Risk Of Subsequent Myocardial Infarction Research Articles

Application of the Universal Definition of Myocardial Infarction in Clinical Practice in Scotland and Sweden

Whether the diagnostic classifications proposed by the universal definition of myocardial infarction (MI) to identify type 1 MI due to atherothrombosis and type 2 MI due to myocardial oxygen supply-demand imbalance have been applied consistently in clinical practice is unknown. To evaluate the application of the universal definition of MI in consecutive patients with possible MI across 2 health care systems. This cohort study used data from 2 prospective cohorts enrolling consecutive patients with possible MI in Scotland (2013-2016) and Sweden (2011-2014) to assess accuracy of clinical diagnosis of MI recorded in hospital records for patients with an adjudicated diagnosis of type 1 or type 2 MI. Data were analyzed from August 2022 to February 2023. The main outcome was the proportion of patients with a clinical diagnosis of MI recorded in the hospital records who had type 1 or type 2 MI, adjudicated by an independent panel according to the universal definition. Characteristics and risk of subsequent MI or cardiovascular death at 1 year were compared. A total of 50 356 patients were assessed. The cohort from Scotland included 28 783 (15 562 men [54%]; mean [SD] age, 60 [17] years), and the cohort from Sweden included 21 573 (11 110 men [51%]; mean [SD] age, 56 [17] years) patients. In Scotland, a clinical diagnosis of MI was recorded in 2506 of 3187 patients with an adjudicated diagnosis of type 1 MI (79%) and 122 of 716 patients with an adjudicated diagnosis of type 2 MI (17%). Similar findings were observed in Sweden, with 970 of 1111 patients with adjudicated diagnosis of type 1 MI (87%) and 57 of 251 patients with adjudicated diagnosis of type 2 MI (23%) receiving a clinical diagnosis of MI. Patients with an adjudicated diagnosis of type 1 MI without a clinical diagnosis were more likely to be women (eg, 336 women [49%] vs 909 women [36%] in Scotland; P < .001) and older (mean [SD] age, 71 [14] v 67 [14] years in Scotland, P < .001) and, when adjusting for competing risk from noncardiovascular death, were at similar or increased risk of subsequent MI or cardiovascular death compared with patients with a clinical diagnosis of MI (eg, 29% vs 18% in Scotland; P < .001). In this cohort study, the universal definition of MI was not consistently applied in clinical practice, with a minority of patients with type 2 MI identified, and type 1 MI underrecognized in women and older persons, suggesting uncertainty remains regarding the diagnostic criteria or value of the classification.

Do patients with bipolar disorders have an increased risk of myocardial infarction? A systematic review and meta-analysis.

Research shows that patients with bipolar disorders (BD) may have an altered risk of cardiovascular diseases; however, the association between the two is not clear. In this study, we reviewed evidence on the association between BD and subsequent risk of myocardial infarction (MI). Studies published on PubMed, Embase, Scopus, CENTRAL, and Web of Science were identified up to 30th August 2023. Random-effects meta-analysis was done to calculate the pooled odds ratio (OR). A total of six studies with 19,862,894 individuals were included. Of these, 46,627 were diagnosed with BD (0.23%). The median follow-up of the studies varied from 7.6 to 20 years. Meta-analysis of all six studies showed that BD patients do not have a higher risk of MI as compared to the general population (OR: 1.36, 95% CI: 0.99, 1.86). The overall analysis had substantial heterogeneity with I2=86%. No publication bias was noted among the studies. Results did not change during sensitivity analysis. Current evidence fails to show an association between BD and subsequent risk of MI. The high heterogeneity in the meta-analysis and lack of adjustment of all important confounders are significant limitations that need to be overcome by future studies.

Implementation of a high sensitivity cardiac troponin I assay and risk of myocardial infarction or death at five years: observational analysis of a stepped wedge, cluster randomised controlled trial

ObjectiveTo evaluate the impact of implementing a high sensitivity assay for cardiac troponin I on long term outcomes in patients with suspected acute coronary syndrome.DesignSecondary observational analysis of a stepped...

Use of the CHA2DS2-VASc score to predict subsequent myocardial infarction in atrial fibrillation

BackgroundThe risk of subsequent myocardial infarction (MI) varies widely in patients with atrial fibrillation (AF). No convenient scoring system currently exists to identify MI in AF. While each element of the CHA2DS2-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke or thromboembolism [doubled]; vascular disease; age 65–75 years; and sex category) score can increase the likelihood of MI, this retrospective longitudinal study aimed to determine the accuracy of the CHA2DS2-VASc score in predicting subsequent MI risk in AF. MethodsA total of 29,341 patients with AF were enrolled and followed up from January 2010 until the first occurrence of MI or until December 2020. The primary endpoint was the occurrence of subsequent MI. ResultsThe average age of the study population was 71 years, and 43.2% were male. The mean CHA2DS2-VASc score was found to be higher in patients with AF who had experienced an MI than in those who had not (3.56 ± 1.92 vs. 3.32 ± 1.81, p < 0.001). During the long-term follow-up, the risk of subsequent MI increased by 22% with every one-point increase in the CHA2DS2-VASc score (hazard ratio 1.22, 95% confidence interval 1.19–1.25; p < 0.001). Kaplan–Meier analysis revealed that high CHA2DS2-VASc scores were more likely to experience an MI than those with low CHA2DS2-VASc scores (log-rank p < 0.001). Furthermore, the CHA2DS2-VASc score was a significant predictor of MI in multivariate regression analysis. ConclusionThe CHA2DS2-VASc score is a valuable predictor of subsequent MI risk in patients with AF.

Implementation of high-sensitivity cardiac troponin and risk of myocardial infarction or death at 5 years: a stepped-wedge cluster-randomised controlled trial

Abstract Background Implementation of a high-sensitivity cardiac troponin I assay with the sex-specific 99th centile as the diagnostic threshold identifies more patients with myocardial injury and infarction, but whether this impacts on long-term clinical outcomes is unknown. Purpose In a prespecified analysis of a stepped-wedge cluster-randomised controlled trial performed across ten hospitals in Scotland, we evaluated the impact of implementing a high-sensitivity cardiac troponin I assay on outcomes at 5 years in consecutive patients with suspected acute coronary syndrome. Methods Throughout the trial, all 48,282 patients had cardiac troponin I concentrations measured using both a contemporary (standard care) and high-sensitivity (implementation) assay. During standard care, results from the high-sensitivity assay were concealed and the contemporary assay was used to guide care. Hospitals were randomly allocated to early (n=5) or late (n=5) implementation of the high-sensitivity assay using the sex-specific 99th centile to guide care and results from the contemporary assay were concealed. Patients reclassified by the high-sensitivity assay were defined as those with cardiac troponin concentrations above the sex-specific 99th centile but below the contemporary assay diagnostic threshold. Subsequent myocardial infarction or all-cause death at 5 years was compared before and after implementation using an adjusted Cox proportional hazards model in those reclassified by the high-sensitivity assay and stratified by index diagnosis. Results Overall, 10,360 patients had cardiac troponin concentrations greater than the sex-specific 99th centile of whom 1,771 (17%) were reclassified by the high-sensitivity assay. Compared to those identified as having elevated cardiac troponin by the contemporary assay, patients reclassified by the high-sensitivity assay were more likely to have non-ischemic myocardial injury (54% versus 28%) and less likely to have type 1 myocardial infarction (33% versus 59%; P&amp;lt;0.001 for both). In those reclassified, the 5-year incidence of subsequent myocardial infarction or all-cause death was 63% (456/720) before and 54% (567/1051) after implementation of the high-sensitivity assay (adjusted hazard ratio [aHR] 0.75 [95% CI 0.57–0.98]) (Figure 1). Following implementation, subsequent myocardial infarction or all-cause death at 5 years was reduced in patients with non-ischemic myocardial injury (aHR 0.66 [0.51–0.86]) but not type 1 or type 2 myocardial infarction (aHR 0.90 [0.78–1.03] and 0.81 [0.55–1.20], respectively). Conclusions In patients with suspected acute coronary syndrome, implementation of a high-sensitivity cardiac troponin assay was associated with a lower risk of subsequent myocardial infarction or death at 5 years. Improvements in outcome were greater in those with a diagnosis of non-ischemic myocardial injury rather than infarction. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Cardiovascular risk factors, radiation therapy, and myocardial infarction among lymphoma survivors

Background Mediastinal radiation is associated with increased risk of myocardial infarction (MI) among non-Hodgkin lymphoma (NHL) survivors. Objective To evaluate how preexisting cardiovascular risk factors (CVRFs) modify the association of mediastinal radiation and MI among a national population of NHL survivors with a range of CVRFs. Material and methods Using Danish registries, we identified adults diagnosed with lymphoma 2000–2010. We assessed MI from one year after diagnosis through 2016. We ascertained CVRFs (hypertension, dyslipidemia, and diabetes), vascular disease, and intrinsic heart disease prevalent at lymphoma diagnosis. We used multivariable Cox regression to test the interaction between preexisting CVRFs and receipt of mediastinal radiation on subsequent MI. Results Among 3151 NHL survivors (median age 63, median follow-up 6.5 years), 96 were diagnosed with MI. Before lymphoma, 32% of survivors had ≥1 CVRF. 8.5% of survivors received mediastinal radiation. In multivariable analysis, we found that mediastinal radiation (HR = 1.96; 95% CI = 1.09–3.52), and presence of ≥1 CVRF (HR = 2.71; 95% CI = 1.77–4.15) were associated with an increased risk of MI. Although there was no interaction on the relative scale (p = 0.14), we saw a clinically relevant absolute increase in risk for patients with CVRF from 10-year of MI of 10.5% without radiation to 29.5% for those undergoing radiation. Conclusion Patients with CVRFs have an importantly higher risk of subsequent MI if they have mediastinal radiation. Routine evaluation of CVRFs and optimal treatment of preexisting cardiovascular disease should continue after receiving cancer therapy. In patients with CVRFs, mediastinal radiation should only be given if oncologic benefit clearly outweighs cardiovascular harm.

MO445: Implications of Cardiac Biomarkers in Patients With Renal Insufficiency on Probability of Coronary Angiography and Subsequent Cardiovascular Outcomes

Abstract BACKGROUND AND AIMS Renal insufficiency is associated with an increased risk of cardiovascular morbidity and mortality. Although cardiac troponin remains essential marker for the diagnosis of myocardial injury in the general population, the diagnostic utility remains uncertain in patients with renal insufficiency. We examined the likelihood of coronary angiography and the risk of myocardial infarction after hospitalization with elevated troponin levels in patients with renal insufficiency. METHOD Based on data from multiple Danish nationwide healthcare registries, all hospitalized patients with elevated troponin I or T were identified between 2000 and 2021. Patients with age &amp;lt; 18 years, estimated glomerular filtration rate (eGFR) ≥60mL/min/1.73m2 and patients hospitalized with myocardial infarction &amp;lt; 30 days prior to the index were excluded. Renal function was calculated based on preceding plasma creatinine using the CKD-EPI equation. The probability of being referred for coronary angiography was computed across strata of renal insufficiency [eGFR (mL/min/1.73m2) 59–45, 44–30, 29–15 and &amp;lt; 15, respectively] based on multiple Cox regression calculating hazard ratios for 30-day likelihood of coronary angiography, with subsequent comparison of cumulative risk and hazard ratios for myocardial infarction using the Aalen-Johansen estimator and multiple Cox regression, respectively. RESULTS In total 57 044 patients were included in the study. Patients were predominantly male (53%, n = 30 222), with a median age of 81 years (IQR 74–87 years). eGFR strata (%): 59–45: 46.8%; 44–30: 30.6%; 29–15; 15.6%; &amp;lt;15: 7.%. Cardiovascular comorbidity was substantial; 47.1% of patients had a history of hypertension, 20.5%% of patients had a history of heart failure, 26.6% of patients had a history of diabetes and 25.3% of patients had a history of ischemic heart disease. Hazard ratios for 30-day likelihood of coronary angiography were 1.26 [95% confidence interval (CI) 1.10–1.44] for eGFR 15–29 mL/min/1.73m2, 2.00 (95% CI 1.77–2.25) for eGFR 30–44 mL/min/1.73m2 and 2.95 (95% CI 2.63–3.31) for eGFR 45–59 mL/min/1.73m2, using eGFR &amp;lt; 15 as reference. Subsequent cumulative risk of myocardial infarction is shown in Figure 1. Hazard ratios for risk of myocardial infarction were 0.86 (95% CI 0.71–1.03) for eGFR 15–29 mL/min/1.73m2, 0.58 (95% CI 0.49–0.69) for eGFR 30–44 mL/min/1.73m2 and 0.49 (95% CI 0.42–0.58) for eGFR 45–59 mL/min/1.73m2, using eGFR &amp;lt; 15 as reference. CONCLUSION In patients with elevated troponin levels, renal insufficiency is associated with an incrementally decreased probability of coronary angiography despite a graded proportional increase in the risk of subsequent myocardial infarction.

Patient-Reported Symptoms and Subsequent Risk of Myocardial Infarction in Chronic Kidney Disease.

Although patient-reported symptoms often precede acute presentations of cardiovascular disease, patients with nondialysis-requiring CKD are less likely to have typical symptoms of atherosclerotic disease when presenting with acute myocardial infarction. However, the associations between typical atherosclerotic symptoms and subsequent risk of myocardial infarction are unknown in ambulatory patients with CKD. To determine whether typical atherosclerotic symptoms are associated with risk for subsequent myocardial infarction in people with CKD, we examined participants from the Chronic Renal Insufficiency Cohort Study. Chest pain, shortness of breath, and inability to climb stairs were evaluated annually using the Kidney Disease Quality of Life Instrument. Associations between categorical time-updated symptoms and physician-adjudicated incident myocardial infarction were assessed using Cox regression models. Among 3910 participants (mean age of 58±11 years; mean eGFR =44±15 ml/min per 1.73 m2), there were 476 incident myocardial infarctions over a median follow-up period of 10.4 years (interquartile range, 5.36-12.6 years). Median time from symptom assessment to incident myocardial infarction was 213 days (interquartile range, 111-333 days). Compared with no symptoms, mild, and moderate or worse, symptoms of chest pain (hazard ratio, 1.30; 95% confidence interval, 1.01 to 1.67; and hazard ratio, 1.70; 95% confidence interval, 1.27 to 2.27, respectively) and shortness of breath (hazard ratio, 1.37; 95% confidence interval, 1.10 to 1.70; and hazard ratio, 1.33; 95% confidence interval, 1.05 to 1.69, respectively) were significantly associated with greater risks for subsequent myocardial infarction. Participants reporting mild and severe limitations in climbing stairs (versus no limitation) had significantly higher adjusted risk of myocardial infarction (hazard ratio, 1.44; 95% confidence interval, 1.10 to 1.89; and hazard ratio, 1.89; 95% confidence interval, 1.44 to 2.49, respectively). In a large ambulatory cohort of adults with CKD, symptoms of atherosclerotic cardiovascular disease were strongly associated with a higher risk for subsequent myocardial infarction. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_03_17_CJN12080921.mp3.

Trajectories of precarious employment and the risk of myocardial infarction and stroke among middle-aged workers in Sweden: A register-based cohort study.

SummaryBackgroundThe aim is to identify trajectories of precarious employment (PE) over time in Sweden to examine associations of these with the subsequent risk of myocardial infarction (MI) and stroke.MethodsThis is a nation-wide register-based cohort study of 1,583,957 individuals aged 40 to 61 years old residing in Sweden between 2003-2007. Trajectories of PE as a multidimensional construct and single PE components (contractual employment relationship, temporariness, income levels, multiple job holding, probability of coverage by collective agreements) were identified for 2003-2007 by means of group-based model trajectories. Risk Ratios (RR) for MI and stroke according to PE trajectories were calculated by means of generalized linear models with binomial family.FindingsAdjusted estimates showed that constant PE and borderline PE trajectories increased the risk of MI (RR: 1·08, CI95%:1·05-1·11 and RR:1·13, CI95%: 1·07-1·20 respectively) and stroke (RR:1·14, CI95%: 1·10-1·18 and HR:1·24, CI95%: 1·16-1·33 respectively) among men. A higher risk of stroke in men was found for the following unidimensional trajectories: former agency employees (RR:1·32, CI95%:1·04-1·68); moving from high to a low probability of having collective agreements (RR: 1·10, CI95%:1·01-1·20). Having constant low or very low income was associated to an increased risk of MI and Stroke for both men and women.InterpretationThe study findings provide evidence that PE increases the risk of stroke and possibly MI. It highlights the importance of being covered by collective bargaining agreements, being directly employed and having sufficient income levels over time.FundingThe Swedish Research Council for Health, Working Life and Welfare, no. 2019-01226.

Patient-Reported Symptoms and Subsequent Risk of Myocardial Infarction in CKD

Patient-Reported Symptoms and Subsequent Risk of Myocardial Infarction in CKD

Adverse childhood experiences related to subsequent myocardial infarction: A systematic review

The purpose of this study was to systematically review existing research on the relationship between adverse childhood experiences (ACEs) and subsequent risk of myocardial infarction (MI). A systematic review using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines was performed by searching four bibliographic databases. PubMed/Medline, PsycINFO, ScienceDirect, and ProQuest Dissertations and Theses were searched to obtain papers published between September 1, 2004 and August 31, 2019. A total of 14 articles met all eligibility criteria. The present systematic review suggests a strong correlation between ACEs and increased risk of MI in adulthood. Further research, nonetheless, is still needed to identify in more precise terms the mediating factors involved in the direct association between exposure to potentially traumatic situations during childhood or adolescence and the subsequent occurrence of ischemic heart disease. Supplemental data for this article is available online at https://doi.org/10.1080/26904586.2021.1970690 .

Outcomes of a multi-ethnic Asian population on combined treatment with clopidogrel and omeprazole in 12,440 patients.

Omeprazole is commonly co-prescribed with clopidogrel. Clopidogrel requires bio-activation by cytochrome P450 CYP2C19. Omeprazole may reduce clopidogrel's antithrombotic efficacy by inhibiting CYP2C19. Studies in Caucasians receiving omeprazole with clopidogrel showed no significant increase in death and myocardial infarction with this drug-drug interaction. There are limited large-scale studies in Asians, who may have a greater prevalence of CYP2C19 loss-of-function polymorphisms. A single centre retrospective cohort study was undertaken based on a review of medication records and prescription data. Patients prescribed clopidogrel from 2009 to 2012 were followed-up with until December 2012 (median:29months). The primary outcome was all-cause mortality and secondary outcomes were myocardial infarction (MI), cerebrovascular accidents, and subsequent coronary interventions. Of 12,440 patients prescribed clopidogrel, 62%(n = 7714) were on omeprazole (63.8% Chinese, 13.9% Malay, 12.4% Indian, 10.0% others), and 38%(n = 4726) were not on omeprazole or other proton pump inhibitors (62.6% Chinese, 13.5% Malay, 10.7% Indian, 13.2% others). Mortality after co-prescription occurred in 14.3%(n = 1101) of patients, compared to 6.3%(n = 300) of patients prescribed clopidogrel only. Multivariate analysis using propensity score adjusted analysis showed no significant increase in all-cause mortality with co-prescription (adjusted hazards ratio [AHR] 1.13, [95%CI 0.95-1.35]). Patients on co-prescription had a higher risk of subsequent MI (16% vs 3.8%; AHR 2.03 [95%CI 1.70-2.44]), but not of cerebrovascular accidents (5.0% vs 2.0%; AHR 0.98 [95%CI 0.76-1.27]) or coronary interventions (1.7% vs 0.7%; AHR 1.28 [95%CI 0.83-1.96]). The risk of a subsequent MI was higher in the Malay (AHR 2.43 [95%CI 1.68-3.52]) and Chinese (AHR 2.06 [95%CI 1.63-2.60]) population as compared to the Indian (AHR 1.56 [95%CI 1.06-2.31]) population. In conclusion, the use of clopidogrel with omeprazole is associated with an increased risk of MI, but not mortality or stroke, in this multi-ethnic Asian population. These risks appear to vary among different ethnic groups.

Sex-Specific Computed Tomography Coronary Plaque Characterization and Risk of Myocardial Infarction

ObjectivesThis study was designed to investigate whether coronary computed tomography angiography assessments of coronary plaque might explain differences in the prognosis of men and women presenting with chest pain. BackgroundImportant sex differences exist in coronary artery disease. Women presenting with chest pain have different risk factors, symptoms, prevalence of coronary artery disease and prognosis compared to men. MethodsWithin a multicenter randomized controlled trial, we explored sex differences in stenosis, adverse plaque characteristics (positive remodeling, low-attenuation plaque, spotty calcification, or napkin ring sign) and quantitative assessment of total, calcified, noncalcified and low-attenuation plaque burden. ResultsOf the 1,769 participants who underwent coronary computed tomography angiography, 772 (43%) were female. Women were more likely to have normal coronary arteries and less likely to have adverse plaque characteristics (p < 0.001 for all). They had lower total, calcified, noncalcified, and low-attenuation plaque burdens (p < 0.001 for all) and were less likely to have a low-attenuation plaque burden >4% (41% vs. 59%; p < 0.001). Over a median follow-up of 4.7 years, myocardial infarction (MI) occurred in 11 women (1.4%) and 30 men (3%). In those who had MI, women had similar total, noncalcified, and low-attenuation plaque burdens as men, but men had higher calcified plaque burden. Low-attenuation plaque burden predicted MI (hazard ratio: 1.60; 95% confidence interval: 1.10 to 2.34; p = 0.015), independent of calcium score, obstructive disease, cardiovascular risk score, and sex. ConclusionsWomen presenting with stable chest pain have less atherosclerotic plaque of all subtypes compared to men and a lower risk of subsequent MI. However, quantitative low-attenuation plaque is as strong a predictor of subsequent MI in women as in men. (Scottish Computed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590)

Socio-Economic Burden of Myocardial Infarction Among Cancer Patients

Cancer patients face a higher risk of future myocardial infarction (MI), even after completion of anticancer therapies. MI is a critical source of physical and financial stress in noncancer patients, but its impacts associated with cancer patients also saddled with the worry (stress) of potential reoccurrence is unknown. Therefore, we aimed to quantify MI's stress and financial burden after surviving cancer and compare to those never diagnosed with cancer. Utilizing cross-sectional national survey data from 2013 to 2018 derived from publicly available United States datasets, the National Health Interview Survey , and economic data from the National Inpatient Sample , we compared the socio-economic outcomes in those with MI by cancer-status. We adjusted for social, demographic, and clinical factors. Overall, 19,504 (10.2%) of the 189,836 National Health Interview Survey responders reported having cancer for more than 1 year. There was an increased prevalence of MI in cancer survivors compared with noncancer patients (8.8% vs 3.2%, p <0.001). MI was associated with increased financial worry, food insecurity, and financial burden of medical bills (p <0.001, respectively); however, concurrent cancer did not seem to be an effect modifier (p >0.05). There was no difference in annual residual family income by cancer status; however, 3 lowest deciles of residual income representing 21.1% cancer-survivor with MI had a residual income of <$9,000. MI continues to represent an immense source of financial and perceived stress. In conclusion, although cancer patients face a higher risk of subsequent MI, this does not appear to advance their reported stress significantly.

Abstract 15837: Particulate Matter 2.5 Exposure Increases Risk of Subsequent Myocardial Infarction

Introduction: Particulate matter 2.5 (PM 2.5 ) are airborne particles small enough to be inhaled into the pulmonary alveoli, and are associated with increased hospitalization rates, morbidity, and mortality. The purpose of this study was to evaluate the levels of PM 2.5 in southeastern Louisiana and describe associated cardiovascular outcomes in patients with a history of myocardial infarction (MI). Methods: Air quality monitoring stations were placed around southeastern Louisiana and were analyzed from March 1 st , 2019 to March 1 st , 2020. Samples were collected every 80 seconds, and values were aggregated at the hourly and daily level. We used conditional logistic regression models to determine the risk of MI. Control observations per patient were created using PM 2.5 exposure on the same day of the week for the two weeks before and after the event. Temperature, pressure, humidity, and their interactions with PM 2.5 were included in the model. Results: The average PM 2.5 exposure for the year was 10.41 ug/m 3 +/- 5.57 ug/m 3 , with a daily low of 1.93 ug/m 3 and a daily high of 31.32 ug/m 3 . Peaks from individual sensors reached PM 2.5 concentrations greater than 100 ug/m 3 . PM 2.5 concentration showed a significant, weakly positive correlation with daily average temperature and a significant, weakly negative correlation with daily average barometric pressure. Among patients (n=263) with history of MI, risk of subsequent MI increased by 24.3% per 10 ug/m 3 increase in PM 2.5 exposure with a lag of three days after exposure. (Figure) No significant risk associated with PM 2.5 exposure was observed at shorter lag times. Conclusion: Although the average PM 2.5 levels in southeastern Louisiana were within the WHO guidelines of air quality, PM 2.5 exposure remained a significant risk factor for MI among a those with previous MI.

Distinct eGFR trajectories are associated with risk of myocardial infarction in people with diabetes or prediabetes.

The relationship between estimated glomerular filtration rate (eGFR) trajectories and myocardial infarction (MI) has so far been unclear in people with diabetes or prediabetes. We aimed to identify common eGFR trajectories in people with diabetes or prediabetes and to examine their association with MI risk. The data of this analysis were derived from the Kailuan study, which was a prospective community-based cohort study. The eGFR trajectories of 24 723 participants from the year 2006 to 2012 were generated by latent mixture modeling. Cox proportional hazards models were used to calculate hazard ratios (HR) and their 95% CI for the subsequent risk of MI of different eGFR trajectories. We identified five distinct eGFR trajectories during 2006 to 2012 and named them according to their eGFR range and pattern over time: low-stable (9.4%), moderate-stable (31.4%), moderate-increasing (29.5%), high-decreasing (13.9%), and high-stable (15.8%). During a mean follow-up of 4.61 years, there were a total of 235 incident MI. Although the high-decreasing group had similar eGFR levels to the moderate-stable group during the last exposure period, the risk was much higher (adjusted HR, 3.57; 95% CI, 1.63-7.85 vs adjusted HR, 2.88; 95% CI, 1.36-6.08). Notably, the moderate-increasing group had reached the normal range, but still had a significantly increased risk (adjusted HR, 2.63; 95% CI, 1.24-5.55). eGFR trajectories were associated with MI risk in people with diabetes or prediabetes. These observations suggest that long-term trajectories of eGFR may be important for risk prediction of MI and should be highlighted in primary prevention.

Protective effect of smoking cessation on subsequent myocardial infarction and ischemic stroke independent of weight gain: A nationwide cohort study.

Smoking cessation reduces the cardiovascular risk but increases body weight. We investigated the risk of subsequent myocardial infarction and ischemic stroke according to weight gain after smoking cessation, using a nationwide population based cohort. We enrolled 3,797,572 Korean adults aged over 40 years who participated in national health screenings between 2009 and 2010. Subjects who quit smoking were classified into three subgroups according to the weight change between baseline and 4 years prior. Myocardial infarctions and ischemic strokes were followed until the end of 2015. We compared the hazard ratios among smoking cessation subgroups, non-smokers, and current smokers. The mean changes in weight (1.5 ± 3.9 kg) of the smoking cessation group were higher than those of the other groups (p < 0.0001). A total of 31,277 and 46,811 subjects were newly diagnosed with myocardial infarction and ischemic stroke, respectively. Regardless of weight change, all subgroups of smoking cessation had significantly less risk than current smokers. The subgroup of smoking cessation with weight gain over 4kg showed the lowest risk for myocardial infarctions (hazard ratio 0.646, 95% confidence interval 0.583-0.714, p < 0.0001) and ischemic strokes (hazard ratio 0.648, 95% confidence interval 0.591-0.71, p < 0.0001) after multivariable adjustment. In conclusion, weight gain after smoking cessation did not adversely affect the cardiovascular protective effect.

Long-Term Outcomes and Associations With Major Adverse Limb Events After Peripheral Artery Revascularization

BackgroundLong-term cardiovascular and limb outcomes after revascularization for peripheral artery disease and, in particular, prognosis after post-procedure major adverse limb events (MALE) are not well-studied. ObjectivesThis study sought to describe outcomes after peripheral revascularization and assess relationships between post-procedure MALE hospitalization and subsequent events. MethodsPatients undergoing peripheral artery revascularization between January 1, 2009, and September 30, 2015, in the Premier Healthcare Database were examined for the co-primary outcomes of interest, composite myocardial infarction (MI) or stroke and composite major amputation or peripheral revascularization. Multivariable adjusted Cox proportional hazards models with post-procedure MALE hospitalization included as a time-dependent covariate were developed to estimate hazard ratios for outcomes. ResultsAmong 393,017 revascularized patients followed for a median of 2.7 years (interquartile range: 1.3 to 4.4 years), the cumulative incidence of MI or stroke was 9.8% and that of major amputation or peripheral revascularization was 41.9%. A total of 50,750 patients (12.9%) had at least 1 post-procedure MALE hospitalization. In time-dependent covariate adjusted models, post-procedure MALE hospitalization was associated with greater risk of subsequent MI or stroke (hazard ratio: 1.34; 95% confidence interval: 1.28 to 1.40) and major amputation or peripheral revascularization (hazard ratio: 8.13; 95% confidence interval: 7.96 to 8.29). After peripheral revascularization with or without post-procedure MALE hospitalization, risk of limb events increased rapidly post-procedure and more slowly after the first year, whereas cardiac risk increased steadily during follow-up. ConclusionsRevascularized peripheral artery disease patients face earlier limb and later cardiovascular ischemic risk that is heightened among patients with post-procedure MALE hospitalization. Increased provider awareness of these long-term risks may guide efforts to improve post-procedural outcomes.

Severe Hypoglycemia and Risk of Subsequent Cardiovascular Events: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Intensive glycemic control significantly increases the risk of hypoglycemia in patients with diabetes mellitus. Recent data have shown that hypoglycemia may also be a marker of cardiovascular disease in these patients. We performed a systemic review and a meta-analysis to evaluate the relationship between severe hypoglycemic events (SHEs) and the subsequent risk of mortality and major adverse cardiovascular events (MACE) in patients with diabetes mellitus. PubMed, Cochrane library, and Embase were searched for randomized controlled trials between January 2006 and December 17, 2018 that reported cardiovascular outcomes in diabetic patients with a history of SHEs. The primary outcomes of interest were all-cause mortality, cardiovascular mortality, and MACE. Other outcomes assessed included myocardial infarction and hospitalization for unstable angina or heart failure. Data from 9 RCTs and 3,462 randomized patients were available. Patients who suffered an SHE were found to have a significantly increased risk of subsequent all-cause mortality (hazard ratio [HR] 2.24; 95% confidence interval [CI] 1.70, 2.95; P-value <0.01), cardiovascular mortality (HR 2.32; 95% CI 1.67, 3.22; P-value <0.01), and MACE (HR 1.66; 95% CI 1.35, 2.06; P-value <0.01) compared to the patients without an SHE. The increased risks of subsequent stroke and arrhythmic death (P-value<0.05) were also found. There was no significant association between SHE and the risk of subsequent myocardial infarction or hospitalization for unstable angina or heart failure. In conclusion, the occurrence of an SHE in patients with diabetes mellitus was associated with a significantly increased risk for subsequent cardiovascular morbidity and mortality.

Assessment of Cardiovascular Risk by the Combination of Clinical Risk Scores Plus Platelet Expression of FcγRIIa

Platelet expression of FcγRIIa was quantified after myocardial infarction (MI) and we found that patients with high platelet FcγRIIa expression (>11,000/platelet) had a fourfold greater risk of subsequent MI, stroke, and death. This analysis of the original cohort of 197 patients was designed to determine whether platelet expression of FcγRIIa could be used in combination with clinical risk scores (GRACE [Global Registry of Acute Coronary Events] and DAPT [Dual Antiplatelet Therapy]) to refine cardiovascular risk assessment. Platelet expression of FcγRIIa quantified with the use of flow cytometry was broadly distributed in patients stratified into high and low risk groups based on clinical risk scores. In patients identified as high risk by the GRACE score, 62% had high platelet FcγRIIa expression. Similarly, in patients identified as high risk by DAPT, 55% had high platelet FcγRIIa expression. High platelet FcγRIIa expression discriminated high and low risk cohorts in patients with high cardiovascular risk defined by either the GRACE score (high platelet FcγRIIa 18.9% vs low platelet FcγRIIa 0%; odds ratio = 15.7, p = 0.06) or the DAPT score (high platelet FcγRIIa 15.4% vs low platelet FcγRIIa 3.7%; odds ratio = 5.6, p = 0.03) assessment. Platelet expression of FcγRIIa merits additional study to determine whether low platelet FcγRIIa expression can be used to guide early transition to aspirin monotherapy and high platelet FcγRIIa expression can be used to guide continuation of DAPT.