Survivors Of ST-elevation Myocardial Infarction Research Articles

Contemporary secondary prevention in survivors of ST-elevation myocardial infarction with and without chronic kidney disease: a retrospective analysis.

Survivors of myocardial infarction have an elevated risk of long-term mortality. We sought to evaluate guideline-directed medical treatment and its impact on long-term mortality in survivors of ST-elevation myocardial infarction (STEMI) according to their chronic kidney disease (CKD) stage. Using German health insurance claims data, 157663 hospitalized survivors of STEMI were identified. Regarding different CKD stages, we retrospectively analysed the filled prescriptions of platelet inhibitors (PAI)/oral anticoagulation, statins, beta-blocker and angiotensin-converting enzyme inhibitors/angiotensin II type 1 receptor antagonists (ACE-I/AT1-A) and their association with long-term mortality. Prescription rates for all four guideline-directed drugs were highest in patients without or with mild CKD and lowest in patients on dialysis. They dropped from 73.4% to 39.2% in patients without CKD and from 47.1% to 29% in patients on dialysis within the 5-year follow-up period. Mortality rates were dramatically increased in patients with CKD compared with patients without CKD (5-year mortality: no CKD, 16.7%; CKD stage 3, 47.1%; CKD stage 5d, 69.7%). Filled prescriptions of at least one drug class [one drug: hazard ratio (HR) 0.70, 95% confidence interval (95% CI) 0.66-0.74; four drugs: HR 0.28, 95% CI 0.27-0.30; P<.001 for both] as well as the distinct drug classes (statins: HR 0.55, 95% CI 0.54-0.56; ACE-I/AT1-A: HR 0.68, 95% CI 0.67-0.70; beta-blocker: HR 0.87, 95% CI 0.85-0.90; PAI/oral anticoagulation: HR 0.97, 95% CI 0.95-1.00; all P<.05) improved long-term mortality. An improved long-term guideline-recommended drug therapy after STEMI regardless of renal impairment might lead to beneficial effects on long-term mortality.

Prognostic significance of left ventricular functional parameters in relation to infarct location after ST-elevation myocardial infarction

Abstract Aims In survivors of ST-elevation myocardial infarction (STEMI), the impact of infarct location on the prognostic significance of left ventricular functional parameters is not well established. The aim of this study was to investigate the prognostic relevance of left ventricular (LV) functional parameters in relation to infarct location in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI). Methods This observational study analyzed 803 patients with STEMI that underwent a cardiac magnetic resonance imaging scan in median 3 (interquartile range [IQR]: 2–5) days after primary PCI. The following LV functional parameters were evaluated: LV ejection fraction, LV global longitudinal strain, fast manual long-axis strain (LAS) and mitral annular plane systolic excursion (MAPSE). Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure. Results Three hundred and sixty nine patients (46%) had anterior STEMI. These patients had lower LV functional parameters including LV ejection fraction (p&amp;lt;0.001), LV global longitudinal strain (p&amp;lt;0.001), LAS (p&amp;lt;0.001) and MAPSE (p&amp;lt;0.014). MACE was evaluated at a median of 13 (IQR: 12–37) months after STEMI and occurred in 78 patients (10%). In receiver operating curve analysis, the predictive value of LV ejection fraction, LV global longitudinal strain, LAS and MAPSE was 0.59 (p=0.013), 0.64 (p&amp;lt;0.001), 0.67 (p&amp;lt;0.001) and 0.66 (p&amp;lt;0.001), respectively. When divided according to infarct location, MACE occurred in 47 (13%) anterior STEMI patients, and in 31 (7%) non-anterior STEMI patients, respectively. Area under the curve for the prediction of MACE in anterior vs. non-anterior STEMI was 0.59 vs 0.55 for LV ejection fraction, 0.61 vs 0.63 for LV global longitudinal strain, 0.69 vs 0.62 for LAS and both 0.66 for MAPSE. In multivariable analysis, LAS was independently associated with an increased risk of MACE (hazard ratio: 1.20; 95% confidence interval: 1.10–1.30; p&amp;lt;0.001) in anterior STEMI, whereas in non-anterior STEMI, LV global longitudinal strain was an independent predictor of MACE (hazard ratio: 1.22; 95% confidence interval: 1.08–1.38; p=0.002). Conclusion Fast manual LAS emerged as independent predictor of MACE in anterior STEMI treated with contemporary primary PCI whereas LV global longitudinal strain was independently associated with MACE in non-anterior STEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

The Capacity of APOB-Depleted Plasma in Inducing ATP-Binding Cassette A1/G1-Mediated Macrophage Cholesterol Efflux-But Not Gut Microbial-Derived Metabolites-Is Independently Associated with Mortality in Patients with ST-Segment Elevation Myocardial Infarction.

Impaired HDL-mediated macrophage cholesterol efflux and higher circulating concentrations of trimethylamine N-oxide (TMAO) levels are independent risk factors for cardiovascular mortality. The TMAO precursors, γ-butyrobetaine (γBB) and Trimethyllysine (TML), have also been recently associated with cardiovascular death, but their interactions with HDL-mediated cholesterol efflux remain unclear. We aimed to determine the associations between APOB depleted plasma-mediated macrophage cholesterol efflux and plasma TMAO, γBB, and TML concentrations and explore their association with two-year follow-up mortality in patients with acute ST-elevation myocardial infarction (STEMI) and unstable angina (UA). Baseline and ATP-binding cassette transporter ABCA1 and ABCG1 (ABCA1/G1)-mediated macrophage cholesterol efflux to APOB-depleted plasma was decreased in patients with STEMI, and the latter was further impaired in those who died during follow-up. Moreover, the circulating concentrations of TMAO, γBB, and TML were higher in the deceased STEMI patients when compared with the STEMI survivors or UA patients. However, after statistical adjustment, only ABCA1/G1-mediated macrophage cholesterol efflux remained significantly associated with mortality. Furthermore, neither the TMAO, γBB, nor TML levels altered the HDL-mediated macrophage cholesterol efflux in vitro. We conclude that impaired ABCA1/G1-mediated macrophage cholesterol efflux is independently associated with mortality at follow-up in STEMI patients.

Assessment of appropriate body mass index cut-off points for long-term mortality among ST-elevation myocardial infarction survivors in Asian population using machine learning algorithm.

Low body mass index (BMI) is a predictor of adverse events in patients with ST-elevated myocardial infarction (STEMI) in Western countries. Because the average BMI of Asians is significantly lower than that of the Western population, the appropriate cut-off BMI value and its role in long-term mortality are unclear in Asian patients. Between January 2006 and December 2017, 1215 patients who underwent percutaneous coronary intervention (PCI) for acute STEMI and were alive at discharge (mean age, 67.7years; male, 75.4%) were evaluated. The cut-off BMI value, which could predict all-cause mortality within 10years, was detected using a survival classification and regression tree (CART) model. The causes of death according to the BMI value were evaluated in each group. Based on the CART model, the patients were divided into three groups (BMI < 18kg/m2: 54 patients, 18kg/m2 ≤ BMI ≤ 20kg/m2: 109 patients, and BMI > 20kg/m2: 1052 patients). The BMI decreased with age; with an increased BMI, patients with dyslipidemia, diabetes mellitus, and smoking habit increased. During the study period (median, 4.9years), 194 patients (26.8%) died (cardiac death, 59 patients; non-cardiac death, 135 patients). All-cause mortality was more frequent as the BMI decreased (BMI < 18kg/m2; 72.8%, 18kg/m2 ≤ BMI ≤ 20kg/m2; 40.5%, and BMI > 20kg/m2; 22.8%; log-rank p < 0.001). Non-cardiac deaths were more frequent than cardiac deaths in all groups, and the dominance of non-cardiac death was highest in the lowest BMI group. Cut-off BMI values of 18kg/m2 and 20kg/m2 can predict long-term mortality after PCI in Asian STEMI survivors, whose cut-off value is lower than that in the Western populations. The main causes of death in this cohort differed according to the BMI values.

Fifteen-Year Mortality and Cardiac, Thrombotic, and Bleeding Events in Survivors of ST-Elevation Myocardial Infarction

BackgroundAlthough short-term mortality in ST-elevation myocardial infarction (STEMI) has improved, data is limited regarding very long-term mortality and concomitant clinical events in STEMI survivors who undergo primary percutaneous coronary intervention (p-PCI). This study aimed to evaluate these parameters at 15 years and to determine the predictors of 15-year mortality in these patients. MethodsThe study endpoints were all-cause mortality and cardiac mortality at 15 years. Independent predictors of all-cause mortality were also analyzed. Furthermore, each thrombotic and bleeding event was evaluated. ResultsBetween January 2004 and December 2006, 260 STEMI survivors who underwent p-PCI (median follow-up period: 3970 days) were evaluated from the Ogaki Municipal hospital registry. The rates of all-cause mortality (cardiac mortality) at 5, 10, and 15 years were 12.1% (4.9%), 23.4% (9.5%), and 34.9% (12.4%), respectively. The cumulative incidences of recurrent myocardial infarction, target vessel revascularization, ischemic stroke, hemorrhagic bleeding, and gastric bleeding at 15 years were 11.3%, 43.6%, 14.3%, 6.9%, and 10.9%, respectively. Cox regression analysis showed that age ≥ 75 years [adjusted hazard ratio (aHR), 7.074, p < 0.001], chronic kidney disease (aHR, 2.320, p = 0.001), left ventricular ejection fraction <40% (aHR, 2.930, p = 0.001), Killip class ≥II at admission (aHR, 2.639, p = 0.003), untreated chronic total occlusion (aHR, 2.090, p = 0.042), and final TIMI grade ≤ 2 (aHR, 1.736, p = 0.048) were independent predictors of all-cause mortality. ConclusionThis study demonstrated that all-cause and cardiac mortality at 15 years were 34.9% and 12.4%, respectively, in all-comers STEMI survivors after p-PCI, indicating that STEMI survivors might have a benign prognosis.

Validation of a simple ECG score for infarct size estimation in patients with first-time ST-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund Background The magnitude of myocardial damage after acute ST-elevation myocardial infarction (STEMI) is a crucial prognostic determinant. Cardiac magnetic resonance (CMR) imaging offers a precise infarct severity assessment after STEMI; however, limited to restricted availability in daily clinical routine. Recently, a simple ECG score (DETERMINE score) was developed for infarct size (IS) estimation in STEMI patients with prior infarction. We sought to validate this score in patients with first-time STEMI for the assessment of myocardial injury visualized by CMR. Methods In this validation study, 423 revascularized first-time STEMI patients (median age 56, 17% women) were included. ECG was conducted at discharge for evaluation of the DETERMINE and Selvester score. CMR imaging was performed at a median of 3 days for the assessment of infarct characteristics (IS and microvascular obstruction [MVO]). Results Median DETERMINE score of the overall cohort was 8 points (interquartile range: 5-11). Patients presenting with a score &amp;gt; 8 points had more often anterior infarct localization (64% vs. 29%, p &amp;lt; 0.001) and higher peak hs-TnT levels (6957 ng/l vs. 3117 ng/l, p &amp;lt; 0.001). In linear and binary multivariable logistic regression analysis, the DETERMINE score remained as independent associate of IS (odds ratio [OR]: 1.09, 95% confidence interval [CI] 1.00 to 1.18, p = 0.047) and MVO (OR: 1.09, 95% CI 1.02 to 1.16, p = 0.016), after adjustment for Selvester score and peak hs-cTnT. Conclusions In survivors of first-time STEMI, the DETERMINE score provides an easy and inexpensive tool for suitable IS estimation. Moreover, the DETERMINE score showed significant and independent association with MVO. Thus, this simple ECG score might help identify patients at high risk of large infarct burden who might benefit from more aggressive treatment strategies.

The Mid-term Mortality and Mode of Death in Survivors with ST-elevation Myocardial Infarction.

Objective The popularity of primary percutaneous coronary intervention (p-PCI) for ST-elevation myocardial infarction (STEMI) has increased over the past decades. Despite improvements in in-hospital mortality rates, it is clinically important to investigate the prognoses after discharge. However, data on the mode of death and prognostic factors are limited. We analyzed these factors in a Japanese cohort in the modern p-PCI era. Methods Between January 2004 and December 2017, a total of 1,222 patients who underwent p-PCI within 24 hours from the onset of STEMI and were alive at discharge (mean age, 67.7 years old; men, 75.5%), were evaluated. The two-year mortality was analyzed using a Cox regression model, and the mode of death was evaluated. Results The rate of mortality at 2 years was 5.7%. Non-cardiac death was more frequent than cardiac death (62.6% vs. 37.4%). A Cox multivariate analysis identified the following as independent predictors of the 2-year mortality: hemoglobin (log-transformed) [adjusted hazard ratio (HR), 0.048; 95% confidence interval (CI), 0.008-0.29; p<0.001], age above 80 years old (adjusted HR, 2.26; 95% CI, 1.30-3.91; p=0.004), Killip class ≥II (adjusted HR, 1.99; 95% CI, 1.17-3.39; p=0.011), brain natriuretic peptide level (log-transformed) (adjusted HR, 1.47; 95% CI, 1.09-2.01; p=0.013), and body mass index (log-transformed) (adjusted HR, 0.16; 95% CI, 0.030-0.84; p=0.030). Conclusion This study demonstrated that the 2-year mortality was 5.7% in STEMI survivors after p-PCI. Non-cardiac death was more frequent than cardiac death. Compared to well-known clinical variables, angiographic findings did not have a significant influence on the mid-term mortality.

High sensitivity C-reactive protein is associated with worse infarct healing after revascularized ST-elevation myocardial infarction

Background:The inflammatory response due to myocardial tissue injury in the setting of acute ST-elevation myocardial infarction (STEMI) is essential for proper local infarct healing. However, an excessive inflammatory response may aggravate myocardial damage and hampers infarct healing processes. The present study aimed to investigate the association of systemic inflammatory biomarkers with infarct size (IS) dynamics post-STEMI, using cardiac magnetic resonance (CMR) imaging. MethodsThis prospective observational study included 245 STEMI patients treated with primary percutaneous coronary intervention (pPCI). Peak values of high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBCc) and fibrinogen were determined serially until 96 h after pPCI. Infarct healing, defined as relative IS reduction from baseline to 4 months after STEMI, was assessed using late gadolinium enhanced CMR imaging. ResultsIS significantly decreased from 16% of left ventricular mass (LVM) (Interquartile range [IQR]:8–24) at baseline to 10% (IQR:5–17) at 4 months (p < 0.001). Relative IS reduction was 35% (IQR:8–50). Whereas peak WBCc (p = 0.926) and peak fibrinogen (p = 0.161) were not significantly associated with relative IS reduction, peak hs-CRP showed a significant association with IS reduction (p = 0.003). In multivariable logistic regression analysis, the association between peak hs-CRP and relative IS reduction remained significant after adjustment for baseline IS, hypertension, hs-cardiac troponin T and N-terminal pro B-type natriuretic peptide (odds ratio:0.35 [95% confidence interval:0.19–0.63]; p = 0.001). ConclusionsIn STEMI patients treated with pPCI, hs-CRP was independently associated with 4 months IS reduction as determined by CMR, suggesting a pathophysiological interplay between inflammation and adverse infarct healing in survivors of acute STEMI.

High sensitivity C-reactive protein is associated with worse infarct healing after revascularized ST-elevation myocardial infarction

Abstract Background The inflammatory response due to myocardial tissue injury in the setting of acute ST-elevation myocardial infarction (STEMI) is essential for proper local infarct healing. However, an excessive inflammatory response may aggravate myocardial damage and hampers infarct healing processes. The present study aimed to investigate the association of systemic inflammatory biomarkers with infarct size (IS) dynamics post-STEMI, using cardiac magnetic resonance (CMR) imaging. Methods This prospective observational study included 245 STEMI patients treated with primary percutaneous coronary intervention (pPCI). Peak values of high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBCc) and fibrinogen were determined serially until 96 hours after pPCI. Infarct healing, defined as relative IS reduction from baseline to 4 months after STEMI, was assessed using late gadolinium enhanced CMR imaging. Results IS significantly decreased from 16% of left ventricular mass (LVM) (Interquartile range [IQR]:8–24) at baseline to 10% (IQR:5–17) at 4 months (p&amp;lt;0.001). Relative IS reduction was 35% (IQR:8–50). Whereas peak WBCc (p=0.926) and peak fibrinogen (p=0.161) were not significantly associated with relative IS reduction, peak hs-CRP showed a significant association with IS reduction (p=0.003). In multivariable logistic regression analysis, the association between peak hs-CRP and relative IS reduction remained significant after adjustment for baseline IS, hypertension, hs-cardiac troponin T and N-terminal pro B-type natriuretic peptide (odds ratio:0.35 [95% confidence interval:0.19–0.63]; p=0.001). Conclusions In STEMI patients treated with pPCI, hs-CRP was independently associated with 4 months IS reduction as determined by CMR, suggesting a pathophysiological interplay between inflammation and adverse infarct healing in survivors of acute STEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Austrian Society of Cardiology

Association between discharge destination and mid-term mortality in octogenarian patients with ST-elevation myocardial infarction

BackgroundOwing to an increasing aging population, the number of elderly patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is escalating. The onset of STEMI in elderly patients may lead to increased frailty, resulting in failure of discharge to home despite survival. However, the association of discharge destination with prognosis has not been fully evaluated in this population. MethodsBetween January 2014 and December 2016, a total of 245 octogenarian STEMI survivors who underwent PCI (mean age, 84.4 years; male, 46.5%) were evaluated from a multicenter registry. The 2-year mortalities of the home discharge and non-home discharge groups were compared and analyzed using a Cox regression model. ResultsNon-home discharge, which was defined as transfer to another hospital or nursing home after STEMI, was seen in 36 patients. During the 2 years, 37 patients died (home discharge, 27 patients; non-home discharge, 10 patients). The most frequent cause of death was due to infection (21.6%), followed by sudden death (18.9%) and heart failure (16.2%). The cumulative all-cause mortality was significantly higher in the non-home discharge group than in the home discharge group [36.4% vs. 14.8%; hazard ratio (HR), 2.95; 95% confidence interval (CI), 1.43−6.10; p = 0.003]. After multivariate analysis, non-home discharge (adjusted HR, 2.62; 95% CI, 1.20−5.75; p = 0.016) together with left ventricular ejection fraction <40% (adjusted HR, 3.15; 95% CI, 1.57−6.31; p = 0.001), prior heart failure (adjusted HR, 4.88; 95% CI, 1.82−13.13; p = 0.002), target lesion in the left anterior descending artery (adjusted HR, 2.20; 95% CI, 1.12−4.32; p = 0.022), and serum albumin level <3.5 g/dL (adjusted HR, 2.13; 95% CI, 1.06−4.27; p = 0.034) remained significant predictors of all-cause mortality. ConclusionNon-home discharge was associated with an increased risk of mid-term mortality in octogenarian STEMI survivors.

Association Between C-Reactive Protein to Albumin Ratio and Left Ventricular Thrombus Formation Following Acute Anterior Myocardial Infarction

Left ventricular thrombus (LVT) is associated with inflammatory response in survivors with anterior ST-elevation myocardial infarction (STEMI). The C-reactive protein to albumin ratio (CAR) has been proposed as a marker of inflammation. However, there is a lack of data with respect to the role of CAR in LVT development. We investigated the relationship between CAR and LVT development in patients with anterior STEMI treated percutaneously; 955 consecutive patients were enrolled and LVT was observed in 126 (13.2%) patients. Clinical, demographic, and laboratory parameters were recorded. The CAR was significantly higher in patients with LVT (12.6 [8.6-16.1] vs 18.1 [11.5-23], P < .001). Other independent predictors for LVT development were lower ejection fraction, the presence of left ventricular apical aneurysm, proximal left anterior descending lesion location, glycoprotein IIb/IIIa inhibitors treatment, >1 diseased arteries, higher total protein level, neutrophil count, and peak creatine kinase myocardial band activity. In conclusion, the CAR may be useful as a simple tool for predicting LVT development among survivors of anterior STEMI.

Association of lymphocyte-to-monocyte ratio with the long-term outcome after hospital discharge in patients with ST-elevation myocardial infarction: a retrospective cohort study.

Lymphocyte-to-monocyte ratio (LMR), a novel systemic inflammatory factor, correlates with adverse outcomes in patients with cardiovascular disease. However, data are limited regarding the prognostic value of LMR in patients with ST-elevation myocardial infarction (STEMI) after hospital discharge. Therefore, the aim of our study was to evaluate the prognostic impact of admission LMR in hospital survivors of STEMI. This retrospective observational study enrolled 1369 STEMI patients between 2014 and 2017. The study population was divided into three groups according to tertiles (T) of LMR (T1: ≥2.84; T2: 1.85-2.83; T3: <1.85). The primary outcomes were long-term outcomes after discharge including major adverse cardiac events (MACE) and all-cause mortality. The associations between LMR and long-term outcomes were assessed using Cox regression analysis. The median follow-up period was 556 days (interquartile range, 342-864 days). Independent correlations were observed between LMR and both long-term MACE and all-cause mortality. For long-term MACE, the T3 (adjusted hazard ratio [HR], 1.74; 95% confidence interval [CI]: 1.12-2.70; P = 0.013) and T2 groups (adjusted HR, 1.65; CI: 1.07-2.54; P = 0.024) showed significantly higher risk of MACE than did the T1 group. For long-term all-cause mortality, the adjusted HR was 3.07 (CI: 1.10-8.54; P = 0.032) in the T3 group and 2.35 (CI: 0.82-6.76; P = 0.112) in the T2 group compared with that of the T1 group. Decreased admission LMR was independently associated with long-term all-cause mortality and MACE after discharge in patients with STEMI.

Global longitudinal strain by feature tracking for optimized prediction of adverse remodeling after ST-elevation myocardial infarction.

The role of left ventricular (LV) myocardial strain by cardiac magnetic resonance feature tracking (CMR-FT) forthe prediction of adverse remodeling following ST-elevation myocardial infarction (STEMI), as well as its prognostic validity compared to LV ejection fraction (LVEF) and CMR infarct severity parameters, is unclear. This study aimed to evaluate the independent and incremental value of LV strain by CMR-FT for the prediction of adverse LV remodeling post-STEMI. STEMI patients treated with primary percutaneous coronary intervention were enrolled in this prospective observational study. CMR core laboratory analysis was performed to assess LVEF, infarct pathology and LV myocardial strain. The primary endpoint was adverse remodeling, defined as ≥ 20% increase in LV end-diastolic volume from baseline to 4months. From the 232 patients included, 38 (16.4%) reached the primary endpoint. Global longitudinal strain (GLS), global radial strain, and global circumferential strain were all predictive of adverse remodeling (p < 0.01 for all), but only GLS was an independent predictor of adverse remodeling (odds ratio: 1.36[1.03-1.78]; p = 0.028) after adjustment for strain parameters, LVEF and CMR markers of infarct severity. A GLS > -14% was associated with a fourfold increase in the risk for LV remodeling (odds ratio: 4.16[1.56-11.13]; p = 0.005). Addition of GLS to a baseline model comprising LVEF, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.26 ([0.13-0.38]; p < 0.001) and integrated discrimination improvement of 0.02 ([0.01-0.03]; p = 0.006). In STEMI survivors, determination of GLS using CMR-FT provides important prognostic information for the development of adverse remodeling that is incremental to LVEF and CMR markers of infarct severity. NCT04113356.

CIRCULATING FIBROCYTE LEVEL AS A MARKER OF MYOCARDIAL FIBROSIS FOLLOWING ACUTE ST ELEVATION MYOCARDIAL INFARCTION

Fibrocytes are bone marrow-derived progenitor cells that have been linked to myocardial fibrosis in mouse models of acute myocardial infarction (MI) and ischemic cardiomyopathy. Our hypothesis is that among survivors of ST elevation MI, the number and phenotype of circulating fibrocytes correlate

4937Global longitudinal strain by feature tracking predicts adverse remodeling in ST-elevation myocardial infarction incremental to

Abstract Objectives To evaluate the independent and incremental value of left ventricular (LV) strain assessed by cardiac magnetic resonance feature tracking (CMR-FT) for prediction of adverse LV remodeling following ST-elevation myocardial infarction (STEMI). Background The role of LV myocardial strain by CMR-FT for prediction of adverse remodeling after STEMI in comparison to LV ejection fraction and infarct severity is unclear. Methods STEMI patients treated with primary percutaneous coronary intervention within 24 hours after symptom onset were enrolled. CMR core laboratory analysis was performed to assess LV ejection fraction, infarct pathology and LV myocardial strain. The primary endpoint was adverse remodeling defined as ≥20% increase in LV end-diastolic volume from baseline to 4 months. Results From the 232 patients included, 38 (16.4%) reached the primary endpoint. Global longitudinal strain (GLS), global radial strain, and global circumferential strain were all predictive of adverse remodeling (p&lt;0.01 for all), but among strain values only GLS was an independent predictor of adverse remodeling (hazard ratio: 1.36 [1.03–1.78]; p=0.028) after adjustment for strain parameters, ejection fraction and CMR markers of infarct severity. A GLS &gt;-14% was associated with a 4-fold increase in risk for LV remodeling (hazard ratio: 4.16 [1.56–11.13]; p=0.005). Addition of GLS to a baseline model comprising ejection fraction, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.26 ([0.13–0.38]; p&lt;0.001) and integrated discrimination improvement of 0.02 ([0.01–0.03]; p=0.006). Conclusions In STEMI survivors, determination of GLS using CMR-FT provides important prognostic information for the development of adverse remodeling that is incremental to LV ejection fraction and CMR markers of infarct severity.

Sustained endothelial dysfunction in the infarct-related coronary artery is associated with left ventricular adverse remodeling in survivors of ST-segment elevation myocardial infarction

BackgroundIschemia-reperfusion causes endothelial injury and dysfunction in the infarct-related coronary artery (IRA). Using serial assessment of coronary endothelial vasomotor function and left ventriculography (LVG), this study prospectively investigated the clinical impact of endothelial vasomotor dysfunction in the patent IRA on left ventricular (LV) remodeling in survivors of ST-elevation myocardial infarction (STEMI). MethodsThis study included 78 patients with STEMI due to occlusion of the left anterior descending coronary artery (LAD) and successful reperfusion therapy with percutaneous coronary intervention. All of them had LV ejection fraction (LVEF) <55%. LVG and the vasomotor responses to acetylcholine (ACh) in the LAD were examined within 2 weeks (1st test) and 6 months (2nd test) after MI. Cut-off values for coronary vasomotor dysfunction in response to ACh were based on the lower 10% of the distribution of coronary vasomotor responses to ACh in 20 control subjects. ResultsLV adverse remodeling, defined as a >10% increase in either LV end-diastolic volume index (LVEDVI) and/or end-systolic volume index (LVESVI) from the 1st to the 2nd test, occurred in 21 (70%) of 30 patients with sustained impairment of the coronary flow response to ACh at both the 1st and 2nd tests and 14 (29%) of 48 in the other coronary flow response group (p < 0.01). In multivariate logistic regression analysis, a >10% increase in LVEDVI and LVESVI was respectively associated with sustained impairment of the coronary diameter and flow responses to ACh (OR 4.9 and 3.5, 95% CI 1.7–14.1 and 1.1–10.9, p < 0.01 and p = 0.03, respectively), that was independent of hypertension, peak creatine phosphokinase, and the baseline coronary flow response to ACh at the 1st test. ConclusionsSustained endothelial vasomotor dysfunction in the IRA was associated with LV adverse remodeling in STEMI survivors with successful reperfusion therapy.

Visit-to-visit systolic blood pressure variability in patients with ST-elevation myocardial infarction predicts long-term cardiovascular outcomes

Elevated visit-to-visit blood pressure variability (BPV), independent of mean BP, has been associated with cardiovascular events. However, its impact after ST-elevation myocardial infarction (STEMI) has not been established. This study aimed to investigate the prognostic impact of BPV on patients after STEMI. We analyzed the data and clinical outcomes of STEMI survivors who underwent successful primary coronary intervention from 2003 to 2009. BP was measured at discharge and at 1, 3, 6, 12, 24, and 36 months, and we calculated BPV as the intra-individual standard deviations (SDs) of systolic BP (SBP) across these measurements. We classified the patients as high and low-BPV group, and evaluated the outcomes: occurrence of major adverse cardiovascular events (MACEs), death, recurrent myocardial infarction, and target vessel revascularization within 60 months. We enrolled 343 patients, and mean follow-up duration was 68 ± 34 months (median: 76 months). Mean and median SBP SDs were 13.2 and 12.3 mmHg, and patients were divided into one of the two groups based on the median (high-BPV group = SD ≥ 12.3 mmHg; low-BPV group = SD < 12.3 mmHg). The MACE-free survival in the high-BPV group was significantly worse than that in low-BPV group (log-rank p = 0.035). For the high-BPV group, the risk of a MACE significantly increased by 57% (95% confidence interval: 1.03–2.39; p = 0.038). Visit-to-visit systolic BPV was associated with increased rates of adverse clinical outcomes in patients after STEMI. Careful assessment of BP and attempts to reduce BPV might be also important in STEMI survivors.

Reverse, stationary and progressive left ventricular dilatation in dilated and nondilated ventricles on admission following first anterior STEMI

The relationship between admission left ventricular (LV) volumes, regional contractility and persistent ST elevation in first anterior ST elevation myocardial infarction (STEMI) with evolution of LV volumes at 12 months remains inconclusive. Thus possible differences among patients with reverse dilatation (RD), stationary dilatation (SD) or progressive dilatation (PD) at 12 months based on left ventricle end-systolic volume (LVESV) index changes were investigated. ECG and echocardiographic features of 394 1-year survivors of anterior STEMI were analyzed at admission, 6 and 12 months in those with RD (≥15% reduction of LVESV index, at 12 months n=141), SD (<15% reduction or increase, n=123) or PD (≥15% increase, n=130). Long-term outcome was also evaluated. Admission LVESV values in tertiles and incidence of moderate-severe mitral regurgitation were similar in three groups. In patients with RD, LVESV decreased at 6 months (P<0.001) and further at 12 months (P=0.003), whereas in PD, it increased at 6 months (P<0.001) and further at 12 months (P=0.016). Contractility score in PD was higher on admission (P=0.050) than in the other groups, but it involved the same segments. At 12 months, it improved in each of the six most affected in RD (P<0.001) and SD (P=0.025-0.001) but not in PD group (P=0.452-1.00). Persistent ST elevation at 24 h and peak troponin I were the only independent predictors for RD (odds ratio: 0.900, 95% confidence interval: 0.840-0.905, P=0.003; 0.996, 0.986-0.994, P<0.001) and PD (1.143, 1.001-1.304, P=0.048; 1.004, 1.002-1.006, P<0.001), respectively. During an 8-year follow-up, 77 (19.5%) patients died and although the total mortality was comparable in the three groups, cardiac death or hospitalization for heart failure was higher in the PD (16/130, 14%) than in the other two groups (14/250, 5.6%, P=0.014). Admission normal or enlarged LV volumes may evolve towards RD, SD or PD at 12 months following first anterior STEMI mainly depending in part on infarct size. Importantly, relevant changes occur at not only 6 months but also between 6 and 12 months.

Impact of a 'stent for life' initiative on post-ST elevation myocardial infarction heart failure: a 15year heart failure clinic experience.

AimsMultidisciplinary heart failure (HF) clinics are a cornerstone of contemporary HF management. The stent‐for‐life (SFL) initiative improves mortality after ST elevation myocardial infarction (STEMI), but its impact in post‐STEMI HF is not well characterized. Here we assessed the impact of SFL among patients referred to a multidisciplinary HF clinic over a 15 year time period.Methods and resultsBetween 2001 and 2015, 1921 patients were admitted to our HF clinic. In 2009, Catalonia established the Codi IAM network, a regional STEMI network that prioritizes primary percutaneous coronary intervention in STEMI. Patients admitted during the study period were divided into two groups based on admission date: pre‐SFL (2001–June 2009; n = 1031) and post‐SFL (July 2009–2015; n = 890). Compared with those in the pre‐SFL group, patients admitted in the post‐SFL period had better New York Heart Association (NYHA) functional class (22.1 vs. 38.7 NYHA classes III–IV; P < 0.001) and higher left ventricular ejection fraction (LVEF) (36.1 ± 19.6 vs. 32.6 ± 13.4; P < 0.001). Among STEMI survivors, 101 (6.7%) pre‐SFL patients and 40 (2%) post‐SFL patients (P < 0.001) fulfilled the criteria for HF clinic referral (Killip–Kimball class ≥ 2 during index admission and/or LVEF of <40%). Furthermore, among patients admitted to the HF clinic, post‐STEMI HF with reduced ejection fraction patients comprised 8.9% of the pre‐SFL group and only 4.2% of the post‐SFL group (P < 0.001).ConclusionsAmong patients treated at our multidisciplinary HF clinic, the adoption of an SFL network has decreased the prevalence of post‐STEMI HF with reduced ejection fraction.

Fine particulate air pollution and hospital admissions and readmissions for acute myocardial infarction in 26 Chinese cities

Monitoring data on fine particulate matter (PM2.5) level in China's major cities were available since 2013. We conducted a time-stratified case-crossover study to evaluate the association between short-term exposure to PM2.5 and hospital admissions for acute myocardial infarction (AMI), as well as subsequent cardiac and AMI readmissions among AMI survivors. Hospital admissions for ST-elevation myocardial infarction (STEMI) and non ST-elevation myocardial infarction (NSTEMI) from 1 January 2014 through 31 December 2015 were identified from electronic Hospitalization Summary Reports. Conditional logistic regression was used to explore the relation between PM2.5 and hospital admissions for AMI. Individuals discharged alive following STEMI in 2014 were followed up for subsequent readmissions through 31 December 2015. We used the Cox proportional hazards model to evaluate the effect of PM2.5 pollution on subsequent cardiac and STEMI readmissions. Hospital admissions for STEMI (n = 106,467) and NSTEMI (n = 12,719) were examined separately. Exposure to an interquartile range (IQR) increase in PM2.5 concentration (47.5 μg/m3) at lags 2, 3, 4 and 0–5 days corresponded with 0.6% (95% CI, 0.1%–1.1%), 0.8 (95% CI, 0.3%–1.3%), 0.6% (95% CI, 0.1%–1.1%) and 0.9% (95% CI, 0–1.8%) increases in STEMI admissions, respectively. For NSTEMI, no significant association was observed with PM2.5. We also observed significant associations of PM2.5 concentration with both subsequent cardiac and STEMI readmissions among STEMI survivors. In conclusion, short-term elevations in PM2.5 concentration may increase the risk of STEMI but not NSTEMI, and the association appeared to be more evident among STEMI survivors.