Total Myocardial Infarction Research Articles

CMR measurements of myocardial infarct heterogeneity using MCLE and IR-FGRE: correlation with arrhythmia inducibility and severe ICD events in patients with ischemic heart disease

Summary This study used CMR to evaluate patients with IHD prior to ICD implantation and correlated CMR measurements to VA inducibility and spontaneous VA events during follow-up. The results demonstrated that the gray-zone measurement using MCLE may be more sensitive in predicting appropriate ICD therapy for VA. Background In addition to measures of left ventricular ejection fraction (LVEF) and clinical staging of heart failure, myocardial infarct (MI) heterogeneity including MI and periinfarct gray-zone (GZ) has the potential to predict the occurrence of inducible sustained ventricular arrhythmia (VA) and spontaneous VA events after implantation of implantable defibrillator (ICD) in patients with ischemic heart disease (IHD). Late-gadolinium (Gd)-enhancement (LGE) cardiac MR (CMR) using inversion-recovery fastgradient-echo (IR-FGRE) is commonly used for the determination of infarct heterogeneity in these patients. Recently, a multi-contrast late-enhancement (MCLE) sequence has been developed for better infarct heterogeneity quantification. Compared to IR-FGRE, we hypothesized that MCLE may be a more sensitive method to predict the occurrence of inducible VA and severe events post-ICD implantation. Methods This study used CMR to evaluate patients with IHD prior to ICD implantation and correlated CMR measurements to VA inducibility and spontaneous VA events during follow-up. The MRI protocol included LV functional parameter assessment using steady-state free precession (SSFP), as well as LGE-MRI using IR-FGRE and MCLE post double-dose Gd injection. LV functional parameters were measured using Q-Mass or CMR42 software. The GZ analysis in IR-FGRE used a full-width half-maximum method. For MCLE, GZ analysis used a semi-automated data clustering algorithm. An unpaired t-test with unequal variance was used for the statistical analysis of the proportion of GZ, MI core and total MI relative to LV myocardium mass. Results

Rationale and design of The Coronary Artery Bypass Grafting Surgery Off or On Pump Revascularization Study: A large international randomized trial in cardiac surgery

Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart (off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relatively short follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- and long-term impact of the 2 approaches to CABG. We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or off pump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at 30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will also undertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitive dysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life. As of May 3, 2011, CORONARY has recruited >3,884 patients from 79 centers in 19 countries. Currently, patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and 34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triple vessel disease. CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its results will lead to a better understanding of the safety and efficacy of off-pump CABG.

Prediction of modifications in size and peri-infarct zone by T2-imaging after an acute myocardial infarction during longitudinal follow-up by cardiac MRI

Background Fat suppressed T2-weighted black blood turbo spin echo (BBTSE) imaging can detect myocardial edema developed after acute myocardial infarction (MI) and characterize the extent of myocardium at risk in comparison to late gadolinium enhancement (LGE) imaging. Purpose We hypothesized that T2-extent at baseline and changes during follow-up are associated with dynamic changes of infarct heterogeneity during the convalescence phase of infarct healing. We further explored the strength of association in quantifying T2-based myocardial edema, using a semi-automated method and manual tracing. Methods Fifty-one patients (40 men) underwent 3T cardiac MRI both at 18±10 days and 7.7±1.1 months after an acute MI, including: 3 short-axis slices of T2-weighted fat-suppressed BBTSE, LV function assessment by SSFP and LGE imaging. Area of hyperintensity on T2 images was assessed by a semi-automated method using a threshold of mean signal intensity in the remote ROI ± 2 SD and by manual tracing. In further analyses, correlations of T2 extent, expressed as the percentage of total myocardium, and other MRI results were assessed by Spearman correlation. Results Correlations between the T2 extent, LV parameters, infarct heterogeneity and their respective changes are displayed in the table. At baseline, hyperintense T2 myocardium was demonstrated in 50 patients (98%) and represented 20.5±14.0% of total myocardium. Baseline T2 size was inversely correlated with LVEF and was directly correlated with total MI size. Hyperintense T2 areas persisted in 12 patients (24%) at follow-up. Manual-tracing was correlated well with the semi-automated method (Spearman’s rho 0.84; P<0.0001). Table 1

Genetic variants in eleven telomere-associated genes and the risk of incident cardio/cerebrovascular disease: The Women's Genome Health Study

Background Candidate genes associated with telomere length maintenance, an important molecular marker for biological aging, represent potential risk predictors for cardiovascular disease (CVD). To date, no prospective data are available. Methods The associations between 154 tag-single nucleotide polymorphisms (tSNPs) of 11 telomere-associated candidate genes ( TERT, POT1, TNKS, TERF1, TNKS2, UCP2, TEP1, ACD, TERF2, TERF2IP, and TERC) were investigated in 23,294 Caucasian participants of the Women's Genome Health Stud y. All were free of known CVD and cancer at baseline. The primary outcome measure was a composite CVD end point (incident ischemic stroke, myocardial infarction (MI), or death due to ischemic CVD); other measures were incident MI and ischemic stroke. During follow-up, 1178 total incident CVD, 315 incident MI cases, and 323 incident ischemic stroke events were identified. Multivariable Cox regression analysis and a haplotype-based approach were performed to investigate the relationship between genotypes/haplotypes and CVD risk, assuming an additive model. Results In a marker-by-marker analysis, 7 ( TEP1, TNKS, and ACD), 11 ( TEP1, ACD, and TERT), and 24 ( TEP1, TNKS, TERT, TERF2IP, TNKS2, and UCP2) SNPs were associated—at the level of p < 0.05—with the total CVD, MI, and ischemic stroke risk, respectively. Further analysis using a haplotype-based approach showed similar findings. Although none remained significant after the correction of multiple testing, the false discovery rate analysis revealed 28% of the nominally significant SNPs with true associations in relation to ischemic stroke risk. Conclusions The present large prospective study encourages further investigation of the biological role of telomere-associated pathway genes in the pathogenesis and early assessment of vascular events.

Efeitos de autoanticorpos antilipoproteína lipase, antilipoproteína de baixa densidade e antilipoproteína de baixa densidade oxidada sobre o metabolismo lipídico e aterosclerose no lúpus eritematoso sistêmico

Premature development of atherosclerosis in systemic lupus erythematosus has been widely reported. Anti-lipoprotein lipase antibody may be one cause contributing to this disorder. To assess the extent of coronary risk due to autoimmune antibodies in terms of carotid plaque in lupus patients. We compared 114 documented lupus patients with 111 normal controls matched for sex and age. Anti-lipoprotein lipase (A-LPL), anti-oxidized low density lipoprotein (A-OXLDL), and anti-low density lipoprotein (A-LDL) were measured by enzme-linked immunoabsorbent assay. Low density lipoprotein-triglyceride (LDL-Trig) and high density lipoprotein-triglyceride (HDL-Trig) were also measured. Plaque was measured by bilateral carotid ultrasound. 45.6% of patients tested positive for A-LPL, and 34.4% for A-OXLDL. 44% of normal controls tested positive for A-LPL, and 20% for A-OXLDL. Risk increased sharply in subgroups with increased antibody levels. Patients with A-LPL and A-OXLDL > 0.40 (n = 12) showed coronary risk correlations of: A-LPL x LDL-Trig = 0.7008, P = 0.0111; bilateral ultrasound vs total cholesterol = 0.62205, P = 0.0308; LDL-Trig vs myocardial infarction (MI) = 0.76562, P = 0.0037; total triglycerides vs MI = 0.78191, P = 0.0027); LDL-Trig/LDL-cholesterol vs MI = 0.80493, P = 0.0016; A-OXLDL vs USBL = 0.71930, P = 0.0084. Correlations of SLEDAI with risk variables were highly significant only in subgroups of elevated antibody levels (SLEDAI x A-OXLDL = 0.70366, P = 0.0107). A-LPL initiates the development of LDL mutations, followed by antibody production, plaque formation and coronary risk in some SLE patients.

Inclusion of Stroke as an Outcome and Risk Equivalent in Risk Scores for Primary and Secondary Prevention of Vascular Disease

Current guideline statements for primary and secondary prevention of cardiovascular disease (CVD) rely on estimates of absolute risk of coronary events. For example, the American Heart Association guidelines on primary prevention state that persons with ≥10% risk over 10 years of myocardial infarction (MI) or coronary death should be considered for antiplatelet therapy with aspirin.1 Similarly, the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines2 state that target low-density lipoprotein level should be based on projected absolute risk of future coronary events rather than on presence or absence of specific risk factors. These guidelines state that patients at high risk of MI and coronary death, defined as an absolute 10-year risk of ≥20%, should have a target low-density lipoprotein level <100 mg/dL and should receive statin therapy if needed to achieve this goal. Stroke, however, is not included as one of the outcomes contributing to these absolute risk levels. Included in the group of patients with elevated risk, moreover, are those who already have ischemic heart disease, as well as patients deemed to be “coronary heart disease (CHD) risk equivalents,” indicating those at the same elevated risk as patients with ischemic heart disease. CHD risk equivalents include patients with diabetes mellitus, those with multiple risk factors that put them at elevated risk based on calculation of their Framingham Score, and patients with “other forms of symptomatic atherosclerotic disease.” The latter group is further defined to include those with peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA), and carotid artery disease. The category of “risk equivalents” in the ATP III guidelines, however, does not include the vast majority (≈80%3) of ischemic stroke patients without carotid artery disease as cause of their stroke. Ischemic stroke is therefore notably excluded from the list of outcomes contributing to …

Cardiovascular Safety of Tiotropium in Patients With COPD

The clinical trial safety database for tiotropium has been augmented with a 4-year trial in patients with COPD, which provides an opportunity to better evaluate the cardiovascular (CV) profile of tiotropium. Trials with the following criteria were considered: > or = 4 weeks, randomized, double-blind, parallel-group, placebo-controlled. Inclusion/exclusion criteria were similar, including spirometry-confirmed COPD, > or = 10 pack-year smoking, and age > or = 40 years. Adverse events were collected throughout each trial using standardized case report forms. Incidence rates (IRs) were determined from the total number of patients with an event divided by total time at risk. Rate ratios (RRs) and 95% CI for tiotropium/placebo were calculated. IRs were determined for all-cause mortality and selected CV events, including a composite CV end point encompassing CV deaths, nonfatal myocardial infarction (MI), nonfatal stroke, and the terms sudden death, sudden cardiac death, and cardiac death. There were 19,545 patients randomized: 10,846 (tiotropium) and 8,699 (placebo) from 30 trials. Mean FEV(1) = 1.15 +/- 0.46 L (41 +/- 14% predicted), 76% men, mean age = 65 +/- 9 years. Cumulative exposure to study drug was 13,146 (tiotropium) and 11,095 (placebo) patient-years. For all-cause mortality, the IR was 3.44 (tiotropium) and 4.10 (placebo) per 100 patient-years (RR [95% CI] = 0.88 [0.77-0.999]). IR for the CV end point was 2.15 (tiotropium) and 2.67 (placebo) per 100 patient-years (RR [95% CI] = 0.83 (0.71-0.98]). The IR for the CV mortality excluding nonfatal MI and stroke was 0.91 (tiotropium) and 1.24 (placebo) per 100 patient-years (RR [95% CI] = 0.77 [0.60-0.98]). For total MI, cardiac failure, and stroke the RRs (95% CI) were 0.78 (0.59-1.02), 0.82 (0.69-0.98), and 1.03 (0.79-1.35), respectively. Tiotropium was associated with a reduction in the risk of all-cause mortality, CV mortality, and CV events.

The PECAM-1 gene polymorphism — a genetic marker of myocardial infarction

Abstract We investigated a possible association between the C373G (Leu125Val) polymorphism in the platelet endothelial cell adhesion molecule-1 (PECAM-1) and myocardial infarction (MI) among patients with type 2 diabetes (T2DM) in the Slovene population (Caucasians). The study population of this cross-sectional analysis consisted of 452 subjects with T2DM lasting more than 10 years: 142 patients with MI (MI group) and 310 patients (control group) with no history of coronary diseases. There were significant differences of PECAM-1 genotype distribution in patients with MI (CC=28.2%, CG=47.2% and GG=24.6%) compared with subjects in the control group (CC=17.1%, CG=53.5% and GG=29.4%). The multivariate model showed that the CC genotype of the PECAM-1 gene polymorphism (C373G) (OR=1.9, 95% CI 1.2–3.0, P=0.007) was an independent risk factor for MI. The C allele frequency was also significantly higher (P=0.005) in MI (51.8%) than in control subjects (41%). In addition, our study revealed the connection between smoking habits, the duration of diabetes and the total and LDL cholesterol serum levels and MI in Slovene T2DM patients. We suggest that the tested polymorphism of PECAM-1 (C373G) is associated with MI. Therefore, it might be used as genetic marker of MI in T2DM.

Clinical Summaries

Clinical Summaries

Air Temperature and the Occurrence of Myocardial Infarction in Augsburg, Germany

Air temperature changes have been associated with cardiovascular mortality and morbidity. The objective of this study was to examine in detail the registry-based myocardial infarction (MI) rates and coronary deaths in relation to air temperature in the area of Augsburg, Germany. Between 1995 and 2004, the Monitoring Trends and Determinants on Cardiovascular Diseases/Cooperative Health Research in the Region of Augsburg (MONICA/KORA) registry recorded 9801 cases of MI and coronary deaths. Over the same period, meteorological parameters and air pollutant concentrations were measured in the study region. Poisson regression analyses adjusting for time trend, relative humidity, season, and calendar effects were used to estimate immediate, delayed, and cumulative temperature effects on the occurrence of MIs. The daily rates of total MI, nonfatal and fatal events, and incident and recurrent events were analyzed. For the total MI cases, a 10 degrees C decrease in 5-day average temperature was associated with a relative risk of 1.10 (95% confidence interval, 1.04 to 1.15). The effect of temperature on the occurrence of nonfatal events showed a delayed pattern, whereas the association with fatal MI was more immediate. No association could be observed for recurrent events. The effects of temperature decreases on total MI cases were more pronounced in years with higher average temperatures and were visible in summer. We observed an inverse relationship between temperature and MI occurrence not only during winter but also during summer. Thus, our results suggest not a pure "cold effect" but an influence of unusual temperature decreases.

Abstract 2298: Impact of Preopeartive Anemia on Long-term Outcomes Following Isolated Coronary Artery Bypass Surgery

Background: The prognostic and clinical value of preopeartive anemia in patients undergoing cardiac surgery has recently been recognized. However, very limited information exists on the impact of preopeartive anemia on long-term outcomes following coronary artery bypass graft (CABG) surgery. This study aimed at examining the degree to which preopeartive anemia affects long-term outcomes after isolated CABG surgery. Methods: A unicenter study was conducted on 5488 consecutive survivors of isolated CABG between January 1999 and December 2005. Preopeartive anemia was defined according to the World Health Organization definition (hemoglobin &lt; 13g/dL for male; hemoglobin &lt; 12g/dL for female). Long-term outcomes of interest were total mortality, myocardial infarction (MI), repeated revascularization, and major adverse cardiac events (MACEs=total mortality or MI or repeated revascularization). These outcomes were compared after adjustment for differences in baseline risk factors among the patients. Results: 1437 (26.2%) patients had preoperative anemia. After a mean follow-up of 43.3±18.3 months, preoperative anemia was found to be an independent risk factor for total mortality (hazard ration [HR]: 1.490; 95% CI: 1.074 to 2.067; p=0.017), MI (HR: 1.595; 95% CI: 1.028 to 2.474; p=0.037) and MACEs (HR: 1.363; 95% CI: 1.059 to 1.755; p=0.016). We also found that aspirins and beta-blockers were underused in patients with anemia during follow-up. Conclusions: Preopeartive anemia has a strong negative impact on long-term outcomes following isolated CABG. Our data also suggest that the incorporation of preoperative anemia into the risk assessments of long-term outcomes after CABG is recommended. Future intense and systematic studies are needed to help ensure high-quality cardiac care of patients with anemia.

Verapamil-sustained release–based treatment strategy is equivalent to atenolol-based treatment strategy at reducing cardiovascular events in patients with prior myocardial infarction: An INternational VErapamil SR-Trandolapril (INVEST) substudy

In patients with prior myocardial infarction (MI), beta-blockers reduce mortality by 23% to 40%. However, despite this favorable effect, adverse effects limit compliance to this medication. The purpose of the study was to compare a beta-blocker-based strategy with a heart rate-lowering calcium antagonists-based strategy in patients with prior MI. We evaluated 7,218 patients with prior MI enrolled in the INternational VErapamil SR-Trandolapril (INVEST) substudy randomized to verapamil-sustained release (SR)- or atenolol-based strategies. Primary outcome was time to first occurrence of death (all-cause), nonfatal MI, or nonfatal stroke. Secondary outcomes included death, total MI (fatal and nonfatal), and total stroke (fatal and nonfatal) considered separately. During the 2.8 +/- 1.0 years of follow-up, patients assigned to the verapamil-SR-based and atenolol-based strategies had comparable blood pressure control, and the incidence of the primary outcome was equivalent. There was no difference between the 2 strategies for the outcomes of either death or total MI. However, more patients reported excellent/good well-being (82.3% vs 78.0%, P = .02) at 24 months with a trend toward less incidence of angina pectoris (12.0% vs 14.3%, adjusted P = .07), nonfatal stroke (1.4% vs 2.0%; P = .06), and total stroke (2.0% vs 2.5%, P = .18) in the verapamil-SR-based strategy group. In hypertensive patients with prior MI, a verapamil-SR-based strategy was equivalent to a beta-blocker-based strategy for blood pressure control and prevention of cardiovascular events, with greater subjective feeling of well-being and a trend toward lower incidence of angina pectoris and stroke in the verapamil-SR-based group.

The Newly Identified Hypertensive Patient: Cost‐Effective Laboratory Investigation

The Newly Identified Hypertensive Patient: Cost‐Effective Laboratory Investigation

Dual Therapy in Hypertensive Patients with Coronary Artery Disease: The Role of Calcium Channel Blockers and ??-Blockers

The majority of hypertensive patients require combination therapy to achieve BP goals. Guidelines recommend dual therapy in newly diagnosed patients with BP > 160/100mm Hg. Calcium channel blocker (CCB)/ACE inhibitor and beta-blocker (beta-adrenoceptor antagonists)/diuretic combinations are among regimens considered effective for BP control. ACE inhibitors, beta-blockers, and CCBs are recommended for use in patients after myocardial infarction (MI). Statistical modeling from INVEST (INternational VErapamil-Trandolapril STudy), suggests an association between dual and triple therapy and decreased risk of primary outcome ([PO] first occurrence of death, nonfatal MI, or nonfatal stroke) in patients with hypertension and coronary artery disease (CAD). This study explores the utility of dual antihypertensive therapy by reporting BP and cardiovascular outcomes for INVEST patients who predominantly received either a CCB/ACE inhibitor or a beta-blocker/ diuretic regimen. 1170 patients were selected for analysis. After 24 months of treatment, BP control (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VI criteria) was 82.1% and 82.6% in the verapamil sustained release (SR) + trandolapril (Ve + Tr) and atenolol + hydrochlorothiazide (At + HCTZ) groups, respectively (p = 0.86). In Ve + Tr compared to At + HCTZ patients, adjusted risk for PO (hazard ratio [HR] 0.63; 95% CI 0.37, 1.05; p = 0.07) and unadjusted risks for secondary outcomes including death (HR 0.70; 95% CI 0.40, 1.25), total MI (HR 0.82; 95% CI 0.35, 1.90), total stroke (HR 0.81; 95% CI 0.25, 2.65) and new diabetes (HR 0.88; 95% CI 0.55, 1.41) were not statistically different. This analysis shows that combination treatment with either Ve+ Tr or At +- HCTZ is effective in achieving BP control and produces similar outcomes in hypertensive patients with CAD.

Aspirin prevents stroke but not MI in women; vitamin E has no effect on CV disease or cancer.

Low-dose aspirin taken every other day helps prevent stroke in women aged 45 years and older, but does not prevent a first myocardial infarction (MI) or cardiovascular death among healthy women. Women receive no benefit from alternate-day vitamin E in the primary prevention of cardiovascular disease or cancer. These were the findings of the Women's Health Study, in which investigators followed 39,876 female health professionals over 10 years. The women were randomized to receive either 100 mg of aspirin or a placebo tablet every other day; they were also randomized to take 600 IU of vitamin E or a placebo capsule on the intervening days. No statistically significant differences were seen between the aspirin and placebo groups in the primary cardiovascular end point, which was the combined number of nonfatal MIs, nonfatal strokes, and cardiovascular deaths. Analysis of secondary cardiovascular end points revealed that aspirin use was associated with no significant effect on the number of total MIs, fatal MIs, and nonfatal MIs, and a nonsignificant decrease in cardiovascular mortality. However, aspirin users did experience significantly fewer strokes, in particular ischemic strokes. Vitamin E had very little impact on the primary prevention of both cardiovascular events and cancer.

Pulsatile Versus Nonpulsatile Cardiopulmonary Bypass Flow: An Evidence-Based Approach

To derive evidence-based recommendations for the use of pulsatile perfusion (PP) technique for the reduction of mortality and nonfatal complications after elective coronary artery bypass grafting surgery (CABG). Incidence of total mortality, myocardial infarction (MI), stroke, and renal failure during hospital stay. Medline, Embase, and the Cochrane controlled trial register (CCTR) on the Cochrane library were searched from the earliest achievable date of each database to March 2005. No language restrictions were applied. Retrieved reprints were evaluated according to a priori inclusion criteria, and those included were critically appraised using established internal validity criteria. BENEFITS AND HARMS: Only one fair quality randomized controlled trial demonstrated the beneficial effect of PP in reducing the incidence of total mortality and MI. No studies demonstrated the beneficial effect of PP in reducing the incidence of stoke or renal failure. One randomized controlled trial demonstrated that PP was associated with increased hemolysis compared to nonpulsatile (NP) perfusion. The evidence is conflicting and therefore does not support making recommendation for or against routinely providing the PP to reduce the incidence of mortality or MI. The evidence is insufficient to recommend for or against routinely providing the pulsatile profusion to reduce the incidence of stroke or renal failure.

Effects of Early Treatment With Statins on Short-term Clinical Outcomes in Acute Coronary Syndromes

The short-term effects of early treatment with statins in patients after the onset of acute coronary syndromes (ACS) for the outcomes of death, myocardial infarction (MI), and stroke are unclear. To evaluate relevant outcomes of patients from randomized controlled trials comparing early statin therapy with placebo or usual care at 1 and 4 months following ACS. Systematic search of electronic databases (MEDLINE, EMBASE, PASCAL, Cochrane Central Register) from their inception to August 2005, which was supplemented by contact with experts in the field. Two reviewers independently determined the eligibility of randomized controlled trials that compared treatment with statins with a control, were initiated within 14 days after onset of ACS, and had a minimal follow-up of 30 days. Trials with cerivastatin were only included in a sensitivity analysis. Information on baseline characteristics of included trials and patients, reported methodological quality, lipid levels, and clinical outcome was independently extracted by 2 investigators. Investigators from each included trial contributed additional data if necessary. Twelve trials involving 13 024 patients with ACS were included in the meta-analysis. The risk ratios for the combined end point of death, MI, and stroke for patients treated with early statin therapy compared with control therapy were 0.93 (95% confidence interval [CI], 0.80-1.09; P = .39) at 1 month and 0.93 (95% CI, 0.81-1.07; P = .30) at 4 months following ACS. There were no statistically significant risk reductions from statins for total death, total MI, total stroke, cardiovascular death, fatal or nonfatal MI, or revascularization procedures (percutaneous coronary intervention or coronary artery bypass graft surgery). Sensitivity analyses with restriction to trials of high quality or with additional data from a large trial using cerivastatin indicated summary risk ratios even closer to 1. Based on available evidence, initiation of statin therapy within 14 days following onset of ACS does not reduce death, MI, or stroke up to 4 months.

The Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER)—Evaluating the impact of myocardial infarction on patient outcomes

More information on the longitudinal care and outcomes of patients after myocardial infarction (MI) is needed to further improve the quality of MI care. The PREMIER study was designed to meet this need. Patients with MI were prospectively screened and enrolled from 19 US centers between January 1, 2003, and June 28, 2004. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed, patient-centered interview. Centralized follow-up at 1, 6, and 12 months is being conducted to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). In 2003, detailed chart abstractions, devoid of all personal health information, were collected for patients eligible but not enrolled in PREMIER. Of 10,911 patients screened, 3953 were eligible and 2498 enrolled into PREMIER. Few clinically significant differences between the total MI population and those enrolled into PREMIER were observed. Adherence to accepted processes of quality care, such as aspirin and beta-blockers on admission (96% and 91%) or discharge (96% and 93%), was high. One-month follow-up rates were high, with only 9% of patients being lost to follow-up. PREMIER is a novel registry with detailed insights into patients' sociodemographic, clinical, and health status characteristics, as well as detailed monitoring of their inpatient and outpatient processes of care. Ultimately, PREMIER will describe patients' health status outcomes and identify determinants of these outcomes as an important step toward improving MI care.

Risk of Myocardial Infarction and Vascular Death After Transient Ischemic Attack and Ischemic Stroke

Whether stroke patients should be investigated for asymptomatic coronary artery disease remains matter of debate. Absolute risks of myocardial infarction (MI) and vascular death after a stroke have not been accurately assessed. We performed a systematic review and a meta-analysis to determine the risk of MI and nonstroke vascular death after transient ischemic attack (TIA) and ischemic stroke. Cohort studies of TIA or ischemic stroke patients were included if they were published between 1980 and March 2005, reported risk of MI and nonstroke vascular death, enrolled >100 patients, and had at least 1 year of follow-up. We included 39 studies in a total of 65,996 patients with mean follow-up of 3.5 years. Two reviewers independently carried out data extraction using a standardized form. Absolute annual risks were estimated through weighted meta-regressions with a random effect. To test the predictions of expected event rates derived from our analysis, we used individual patient data. The annual risks were 2.1% (CI 95%: 1.9 to 2.4) for nonstroke vascular death, 2.2% (1.7 to 2.7) for total MI, 0.9% (0.7 to 1.2) for nonfatal MI and 1.1% (0.8 to 1.5) for fatal MI. The time course of risk was linear. Estimated risks fitted well with observed risks at the individual level. There was no heterogeneity in the absolute risks according to baseline study characteristics. Patients with TIA or stroke have a relatively high risk of MI and nonstroke vascular death. Additional research is needed to identify the determinants of coronary artery disease in stroke patients.

Association of Visceral Adipose Tissue With Incident Myocardial Infarction in Older Men and Women: The Health, Aging and Body Composition Study

Relatively strong associations have been found between risk factors for coronary heart disease and the amount of adipose tissue, measured directly in and around the visceral organs. This prospective study used several measures of adiposity, including total adiposity (body mass index [BMI] and fat mass), body fat distribution, and visceral adipose tissue relative to subcutaneous fat and total fat mass, to analyze the risk of incident myocardial infarction (MI). Subjects were 1116 men and 1387 women 70 to 79 years of age who were enrolled in the Health, Aging and Body Composition Study. MI events totalled 116 during an average follow up of 4.6 years; 40% of them proved fatal. Patients were assessed at 6-month intervals. Total fat mass was estimated by using whole-body dual-energy x-ray absorptiometry and body fat distribution using a computed tomography scanner. Women who had an MI had more visceral adipose tissue at baseline as well as a greater amount of such tissue relative to subcutaneous adipose tissue and to total fat mass compared with other women. No such differences were noted in men. Adjusting for confounding variables, both visceral adipose tissue and visceral adipose tissue/fat mass were significant predictors of MI, but total adiposity did not correlate with incident MI. The hazard ratio was 1.24 for visceral adipose tissue and 1.21 for visceral adipose tissue/fat mass. After stratifying by gender, no connection was found between any adiposity measure and incident MI in men. There was no evident association between the BMI or total fat mass and MI in women. The association with visceral adipose tissue in women was independent of levels of high-density lipoprotein cholesterol and interleukin-6, hypertension, and diabetes. These observations, in accord with those from previous studies, indicate that although the absolute volume of visceral fat may be relatively small, it remains the best obesity-related predictor of MI in elderly women.