Acute ST-segment Elevation Myocardial Infarction Research Articles

Relationship between Myocardial Performance Index (Tei Index) and angiographic severity of coronary artery disease in patients with Acute ST Elevation Myocardial Infarction

Background: Tei index is a Doppler derived measure of combined systolic and diastolic myocardial function and a better predictor of global LV function and outcome in patients with acute STEMI. The objective of this study was to determine the relationship between the myocardial performance index of LV (Tei index) and angiographic severity of coronary artery disease as assessed by SYNTAX score in patients with acute STEMI. Methods: This was a prospective, observational single centered study conducted from March 2022 to November 2022 at Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine. (MCVTC, IOM). 160 patients with acute STEMI were enrolled. LV Tei index was calculated with the help of 2D and Tissue Doppler imaging, and the lesion severity was categorized with the help of SYNTAX score after the patients underwent coronary angiography. Results: The mean age was 61.23±12.33 years with a male preponderance. 107 (67%) were male with male to female ratio of 2:1. Tei index was significantly higher among the hypertensive (0.74±0.17) and diabetic (0.78±0.18) patients. 64 (40%), 51(31.9%) and 45(28.1%) had Single vessel disease (SVD), Double vessel disease (DVD) and Triple vessel disease (TVD) respectively with the Mean Tei index values 0.57 ± 0.10, 0.76 ± 0.11, and 0.88±0.11 (p<0.05). The Tei index increased when patients were divided into low, mid, and high SYNTAX score groups as 0.58±0.11, 0.61±0.73, 0.88±0.13 respectively, p-value < 0.05). Moreover, the study showed a positive correlation between Tei index and SYNTAX score with increasing severity of coronary artery stenosis. (r=0.654, p-value<0.001). Proximal LAD, LCx and RCA lesions had greater Tei index than the distal lesions. Conclusion: More proximally located LAD, LCx, RCA lesions had higher value of Tei index, as assessed with the SYNTAX score.

Platelet-to-albumin ratio is an independent predictor for ventricular aneurysm formation in ST segment elevation myocardial infarction.

Left ventricular aneurysm (LVA) is a common complication of acute myocardial infarction. We aimed to investigate the association of the platelet-to-albumin ratio (PAR) with LVA formation in patients with acute ST segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). A total of 767 consecutive patients with STEMI were prospectively enrolled. Logistic regression analysis and restricted cubic spline (RCS) were used to assess the association between PAR and LVA formation. The predictive ability of PAR and combined variable for LVA formation were assessed using receiver-operating characteristic (ROC) curve. The prevalence of LVA was 14.1%. Univariable logistic regression analysis revealed that PAR was associated with the risk of LVA at both 1 month [odds ratio (OR) = 4.42, P < 0.001] and 6 months (OR = 4.35, P < 0.001) of follow-up. The predictive value of PAR remained significant even after multivariate logistic regression analysis at 1 month (OR = 3.42, P = 0.004) and 6 months (OR = 4.28, P < 0.001). RCS analysis revealed a nonlinear association between a higher PAR and an increased risk of LVA (nonlinear P < 0.05). In addition, the predictive abilities of PAR for LVA were 0.659. The combination of PAR, hemoglobin, left ventricular ejection fraction, and the use of angiotensin-converting enzym inhibitor/angiotensin receptor blocker significantly enhanced the ability to predict LVA formation (C statistic= 0.887). A higher PAR was significantly associated with an increased risk of LVA formation in patients with acute STEMI who underwent primary PCI.

Clinical presentation, management and outcomes of myocardial infarction in the Heart Center, Al-Thawra Hospital, Sana'a City, Yemen: Stemi cardiac arrest management outcomes

Background and aim: Acute ST-segment elevation myocardial infarction (STEMI) is a critical medical emergency requiring emergency evaluation, diagnosis, and intervention. The aim of the study was to evaluate the clinical presentation, type of treatment, and outcomes of patients with acute ST-segment elevation myocardial infarction at the Heart Center of Al-Thawra Hospital, Sana'a. Methods: prospective study. We enrolled all patients with a final diagnosis of STEMI who have been admitted to the cardiac CCU in the cardiac center in AL-Thawrah Hospital during one year, January to December 2023. Results: A total of 358 patients with STEMI were analyzed. The mean age was 55 ± 8 years old, with male patients representing 80% (286)). The traditional risk factors among these patients were: hypertension 28.23% (101), smoking represents 26.05% (93), diabetes mellitus represents 19% (68), BMI &gt; 30 kg/m2 represents 16.34% (57), and khat chewing represents 78.2% (279). STEMI patients who managed by primary PCI were 14% (50). Patients who have been managed by thrombolytic therapy were 28% (101) and the conventional medical treatment was managed for those who arrived after 12 hours and represent 58%% (204). The most commonly used thrombolytic was streptokinase in 96% (97) of patients who received thrombolytics. Primary PCI within 24 hours has been done in 14% (50) of cases. Heart failure (EF &lt; 50%) represented (26%) (93), cardiovascular shock was 13% (46 cases), and mortality rate was 11% (39 cases))

Time trends in mortality, incidence and case-fatality of acute myocardial infarction in Norway - do we see the end of the coronary heart disease epidemic?

Abstract Background In Norway and most industrialized countries the mortality rates from acute myocardial infarction (AMI) increased after World War II, peaked in the 1960s – 1970s, and have since that time declined (Figure). Recent studies have suggested that the decline may have leveled off, and that the favourable trends do not include younger age groups, possibly due obesity and diabetes. Also, the relative contribution of a reduction in incidence and improved case-fatality rates (CFR) to the AMI mortality trends are not known with certainty. We examined mortality trends of AMI in Norway during 1951 – 2021, and the incidence and CFR of hospitalized and non-hospitalized AMI during 2013-2021. Methods Fatal AMI cases were identified in the National Causes of Death Registry. Norwegian hospitals are required by law to register all patients hospitalized for AMI in the Norwegian AMI Registry. Hospitalized cases not registered in the AMI registry were retrieved from the Norwegian Patient Registry which contains discharge diagnoses for hospitalized patients. The national unique 11-digit identification number allowed linkage of the registries and identification of transfers between hospitals and re-hospitalizations. An AMI (either hospitalization or death) was classified as incident if no hospitalization was found for that individual during the previous 5 years. We calculated age-adjusted rates with the Norwegian population in 2017 as standard. Results Norwegian AMI mortality rates increased from 1951, peaked in the late 1960s, and have since that time declined steadily, although steeper after around 1990 (Figure). Present AMI mortality rates are lower than in the 1950s, and are still declining. Incidence of AMI (hospitalized and non-hospitalized) fell from 391/100 000 in 2013 to 271/100 000 in 2021, corresponding to a mean reduction of 3.6 % per year (p&amp;lt;0.001). Incidence of out-of-hospital fatal AMI fell by 6.5 % per year, incidence of hospitalized ST-segment elevation AMI (STEMI) fell by 2.3 % per year, and incidence of non-ST-segment elevation AMI (NSTEMI) fell by 3.1 % per year (all p&amp;lt;0.001). 30-days CFR of hospitalized and non-hospitalized AMI fell from 21.3 % in 2013 to 17.5 % (3.6 % per year; p&amp;lt;0.001). CFR after NSTEMI fell from 8.2 % in 2013 to 6.4 % in 2021 (4.4 % per year; p&amp;lt;0.001), whereas there was no significant change in CFR after STEMI (13.3 % in 2013 and 12.0 % in 2021). The incidence and CFR trends were similar in men and women aged 20-49, 50-79 and 80+ years. Comments Declining incidence of out-of-hospital fatal AMI and declining incidence of hospitalized STEMI and NSTEMI were major contributors to the declining AMI mortality rates in Norway. Improved case-fatality rates among hospitalized patients have contributed to the declining mortality rates, but there was no improvement in case-fatality in STEMI during 2013-2021.

The clinical characteristics and prognosis of patients with acute ST-segment elevation myocardial infarction complicated with impaired activity daily living

Abstract Background Previous studies have indicated that activities of daily living (ADL) can influence the prognosis of patients with acute myocardial infarction. The purpose of this study is to delineate the clinical characteristics, treatment regimens, and prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) who have impaired ADL. Methods The data for this study were derived from a Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. The inclusion criteria encompassed patients with a discharge diagnosis of STEMI.ADL prior to STEMI was evaluated using the Barthel index(BI),a widely used assessment tool for evaluating ADL.The patients' BI were obtained from their resident health records.Patients were categorized into two groups: ADL normal group and ADL impaired group. A comparative analysis was conducted between the two groups regarding clinical characteristics, treatment regimens, and prognosis. Results This study included 24,906 STEMI patients with normal ADL and 1,002 STEMI patients with impaired ADL. Baseline data revealed that patients in the ADL impaired group had a higher proportion of females (43.0% vs. 37.8%, p=0.001), were older (74.0[64.0,81.0] vs. 69.0[65.0,75.0], p&amp;lt;0.001), and had a higher proportion of Killip III and above (24.30% vs. 14.10%, p&amp;lt;0.001). Additionally, the ADL impaired group had a higher prevalence of comorbidities. In terms of treatment, the ADL impaired group had lower proportions of patients undergoing percutaneous coronary intervention (PCI) (43.8% vs. 65.3%, p&amp;lt;0.001) and primary PCI (PPCI) (36.4% vs. 55.1%, p&amp;lt;0.001). Additionally, the ADL impaired group exhibited lower utilization rates of antiplatelet drugs, ACEI/ARB, beta-blockers, ARNI, and statins, but higher rates of diuretics and cardiac glycosides. Regarding prognosis, the ADL impaired group had a higher in-hospital mortality rate (5.69% vs. 2.89%, p&amp;lt;0.001). The median follow-up time was 1,220 days. In the ADL impaired group, the rates of all-cause mortality (52.0% vs. 24.7%, p&amp;lt;0.001), cardiovascular mortality (37.3% vs. 17.3%, p&amp;lt;0.001), recurrent non-fatal myocardial infarction (11.1% vs. 8.30%, p=0.002), and recurrent stroke (11.9% vs. 8.66%, p=0.001) were higher. However, the rate of revascularization was lower in the ADL impaired group (6.69% vs. 9.20%, p=0.008), and the risk of cerebral hemorrhage showed no significant difference (1.00% vs. 0.81%, p=0.631). In a multivariate Cox regression analysis adjusting for age, gender, Killip, medical history, and treatment strategies, impaired ADL remained an independent risk factor for increased all-cause mortality (aHR 1.309, 95% CI: 1.195-1.434, p&amp;lt;0.001). Conclusions Impairment of ADL is associated with adverse clinical outcomes in patients with STEMI.Baseline characteristics of patientsMedications of patients

Multi-biomarker approach for predicting cardiac magnetic resonance parameters at 30 days after ST-segment elevation myocardial infarction

Abstract Background Prior data showed associations of circulating Proprotein Convertase Subtilisin / Kexin type 9 (PCSK9) and inflammatory/anti-fibrotic Cellular Communication Network factor 1 (CCN1) at index ST-segment elevation acute myocardial infarction (STEMI) with left ventricular ejection fraction at 6 and 12 months, respectively and for CCN1 also with infarct size. Purpose PCSK-9, CCN1 and reference biomarkers high-sensitivity Troponin T (hsTNT) and N-terminal pro-brain natriuretic peptide (NTproBNP) were measured in patients from the CLEVER-ACS trial (clinicaltrials.gov NCT01529554) at presentation with STEMI and correlated with clinically relevant cardiac magnetic resonance (CMR) parameters at 30 days. Methods Associations between baseline biomarkers (PCSK-9, CCN1, hsTNT, NTproBNP) and CMR parameters at 30 days were evaluated using Spearman correlation and linear regression analysis (dichotomised at their median). Receiver operating characteristic (ROC) and area under the curve (AUC) were determined for significant values based on correlation analysis; AUC &amp;gt; 0,7 considered relevant. CMR parameters comprised left ventricular structural and functional parameters including scar mass and microvascular obstruction. Results We identified 56 STEMI patients (mean age 61.7 ± 11.2 (SD) years) who completed 30 days follow-up with biomarker data. Among biomarkers, significant associations with CMR parameters were only found for hsTNT, and NTproBNP. The strongest associations were found for left ventricular ejection fraction (LVEF; hsTNT RSp =-0.66; NTproBNP RSp =-0.57), left ventricular scar (LVSCAR; hsTNT RSp =0.58; NTproBNP RSp =0.56) and scar mass (SM; hsTNT RSp =0.65; NTproBNP RSp =0.55). Conversely, left ventricular end-diastolic volume index (LVEDVI; hsTNT RSp =0.47; NTproBNP RSp =0.32), left ventricular end-systolic volume index (LVESVI; hsTNT RSp =0.51; NTproBNP RSp =0.39) and microvascular obstruction (MVO; hsTNT RSp =0.34; NTproBNP RSp =0.34) were significantly, albeit only modestly associated. ROC and AUC analysis yielded relevant associations of biomarkers with CMR parameters LVEF (hsTNT=0.79; NTproBNP=0.81), LVSCAR (hsTNT=0.84; NTproBNP=0.76) and scar mass (hsTNT=0.83; NTproBNP=0.78). Furthermore, relevant associations of biomarkers with CMR were found for LVEDVI (hsTNT=0.79; NTproBNP=0.72), LVESVI (hsTNT=0.84; NTproBNP=0.72) and MVO (hsTNT=0.72; NTproBNP=0.71). Conclusion Baseline levels of hsTNT and NT-proBNP are strong predictors for functional and dimensional CMR parameters of the left ventricle including clinically relevant imaging surrogates of myocardial injury shortly after STEMI.ROC LVEF

Supersaturated oxygen therapy in patients with acute anterior myocardial infarction reduces infarct size

Abstract Background Myocardial final infarct size (FIS) is associated with heart failure hospitalizations and mortality in patients with ST-segment elevation myocardial infarction (STEMI). Interventional therapies beyond primary percutaneous coronary intervention (PCI) to reduce FIS are needed. Hyperoxemic supersaturated oxygen therapy (SSO2) has shown to reduce infarct size in previous clinical trials. Methods We performed routine SSO2 therapy in patients with acute anterior STEMI after successful primary PCI. Results from 22 SSO2 patients were compared with those from 22 pair-matched non-SSO2 acute anterior STEMI patients. Cardiac magnetic resonance imaging (MRI) was performed to assess left ventricular (LV) function, myocardial FIS (late gadolinium enhancement), area-at-risk (AAR, myocardial oedema), myocardial salvage index (MSI, proportion of non-necrotic inside oedematous myocardium), and microvascular obstruction (MVO, necrotic myocardium within the infarct zone). Results Both groups did not significantly differ regarding sex, age, weight, body mass index, hypertension, dyslipidaemia, smoking and diabetes status, prehospital cardiac arrest, door-to-balloon time, TIMI flow before and after PCI, numbers of stents placed, and renal function (p&amp;gt;0.1 each). SSO2 patients had significant lower maximum creatine kinase levels (2111 U/l) vs. non-SSO2 patients (4571 U/l, p=0.003). Cardiac MRI was performed 4 ± 2 days after PCI. LV ejection fraction (48% in SSO2 vs. 43% in non-SSO2, p=0.11) and AAR (42% of LV mass in SSO2 vs. 48% of LV mass in non-SSO2, p=0.096) did not significantly differ between the groups. SSO2 significantly reduced FIS by 38% (21% of LV mass vs. 34% of LV mass, p&amp;lt;0.001). MSI was significantly higher in SSO2 patients (46% vs. 18%, p&amp;lt;0.001). MVO occurred in 60% of SSO2 patients vs. 90% of non-SSO2 patients with a significant absolute difference (2.3% in SSO2 vs. 5.7% in non-SSO2, p=0.011). Conclusion While areas at risk were similar between both groups, SSO2 significantly reduced maximum creatine kinase levels, final infarct size and microvascular obstruction in patients with acute anterior STEMI.

Relation of plasma neuropeptide-Y with myocardial function and infarct severity in acute ST-elevation myocardial infarction

Abstract Background Acute myocardial infarction is associated with high levels of cardiac sympathetic stimulation, which leads to the release of the co-transmitter neuropeptide-Y (NPY). NPY acts as a potent vasoconstrictor and an association with increased risk for heart failure and microvascular dysfunction after acute ST-elevation myocardial infarction (STEMI) has been suggested. Purpose This study aims to comprehensively evaluate the association of plasma NPY with myocardial function and infarct severity, visualized by cardiac magnetic resonance (CMR) imaging, in STEMI patients revascularized by primary percutaneous coronary intervention (PCI). Methods In this observational study, we included 260 STEMI patients treated with primary PCI. Plasma NPY concentrations were measured by an immunoassay 24h after PCI from peripheral venous blood samples. Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), infarct size (IS) and microvascular obstruction (MVO) were determined using CMR imaging 4 days and 4 months after PCI. Results Median plasma concentrations of NPY were 70 [interquartile range (IQR): 35-115] pg/ml. NPY levels above median were significantly associated with lower LVEF (48% vs. 52%, p=0.004), decreased GLS (-8.8% vs. -12.6%, p&amp;lt;0.001) and larger IS (17% vs. 13%, p=0.041) in the acute phase after infarction as well as in the chronic stage (LVEF: 50% vs. 52%, p=0.030, GLS: -10.5 vs. -12.9, p&amp;lt;0.001, IS: 13% vs. 10%, p=0.011). In addition, NPY levels were significantly related to presence of MVO (58% vs. 52%, p=0.041). Moreover, in multivariable linear regression analysis, NPY remained significantly associated with all investigated CMR parameters (LVEF: p&amp;lt;0.001, GLS: p&amp;lt;0.001, IS: p=0.003, MVO: p=0.042) independent of other established clinical variables including high-sensitivity cardiac troponin T, pre-interventional TIMI flow 0 and left anterior descending artery as culprit lesion location. Conclusion High plasma levels of NPY, measured 24h after STEMI, were independently associated with lower LVEF, decreased GLS, larger IS as well as presence of MVO, indicating plasma NPY as a valuable biomarker for optimized risk stratification.

Real-life impact of complete revascularization of non-ST elevation myocardial infarction during index hospitalization

Abstract Introduction patients with non-ST elevation acute myocardial infarction (NSTEMI) frequently present multivessel disease (MVD) with significant stenosis in non-infarct-related arteries (non-IRA). Unlike for ST elevation acute myocardial infarction, there is a paucity of studies evaluating the prognostic impact of complete revascularization in these patients. In fact, recommendation for complete revascularization is based in observational and non-randomized studies suggesting a possible benefit regarding mortality and major cardiovascular events. Purpose to evaluate the prognostic impact of complete revascularization during the index hospitalization in the Portuguese patients with NSTEMI and MVD. Methods patients hospitalized for NSTEMI with MVD included in a national multicentre retrospective study between October 2010 and December 2022 were divided into two groups: group 1 was submitted to complete percutaneous revascularization during the index hospitalization (IRA and non-IRA with diameter stenosis ≥50% on angiography), and group 2 performed IRA-only revascularization. The impact of complete revascularization on the probability of cardiovascular re-hospitalization, as well as on in-hospital and one-year mortality rates was evaluated. Results a total of 3084 patients was included, 74.8% were males, with a mean age of 67.8±11.9 years. Most patients were submitted to IRA-only revascularization (72.9%). From the remaining, 81.4% performed complete revascularization during the index procedure and 18.6% staged during index hospitalization. Group 1 patients were younger (65.5±11.8 vs. 68.6±11.8 years, p&amp;lt;0.001), with fewer comorbidities and slightly higher left ventricular ejection fraction (55±11 vs. 51±11%, p&amp;lt;0.001). On the other hand, group 2 patients revealed a significantly higher percentage of previous, revascularization (14.8% vs. 1.6%), mostly surgical. Besides overall similar incidence of in-hospital complications, including recurrence of acute myocardial infarction, patients submitted to complete revascularization showed a non-significant trend to an inferior in-hospital mortality rate (0.7 vs. 1.6%, p=0.06). Also, 1-year mortality rate was similar between groups (4.2 vs. 5.0%, p=0.54). However, complete revascularization appeared to result in a long-term prognostic benefit, halving the incidence of unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 18.8%, p&amp;lt;0.001). Conclusion complete revascularization led to an overall long-term benefit, mainly due to a reduction in cardiovascular re-hospitalizations, without a significant impact on 1-year mortality rate.

Efficacy of combination therapy with statin and ezetimibe versus high dose statin monotherapy in secondary prevention in high-risk patients

Abstract Background Secondary prevention in patients with acute coronary syndrome focuses on lowering low-density lipoprotein (LDL) cholesterol below 55 mg/dL. In all statin-naïve patients at high risk (LDL-cholesterol target &amp;lt;55 mg/dL), initiation of high-intensity statin monotherapy is recommended by ESC guidelines. Nonetheless, at one month, a significant proportion of patients do not reach their LDL-cholesterol target. Purpose The aim of this study was to compare lipid-lowering therapy with statin monotherapy versus statin with ezetimibe in secondary prevention in patients at high risk. Methods The current prospective study included 264 consecutive patients admitted with acute ST elevation myocardial infarction who underwent percutaneous coronary intervention. None of the patients had taken lipid-lowering drugs in the previous 12 months. Patients were randomly assigned to one of two treatment groups: Group 1 - rosuvastatin 40 mg (n= 144) and Group 2 - rosuvastatin 40 mg and ezetimibe 10 mg (n= 120). All patients' lipid profiles were assessed upon admission and after one month of lipid-lowering treatment. Results At baseline, no patient had LDL cholesterol level lower than 55 mg/dL. There was no significant difference in lipid profile at baseline between the two groups (all p &amp;gt; 0.05). No differences were observed between the two groups in terms of baseline LDL-cholesterol deviation from the target (103.4% versus 99.70%; p= 0.66). As expected, the combination therapy reduced LDL-cholesterol at one month significantly higher compared to high-dose statin monotherapy (-59.65% versus -37.54%; p&amp;lt; 0.0001). After one month of treatment, only 47.92% of patients in Group 1 reached the LDL-cholesterol target (&amp;lt;55 mg/dL) compared to 90.00% of the patients in Group 2 (p&amp;lt;0.0001; R.R.= 0.53). Conclusion(s) Our findings show that statin and ezetimibe combination therapy is more effective in reduction in LDL-cholesterol levels and reaching targets compared to statin monotherapy alone. In statin-naïve patients at high risk, early initiation of the statin and ezetimibe combination instead of statin monotherapy should be taken into account in secondary prevention, for an earlier reach of the LDL-cholesterol target and to reduce the overall cardiovascular risk.

Prior fecal immunochemical test positivity is associated with adverse prognosis in patients with acute ST-segment elevation myocardial infarction

Abstract Backgrounds While fecal immunochemical testing (FIT) is commonly used for disease screening, its significance in other conditions, particularly in patients with ST-segment elevation myocardial infarction (STEMI), is not extensively researched. Purpose This study aimed to investigate the impact of prior positive FIT results on the clinical prognosis of patients with STEMI. Methods The data for this study were derived from the Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients discharged from 72 hospitals from 2010 to 2023. A total of 76,157 patients with acute STEMI patients were enrolled. Positive FIT was defined as "+-" or higher on the fecal occult blood test. Propensity score matching (PSM) was employed to balance differences between the two groups. Kaplan-Meier analysis with log-rank tests compared endpoint risks between groups, and a multivariable Cox regression model adjusted for potential confounders. The primary endpoint was Net Adverse Clinical Event (NACE), including cardiac death, recurrent myocardial infarction, revascularization, stroke, cerebral hemorrhage, and gastrointestinal bleeding. Results After 1:3 PSM,2,148acute STEMI patients were included, with 537 having prior positive FIT and 1,611 without. Patients with prior positive FIT were more likely to have comorbidities such as hyperlipidemia, prior malignancy, post-coronary artery bypass grafting, renal insufficiency, and prior cerebral hemorrhage. The prior positive FIT group had a higher proportion of prior clopidogrel and indobufen usage, while aspirin use during follow-up was lower. Kaplan-Meier analysis demonstrated a significantly higher risk of NACE in acute STEMI patients with prior positive FIT (before PSM: log-rank P = 0.001, after PSM: log-rank P = 0.005, Figure 1）, as well as increased rates of Major Adverse Cardiac and Cerebral Events (MACCE), all-cause death, and gastrointestinal bleeding (log-rank P &amp;lt; 0.05 for all). Multivariate Cox-proportional hazard analysis adjusted for age, sex, percutaneous coronary intervention during hospitalization, diabetes, hypertension, ischemic stroke, atrial fibrillation, medication during hospitalization, and follow-up showed similar results (Figure 2). Conclusions This study reveals a significant association between prior positive FIT and higher rates of NACE, MACCE, all-cause death, and gastrointestinal bleeding in STEMI patients within 1 year. A history of positive FIT results could serve as a prognostic indicator in this specific patient population.

Predicting ECGs masquerading AS STEMI with machine learning

Abstract Background Advancements in the management of ST elevation myocardial infarction (STEMI) in the last 15 years include early STEMI identification in the prehospital setting leading to expedited cardiac catheterisation laboratory (CCL) activation or fibrinolytic therapy. We have previously reported of patients who met the Glasgow algorithm (GA) ECG criteria for STEMI; 50% did not actually have an acute STEMI according to the 4th universal definition of MI (4UDMI)1. Identifying such patients could avoid unnecessary emergency CCL activations or inappropriate fibrinolytic administration. Methods From June 2010 to October 2021, we identified 2992 patients with ECG transmissions to Liverpool Hospital, Sydney Australia which met GA criteria for STEMI. These were adjudicated according to the 4UDMI for true-positive STEMI. We used univariate and multivariate logistic regression to identify likely patient characteristics that were predictive of true-positive STEMI. We then improved model performance using receiver-operator curve (ROC) with simple random forest machine learning algorithms. Results Among 2994 patients with prehospital ECG transmissions that met GA-criteria, 1553 (51%) were adjudicated as true-positive STEMI, which is comparable to previous findings1. All standard modifiable and non-modifiable risk factors were independently predictive of true-positive STEMI; however, in multivariate logistic regression gender, hypertension and diabetes lost significance. Dyslipidemia and current smoking were positively predictive of true-positive STEMI status (OR = 1.64 and 1.32 respectively), whereas age and previous MI were negatively associated (OR = 0.98 (per year increment) and 0.4). Using these identified predictors in a random forest to predict true-positive STEMI yielded an AUC of 0.65 (Figure 1). Conclusion Specific clarification of dyslipidaemia and current smoking status at first medical contact may be the most salient in predicting a true-positive STEMI during prehospital assessment which may assist in avoiding unnecessary emergency CCL activation or inappropriate fibrinolytic administration.ROC of ST elevation STEMI recognition

Thrombus aspiration in people living with HIV- a night mare for interventionist

Abstract Background Cardiovascular disease, particularly atherosclerosis, and its complications are a growing cause of morbidity and mortality among individuals living with human immunodeficiency virus (HIV) in the post-antiretroviral therapy era. The role of thrombus aspiration combined with primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) within this population remains contentious. While PCI is the preferred strategy for immediate revascularization in acute STEMI, challenges persist, with about 30% of patients experiencing persistent chest pain and ST-segment elevation despite achieving TIMI III flow in the culprit vessel. Methods We conducted a prospective observational study spanning from January 2015 to September 2023, involving ten consecutive HIV-infected patients presenting with STEMI to our acute coronary care unit. The study encompassed an analysis of baseline clinical characteristics, response to fibrinolytic therapy, angiographic findings, thrombus aspiration using the Export Aspiration Catheter, and the outcomes of percutaneous coronary intervention (PCI). Patients were closely monitored for in-hospital outcomes and followed up for five years, during which they received adjuvant highly active antiretroviral therapy (HAART). Results The mean age of the patients was 46 years, lower than their uninfected counterparts. Most patients presented with a lower Killip class, indicating favorable outcomes. CD4 count distribution showed variability, with ten patients undergoing rescue angioplasty with thrombus aspiration using the Export Catheter. The cohort was followed for five years, receiving consistent HAART therapy. Conclusion HIV-associated atherosclerosis presents a considerable health burden, characterized by distinctive non-calcified and inflammatory plaques vulnerable to rupture. Thrombus aspiration during PCI emerged as a valuable strategy, reducing thrombotic burden and contributing to improved clinical outcomes in people living with HIV.

Prognostic value of combined myocardial performance index in patients with acute ST-elevation myocardial infarction

Abstract Background Myocardial performance index (MPI) also known as Tei index is a unique echocardiographic parameter which can estimate both systolic and diastolic performances of left and right ventricles. We previously suggested the echocardiographic parameter combined MPI (CMPI) as a new predictor of the prognosis of acute ST-elevation myocardial infarction (STEMI). The CMPI is the sum of left ventricular (LV) MPI and right ventricular (RV) MPI (CMPI = LV MPI + RV MPI). We supposed that CMPI might be a better predictor in STEMI, because it reflects both ventricular systolic and diastolic functions. Objectives The purpose of this study is to assess the prognostic value of a new echocardiographic parameter CMPI in STEMI patients calculated in acute phase. Methods 240 STEMI patients who underwent primary PCI have been included in the study. Echocardiography (EchoCG) was performed, and LV MPI and RV MPI were assessed within 24 hours after the symptom onset, prior to primary PCI. The MPI was calculated as the sum of isovolumic contraction time (ICT) and isovolumic relaxation time (IRT), divided by the ejection time (ET): MPI = (ICT + IRP) / ET. 50 % of the patients had anterior STEMI. 30 patients (12.5%) had concomitant RV myocardial infarction (MI). Patients were divided into two groups: Group 1 – CMPI &amp;gt; 0.9 (110 patients), Group 2 – CMPI ≤ 0.9 (130 patients). Baseline demographic and clinical characteristics were similar in both groups. Also, there were no differences in LV MI localization and concomitant RV MI between the groups. Primary endpoints were in-hospital and the one-year cardiovascular mortality rates. The secondary endpoint was the one-year heart failure hospitalization rate. Results In Group 1 the in-hospital mortality rate was 9.1%, and 3.1% in Group 2 (p = 0.0489). One-year cardiovascular mortality rate was 12.7% in and 5.4%, respectively (p = 0.0465). One-year heart failure hospitalization was also significantly lower in Group 2 (22.7% vs. 12.3%, p = 0.0332). Conclusion CMPI can be offered as a new predictor for the in-hospital and one-year cardiovascular mortality and one-year heart failure hospitalization rate in patients with acute STEMI.

ORBI risk score and inflammatory response in patients with acute ST-elevation myocardial infarction

Abstract Background The ORBI risk score was developed to predict in-hospital cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) [1]. An inflammatory response is seen in STEMI and may precede CS. The association between ORBI score and systemic inflammatory response is of interest both for improving risk assessment of CS but also for identifying potential therapeutic targets. Methods Using data from one center in the Third DANish Study of Optimal Acute Treatment of Patients With ST-Segment Elevation Myocardial Infarction (DANAMI 3) trial, the inflammat ory status was detected by peak C-reactive protein level (CRP) and white blood cell count (WBC) analyzed from blood samples taken within 96 hours from percutaneous coronary intervention (PCI). Patients were stratified into two ORBI risk groups: ‘Low’ (0-7) and ‘intermediate-high’ (&amp;gt;=8). Patients with CS at the time of PCI were not included, nor were those with out-of-hospital cardiac arrest. Logistic- and Cox Proportional Hazards regression was used to assess the association between ORBI risk groups and 1/ an above-median inflammatory status, and 2/ one-year mortality when combining risk group with inflammatory status. Results Of 1603 patients included, at least one 0–96-hour CRP was available in 631 (39.4%), and WBC in 628 (39.2%) of patients. Mortality at 96 hours was 1.3%. Median CRP and median WBC in the ‘intermediate-high’ ORBI risk group were 61.5 mg/L (interquartile range (IQR) 16-158) and 12 x 10^9/L (IQR 8.8-15.8) vs. 14 (IQR 5-38.8) and 10 (IQR 8.3-12.8) in the ‘low-risk’ group (p&amp;lt;0.001). ‘Intermediate-high’ ORBI score was associated with increased odds of an above-median CRP (OR 3.34, 95% confidence interval (CI) 2.20-5.18, p&amp;lt;0.001), as well as increased odds of an above-median WBC (OR 2.24, 95%CI 1.50-3.38, p&amp;lt;0.001) in univariate analyses. In patients having CRP levels above the median compared to those below, the median age was higher (66 years vs. 60 years, p&amp;lt;0.001). The prevalence of chronic heart failure was greater (26% vs. 13%, p&amp;lt;0.001), as was the incidence of renal failure (6.1% vs. 1.2%, p=0.003). A higher number of patients were classified within Killip classes 3-4 (24% vs. 2.6%, p&amp;lt;0.001). For patients with WBC above the median versus those below, there was a higher prevalence of chronic heart failure (24% vs. 16%, p=0.009). Killip 3-4 was also more common (22% vs. 4.2%, p&amp;lt;0.001). Patients with CRP and WBC at or above the median and an ‘intermediate-high’ ORBI score faced a higher risk of one-year mortality (HR CRP: 5.23, 95%CI: 2.59-10.6, p&amp;lt;0.001 and HR WBC: 6.15, 95%CI 3.04-12.4, p&amp;lt;0.001, figure 1). Conclusions An ‘intermediate-high’ ORBI risk score in STEMI patients was associated with significantly higher odds of increased levels of systemic inflammation within 0-96 hours of admission. An intermediate-high score combined with an elevated inflammatory response was associated with a five to six-fold increased risk of one-year mortality.Fig. 1:KM-plot, 1 year (scale is 1-0.9)

Combined activation of complement and coagulation is associated with myocardial injury in ST-elevation myocardial infarction

Abstract Introduction Experimental data indicates that the complement system and the coagulation cascade can activate each other. The magnitude of this interaction in acute myocardial infarction is not known. We aimed to investigate a possible association between complement activation and coagulation activation in patients with acute ST-elevation myocardial infarction (STEMI), as well as how they relate to myocardial injury estimated by troponin T (TnT) and myocardial function assessed by echocardiography. Purpose To increase the understanding of the interaction between complement activation and coagulation activation in STEMI, and the clinical relevance to myocardial injury. Methods Blood samples were drawn after percutaneous coronary intervention (PCI) in 864 patients with STEMI. Myocardial function was measured as left ventricular ejection fraction (LVEF), estimated by visual approximation or Simpson biplane method within 3 months. Complement activation was assessed by ELISA of circulating levels of the terminal complement complex (TCC). Activation of coagulation was assessed by ELISA of prothrombin fragment 1+2 (F1+2) and D-dimer, and endogenous thrombin potential (ETP), analyzed by calibrated automated thrombogram assay. Results TCC was weakly correlated to F1+2 (r=0.086, p=0.012), D-dimer (r=0.176, p&amp;lt;0.001) and ETP (r=0.144, p&amp;lt;0.001). In univariate linear regression analysis, this association persisted for D-dimer and ETP. When adjusting for associated covariables, the association only persisted for ETP (Table 1). Patients with above-median TCC and D-dimer had significantly higher peak TnT (Figure 1). In logistic regression, having combined above-median TCC and D-dimer was predictive of an LVEF ≤40% (Table 2). Conclusion In this large STEMI cohort, complement activation by TCC was weakly associated with coagulation activation. Combined high levels of TCC and D-dimer were linked to higher peak TnT and lower LVEF, possibly reflecting greater myocardial injury. The interaction between complement and coagulation activation might be relevant for clinical outcomes in STEMI patients and warrants further investigation.

Cardiac autonomic dysfunction in Takotsubo cardiomyopathy: an observational study

Abstract Takotsubo syndrome (TTS), commonly perceived as a benign and reversible condition has received attention due to emerging registry data revealing its prognosis to be comparable to acute coronary syndrome (ACS). Following ACS, a notable subset of patients develops autonomic dysfunction, whith unfavourable prognostic implications. Periodic repolarization dynamics (PRD) and deceleration capacity (DC), derived from ECG signals, are parameters capable of quantifying cardiac autonomic function. In this study, we aimed to assess autonomic dysfunction in patients with TTC in comparison to ST-elevation myocardial infarction (STEMI) patients. Consecutive patients diagnosed with TTS were prospectively recruited into an observational, single-centre cohort study. All patients underwent a 30-minute high-resolution ecg recording. Subsequent recordings were conducted at 4 and 12 months post-acute event. PRD and DC as markers for sympathetic and parasympathetic activity, respectively, were assessed using established methods. The control group comprised patients with STEMI. Statistical comparisons between groups were performed using the Mann-Whitney U-test, with a corrected significance level for multiple testing of α&amp;lt; .017. Between July 2021 and December 2023, 57 patients diagnosed with TTS were recruited (interquartile range [IQR]) 69.0 years (62.0-78.0), 98.3% women. A control group was derived from a pre-existing cohort of STEMI patients, matched through propensity score matching to adjust for age and sex (median age [IQR]: 69.0 [59.0-76.0] years, 98.3% women). At baseline, there was no significant difference in PRD between TTS patients and controls (median [IQR]: TTS: 5.28deg² [3.43-9.93], STEMI: 4.40deg² [2.24-7.21]; p = .04). However, at 4 months post-acute event, PRD was notably higher in TTS patients compared to controls (median [IQR]: TTS: 5.20deg² [2.71-8.17], STEMI: 2.63deg² [1.86-4.92]; p = .011). Interestingly, at 12-month follow-up, PRD in TTS patients did not differ from that of controls (median [IQR]: TTS: 4.55deg² [2.89-8.40], STEMI: 4.15deg² [2.42-6.85]; p = .68). Regarding DC, no significant differences were observed between TTS and STEMI patients at any time point (baseline: median [IQR]: TTS: 3.95 ms [2.27-5.51], STEMI: 3.52 ms [2.30-7.24], p = .51; 4 months: median [IQR]: TTS: 6.63 ms [4.59-8.64], STEMI: 7.41 ms [4.63-9.25], p = .39; 12 months: median [IQR]: TTS: 4.98 ms [4.19-6.67], STEMI: 7.48 ms [4.92-10.28], p = .17). Patients with TTS show substantial signs of cardiac autonomic dysfunction, similar or even higher than acute STEMI patients. This dysfunction persists even up to 4 months after the acute event, whereas STEMI patients show recovery of autonomic function in this 4 month period. DC remained consistent between TTS and STEMI patients across all time points. Further research elucidating the long-term implications of these autonomic alterations is warranted to refine risk stratification and therapeutic strategies in TTS management.

Evaluation of Pharmaco-invasive PCI in Terms of in Hospital Clinical Outcome of Acute Anterior ST Segment Elevation Myocardial Infarction Patients Compared to Primary PCI

Background: The strategic reperfusion early after Myocardial Infarction trial and the French Registry of Acute Anterior ST segment elevation MI suggested that pharmaco-invasive strategy compares favorably with primary percutaneous coronary intervention (PPCI). Objectives: To evaluate in hospital clinical outcome of patients with acute anterior ST segment elevation myocardial infarction undergoing Primary PCI and pharmaco-invasive PCI. Methods: This cross sectional study was conducted in United Hospital, Dhaka. A total of 120 patients were studied. These patients were categorized into two groups. Those with acute anterior ST segment elevation MI who underwent primary PCI was denoted as group A (n= 55) and those with acute anterior ST segment elevation thrombolysed by streptokinase followed by PCI confined to pharmaco-invasive PCI was denoted as group B (n=65). Results: Acute LVF was more in pharmaco-invasive group than in primary PCI group and was statistically significant (p= 0.032). 02 patients (3.6%) died in primary PCI group: one of which was due to ventricular fibrillation followed by asystole 3 hours after procedure and the other died due to cardiac arrest 10 hours after the procedure. No major bleeding incidence was found in both groups. Conclusion: Acute anterior ST segment elevation myocardial infarction patients receiving pharmaco-invasive treatment compared with the Primary PCI had higher incidence of acute LVF and no significant discrepancy was observed regarding bleeding events, death, stent thrombosis, arrythymia, heart block and cardiac arrest. J Shaheed Suhrawardy Med Coll 2023; 15(1): 34-38

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed. Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 1: Patient presentation through revascularization.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the critical initial phases of care are reviewed. Despite established value in the emergency department (ED), cardiac care, and intensive care settings, there is currently little published literature describing or supporting clinical pharmacist roles in the acute management of STEMI. The high-risk period from hospital presentation through revascularization and stabilization involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. While rife with opportunities for pharmacists to optimize care, this timeframe appears inconsistently targeted by clinical pharmacy services, which may halt after ED evaluation and then resume upon postcatheterization cardiac unit admission. Herein we review the key pharmacotherapeutic modalities and considerations for the patient with STEMI across the critical initial phases of care. These include supportive therapies prior to revascularization, the host of antithrombotics involved in revascularization by percutaneous coronary intervention and/or fibrinolysis, and other periprocedural medications. Important practice guidelines and clinical resources are summarized from the clinical pharmacist perspective, and roles and responsibilities of the responding pharmacist are suggested. A companion article will extend the review to periprocedural adverse event management, key early decision-making regarding long-term risk reduction, and pharmacist involvement in institutional quality improvement efforts. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population, and we call for further research delineating pharmacist impact on patient and institutional STEMI outcomes. Patients presenting with STEMI rapidly traverse multiple phases of care and receive a host of antithrombotic and supportive medications during acute management, presenting many important pharmacotherapeutic decision points and roles for pharmacists.