Silent Myocardial Infarction Research Articles

Silent Myocardial Infarction and Long-Term Risk of Frailty: The Atherosclerosis Risk in Communities Study.

BackgroundSilent myocardial infarction (SMI) accounts for more than half of all MIs, and common risk factors and pathophysiological pathways coexist between SMI and frailty. The risk of frailty among patients with SMI is not well established. This study aimed to examine the association between SMI and frailty.Methods and ResultsThis analysis included data from the Atherosclerosis Risk in Communities study. Patients without MI at baseline were eligible for inclusion. SMI was defined as electrocardiographic evidence of MI without clinical MI (CMI) after the baseline and until the fourth visit. Frailty was assessed during the fifth visit. A total of 4953 participants were included with an average age of 52.2±5.1 years. Among these participants, 2.7% (n=135) developed SMI, and 2.9% (n=146) developed CMI. After a median follow-up time of 14.7 (14.0–15.3) years, 6.7% (n=336) of the participants developed frailty. Patients with SMI and CMI were significantly more likely to become frail than those without MI (15.6% vs 6.2%, P<0.001 and 16.4% vs 6.2%, P<0.001, respectively). After adjusting for confounders, SMI and CMI were found to be independent predictors of frailty (odds ratio [OR]=2.243, 95% confidence interval [CI]=1.307–3.850, P=0.003 and OR=2.164, 95% CI=1.259–3.721, P=0.005, respectively). The association was consistent among the subgroups of age, sex, race, diabetes, and hypertension.ConclusionIn conclusion, both SMI and CMI were found to be associated with a higher risk of frailty. Future studies are needed to confirm the beneficial effects of screening for SMI as well as to implement standardized preventive treatment to reduce the risk of frailty.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT00005131.

Silent Myocardial Infarction and Subsequent Ischemic Stroke in the Cardiovascular Health Study.

To test the hypothesis that silent myocardial infarction (MI) is a risk factor for ischemic stroke, we evaluated the association between silent MI and subsequent ischemic stroke in the Cardiovascular Health Study. The Cardiovascular Health Study prospectively enrolled community-dwelling individuals ≥65 years of age. We included participants without prevalent stroke or baseline evidence of MI. Our exposures were silent and clinically apparent, overt MI. Silent MI was defined as new evidence of Q-wave MI, without clinical symptoms of MI, on ECGs performed during annual study visits from 1989 to 1999. The primary outcome was incident ischemic stroke. Secondary outcomes were ischemic stroke subtypes: nonlacunar, lacunar, and other/unknown. Cox proportional hazards analysis was used to model the association between time-varying MI status (silent, overt, or no MI) and stroke after adjustment for baseline demographics and vascular risk factors. Among 4,224 participants, 362 (8.6%) had an incident silent MI, 421 (10.0%) an incident overt MI, and 377 (8.9%) an incident ischemic stroke during a median follow-up of 9.8 years. After adjustment for demographics and comorbidities, silent MI was independently associated with subsequent ischemic stroke (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.03-2.21). Overt MI was associated with ischemic stroke both in the short term (HR, 80; 95% CI, 53-119) and long term (HR, 1.60; 95% CI, 1.04-2.44). In secondary analyses, the association between silent MI and stroke was limited to nonlacunar ischemic stroke (HR, 2.40; 95% CI, 1.36-4.22). In a community-based sample, we found an association between silent MI and ischemic stroke.

Diabetes Mellitus with Silent Myocardial Ischemia: A Single-Center Cross-Sectional Study of Karachi, Pakistan

Background: Previous studies have established the fact that diabetic patients are predominantly inclined towards silent myocardial infarction (SMI). The objective of the present study is to determine the incidence of SMI in diabetes mellitus (DM) patients.&#x0D; Methodology: In this cross-sectional study, patient data was gathered on a predesigned proforma regarding the detailed history of dyspnea, DM and its duration, chest pain either present or not. Those patients who had normal ECG labeled negative for SMI, while those who had either ST-segment elevation or ST-segment deviation on resting ECG were positive for SMI. Study was conducted at the National Institute of Cardiovascular Diseases (NICVD) Karachi- Pakistan.&#x0D; Results: The mean age of the enrolled patients was 54.21±8.65 (40-70) years. Out of 210, majority were female (51.90%).Overall, 94(44.76%) patients were obese, 122(58.09%) were hypertensive, 90(42.85%) had dyslipidemia and 98(46.66%) diabetic patients were smokers. There were 93 (44.3%) DM patients who had SMI. Moreover, 109(51.90%) patients had a family history of myocardial ischemia.&#x0D; Conclusion: The SMI incidence among diabetic patients was found higher in local population. It is proposed that diabetic patients with demonstrated cardiovascular autonomic neuropathy must be screened for the manifestation of SMI.

Cardiac Magnetic Resonance as a diagnostic tool in arrhythmias

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Etiology of cardiac arrhythmias is often difficult to determine.As the gold standard to anatomical and functional cardiac evaluation,Cardiac Magnetic Resonance(CMR)can be a fundamental technique for accurate assessment of myocardial arrhythmic substrates or for arrhythmias management. Purpose The aim of this study is to determine diagnostic and arrhythmic risk stratification impact of CMR performed in patients with suspected or confirmed arrhythmias. Methods We performed a six-years prospective study of patients with suspected or confirmed arrhythmias which evaluation with other techniques did not provide a definitive diagnosis.These patients underwent CMR for diagnostic and risk stratification assessment.We applied a protocol to evaluate both ventricles’ morphology and functional and late gadolinium enhancement (LGE) presence. Results A total of 93 patients were included,of which 66% were male, with a mean age of 45 ± 17 years old. The indications for patients with suspected or confirmed arrhythmias performing CMR evaluation were the following: 33% (n = 31) of the patients had very frequent premature ventricular complexes, 23% (n = 21) had sustained ventricular tachycardia (VT), 5%(n = 5) non-sustained VT, 17%(n = 16) suspected structural heart disease with high arrhythmic potential,10%(n = 9) unexplained recurrent syncope,9 %(n = 8) supraventricular tachycardia and 3% (n = 3) aborted sudden cardiac death. Depressed ejection fraction (EF)(&amp;lt;50%) was present in 10% (n = 9) for LV(mean EF 38 ± 9%) and 15%(n = 14) for RV (mean EF 42 ± 7%). Dilation of LV was found in 25% of patients (n = 23, mean LV volume: 115 ± 7ml/m²), with RV dilation being present in only 1 patient, who had right ventricle arrhythmogenic dysplasia (RVAD) (RV volume: 152ml/m²). In total, 16%had interventricular septum hypertrophy (mean 15 ± 4mm/m2).We found slight anterior leaflet prolapse of mitral valve in 10% (n = 9) of the cases and mild mitral regurgitation in 15% (n = 14). Left atrium dilation was observed in 17% (n = 16) of patients (mean area of 18 ± 2cm2/m2), as right atrium was dilated in only two. In 20% of the patients, CMR contributed to establish a previously unknown diagnosis: 6% (n = 5) have hypertrophic cardiomyopathy,4%(n = 4)a myocarditis sequelae and 2%(n = 2)had RVAD. LV non-compaction,a silent myocardial infarction scar and non-ischemic dilated cardiomyopathy were diagnosed in 3%of the cases each. In 15%(n = 14)we found nonspecific variations, which deserve follow-up. On the remaining patients, CMR was considered normal. Conclusion As a high reproducible, accurate and versatile technique, CMR allowed an increase on diagnosis in 20% of the patients with suspected or confirmed arrhythmias. Consequently, it contributed to the risk stratification of our study population with suspected high arrhythmic potential when the first-line complementary exams were inconclusive.

БЕЗБОЛЕВОЙ ИНФАРКТ МИОКАРДА

The aim of the study was to analyze the available publications on silent myocardial infarction.

Abstract 58: Silent Myocardial Infarction and Subsequent Ischemic Stroke in the Cardiovascular Health Study

Background: Whether silent myocardial infarction (MI) is a risk factor for ischemic stroke remains uncertain. Hypothesis: Silent MI is associated with incident ischemic stroke. Methods: The Cardiovascular Health Study prospectively enrolled community-dwelling individuals ≥65 years of age with follow-up through June 30, 2015. For this study, we included participants from the first study cohort (enrolled in 1989-1990) without prevalent stroke or baseline electrocardiographic (ECG) evidence of MI. Our exposures were silent and clinically apparent MI. Silent MI was defined as new evidence of Q-wave MI, without clinical symptoms of MI, on ECGs performed during annual study visits from 1989-1999. Clinically apparent (overt) MI was adjudicated on the basis of information about chest pain, ECG changes, and cardiac enzymes. The primary outcome was incident ischemic stroke. Secondary outcomes were ischemic stroke subtypes: non-lacunar, lacunar, and other/unknown. Cox proportional hazards analysis was used to model the association between time-varying MI status (silent, overt, or no MI) and stroke after adjustment for baseline demographics and vascular risk factors. Due to a violation of the proportional hazards assumption, the association between overt MI and stroke was modeled separately for short-term (within 30 days) and long-term (beyond 30 days) risk. Results: Among 4,224 participants included in this analysis, 362 (8.6%) had an incident silent MI, 421 (10.0%) an incident overt MI, and 377 (8.9%) an incident ischemic stroke during a median follow-up of 9.8 years. After adjustment for demographics and comorbidities, silent MI was independently associated with subsequent ischemic stroke (HR, 1.47; 95% CI, 1.01-2.16). Overt MI was associated with ischemic stroke both in the short term (HR, 80; 95% CI, 53-119) and long term (HR, 1.60; 95% CI, 1.04-2.44). In secondary analyses, the association between silent MI and stroke was limited to non-lacunar ischemic stroke (HR 2.18; 95% CI, 1.24-3.83). Conclusions: In a community-based sample, we found an association between silent MI and ischemic stroke, specifically non-lacunar stroke. These findings suggest that silent MI may be a novel risk factor for ischemic stroke.

Coronary Artery Disease as the Cause of Sudden Cardiac Death Among Victims < 50 Years of Age

Coronary artery disease (CAD) is the most common cause of sudden cardiac death (SCD). Atherosclerosis increases with age, but also many victims of SCD in young and middle-aged population have CAD at autopsy. The purpose of this study was to determine the characteristics and autopsy findings of SCD due to CAD among victims of SCD under the age of 50. Fingesture is a population-based study consisting of consecutive series of victims of autopsy verified SCD in Northern Finland between the years 1998 to 2017 (n = 5,869). Histological examinations were part of all autopsies and a toxicology investigation was performed if needed. Analyses included information accumulated from death certificates, medical records, autopsy data, standardized questionnaire to the closest family members of the victims of SCD and police reports of the conditions of the death. Overall, 10.4% of all SCDs occurred among victims under the age of 50 years (610 victims). Most common underlying cause of SCD among these younger SCD victims was CAD (43.6%). The prevalence of CAD as the cause of SCD became more common in young SCD victims after the age of 35 years. The mean age of ischemic SCD victims was 44±5 years and most were men (89.5%). Most victims (90.2%) had no clinical diagnosis of CAD, however 33.8% had an autopsy evidence of silent myocardial infarction. SCD occurred during physical activity in 24.1%. Three-vessel disease was detected in 44.4% of the study victims. Cardiac hypertrophy (58.3%) and myocardial fibrosis (82.6%) were also common. At least 1 cardiovascular risk factor was present in 64.7% of SCD victims. In conclusion, most SCDs among victims < 50 years of age are due to CAD.

Subepicardial aneurysm with free wall rupture and its successful surgical intervention: a case report

BackgroundSubepicardial aneurysm (SEA) is an uncommon but potentially fatal complication of acute myocardial infarction (MI) associated with an increased risk of free wall rupture (FWR) leading to sudden death. We describe a rare case of a silent myocardial infarction complicated by SEA and subsequent FWR, resulting in cardiac tamponade.Case summaryA 68-year-old man with no previous chest symptoms presented with syncope. Cardiac computed tomography incidentally revealed a small aneurysmal cavity at the inferolateral wall of the left ventricle, which was overlooked on initial transthoracic echocardiography. Coronary angiography demonstrated a narrowed first obtuse marginal branch with coronary slow flow, suggesting that spontaneous recanalization of the occluded obtuse marginal branch induced SEA and subsequent FWR. The patient underwent an emergency left ventricular aneurysm repair. The post-operative course was uneventful, and the patient was discharged from the hospital on post-operative day 20.DiscussionThis case emphasizes the importance of prompt detection and surgical intervention for SEA. Subepicardial aneurysm should be suspected in patients with pericardial effusion and suspected MI. Cardiac computed tomography is not only useful in the detection of such cases but also facilitates the development of a successful surgical strategy.

The utility of silent myocardial infarction on electrocardiogram as an ASCVD risk enhancer for primary prevention: The multi-ethnic study of atherosclerosis

BackgroundThe 2018 AHA/ACC cholesterol guidelines introduced a new list of markers called “risk enhancers” that, if present, confer an increased risk of atherosclerotic cardiovascular disease (ASCVD). Silent myocardial infarction (SMI) on electrocardiogram (ECG) is notably absent, even though it associated with future ASCVD. MethodsWe assessed the utility of SMI on ECG as a risk-enhancer in intermediate-risk participants in MESA (Multi-Ethnic Study of Atherosclerosis) – those with 10-year ASCVD risk of 5–20% by the pooled cohort equation (PCE). SMI was defined as major Q-wave abnormality or minor Q/QS waves in the setting of major ST-T abnormalities without prevalent clinical cardiovascular disease. ResultsAmong 2946 participants (mean age 63.1 ± 7.6, 53.9% women, 36% white, 11% Chinese-American, 33% African-American, 19% Hispanic), 66 (2.2%) had SMI at baseline. After a median 15.8 years of follow-up, incident ASCVD events occurred in 431/2876 (15.0%) of those without SMI and 16/66 (24.2%) of those with SMI. In a multivariable-adjusted Cox proportional hazards model, baseline SMI was associated with an increased risk of incident ASCVD events (HR 1.68, 95% CI 1.02–2.77, p = 0.04). However, adding SMI to the PCE did not improve discrimination and reclassification was modest—net reclassification improvement was 0.0161 (95% CI 0.002–0.034, p = 0.08). ConclusionOur findings suggest that the prevalence of SMI is 2.2% among those without known clinical cardiovascular disease considered intermediate-risk by the PCE. In our analysis, SMI only modestly improved classification of risk, suggesting that it may not be very useful as an ASCVD risk enhancer.

Cardiovascular magnetic resonance imaging and its role in the investigation of stroke: an update.

Recent advances in complementary diagnostic exams have helped to clarify stroke etiology, not only by helping to confirm established stroke causes but also by unveiling new possible stroke mechanisms. Etiological investigation for cardioembolic stroke has benefited in the last years from information provided by studies analysing serum biomarkers, heart rhythm monitoring and imaging methods like cardiovascular magnetic resonance (CMR) imaging. CMR has been particularly important for the characterization of possible new cardioembolic stroke mechanisms including atrial cardiomyopathy, silent myocardial infarction and cardiomyopathies.

A Study of Cardiac Autonomic Neuropathy Among Type-II Diabetic Patients

Background: Though very common, CAN is a least understood complication of diabetes which is often under diagnosed. In diabetes mellitus patients, CAN leads to silent myocardial infarction and sudden death. So by identifying CAN early, which is asymptomatic will help to delay or arrest its progression. AIM: To find out the prevalence and the associated risk factors of Cardiac autonomic neuropathy (CAN) among type-II Diabetes Mellitus patients in a tertiary care hospital. Materials & Methods: A total of 273 type-II diabetic participants were selected after taking into consideration of inclusion & exclusion criteria. The prevalence of CAN was assessed by ewings and clarkesnon invasive cardiac autonomic neuropathy reflex tests. The association of risk factors with the presence of CAN was analysed by using Pearson’s chi square test. Data were analysed by using SPSS 16. The accepted level of significance was set below 0.05 (P<0.05). Results: The prevalence of CAN among type-II diabetic patients in this study was found to be 34%. Prevalence of CAN increased in the participants with male gender, increased age, and increased BMI, increased duration of diabetes, poor glycaemic control,dyslipidimea, smokers and hypertension and it is statistically significant. Conclusion: In this study it is observed that the prevalence of CAN increased with old age, male gender, poor glycemic control, increased duration of diabetes, Dyslipidemia, higher BMI, Hypertension & smoking. So risk factors associated with the CAN be detected and treated at an early stage to further reduce morbidity and mortality.

Screening Cardiovascular Autonomic Neuropathy in Diabetic Patients With Microvascular Complications Using Machine Learning: A 24-Hour Heart Rate Variability Study

Cardiovascular autonomic neuropathy (CAN) is one of the most overlooked complications associated with diabetes. It is characterized by damage in the autonomic nerves regulating heart rate and vascular compliance. Ewing battery is currently the diagnostic tool of choice but is unable to detect sub-clinical CAN and requires patient cooperation. In addition, appropriate timing (day/night) of CAN diagnostic test was not explored in the past. Therefore, a novel approach is proposed herein to investigate the feasibility of using heart rate variability (HRV) features over 24 hours embedded within machine learning algorithms to provide a complete screening for patients suffering from CAN. 24-hour Holter ECG data were acquired from a Bangladeshi cohort (n = 95 patients [75 Diabetic and 25 healthy]). HRV features were extracted from every 5-minute segment of the HRV signal and used as input to four machine learning algorithms for hourly training and testing. A complete hierarchical step by step diagnosis procedure (4 tests) was developed; namely test 1 to check for being healthy or diabetic; test 2 to check for any microvascular complications (including neuropathy such as CAN, peripheral neuropathy (DPN), nephropathy (NEP), and retinopathy (RET)) or not; test 3 to check for presence of only CAN; test 4 to check for combined or multiple complications along with CAN. The highest levels of performance were achieved with accuracy measures of 85.5% (test 1 - convolutional neural network (CNN)), 98.5% (test 2 - CNN), 98.3% (test 3 - one-class support vector machines (SVM)), and 90.9% (test 4 - random forest). Hours 7:00 AM and 7:00 PM were found to be most significant in the diagnosis of CAN in diabetic patients (test 1, 3, and 4). Early screening of CAN by our proposed models could help primary healthcare centers stratify the risk leading to early treatment in preventing sudden cardiac death due to silent myocardial infarction. The approach is considered to be simple and effective, especially for under-resourced clinical settings.

Association Between Silent Myocardial Infarction and Long-Term Risk of Sudden Cardiac Death.

BackgroundAlthough silent myocardial infarction (SMI) is prognostically important, the risk of sudden cardiac death (SCD) among patients with incident SMI is not well established.Methods and ResultsWe examined 2 community‐based cohorts: the ARIC (Atherosclerosis Risk in Communities) study (n=13 725) and the CHS (Cardiovascular Health Study) (n=5207). Incident SMI was defined as electrocardiographic evidence of new myocardial infarction during follow‐up visits that was not present at the baseline. The primary study end point was physician‐adjudicated SCD. In the ARIC study, 513 SMIs, 441 clinically recognized myocardial infarctions (CMIs), and 527 SCD events occurred during a median follow‐up of 25.4 years. The multivariable hazard ratios of SMI and CMI for SCD were 5.20 (95% CI, 3.81–7.10) and 3.80 (95% CI, 2.76–5.23), respectively. In the CHS, 1070 SMIs, 632 CMIs, and 526 SCD events occurred during a median follow‐up of 12.1 years. The multivariable hazard ratios of SMI and CMI for SCD were 1.70 (95% CI, 1.32–2.19) and 4.08 (95% CI, 3.29–5.06), respectively. The pooled hazard ratios of SMI and CMI for SCD were 2.65 (2.18–3.23) and 3.99 (3.34–4.77), respectively. The risk of SCD associated with SMI is stronger with White individuals, men, and younger age. The population‐attributable fraction of SCD was 11.1% for SMI, and SMI was associated with an absolute risk increase of 8.9 SCDs per 1000 person‐years. Addition of SMI significantly improved the predictive power for both SCD and non‐SCD.ConclusionsIncident SMI is independently associated with an increased risk of SCD in the general population. Additional research should address screening for SMI and the role of standard post–myocardial infarction therapy.

Cardiovascular outcomes associated with Ultrathin bioresorbable polymer sirolimus eluting stents versus thin, durable polymer everolimus eluting stents following percutaneous coronary intervention in patients with type 2 diabetes mellitus: A meta-analysis of published studies.

Background:Percutaneous coronary intervention with the new generation drug eluting stents (DES) is 1 among the revascularization procedures required to treat patients with coronary artery disease (CAD). Since late stent thrombosis and silent myocardial infarction are highly associated with type 2 diabetes mellitus (T2DM), an analysis comparing the newer generation DES in this specific subgroup of patients would be scientifically relevant.In this analysis, we aimed to systematically compare the cardiovascular outcomes observed with the ultrathin bioresorbable polymer sirolimus eluting stents (SES) versus thin, durable polymer everolimus eluting stents (EES) following percutaneous coronary intervention in patients with T2DM.Methods:Through online databases, relevant studies comparing ultrathin bioresorbable polymer SES versus the durable polymer EES were carefully searched. The cardiovascular outcomes were assessed during a follow-up time period of 1 year and more than 1 year (1–5 years) respectively. This meta-analysis was carried out by the latest version of the RevMan software. Following analysis, the results were represented by odds ratios (OR) with 95% confidence intervals (CI).Results:A total number of 1967 patients with T2DM were included in this analysis. During a 1 year follow-up time period, target lesion failure (TLF) (OR: 0.59, 95% CI: 0.34–1.02; P = .06, target vessel revascularization (TVR) (OR: 0.97, 95% CI: 0.55–1.70; P = .91) and target lesion revascularization (TLR) (OR: 0.91, 95% CI: 0.44–1.87; P = .79) were similarly observed with ultrathin bioresorbable polymer SES versus the thin, durable polymer EES in these patients with T2DM. Other cardiovascular outcomes including myocardial infarction (MI), major adverse cardiac events, all-cause mortality (OR: 0.72, 95% CI: 0.37–1.40; P = .34), cardiac death and stent thrombosis (OR: 0.85, 95% CI: 0.45–1.62; P = .63) were also similarly observed with these 2 types of new stents. During a follow-up time period above 1 year (1–5 years), still no significant difference was observed in TLF, TVR, TLR, major adverse cardiac events, MI, all-cause mortality, cardiac death and stent thrombosis (OR: 0.62, 95% CI: 0.33–1.16; P = .14).Conclusions:The ultrathin bioresorbable polymer SES were similar to the durable polymer EES in these patients with T2DM. These 2 types of new generation stents were comparable in terms of cardiovascular outcomes. Hence, they might be recommended in patients with T2DM. Upcoming trials should be able to confirm this hypothesis.

Abstract 13196: The Utility of Silent Myocardial Infarction on Electrocardiogram as an ASCVD Risk Enhancer for Primary Prevention: The Multi-Ethnic Study of Atherosclerosis

Introduction: The 2018 AHA/ACC cholesterol guidelines introduced a new list of markers called “risk enhancers” that, if present, confer an increased risk of atherosclerotic cardiovascular disease (ASCVD). Notably absent is silent myocardial infarction (SMI) on electrocardiogram (ECG), even though SMI has been shown to be associated with future ASCVD. Hypothesis: Adding SMI to the pooled cohort equation (PCE) will improve risk discrimination and classification in those with intermediate ASCVD risk (5 - 20% 10-year risk). Methods: SMI was defined as a major Q-wave abnormality or minor Q/QS waves in the setting of major ST-T abnormalities in the absence of history of clinical cardiovascular disease. Incident ASCVD events included myocardial infarction, coronary heart disease death, and fatal and non-fatal stroke. Results: Among 2,278 intermediate-risk MESA participants, 48 (2.1%) had SMI at baseline. Over 32,150 person-years (median 15.8), incident ASCVD events occurred in 297/2,230 (13%) of those without SMI and 13/48 (27%) of those with SMI. In a Cox proportional hazards model that was adjusted for calculated 10-year ASCVD risk based on the PCE, SMI was associated with increased risk of ASCVD (HR 2.22, 95% CI 1.27 - 3.87, p = 0.005). Adding SMI to the PCE did not improve discrimination, with areas under the receiver operating characteristic curves for models without and with SMI of 0.5812 and 0.5874, respectively (p-value for difference 0.22; Figure 1a). The net reclassification improvement for adding SMI as a risk enhancer to reclassify participants from intermediate-risk to high-risk was 0.0242 (95% CI 0.0011 - 0.0472, p = 0.04; Figure 1b). Conclusions: Our findings suggest that the prevalence of SMI is 2.1% among those without known clinical cardiovascular disease considered intermediate-risk by the pooled cohort equation. In our analysis, SMI only modestly improved classification of risk, suggesting that it may not be very useful as an ASCVD risk enhancer.

Diabetic cardiovascular autonomic neuropathy in children

Abstract Diabetic cardiovascular autonomic neuropathy (CAN) encompasses damage to the autonomic nerve fibers innervating the heart and blood vessels, resulting in abnormalities in heart rate control and vascular dynamics. Clinical symptoms associated with CAN include resting tachycardia, postural hypotension, dizziness, syncope, exercise intolerance, silent myocardial infarction. The earliest finding of CAN, even at the subclinical stage, is a decrease in heart rate variability (HRV) Purpose To study CAN prevalence and understand the diagnostic capabilities of HRV - tests of diabetic cardiovascular autonomic neuropathy in children with type 1 diabetes. Methods 100 children with type 1 diabetes were assessed for CAN (age 15.2 yrs [9.0–17.8], duration 6.5 yrs [4.0–10.6], HbA1c 8.1% 6.3–9.7]). The degree of compensation of diabetes was estimated according to criteria ISPAD Consensus Guidelines, 2018. Optimal level (HbA1c &amp;lt;7.0%) of compensation was revealed in 62% of children (group I) and nonoptimal in 38% of children (group II). For evaluation of the CAN we used HRV - tests: RR 30:15 ratio, ΔRR quiet breath, ΔRR deep breath, BP response to standing. Results Diabetic cardiovascular autonomic neuropathy was diagnosed in 41 children: in group I – in 6 (29%) and in group II – 35 (71%) children (p=0.00001). The prevalence of DCN correlated with HbA1c level in children and adolescents (groups I and II): ΔRR quiet breath r=−0.47 &amp; r=−0.9; ΔRR deep breath r=−0.65 &amp; r=−0.85; RR30:15 r=−0.77 &amp; r=−0.88 respectively. Prevalence of CAN increased parallel to type 1 diabetes duration (p&amp;lt;0.01). Conclusions Diabetic cardiovascular autonomic neuropathy in children with type 1 diabetes was diagnosed in 41%. Prevalence of diabetic cardiovascular autonomic neuropathy increases parallel to type 1 diabetes duration (p&amp;lt;0.01). In this study we found an association between HRV indexes and HbA1c level. This provides support for HRV - testing to assess diabetic cardiovascular autonomic neuropathy in children. Funding Acknowledgement Type of funding source: None

Silent myocardial infarction among young sudden cardiac death victims

Abstract Background Silent myocardial infarctions (SMIs) occur with atypical or no symptoms at all. The burden of SMIs among sudden cardiac death victims have recently been acknowledged. However, the prevalence of previously undetected SMI in young victims remains unclear. Purpose The aim of the present study was to determine the prevalence of autopsy verified SMI in SCD victims under 50 years old without a prior diagnosis of coronary artery disease (CAD). Methods Fingesture study consists of systematically collected consecutive victims of SCD in Northern Finland between years 1998–2017 (n=5,869). According to Finnish law, all unexpected deaths undergo medico-legal autopsy. The autopsies routinely included histological examinations, and a toxicology investigation was carried out if needed. The SMI was defined as focal scar detected by macroscopic evaluation of the dissected ventricles and histologic analysis of the myocardial samples with an absence of a history of previously diagnosed CAD. Pre-mortem clinical history was obtained from medical records, standardized questionnaire to the closest family members of the victims and police reports about the conditions of the death. Results Overall, 10.4% off all SCDs occurred among victims under the age of 50 years (610 victims). Most common underlying cause of SCD among young was CAD (44%). About 90% of the victims had no clinical diagnosis of CAD, however, 34% (78 victims) had previously undetected myocardial scar at autopsy indicating a previous SMI. The mean age of the young SMI victims was 44±4 and they were mostly men (87%). 24% of SCDs occurred during physical activity and 21% had SCD outdoors. The mean heart weight was 466±110 g and 67% had hypertrophied hearts. Three vessel disease was detected in 69% of the victims. Alcohol was detected in 17% of victims in toxicology investigations. Conclusions Previously undetected myocardial infarction is also common among young victims who experienced CAD associated SCD. Three vessel disease and cardiac hypertrophy were common autopsy findings among young SMI victims and about a fourth had SCD during physical activity. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Sigrid Juselius Foundation, Finnish Foundation for Cardiovascular Research

Non-cardiovascular comorbidities in patients with chronic coronary syndromes (review) (2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes)

С areful evaluation of patient history, including of anginal symptoms, and evaluation of risk factors and manifestation of coronary artery disease (CAD), as well as proper physical examination and basic testing, are crucial for the diagnosis and management of chronic coronary syndrome(s) (CCS) and non-cardiovascular comorbidities. Anti-ischaemic treatment must be adapted to the individual patient based on comorbidites, co-administered therapies, expected tolerance and adherence, and patient preferences. The choice of anti-ischaemic drugs to treat chronic coronary sydromes should be adapted to the patient’s heart rate, blood pressure, and left-ventricular (LV) function. In patients with active cancer treatment decisions should based on life be expectancy, additional comorbidities such as thrombocytopenia, increased thrombosis propensity. and potential interactions between drugs used in CCS management and antineoplastic agents. In asymptomatic patients with diabetes mellitus, a periodic resting electrocardiogram is recommended for cardiovascular detection of conduction abnormalities, atrial fibrillation, and silent myocardial infarction. Recommendations for chronic kidney disease (CRD): use iodinated contrast agents is minimized in patients with severe CKD and preserved urine production to prevent further deterioration. It is recommended that particular attention is paid to side effects of drugs, intolerance, and overdosing in elderly patients with chronic coronary syndromes. Hormone replacement therapy is not recommended for risk reduction in post- menopausal women. Тransmyocardial revascularization is not recommended in patients with debilitating angina refractory to optimal medical and revascularization strategies.

Diabetic autonomic neuropathies as a major risk factor for silent myocardial ischemia and infarction: a literature review

A substantial number of myocardial infarctions (MIs) are asymptomatic or associated with mi-nor and atypical symptoms. These symptoms are often atypical or even absent, especially in di-abetic patients. A number of studies on this topic have shown that in the presence of myocardial ischemia and infarction, diabetic patients report angina less frequently than non-diabetic pa-tients. In this article review, we researched several published articles written about this subject and investigated the relationship between Diabetes Mellitus (DM) in patients and the occur-rence of silent myocardial ischemia and infarction due to the onset of diabetic neuropathy (DN), which is brought about by prolonged diabetes. Based on our research of published articles and studies, we found overwhelming evidence that supports the fact that diabetic autonomic neu-ropathy (DAN) is a major contributing factor in the morbidity of silent myocardial ischemia and infarction among patients suffering from DM. Â

4-OR: Diabetes Duration and the Relative Importance of Cardiovascular Risk Factors in Type 1 Diabetes

Based on a Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) report and their own findings, Pittsburgh Epidemiology of Diabetes Complications investigators concluded that the relative impact of HbA1c and kidney disease in type 1 diabetes (T1D) on cardiovascular disease (CVD) varies according to T1D duration. We investigate the relative importance of HbA1c and other CVD risk factors during ∼ 30 years of DCCT/EDIC follow-up within the primary (RET-: subjects with a mean T1D duration of 2.6 years and without retinopathy at baseline) and within the secondary DCCT cohort (RET+: subjects with a mean T1D duration of 8.6 years and with mild to moderate retinopathy at baseline). CVD included fatal/nonfatal myocardial infarction (MI) or stroke, silent MI, revascularization, confirmed angina, or congestive heart failure. Cox regression models with robust error variances were used to find the most significant CVD risk factors (p&amp;lt;0.05) within RET- and within RET+. The importance of risk factors was determined by evaluating the z value, a measure of association strength between risk factor and CVD. In case of hazard assumption violation, time by covariate interaction was included in model. DCCT enrolled 1441 subjects (age 13-39); 115 of 715 RET+ subjects and 69 of 726 RET- subjects had a CVD event. For RET+, the most important risk factors were baseline (B) age (z ∼4.2), time dependent (T) mean (M) systolic blood pressure (SBP) (z ∼4.0), any severe hypoglycemia (z ∼3.7), and TM HbA1c (z ∼3.2). Other significant risk factors included B autonomic neuropathy, TM insulin dose, TM LDL, T current (C) ACE inhibitor use, TC insulin regimen and B severity of retinopathy but not T1D duration. For RET-, B age, TM HbA1c, TC triglycerides and TM SBP with an increasing CVD effect over follow-up time were significant. The relative importance of CVD risk factors in a young T1D cohort varies according to microvascular complications, which correlate with T1D duration. Disclosure E.R. Fahrmann: None. H. Driscoll: None.