .73). Similarly, depression independently predicted these end points in patients with SA (p <.001 for both) but not in those without SA (p = .12 and p = .61). Depression and SA are interactively associated with adverse clinical outcomes after AMI. clinicaltrials.gov Identifier: NCT00313573.

Correlation between Left Ventricular Global and Regional Longitudinal Systolic Strain and Impaired Microcirculation in Patients with Acute Myocardial Infarction

We investigated the correlation between left ventricular global and regional longitudinal systolic strain (GLS and LRS) and coronary flow reserve (CFR) assessed by transthoracic echocardiography (TTE) in patients with a recent acute myocardial infarction (AMI). Furthermore, we investigated if LRS and GLS imaging is superior to conventional measures of left ventricle (LV) function. In a consecutive population of first time AMI patients, who underwent successful revascularization, we performed comprehensive TTE. GLS and LRS were obtained from the three standard apical views. Assessment of CFR by TTE was performed in a modified apical view using color Doppler guidance. The study population consisted of 183 patients (51 females) with a median age of 63 [54;70] years. Eighty-nine (49%) patients had a non-ST elevation myocardial infarction and 94 (51%) patients had a ST elevation myocardial infarction. The GLS was -15.2 [-19.3;-10.1]% in the total population of 183 patients. Total wall motion score index (WMSI) in the population was 1.19 [1;1.5]. Eighty-five patients suffered from culprit lesion in left anterior descending artery (LAD). The CFR in these patients was 1.86 [1.36;2.35] and the GLS was -14.3 [-18.9; -9.8]%. A significant difference was observed in the LRS in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (-9.6 [-13.77;-6.44]) compared with the LRS in LAD territory in culprit LAD infarction patients with a CFR > 2 (-19.33 [-21.1;-16.5]), P < 0.0001. We found no significant difference between WMSI in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (1.56 [1.06;2.23]) compared with WMSI in LAD territory in culprit LAD infarction patients with a CFR > 2 (1.37 [1.03;2.11]); P = 0.18. The same pattern was observed in both circumflex coronary artery (CX) and right coronary artery (RCA) territories. In the total population, we found a strong correlation between CFR and GLS (r = -0.85, P < 0.0001). This was also seen in the multivariate regression model adjusting for possible confounders including WMSI (P < 0.001). In this study, we have shown a close association between myocardial deformation in patients with a recent AMI and the degree of diminished microcirculation. We found that both GLS and LRS correlated with CFR. We conclude that GLS and LRS are significantly better tools to assess impaired CFR and LV function after a recent AMI, than conventional echocardiographic measurements.