ST-elevation Myocardial Infarction Registry Research Articles

Impact of Bivalirudin on Ischemia/Reperfusion Injury in Patients with Reperfused STEMI Assessed by Cardiac Magnetic Resonance.

Thrombin is an important ischemia/reperfusion injury (IRI) mediator in patients with ST-elevation myocardial infarction (STEMI). This study examines the use of bivalirudin, a direct thrombin inhibitor, in reducing IRI in STEMI patients. STEMI patients (n = 21) were treated with bivalirudin and compared to 21 patients treated with unfractionated heparin (UFH) from the EARLY Assessment of Myocardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). Infarct size (IS) and left ventricular ejection fraction (LVEF) were comparable between the two groups at follow up. During the first cardiac magnetic resonance (CMR) scan within the first week after percutaneous coronary intervention (PCI), all patients in both the bivalirudin and UFH groups exhibited myocardial edema. However, the myocardium edema volume was significantly less in the bivalirudin group (p < 0.05). At the one-month follow-up, a smaller proportion of patients in the bivalirudin group than in the UFH group exhibited myocardial edema (4.7% vs. 33.3%, p < 0.05). At the three-month follow-up, myocardial edema had completely resolved in the bivalirudin group, while it persisted in two patients in the UFH group. The incidence and volume of microvascular obstruction (MVO) were significantly lower in the bivalirudin group during the acute phase. Additionally, the incidence of intramyocardial hemorrhage (IMH) was significantly lower in the bivalirudin group during both the acute and follow up (p < 0.05). These findings were corroborated by T2 and T1 mapping results. The study concluded that the use of bivalirudin for anticoagulation is associated with attenuated IRI in STEMI patients who receive primary PCI.

Rural EMS STEMI Patients – Why the Delay to PCI?

Background The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI). Methods We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency. Results Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7–19) in the group that received PCI within the time goal compared to 21 min (IQR 10–37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11–4.10) compared to the female sex. Conclusion Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.

The national moroccan registry of ST-elevation myocardial infarction (MR-MI)

BackgroundMR-MI is the first national Moroccan ST-elevation myocardial infarction (STEMI) registry. Its objectives are to assess patient management modalities and highlight the clinical and therapeutic characteristics of this pathology in all cardiology centres on a national scale.MethodsAdult patients presenting with STEMI within 5 days of symptoms onset were enrolled over a period of 18 weeks from April to August 2018. 57 cardiology centres distributed in 22 cities in Morocco participated in the study, including 5 university hospitals, representing 70% of Moroccan centres managing STEMI patients. A case report form was sent to the investigators in both electronic and paper forms. Sociodemographic, clinical, management, revascularization, and follow-up data were collected.ResultsA total of 809 patients were recruited. The population was mostly male (74.8%) with an average age of 62.6 ± 11.6 years. The most common risk factors were smoking (38.3%) arterial hypertension (30.7%), and diabetes (28%). 30% of patients were admitted within the first 6 h of symptoms onset and early revascularization was performed on 49.6%. Mortality rate was 5.2% in-hospital and 3.2% at the one-month follow-up.ConclusionMR-MI is the first Moroccan STEMI registry on a national scale. Relevant management delays are much longer than other countries, and less than 50% of the patients that present on time benefit from early revascularization. Efforts remain to be done on the optimal diagnosis and treatment of STEMI.

Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018.

Limited data are available on the changes in the quality of care for ST elevation myocardial infarction (STEMI) during China's health system reform from 2009 to 2020. This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018. We compared the data from the Henan STEMI survey conducted in 2011-2012 ( n = 1548, a cross-sectional study) and the Henan STEMI registry in 2016-2018 ( n = 4748, a multicenter, prospective observational study). Changes in care processes and in-hospital mortality were determined. Process of care measures included reperfusion therapies, aspirin, P2Y12 antagonists, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Therapy use was analyzed among patients who were considered ideal candidates for treatment. STEMI patients in 2016-2018 were younger (median age: 63.1 vs . 63.8 years) with a lower proportion of women (24.4% [1156/4748] vs . 28.2% [437/1548]) than in 2011-2012. The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018 (60.9% [5424/8901] vs . 82.7% [22,439/27,129], P <0.001). The proportion of patients treated by reperfusion within 12 h increased from 44.1% (546/1237) to 78.4% (2698/3440) ( P <0.001) with a prolonged median onset-to-first medical contact time (from 144 min to 210 min, P <0.001). The use of antiplatelet agents, statins, and β-blockers increased significantly. The risk of in-hospital mortality significantly decreased over time (6.1% [95/1548] vs . 4.2% [198/4748], odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.50-0.88, P = 0.005) after adjustment. Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality. However, gaps persist between clinical practice and guideline recommendation. Public awareness, reperfusion strategies, and construction of chest pain centers need to be further underscored in central China.

Trends in Modifiable Risk Factors Amongst First Presentation ST Elevation Myocardial Infarction Patients in a Large Longitudinal Registry.

Recent studies suggest that the risk factor profile of patients presenting with ST elevation myocardial infarction (STEMI) is changing. The aim is to determine if there has been a shift of cardiovascular risk factors to cardiometabolic causes in the first presentation STEMI population. We analysed data from a STEMI registry from a large tertiary referral percutaneous coronary intervention centre to determine the prevalence and trends of the modifiable risk factors of hypertension, diabetes, smoking and hypercholesterolaemia. Consecutive first presentation STEMI patients between January 2006 to December2018. Among the 2,366 patients included (mean age 59, SD 12.66, 80% male) the common risk factors were hypertension (47%), hypercholesterolaemia (47%) current smoking (42%) and diabetes (27%). Over the 13 years, patients with diabetes (20% to 26%, OR 1.09 per year, CI 1.06-1.11, p<0.001) and patients with no modifiable risk factors increased (9% to 17%, OR 1.08, CI 1.04-1.11, p<0.001). Concurrently there was a fall in prevalence of hypercholesterolaemia, (47% to 37%, OR 0.94 per year, CI 0.92-0.96, p<0.001) and smoking (44% to 41%, OR 0.94, CI 0.92-0.96, p<0.001) but no significant change in rates of hypertension (53% to 49%, OR 0.99, CI 0.97-1.01, p=0.25). The risk factor profile of first presentation STEMI has changed over time with a reduction in smoking and a concurrent rise in patients with no traditional risk factors. This suggests the mechanism of STEMI may be changing and further investigation of potential causal factors is warranted for the prevention and management of cardiovascular disease.

Outcomes of ST Segment Elevation Myocardial Infarction without Standard Modifiable Cardiovascular Risk Factors - Newer Insights from a Prospective Registry in India.

Patients with ST elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs; dyslipidaemia, hypertension, diabetes mellitus and smoking) are reported to have a worse clinical outcome compared to those with SMuRFs. However, robust prospective data and low-and middle-income country perspective are lacking. We aimed to study the patients with first STEMI and assess the influence of SMuRFs on clinical outcomes by comparing the patients with and without SMuRFs. We included all consecutive STEMI patients without prior coronary artery disease enrolled in the Madras Medical College STEMI Registry from September 2018 to October 2019. We collected baseline clinical characteristics, revascularisation strategies and clinical outcome. We analysed suboptimal self-reported sleep duration as a 5th extended SMuRF (eSMuRF). Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications and one-year all-cause mortality. Among 2,379 patients, 605 patients (25.4%) were SMuRF-less. More women were SMuRF-less than men (27.1% vs 22.1%; P = 0.012). SMuRF-less patients were older (57.44 ± 13.95 vs 55.68 ± 11.74; P < 0.001), more often former tobacco users (10.4% vs 5.0%; P < 0.001), with more anterior wall MI (62.6% vs 52.1%; P = 0.032). The primary outcome [in-hospital mortality (10.7% vs 11.3%; P = 0.72)] and secondary outcomes [in-hospital complications (29.1% vs 31.7%; P = 0.23) and one-year all-cause mortality (22.3% vs 22.7%; P = 0.85)] were similar in both groups. Addition of suboptimal self-reported sleep duration as a 5th eSMuRF yielded similar results. 25% of first STEMI patients were SMuRF-less. Clinical outcomes of patients without SMuRFs were similar to those with SMuRFs. Suboptimal sleep duration did not account for the risk associated with the SMuRF-less status.

Sex Disparity in Characteristics, Management, and In-Hospital Outcomes of Patients with ST-Segment Elevated Myocardial Infarction: Insights from Henan STEMI Registry.

Background Women hospitalized with ST-elevation myocardial infarction (STEMI) experience higher risk of early mortality than men. We aimed to investigate the potential impact of risk factors, clinical characteristics, and management among gender-related risk differences. Method We analyzed 5063 STEMI patients prospectively enrolled from 66 hospitals during 2016–2018 and compared sex differences in mortality, death, or treatment withdrawal and main adverse cardiovascular and cerebrovascular events (MACCE) using the generalized linear mixed model, following sequential adjustment for covariates. Results Women were older and had a higher prevalence of hypertension (53.3% vs. 41.1%, P < 0.001) and diabetes (24.5% vs. 15.2%, P < 0.001). Eligible women were less likely to receive reperfusion therapy (56.1% vs. 62.4%, P < 0.001); the onset to first medical contact (FMC) (255 vs. 190 minutes, P < 0.001), onset to fibrinolysis (218 vs. 185 minutes, P < 0.001), and onset to percutaneous coronary intervention (PCI) (307 vs. 243 minutes, P < 0.001) were significantly delayed in women. The incidence of in-hospital death (6.8% vs. 3.0%, P < 0.001), death or treatment withdrawal (14.5% vs. 5.6%, P < 0.001), and MACCE (18.5% vs. 9.4%, P < 0.001) were notably higher. The gender disparities persist in death (OR: 1.61, 95% CI: 1.12–2.33), death or treatment withdrawal (OR: 1.68, 95% CI: 1.26–2.24), and MACCE (OR: 1.37, 95% CI: 1.08–1.74) after adjustment for covariates. Among possible explanatory factors, age (−58.46%, −59.04%, −62.20%) and cardiovascular risk factors (−40.77%, −39.36%, −41.73%) accounted for most of the gender-associated risk differences. Conclusions Women experienced worse in-hospital outcomes, and age and cardiovascular risk factors were major factors influencing sex-related differences. The sex disparity stressed the awareness and importance of quality improvement efforts against female patients in clinical practice.

Lifestyle and metabolic risk factors in patients with early-onset myocardial infarction: a case-control study.

Family history is a known risk factor for early-onset myocardial infarction (EOMI). However, the role of modifiable lifestyle and metabolic factors in EOMI risk is unclear and may differ from that of older adults. This case-control study included myocardial infarction (MI) patients aged ≤45 years from the Bremen ST-elevation MI Registry and matched controls randomly selected from the general population (German National Cohort) at the same geographical region. Multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the individual and combined associations of lifestyle and metabolic factors with EOMI risk, overall and according to family history for premature MI. A total of 522 cases and 1191 controls were included. Hypertension, current smoking, elevated waist-to-hip ratio, and diabetes mellitus were strongly associated with the occurrence of EOMI. By contrast, higher frequency of alcohol consumption was associated with decreased EOMI risk. In a combined analysis of the risk factors hypertension, current smoking, body mass index ≥25.0 kg/sqm, and diabetes mellitus, participants having one (OR = 5.4, 95%CI = 2.9-10.1) and two or more risk factors (OR = 42.3, 95%CI = 22.3-80.4) had substantially higher odds of EOMI compared to those with none of these risk factors, regardless of their family history. This study demonstrates a strong association of smoking and metabolic risk factors with the occurrence of EOMI. The data suggest that the risk of EOMI goes beyond family history and underlines the importance of primary prevention efforts to reduce smoking and metabolic syndrome in young persons.

Reperfusion therapy for ST-elevation myocardial infarction complicated by cardiogenic shock: the European Society of Cardiology EurObservational programme acute cardiovascular care-European association of PCI ST-elevation myocardial infarction registry.

To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in European Society of Cardiology (ESC) member and affiliated countries for patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). ESC EurObservational Research Programme prospective international cohort study of admissions with STEMI within 24 h of symptom onset (196 centres; 26 ESC member and 3 affiliated countries). Of 11 462 patients enrolled, 448 (3.9%) had CS. Patients with compared to patients without CS, less frequently received primary percutaneous coronary intervention (PCI) (65.5% vs. 72.2%) and fibrinolysis (15.9% vs. 19.0), and more often had no reperfusion therapy (19.0% vs. 8.5%). Mechanical support devices (intraaortic ballon pump 11.2%, extracoporeal membrane oxygenation 0.7%, other 1.1%) were used infrequently in CS. Bleeding definition academic research consortium 2-5 bleeding complications (10.1% vs. 3.0%, P < 0.01) and stroke (4.2% vs. 0.9%, P < 0.01) occurred more frequently in patients with CS. In-hospital mortality was 10-fold higher (35.5% vs. 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis, and no reperfusion therapy were 27.4%, 36.6%, and 62.4%, respectively. In this multi-national registry, patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore, strategies to improve clinical outcome in STEMI with CS are needed.

Predictors of Radial to Femoral Artery Access Crossover During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Radial access for primary percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding, when compared to femoral access. However, radial access failure may be associated with an increased door-to-device (DTD) time. To identify predictors of radial access failure requiring crossover to femoral artery access during primary PCI. From 2013 to 2020, 2,256 consecutive patients treated for PPCI at a single tertiary hospital were prospectively recruited into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariable logistic regression was used to identify independent predictors of radial to femoral access crossover. From 2,256 STEMI patients, primary radial access was used in 1,778 (78.8%), with 171 (9.6%) experiencing radial-to-femoral crossover. Patients with failed versus successful radial access experienced longer DTD times (67 mins, interquartile range [IQR] 46-99 vs 54 mins [IQR 39-78]; p<0.001). Independent predictors of radial-to-femoral access crossover included female sex (Adjusted Odds Ratio [AOR] 2.1, 95% Confidence Interval [CI] 1.4-3.0; p<0.001) and baseline hypertension (AOR 1.5, 95% CI 1.1-2.1; p=0.018). In a real-world STEMI registry, almost 1 in 10 patients experienced access crossover from the radial to femoral artery which resulted in longer DTD times. Independent predictors of radial access failure included female sex and baseline hypertension. Knowing which patient characteristics are associated with increased risk of radial artery failure enables catheter laboratory staff to ensure equipment is readily available to maximise successful primary PCI are available.

Guideline based eligibility for primary prevention statin therapy – Insights from the North India ST-elevation myocardial infarction registry (NORIN-STEMI)

Current risk scores to estimate atherosclerotic cardiovascular disease (ASCVD) risk and allocate statins in at-risk persons have largely been developed in Western populations; their applicability in India is uncertain. To assess eligibility for primary prevention statin therapy using the 2018 U.S Multisociety Guideline and other contemporary cholesterol guidelines in patients presenting with ST-elevation myocardial infarction (STEMI) in the North India STEMI (NORIN-STEMI) registry. NORIN-STEMI registry prospectively enrolled 3,635 patients at 2 tertiary care centers in Delhi, India from January 2019 to February 2020. Pooled cohort risk equations were used to estimate ASCVD risk at presentation. Patients were evaluated for statin eligibility using the 2018 U.S Multisociety Guideline, United States Preventive Services Task Force (USPSTF), and National Cholesterol Education Program (NCEP) III cholesterol guidelines. A total of 2,551 met the inclusion criteria. The median age was 54 years; 17% were women. The median ASCVD risk was 7.0%. At the time of MI, 54% of patients were eligible for primary prevention statin therapy by Multisociety Guideline, 46% by USPSTF, and 30% by NCEP III guidelines. These findings were applicable in both women and men. Compared with patients aged ≥50 years, those <50 years were less likely to be recommended statin therapy by all the three guidelines. A significant proportion of patients with STEMI in India did not meet the current guideline-based threshold for statin therapy for primary prevention. Novel risk stratification tools are needed to identify patients for primary prevention statin therapy in this population.

Frequency, Etiology, and Impact of Unplanned Repeat Coronary Angiography After ST-Elevation Myocardial Infarction

Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p=0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p=0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.

Efficacy and safety comparison between pro-urokinase and reteplase in the treatment of patients with acute ST elevation myocardial infarction

Objective: To compare the efficacy and safety of pro-urokinase and reteplase in the treatment of patients with acute ST elevation myocardial infarction (STEMI). Methods: STEMI patients, who received intravenous thrombolytic therapy in Henan STEMI registry between September 2016 and August 2018, were eligible for this study. A total of 5479 patients from 66 hospitals were screened and patients were divided into pro-urokinase group (n=638) and reteplase group (n=702) according to thrombolytic drugs. Data including patient demographics, risk factors, medical histories, patient information at admission, in-hospital treatment, time delays, and clinical events were collected. The clinical recanalization rate, in-hospital mortality, in-hospital death or treatment withdrawal, in-hospital main adverse cardiovascular and cerebrovascular events (MACCE, death or treatment withdrawal, congestive heart failure, reinfarction and ischemic stroke) and post-thrombolysis bleeding were compared between the two groups. Bleeding events were evaluated with Bleeding Academic Research Consortium (BARC) criteria. Results: The median age [61.8 (53.2, 69.0) vs. 62.6 (52.1, 69.8), P=0.833] or the proportion of women [23.0% (147/638) vs. 25.1% (176/702), P=0.385] were similar between the pro-urokinase and reteplase groups. Clinical recanalization rates were similar between the pro-urokinase and reteplase groups [82.1% (524/638) vs. 84.9% (596/702), P=0.172], and there was no difference in the median time from onset to thrombolysis [194.5 (135.0,290.0) min vs. 190 (126.0,292.0) min, P=0.431] and the median recanalization time [95 (67.5,120.0) min vs. 95 (71.0,119.0) min, P=0.561] between the two groups. There was no significant difference in in-hospital mortality [5.5% (35/638) vs. 5.1% (36/702), P =0.770], in-hospital all-cause mortality, treatment withdrawal [8.9% (57/638) vs.7.7% (54/702), P=0.410], and in-hospital MACCE [13.0% (83/638) vs. 10.4% (73/702), P=0.137] between pro-urokinase and reteplase groups. However, the incidence of post-thrombolysis bleeding was significantly higher in reteplase group than in pro-urokinase group [7.8% (55/702) vs. 3.8% (24/638), P=0.002]. Further analysis found that the incidence of oral bleeding and the BARC grades 1-2 bleeding were significantly higher in reteplase group than in pro-urokinase group, whereas the incidence of cerebral hemorrhage was similar between the two groups [0.6% (4/638) vs. 0.4% (3/702), P=0.715]. The comparison of efficacy and safety outcomes between the two groups after adjusting for baseline characteristics using general linear mixed models was consistent with those before the adjustment. There was no significant difference in in-hospital mortality, in-hospital death or treatment withdrawal, in-hospital MACCE after adjusting for baseline characteristics and post-thrombolysis bleeding between the two groups. Conclusions: Pro-urokinase and reteplase have similar clinical efficacy in the treatment of STEMI. In terms of safety, the incidence of cerebral hemorrhage is similar, while the incidence of BARC grades 1-2 bleeding and oral bleeding is higher in reteplase group than in pro-urokinase group, which has no impact on in-hospital outcomes.

Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology.

The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI). Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset <24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0-100%), fibrinolysis (18.8%; 0-100%), and no reperfusion therapy (9.0%; 0-75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5-5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8-97.5%) for the performance of reperfusion therapy of all patients with STEMI <12 h and 54.4% (region range 37.1-70.1%) for timely reperfusion. The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.

Machine learning for holistic visualization of STEMI registry data

BackgroundWidespread adoption of evidence-based guidelines and treatment pathways in ST-Elevation Myocardial Infarction (STEMI) patients has considerably improved cardiac survival and decreased the risk of recurrent myocardial infarction. However, survival outcomes appear to have plateaued over the last decade. The hope underpinning the current study is to engage data visualization to develop a more holistic understanding of the patient space, supported by principles and techniques borrowed from traditionally disparate disciplines, like cartography and machine learning. Methods and ResultsThe Minnesota Heart Institute Foundation (MHIF) STEMI database is a large prospective regional STEMI registry consisting of 180 variables of heterogeneous data types on more than 5000 patients spanning 15 years. Initial assessment and preprocessing of the registry database was undertaken, followed by a first proof-of-concept implementation of an analytical workflow that involved machine learning, dimensionality reduction, and data visualization. 38 pre-admission variables were analyzed in an all-encompassing representation of pre-index STEMI event data. We aim to generate a holistic visual representation — a map of the multivariate patient space — by training a high-resolution self-organizing neural network consisting of several thousand neurons. The resulting 2-D lattice arrangement of n-dimensional neuron vectors allowed patients to be represented as point locations in a 2-D display space. Patient attributes were then visually examined and contextualized in the same display space, from demographics to pre-existing conditions, event-specific procedures, and STEMI outcomes. Data visualizations implemented in this study include a small-multiple display of neural component planes, composite visualization of the multivariate patient space, and overlay visualization of non-training attributes. ConclusionOur study represents the first known marriage of cartography and machine learning techniques to obtain visualizations of the multivariate space of a regional STEMI registry. Combining cartographic mapping techniques and artificial neural networks permitted the transformation of the STEMI database into novel, two-dimensional visualizations of patient characteristics and outcomes. Notably, these visualizations also drive the discovery of anomalies in the data set, informing corrections applied to detected outliers, thereby further refining the registry for integrity and accuracy. Building on these advances, future efforts will focus on supporting further understanding of risk factors and predictors of outcomes in STEMI patients. More broadly, the thorough visual exploration of display spaces generated through a conjunction of dimensionality reduction with the mature technology base of geographic information systems appears a promising direction for biomedical research.

Efficacy of Drug-Eluting Stents in Diabetic Patients Admitted with ST-Elevation Myocardial Infarctions Treated with Primary Percutaneous Coronary Intervention.

Background: Diabetic patients show higher adverse ischemic event rates and mortality when undergoing percutaneous coronary intervention (PCI) in acute myocardial infarctions. Therefore, diabetic patients might benefit even more from modern-generation drug-eluting stents (DES). The aim of the present study was to compare adverse ischemic events and mortality rates between bare-metal stents (BMS) and DES in diabetic patients admitted with ST-elevation-myocardial infarction (STEMI) with non-diabetic patients as the control group. Methods: All STEMI patients undergoing emergency PCI and stent implantation documented between 2006 and 2019 in the Bremen STEMI registry entered the analysis. Efficacy was defined as a combination of in-stent thrombosis, myocardial re-infarction or additional target lesion revascularization at one year. Results: Of 8356 patients which entered analysis, 1554 (19%) were diabetics, while 6802 (81%) were not. 879 (57%) of the diabetics received a DES. In a multivariate model, DES implantation in diabetics compared to BMS was associated with lower rates of in-stent thrombosis (OR 0.16, 95% CI 0.05–0.6), myocardial re-infarctions (OR 0.35, 95%CI, 0.2–0.7, p < 0.01) and of the combined endpoint at 1 year ((ST + MI + TLR): OR 0.31, 95% CI 0.2–0.6, p < 0.01), with a trend towards lower 5-year mortality (OR 0.56, 95% CI 0.3–1.0, p = 0.058). When comparing diabetic to non-diabetic patients, an elevation in event rates for diabetics was only detectable in BMS (OR 1.78, 95% CI 0.5–0.7, p < 0.01); however, this did not persist when treated with a DES (OR 1.03 95% CI 0.7–1.6, p = 0.9). Conclusions: In STEMI patients with diabetes, the use of DES significantly reduced ischemic event rates and, unlike with BMS, adverse ischemic event rates became similar to non-diabetic patients.

Prognostic implications of left ventricular torsion by feature-tracking cardiac magnetic resonance in patients with ST-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the National Key Research and Development Program of China OnBehalf Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University Background The prognostic implications of left ventricular (LV) torsion on the long-term prognosis of patients with acute ST-elevation myocardial infarction (STEMI) is not clear. Methods We analyzed Cardiac Magnetic Resonance (CMR) images and followed up 420 first STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). These patients received timely primary percutaneous coronary intervention (PCI) within 12h and CMR examination within 1 week (median,5 days; range, 2-7 days) after infarction. Besides, CMR images of 40 normal people were enrolled as the control group. LV torsion, torsion rate and other conventional CMR indexes were measured. Ultrasound cardiogram examinations were performed in the acute phase and 1 year post-STEMI to assess LV remodeling (≥ 20% increase in LV end-diastolic volume). Primary end point was composite major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, re-hospitalization for heart failure and stroke. Secondary end points were the formation of LV aneurysm/thrombus in hospital as well as LV remodeling at 1 year post-STEMI. Results During follow-up (median: 52 months, inter-quartile range: 29–78 months), 80 patients developed MACCEs. Compared with normal people, patients with STEMI had more decreased LV torsion (P &amp;lt; 0.001) and torsion rate (P = 0.033). Patients who experienced MACCEs had more impaired LV torsion (P &amp;lt; 0.001) and torsion rate (P &amp;lt; 0.001) than those who didn’t. LV torsion ≤ 0.876 deg/cm in the acute phase of STEMI was an independent predictive factor of MACCE (P = 0.001) and LV remodeling (P = 0.001). Patients with impaired LV torsion were more likely to experience MACCEs (P &amp;lt; 0.001). The impairment of LV torsion was also associated with the higher incidence of LV aneurysm (P &amp;lt; 0.001) and thrombus (P = 0.006). The addition of LV torsion to a risk model comprising LV ejection fraction (LVEF), infarct size (IS), and microvascular obstruction (MVO) led to a net reclassification improvement (continuous NRI 0.499 [95% CI, 0.261–0.737]; P &amp;lt; 0.001). Hypertension (P = 0.047), tobacco use (P = 0.005), worse TIMI flow post-PCI (P &amp;lt; 0.001), more extensive IS (P &amp;lt; 0.001) / MVO size (P = 0.002) were associated with the impairment of LV torsion. Conclusions Compared with normal people, patients with STEMI had more decreased LV torsion and torsion rate. LV torsion ≤ 0.876 deg/cm in the acute phase was an independent predictive factor of MACCE and LV remodeling. The addition of LV torsion to a risk model comprising LVEF, LV-IS and LV-MVO significantly improved risk stratification of patients with STEMI .

Prognostic implications of peak early diastolic strain rate (PEDSR) by feature-tracking cardiac magnetic resonance in patients with st-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the National Key Research and Development Program of China OnBehalf Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University Background：The prognostic value of Peak Early Diastolic Strain Rate (PEDSR) measured by Cardiac Magnetic Resonance (CMR) in ST-Elevation Myocardial Infarction (STEMI) is not clear. Methods：420 first-STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453) and 40 normal people were enrolled and followed up. The patients received timely percutaneous coronary intervention (PCI) within 12h and CMR within 1 week (median,5 days; range, 2-7 days) after infarction. LV circumferential, radial, longitudinal PEDSR and other routine CMR parameters were measured. Clinical end point was a composite major adverse cardiovascular events (MACEs) including cardiovascular death, re-infarction and re-hospitalization for heart failure. Results：During follow-up (median: 52 months, inter-quartile range: 29–78 months), 73 (17.4%) patients experienced a MACE event. Compared with normal people, STEMI patients had lower PEDSR (circumf. PEDSR 0.77 vs. 1.27%/s, P &amp;lt; 0.001). Patients who developed MACEs also had lower PEDSR than patients who didn’t (circumf. PEDSR 0.64 vs. 0.78%/s, P &amp;lt; 0.001). Circumf. PEDSR can significantly predict MACEs with an AUC of 0.659 (95%CI 0.587-0.731, P &amp;lt; 0.001) which is not inferior to LVEF (0.659 vs. 0.651, P = 0.843), LVIS (0.659 vs. 0.661, P = 0.678) and LVMVO (0.659 vs. 0.666, P = 0.600). Circumf. PEDSR ≤ 0.665%/s is the independent predictive factor of MACEs in clinical (HR 2.099 [95%CI 1.273-3.461], P = 0.004) and CMR models (HR 1.795 [95%CI 1.065-3.026], P = 0.028). In Kaplan-Meier curve, patients with impaired PEDSR are more likely to experience MACEs (P &amp;lt; 0.001). When subdivided by LVEF, PEDSR still makes a significant difference to MACEs in patients with LVEF &amp;gt; 50.28% (P = 0.003) but not in reduced LVEF patients (P = 0.204). PEDSR is also incremental to LVEF (Continuous NRI 0.515 [95%CI 0.268-0.763], P &amp;lt; 0.001), LVIS (Continuous NRI 0.576 [95%CI 0.330-0.822], P &amp;lt; 0.001), and LVMVO (Continuous NRI 0.576 [95%CI 0.330-0.822], P &amp;lt; 0.001). Finally, worse TIMI flow post-PCI (HR 3.353 [95%CI 1.603-7.016], P = 0.001) and LVEF (HR 0.920 [95%CI 0.900, 0.940], P &amp;lt; 0.001) are the risk factors for PEDSR impairment. Conclusions：CMR-derived PEDSR can significantly predict MACEs with the discriminative power not inferior to LVEF, LVIS and LVMVO. Circumf. PEDSR ≤ 0.665%/s is an independent predictive factor of MACEs and is incremental in the prognostic risk stratification of STEMI.

Impact of concomitant impairments of the left and right ventricular myocardial strain on the prognoses of patients with ST-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the National Key Research and Development Program of China OnBehalf Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University Background The impact of concomitant impairments of left and right ventricular (LV and RV) strain on the long-term prognosis of acute ST-elevation myocardial infarction (STEMI) is not clear. Methods We analyzed CMR images and followed up 420 first STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). These patients received timely primary percutaneous coronary intervention (PCI) within 12h and CMR examination within 1 week (median,5 days; range, 2-7 days) after infarction. Global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) of both ventricles were measured based on CMR cine images. Conventional CMR indexes were also assessed. Primary clinical outcome was composite major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, re-hospitalization for heart failure and stroke. Results During follow-up (median: 52 months, interquartile range: 29–78 months), 80 patients experienced major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, heart failure, and stroke. LV-GCS &amp;gt; -11.20% was an independent predictor of MACCEs (P &amp;lt; 0.001). The impairment of RV strain was found in 177 patients (42.14%), including 37.8% of patients with left anterior descending occlusions, 37.5% with left circumflex occlusions, and 51.5% with right coronary artery occlusions. Although none of the three individual RV strain measurements, the RV-GLS, RV-GRC and RV-GCS, was independently associated with the risk of MACCEs, patients who had RV-GRS ≤ 38.79% in addition to an impaired LV-GCS however were more likely to experience MACCEs than patients with decreased LV-GCS alone (log rank P = 0.010). Moreover, the addition of RV-GRS to LV-GCS improved the predictive power for MACCEs compared to the predictive power of LV-GCS alone (continuous NRI: 0.327; 95% CI: 0.095 - 0.558; P = 0.006). Finally, Tobacco use (P = 0.003), right coronary artery involvement (P = 0.002), and LV-GCS &amp;gt; -11.20% (P = 0.012) were found to be independent risk factors of RV-GRS impairment. Conclusions Impairment of the RV strain is prevalent in infarctions occurring at all cardiac locations. While LV-GCS is an independent predictor of long-term MACCEs, the concomitant impairment of RV-GRS results in a worsened prognosis. Combination assessment of both LV and RV strain indexes could improve risk stratification of STEMI patients.

Impact of Concomitant Impairments of the Left and Right Ventricular Myocardial Strain on the Prognoses of Patients With ST-Elevation Myocardial Infarction.

Background: The impact of concomitant impairments of left and right ventricular (LV and RV) strain on the long-term prognosis of acute ST-elevation myocardial infarction (STEMI) is not clear.Methods: We analyzed CMR images and followed up 420 first STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). These patients received timely primary percutaneous coronary intervention (PCI) within 12 h and CMR examination within 1 week (median, 5 days; range, 2–7 days) after infarction. Global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) of both ventricles were measured based on CMR cine images. Conventional CMR indexes were also assessed. Primary clinical outcome was composite major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, re-hospitalization for heart failure and stroke. In addition, CMR data from 40 people without apparent heart disease were used as control group.Results: Compared to controls, both LV and RV strains were remarkably reduced in STEMI patients. During follow-up (median: 52 months, interquartile range: 29–68 months), 80 patients experienced major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, heart failure, and stroke. LV-GCS > −11.20% was an independent predictor of MACCEs (P < 0.001). RV-GRS was the only RV strain index that could effectively predict the risk of MACCEs (AUC = 0.604, 95% CI [0.533, 0.674], P = 0.004). Patient with RV-GRS ≤ 38.79% experienced more MACCEs than those with preserved RV-GRS (log rank P < 0.001). Moreover, patients with the concomitant decrease of LV-GCS and RV-GRS were more likely to experience MACCEs than patients with decreased LV-GCS alone (log rank P = 0.010). RV-GRS was incremental to LV-GCS for the predictive power of MACCEs (continuous NRI: 0.327; 95% CI: 0.095–0.558; P = 0.006). Finally, tobacco use (P = 0.003), right coronary artery involvement (P = 0.002), and LV-GCS > −11.20% (P = 0.012) was correlated with lower RV-GRS.Conclusions: The concomitant decrease of LV and RV strain is associated with a worse long-term prognosis than impaired LV strain alone. Combination assessment of both LV and RV strain indexes could improve risk stratification of patients with STEMI.Trial Registration: ClinicalTrials.gov, NCT03768453. Registered 7 December 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03768453.