Recurrent Myocardial Infarction In Patients Research Articles

Recurrent Myocardial Infarction After Primary Percutaneous Coronary Intervention in Multivessel Coronary Disease Is Primarily Related to Stent Failure: Post-Hoc Analysis of the PASSION Trial.

Our aim was to investigate the risk of events related to non-culprit lesions after primary percutaneous coronary intervention (PCI) in patients with multivessel coronary disease (MVD). In patients undergoing primary PCI for ST-elevation myocardial infarction (STEMI) who are diagnosed with MVD, the optimal treatment strategy is currently under debate. Although observational data exposed an increased risk of multivessel PCI in the acute phase of STEMI, 2 recently published randomized controlled trials showed a reduction of death or recurrent myocardial infarction (MI) after preventive PCI of non-culprit lesions when compared with culprit-lesion PCI only. We performed a post-hoc analysis of 279 patients with MVD included in the Paclitaxel-Eluting Stent versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation (PASSION) trial. We analyzed the incidence and cause of recurrent MI. Recurrent MI due to stent failure was assumed in the event of definite or probable stent thrombosis. After 5 years, 14 patients (5.7%) with MVD had a recurrent MI versus 17 (5.4%) patients with 1-vessel disease (HR 1.06, 95%CI 0.52-2.15, P = 0.87). The majority of events was attributable to stent failure, while of the remaining 6 events, only 1 was proven to originate from a lesion that was judged significant at enrolment. In this post-hoc analysis of the PASSION trial, recurrent MI in patients with MVD was mainly related to stent failure rather than a new event originating from a significant stenosis in a non-culprit coronary artery.

Indoleamine 2,3-Dioxygenase Fine-Tunes Immune Homeostasis in Atherosclerosis and Colitis through Repression of Interleukin-10 Production

Indoleamine 2,3-dioxygenase 1 (Ido1) is a rate-limiting enzyme that catalizes the degradation of tryptophan along the kynurenine pathway. Here, we show that Ido1 activity sustains an immunostimulatory potential through inhibition of interleukin (Il)10. In atherosclerosis, Ido1-dependent inhibition of Il10 translates into disease exacerbation. The resistance of Ido1-deficient mice to enhanced immune activation is broken in Ido1/Il10 double-deficient mice, which show exaggerated immune responses and develop severe spontaneous colitis. We demonstrate that Ido1 activity is required for the regulation of Il10 and that kynurenic acid (Kna), an Ido1-derived metabolite, is responsible for reduced Il10 production through activation of a cAMP-dependent pathway and inhibition of Erk1/2 phosphorylation. Resupplementation of Ido1-deficient mice with Kna limits Il10 expression and promotes atherosclerosis. In human atherosclerotic lesions, increased levels of Kna are associated with an unstable plaque phenotype, and its blood levels predict death and recurrent myocardial infarction in patients with coronary artery disease.

Reduced risk of recurrent myocardial infarction in homozygous carriers of the chromosome 9p21 rs1333049 C risk allele in the contemporary percutaneous coronary intervention era: a prospective observational study

ObjectivesChromosome 9p21 single nucleotide polymorphism (SNP) is a susceptibility variant for acute myocardial infarction (AMI) in the primary prevention setting. However, it is controversial whether this SNP is also associated...

Factor XIII Val34Leu polymorphism and recurrent myocardial infarction in patients with coronary artery disease

Factor XIII (FXIII) is necessary for cross linking of fibrin strands and generation of stable fibrin clot. FXIII Val34Leu is a common genetic single nucleotide polymorphism that has been associated with accelerated fibrin stabilization and reduced rate of fibrinolysis. The contribution of Val34Leu to long term risk of recurrent myocardial infarction (MI) in patients with coronary stenting has not been conclusively established. The objective of the study was to examine the effects of Val34Leu on fibrin generation, platelet aggregation, and long term clinical outcomes in patients with coronary artery disease treated with dual antiplatelet therapy. Patients with angiographically documented coronary artery disease who were treated with aspirin and clopidogrel were enrolled (n = 211). Light transmittance aggregometry and plasma fibrin clot formation using thrombelastography (TEG) were determined. Genotyping of Val34Leu was performed using Taqman assay. Clinical events during follow up were recorded. Homozygous carriers of 34 Leu variant had significantly shorter fibrin clot formation time as compared to wild type individuals (TEG K: 1.27 ± 0.3 vs. 1.68 ± 1.1 min, p = 0.011). The Val34Leu variant was associated with gene dose dependent increased risk of MI (log rank, p = 0.002) or occurrence of composite of MI and CV death (log rank, p = 0.005) with highest event rates observed in homozygous carriers of 34 Leu. In summary, FXIII Val34Leu polymorphism was associated with increased rate of fibrin stabilization in homozygous carriers of the variant and may increase risk of recurrent MI and death in patients with angiographically established coronary artery disease treated with dual antiplatelet therapy.

Timing of Mortality After Severe Bleeding and Recurrent Myocardial Infarction in Patients With ST-Segment–Elevation Myocardial Infarction

The prognosis of initial survivors of ST-segment-elevation myocardial infarction (STEMI) is affected by both recurrent myocardial infarction (MI) and severe bleeding. The aim of the current study was to investigate how mortality is affected in time after bleeding and recurrent MI. From January 1, 2003, to July 31, 2008, a total of 2002 patients were treated with primary percutaneous coronary intervention for ST-segment-elevation MI and followed up for the occurrence of recurrent MI and Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) severe bleeding. Primary outcome was all-cause mortality within 4 years of follow-up. In a time-dependent, covariate-adjusted Cox regression model, both bleeding and recurrent MI were associated with an increase in mortality shortly after the adverse event: hazard ratio, 14.37 (95% confidence interval [CI], 7.69-26.84) for the first day after recurrent MI and 5.42 (95% CI, 2.88-10.22) for the first day after bleeding. Thereafter the risk of subsequent mortality gradually decreased but remained elevated long after a recurrent MI (hazard ratio, 4.95 [95% CI, 3.27-7.48] between 1 day and 1 year after recurrent MI and hazard ratio, 2.56 [95% CI, 1.56-4.21] beyond 1 year after recurrent MI), but decreased to nonsignificant level beyond 1 month after the bleeding (hazard ratio, 0.56 [95% CI, 0.27-1.14]). The occurrence of both recurrent MI and bleeding in the first year after ST-segment-elevation MI is associated with subsequent mortality. The risk implication of recurrent MI, however, was greater and more sustained over time than that of severe bleeding.

OP0203-PC New Data, New Problem; Assessing the Prevalence of Nsaid Prescribing in Primary Care in Those with a Background of Ischaemic Heart Disease (IHD) or Risk Factors for IHD

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed in the treatment of patients in primary care with rheumatic problems (1). The side effect profile and safety of NSAID use has been...

AB0810-PC Even short term treatment with nsaids may be unsafe: the feasibility of replacing the nsaid prescription with regular paracetemol

BackgroundThe NSAID prescription is prevalent in patients seen in primary care with rheumatic and musculoskeletal problems (1). New evidence suggests that there is a significant increase in the risk of...

Incidence, Predictors, and Subsequent Mortality Risk of Recurrent Myocardial Infarction in Patients Following Discharge for Acute Myocardial Infarction

In the percutaneous coronary intervention (PCI) era, little evidence exists regarding the incidence, predictors and long-term mortality of recurrent myocardial infarction (Re-MI) following discharge for acute myocardial infarction (AMI). A total of 7,870 patients who survived AMI were studied with a median follow-up period of 3.9 years: 353 patients (4.5%) experienced Re-MI, with 7 of those dying within 30 days, which was classified as fatal Re-MI. The incidence of Re-MI per year was 2.65% for the first year, and 0.91-1.42% thereafter up to 5 years. Multivariate Cox regression analyses revealed that predictors of Re-MI were diabetes mellitus (hazard ratio (HR): 2.079, P<0.001), history of MI (HR: 1.767, P=0.001), and advanced age (HR: 1.021, P=0.001). These 3 predictors remained significant when angiographic and procedural parameters were incorporated into the analyses. The incidence and adjusted risk of Re-MI increased when these variables were clustered (P<0.001). The all-cause mortality rate was significantly higher in patients with Re-MI than in those without (HR: 2.206, P<0.001). In post-AMI patients treated in the PCI era, the incidence of Re-MI is low compared with that reported during the past 30 years. Patients' clinical factors of diabetes mellitus, history of MI, and advanced age appear to affect the occurrence of Re-MI after hospital discharge, and Re-MI still carries a risk for subsequent mortality.

Chromosome 9p21 Single Nucleotide Polymorphisms Are Not Associated With Recurrent Myocardial Infarction in Patients With Established Coronary Artery Disease

Chromosome 9p21 single nucleotide polymorphisms (SNPs) have been shown to be associated with coronary heart disease in multiple studies. The aim of the present study was to identify whether these SNPs are associated with recurrent myocardial infarction (MI), revascularization, or death in acute coronary syndrome (ACS) patients or in those undergoing coronary artery bypass grafting (CABG). TexGen registry participants with ACS (n=2,067) or CABG (n=1,176) were evaluated, to assess whether 9p21 SNPs (rs1333049, rs2383206, rs10757278, rs10757274) were associated with recurrent MI (primary outcome), recurrent revascularization, or death (secondary outcomes) at approximately 3.2 years of follow-up. Carriers of risk allele (C) for rs1333049 presented at an earlier age (62 vs. 63.5 years in non-carriers, P=0.0004) with more extensive disease (number of vessels with significant stenosis: 1.9 vs. 1.7 in non-carriers, P=0.001) in the ACS group. In adjusted models, the C allele was not associated with recurrent MI (hazard ratio [HR], 1.01; 95% confidence interval [CI]: 0.74-1.38), recurrent revascularization (HR, 0.98; 95%CI: 0.78-1.23), or death (HR, 0.91; 95%CI: 0.69-1.18) in the ACS or CABG groups (recurrent MI: HR, 0.64; 95%CI: 0.40-1.05; recurrent revascularization: HR, 0.98; 95%CI: 0.61-1.55; death: HR, 0.89; 95%CI: 0.61-1.30). Results were similar for the other 3 SNPs. 9p21 SNPs were not associated with recurrent MI, revascularization, or mortality after ACS or CABG. Individuals with the rs1333049 C allele, however, may present with earlier and more extensive disease.

Letter by Alla et al Regarding Article, “Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction: A Nationwide Cohort Study”

To the Editor: We read with interest the article by Schjerning Olsen et al1 on the risk of myocardial infarction (MI) and the duration of nonsteroidal anti-inflammatory drug (NSAID) use. Using a national database, the authors elegantly demonstrate that even short-term use of NSAID carries an increased risk of death and recurrent MI in patients with prior MI. Although we agree with the authors' conclusions, a few issues require further clarification. First, competitive inhibition of aspirin binding at the platelet cyclooxygenase-1 receptor is 1 of the proposed mechanisms contributing to the adverse effect of nonselective NSAIDs in patients with MI. …

Letter by Altman and Gonzalez Regarding Article, “Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction: A Nationwide Cohort Study”

To the Editor: We read with great interest the article by Schjerning Olsen et al1 reporting the recurrence of myocardial infarction after the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with established cardiovascular disease. Although the presented data are not new,2,3 they are of relevance for clinicians working in the real world. The mechanism underlying the prothrombotic effect of NSAIDs remains poorly understood, but it …

Letter by Naimer Regarding Article, “Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction: A Nationwide Cohort Study”

To the Editor: I read with great interest the article by Schjerning Olsen et al,1 in which they demonstrated the apparent detrimental impact of nonsteroidal anti-inflammatory drugs on the incidence of cardiac events in patients with a previous infarct. Although an abundance of evidence confirms the harmful influence of the class effect of cyclooxygenase inhibitors on cardiac function and coronary vascularity, the authors assert further epidemiological support that short-term treatment too can have dangerous implications. However, the authors' methods overlooked the …

Response to Letters Regarding Article, “Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction: A Nationwide Cohort Study”

We appreciate the interest in our article in Circulation 1 and welcome further discussion on this important topic. Dr Naimer, Dr Alla, and colleagues comment on the influence that stress and rheumatic diseases have on risk in patients. We agree that confounding by indication may influence observational studies such as ours, and that lack of information on nonsteroidal anti-inflammatory drug (NSAID) treatment indication is a limitation of the study. However, our findings were consistent, and we found different degree of risk between the individual NSAIDs, which were probably all used for the same indications, a clear correlation between the degree of cyclooxygenase-2 inhibition (as reported in the literature) and risk, and a clear dose-dependent increase in …

Comment on «Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction. A Nationwide Cohort Study»

BackgroundDespite the fact that nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated among patients with established cardiovascular disease, many receive NSAID treatment for a short period of time. However, little is known about the association between NSAID treatment duration and risk of cardiovascular disease. We therefore studied the duration of NSAID treatment and cardiovascular risk in a nationwide cohort of patients with prior myocardial infarction (MI). Methods and resultsPatients ≥30 years of age who were admitted with first-time MI during 1997 to 2006 and their subsequent NSAID use were identified by individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark. Risk of death and recurrent MI according to duration of NSAID treatment was analyzed by multivariable time-stratified Cox proportional-hazard models and by incidence rates per 1000 person-years. Of the 83 677 patients included, 42.3% received NSAIDs during follow-up. There were 35 257 deaths/recurrent MIs. Overall, NSAID treatment was significantly associated with an increased risk of death/recurrent MI (hazard ratio, 1.45; 95% confidence interval, 1.29 to 1.62) at the beginning of the treatment, and the risk persisted throughout the treatment course (hazard ratio, 1.55; 95% confidence interval, 1.46 to 1.64 after 90 days). Analyses of individual NSAIDs showed that the traditional NSAID diclofenac was associated with the highest risk (hazard ratio, 3.26; 95% confidence interval, 2.57 to 3.86 for death/MI at day 1 to 7 of treatment). ConclusionsEven short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population, and any NSAID use should be limited from a cardiovascular safety point of view.

5 Implementation of a sensitive troponin I assay reduces death and recurrent myocardial infarction in patients with suspected acute coronary syndrome

<h3>Introduction</h3> Although troponin assays have become increasingly more sensitive, it is unclear whether further reductions in the threshold of detection for plasma troponin concentrations impact on clinical outcomes in patients with suspected acute coronary syndrome. The aim of this study was to determine whether lowering the diagnostic threshold for myocardial infarction with a sensitive troponin assay will improve clinical outcomes. <h3>Methods</h3> Consecutive patients admitted with suspected acute coronary syndrome before (n=1038; validation phase) and after (n=1054; implementation phase) lowering the threshold of detection for myocardial necrosis from 0.20 to 0.05 ng/ml with a sensitive troponin I assay were stratified into three groups: &lt;0.05, 0.05–0.19 and ≥0.20 ng/ml. During the validation phase, only concentrations above the original diagnostic threshold of ≥0.20 ng/ml were reported to clinicians. Event-free survival (reinfarction and death) at 1 year were compared in patients grouped by plasma troponin concentrations. <h3>Results</h3> Plasma troponin concentrations were &lt;0.05 ng/ml in 1340 (64%), 0.05–0.19 ng/ml in 170 (8%) and ≥0.20 ng/ml in 582 (28%) patients. During the validation phase, 39% of patients with undisclosed plasma troponin concentrations of 0.05–0.19 ng/ml were dead or had recurrent myocardial infarction at 1 year, compared to 7% and 24% of those with troponin concentrations &lt;0.05 ng/ml (p&lt;0.001) or ≥0.20 ng/ml (p=0.007) respectively. During the implementation phase, lowering the diagnostic threshold to 0.05 ng/ml reduced 1-year death and recurrent myocardial infarction from 39% to 21% in patients with troponin concentrations of 0.05–0.19 ng/ml (OR 0.42, 95%CI 0.24 to 0.84, p=0.013), whereas clinical outcomes were unchanged in patients with troponin concentrations &lt;0.05 ng/ml or ≥0.20 ng/ml (Abstract 5 figure 1). <h3>Conclusions</h3> In patients with suspected acute coronary syndrome, implementation of a sensitive troponin assay increases the diagnosis of myocardial infarction by a third, and identifies those at high-risk of reinfarction and death. Lowering the diagnostic threshold of plasma troponin is associated with major reductions in morbidity and mortality.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction

Background— Despite the fact that nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated among patients with established cardiovascular disease, many receive NSAID treatment for a short period of time. However, little is known about the association between NSAID treatment duration and risk of cardiovascular disease. We therefore studied the duration of NSAID treatment and cardiovascular risk in a nationwide cohort of patients with prior myocardial infarction (MI). Methods and Results— Patients ≥30 years of age who were admitted with first-time MI during 1997 to 2006 and their subsequent NSAID use were identified by individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark. Risk of death and recurrent MI according to duration of NSAID treatment was analyzed by multivariable time-stratified Cox proportional-hazard models and by incidence rates per 1000 person-years. Of the 83 677 patients included, 42.3% received NSAIDs during follow-up. There were 35 257 deaths/recurrent MIs. Overall, NSAID treatment was significantly associated with an increased risk of death/recurrent MI (hazard ratio, 1.45; 95% confidence interval, 1.29 to 1.62) at the beginning of the treatment, and the risk persisted throughout the treatment course (hazard ratio, 1.55; 95% confidence interval, 1.46 to 1.64 after 90 days). Analyses of individual NSAIDs showed that the traditional NSAID diclofenac was associated with the highest risk (hazard ratio, 3.26; 95% confidence interval, 2.57 to 3.86 for death/MI at day 1 to 7 of treatment). Conclusions— Even short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population, and any NSAID use should be limited from a cardiovascular safety point of view.

AS-068 Lipid Level of Patients with Acute Myocardial Infarction Undergoing Primary Angioplasty is related with Prognosis

TO evaluate the correlation between acute lipids level and on-statins treatment lipids and 1 year major adverse cardiovascular and cerebrovascular events (MACCE), including cardiac death, ischemic stroke, and recurrent myocardial infarction in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Predictors and prognostic impact of recurrent myocardial infarction in patients with left ventricular dysfunction, heart failure, or both following a first myocardial infarction

IMS: Recurrent myocardial infarction (MI) is common after a first MI and is associated with increased morbidity and mortality. Predictors and prognosis of a recurrent MI with contemporary management are not well known. We assessed the predictors and prognostic impact of a first recurrent MI in 10,599 patients with left ventricular dysfunction, heart failure, or both following a first MI from the Valsartan in Acute Myocardial Infarction Trial (VALIANT) cohort. During a median follow-up of 27.4 months, 861 patients (9.6%) had a recurrent MI. The median time to recurrence was 136 days (quartiles 35-361 days), with a declining rate of recurrent MI within the first 3 months. The strongest predictors of recurrent MI were reduced estimated glomerular filtration rate, unstable angina, diabetes, and age. Mortality was markedly elevated (20.5%) within the first 7 days of a recurrent MI. Patients who survived 7 days after a recurrent MI continued to be at increased risk of death compared with patients without a recurrent MI and the risk of death remained elevated more than two-fold a year after the recurrent MI (adjusted hazards ratio 2.4, 95% confidence interval 1.7-3.2). One-year mortality for the entire VALIANT cohort was 10.3%, whereas 38.3% of the patients were dead 1 year after recurrent MI. Early reinfarctions (within 1 month) was associated with significantly higher 30-day mortality than later reinfarctions. Even in the context of contemporary treatment, a recurrent MI confers a significantly increased risk of death in patients following a high-risk first MI. Strategies aimed at reducing recurrent MI will thus likely prolong survival in post-MI survivors.

Perfusion CT Imaging of Brain Tumors: An Overview

Perfusion imaging of brain tumors has been performed by using various tracer and nontracer modalities and can provide additional physiologic and hemodynamic information, which is not available with routine morphologic imaging. Tumor vascular perfusion parameters obtained by using CT or MR perfusion have been used for tumor grading, prognosis, and treatment response in addition to differentiating treatment/radiation effects and non-neoplastic lesions from neoplasms. This article is an overview of the utility of PCT for assessment of brain tumors and describes the technique, its advantages, and limitations.