Recurrent Myocardial Infarction Research Articles

Silent Myocardial Infarction and Risk of Stroke Recurrence: A Post Hoc Analysis of the IRIS Trial.

Unrecognized or silent myocardial infarction (MI) detected on an ECG is associated with first-ever stroke, but the impact on stroke recurrence is unknown. We aimed to determine the association of silent MI with stroke recurrence in patients with a recent ischemic stroke. Subjects from the IRIS (Insulin Resistance Intervention After Stroke) trial with an available ECG were included. Clinical MI was defined as a history of hospitalization for MI. Silent MI was defined as ECG evidence of MI in the absence of clinical MI. The primary outcome was recurrent stroke. Ischemic stroke and subtype were assessed as secondary outcomes. Multivariable Cox regression analysis adjusted for demographics, pioglitazone, and vascular risk factors was used to examine the association between MI and stroke recurrence. A total of 2282 participants met the inclusion criteria. Clinical and silent MI were identified in 161 (7.1%) and 94 (4.1%) subjects, respectively. Over the study period, 209 recurrent strokes occurred, with 191 classified as ischemic. In the fully adjusted model, silent MI was significantly associated with any stroke (hazard ratio [HR], 2.29 [95% CI, 1.34-3.90]) and ischemic stroke (HR, 2.09 [95% CI, 1.18-3.70]) recurrence. Clinical MI was associated with stroke recurrence in the unadjusted analysis but not in the fully adjusted model (HR, 1.31 [95% CI, 0.81-2.11]). Silent MI was not associated with potential cardioembolic subtypes (HR, 1.50 [95% CI, 0.70-3.22]). Among patients with a recent ischemic stroke, silent MI was associated with stroke recurrence. Tailored prevention strategies in this population warrant future investigation. URL: https://clinicaltrials.gov. Unique Identifier: NCT00091949.

Comparative Effectiveness of Rosuvastatin Versus Atorvastatin in Acute Ischemic Stroke Treatment.

Research specifically addressing the efficacy of rosuvastatin versus atorvastatin in patients with ischemic stroke is insufficient. Using a large stroke registry, we investigated whether 2 commonly used statins, rosuvastatin and atorvastatin, differ in their effectiveness in reducing the risk of vascular events in patients with acute ischemic stroke. We analyzed data from a nationwide stroke registry in South Korea between January 2011 and April 2022. Patients with acute ischemic stroke within 7 days of onset who were prescribed either atorvastatin or rosuvastatin at discharge were included. The primary outcome was a composite of recurrent stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality within 1 year. A total of 43 512 patients (age, 69.2±12.5 years; male, 59.8%) were analyzed in this study. Atorvastatin was used in 84.8% (n=36 903), and rosuvastatin was used in 15.2% (n=6609). The 1-year cumulative event rate of the composite of recurrent stroke, myocardial infarction, and all-cause mortality was significantly lower in the rosuvastatin group than in the atorvastatin group (9.7% [95% CI, 9.0-10.5] versus 10.7% [95% CI, 10.4-11.0]; P=0.049). Cox proportional hazards analysis revealed that rosuvastatin, compared with atorvastatin, was significantly associated with less risk of 1-year composite of recurrent stroke, myocardial infarction, and all-cause mortality, with an absolute risk reduction of 1% [95% CI, -1.8 to -0.2] and a relative risk reduction of 11% (hazard ratio, 0.89 [95% CI, 0.82-0.97]). However, there were discrepancies in the statistical significance of the results between the propensity score matching and stabilized inverse probability of treatment weighting analysis. The results of this analysis of a large cohort of patients with ischemic stroke suggested that, compared with atorvastatin, rosuvastatin was significantly associated with a reduced risk of a 1-year composite of recurrent stroke, myocardial infarction, and all-cause mortality in patients with acute ischemic stroke. However, in real clinical practice, rosuvastatin is used less than one-fifth as frequently as atorvastatin in patients with acute ischemic stroke. This study serves as a hypothesis-generating function.

Comparative efficacy of clopidogrel-aspirin combination therapy versus aspirin monotherapy in preventing recurrent events in transient ischemic attack and minor stroke: a systematic review and meta-analysis

Background and objectiveStroke is a leading cause of disability and death globally. Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is a common intervention for acute ischemic stroke (AIS) and transient ischemic attack (TIA). This meta-analysis aims to evaluate the efficacy and safety of DAPT compared to aspirin monotherapy in preventing recurrent stroke.MethodsWe performed a systematic search of electronic databases including PubMed, MEDLINE, Embase, and Scopus up to April 1, 2024. Eligible studies involved adult patients with acute stroke or TIA receiving either DAPT with clopidogrel and aspirin or aspirin monotherapy, with follow-up durations between 30 and 90 days. Data were extracted on recurrent stroke, hemorrhagic stroke, myocardial infarction, all-cause mortality, and functional outcomes measured by the modified Rankin Scale (mRS). Statistical analyses were conducted using relative risk (RR) and odds ratio (OR) with 95% confidence intervals, and heterogeneity was evaluated using I2 statistics.ResultsFrom 2344 articles screened, 33 studies involving 15,376 participants were included. DAPT significantly reduced the risk of recurrent stroke (RR 0.85, 95% CI 0.75–0.97, I2 = 42%, p = 0.02). However, DAPT was associated with an increased, but not statistically significant, risk of hemorrhagic stroke (RR 1.27, 95% CI 0.55–2.90, I2 = 51%, p = 0.23). There were no significant differences in the risk of myocardial infarction or all-cause mortality between the two groups. Functional outcomes indicated that DAPT reduced the risk of disability (OR 0.80, 95% CI 0.70–0.92, I2 = 35%, p = 0.004).ConclusionDAPT with clopidogrel and aspirin is more effective than aspirin monotherapy in reducing recurrent strokes but may increase the risk of hemorrhagic stroke. Individualized patient assessment is crucial to balance the benefits and risks of DAPT. Further high-quality, long-term studies are needed to confirm these findings and inform clinical practice.

Impact of type 1 diabetes mellitus on mortality rate and outcome of hospitalized patients with myocardial infarction.

Type 1 diabetes mellitus (T1D) is associated with an increased cardiovascular risk. We aimed to investigate the influence of T1D on myocardial infarction (MI) patients' mortality. The German nationwide inpatient sample 2005-2016 was used for statistical analysis. Hospitalized MI patients were stratified for T1D and impact of T1D on in-hospital outcomes was investigated. In total, 3,307,703 hospitalizations of MI patients (37.6% females, 56.8% aged ≥70 years) were counted in Germany 2005-2016 and included in this analysis. In 18,625 (0.6%) of the cases additionally T1D was coded. Overall, 410,737 (12.4%) in-hospital deaths occurred within the investigation period. MI patients with T1D were younger (64.0 [IQR 52.0-75.0] vs. 73.0 [62.0-81.0] years, P<0.001), more often female (38.7% vs. 37.6%, P<0.001) and obese (13.2% vs. 9.3%, P<0.001). Comorbidities like peripheral arterial (14.2% vs. 6.4%, P<0.001) and kidney disease (38.5% vs. 27.2%, P<0.001) were more prevalent in MI patients with T1D. T1D was an independent risk factor for in-hospital death (OR 1.23 [95%CI 1.18-1.29], P<0.001), recurrent MI (OR 1.56 [95%CI 1.35-1.80], P<0.001), and stroke (OR 1.75 [95%CI 1.63-1.88], P<0.001). While percutaneous coronary intervention (PCI, 37.8% vs. 42.0%, P<0.001) was less often, coronary artery bypass grafting (CABG, 7.4% vs. 4.6%, P<0.001) was more often performed in MI patients with T1D, confirmed by regression analysis (PCI: OR 0.66 [95%CI 0.64-0.68], P<0.001; CABG: OR 1.54 [95%CI 1.45-1.63], P<0.001). T1D represents an important and independent risk factor for mortality in MI patients. The results emphasize the high vulnerability of T1D patients who suffer from MI.

Evaluation of a machine learning-based metabolic marker for coronary artery disease in the UK Biobank.

An in silico quantitative score of coronary artery disease (ISCAD), built using machine learning and clinical data from electronic health records, has been shown to result in gradations of risk of subclinical atherosclerosis, coronary artery disease (CAD) sequelae, and mortality. Large-scale metabolite biomarker profiling provides increased portability and objectivity in machine learning for disease prediction and gradation. However, these models have not been fully leveraged. We evaluated a quantitative score of CAD derived from probabilities of a machine learning model trained on metabolomic data. We developed a CAD-predictive learning model using metabolic data from 93,642 individuals from the UK Biobank (median [IQR] age, 57 [14] years; 39,796 [42%] male; 5640 [6%] with diagnosed CAD), and assessed its probabilities as a quantitative metabolic risk score for CAD (M-CAD; range 0 [lowest probability] to 1 [highest probability]) in participants of the UK Biobank. The relationship of M-CAD with arterial stiffness index, ejection fraction, CAD sequelae, and mortality was assessed. The model predicted CAD with an area under the receiver-operating-characteristic curve of 0.712. Arterial Stiffness Index increased by 0.19 and ejection fraction decreased by 0.2% per 0.1 increase in M-CAD. Both incident and recurrent myocardial infarction increased stepwise over M-CAD quartiles (odds ratio (OR) 15.3 [4.2%] and 12.5 [0.2%]) in top quartiles as compared to the first quartile of incident and recurrent MI respectively). Likewise, the hazard ratio and prevalence of all-cause mortality, CVD-associated mortality, and CAD-associated mortality increased stepwise over M-CAD deciles (2.98 [14%], 9.34 [4.3%], 26.7 [2.7%] in the top deciles as compared to the first decile of all-cause, CVD, and CAD mortality respectively). Metabolic-based machine learning can be used to build a quantitative risk score for CAD that is associated with atherosclerotic burden, CAD sequelae and mortality.

High-sensitivity C-reactive protein, plaque vulnerability and adverse events in patients with stable coronary disease: An optical coherence tomography study.

Higher levels of high-sensitivity C-reactive protein (hsCRP) are associated with increased risk of cardiovascular events in patients with coronary artery disease (CAD). To elucidate the characteristics of coronary plaques in patients with CAD with high hsCRP levels. A total of 793 consecutive patients with stable CAD who underwent optical coherence tomography (OCT) of the culprit vessel during percutaneous coronary intervention were included. Patients were classified into the higher hsCRP group (hsCRP ≥0.2mg/dL, n=247) or lower hsCRP group (hsCRP <0.2mg/dL, n=546). OCT characteristics and clinical outcomes were investigated according to hsCRP levels. The prevalence of thin-cap fibroatheroma (TCFA) (32.0% vs. 20.9%, p<0.001) was significantly higher in the higher hsCRP group than in the lower hsCRP group. The incidence of myocardial infarction was significantly higher in the higher hsCRP group than in the lower hsCRP group (log-rank p=0.006) during a median follow-up of 938days, although the incidence of major adverse cardiac events was comparable (log-rank p=0.282). Among the four groups classified by hsCRP level and the presence of TCFA, the incidence of myocardial infarction was highest in the group with both higher hsCRP levels and TCFA (log-rank p=0.017). Higher hsCRP levels were associated with a higher prevalence of vulnerable characteristics of coronary plaques and worse clinical outcomes in patients with stable CAD. The risk of recurrent myocardial infarction in patients with high hsCRP levels was further increased in the presence of TCFA.

Incident heart failure and recurrent coronary events following acute myocardial infarction.

Recurrent myocardial infarction (MI) and incident heart failure (HF) are major post-MI complications. Herein, contemporary post-MI risks for recurrent MI and HF are described. A total of 6804 patients with a primary discharge diagnosis of MI at 28 Baylor Scott & White Health hospitals (January 2015 to December 2021) were studied. Patient characteristics, treatment, and outcomes, including incident HF, recurrent MI, all-cause death, and all-cause and cardiovascular rehospitalizations, were assessed. Landmark approach anchored at 3 months post-discharge was used to assess 1-year outcomes. Median age was 69 years, 59.7% were male, and 76.7% had non-ST-elevation MI. Comorbidities included hypertension (89%), dyslipidaemia (87%), Type 2 diabetes (48%), and chronic kidney disease (34%); 17% had a history of MI and 23% of HF; 63% underwent percutaneous/surgical revascularization. In landmark-anchored 1-year outcomes (N = 6210), 413 (6.7%) patients died, 1730 (27.9%) had all-cause and 735 (11.8%) cardiovascular hospitalizations, 234 (3.8%) had recurrent MI. Of patients without history of HF, 1160 (23.8%) developed incident HF [42.2%, 26.7%, and 31.1% with ejection fraction (EF) < 40%, 41-49%, and >50%, respectively) within 3 months of discharge. Patients who developed HF had higher risk of death and hospitalizations (all P < .001), irrespective of EF. Of 2179 patients with EF > 50% without prevalent HF or HF during index hospitalization, 257 (11.8%) developed HF and 77 (3.5%) recurrent MI within 1 year. In a contemporary post-MI cohort, the risk for incident HF was greater than recurrent MI, even among those with normal EF and no HF at discharge.

Excessive Supraventricular Ectopic Activity in Patients With Acute Ischemic Stroke Is Associated With Atrial Fibrillation Detection Within 24 Months After Stroke: A Predefined Analysis of the MonDAFIS Study.

Excessive supraventricular ectopic activity (ESVEA) is regarded as a risk marker for later atrial fibrillation (AF) detection. The investigator-initiated, prospective, open, multicenter MonDAFIS (Impact of Standardized Monitoring for Detection of Atrial Fibrillation in Ischemic Stroke) study randomized 3465 patients with acute ischemic stroke without known AF 1:1 to usual diagnostic procedures for AF detection or additive Holter monitoring in hospital for up to 7 days, analyzed in a core laboratory. Secondary study objectives include the comparison of recurrent stroke, myocardial infarction, major bleeding, and all-cause death within 24 months in patients with ESVEA (defined as ectopic supraventricular beats ≥480/day or atrial runs of 10-29 seconds or both) versus patients with newly diagnosed AF versus patients without ESVEA or AF (non-ESVEA/AF), randomized to the intervention group. Overall, 1435 (84.8%) of 1714 patients randomized to the intervention group had analyzable study ECG monitoring of at least 48 hours' duration within the first 72 hours of monitoring. ESVEA was detected in 363 (25.3%) patients, while AF was first detected in 48 (3.3%) patients. Within 24 months, AF was newly detected in 67 (18.5%) patients with ESVEA versus 60 (5.9%) patients without ESVEA/AF- (P<0.001). The composite outcome at 24 months was not different between patients with ESVEA and patients without ESVEA/AF (15.2% versus 12.6%; P=0.242). All-cause death was numerically higher in patients with ESVEA (6.6% versus 3.2%), but failed statistical significance (P=0.433) in multivariate analysis (including age, heart failure, stroke severity, and creatinine at baseline). ESVEA in the acute phase of ischemic stroke or transient ischemic attack is associated with AF detection during follow-up and therefore may be used to select patients for prolonged ECG monitoring. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02204267.

Restrictive or Liberal Blood Transfusion in Patients with Myocardial Infarction and CKD.

Chronic kidney disease (CKD) is associated with higher risk of myocardial infarction and anemia. Among patients with anemia and CKD who experience myocardial infarction, it remains uncertain if a liberal red blood cell transfusion threshold strategy (hemoglobin cutoff [Hgb] < 10 g/dL) is superior to a restrictive transfusion threshold (Hgb 7-8 g/dL) strategy. Among the 3,504 patients enrolled in the Myocardial Ischemia and Transfusion (MINT) trial with non-missing creatinine, we compared baseline characteristics and 30-day and 6-month outcomes of patients without CKD (N = 1279), CKD with eGFR 30-60 mL/min/1.73 m2 (N = 999), CKD with eGFR < 30 mL/min/1.73 m2 (N = 802), and CKD requiring dialysis (N = 415) by assigned transfusion strategy. No statistically significant interactions were observed between CKD stage and assigned transfusion strategy. Among non-dialysis dependent patients with an eGFR < 30 mL/min/1.73 m2, a restrictive transfusion strategy was associated with a higher risk of 30-day death or recurrent myocardial infarction (risk difference [RD], 5.8%, 95% CI 0.4% to 11.2%) compared to a liberal transfusion strategy. Among patients with an eGFR 30-60 mL/min/1.73 m2, a restrictive strategy was associated with a similar risk of 30-day death or recurrent myocardial infarction (RD, 3.7%, 95% CI -0.9% to 8.2%) compared to a liberal transfusion strategy. Among patients with CKD requiring dialysis, a restrictive strategy was also associated with a similar risk of 30-day death or recurrent myocardial infarction (RD, -2.6%, 95% CI -10.0% to 4.8%) compared to a liberal transfusion strategy. In patients with CKD included in this MINT subgroup analysis, a liberal transfusion strategy was not worse than a restrictive transfusion strategy and was associated with less harm in subgroups not receiving dialysis.

Physiology-Versus Angiography-Guided Complete Coronary Revascularization in STEMI Patients with Multivessel Disease: A Network Meta-Analysis.

Background: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), complete revascularization (CR) is recommended over culprit-only PCI to reduce adverse cardiovascular outcomes. However, the optimal strategy for CR, whether angiography (Angio)-guided or physiology-guided, remains uncertain. Methods: This network meta-analysis included 14 randomized controlled trials (RCTs) with 11,568 patients to compare the efficacy of angio-guided CR, physiology-guided CR, and culprit-only PCI in reducing major adverse cardiovascular events (MACE), all-cause mortality, recurrent myocardial infarction (MI), cardiovascular (CV) death, and unplanned revascularization. The frequentist and Bayesian approaches were applied to assess the effectiveness of each strategy. Results: The pairwise meta-analysis showed that angio-guided CR showed superior efficacy, significantly reducing MACE (OR = 0.44; 95% CI: 0.37-0.52), recurrent myocardial infarction, and unplanned revascularization compared to culprit-only PCI. Physiology-guided CR also reduced MACE (OR = 0.64, 95% CI: 0.45-0.91) and unplanned revascularization. The network metanalysis showed that CV death was lower in the physiology-guided CR group (OR 0.56; 95% CI 0.25-1.05), suggesting a protective effect, but the difference did not reach statistical significance. Furthermore, physiology-guided CR was not significantly better than angio-guided CR in most outcomes. Conclusions: Angio-guided CR appears to provide the best overall outcomes for patients with STEMI and MVD, outperforming physiology-guided CR in most endpoints. Further large-scale trials are needed to clarify the relative efficacy of angio-guided CR and physiology-guided CR in this patient population.

Cardiovascular Profile and Cardiovascular Imaging After Bariatric Surgery: A Narrative Review.

Background and Objectives: Up until now, behavioral interventions and pharmacological therapies were the main approach available for the management of obesity. Diet and exercise, when used as a singular therapeutic method, are inadequate for a successful outcome. Research shows promising results for the surgical treatment of obesity, especially in the area of bariatric surgery (BaS). The relevance of this study is the valuable analysis of the evolution of obese patients with increased cardiovascular risk. Materials and Methods: The patients eligible for BaS commonly suffer from multiple chronic conditions, including type 2 diabetes, obstructive sleep apnea, cardiovascular diseases, and non-alcoholic fatty liver disease. Additionally, obesity contributes to an increased probability of developing certain types of cancer, osteoarthritis, urinary incontinence, and chronic kidney disease. In this review, we focused especially on the cardiovascular status of obese patients who underwent bariatric procedures. Results: BaS has been found to be strongly associated with a reduced incidence of severe complications in individuals with a history of myocardial infarction (MI) and severe obesity. Specifically, this procedure is linked to a lower occurrence of major adverse cardiovascular events and a decrease in overall mortality. Also, BaS is correlated with a reduced risk of recurrent MI and the development of new-onset heart failure. Conclusions: The results of BaS involve a significant amelioration of the BMI, contributing to a considerable decrease in cardiovascular risk factors and to a notable refinement in the cardiovascular structure and function.

Long-term prognostic impact of glucagon-like peptide-1 receptor agonist before ST-segment elevation myocardial infarction in patients with type 2 diabetes: a nationwide cohort study

BackgroundGlucagon-like peptide-1 receptor agonist (GLP-1RA) treatment reduces cardiovascular events in type 2 diabetes. Yet, the impact of GLP-1RA treatment before ST-segment elevation myocardial infarction (STEMI) on long-term prognosis in patients with type 2 diabetes remains unclear. In patients with STEMI and type 2 diabetes, we aimed to investigate the association between long-term prognosis and GLP-1RA treatment before STEMI.MethodsThis nationwide cohort study included consecutive patients admitted with type 2 diabetes and STEMI in Denmark from 2010 to 2016. All data were retrieved from nationwide Danish registries. Type 2 diabetes was defined by prior hospital admission with type 2 diabetes or anti-diabetic prescriptions within one year before STEMI. Dispensed GLP-1RA medication was retrieved within one year before STEMI.ResultsOf 1421 patients with STEMI and diabetes, 7% were treated with GLP-1RA before STEMI and 93% were not. Patients treated with GLP-1RA were younger, had more comorbidities, and more often treated with other anti-diabetics. During 8.4 years, 36% patients treated with GLP-1RA died whereas 52% died in the no GLP-1RA group (p = 0.002). In adjusted Cox analysis, GLP-1RA was associated with lower long-term mortality (hazard ratio (HR) 0.60, 95% confidence interval (CI) 0.43–0.84). There was no association between GLP-1RA and ischemic stroke (adjusted HR 1.05, 95% CI 0.57–1.94), recurrent myocardial infarction (adjusted HR 0.74, 95% CI 0.48–1.15), or hospitalisation for heart failure (adjusted HR 0.71, 95% CI 0.48–1.05).ConclusionsIn patients with diabetes and STEMI, GLP-1RA treatment prior to STEMI admission was associated with significantly lower long-term mortality.

Cardioprotection exerted by intravenous statin at index myocardial infarction event attenuates cardiac damage upon recurrent infarction.

Recurrent acute myocardial infarction (RE-AMI) is a frequent complication after STEMI, and its association with stent thrombosis can be life-threatening. Intravenous atorvastatin (IV-atorva) administration during AMI has been shown to limit infarct size and adverse cardiac remodeling. We determined by cardiac magnetic resonance (CMR) whether the cardioprotection exerted by IV-atorva at the index AMI event translates into a better prognosis upon RE-AMI in dyslipidemic pigs. Hypercholesterolemic pigs underwent a first AMI (90-minute coronary balloon occlusion). During ongoing ischemia, animals received IV-atorva or vehicle. Forty days later, animals underwent RE-AMI and were sacrificed on day43. All animals remained on p.o. atorvastatin and a high-cholesterol diet from the first AMI until sacrifice. Serial CMR analysis was performed on day3 post-AMI, prior- (day40) and post-RE-AMI (day43). No differences were detected in edema formation in both animal groups during AMI and RE-AMI. Gadolinium DE-CMR revealed smaller infarcts in IV-atorva-treated animals at index event at 3days and 40days post-AMI compared to vehicle-administered pigs (p<0.05). CMR analyses post-RE-AMI revealed smaller infarcts in the animals treated with IV-atorva at index event than in the vehicle-administered pigs. These IV-atorva at index event benefits were associated with higher LVEF and normal LV wall motion in the jeopardized myocardium at RE-AMI (p<0.05 vs. vehicle). The scar region of RE-AMI of animals treated with IV-atorva at index event showed reduced cardiac inflammatory infiltrate, apoptosis and senescence activation, and increased reparative fibrosis and neovessel formation vs. vehicle-administered pigs. Animals treated with IV-atorva at index event also showed lower CRP and higher IL-10 plasma levels in the setting of RE-AMI. The cardioprotection afforded by IV-atorva administration during an index-AMI event shows a legacy effect attenuating myocardial damage and preserving cardiac contractile function upon RE-AMI. The potential benefits of this intravenous approach should be tested in the clinical setting.

Association of Time in Target Range of Resting Heart Rate With Adverse Clinical Outcomes in Patients With Acute Coronary Syndromes After Percutaneous Coronary Intervention.

Heart rate (HR) has been proved to be associated with major adverse cardiovascular events (MACE) in Acute coronary syndrome patients. However, the threshold value and clinical significance of time in target of resting heart rate (TTR-HR) remain insufficiently elucidated. Our study aimed to evaluate the independent association between TTR-HR and cardiovascular outcomes in the follow-up study of ACS. A total of 1455 ACS patients who underwent percutaneous coronary intervention (PCI) and were admitted to 22 hospitals between 2019 and 2022 were enrolled and followed up for 12 months. MACE was defined as a composite of cardiac death, nonfatal recurrent myocardial infarction, ischemic-driven revascularization, and ischemic stroke. The association between TTR-HR and cardiovascular outcomes was assessed using Cox regression model. Compared to patients with TTR-HR 0-50% and >50%-75%, patients with TTR-HR > 75%-100% were older and less alcohol user, less likely to use diuretics and anti-diabetic drugs, these patients had less comorbidities of hyperlipidemia, diabetes, heart failure, and cardiac shock. After 12 months follow up, the incidence of MACE and composite endpoint but not mortality was higher in patients with TTR-HR 0-50% and >50%-75% than those with TTR-HR > 75%-100%. After multivariate adjustment, TTR-HR [hazard ratio = 2.11, 95% CI: 1.19-3.74, p = 0.01] was independently associated with composite endpoint. In summary, our study demonstrates that TTR-HR holds significant prognostic value, with TTR-HR > 75%-100% being independently associated with reduced composite endpoint risk in ACS patients following PCI. These findings emphasize the importance of effective heart rate control in ACS patients following PCI.

Predictors and Outcomes of Slow Flow or No Reflow in Patients Undergoing Primary Percutaneous Coronary Intervention: A Comprehensive Analysis

Objectives: This study aims to identify predictors of slow-flow or no-reflow (SF/NR) in patients undergoing primary percutaneous coronary intervention (PCI), evaluate associated clinical outcomes, and assess the effectiveness of various medications. Methodology: We conducted a prospective observational study involving 150 patients with acute coronary syndromes (ACS) treated at Hayatabad Medical Complex from July 2023 to July 2024. Data were collected on patient demographics, clinical history, laboratory tests, and procedural details. SF/NR was defined as a TIMI flow grade of &lt;3 following PCI. We examined the incidence of SF/NR and major adverse cardiovascular events (MACE). Statistical analyses were performed using SPSS version 25.0, with multivariate logistic regression used to identify independent predictors of SF/NR. Results: SF/NR occurred in 34.7% of patients. Significant predictors identified included advanced age, male gender, diabetes mellitus, high thrombus burden, elevated high-sensitivity C-reactive protein (Hs-CRP), and reduced estimated glomerular filtration rate (eGFR). Patients presented with both single-vessel disease (SVD) and three-vessel disease (3VD). Medications used to manage SF/NR included intracoronary adenosine and epinephrine, which demonstrated variable effectiveness in improving coronary flow and reducing myocardial damage. Patients with SF/NR experienced significantly higher rates of MACE: cardiac death (10 vs. 2), recurrent myocardial infarction (8 vs. 3), target vessel revascularization (5 vs. 1), and heart failure (12 vs. 5). Multivariate analysis confirmed diabetes mellitus (OR: 1.56, CI: 1.12-2.18), high thrombus burden (OR: 2.33, CI: 1.60-3.39), and elevated Hs-CRP (OR: 1.45, CI: 1.01-2.07) as independent predictors of SF/NR. Conclusion: SF/NR represents a significant complication during primary PCI, with severe adverse outcomes. Key predictors include renal dysfunction, diabetes mellitus, and high thrombus burden. Intracoronary adenosine and epinephrine were used with varying effectiveness. Future research should focus on refining management strategies and improving patient outcomes.

Beta-Blockers in Patients with Myocardial Infarction and Preserved Left Ventricular Ejection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: The benefit of beta-blockers (BBs) for myocardial infarction (MI) patients with a preserved left ventricular ejection fraction (LVEF) is uncertain. While beneficial for a reduced LVEF, their efficacy with a preserved LVEF, especially with modern revascularization, is unclear. Methods: A PRISMA-guided systematic review and meta-analysis utilized PubMed and EMBASE. Three randomized controlled trials comparing outcomes in MI patients with a preserved LVEF treated with BBs versus no treatment were included. The primary outcome was composite all-cause mortality and MI; secondary outcomes were all-cause mortality, cardiovascular mortality, MI, and stroke. Results: Three studies, including a total of 9512 participants, were analyzed. Beta-blockers did not demonstrate a statistically significant benefit in reducing the composite endpoint of all-cause mortality and myocardial infarction (RR 0.97, 95% CI: 0.84-1.12, p = 0.671, I2 = 0%). Similarly, no significant effect was observed for secondary outcomes: all-cause mortality (RR 0.96, 95% CI: 0.79-1.17, p = 0.708), cardiovascular mortality (RR 1.22, 95% CI: 0.87-1.72, p = 0.247), myocardial infarction (RR 0.97, 95% CI: 0.78-1.19, p = 0.759), and stroke (RR 0.96, 95% CI: 0.66-1.38, p = 0.819). Conclusions: In patients with myocardial infarction and a preserved LVEF, beta-blockers did not significantly reduce mortality, recurrent myocardial infarction, or stroke, suggesting a limited benefit in this population under contemporary management protocols.

Effects of sodium-glucose cotransporter-2 inhibitors in myocardial infarction patients: A systematic review and meta-analysis.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are known to improve cardiovascular outcomes in individuals with heart failure (HF), type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, their efficacy following myocardial infarction (MI) remains unclear. A systematic search was conducted using PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov. Primary outcomes included hospitalization for heart failure (HHF), cardiovascular (CV) death, a composite of HHF or CV death, all-cause death, major cardiovascular events (MACE), recurrent MI, severe arrhythmia, renal injury and stroke. Secondary outcomes targeted improvements in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV). Thirteen studies comprising 22 370 patients were included. Meta-analysis revealed that SGLT2 inhibitors reduced HHF (RR 0.69, 95% CI 0.61 to 0.78, p < 0.001), combined HHF or CV death (RR 0.87, 95% CI 0.77 to 0.99, p = 0.028), all-cause mortality (RR 0.82, 95% CI 0.73 to 0.93, p = 0.002), MACE (RR 0.68, 95% CI 0.53 to 0.88, p = 0.004), recurrent MI (RR 0.81, 95% CI 0.69 to 0.94, p = 0.007), severe arrhythmia (RR 0.54, 95% CI 0.34 to 0.85, p = 0.009) and renal injury (RR 0.68, 95% CI 0.53 to 0.87, p = 0.002). Improvement in LVEF (MD 3.96%, 95% CI 2.52 to 5.40; p < 0.001) and LVEDV (MD -5.52 mL, 95% CI -10.21 to -0.83; p = 0.021) was notably greater in the SGLT2 inhibitors group. In post-MI patients, we first found that SGLT2 inhibitors significantly lowered the risk of HHF, combined CV death or HHF, all-cause death, MACE, recurrent MI, severe arrhythmias and renal injury. Additionally, SGLT2 inhibitors improved LVEF and LVEDV.

Retrospective Comparison of Outcomes and Cost of Virtual Versus Center-Based Cardiac Rehabilitation Programs.

Despite robust evidence supporting an association with improved outcomes in eligible patients, cardiac rehabilitation (CR) remains underused, with a minority of eligible patients participating. Virtual cardiac rehabilitation (VCR) has been proposed as an alternative to traditional center-based CR (CBCR) to improve usage rates. However, data supporting the efficacy and cost-effectiveness of VCR are limited. In the present study, we compared the outcomes and cost of a VCR versus traditional CBCR program. In a retrospective cohort study comparing VCR versus CBCR, CBCR data were collected from a period of January 2018 to September 2023. VCR data were collected from program initiation in July 2021 to September 2023. Primary health outcomes measured were 1-year mortality rates, recurrent myocardial infarction, all-cause hospital readmission, and emergency department visits. Primary cost outcomes were analyzed as cost ratios related to VCR versus CBCR assessing total medical costs allowed, pharmacy costs, and total costs of care over the 12 months post-CR enrollment. VCR was associated with a significant reduction in 1-year all-cause hospital readmission (incident rate ratio [IRR], 0.616 [95% CI, 0.489-0.777], P<0.001) and ED admission (IRR, 0.557 [95% CI, 0.452-0.687], P<0.001) at 1 year. The IRR of myocardial infarction and all-cause mortality did not significantly differ between VCR and CBCR. In addition, VCR was associated with significant reductions in medically related (cost ratio, 0.814 [95% CI, 0.690-0.960], P=0.0144) and total costs allowed (cost ratio, 0.838 [95% CI, 0.725-0.970], P=0.0176). VCR is a viable alternative to CBCR with at least comparable efficacy and cost, and as such, represents a key mechanism for improving access to and participation in CR for eligible patients.

Association between trimethylamine N-oxide and prognosis of patients with myocardial infarction: a meta-analysis

BackgroundTrimethylamine N-oxide (TMAO) has been widely explored and considered as a biomarker for adverse cardiovascular events. However, the relationships between TMAO adverse cardiovascular events are inconsistent in patients. Therefore, this meta-analysis aimed to estimate association between TMAO levels and the prognosis of patients with myocardial infarction (MI).MethodsWe searched PubMed, EMBASE, the Cochrane Library, and Web of Science from inception to July 2, 2023, to retrieve all relevant clinical trials. Associations between TMAO levels, major adverse cardiovascular events (MACE), all-cause mortality, recurrent MI, stroke, etc., were systematically addressed. Outcomes included MACE, all-cause mortality, recurrent MI, rehospitalization caused by heart failure, stroke, revascularization, SYNTAX score, and multivessel disease. A fixed/random-effects model should be adopted to calculate the pooled estimates. Besides, funnel plot, Begg's test and Egger' test were used to test publication bias.ResultsA total of nine studies were included in our meta-analysis. Our results indicated that higher TMAO levels were associated with greater risk of MACE (RR = 1.94; 95% CI = 1.39 to 2.73), all-cause mortality (RR = 1.56; 95% CI = 1.00 to 2.44), and MI (RR = 1.21; 95% CI = 1.01 to 1.45). No significant association was found in stroke, SYNTAX, and multivessel disease. Besides, our results reported that the association between TMAO levels and MACE after MI was not affected by the geographic localization.ConclusionThis study was the first meta-analysis that showed a significant positive association of TMAO levels with MACE, all-cause mortality, and recurrent MI in patients with MI.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=460400, PROSPERO (CRD42023460400).

A comparison of the effects of ticagrelor and clopidogrel in patients with acute ST-segment elevation myocardial infarction: a systematic review and meta-analysis of randomized clinical trials

BackgroundRupture of unstable coronary atherosclerotic plaque leads to acute ST-segment elevation myocardial infarction (STEMI). Dual anti-platelet therapy is one of the main treatments, and the combination of Aspirin and Clopidogrel is recognized as the standard oral regimen in most cases. Ticagrelor is a new generation of P2Y12 receptor inhibitors. We aimed to compare the effect of Ticagrelor and Clopidogrel in the treatment of patients post-STEMI.MethodsThis study investigated Pub Med, Scopus, Google Scholar Web of Science, and Embase Cochrane Library clinical trials.gov databases. Heterogeneity between studies was assessed using the I2 index and the Q statistic. The random effects model was used to combine studies and the Funnel plot and Egger’s test were used to assess the publication bias.ResultsEleven studies were included in this meta-analysis. 5274 patients in the Ticagrelor and 5,295 patients in the Clopidogrel groups were examined. The mean age of the patients was 58.84 years (2.70) and 59.92 years (3.19) in the Ticagrelor and Clopidogrel groups, respectively. Based on the results of the meta-analysis, compared to Clopidogrel, Ticagrelor had decreased the outcomes of mortality, recurrent myocardial infarction, stroke, and Major Adverse Cardiovascular Events (MACE). However, the post-myocardial infarction bleeding according to Bleeding Academic Research Consortium (BARC) criteria and reperfusion state regarding thrombolysis in myocardial infarction (TIMI) Flow Grading system showed no differences in both groups. However, these effects were not statistically significant.ConclusionsTicagrelor decreased the chance of mortality, re-infarction, stroke, and MACE in post-STEMI patients compared to clopidogrel. But there was no difference in the chance of major bleedings (BARC ≥ 3) and improvement in TIMI grade flow between these two drugs. However, none of these findings were statistically significant, and more studies are needed to reach definitive results.