ST-elevation Myocardial Infarction Cohort Research Articles

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<0.001) and ETP (r=0.144, p<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.

Revascularisation after discharge in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Background Multivessel coronary artery disease frequently occurs in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS), which is associated with a higher mortality rate. Previous studies have focused on revascularisation during the initial admission. The need for revascularisation after discharge has not yet been well-studied. Purpose To determine the incidence of revascularisation after discharge in patients initially hospitalised with AMICS compared to ST-elevation myocardial infarction (STEMI) patients without CS. Methods Data from a cohort of individually validated AMICS patients admitted to two tertiary cardiac centres in Denmark between 2010 and 2017 - the RETROSHOCK cohort - were included (fig.1). Data were cross-linked with The National Patient Register, containing diagnostic and procedural codes for all hospital contacts for Danish citizens. For comparison, an age- and sex-matched cohort of STEMI patients (4:1 ratio) without CS treated at the same centres and within the same timeframe was established from The National Patient Register. The incidence of revascularisation (percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG)) was assessed in patients surviving a "blanking period" of 60 days after discharge to take staged elective revascularisation into account and until a maximum follow-up of 5 years. The cumulative incidence function with death as a competing event was used. Gray’s test was used for comparison of incidence functions. Results A total of 1,716 AMICS patients were included, of whom 753 (44%) survived to 60 days after discharge – of those, 538 (71%) patients had STEMI. Revascularisation was performed during follow-up and after the 60-day ‘blanking period’ in 68 patients (9%) – median follow-up time was 3.4 years in the AMICS group and 3.5 years in the control group. Multivessel disease, out-of-hospital cardiac arrest and hyperlipidaemia at index hospitalisation were more prevalent in patients revascularised during the follow-up period (69% vs. 52% p=0.009, 62% vs. 47% p=0.018 and 42% vs. 27% p=0.014) for revascularised vs. not-revascularised). No significant differences in sex or age were present in revascularised vs. not-revascularised patients. The five-year cumulative incidence rate for revascularisation after discharge was 10.0% (95% Confidence Interval (CI) 7.9-12.7%), which was similar compared to the matched STEMI cohort without CS (11.5% 95% (CI) 10.7-12.4%), HR 0.88 95% (CI) 0.68-1.13, p=0.319) (fig.1a). The finding was similar in a subgroup analysis of STEMI-only patients with CS compared to the non-CS cohort. Conclusions The cumulative incidence of revascularisation after discharge for AMICS patients was comparable to STEMI patients without CS during five years follow-up. Multivessel disease, out-of-hospital cardiac arrest and hyperlipidaemia at index admission were more prevalent in patients who were revascularised during follow-up.

Validation of the CREST model and comparison with SCAI shock classification for the prediction of circulatory death in resuscitated out-of-hospital cardiac arrest.

We validated the CREST model, a 5 variable score for stratifying the risk of circulatory aetiology death (CED) following out-of-hospital cardiac arrest (OHCA) and compared its discrimination with the SCAI shock classification. Circulatory aetiology death occurs in approximately a third of patients admitted after resuscitated OHCA. There is an urgent need for improved stratification of the patient with OHCA on arrival to a cardiac arrest centre to improve patient selection for invasive interventions. The CREST model and SCAI shock classification were applied to a dual-centre registry of 723 patients with cardiac aetiology OHCA, both with and without ST-elevation myocardial infarction (STEMI), between May 2012 and December 2020. The primary endpoint was a 30-day CED. Of 509 patients included (62.3 years, 75.4% male), 125 patients had CREST = 0 (24.5%), 162 had CREST = 1 (31.8%), 140 had CREST = 2 (27.5%), 75 had CREST = 3 (14.7%), 7 had a CREST of 4 (1.4%), and no patients had CREST = 5. Circulatory aetiology death was observed in 91 (17.9%) patients at 30 days [STEMI: 51/289 (17.6%); non-STEMI (NSTEMI): 40/220 (18.2%)]. For the total population, and both NSTEMI and STEMI subpopulations, an increasing CREST score was associated with increasing CED (all P < 0.001). The CREST score and SCAI classification had similar discrimination for the total population [area under the receiver operating curve (AUC) = 0.72/calibration slope = 0.95], NSTEMI cohort (AUC = 0.75/calibration slope = 0.940), and STEMI cohort (AUC = 0.69 and calibration slope = 0.925). Area under the receiver operating curve meta-analyses demonstrated no significant differences between the two classifications. The CREST model and SCAI shock classification show similar prediction results for the development of CED after OHCA.

Effects of cardiovascular risk factors and pre-existing diseases on the short-term outcome of Takotsubo syndrome.

The effects of cardiovascular risk factors (CVRF) on the development of most acute cardiac conditions are well established; however, little is known about the frequency and effects of CVRF in Takotsubo syndrome (TTS) patients. The aim of our study was to compare the frequency of CVRF and pre-existing diseases (PD) of TTS patients to ST-elevation myocardial infarction (STEMI) patients and analyze their effects on short-term outcome. We analyzed the frequency of CVRF (hypertension, hyperlipidemia, type II diabetes mellitus, smoking, chronic kidney disease, family history) as well as somatic and psychiatric PD at admission in TTS patients and compared them with STEMI patients. Their effect on short-term outcome was calculated using acombined endpoint of cardiogenic shock, cardiopulmonary resuscitation, mechanical ventilation, and/or in-hospital death. In total, 150 TTS and 155 STEMI patients were included in our study. We observed ahigher frequency of psychiatric (30% vs. 7%, p < 0.001), neurological (5% vs. 0%, p = 0.01), and pulmonary (18% vs. 5%, p < 0.001) PD in TTS patients as compared to STEMI patients. There were less smokers (47% vs. 61%, p = 0.03) and patients with hyperlipidemia (24% vs. 51%, p < 0.001) in the TTS cohort than in the STEMI cohort. None of the CVRF or PD behaved as an independent predictor for adverse short-term outcome in TTS patients. Psychiatric, neurological, and pulmonary pre-existing diseases are more common in TTS than in STEMI patients. Interestingly, PD and CVRF do not seem to have any impact on the short-term outcome of TTS patients.

Cardiovascular magnetic resonance imaging-derived intraventricular pressure gradients in ST-segment elevation myocardial infarction: a long-term follow-up study.

Recently, novel post-processing tools have become available that measure intraventricular pressure gradients (IVPGs) on routinely obtained long-axis cine cardiac magnetic resonance (CMR) images. IVPGs provide a comprehensive overview of both systolic and diastolic left ventricular (LV) functions. Whether IVPGs are associated with clinical outcome after ST-elevation myocardial infarction (STEMI) is currently unknown. Here, we investigated the association between CMR-derived LV-IVPGs and major adverse cardiovascular events (MACE) in a large reperfused STEMI cohort with long-term outcome. In this prospectively enrolled multi-centre cohort study, 307 patients underwent CMR within 14 days after the first STEMI. LV-IVPGs (from apex-to-base) were estimated on the long-axis cine images. During a median follow-up of 9.7 (5.9-12.5) years, MACE (i.e. composite of cardiovascular death and de novo heart failure hospitalisation) occurred in 49 patients (16.0%). These patients had larger infarcts, more often microvascular injury, and impaired LV-IVPGs. In univariable Cox regression, overall LV-IVPG was significantly associated with MACE and remained significantly associated after adjustment for common clinical risk factors (hazard ratio (HR) 0.873, 95% confidence interval (CI) 0.794-0.961, P = 0.005) and myocardial injury parameters (HR 0.906, 95% CI 0.825-0.995, P = 0.038). However, adjusted for LV ejection fraction and LV global longitudinal strain (GLS), overall LV-IVPG does not provide additional prognostic information (HR 0.959, 95% CI 0.866-1.063, P = 0.426). Early after STEMI, CMR-derived LV-IVPGs are univariably associated with MACE and this association remains significant after adjustment for common clinical risk factors and measures of infarct severity. However, LV-IVPGs do not add prognostic value to LV ejection fraction and LV GLS.

The role of arginine vasopressin in the pathophysiology of microvascular dysfunction after ST-elevation myocardial infarction

Abstract Background Coronary microvascular dysfunction (CMD) after ST-elevation myocardial infarction (STEMI), in part due to impaired vasomotor tone, predicts heart failure and mortality at one year. Arginine vasopressin (AVP) may be implicated in CMD as it is released during MI and has known vasoconstrictor effects, but data in humans are lacking. We examined the role of copeptin, a stable plasma surrogate marker of AVP, in humans with STEMI. Methods We included three cohorts. The first cohort prospectively recruited patients presenting with STEMI eligible for primary percutaneous coronary intervention (PPCI) (n= 55). In this cohort, the index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) were measured in the culprit artery at the end of the procedure. The second cohort included 45 patients from a sub-study of the CAPRI trial (Evaluating the effectiveness of intravenous Ciclosporin on reducing reperfusion injury in pAtients undergoing PRImary PCI; NCT02390674). In this cohort, patients underwent cardiac magnetic resonance (CMR) imaging at one and 12 weeks post-MI, allowing precise measurement of infarct size and microvascular obstruction (MVO), the imaging hallmark of CMD. Both cohorts had serum copeptin measured at four time points. The 3rd cohort included two patients undergoing trans-coronary alcohol ablation of septal hypertrophy (TASH). Serial copeptin measurements were performed in this cohort to assess copeptin release in an induced ischaemia setting. Results One hundred patients were included from both STEMI cohorts. Copeptin levels paralleled AVP plasma levels closely, with mean levels falling in the 24 hours after reperfusion from 92.5 pmol/L to 6.4 pmol/L, and this was mirrored in the TASH patients. Copeptin release wasinversely linked to admission diastolic blood pressure (DBP) (Spearman’s rho r= -0.431, p=0.001), but did not correlate with systolic blood pressure. Copeptin levels at 24 hours were significantly associated with high IMR (r=0.372, p=0.011) and low CFR (r=-0.467, p=0.001). Patients with IMR &amp;gt;40 also had significantly higher mean copeptin concentration at 24 hours than those with lower IMR (19.1 vs 7.1pmol/L, p=0.019, Figure 1). Finally, patients with MVO on early CMR showed a trend towards higher mean copeptin concentration at baseline, although this was not statistically significant. Notably, copeptin levels were not associated with infarct size on either early or late CMR. Conclusions Copeptin, and therefore AVP, is released secondary to acute myocardial ischaemia, particularly in response to reduced coronary perfusion, as evidenced by the inverse correlation with DBP, and normalises by 24 hours. However, evidence of CMD was seen in patients with persistently elevated copeptin at 24 hours, suggesting AVP may contribute to microcirculatory dysfunction. AVP receptor antagonists may represent a novel therapeutic option in patients with STEMI and evidence of microvascular dysfunction.

Prevalence of Modifiable Risk Factors in First-Presentation ST Elevation Myocardial Infarction Patients in Christchurch Hospital, New Zealand, Over a 5-Year Period in Māori and Non-Māori Populations

The prevalence of modifiable risk factors is known to be changing in some first-presentation ST elevation myocardial infarction cohorts worldwide. Many studies have noted an increase in patients without modifiable risk factors. This study aimed to assess the risk factors in first-presentation ST elevation myocardial infarction patients in Christchurch, New Zealand, over a 5-year period in Māori and Non-Māori populations. Data were extracted from the ANZACS-QI database from 1 January 2017 to 1 January 2023, for patients with ST elevation myocardial infarction presenting to Christchurch Hospital. Patients with prior cardiovascular disease were excluded. Prevalence of smoking, hypertension, dyslipidaemia, diabetes, and no modifiable risk factors were analysed using a two-proportion z-test. Of 1,138 patients, 66 were Māori. There was high prevalence of modifiable risk factors present with a disproportionately high rate of smoking among Māori (z=5.7; p<0.001). A total of 6.9% of the patients had no modifiable risk factors, with no significant difference found between Māori and Non-Māori (z=–0.29; p=0.2). Modifiable risk factors were still highly prevalent in this first ST elevation myocardial infarction population. Whilst risk factors such as smoking are declining in the general population, they remain highly prevalent in this group and disproportionally higher in Māori, likely contributing to health inequities. The proportion of patients who have no modifiable risk factors is relatively small.

Creatinine clearance is key to solving the enigma of sex difference in in-hospital mortality after STEMI: Propensity score matching and mediation analysis.

The precise impact of sex difference on in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients are unclear, and the studies are no longer consistent. Therefore, we sought to evaluate the impact of sex differences in a cohort of STEMI patients. We analyzed the data of 2647 STEMI patients enrolled in the Kermanshah STEMI Cohort from July 2017 to May 2020. To accurately clarify the relationship between sex and hospital mortality, propensity score matching (PSM) and causal mediation analysis was applied to the selected confounder and identified intermediate variables, respectively. Before matching, the two groups differed on almost every baseline variable and in-hospital death. After matching with 30 selected variables, 574 male and female matched pairs were significantly different only for five baseline variables and women were no longer at greater risk of in-hospital mortality (10.63% vs. 9.76%, p = 0.626). Among the suspected mediating variables, creatinine clearance (CLCR) alone accounts for 74% (0.665/0.895) of the total effect equal to 0.895(95% CI: 0.464-1.332). In this milieu, the relationship between sex and in-hospital death was no longer significant and reversed -0.233(95% CI: -0.623-0.068), which shows the full mediating role of CLCR. Our research could help address sex disparities in STEMI mortality and provide a consequence. Moreover, CLCR alone can fully explain this relationship, which can highlight the importance of CLCR in predicting the short-term outcomes of STEMI patients and provide a useful indicator for clinicians.

Long-Term Hospital Readmission after ST-Elevation Myocardial Infarction: A 3-Year Follow-up from the SEMI-CI Study.

This study aimed to investigate readmission risk factors after ST-elevation myocardial infarction (STEMI) during a 3-year follow-up. This study is a secondary analysis of the STEMI Cohort Study (SEMI-CI) in Isfahan, Iran, with 867 patients. A trained nurse gathered the demographic, medical history, laboratory, and clinical data at discharge. Then the patients were followed up annually for 3 years by telephone and invitation for in-person visits with a cardiologist concerning readmission status. Cardiovascular readmission was defined as MI, unstable angina, stent thrombosis, stroke, and heart failure. Adjusted and unadjusted binary logistic regression analyses were applied. Of 773 patients with complete information, 234 patients (30.27%) experienced 3-year readmission. The mean age of the patients was 60.92±12.77 years, and 705 patients (81.3%) were males. The unadjusted results showed that smokers were 21% more likely to be readmitted than nonsmokers (OR, 1.21; P=0.015). Readmitted patients had a 26% lower shock index (OR, 0.26; P=0.047), and ejection fraction had a conservative effect (OR, 0.97; P<0.05). The creatinine level was 68% higher in patients with readmission. An adjusted model based on age and sex showed that the creatinine level (OR, 1.73), the shock index (OR, 0.26), heart failure (OR, 1.78), and ejection fraction (OR, 0.97) were significantly different between the 2 groups. Patients at risk of readmission should be identified and carefully visited by specialists to help improve timely treatment and reduce readmissions. Therefore, it is recommended to pay special attention to factors affecting readmission in the routine visits of STEMI patients.

Complement activation in association with clinical outcomes in ST-elevation myocardial infarction

IntroductionThe complement system and neutrophil extracellular traps (NETs) might contribute to ischemia-reperfusion injury in ST-elevation myocardial infarction (STEMI). We aimed to estimate associations between complement activation and NETs in STEMI, and their prognostic value on clinical endpoints. MethodsIn this cohort study, 864 patients admitted for PCI during STEMI were included. Complement activation was analyzed by the terminal complement complex (TCC), while NETs were analyzed by myeloperoxidase-DNA, citrullinated histone 3 (CitH3) and dsDNA. The composite endpoint was reinfarction, unscheduled revascularization, stroke, hospitalization due to heart failure, or death, and the secondary endpoint was total mortality. The association between TCC and clinical endpoints was assessed by Cox regression and ROC curve analysis. ResultsTCC was weakly correlated to dsDNA (r = 0.127, p < 0.001) and CitH3 (r = 0.102, p = 0.003). After a median follow-up time of 4.6 years, 184 (21.3 %) patients had reached a clinical endpoint. TCC was not associated with the composite endpoint, but with total mortality (HR: 1.673, 95 % CI: [1.014, 2.761], p = 0.044). The significant association was lost when adjusting for CRP, NT-proBNP, LVEF and time from symptoms to PCI. In ROC curve analysis of total mortality, the AUC for TCC alone was 0.549 (95 % CI: [0.472, 0.625]), AUC for dsDNA alone was 0.653 (95 % CI: [0.579, 0.720]), while AUC for TCC and dsDNA combined was 0.660 (95 % CI: [0.590, 0.730]). ConclusionsIn this STEMI cohort, TCC was not associated with the composite endpoint, but somewhat with total mortality. Combining TCC and dsDNA did not increase the prognostic value compared to dsDNA alone.

Temporal trends, short- and long-term prognostic impact of pre-hospital delay times in ST elevation myocardial infarction – 20 years national data from the SWEDEHEART registry

Abstract Background Previous studies have demonstrated that total ischaemic time during ST-elevation myocardial Infarction (STEMI) is associated with mortality. However, how duration from symptom onset to hospital admission affects outcomes and how pre-hospital delay times (PHDT) have evolved over time in STEMI in total, as well as in prespecified subgroups, remains unknown. Aim The aim was to explore temporal trends and prognostic impact of PHDT in STEMI patients during the last two decades in Sweden, including the fibrinolytic era as well as the primary percutaneous coronary intervention (PPCI) era. Temporal trends of PHDT was aimed to be studied in the total STEMI cohort as well as in subgroups according to age, sex and presence or absence of diabetes. Method This was an observational retrospective cohort study based on the SWEDEHEART registry including 89,155 STEMI patients between 1998 and 2017. Results In total, the PHDT curve was hump-shaped without any significant trend. The median PHDT was 150 min (Q1 80; Q3 302), and the shortest PHDT of 140 (Q1 85; Q3 274) min was found during the last period. During the fibrinolytic era (1998–2004) there was a significant increase in PHDT while delay times decreased during the PPCI era (2005–2017). There were consistent differences within subgroups; women sought care 25 min later than men, older (&amp;gt;70 years) delayed 30 min longer than younger and patients with diabetes 29 min longer than those without. Higher short- and long-term mortality was seen with increasing delay except for the group seeking care within 1 hour, which had higher short-term mortality. In five years follow up, mortality incrementally increased with delay, from 24.1% (0–1 hours) to 31.1% (&amp;gt;12 hours) of PHDT, p&amp;lt;0.01. When adjusting for confounders the risk of dying within 1 and 5 years was approximately 1% per hour of increase of PHDT (HR 1.011, 95% CI 1.006–1.016 and HR 1.008, 95% CI 1.004–1.013, respectively). Conclusions PHDT is an independent predictor of short- and long-term mortality and reducing PHDT will diminish the risk of heart failure and premature death. We found only a modest decrease in PHDT over time and the trend was hump shaped. Since the implementation of PPCI, with the diagnosis of STEMI made in the ambulances, these have been redirected in the pre-hospital setting, transporting the patient directly to cath lab. This may explain why the PHDT initially increased in the beginning of this era when new routines were being established. Although we did not find any significant trend during the total 20-year period it is reassuring that the PHDT decreased during the PPCI era. Anyhow, there are subgroups with consistently prolonged PHDT, such as women, the elderly, and patients with diabetes, who need to be targeted in future interventions. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This study was funded with grants from the Medical Research Council of Southeast Sweden (FORSS), Region Östergötland and Linköping University Hospital Research Fund, Sweden.

Short-term mortality differs between men and women according to the presence of previous cardiovascular disease: Insights from a nationwide STEMI cohort

BackgroundSex and prior cardiovascular disease (CVD) are known independent prognostic factors following an ST-elevation myocardial infarction (STEMI). We aimed to examine whether the association between sex and 30-day mortality differ according to the presence of previous CVD in STEMI patients. MethodsProspective, observational, multicentre registry of consecutive patients managed in 17 STEMI networks in Spain (83 centres), between April and June 2019. Unadjusted and adjusted logistic regression models assessed the association of 30-day mortality with sex and prior CVD status, as well as their interaction. ResultsAmong 4366 patients (mean age 63.7 ± 13.0 years; 78% male), there were 337 (8.1%) deaths within the first 30 days. There was an association between crude 30-day mortality and sex (women 10.4% vs. men 7.4%, p = 0.003), and prior CVD (CVD 13.7% vs non-CVD 6.8%, p < 0.001). After adjustment for potential confounding, neither sex nor prior CVD were apparently associated with mortality. Nevertheless, we found a significant sex-CVD interaction (p-interaction = 0.006), since women were at lower risk than men in the subset of patients with prior CVD (OR = 0.30, 95%CI = 0.12–0.80) but not in those without CVD (OR = 1.17, 95%CI = 0.79–1.74). ConclusionsWomen as well as patients with prior CVD have an increased crude risk of 30-day mortality. However, sex-related differences in short term mortality are modulated by the interaction with CVD in STEMI patients. Compared to men, women had a similar prognosis in the subset of patients without CVD, whereas they were associated with a lower risk of mortality among those with prior CVD after adjusting for other prognostic factors.

Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction.

Background and HypothesisTwo cohorts face high mortality after ST‐elevation myocardial infarction (STEMI): females and patients with in‐hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in‐hospital STEMI patients.MethodsConsecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013−2018). Sex discrepancies within in‐hospital STEMIs were compared with out‐of‐hospital STEMIs. The primary endpoint was 12‐month all‐cause mortality. Secondary endpoints included symptom‐to‐device (STD) time and 30‐day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12‐month mortality for in‐hospital versus out‐of‐hospital STEMIs, an interaction analysis was included in the multivariable models.ResultsA total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in‐hospital. In‐hospital versus out‐of‐hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in‐hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in‐hospital STEMIs had no difference in 12‐month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12‐month mortality for in‐hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94–1.70, p = .13).ConclusionsIn‐hospital STEMIs are more frequent in females relative to out‐of‐hospital STEMIs. Despite already being under medical care, females with in‐hospital STEMIs experienced a 10‐min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12‐month mortality and MACE were similar to males.

Heart Failure Incidence Following ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF) <50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF <50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p <0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF <50% independently predicted the development of HF and all-cause death.

A serial optical frequency-domain imaging study of early and late vascular responses to bioresorbable-polymer sirolimus-eluting stents for the treatment of acute myocardial infarction and stable coronary artery disease patients: results of the MECHANISM-ULTIMASTER study

The purpose of this study was to assess early and late vascular healing in response to bioresorbable-polymer sirolimus-eluting stents (BP-SESs) for the treatment of patients with ST-elevation myocardial infarction (STEMI) and stable coronary artery disease (CAD). A total of 106 patients with STEMI and 101 patients with stable-CAD were enrolled. Optical frequency-domain images were acquired at baseline, at 1- or 3-month follow-up, and at 12-month follow-up. In the STEMI and CAD cohorts, the percentage of uncovered struts (%US) was significantly and remarkably decreased during early two points and at 12-month (the STEMI cohort: 1-month: 18.75 ± 0.78%, 3-month: 10.19 ± 0.77%, 12-month: 1.80 ± 0.72%; p < 0.001, the CAD cohort: 1-month: 9.44 ± 0.78%, 3-month: 7.78 ± 0.78%, 12-month: 1.07 ± 0.73%; p < 0.001 respectively). The average peri-strut low-intensity area (PLIA) score in the STEMI cohort was significantly decreased during follow-up period (1.90 ± 1.14, 1.18 ± 1.25, and 1.01 ± 0.72; p ≤ 0.001), whereas the one in the CAD cohort was not significantly changed (0.89 ± 1.24, 0.67 ± 1.07, and 0.64 ± 0.72; p = 0.59). In comparison with both groups, differences of %US and PLIA score at early two points were almost disappeared or close at 12 months. The strut-coverage and healing processes in the early phase after BP-SES implantation were significantly improved in both cohorts, especially markedly in STEMI patients. At 1 year, qualitatively and quantitatively consistent neointimal coverage was achieved in both pathogenetic groups.

Impact of STEMI Diagnosis and Catheterization Laboratory Activation Systems on Sex- and Age-Based Differences in Treatment Delay

BackgroundWomen and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems. MethodsThis observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated “physician-blind” prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts. ResultsFive hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P = 0.04). When examining prehospital activation cohorts only, female sex (P = 0.03), off-hours presentation (P < 0.01), and physician oversight (P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 (P < 0.01), Killip class (P < 0.01), and female sex (P = 0.04) were independently associated with in-hospital mortality. ConclusionsAutomated “physician-blind” STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care.

Abstract 201: Sex Differences in Management and Outcomes in Young Adults With Myocardial Infarction

Objectives: Sex differences are known to exist in the management ofolder patients presenting with myocardial infarction (MI). Whether inpatient MI management, outcomes and readmissions differ by sex in young adults is not known. Methods: Nationwide Readmissions Database (NRD) was queried for hospitalizations with MI in adults between 18 and 50 years of age from October 2015 and November 2016 using ICD-10 CM codes. Hospitalizations with discharges in December were excluded as 30-day follow-up for these could not be completed in NRD. Logistic regression analysis was used to estimate the association between gender and percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), coronary angiography, non-invasive testing, death and 30-day readmissions. ST-elevation MI (STEMI) subset was similarly analyzed. Results: Of 33,981 hospitalizations, 29% were females. Mean age was 43 years. STEMI constituted 13,177 hospitalizations with 22% females. As compared with men, women were more likely to have peripheral vascular disease (6% vs 4%), chronic pulmonary disease (17% vs 10%), diabetes mellitus (36% vs 28%); and less likely to have a prior history of MI (10% vs 12%). Women were less likely to undergo noninvasive testing (10% vs 11 %, p=0.002) and were revascularized less often than men with PCI (45% vs 56%, p&lt;0.0001) and CABG (6% vs 7%, p&lt;0.0001). Women underwent PCI less often in STEMI as well (72% vs. 76%, p&lt;0.0001). Inpatient mortality and 30-day readmissions were higher in women overall (1.9% vs 1.6%, p=0.04) and (14% vs 9%, p&lt;0.0001); as well as in STEMI: (4% vs 3%, p&lt;0.0001) and (12% vs 8%, p&lt;0.0001). In adjusted analysis (Figure 1: A, B), women were less likely to undergo non-invasive testing or revascularization in the overall cohort; and were less likely to undergo PCI in the STEMI cohort. Additionally, women had higher odds of 30-day readmissions overall, while the odds of inpatient mortality were higher only in STEMI subset. Conclusion: In a large MI cohort, young women were less likely to undergo ischemic workup and be revascularized, and had higher odds of 30-day readmissions. Women had higher odds of mortality in STEMI

Kinetics Analysis of Circulating MicroRNAs Unveils Markers of Failed Myocardial Reperfusion.

Failed myocardial reperfusion occurs in approximately 50% of patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI). It manifests as microvascular obstruction (MVO) on cardiac magnetic resonance (CMR) imaging. Although prognostically important, MVO is not routinely screened for. Our aim was to investigate the kinetics of circulating short noncoding ribonucleic acids [microRNAs (miRNAs)] following PPCI and their association with MVO in STEMI patients. Screening of 2083 miRNAs in plasma from STEMI patients with (n = 6) and without (n = 6) MVO was performed by next-generation sequencing. Two candidate miRNAs were selected and quantified at 13 time points within 3 h postreperfusion in 20 STEMI patients by reverse transcription and quantitative PCR. Subsequently, these 2 miRNAs were measured in a "validation" STEMI cohort (n = 50) that had CMR imaging performed at baseline and 3 months post-PPCI to evaluate their association with MVO. miR-1 and miR-133b were rapidly released following PPCI in a monophasic or biphasic pattern. Both miRNAs were enriched in circulating microparticles. A second miR-1 peak (90-180 min postreperfusion) seemed to be associated with a higher index of microvascular resistance. In addition, miR-1 and miR-133b levels at 90 min post-PPCI were approximately 3-fold (P = 0.001) and 4.4-fold (P = 0.008) higher in patients with MVO, respectively. Finally, miR-1 was significantly increased in a subgroup of patients with worse left ventricular (LV) functional recovery 3 months post-PPCI. miR-1 and miR-133b levels increase within 3 h of PPCI. They are positively associated with MVO and worse LV functional recovery post-PPCI.

ASSOCIATION OF MAJOR BLEEDING AND BLEEDING AVOIDANCE STRATEGIES WITH IN-HOSPITAL OUTCOMES AMONG ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION PATIENTS RECEIVING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Major bleeding is an independent predictor of mortality, reinfarction, and stroke among ST-elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (pPCI). Limited data exists on the association of major bleeding post-PCI and other significant in-hospital outcomes. Furthermore, bleeding avoidance strategies (BAS) such as radial access and bivalirudin are associated with reductions in major bleeding but the impact on the reduction of other in-hospital adverse events has not been reported. We identified 1494 STEMI patients who underwent primary pPCI within the Vancouver Coastal Health Authority (2012-2018) of whom 121 (8.1%) had major bleeding. Access site bleeding occurred in 2.0% whereas non-access site bleeding occurred in 6.1%. Between-group differences in (unadjusted) in-hospital clinical outcomes including cardiac arrest, reinfarction, stroke, cardiogenic shock, heart failure, and mortality were assessed. Spearman correlation and multivariate logistic regression were used to evaluate the relationship of major bleeding with in-hospital outcomes. Compared with no major bleeding, patients experiencing major bleeding were more likely to be female, older, have atrial fibrillation, chronic kidney disease, anemia, heart failure, prehospital cardiac arrest or cardiogenic shock at baseline. Major bleeding was associated with higher rates of in-hospital death (20.7% vs. 4.4%; P < 0.001), stroke or intracranial hemorrhage (10.8% vs 1.1%; P < 0.001), cardiogenic shock (38.3 vs 6.3%; P < 0.001), heart failure (40.8% vs. 12.0%; P < 0.001), or cardiac arrest post-PCI (20.0 vs 3.5%; P < 0.001). Major bleeding was also associated with a significantly longer hospital stay (median 7.8. vs 3.0 days; P < 0.001). Major bleeding was independently associated with death (OR 3.15; 95% CI 1.59-6.25), cardiogenic shock (OR 8.10; 95% CI 4.46-14.72), heart failure (OR 3.43; 95% CI 2.09-5.63), and in-hospital cardiac arrest post-PCI (OR 4.19; 95% CI 2.21-7.94). The use of any BAS (radial access, bivalirudin, vascular closure device) was associated with a reduction in major bleeding (OR 0.49; 95% CI 0.32-0.74) and mortality (OR 0.20; 95% CI 0.13 to 0.32) but after adjustment did not reduce major bleeding (OR 0.68; 95% CI 0.43-1.07) or mortality (OR 0.63; 95% CI 0.33-1.20). In a contemporary STEMI cohort receiving pPCI, major bleeding was predominately caused by non-access site bleeding and was independently associated with in-hospital mortality, cardiogenic shock, heart failure, and cardiac arrest post-PCI. After adjustment, BAS were not associated with a reduction in major bleeding nor in-hospital mortality, likely due to low rates of access-site bleeding. Additional study of strategies to reduce the incidence or impact of non-access site bleeding appears warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Paramedic-initiated helivac to tertiary hospital for primary percutaneous coronary intervention: a strategy for improving treatment delivery times.

In regions of New Zealand without coronary catheterisation laboratory (CCL) facilities, patients presenting with ST-elevation myocardial infarction (STEMI) are often subjected to prolonged delays before receiving primary percutaneous coronary intervention (PPCI) if it is the chosen reperfusion strategy. Therefore, we aimed to trial a new process of paramedic-initiated helivac of STEMI patients from the field directly to the CCL. Utilising a prospective observational approach, over a 48-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI and transported them directly to the regional air ambulance base for helivac to the CCL (flight time 30-35 minutes). These patients were compared to two historic STEMI cohorts either transported by paramedics to the region's local hospital or self-presenting, prior to helivac. The primary outcome measures were: first medical contact-to-balloon (FMCTB) time and accuracy of paramedic diagnosis. Secondary outcome measures were mortality at 30 days and six months, and hospital length of stay (LOS). A total of 92 patients underwent helivac for PPCI (mean age of 64 years, SD ±10.3). Median FMCTB time was 155 minutes (IQR 27) for the historic cohorts (n=57), versus 102 minutes (IQR 16) for the experimental cohort (n=35, P<0.001). Paramedic diagnosis showed a sensitivity of 97% (95% CI: 85 to 99) and a specificity of 100% (95% CI: 84 to 100) with no inappropriate CCL activations. No significant difference was observed between groups in terms of 30 day and 6-month mortality. Hospital LOS was significantly shorter among the experimental cohort (P=0.01). Paramedic-initiated helivac of STEMI patients from the field directly to the CCL for PPCI is safe and feasible and can significantly improve time-to-treatment to within benchmark timeframes, resulting in reduced hospital LOS.