Recurrent MI Research Articles

Prognostic factors of patients with myocardial infarction with nonobstructive coronary artery disease: a seven-year longitudinal follow-up

Abstract Background Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a common condition associated with major adverse events (MAE). Unlike obstructive coronary artery disease (OCAD), data regarding the prognosis of MINOCA are scarce. Methods We conducted a retrospective study among consecutive patients with MINOCA in a large tertiary medical center in Israel between the years 2005–2018. We assessed parameters associated with MAE, defined as all-cause mortality or recurrent MI. Patients with probable alternative cause for myocardial injury, as stress-induced cardiomyopathy and myocarditis, were excluded. Results Among 36,501 admitted with AMI during the study period, 1,544 patients (4.2%) had MINOCA. The mean age was 61±13, and 710 (46%) were females. At a median follow-up of 7 years, the MAE rate was 17%, as 153 (9.9%) died, and 117 (7.5%) had recurrent MI. ST-elevation MI at presentation and older age were associated with increased 30-day MAE. In multivariate models, independent factors associated with MAE were female gender (HR=0.58; 95% CI 0.43–0.76), age (HR=1.04; 95% CI 1.03–1.05), left ventricular ejection fraction (LVEF) <40% (HR=2.68; 95% CI 1.74–4.12), increased serum-creatinine (HR=1.11; 95% CI 1.02–1.21), higher hemoglobin (HR=0.81; 95% CI 0.76–0.88), and documented sinus rhythm (HR=0.58; 95% CI 0.38–0.86). Conclusion MINOCA carries an increased risk for long-term MAE. Among MINOCA patients older age, LVEF <40%, and increased serum-creatinine are associated with increased MAE risk, while female gender, higher hemoglobin, and sinus rhythm are associated with lower MAE risk. Funding Acknowledgement Type of funding sources: None.

High bleeding risk in all-comers with ST-segment elevation myocardial infarction and use of P2Y12-inhibitiors

Abstract Background Bleeding has an important prognostic impact in patients with ST-segment elevation myocardial infarction (STEMI), yet stratification of bleeding risk to guide dual antiplatelet therapy (DAPT) is not routinely performed in clinical practice. Purpose To describe high bleeding risk (HBR) patients according to the PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent DAPT) score and use of P2Y12-inhibitors. Methods This single-centre observational study included consecutive patients with STEMI who were treated with percutaneous coronary intervention (PCI) from 2009–2016. Individual linkage to Danish nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Age, prior bleeding diagnosis, and blood samples before PCI (maximum 30 days before hospitalisation) were used to calculate the PRECISE-DAPT score. A score ≥25 was considered as HBR. Due to 26.7% missing on blood parameters (mainly leucocytes), the maximum and minimum values of the missing parameters and respective imputed PRECISE-DAPT scores were calculated. If both the maximum and minimum score were ≥25 or <25, patients were categorised accordingly, and a maximum score of ≥25 and minimum score of <25 as missing. Differences between continuous (median [interquartile range, IQR]) and categorical variables (frequency [percentage]) were assessed using Wilcoxon rank-sum and χ2-test for patients with vs. without HBR. Cumulative incidence of major bleeding (composite of bleedings leading to hospitalisation) and major adverse cardiovascular events (MACE) (composite of all-cause mortality, recurrent MI, and ischemic stroke) 1 year after PCI were plotted for patients with and without HBR. Number of HBR patients alive and collecting a P2Y12-inhibitor prescription within 30 days from discharge was reported. Results We identified 6179 PCI-treated patients with STEMI, of whom 5530 (89.5%) had imputed PRECISE-DAPT scores (Figure 1). A total of 1821 (32.9%) were at HBR, and these were more often female (38.3 vs. 18.2%, p-value<0.001), elderly (median age 75 [IQR 67, 81] vs. 57 years [IQR 51, 64], p-value<0.001), and had more comorbidities (diabetes [16.7 vs. 12.1%], heart failure [16.2 vs. 7.6%], cardiac arrhythmia [24.9 vs. 12.3%], cancer [17.5 vs. 5.7%], and ischemic stroke [8.1 vs. 2.6%], all p-values<0.001) compared with patients not at HBR. One-year cumulative incidence of major bleeding and MACE for patients with and without HBR were plotted (Figure 2). Of the 1431 (78.6%) HBR patients who were alive and claimed a P2Y12-inhibitior prescription 30 days from discharge, 459 (32.1%) were treated with clopidogrel, 672 (46.9%) with ticagrelor, and 300 (21.0%) with prasugrel (Figure 1). Conclusion Every third PCI-treated all-comer with STEMI was at HBR according to the PRECISE-DAPT score. HBR patients were more often treated with potent P2Y12-inhibitors (prasugrel or ticagrelor) instead of clopidogrel. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship.

The value of coronary computed tomography and very early invasive coronary angiography compared to standard intervention in older patients after non-ST segment elevation acute coronary syndromes

Abstract Background The optimal management of patients with non-ST elevation acute coronary syndromes (NSTEACS) remains a challenge. The merits of both computed tomography angiography (CTA) as a rule-out test for significant coronary artery disease and early invasive coronary angiography (ICA) are debated. Furthermore, there are limited data in older NSTEACS patients, who likely have more coronary artery calcification and are at higher risk of ACS-related complications. Methods This is a post hoc analysis of patients ≥75 years included in the Very Early Versus Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial (VERDICT). The diagnostic accuracy of CTA was investigated in patients without previous coronary artery bypass grafting, renal dysfunction, or atrial fibrillation; the presence of a coronary artery stenosis ≥50% determined by ICA was used as reference. Patients were randomised to very early ICA within 12 hours of diagnosis or standard care (ICA within 48–72 hours of diagnosis) and followed for up to five years. The primary endpoint was the composite of all-cause mortality, nonfatal recurrent MI, hospital admission for refractory myocardial ischaemia or hospital admission for heart failure. Results From November 2010 to June 2016, 2147 patients were included in the VERDICT trial. Of these, 452 (21%) patients were ≥75 years of age. Most older patients had a GRACE score >140 (n=388, 88.8%). At the time of admission, older patients had lower levels of haemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction, and more often displayed elevated troponins and electrocardiogram changes indicating new ischaemia, than those <75 years. Of patients ≥75 years of age, 161 (35.6%) underwent CTA before ICA. Older patients had significantly higher calcium scores than younger patients (1187±1445 vs. 499±858 Agatston units, p<0.001). 19% of CTAs excluded significant coronary artery disease. The negative predictive value of the CTAs was 94 (95% CI 79–99)% and the sensitivity was 98 (95% CI 94–100)%, figure 1. The primary endpoint was observed more frequently in patients ≥75 years as compared to younger patients (n=222, 49% vs. n=390, 23%, p<0.001), even after adjustment for allocated treatment (adjusted HR 2.65, 95% CI 2.25–3.13, p<0.001). Among older patients randomised to very early ICA, there were no differences in the cumulated number of primary endpoints compared to older patients randomised to standard ICA (log-rank p=0.36), figure 2. Conclusion Among patients ≥75 years old with NSTEACS, CTA showed a high diagnostic accuracy. A very early ICA within 12 hours of diagnosis did not improve long-term composite outcome in these older patients with NSTEACS. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Rigshospitalets Research Foundation

Comparison of 3-Year Outcomes between Early and Delayed Invasive Strategies in Older and Younger Adults with Non-ST-Segment Elevation Myocardial Infarction Undergoing New-Generation Drug-Eluting Stent Implantation.

We evaluated the 3-year clinical outcomes of early invasive (EI) and delayed invasive (DI) strategies in older and younger adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stent (DES) implantation to reflect current real-world practice. Overall, 4513 patients with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health and divided into two groups according to age: group A (age ≥ 65 years, n = 2253) and group B (age < 65 years, n = 2260). These two groups were further divided into two subgroups: group EI (A1 and B1) and DI (A2 and B2). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined as all-cause death, recurrent MI (re-MI), any repeat coronary revascularization, or stroke. The secondary clinical outcome was definite or probable stent thrombosis (ST). In both groups A and B, after multivariable-adjusted and propensity score-adjusted analyses, MACCE (group A, p = 0.137 and p = 0.255, respectively; group B, p = 0.171 and p = 0.135, respectively), all-cause death, cardiac death (CD), non-CD, re-MI, any repeat revascularization, stroke, and ST rates were similar between the EI and DI groups. When including only those with complex lesions, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. In the era of new-generation DESs, major clinical outcomes were not significantly different between the EI and DI strategies in both older and younger adults with NSTEMI.

Cost-effectiveness of population-wide genomic screening for familial hypercholesterolemia in the United States

Population genomic screening for familial hypercholesterolemia (FH) in unselected individuals can prevent premature cardiovascular disease. To estimate the clinical and economic outcomes of population-wide FH genomic screening versus no genomic screening. We developed a decision tree plus 10-state Markov model evaluating the identification of patients with an FH variant, statin treatment status, LDL-C levels, MI, and stroke to compare the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness of population-wide FH genomic screening. FH variant prevalence (0.4%) was estimated from the Geisinger MyCode Community Health Initiative (MyCode). Genomic test costs were assumed to be $200. Age and sex-based estimates of MI, recurrent MI, stroke, and recurrent stroke were obtained from Framingham risk equations. Additional outcomes independently associated with FH variants were derived from a retrospective analysis of 26,025 participants screened for FH. Sensitivity and threshold analyses were conducted to evaluate model assumptions and uncertainty. FH screening was most effective at younger ages; screening unselected 20-year-olds lead to 111 QALYs gained per 100,000 individuals screened at an incremental cost of $20 M. The incremental cost-effectiveness ratio (ICER) for 20-year-olds was $181,000 per QALY, and there was a 38% probability of cost-effectiveness at a $100,000 per QALY willingness-to-pay threshold. If genomic testing cost falls to $100, the ICER would be $91,000 per QALY. Population FH screening is not cost-effective at current willingness to pay thresholds. However, reducing test costs, testing at younger ages, or including FH within broader multiplex screening panels may improve clinical and economic value.

ST Yükselmeli Miyokard Enfarktüslü Hastalarda Fibrinolitik ile Birlikte Kullanılan Tikagrelorun Etkinliği ve Güvenliği

Objective: The effectiveness and safety of administration ticagrelor simultaneously with fibrinolytic in STEMI remains unclear. Our study aims to compare and evaluate ticagrelor and clopidogrel in STEMI patients treated with fibrinolytics&#x0D; Material and Methods: The study consisted of 180 STEMI patients over 18 age who were given fibrinolytic therapy and had no absolute contraindications for treatment. Ticagrelor was given to 94 patients and clopidogrel was given to 86 patients. Loading doses were given to patients concurrently with fibrinolysis, followed by maintenance doses. The primary outcome was six-month follow-up for all-cause mortality, major cardiovascular events, stroke, recurrent MI, target vessel revascularization, and major bleeding. The secondary outcome was to evaluate patients over 75 years of age, use of rivaroxaban, and major adverse events that will develop in patients with chronic kidney disease.&#x0D; &#x0D; Results: There was no significant difference between the groups in terms of in-hospital death, GFR values (0.05). Mortality was observed in 5 of 86 patients using clopidogrel and in 4 of 94 patients using ticagrelor. (Log-rank test, p:0.63 HR=0.72 (95%CI, 0.19-2.67)). The BARC type 3-5 bleeding in patients using ticagrelor and clopidogrel were statistically similar. (Log-rank test, p:0.77 HR=1.23 (95%CI, 0.31 - 4.79))&#x0D; Conclusions: In this study, we found the use of ticagrelor with fibrinolytic therapy was similar to clopidogrel in terms of effectiveness and safety.

Outcomes of early versus delayed invasive strategy in older adults with non-ST-segment elevation myocardial infarction

We evaluated the 3-year clinical outcomes following early invasive (EI) and delayed invasive (DI) strategies in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stents (DESs) implantation to reflect current real-world practice. Overall, 2437 older adults (age, ≥ 65 years) with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health. They were divided into two groups: EI (n = 1750) and DI (n = 687). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined by all-cause death, recurrent MI, any repeat coronary revascularization, and stroke. The secondary clinical outcome was stent thrombosis (ST). After multivariable-adjusted and propensity score-matched analyses, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. Even after the analysis was confined to those having complex lesions, these major clinical outcomes were similar between these two groups. The EI and DI strategies in older adults with NSTEMI receiving new-generation DES showed comparable results.Clinical Trial Registration: URL: http://cris.nih.go.kr/cris/en/; Unique identifier: KCT0000863.

Restrictive versus Liberal Blood Transfusion Strategy in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomized Clinical Trials.

BackgroundA meta-analysis of observational studies comparing differences in outcomes between restrictive blood transfusion (RBT) and liberal blood transfusion (LBT) in patients with acute myocardial infarction (AMI) reported that LBT is associated with higher all-cause mortality. Few randomized clinical trials (RCTs) have compared RBT to LBT in patients with AMI and anemia, but no meta-analysis of RCTs was performed to date.AimTo assess the clinical effect of RBT compared to LBT in patients with AMI and anemia regarding was all-cause mortality, recurrent MI, revascularization, and heart failure exacerbation.MethodsThe electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar, were systematically searched to identify eligible studies published before June 19th, 2021. RCTs that assessed the effect of RBT compared to LBT were included. The primary endpoint was all-cause mortality. Secondary endpoints included recurrent MI, revascularization, and heart failure exacerbation.ResultsThree RCTs with 821 patients were included (421 received RBT, and 400 received LBT). The mean age was 75.9 ± 6.1 years, and 56% were male. Our meta-analysis showed that RBT was not associated with reduced all-cause mortality (RR = 1.61; 95% CI = 0.38–6.96, p = 0.52), recurrent MI (RR = 0.98; 95% CI = 0.48–1.96, p = 0.94), revascularization (RR = 1.18; 95% CI = 0.26–5.44, p = 0.83) and heart failure exacerbation (RR = 0.86; 95% CI = 0.23–3.22, p = 0.82) when compared to LBT.ConclusionRBT was not associated with reduced all-cause mortality, recurrence of MI, need for revascularization, or heart failure exacerbation in patients with AMI and anemia compared to LBT. A larger RCT is required to confirm the above findings.

Comparison of coronary revascularization strategies in older adults presenting with acute coronary syndromes.

The optimal coronary revascularization strategy to maximize the patient-centered outcome of days alive and out of hospital (DAOH), in multimorbid older (≥65-years) adults after an acute coronary syndrome (ACS) is incompletely understood. Using Kaiser Permanente Northern California Health Plan databases, we identified 3871 patients ≥65-years presenting with ACS between 1/1/2010-3/1/2018 who underwent coronary revascularization with either coronary artery bypass grafting (CABG, N=1575) or multivessel percutaneous coronary intervention (PCI, N=2296). Selection bias was accounted for through propensity score modeling techniques and inverse probability of treatment weighting. Cox proportional hazards models were fit to evaluate the association of revascularization type with outcomes. Absolute DAOH and the relative risk of achieving ≥90%DAOH during three time intervals. All-cause mortality, recurrent MI, stroke, rehospitalization, repeat revascularization, and dialysis initiation. CABG (compared to PCI) was associated with greater absolute number of DAOH, significant after the first year (mean difference at 1-year: +5.8 days, 95% confidence interval [CI], -1.6 to 13 days; 3-years: +56 days, 95%CI, +25 to +88 days; 5-years: + 131 days, 95%CI, +57 to +205 days). The relative risk of achieving ≥90% DAOH significantly favored CABG after the first year (1-year:1.02, 95%CI, 0.98-1.05; 3-years:1.06, 95%CI 1.002-1.11, 5-years:1.12, 95%CI, 1.03-1.22), and was related to lower incidences of all-cause mortality, repeat revascularization, rehospitalization, incident dialysis, and nonfatal MI with CABG. In older adults with multivessel or left main coronary artery disease who presented with ACS, CABG, after the first year, was associated with a greater absolute number of DAOH-a geriatric and patient-centered outcome, compared to PCI. CABG patients also had a higher probability of achieving ≥90%DAOH-with lower all-cause mortality, recurrent MI, repeat revascularization, new dialysis, and rehospitalization rates. Future randomized trials should study the impact of optimal revascularization strategies on the quality of life of older adults with multimorbidity.

Short term outcome of primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction

Background: Percutaneous Coronary intervention (PCI) is a routinely performed procedure in coronary care units. The aim of our study was to investigate the frequency of major adverse cardiac events (MACEs) after percutaneous coronary angiography in acute ST-elevation myocardial infarction (STEMI) patients in our institution. The objective of the study is to determine the frequency of MACEs after Percutaneous Coronary Intervention (PCI) in patients with acute myocardial infarction.Patients &amp; Methods: This prospective observational study was carried out at Punjab Institute of Cardiology, Lahore from May 2017 to June 2017. A total 35 patients with STEMI who underwent Primary PCI were enrolled by consecutive sampling technique. An inclusion criterion was chest pain of 30 minutes to 12 hours duration with ECG showing ≥ 0.1mm ST-elevation in at least two contiguous leads. An exclusion criterion was thrombolysis within last 24 hours, malignancy, stroke and Left Main or equivalent disease on coronary Angiogram. Patients were followed after 2 weeks till 1 month for any MACES. (Including re-admission, need for repeat revascularization, stent thrombosis, recurrent acute MI, angina, stroke, and mortality). Frequency and percentages were calculated for MACEs by using SPSS 23.0.Results: Out of 35 cases, 34 (97.1%) were male and 1 (2.9%) were female. Mean age was 47.11±10.59 years, 14 (40%) patients had hypertension, 10 (28.6%) were diabetics and 12(34.3%) were current smokers while 4 (11.4%) were ex-smokers, 10 (28.6%) had family history of CAD, and 3 (8.6%) had hyperlipidemia. Successful revascularization with TIMI-III flow was attained in 34(97.1%) cases. 33minutes was mean door to balloon time. At one month follow-up, out of 35 patients, angina was reported only in 1 (2.9%) patient. There was no readmission, repeat revascularization, stent thrombosis, myocardial infarction, stroke and death reported in study subjects.Conclusion: Successful revascularization by Primary PCI was associated with very few early MACEs. For the treatment of coronary artery disease, PCI is an effective option. It has a few early MACEs and uses less contrast and has fewer distal complications than conventional angioplasty and invasive procedures.

Assessment of effects of diabetes mellitus on interventional outcome in patients with non-ST-myocardial infarction

Background: Diabetes mellitus (DM) is one of the major risk factors of cardiovascular disease. The present study was conducted to assess effects of diabetes mellitus on interventional outcome in patients with non-ST-myocardial infarction. Materials and Methods: 78 patients who had DM and MI of both genders were enrolled and parameters such as mortality, cardiovascular readmission, and recurrent MI were recorded. We divided patients into 2 groups. Group I were STEMI and group II were MI patients without presentation of ST-segment elevation as NSTEMI. Results: Out of 78 patients, males were 40 and females were 38. BMI (Kg/m2) was 27.3 in group I and 27.5 in group II. The mean HR (bpm) was 71.4 in group I and 72.8 in group II. SBP (mm Hg) was 138.4 in group I and 140.2 in group II. DBP (mm Hg) was 76.2 in group I and 80.4 in group II. Hyperlipidaemia was seen in 30 in group I and 34 in group II, hypertension was seen in 22 in group I and 28 in group II. MI was seen in 8 in group I and 10 in group II, COPD was seen in 4 in group I and 3 in group II and stroke in 2 in group I and 3 in group II. Hyperlipidaemia, hypertension, MI and COPD were independently related with all-cause mortality. Conclusion: Multiple risk factors contribute to a higher incidence of composite outcomes in diabetic patients with MI. STEMI poses a greater threat to adverse events.

Clinical Outcomes in Patients With Delayed Hospitalization for Non–ST-Segment Elevation Myocardial Infarction

BackgroundRecently, the number of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) has reduced, whereas increased mortality was reported. A plausible explanation for increased mortality was prehospital delay because of patients’ reticence of their symptoms. ObjectivesThe purpose of this study was to investigate the association between prehospital delay and clinical outcomes in patients with NSTEMI MethodsAmong 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry–National Institutes of Health, the authors evaluated 6,544 patients with NSTEMI. Study patients were categorized into 2 groups according to symptom-to-door (StD) time (<24 or ≥24 hours). The primary outcome was 3-year all-cause mortality, and the secondary outcome was 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. ResultsOverall, 1,827 (27.9%) patients were classified into the StD time ≥24 hours group. The StD time ≥24 hours group had higher all-cause mortality (17.0% vs 10.5%; P < 0.001) and incidence of secondary outcomes (23.3% vs 15.7%; P < 0.001) than the StD time <24 hours group. The higher all-cause mortality in the StD time ≥24 hours group was observed consistently in the subgroup analysis regarding age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services, hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score. In the multivariable analysis, independent predictors of prehospital delay were the elderly, women, nonspecific symptoms such as atypical chest pain or dyspnea, diabetes, and no use of emergency medical services. ConclusionsPrehospital delay is associated with an increased risk of 3-year all-cause mortality in patients with NSTEMI. (iCReaT Study No. C110016)

Characteristics and Outcomes of MI with Non-obstructive Coronary Arteries in a South-east Asian Cohort

Background: MI with non-obstructive coronary arteries (MINOCA) is caused by a heterogenous group of conditions with clinically significant sequelae. Aim: This study aimed to compare the clinical characteristics and prognosis of MINOCA with MI with obstructive coronary artery disease (MICAD). Methods: Data on patients with a first presentation of MI between 2011 and 2014 were extracted from the Singapore Cardiac Longitudinal Outcomes Database and patients were classified as having either MINOCA or MICAD. The primary outcomes were all-cause mortality (ACM) and major adverse cardiac events (MACE), defined as a composite of ACM, recurrent MI, heart failure hospitalisation and stroke. Results: Of the 4,124 patients who were included in this study, 159 (3.9%) were diagnosed with MINOCA. They were more likely to be women, present with a non-ST-elevation MI, have a higher left ventricular ejection fraction and less likely to have diabetes, previous stroke or smoking history. Over a mean follow-up duration of 4.5 years, MINOCA patients had a lower incidence of ACM (10.1% versus 16.5%) and MACE (20.8% versus 35.5%) compared with MICAD. On multivariable analysis, patients with MINOCA had a lower risk of ACM (HR 0.42; 95% CI [0.21–0.82]) and MACE (HR 0.42; 95% CI [0.26–0.69]). Within the MINOCA group, older age, higher creatinine, a ST-elevation MI presentation, and the absence of antiplatelet use predicted ACM and MACE. Conclusion: While patients with MINOCA had better clinical outcomes compared with MICAD patients, MINOCA is not a benign entity, with one in five patients experiencing an adverse cardiovascular event in the long term.

Long-term outcomes in inferior ST-segment elevation myocardial infarction patients with right ventricular myocardial infarction

ObjectiveTo evaluate the prognostic influence of the presence of right ventricular myocardial infarction (RVMI) on patients with inferior ST-segment elevation myocardial infarction (STEMI) in the contemporary reperfusion era. Methods9308 patients with inferior STEMI were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction Registry, including 1745 (18.75%) patients with RVMI and 7563 (81.25%) patients without RVMI. The primary outcome was two-year all-cause mortality. The secondary outcome was major adverse cardiac and cerebrovascular event (MACCE) defined as a composite of all-cause mortality, recurrent MI, revascularization, stroke, and major bleeding. ResultsAfter two-year follow up, there were no significant differences between inferior STEMI patients with or without RVMI in all-cause mortality (12.0% vs 11.3%; adjusted HR: 1.05; 95% CI: 0.90 to 1.24; P = 0.5103). Inferior STEMI with RVMI was associated with higher risk of MACCE (25.6% vs 22.0%; adjusted HR: 1.17; 95% CI: 1.05 to 1.31; P = 0.0038), revascularization (10.3% vs 8.1%; adjusted HR: 1.23; 95% CI: 1.03 to 1.48; P = 0.0218), and major bleeding (4.6% vs 2.7%; adjusted HR: 1.56; 95% CI: 1.18 to 2.07; P = 0.0019). Primary percutaneous coronary intervention (PCI) and thrombolysis were independent predictors to decrease all-cause mortality. For patients who received timely reperfusion, RVMI involvement did not increase all-cause mortality, whereas for those who did not undergo reperfusion, RVMI increased all-cause mortality (20.3% vs 15.7%; HR: 1.34; 95% CI: 1.10 to 1.63). ConclusionRVMI did not increase all-cause mortality for inferior STEMI patients in contemporary reperfusion era, whereas the risk was increased for patients with no reperfusion treatment.

Effect of COVID-19 pandemic on six-month mortality and clinical outcomes of patients with ST-elevation myocardial infarction.

The coronavirus disease 2019 (COVID-19) infection has changed everyday clinical practice, with a shortage of solid data about its implications for ST-elevation myocardial infarction (STEMI) patients. To evaluate the impact of COVID-19 on 6-month clinical outcomes of patients with STEMI and determine the mortality predictors after STEMI during the COVID-19 pandemic. This prospective observational study was conducted on consecutive STEMI patients who presented to our hospital between April and October 2021. A total of 74 COVID-19-positive patients were included in group I and compared to 148 COVID-19-negative patients (group II). We compared the two cohorts' rates of major adverse cardiovascular events (MACEs; composite of death from any cause, recurrent MI, target-vessel revascularization, and stroke) at 6 months. COVID-19 STEMI patients were more likely to present with angina equivalent symptoms, had higher Killip class at admission, and higher levels of high-sensitive cardiac troponin T and serum C-reactive protein. The 6-month rates of MACEs were significantly higher in STEMI patients with COVID-19 compared to non-COVID-19 patients (41.9% vs. 16.9%, respectively; p < 0.001) and were mainly due to higher in-hospital mortality (20.3% vs. 6.1%, respectively; p = 0.001). The independent predictors of 6-month mortality in STEMI patients during the COVID-19 pandemic were the absence of ST resolution, low systolic blood and higher Killip class on admission, presence of severe MR and atrial fibrillation, and anterior wall STEMI. STEMI patients with superimposed COVID-19 infection had worse clinical outcomes, with almost three times higher in-hospital mortality and 6-month MACEs.

Outcome of early versus delayed invasive strategy in patients with non-ST-segment elevation myocardial infarction and chronic kidney disease not on dialysis

Because of paucity of published data, we evaluated the 2-year major clinical outcomes between early invasive (EI) and delayed invasive (DI) strategies according to the stage of chronic kidney disease (CKD) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), who underwent a successful newer-generation drug-eluting stent (DES) implantation. A total of 8241 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry (KAMIR). Based on baseline estimated glomerular filtration rate (eGFR; ≥90, 60-89, 30-59, and <30mL/min/1.73m2), the patients were classified into groups A (n=3498), B (n=3109), C (n=1178), and D (n=1178). Thereafter, these 4 groups were sub-classified into the EI and DI groups. Major adverse cardiac events (MACE), defined as all-cause death, recurrent MI (re-MI), and any repeat revascularization, were evaluated. After multivariable-adjusted and propensity score-adjusted analyses, the cumulative incidence of MACE (group A, p=0.139 and p=0.103, respectively; group B, p=0.968 and p=0.608, respectively; group C, p=0.111 and p=0.196, respectively; group D, p=0.882 and p=0.571, respectively), all-cause death, re-MI, and any repeat revascularization was similar between the EI and DI groups in the 4 different renal function groups. In the era of newer-generation DES, EI and DI strategies showed comparable major clinical outcomes in patients with NSTEMI and CKD during a 2-year follow-up period. However, to confirm these results, further randomized, large-scale, long-term follow-up studies are needed.

Frequency, Etiology, and Impact of Unplanned Repeat Coronary Angiography After ST-Elevation Myocardial Infarction

Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p=0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p=0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.

Long-term outcomes of delayed percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction: A propensity score-matched retrospective study.

The best time window of percutaneous coronary intervention (PCI) is within 12 hours for ST-segment elevation myocardial infarction (STEMI). However, there is limited evidence about the proper time of PCI for delayed STEMI patients.From June 2014 to June 2015, a total of 268 patients receiving PCI with second-generation drug-eluting stent in a Chinese hospital after 3 days of STEMI onset were enrolled in this retrospective study, who were divided into the early group (3–14 days) and the late group (>14 days). A propensity score match was conducted to reduce the baseline difference. The primary endpoint of all-cause death and secondary endpoints of major adverse cardiac and cerebrovascular event (myocardial infarction [MI], stroke, emergent revascularization, and rehospitalization due to heart failure) were compared using survival analysis.At last, 182 cases were matched after propensity score match, with no statistical difference in baseline characteristics and PCI data. Kaplan-Meier survival curve demonstrated no difference in all-cause death of the 2 groups (P = .512). However, the early group presented a higher incidence of MI than the late group (P = .036). The multivariate Cox regression analysis also demonstrated that the early PCI was an independent risk factor for MI compared with late PCI (hazard ratio = 3.83, 95%CI [1.91–8.82], P = .001). There was no statistical difference in other major adverse cardiac and cerebrovascular event, including stroke, emergent revascularization, and rehospitalization due to heart failure.Using the 2nd drug-eluting stent, early PCI (3–14 days) and late PCI (>14 days) have comparable efficacy and outcomes. However, patients receiving early PCI are subjected to a relatively higher risk of recurrent MI.

Abstract 10426: Worse Clinical Outcomes in Patients with Acute Coronary Syndrome and Prior or New Onset Heart Failure: Insights from 47,474 Patients in a Pooled Analysis of Randomized Clinical Trials

Introduction: Heart failure (HF) frequently complicates acute coronary syndrome (ACS). Despite known associated high rates of mortality, there are only limited data regarding recurrent ischemic events and re-hospitalization for HF (HHF) in those with HF and ACS. Methods: We used a pooled dataset of four randomized clinical ACS trials (Platelet Inhibition and Patient Outcomes [PLATO], Apixaban for Prevention of Acute Ischemic Events 2 [APPRAISE-2], Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome [TRA-CER], and Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndrome [TRILOGY ACS]). We assessed the association between HF status (history of HF, de novo HF, no HF) at presentation for ACS on death, future ischemic events, and HHF at one year following hospital discharge using Cox proportional hazards analysis and estimated cumulative event rates using cumulative incidence function. Results: Of 47,474 patients presenting with ACS, 11.1% showed evidence of acute HF, 55.0% of whom had no previous history of HF. Patients with prior/chronic HF were more likely to present with acute HF than those with no previous HF (40.3% vs 6.9%). Compared to those without HF, patients with prior and de novo HF were at a significantly increased risk at one year of all-cause mortality (adjusted HR (aHR) 2.10, 95% Confidence Interval [CI] 1.80-2.45, and aHR 1.51, CI 1.18-1.93, respectively), MACE (aHR 1.50, CI 1.34-1.69, and aHR 1.40, CI 1.14-1.72), recurrent MI (aHR 1.58, CI 1.41-1.78, and aHR 1.40, CI 1.15-1.70), stroke (aHR 1.93, CI 1.67-2.32, and aHR 1.38, CI 1.09-1.75), and HHF (aHR 2.38, CI 2.09-2.71, and aHR 1.53, CI 1.24-1.88). Conclusion: Following an ACS event, both prior and de novo HF were found to be major predictors of death, recurrent ischemic events, and HHF by one year. These findings highlight the need for improved strategies to prevent and manage adverse outcomes in this high-risk population.

Abstract 11055: Length of Anticoagulation Treatment in Provoked VTE - Lessons from the Maqi 2 Collaborative

Introduction: Anticoagulation (AC) with warfarin or direct oral anticoagulants (DOAC) is the core of VTE treatment. Due to lower risk of VTE recurrence, American College of Chest Physicians (ACCP) recommends three months AC in patients with provoked VTE and without other indication for long-term AC. We aimed to assess how closely “real world” practice followed guideline recommendations. Hypothesis: We hypothesize most patients taking warfarin or DOAC for provoked VTE receive no more than three months AC. Patients who get prolonged AC are more likely to be taking DOAC than warfarin. Methods: We identified patients who initiated warfarin or DOAC from a six center AC clinic registry between 2008-20. Provoked VTE was defined as VTE after a transient risk factor: surgery, lower extremity cast/immobilization, childbirth, or OCPs. AC duration was categorized as &lt;80, 80-120, or &gt;120 days. Appropriate treatment window was defined as 80-120 days to adjust for variability in clinic scheduling. Median AC length for DOAC vs. warfarin was compared with a two-sample test. Prevalence of extended AC was compared using chi-square test. Variables increasing risk of extended AC were analyzed with logistic regression, adjusted for baseline demographic and clinical characteristics. Results: At six centers, we identified 488 patients with provoked VTE on warfarin and 302 on DOAC. Average AC length was 137 days for warfarin and 180 days for DOAC (p&lt;0.0001). 266 (54.5%) patients on warfarin and 215 (71.2%) on DOAC got &gt;120 days of AC (p&lt;0.001). Variables increasing risk of &gt;120 days AC include recurrent VTE (OR 2.11; CI 1.34,3.32), prior MI (OR 4.09; CI 1.37,12.2), and DOAC use (OR 2.34; CI 1.69, 3.23) (Figure 1). Conclusions: In this multi-center analysis, most patients receive AC longer than guideline-recommended. DOAC use, recurrent VTE, and prior MI are associated with prolonged AC. Understanding the relationship between prior MI and AC duration in provoked VTE warrants future investigation.