Segment Elevation Myocardial Infarction Patients Research Articles

Additive prognostic value of left ventricular ejection fraction to the TIMI risk score for in-hospital and long-term mortality in patients with ST segment elevation myocardial infarction.

To investigate whether the addition of left ventricular ejection fraction (LVEF) to the TIMI risk score enhances the prediction of in-hospital and long-term death in ST segment elevation myocardial infarction (STEMI) patients. 673 patients with STEMI were divided into three groups based on TIMI risk score for STEMI: low-risk group (TIMI≤3, n=213), moderate-risk group (TIMI 4-6, n=285), and high-risk group (TIMI≥7, n=175). The predictive value was evaluated using the receiver operating characteristic. Multivariate logistic regression was used to determine risk predictors. The rates of in-hospital death (0.5 vs 3.2 vs 10.3%, p<0.001) and major adverse cardiovascular events (14.6 vs 22.5 vs 40.6%, p<0.001) were significantly higher in high-risk group. Multivariate analysis showed that TIMI risk score (OR1.24, 95% CI 1.04-1.48, P=0.015) and LVEF (OR3.85, 95% CI 1.58-10.43, P=0.004) were independent predictors of in-hospital death. LVEF had good predictive value for in-hospital death (AUC: 0.838 vs 0.803, p=0.571) or 1-year death (AUC: 0.743 vs 0.728, p=0.775), which was similar to TIMI risk score. When compared with the TIMI risk score alone, the addition of LVEF was associated with significant improvements in predicting in-hospital (AUC: 0.854 vs 0.803, p=0.033) or 1-year death (AUC: 0.763 vs 0.728, p=0.016). The addition of LVEF to TIMI risk score enhanced net reclassification improvement (0.864 for in-hospital death, p<0.001; 0.510 for 1-year death, p<0.001). LVEF was associated with in-hospital and long-term mortality in STEMI patients and had additive prognostic value to TIMI risk score.

The effect and safety of tirofiban on acute ST segment elevation myocardial infarction patients receiving no early reperfusion therapy

To study the efficacy and safety of tirofiban on acute ST segment elevation myocardial infarction (STEMI) in patients who do not receive early reperfusion therapy. A total of 153 STEMI patients without early reperfusion therapy were randomly distributed into tirofiban group (therapeutic group, n=78) and non-tirofiban group (control group, n=75). Coronary angiography was performed on the 5(th) and 10(th) day after treatment, and percutaneous coronary intervention (PCI) was conducted when necessary. The differences of initial patency of the infarct related artery (IRA), bleeding complication and clinic events within 30 days between these two groups were compared. Tirofiban did not increase the percentage of patients with initial patency of IRA (60.3% vs 64.0%, P=0.63). The percentage of patients with thrombolysis in myocardial infarction (TIMI) 3 after PCI was 100.0% in tirofiban group and 97.1% in the control group (P=0.09). However, application of tirofiban significantly decreased poor myocardial perfusion rate after PCI (1.4% vs 8.8%, P=0.04). No significant differences were observed in major adverse cardiovascular events (MACE) (3.8% vs 2.7%, P=0.68) between therapeutic and control group. The same is true for mild (5/78 vs 4/75 cases, P=0.78) and severe hemorrhage (2/78 vs 1/75 cases, P=0.58), and severe thrombocytopenia (2/78 vs 0/75 cases, P=0.10) between these two groups within 30 days. Tirofiban did not increase initial patency in STEMI patients without early reperfusion therapy. However, it can improve myocardial perfusion after PCI.

Effect of admission glycometabolic state on clinical outcome in non diabetic subjects with acute st segment elevation myocardial infarction

Background and aimGlycosylated hemoglobin (HbA1c) is a more stable and accurate parameter of the glycometabolic state than fasting glycemia. However, its role in predicting the prognosis in acute myocardial infarction patients remains unclear with conflicting results from the available data. This study evaluates the effect of admission HbA1c as a parameter of the glycometabolic state on the clinical outcome in non diabetic acute st segment elevation myocardial infarction (STEMI) patients. MethodBetween June 2012 and December 2014, 208 consecutive STEMI non diabetic patients who underwent primary percutaneous coronary intervention (PPCI) were enrolled. Patients were divided according to the HbA1c level into 2 groups 112 patients in group I (HbA1c⩽5.6%) and 96 patients in group II (HbA1c 5.7–6.4%). In hospital and at 6months major adverse cardiac outcome (MACE) was calculated. ResultsMean age was 55.9±7.12years, 149 were men and there was no significant difference regarding baseline characteristics. Post PPCI TIMI III flow was higher in group I (p=0.016), angiographic no reflow was higher in group 2 (p=0.003). No significant difference regarding in hospital MACE (p=0.44). At 6month follow up MACE was significantly higher in group 2 (p<0.001) and this mainly due to higher incidence of target lesion revascularization (TLR) in group 2 (p<0.001). Multivariate analysis showed that HbA1c is significantly associated with 6months MACE (hazard ratio 1.9; p=0.022). ConclusionAbnormal glycometabolic state assessed by HbA1c at admission in non diabetic STEMI patients was associated with higher MACE incidence at 6months follow up.

Red cell distribution width predicts totally occluded infarct-related artery in NSTEMI

Objective Since non-ST segment elevation myocardial infarction (NSTEMI) patients with totally occluded infarct-related artery (TO-IRA) have worse prognosis, it is important to recognize TO-IRA in NSTEMI. Red cell distribution width (RDW) and mean platelet volume (MPV) are novel markers of inflammation and oxidative stress and were associated with poor clinical outcomes in acute coronary syndrome. In the present study, association of RDW and MPV with the presence of TO-IRA in NSTEMI was investigated. Methods Data of 201 consecutive patients who underwent coronary angiography with a diagnosis of NSTEMI were analyzed. Independent predictors of TO-IRA were investigated with logistic regression analysis. Results Sixty-six (32.8%) of the patients had TO-IRA. In patients with TO-IRA, RDW and troponin-T were significantly higher and left ventricular ejection fraction (LVEF) was lower. MPV did not differ between groups. Circumflex (CX) IRA was more common in TO-IRA group. The ROC curve analysis showed that the RDW at a cut-point of 13.95% has 76% sensitivity and 66% specificity in detecting TO-IRA. RDW, troponin-T, LVEF and CX-IRA were independent predictors of TO-IRA in NSTEMI, but MPV was not. Conclusion RDW is a cheap and readily available marker that may have a role to predict TO-IRA in NSTEMI.

Relation of Pulmonary Artery Pressure and Renal Impairment in ST Segment Elevation Myocardial Infarction Patients.

Recent reports have demonstrated the adverse effects of venous congestion on renal function in patients having heart failure. None of the above trials, however, included patients with acute ischemia. Echocardiographic correlates of increased right ventricular afterload would be associated with an increased risk of acute kidney injury (AKI) in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We conducted a retrospective study of consecutive 930 STEMI patients who underwent primary PCI and had a full echocardiography study performed within 72 hours of hospital admission between June 2011 and December 2014. Echocardiography demonstrated that patients with AKI had significantly lower left ventricular (LV) ejection fraction, higher systolic pulmonary artery pressure (SPAP), and right atrial pressures (P < 0.001 for all). Following the performance of logistic multivariate analysis model, SPAP (HR 1.07, 95% CI 1.04-1.11; P < 0.001) and LV ejection fraction (HR 0.95, 95% CI 0.92-0.99; P = 0.03) emerged as independent predictors of AKI. On receiver operating characteristic (ROC) curve analysis, the optimal cutoff value of SPAP to predict AKI was measured as more than 32 mmHg, with 71% sensitivity and 62% specificity (AUC 0.739, 95% CI 0.671-0.806, P < 0.001). Among STEMI patients undergoing primary PCI, worse LV function and elevated SPAP were associated with increased risk of AKI.

Acute kidney injury among ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention: a multifactorial entity.

Acute kidney injury is a frequent complication among ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), and is associated with adverse outcomes. While contrast nephropathy is considered the most important reason for worsening of renal function, recent data have suggested the role of other important factors among this specific patient population. In the present review, we examine the various factors leading to renal impairment in STEMI patients and place the findings in the context of this specific patient population in the era of primary PCI. These factors include contrast nephropathy, time to coronary reperfusion, cardiac pump function and hemodynamics as well as various inflammatory and metabolic markers.

Management Strategies and Outcomes of ST‐Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States

Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.

Feasibility and safety of continuous glucose monitoring systems in acute myocardial infarction subjects undergoing primary percutaneous coronary interventions.

The purpose of this study was to evaluate the feasibility and safety of continuous glucose monitoring systems (CGMS) in ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary interventions (p-PCI) in coronary care units (CCU). CGMS was performed for 3 days during CCU hospitalization for each of the subjects. The correlation between glucose values, recorded with CGMS, and finger-stick capillary glucose values was examined. The parameters and safety of CGMS were also investigated. Data from 219 subjects were included in the statistical analysis. Correlation analysis showed a strong positive correlation between interstitial glucose values recorded by CGMS and the corresponding capillary glucose values (P<0.001). The daytime mean blood glucose (MBG), the nighttime MBG and PT7.8 were the highest in the first day of CGMS compared with the second and third day. Furthermore, there were no indications of major hemorrhage or hematoma at the site of sensor insertion. Any adverse events were mild. CGMS glucose values are relatively accurate and reliable. CGMS were safe and can be used as a tool to detect trends in glucose levels and to predict upcoming glucose excursions in STEMI patients undergoing p-PCI.

Abstract 19705: Real-time Home-to-hospital Ischemic Time Dashboard in Patients With ST segment Elevation Myocardial Infarction Results in Significant Improvement of the Logistic Chain and Lower Short-term Mortality

Introduction: Timely reperfusion with primary percutaneous coronary intervention (PCI) in ST segment elevation myocardial infarction (STEMI) patients is associated with superior clinical outcomes. Aiming to reduce ischemic time, an innovative system for H2H time monitoring was implemented. The objective of this study was to assess the results of a real time home-to-hospital (H2H) dashboard for monitoring and evaluation of ischemic time in STEMI patients. Methods: Ischemic time in STEMI patients transported by Emergency Medical Services (EMS) and treated with primary PCI in the Medical Center Alkmaar before (n=843) and after the implementation of the H2H dashboard (n=441) was compared. Time points in the H2H dashboard were semi-automatically registered, enabling evaluation by the EMS and Cardiology departments. Before implementation of the H2H dashboard, time points were recorded on paper and retrospectively collected. Results: Median treatment delay, first medical contact (FMC) to balloon time and door-to-balloon time were significantly shorter in the H2H group (treatment delay 142 minutes [IQR 103;221 minutes] vs. 181 minutes [IQR 134;286 minutes] P value &lt;0.001, FMC-to-balloon time 62 minutes [IQR 52;75 minutes] vs. 86 minutes [IQR 71;111 minutes] P value &lt;0.001 and door-to-balloon time 32 minutes [IQR 25;43 minutes] vs. 52 minutes [IQR 34;76 minutes] P value &lt;0.001). Adjusted for baseline characteristics, the H2H time monitoring dashboard was independently associated with shorter time delays. 90-Days survival rates were significantly higher in the H2H group, this was due to lower incidence of cardiogenic shock. Conclusions: After implementation of the H2H dashboard, significantly shorter ischemic time was observed. The use of the H2H dashboard was independently associated with shorter time delays. Short-term mortality was significantly lower in the H2H group due to lower incidence of cardiogenic shock.

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non–ST‐Segment Elevation Myocardial Infarction Patients

Interhospital transfer invasive management patterns and implications for older non-ST-segment elevation myocardial infarction (NSTEMI) patients initially presenting to non-revascularization-capable hospitals have not been explored. Patients admitted to hospitals with a higher transfer proportion have lower risk of long-term mortality. We linked CRUSADE Registry data on 5678 patients age ≥65 years from 65 United States non-revascularization-capable hospitals (2003-2006) with inpatient Medicare longitudinal claims. Hospitals were categorized according to hospital-level patient transfer-out rates, low (≤40%) vs high (>40%). The associations between transfer-out rates and 30-day, 6-month, and 3-year mortality risk were evaluated using Cox proportional hazard models. Hospital-level transfer-out rates varied widely (median, 43%; interquartile range, 31%-54%). Compared with patients from low-transfer-out hospitals (n = 2715), patients from high-transfer-out hospitals (n = 2963) were more likely to be male, less likely to have renal insufficiency and prior heart failure, and had lower long-term CRUSADE mortality risk scores. These patients also more commonly received evidence-based acute medications before transfer and underwent subsequent revascularization after transfer. The adjusted risks of mortality at various time intervals were similar for those from high- vs low-transfer-out hospitals: 30 days (hazard ratio: 0.95, 95% confidence interval: 0.79-1.14), 6 months (0.97, 0.84-1.12), and 3 years (1.01, 0.91-1.11). Transfer rates for older NSTEMI patients vary widely among non-revascularization-capable hospitals. Despite lower predicted mortality risk and higher rates of post-transfer revascularization, patients from high-transfer-out hospitals had a similar risk for short- and long-term mortality compared with those from low-transfer-out hospitals.

Frame counting improves the assessment of post-reperfusion microvascular patency by TIMI myocardial perfusion grade: Evidence from cardiac magnetic resonance imaging

BackgroundQuantitative modification of TIMI myocardial perfusion grade (TMPG) by the method of frame counting may improve its sensitivity and the false negative rate for post-reperfusion microvascular dysfunction (MVD) in ST segment-elevated myocardial infarction (STEMI) patients. MethodsThe durations of contrast-washout from infarction area of 139 patients were measured by counting the cine-frame numbers between the appearance and disappearance of myocardial blush. The achieved new index, TMP Frame Counting (TMP-FC) was referenced by cardiac magnetic resonance, by which MVD was defined as microvascular obstruction on gadolinium late-enhancement imaging. ResultsMedian TMP-FC differed significantly between patients with and without MVD (126 frames, IQR 105-160 vs. 86 frames, IQR 75-100, p<0.001). By receiver-operating characteristic analysis, the cutoff of TMP-FC at ≥95.5 frames represented an independent predictor of MVD (OR=11.61, p<0.001). TMP-FC had similar specificity (75%) and positive predictive value (88%), but significantly improved sensitivity (85.3%) and negative predictive value (70.2%) for MVD compared with TMPG (88.6%, 86.5%, 33.7% and 38.2%, respectively) and other traditional angiographic assessments, leading to a better overall accuracy (area under the curve: 0.801 compared with 0.612 from TMPG, p<0.001) for the evaluation of microvascular patency. TMP-FC was positively correlated with MVD extent (r=0.5, p<0.001). Abnormal TMP-FC was associated with larger infarction size (28.67±13.72% vs. 16.51±10.68% of left ventricular mass, p<0.001) and lower LVEF (49.37±11.06% vs. 56.84±9.72%, p<0.001). ConclusionFrame counting can improve the accuracy of TMPG for MVD. Moreover, TMP-FC is correlated with the degree of MVD and cardiac detriments, which is useful for risk stratification.

The role of circulating microRNAs in the diagnosis of Takotsubo cardiomyopathy

Their research included TTC patients (n=36), ST segment elevation myocardial infarction patients (STEMI, n=27) and healthy controls (n=28). After the preliminary selection of miRNAs, eight kinds of miRNAs were considered for further verification by RT-PCR. Researchers eventually found that, compared with healthy controls, miRNA-16 and miRNA-26a were both up-regulated in patients with TTC (both P <0.001). Compared to STEMI patients, miRNA-16, miRNA-26a and let7f all increased in patients with TTC (respectively P <0.0001, P <0.05 and P <0.05). As in the previous studies, this study also found that cardiac-specific miRNA-1 and miRNA-133a increased notably in STEMI patients compared with healthy controls (both P <0.0001). In addition, miRNA-133a increased more in STEMI patients compared with TTC patients (P <0.05). A unique signature comprising miRNA-1, miRNA-16, miRNA26a and miRNA-133a distinguished TTC patients from healthy controls [area under the curve (AUC) 0.835, 95% CI 0.7330.937, P <0.0001] and STEMI patients (AUC 0.881, 95% CI 0.793-0.968, P <0.0001). In comparison of TTC patients with healthy controls, the sensitivity and specificity of these markers were 74.19% and 78.57%; in comparison TTC patients with STEMI patients, the sensitivity and specificity were 96.77% and 70.37%. The researchers also found that, compared with healthy controls, the plasma endothelin -1 (ET-1) in TTC patients was elevated. However, the ET-1 regulator, miR-125a-5p was reduced in parallel. In the clinic, diagnostic biomarkers remain an important tool in risk prediction, and determining treatment options during the acute phase of different disease processes. Milosz Jaguszewski and his colleagues have found that four kinds of circulating miRNAs can better distinguish between TTC and STEMI patients. They demonstrate for the first time a unique signature of circulating miRNAs for the sensitive and specific identification of TTC and for distinguishing TTC from STEMI patients. This signature may hold great promise to become an important diagnostic tool for the diagnosis of TTC, just like the discussed markers (BNP and TnI). The true roles of circulating miRNAs need to be confirmed in a larger patient population in prospective investigations. Statement of ethical publishing

HAS-BLED score predicts risk of in-hospital major bleeding in patients with acute non-ST segment elevation myocardial infarction

BackgroundThe role of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs or alcohol use (HAS-BLED) score in the prediction of in-hospital bleeding in non-ST segment elevation myocardial infarction (NSTEMI) patients receiving dual anti-platelet therapy plus heparin was unknown. In this study, we compared the HAS-BLED score with the Can Rapid Risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) and Acute Catheterization and Urgent Intervention Triage strategY and the Harmonizing Outcomes with RevascularIZatiON and Stents in acute myocardial infarction (ACUITY-HORIZONS) bleeding risk scores for in-hospital major bleeding risk stratification in NSTEMI patients. MethodsA real world population of 617 NSTEMI patients receiving dual anti-platelet plus heparin as initial therapy were enrolled. CRUSADE, ACUITY-HORIZONS and HAS-BLED risk scores were calculated for each patient. ResultsThis cohort had a 6.5% incidence of in-hospital major bleeding. For the prediction of in-hospital major bleeding, the discriminations between CRUSADE, ACUITY-HORIZONS and HAS-BLED were good (C-statistic 0.81, 0.82 and 0.80, respectively). There was no significant difference between these three risk scores (HAS-BLED vs. CRUSADE: z=−0.08, p=0.27; HAS-BLED vs. ACUITY-HORIZONS: z=−0.06, p=0.26; CRUSADE vs. ACUITY-HORIZONS: z=−0.15, p=0.28). ConclusionThe CRUSADE, ACUITY-HORIZONS and HAS-BLED scores were useful tools for risk stratification of in-hospital major bleeding in NSTEMI patients. The HAS-BLED score had a simpler calculation and a similar accuracy for risk assessment as the other two scores evaluated.

Analytical performance of high-sensitivity cardiac troponin I detection by VITROS ECIQ with enhanced chemiluminescence method

Objective To evaluate the performances of high-sensitivity cardiac troponin I (cTnI) on VITRO ECIQ with enhanced chemiluminescence method. Methods This verification study validated the limited of detection, function sensitivity, imprecision, linearity of the high-sensitivity cardic troponin used VITROS ECIQ according to the document EP-17A, EP-6A, EP-15A published by Clinical and Laboratory Standards Institute (CLSI) and determined 99th percentiles. All 652 patients with chest pain on immediate admission in TEDA International Cardiovascular Hospital during January to November 2013 were enrolled in this study. Including 323 cases of acute ST segment elevation myocardial infarction and non ST segment elevation myocardial infarction patients as the case group, exclude 329 cases of other diagnosis, 303 cases of apparent normal people as control group. The receiver operating characteristic curve was used to evaluated the sensitivity and the specificity of cTnI. Non-normal distribution of quantitative data were used nonparametric test Mann-Whitney U, With P<0.05 for the difference was statistically significant. Results The LoB was 0.006 5 ng/ml and the LoD was 0.015 5 ng/ml; the FS was 0.016 76 ng/ml; repeatability CV was 1.73 %-2.33 %, reproducibility CV was 4.93%-9.96%.The imprecision were lower than that declared by assay producer. The linearity was 0.015 5-78.4 ng/ml(R2=0.999 9); the 99th percentile reference value was 0.017 ng/ml. The area under the curve(AUC)of cTnI was 0.986, 95%CI 0.973-0.994, with the cut-off value as 0.017 ng/ml, the diagnostic sensitivity and specificity in CIN were 90.09 % and 99.34%. Compared between STEMI and NSTEMI groups after admission, the levels of cTnI had no significantly difference, Z were -0.485, P>0.05; compared between STEMI and control groups after admission, the levels of cTnI had significantly difference, Z were -19.567, P<0.001; compared between NSTEMI and control groups after admission, the levels of cTnI had significantly difference, Z were -14.598, P<0.001. Conclusions High-sensitivity cardiac troponin I detection by VITROS ECIQ with enhanced chemiluminescence method has good performances of sensitivity, linearity, specificity, which meet the clinical needs.(Chin J Lab Med, 2015, 38: 461-465) Key words: Troponin I; Myocardial infarction; Luminescence; Immunoassay; Sensitivity and specificity

Risk factors, clinical features, angiographic characteristics and treatment outcomes of young myocardial infarction patients

Coronary artery disease (CAD) is leading cause of death and accounts for around 12 million deaths annually worldwide (Khan et al., 2004; Maskey et al., 2003). The aim of this paper is to study the clinical profile of young patients with coronary artery disease. Materials and methodsThis study was carried out at the Department of Cardiology, U.N. Mehta Institute of Cardiology from January 2012 to December 2013. CAD was defined as >1 epicardial coronary segment with stenosis >25% and was diagnosed visually and using quantitative coronary angiography (QCA) software. ResultsA total of 302 S-T segment elevation myocardial infarction patients were included. Mean age of presentation was 35.3 years. 93% of the patients were males. Tobacco chewing and smoking were in 38% and 53% of the patients. 70.1% of the patients had single vessel disease. LMCA, LAD, LCX and RCA lesions were present in 2.3%, 18.5%, 14.6%, 26.1% respectively. 142 patients were advised percutaneous intervention in the form of angioplasty, 139 patients medical management and 21 patients bypass surgery. Significant number of patients in the thrombolysed group (51%) had medical management for CAD. The patients who underwent thrombolysis within 3 h of window period had favourable outcome in the form that 52% of them were advised medical management. ConclusionThe present study provides the evidence that young patients with acute MI-STEMI tend to be males with high prevalence of smoking, tobacco chewing, hypertension, dyslipidemia. Thrombolysis within 3 h of window period is extremely favourable as they are predominantly thrombotic occlusions.

Defective functionality of small, dense HDL3 subpopulations in ST segment elevation myocardial infarction: Relevance of enrichment in lysophosphatidylcholine, phosphatidic acid and serum amyloid A

BackgroundLow plasma levels of high-density lipoprotein-cholesterol (HDL-C) are typical of acute myocardial infarction (MI) and predict risk of recurrent cardiovascular events. The potential relationships between modifications in the molecular composition and the functionality of HDL subpopulations in acute MI however remain indeterminate. Methods and resultsST segment elevation MI (STEMI) patients were recruited within 24h after diagnosis (n=16) and featured low HDL-C (−31%, p<0.05) and acute-phase inflammation (determined as marked elevations in C-reactive protein, serum amyloid A (SAA) and interleukin-6) as compared to age- and sex-matched controls (n=10). STEMI plasma HDL and its subpopulations (HDL2b, 2a, 3a, 3b, 3c) displayed attenuated cholesterol efflux capacity from THP-1 cells (up to −32%, p<0.01, on a unit phospholipid mass basis) vs. controls. Plasma HDL and small, dense HDL3b and 3c subpopulations from STEMI patients exhibited reduced anti-oxidative activity (up to −68%, p<0.05, on a unit HDL mass basis). HDL subpopulations in STEMI were enriched in two proinflammatory bioactive lipids, lysophosphatidylcholine (up to 3.0-fold, p<0.05) and phosphatidic acid (up to 8.4-fold, p<0.05), depleted in apolipoprotein A-I (up to −23%, p<0.05) and enriched in SAA (up to +10.2-fold, p<0.05); such changes were most marked in the HDL3b subfraction. In vitro HDL enrichment in both lysophosphatidylcholine and phosphatidic acid exerted deleterious effects on HDL functionality. ConclusionsIn the early phase of STEMI, HDL particle subpopulations display marked, concomitant alterations in both lipidome and proteome which are implicated in impaired HDL functionality. Such modifications may act synergistically to confer novel deleterious biological activities to STEMI HDL. SignificanceOur present data highlight complex changes in the molecular composition and functionality of HDL particle subpopulations in the acute phase of STEMI, and for the first time, reveal that concomitant modifications in both the lipidome and proteome contribute to functional deficiencies in cholesterol efflux and antioxidative activities of HDL particles.These findings may provide new biomarkers and new insights in therapeutic strategy to reduce cardiovascular risk in this clinical setting where such net deficiency in HDL function, multiplied by low circulating HDL concentrations, can be expected to contribute to accelerated atherogenesis.

Comparison of clinical outcomes between culprit vessel only and multivessel percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel coronary diseases.

BackgroundThe clinical significance of complete revascularization for ST segment elevation myocardial infarction (STEMI) patients during admission is still debatable.MethodsA total of 1406 STEMI patients from the Korean Myocardial Infarction Registry with multivessel diseases without cardiogenic shock who underwent primary percutaneous coronary intervention (PPCI) were analyzed. We used propensity score matching (PSM) to control differences of baseline characteristics between culprit only intervention (CP) and multivessel percutaneous coronary interventions (MP), and between double vessel disease (DVD) and triple vessel disease (TVD). The major adverse cardiac event (MACE) was analyzed for one year after discharge.ResultsTVD patients showed higher incidence of MACE (14.2% vs. 8.6%, P = 0.01), any cause of revascularization (10.6% vs. 5.9%, P = 0.01), and repeated PCI (9.5% vs. 5.7%, P = 0.02), as compared to DVD patients during one year after discharge. MP reduced MACE effectively (7.3% vs. 13.8%, P = 0.03), as compared to CP for one year, but all cause of death (1.6% vs. 3.2%, P = 0.38), MI (0.4% vs. 0.8%, P = 1.00), and any cause of revascularization (5.3% vs. 9.7%, P = 0.09) were comparable in the two treatment groups.ConclusionsSTEMI patients with TVD showed higher rate of MACE, as compared to DVD. MP performed during PPCI or ad hoc during admission for STEMI patients without cardiogenic shock showed lower rate of MACE in this large scaled database. Therefore, MP could be considered as an effective treatment option for STEMI patients without cardiogenic shock.

Adiponectin and ischemia-reperfusion injury in ST segment elevation myocardial infarction.

Models of experimental ischemia-reperfusion (IR) in adiponectin knockout animals have shown that adiponectin mediates protection against the development of IR injury. However, the role of adiponectin in IR injury in humans is largely unknown. In a total of 234 ST segment elevation myocardial infarction (STEMI) patients, baseline circulating total adiponectin concentration was correlated with IR injury after primary percutaneous coronary intervention (pPCI) and with major adverse cardiac events (MACE, death and cardiac hospitalization) during one year of follow up. IR injury was defined by serial electrocardiography (ECG) as >30% persistent ST segment elevation despite successful restoration of vessel patency and by angiography as thrombolysis in myocardial infarction (TIMI) blush grade<2. IR injury was present in 31% of patients according to ECG criteria and in 28% of patients according to angiographic criteria. The median adiponectin level was 6.8 µg/ml in patients with ECG signs of IR injury and 6.5 µg/ml in patients without ECG signs of IR (p=0.26). When the angiographic criteria of IR were used, the median adiponectin level was 6.9 µg/ml for patients with IR versus 6.3 µg/ml for patients without IR (p=0.06). MACE occurred in 27% of the patients. Median adiponectin levels were similar in patients with MACE and in those without MACE: 6.3 vs. 6.4 µg/ml (p=0.24). In a multivariate model, no significant relation between circulating adiponectin levels and IR injury or MACE was evident. In the current era of pPCI, IR injury still occurs in almost one third of STEMI patients. Our findings do not support a major protective role of adiponectin in the prevention or attenuation of IR injury in these patients.

Relation of in-hospital serum creatinine change patterns and outcomes among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

The worsening of serum creatinine (sCr) level is a frequent finding among ST-segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short-term and long-term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels. Reversible renal impairment prior to PCI is not associated with adverse outcomes. We retrospectively studied 1260 STEMI patients undergoing primary PCI. The incidence of in-hospital complications and long-term mortality was compared between patients having stable, worsened (>0.3 mg/dL increase), or improved (>0.3 mg/dL decrease) sCr levels throughout hospitalization. Overall, 127 patients (10%) had worsening in sCr levels, whereas 44 (3.5%) had an improvement of sCr compared with admission levels. Patients with worsening sCR had more complications during hospitalization, higher 30-day (13% vs 1%; P < 0.001) and up to 5-year all-cause mortality (28% vs 5%; P < 0.001) compared with those with stable sCR. No significant difference was found regarding complications and mortality between patients having an improvement in sCr and stable sCr. Compared with patients with stable sCr, the adjusted hazard ratio for all-cause mortality in patients with worsened sCr was 6.68 (95% confidence interval: 2.1-21.6, P = 0.002). In STEMI patients undergoing primary PCI, renal impairment prior to PCI is a frequent finding. In contrast to post-PCI sCr worsening, this entity is not associated with adverse short-term and long-term outcomes.

Comparison of the hospital arrival time and differences in pain quality between diabetic and non-diabetic STEMI patients.

The aim of our study was to determine whether diabetic ST segment elevation myocardial infarction (STEMI) patients arrive in the emergency room (ER) later than non-diabetics, compare the differences in pain quality and quantity between those groups, and measure differences in the outcome after an index hospitalization. A total of 266 patients with first presentation of STEMI were included in our study during a period of two years, 62 with diabetes and 204 without diabetes type 2. Pain intensity and quality at admission were measured using a McGill short form questionnaire. Diabetic patients did not arrive significantly later than non-diabetic (χ2; p = 0.105). Most diabetic patients described their pain as “slight” or “none” (χ2; p < 0.01), while most non-diabetic patients graded their pain as “moderate” or “severe” (χ2; p < 0.01). The quality of pain tended to be more distinct in non-diabetic patients, while diabetic patients reported mainly shortness of breath (χ2; p < 0.01). Diabetic patients were more likely to suffer a multi-vessel disease (χ2; p < 0.01), especially in the late arrival group. Therefore, cautious evaluation of diabetic patients and adequate education of target population could improve overall survival while well-organized care like a primary PCI Network program could significantly reduce CV mortality.