Risk Of MI Research Articles

Patients with COVID-19 had increased risk for acute MI and ischemic stroke at 14 d vs. matched controls.

Katsoularis I, Fonseca-Rodriguez O, Farrington P, et al. Risk of acute myocardial infarction and ischaemic stroke following COVID-19 in Sweden: a self-controlled case series and matched cohort study. Lancet. 2021;398:599-607. 34332652.

Contribution of hypertriglyceridemia to ischemic cardiovascular disease in Korean women: A nationwide population-based study

The independent effect of serum triglyceride levels on the development of ischemic cardiovascular disease (CVD) remains inconclusive, which might be due to heterogeneity among study populations. To evaluate the effect of triglyceride levels on ischemic CVD and mortality in Korean women, with stratification according to the menopausal status, diabetes mellitus, or low-density lipoprotein cholesterol levels (LDL-C). We retrospectively investigated Korean women aged 40-69 years who underwent health examination in 2009 and were followed up until 2018 using nationwide claim data. The subjects were divided according to triglyceride quartiles (Q): Q1 <70 mg/dL, Q2 71-99 mg/dL, Q3 100-142 mg/dL, and Q4 ≥143 mg/dL. The primary outcome was the incidence of CVD defined as a composite of myocardial infarction and ischemic stroke. Among 2,208,347 women, primary outcome occurred in 62,255 (2.8%) subjects. As triglyceride levels increased, the event rate of primary outcome increased in both premenopausal and postmenopausal women in the fully adjusted model (hazard ratio [HR] per 1 Q, 1.10 [95% confidence interval (CI), 1.08-1.12] and 1.08 [95% CI, 1.07-1.09], respectively), which was maintained on further stratification according to diabetes or LDL-C (P<0.05 in all). Higher triglyceride levels were more significantly associated with the primary outcome, MI, and stroke risk among women with optimal non-high-density lipoprotein cholesterol levels (non-HDL-C) <130 mg/dL, but only weakly with stroke for women with non-optimal non-HDL-C. Triglyceride is an independent prognosticator in the development of ischemic CVD in Korean women aged 40-69 years.

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 13296: Bivalirudin versus Unfractioned Heparin in Patients With Diabetes Mellitus Undergoing Elective Percutaneous Coronary Intervention: Results at One Year

Introduction: Patients with Diabetes Mellitus (DM) and coronary heart disease have high risk in bleeding and thrombotic events. However, data on safety and effectiveness of bivalirudin in patients with DM undergoing elective percutaneous coronary intervention (PCI) are lacking which needs further scientific research. Methods: 1152 patients undergoing elective PCI anticoagulated with bivalirudin and 10250 patients anticoagulated with unfractioned heparin (UFH) were performed propensity score matching at 1:4 ratio. Finally, 376 (bivalirudin group) and 878 (UFH with or without glycoprotein IIb/IIIa inhibitors [GPI] group)patients with DM were enrolled respectively. The safe endpoints were according to the Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding and BARC 3 or 5 bleeding. The effective endpoint was major adverse cardiac and cerebrovascular events (MACCE), including death, MI, revascularization, stent thrombosis and stroke. Results: During one-year follow-up, multivariate Cox analysis showed there was no significant difference in the risk of BARC 2,3 or 5 bleeding (P=0.451) and BARC 3 or 5 bleeding (P=0.124) between bivalirudin group and UFH with or without GPI group. As for MACCE, there was no significant difference between bivalirudin group and UFH with or without GPI group (P=0.153). Moreover, there was a reduction in the risk of MI between bivalirudin group and UFH with or without GPI group (HR:0.199, 95%CI: 0.047-0.845, P=0.029) but no significant difference in the risk of death, revascularization, stent thrombosis or stroke (all P&gt;0.05). Conclusions: Although DM is considered a high risk factor for bleeding and thrombotic events, compared with UFH with or without GPI, bivalirudin reduced the risk of MI in patients with DM undergoing elective PCI and did not increase the risk of MACCE, while the risk of bleeding was similar in two groups.

Abstract 9500: One-Year Safety and Effectiveness of Bivalirudin in Patients Undergoing Elective Percutaneous Coronary Intervention

Introduction: A lot of large studies (HORIZONS-AMI, BRIGHT, EUROMAX, etc.) have shown that bivalirudin in acute myocardial infarction patients undergoing primary percutaneous coronary intervention (PCI) could reduce the bleeding while prevent thrombosis. However, data on patients undergoing elective PCI are lacking which warrants research attention. Methods: 1152 patients undergoing elective PCI anticoagulated with bivalirudin and 10251 patients anticoagulated with UFH were performed propensity score matching at 1:2 ratio. Finally, 957 and 1713 patients were enrolled in bivalirudin and UFH group respectively. The safe endpoints were according to the Bleeding Academic Research Consortium (BARC). The effective endpoint was major adverse cardiac and cerebrovascular events (MACCE). Results: During one-year follow-up, multivariate Cox analysis showed bivalirudin group had a reduction in the risk of BARC 2, 3 or 5 bleeding (HR: 0.580, 95% CI: 0.340-0.989, P=0.045), but not in the risk of BARC 3 or 5 bleeding (P=0.214) compared with UFH with or without glycoprotein IIb/IIIa inhibitors (GPI) group. To further study, we also analyzed 254 (14.8%) patients with GPI in UFH group and then found the risk of BARC 2, 3 or 5 bleeding in bivalirudin group reduced (P=0.001). As for MACCE, there was no significant difference between bivalirudin group and UFH with or without GPI group (P=0.159). Moreover, there was also no significant difference in the risk of death, revascularization, intrastent thrombosis or stroke, but a reduction in the risk of MI between bivalirudin group and UFH with or without GPI group (P=0.002). Conclusions: In patients undergoing elective PCI, bivalirudin significantly reduced the risk of BARC 2, 3 or 5 bleeding, but not that of BARC 3 or 5 bleeding compared UFH with or without GPI. No significant difference in MACCE between two groups, while bivalirudin significantly reduced the risk of MI.

Abstract 12224: Predictive Power and Value of a CAD Polygenic Risk Score in Primary Prevention Based on Age and Clinical Risk

Background: The clinical utility of polygenic risk scores (PRS) for CAD has not yet been established. We investigated the ability of a CAD PRS to potentially guide statin initiation after accounting for age and clinical risk. Methods: We performed a prospective cohort study in the UK Biobank that included all individuals without a history of CAD and who were not on lipid-lowering therapy. The CAD PRS was comprised of 241 genome-wide significant SNPs. Genetic risk categories were defined as low (bottom 20%), intermediate, and high (top 20%). HRs were calculated as a function of age. Next, 10-year ASCVD risk score was used to classify individuals as low, borderline, intermediate, or high risk. Each ASCVD risk group was further stratified by genetic risk to determine whether genetics could reclassify individuals to help guide decisions regarding statin initiation with more precision. ASCVD events were defined as incident clinical CAD (including MI), stroke, or CV death. Results: The 333,245 patients included in this study were ages 40-74 years (avg 57) and 57% were female. Over the 10-yr follow-up, there were 4,552 MIs. The CAD PRS significantly predicted MI in all age groups but had significantly stronger risk prediction at younger ages (p-int &lt;0.001) ( Figure, A ). This gradient of risk was especially pronounced under 50 years of age, where those with high PRS approached a 6-fold increased risk of MI compared with those in the low PRS category. When CAD PRS testing was added to the 71,534 patients &lt;50 years old, 20% of borderline risk patients were reclassified into intermediate risk, warranting initiation of statin therapy to reduce LDL-C, and 20% of borderline and intermediate risk patients were reclassified as low risk, thus not warranting therapy ( Figure, B ). Conclusion: The predictive ability of a CAD PRS is especially strong in individuals under the age of 50 and can be used to identify more precisely who should be initiated on statin therapy.

Abstract 13280: apoB-Containing Lipoproteins and Risk of Myocardial Infarction: Distinguishing Between Particle Concentration, Content, and Type

Background: Lipid management typically focuses on levels of LDL cholesterol (LDL-C) and, to a lesser extent, triglycerides (TG). Basic investigation and genetic studies, however, suggest that the atherogenic particle subpopulations (LDL &amp; VLDL) are similarly important and that the number of particles is more important than their lipid content. Methods: We performed a prospective cohort analysis in two populations: 1) 389,529 primary prevention patients w/o lipid-lowering therapy from UK Biobank, and 2) 45,708 statin-treated patients w/ established atherosclerosis from the FOURIER and IMPROVE-IT trials. Incident MI was assessed over a median follow up of 11.1 yrs in UKBB and 3.6 yrs in the trials. Adjusted HRs were calculated to determine whether lipid content (non-HDL-C &amp; TG) or particle type (using LDL-C concentration as a surrogate for LDL, and TG concentration as a surrogate for TG-rich lipoproteins) offer predictive value beyond atherogenic particle concentration (apoB). Results: In the primary prevention cohort, apoB, non-HDL-C, and TG each individually predicted incident MI. However, when assessed together, only apoB remained a significant predictor (adj HR per 1-SD = 1.28 [95%CI: 1.16,1.42], p&lt;0.0001) ( Fig, A/B ). Similarly, only apoB remained a predictor of MI in the secondary prevention cohort ( Fig, C/D ). Adjusting for apoB, there was no relationship between the ratio of TG to LDL-C (a surrogate for the ratio of TG-rich lipoproteins to LDL) and the risk of MI (p=0.32, Fig, E ), implying that for a given concentration of apoB-containing lipoproteins, the relative proportion of particle subpopulations is not an independent predictor of risk. Conclusion: Risk for MI is best captured by the number of apoB-containing lipoproteins, independent from lipid content (cholesterol or TG) or type of lipoprotein (LDL or TG-rich). Therefore, therapeutic strategies should take into account lowering the overall concentration of all apoB-containing lipoproteins.

Abstract 9399: A Targeted Proteomic Approach Identifies Novel Biomarkers Associated With Risk of Myocardial Infarction in Post-Menopausal Women

Introduction: There may be unique pathways that contribute to heart disease in women. We used proteomics to evaluate the association between a panel of biomarkers and risk of incident MI in post-menopausal women and thus to inform risk prediction and potential disease biology. Methods: We analyzed 184 candidate biomarkers (Olink CVD II/III) in LOFT, a randomized trial of an osteoporosis drug in post-menopausal women. Cases and controls without prevalent CV disease were matched by age and follow-up time (123 MI cases, 123 controls). A Benjamini-Hochberg correction was applied for false discovery (adj P value &lt;0.05). Conditional logistic regression was adjusted for the ACC/AHA pooled cohort equations (PCE). Results: 16 biomarkers assessed at baseline were associated with incident MI at the FDR threshold (Fig). After multivariable adjustment, 8 markers remained significantly associated with incident MI, including BNP (adj OR per SD 2.52, 95% CI 1.49-4.28), NT-proBNP (adj OR 2.41, 95% CI 1.43-4.08) and metalloproteinases including MMP-2 (adj OR 1.86, 95% CI 1.08-3.22) and MMP-12 (adj OR 1.55, 95% CI 1.02-2.37; Fig). Network analyses suggested these markers were overall strongly concentrated in pathways of inflammation, cellular movement and immune cell trafficking. Conclusions: A targeted proteomic approach identified markers of inflammation and immune cell trafficking as predictors of MI in post-menopausal women independent of traditional risk markers. Metalloproteinases, markers of plaque rupture and erosion, may provide insights into plaque biology and atherogenesis in women and warrant further investigation.

Validating the UK prospective diabetes study outcome model 2 using data of 94,946 Israeli patients with type 2 diabetes

AimsTo externally validate the United Kingdom Prospective Diabetes Study (UKPDS) Outcome Model 2 (OM2) in contemporary Israeli patient populations. MethodsDe-identified patient data on demographics, time-varying risk factors, and clinical events of newly diagnosed type 2 diabetes patients were extracted from the Maccabi Healthcare Services (MHS) diabetes registry over years 2000–2013. Depending on the baseline risk, patients were categorized into low-risk and intermediate-risk groups. In addition to assessing discriminatory performance, the predicted and observed 15-year cumulative incidences of diabetes complications and death were compared among all patients and for the two risk-groups. ResultsThe discriminatory capability of OM2 was moderate to good, C-statistic ranging 0.71–0.95. The model overpredicted the risk for MI, blindness and death (Predicted/Observed events (P/O: 1.32–2.31)), and underpredicted the risk of IHD (P/O: 0.5). In patients with a low baseline risk, overpredictions were even more pronounced. OM2 performed well in predicting renal failure and ulcer risk in patients with a low risk but predicted well the risk of death, stroke, CHF, and amputation in patients with an intermediate risk. ConclusionOM2 demonstrated good to moderate discrimination capability for predicting diabetes complications and mortality risks in Israeli diabetes population. The prediction performance differed between patients with different baseline risks.

Biological Basis and Proposed Mechanism of Action of CSL112 (Apolipoprotein A-I [Human]) for Prevention of Major Adverse Cardiovascular Events in Patients post Myocardial Infarction

Despite current standard of care treatment, the period shortly after acute myocardial infarction (AMI) is associated with particularly high residual cardiovascular (CV) risk, with high rates of recurrent AMI and CV death in the first 90 days following the index event. This represents an area of high unmet need which may be potentially addressed by the recent shift in focus away from raising levels of high-density lipoprotein cholesterol (HDL-C), to ones that optimize HDL function. Apolipoprotein A-I (apoA-I) is the major protein constituent of HDL and a key mediator of cholesterol efflux from macrophages within atherosclerotic plaque, a property which may convey therapeutic efficacy during the high-risk period. CSL112 is a novel formulation of human plasma-derived apolipoprotein A-I (apoA-I), reconstituted with phosphatidylcholine and stabilized with sucrose that is currently being evaluated in a phase 3 clinical trial (AEGIS-II) for the reduction of major adverse CV events (MACE) in the period of high-risk post AMI. Patients with diabetes mellitus are especially at high risk of recurrent MI, and are an enriched patient population in the AEGIS-II study. In this presentation, we provide an overview of the biological properties of CSL112 that contribute to its proposed mechanism of action for reducing rates of MACE post AMI. These properties include rapid and robust promotion of cholesterol efflux from cells abundant in atherosclerotic plaque, in addition to anti-inflammatory effects, which together, may have a stabilizing effect on atherosclerotic plaque. We provide a detailed overview of these mechanisms, in addition to information on the composition of CSL112 and how it is manufactured.

Efficacy and Safety of Lipid-Lowering Drugs of Different Intensity on Clinical Outcomes: A Systematic Review and Network Meta-Analysis.

There have been many meta-analyses for statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) to evaluate clinical outcomes, but the efficacy and safety of different intensity of these three drugs on clinical outcomes was absent. PCSK9i, ezetimibe, and statins were divided into seven interventions as follows: including PCSK9i + high-intensity statins (P9i+HT), PCSK9i + moderate-intensity statins (P9i+MT), ezetimibe + high-intensity statins (Eze+HT), ezetimibe + moderate-intensity statins (Eze+MT), high-intensity statins (HT), moderate-intensity statins (MT), and low-intensity statins (LT). The risk ratios (RR) and 95% confidence intervals (CI) were calculated to evaluate the clinical outcomes in all randomized controlled trials included. In traditional meta-analysis, the more intensive treatment had a lower risk of all-cause mortality (RR 0.91, 95% CI 0.88–0.95), cardiovascular mortality (RR 0.89, 95% CI 0.86–0.92), myocardial infarction (RR 0.79, 95% CI 0.77–0.81), coronary revascularization (RR 0.80, 95% CI 0.76-0.84), and cerebrovascular events (RR 0.84, 95% CI 0.80–0.88) compared with the less intensive treatment. However, the more intensive treatment had a higher risk of new-onset diabetes (RR 1.08, 95% CI 1.04-1.12). The network meta-analysis demonstrated that P9i+HT, P9i+MT, HT, and MT were significantly associated with a risk reduction in coronary revascularization and cerebrovascular events compared with PLBO. LT could effectively reduce the risk of cardiovascular mortality (RR 0.71, 95% CI 0.54–0.92), MI (RR 0.67, 95% CI 0.54-0.82), and coronary revascularization (RR 0.77, 95% CI 0.65–0.91) compared with PLBO. P9i+HT was superior to HT in reducing the risk of MI (RR 0.78, 95% CI 0.68–0.90), coronary revascularization (RR 0.84, 95% CI 0.73–0.96), and cerebrovascular events (RR 0.78, 95% CI 0.64–0.95). However, compared with PLBO, P9i+HT, HT, and MT could increase the risk of new-onset diabetes (RR 1.23, 95% CI 1.11–1.37; RR 1.23, 95% CI 1.14–1.33; RR 1.09, 95% CI 1.02–1.15, respectively). In conclusion, PCSK9i added to background statins may be recommended as preferred lipid-lowering therapy, and did not increase the additional risk of new-onset diabetes. The safety and efficacy of ezetimibe was not superior to that of statins. LT can be recommended as the initial therapy.

Associations between metabolic syndrome at index PCI and 1-year outcomes

Abstract Background The prevalence of obesity, diabetes and metabolic syndrome is rising, with negative health consequences for the community. Purpose We sought to examine the prevalence and impact of metabolic syndrome (MetS) on 1-year outcomes from an Australian cohort of all-comer PCI patients. Methods We retrospectively analysed the GenesisCare Outcomes multicentre Registry of prospectively collected data in patients undergoing PCI from 2008–2020. Metabolic syndrome was defined as presence of any 3 features including hypertension, diabetes, obesity with body mass index ≥30 kg/m2 and dyslipidaemia. We examined 1-year outcomes for death and MACE (death, MI or TLR), and the adjusted risk after accounting for each of the defining variables. Results During the study period from 2005–2018, 14,405 were included, of which 5480 (38%) had metabolic syndrome. MetS patients were somewhat younger without sex differences (∼76% men). They had greater prevalence of defining characteristics, and smoking and lower prevalence of myocardial infarction presentation compared to non-MetS patients. MetS patients had higher prevalence of B2/C type lesions, restenosis, chronic total occlusions and multivessel disease. At 30-days MetS patients had lower risk of re-infarction (0.1% vs. 0.3%, p=0.011) but from 30-days to 1-year they had greater risk of MI (1.1% vs. 0.5%, p&amp;lt;0.01), TLR (1.5% vs. 1.1%, p=0.03), readmissions (21.8% vs. 19.8%, p=0.008) and MACE (3.6% vs. 2.7%, p=0.03) without differences in mortality (1.3% in both, p=0.88). Unadjusted models showed trend for greater risk of 1-year MACE with MetS, HR 1.15 (95% CI 1.00–1.33), p=0.054. In multivariable models, this risk was lost after adjusting individually for hypertension, dyslipidaemia and insulin-treated diabetes, but not after adjustment for obesity and non-insulin diabetes (See Figure). Conclusions Metabolic syndrome was noted in over one-third of all-comer PCI patients, and was associated with greater risk of 1-year MACE. This risk appeared to be related to hypertension, dyslipidaemia and insulin-treated diabetes but not obesity. Funding Acknowledgement Type of funding sources: None.

Cardiovascular benefit of lowering LDL-C below 1 mmol/L (40 mg/dl)

Abstract Background The 2019 ESC/EAS Dyslipidemia Guidelines recommend an LDL-C goal of &amp;lt;1.4 mmol/L (∼55 mg/dl) for patients with very high-risk ASCVD, and &amp;lt;1 mmol/L (∼40 mg/dl) for those with recurrent events within 2 years despite taking maximally tolerated statin therapy. The addition of PCSK9 inhibitors to statin therapy can achieve LDL-C levels well below 1 mmol/L in many patients, yet the clinical benefit of LDL-C lowering beyond this level has recently been questioned. Methods FOURIER was a cardiovascular outcomes trial comparing evolocumab vs. placebo in patients with stable ASCVD on optimized statin therapy with a median follow-up of 2.2 years. We performed an exploratory analysis to determine the consistency of CV risk reduction with LDL-C lowering below ∼1 mmol/L (40 mg/dl) with evolocumab. We modeled the achieved LDL-C at 48 weeks in the two treatment arms as well as the percentage of LDL-C difference between the two arms that was due to LDL-C below ∼1 mmol/L (40 mg/dl) as a function of baseline LDL-C. We then modeled the hazard ratio (HR) for the composite of CV death, MI or stroke (per 1 mmol/L reduction in LDL-C) with evolocumab vs. placebo as a function of baseline LDL-C. Results All 27,564 patients from FOURIER were included in this analysis. Patients with lower baseline LDL-C achieved lower LDL-C levels following evolocumab therapy, with achieved LDL-C typically being below 1 mmol/L (40 mg/dl) once the baseline LDL-C was below 2.4 mmol/L (94 mg/dl) and reaching levels approaching 0.5 mmol/L (∼20 mg/dl). Accordingly, the further baseline LDL-C levels were below 2.4 mmol/L (94 mg/dl), the greater the proportion of the difference in achieved LDL-C between the evolocumab and placebo arms was due to LDL-C levels below ∼1 mmol/L (40 mg/dl), reaching nearly 40% of the difference in LDL-C between treatment arms (Upper Panel). Despite this, the clinical benefit of LDL-C lowering was not attenuated (p=0.78) (and even appeared greater), with robust reductions in risk of CV death, MI or stroke even when LDL-C was lowered to nearly 0.5 mmol/L (∼20 mg/dl) and having close to 40% of the LDL-C difference between treatment arms due to LDL-C lowering below ∼1 mmol/L (40 mg/dl) (Lower Panel). Conclusion PCSK9 inhibitors added to statin therapy can achieve LDL-C well below 1 mmol/L (40 mg/dl). There is no evidence for attenuation of the clinical benefit of lowering LDL-C below this threshold. These data support lowering LDL-C to below 1 mmol/L (40 mg/dl) in patients with ASCVD. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health

CLINICAL OUTCOMES OF EARLY REPATRIATION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION FROM A SINGLE, REGIONAL CARDIAC CARE CENTRE

<h3>BACKGROUND</h3> Centres that perform percutaneous coronary intervention (PCI) have resources specialized in the care of ST-elevation myocardial infarction (STEMI) patients both during and after PCI. Due to limited hospital resources, many centres that perform PCI have adopted protocols where STEMI patients are transferred to a non-PCI capable centre following successful PCI. However, the safety of this practice is not well established. The study objective is to evaluate the clinical outcomes of the current practice of transferring patients to non-PCI capable centres following successful PCI in a single, tertiary care regional PCI centre. <h3>METHODS AND RESULTS</h3> A retrospective analysis was performed of all consecutive STEMI patients presenting to a single, regional cardiac care centre between January 2013 and December 2014. STEMI patients with high-risk features including cardiac arrest, cardiogenic shock, medical complication nof STEMI, requiring transvenous pacing, mechanical ventiliation, mechanical circulatory support or not reperfused by PCI were excluded. Patients who were unable to be linked to the Provincial Population Registry were also excluded. Patients were analyzed based on whether they were transferred to a non-PCI capable centre following PCI for ongoing post-STEMI care. Clinical presentation, comorbidities, angiographic findings, revascularization, and repatriation status data were collected from the electronic medical record and cath lab database. Study data was linked to the Research Repository at the Manitoba Centre for Health Policy for long-term clinical outcomes. Of the 1092 consecutive STEMI patients screened, 337 patients (31%) were excluded (Figure). The final study cohort (n=697) included 397 repatriated patients and 300 non-repatriated patients. The median age of the study cohort was 60 (53-70) years. Baseline characteristics are summarized in the Table. The median length of stay at the PCI-capable hospital was 139 minutes (IQR 97-235 minutes) with 84% of patients transferred within 6 hours. Inverse probability of treatment weighting (IPTW) was used to adjust for unbalanced characteristics between the two study groups. All-cause mortality (12.9% admitted vs 10.4% repatriated patients, adjusted HR 0.90, 95% CI 0.64-1.26, p=0.535) and repeat MI (11.0% admitted vs 5.4% repatriated, adjusted HR 0.71, 95% CI 0.49-1.02, p=0.06) at 5 years were not statistically significant after IPTW adjustment, respectively. <h3>CONCLUSION</h3> This analysis demonstrated that there is no increased risk of mortality or repeat MI at five years in STEMI patients who are transferred to a non-PCI capable centre following successful PCI. This suggests that early repatriation is safe and effective for low-risk STEMI patients.

The Clinical Impact of Proton Pump Inhibitors When Co-Administered With Dual Antiplatelet Therapy in Patients Having Acute Myocardial Infarction With Low Risk of Gastrointestinal Bleeding: Insights From the China Acute Myocardial Infarction Registry.

Background: The latest guidelines recommend the use of proton pump inhibitors (PPIs) to minimize gastrointestinal bleeding (GIB) in patients receiving dual antiplatelet therapy (DAPT), even though this co-administration may increase the risk of ischemia due to drug interactions. We have noticed that there are few studies conducted on patients with a lower risk of GIB. Therefore, we investigated the clinical effect of co-administration of PPI on DAPT patients with low GIB risk.Methods and Results: From January 2013 to September 2014, a total of 17,274 consecutive patients on DAPT from 108 hospitals with low risk for GIB in the China Acute Myocardial Infarction (CAMI) registry were analyzed. The primary endpoints were GIB and major adverse cardiovascular and cerebrovascular events (MACCE). Multivariate logistic regression analysis and Cox proportional hazard models were used to assess the effect of PPIs use. Of the analyzed patients, 66.6% (n = 11,487) were treated with PPIs. PPI use did not show an extra gastrointestinal protective effect in patients with low risk for GIB who were hospitalized and on follow-up after 2 years. Moreover, it was associated with an increased risk of stroke during the 2-year follow-up [hazard ratio (HR) 2.072, 95% confidence interval (CI) 1.388–3.091, p = 0.0003] and an increased risk of MI after 6 months (HR 1.580, 95% CI 1.102–2.265, p = 0.0119). We found the same results after propensity score matching.Conclusion: PPI use is prevalent in DAPT patients with low GIB risk. PPIs did not show an extra gastrointestinal protective effect, while an increased risk of stroke was observed during the 2-year follow-up.Clinical Trial Registration:www.clinicaltrials.gov, identifier NCT01874691.

Plasma and genetic determinants of soluble TREM-1 and major adverse cardiovascular events in a prospective cohort of acute myocardial infarction patients. Results from the FAST-MI 2010 study

IntroductionTriggering receptor expressing on myeloid cells (TREM)-1 is involved in the pathophysiology of ischemic heart disease. Plasma soluble TREM-1 levels (sTREM-1) has been associated with increased risk of major adverse cardiovascular events (MACE) in acute myocardial infarction (AMI) patients. However, the causative link between TREM-1 and MACE remains unknown and requires further investigation before developing potential therapeutic approaches. Methods and resultsUsing the serum and DNA data bank from the prospective, nationwide French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI 2010, N = 1293), we studied the association of plasma levels of sTREM-1 with 9 common genetic variants at the TREM1 locus and their relationship with recurrent MACE over a 3-year follow up. Plasma levels of sTREM-1 were associated with an increased risk of MACEs (death, recurrent MI or stroke) (adjusted HR = 1.86, 95%CI = 1.06–3.26 and HR = 1.11, 95%CI = 0.61–2.02 respectively for tertiles 3 and 2 versus tertile 1, P < 0.001). The study of common variants identified two major genetic determinants of sTREM-1 (rs4714449: beta = −0.11, Padd = 7.85 × 10−5 and rs3804276: beta = 0.18, Padd = 2.65 × 10−11) with a potential role on maintenance and/or differentiation of hematopoietic stem cells. However, associated variants only explained 4% of sTREM-1 variance (P = 2.74 × 10−14). Moreover, the rs4714449 variant, individually and in haplotype, was not significantly associated with MACE (HR = 0.61, 95%CI: 0.35–1.05, P = 0.07). ConclusionsDespite its relationship with increased risk of death, recurrent MI and stroke, genetic determinants of plasma levels of sTREM-1 were not found to be causal prognostic factors in patients with acute myocardial infarction.

Comparative effect of angiotensin converting enzyme inhibitor versus angiotensin ii type i receptor blocker in acute myocardial infarction with non-obstructive coronary arteries; from the Korea Acute Myocardial Infarction Registry - National Institute of Health.

Selecting angiotensin converting enzyme inhibitor (ACEI) or angiotensin II type I receptor blocker (ARB) in patients diagnosed as acute myocardial infarction (AMI) with non-obstructive coronary arteries (MINOCA) is not established. The purpose of this study is to compare the clinical effect of ACEI vs. ARB in MINOCA patients. A total of 273 patients between November 2011 to June 2015, diagnosed with MINOCA who were registered in the Korea Acute Myocardial Infarction Registry - National Institute of Health were enrolled. Patients were divided into ACEI (n = 112) and ARB groups (n = 161). The primary endpoint was cumulative incidence of major adverse cardiac events (MACE) defined as cardiac death, recurrent MI, any new revascularization during 2 years clinical follow-up. Secondary endpoint was heart failure requiring re-hospitalization. Propensity score matching analysis was done. The incidence of primary endpoint was similar (10.4% vs. 15.6%, HR: 0.65; 95% CI: 0.29-1.47; p = 0.301) among both groups. However, the incidence of recurrent MI was significantly lower in ACEI group compared to ARB group (2.1% vs. 10.4%, HR: 0.18, 95% CI: 0.04-0.86; p = 0.031). In the present study, the risk and incidence of MACE was similar between ACEI and ARB therapy in MINOCA patients. However, ACEI significantly reduced the risk of recurrent MI. Further larger scale multi-center randomized clinical trials are needed to clarify the proper use of renin-angiotensin-aldosterone system blocker in these patients.

Risk of Heart Disease after Cholecystectomy: A Nationwide Population-Based Cohort Study in South Korea.

The aim of the study is to evaluate the risk of heart disease in individuals who underwent cholecystectomy. This was a retrospective cohort study using the National Health Insurance Service database of South Korea. A total of 146,928 patients who underwent cholecystectomy and 268,502 age- and sex-matched controls were compared. Multivariate Cox proportional hazard regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for heart disease after cholecystectomy. In results, a previous history of cholecystectomy increased the risk of heart disease (congestive heart failure [CHF], myocardial infarction [MI], atrial fibrillation [AF]) (adjusted HR [aHR]: 1.40, 95% CI: [1.36–1.44]). The increased risk was particularly seen for CHF (1.22 [1.16–1.29]) but not for MI and AF (p > 0.05). In the subgroup analyses, cholecystectomy was associated with an increased risk of MI in patients aged <65 years (1.49 [1.16–1.92] and 1.18 [1.05–1.35] in patients aged 40–49 and 50–64 years, respectively), but not in those aged ≥ 65 years (0.932 [0.838–1.037]). Moreover, the risk of MI was increased in patients without diabetes mellitus (DM) (1.16 [1.06–1.27]); however, it was decreased in patients with DM (0.83 [0.72–0.97]). In contrast, cholecystectomy did not modify the risk of AF in the subgroup analyses (all p > 0.05). In conclusion, a history of cholecystectomy is associated with an increased risk of CHF. Cholecystectomy may increase the risk of MI in the younger population without DM. These findings suggest that the alteration of bile metabolism and homeostasis might be potentially associated with the development of some heart diseases.

Tofacitinib increases risk of MI, lung cancer and lymphoma

Tofacitinib increases risk of MI, lung cancer and lymphoma

Cardiovascular events and mortality in a population-based cohort initially diagnosed with ductal carcinoma in situ

BackgroundDuctal carcinoma in situ (DCIS) patients are usually diagnosed through cancer screening programs, suggesting a healthy user effect. In this population-based cohort, we assessed the risk of cardiovascular events and mortality in DCIS patients.MethodsUsing the Korean National Health Insurance Service database, 13,740 women, who were initially diagnosed with DCIS between 2007 and 2013, were analyzed. A control group was matched according to age and the year of diagnosis at a 3:1 ratio (n = 41,220). Follow-up was performed until 2016. Subgroup analysis was performed according to the subsequent diagnosis of invasive breast cancer within 1 year: pure DCIS and DCIS+Invasive group.ResultsDCIS patients were more likely to have underlying diseases, higher incomes, and to live in urban districts compared to the control group. Women diagnosed of DCIS had lower myocardial infarct risk (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.46–0.90) and lower stroke risk (HR 0.77; 95% CI 0.60–0.98) compared to the control group. This trend of lower risk was sustained after adjusting for age, income, residence and comorbidities. The mortality rate was similar between the control group and pure DCIS patients but was higher in the DCIS+Invasive group (HR 1.63; 95% CI 1.34–1.98). However, after adjusting for age, income, residence and comorbidities, mortality did not differ between the control group and DCIS+Invasive group (HR 0.99; 95% CI 0.78–1.24).ConclusionsDCIS patients were at lower risk for MI and stroke compared to a control group despite a higher rate of comorbidities, which may reflect changes in health behaviour. The importance of managing pre-existing comorbidities along with DCIS treatment should be emphasized.