Type Of MI Research Articles

Focusing on women: dissecting sex-specific factors in cardiogenic shock through a large cohort and propensity score matching

Abstract Background Sex differences in cardiogenic shock (CS) are crucial for tailored interventions. We explored sex-based disparities a CS-registry encompassing both acute myocardial infarction (AMI) and non-AMI-CS. Purpose Investigate specific risk variables by type and sex of CS. Compare women-specific risk in CS types and through a propensity score matching (PSM). Methods 9430 patients in a CS registry, 4414 non-AMI-CS (2432 men, 1982 women) and 5016 AMI-CS (4025 men, 991 women). Utilized KM curves, Cox regression, and a multivariable model (for significant variables P<0.05) to identify sex-specific risk factors. Conducted PSM (K=1, 1:1 radius, caliper 0.2) for significant demographic and management variables, and incorporate age, DM2, MCS, PAC, mechanical ventilation (MV), hemodialysis, and exact for SCAI; and for AMI-CS, considered type of MI and primary reperfusion; to assess sex influence on CS mortality. Results Men with AMI an non-AMI-CS are younger, higher BMIs, and smoking history is more prevalent(P<0.05). Women with AMI had higher comorbidities, including HTN, HF, CKD, and AF(P<0.001). Conversely, men with non-AMI exhibit higher dyslipidemia, COPD, previous MI, PCI, and CABG(P<0.001). In terms of CS management, women with AMI are less likely to receive primary reperfusion(P<0.001), while women receive a higher number of vasoactive(P<0.001). Women receive less dobutamine and levosimendan in non-AMI-CS(P<0.001) but more norepinephrine in AMI & non-AMI(P<0.05), finally, more vasopressin in AMI-CS(P=0.006). The SCAI classification indicates that women with AMI tend to have a higher proportion of higher SCAI classes compared to men in AMI-CS (P<0.001) but comparable in non-AMI(P=0.296). Despite these differences, women experience higher mortality in both AMI & non-AMI(P<0.001 & 0.025).(Table 1) Also, different intensities in management strategies are seen by SCAI, and sex in general has been more intense in MCS(AMI) and vasoactive drugs(non-AMI) in men(data not shown). In multivariate analysis, we notice differences in the specific risk factors in men vs women.(Fig1). In mortality, had differences in both AMI and non-AMI-CS. In the case of AMI-CS Logrank(LR) P<0.001, 30 day-RMST of 2.11(1.12-3.08, P<0.001) days less, with a HR of 1.48(1.28-1.72, P<0.001) for women in AMI-CS. In non-AMI-CS LR P=0.006 in 30-days RSMT, a difference of diminished survival of 0.85(0.08-1.62, P=0.03) days, a HR of 1.18(1.05-1.32; P=0.007) for women in non-AMI-CS. (Fig1). When applying PSM, AMI-CS(931 vs 931) although differences arise in LR P=0.048, no differences are seen in 30-day RSMT 1.09(-0.17-2.35, P=0.09), HR 1.22(1.0-1.48, P=0.052). Non-AMI-CS(1406 vs 1406) no differences were appreciated(LR P=0.359), 30-day RSMT 0.4(-0.55-1.36, P=0.407), a HR 1.07(0.92-1.24, P=0.366). (Fig1). Conclusion Women's distinct risk factors may outweigh the impact of sex alone on outcomes. Sex-specific risk factors vary by CS type, underscoring the importance of tailored approaches.Table 1.Differences by CS type & sexFig 1.Forrest plot by CS type & sex

Mechanical right ventricular involvement is independent of right coronary arterial bed and has a prognostic impact in acute myocardial infarction complicated by cardiogenic shock

Abstract Background In Acute Myocardial Infarction complicated by Cardiogenic Shock(AMI-CS), understanding the implications of right ventricular involvement (RVi) is crucial for refining risk stratification and optimizing management. Purpose Distinguish the prognosis in RVi at baseline(RVB) and persistent(RVP) in AMI-CS Methods 357 patients with AMI-CS+PAC serial measures at 0, 6, 12, 24h. RVi was defined as the presence of all 4 criteria PAPI<1; RVSWi≤4.08; RAP≥15 mmHg; and PVC/PCP≥0.86 and persistent as the presence of the 4 criteria at 4 time points. For hemodynamic measures, repeated measures ANOVA; and KM curves and Cox regression were performed. Results 300 without vs 57 with RVB. Additionally, 344 without vs 13 had RVP. Killip-Kimball classification showed a higher significant association with both RVB(P=0.042). A higher percentage of RVB received vasopressin(P=0.008), and there was a significant association with levosimendan use(P=0.009) in RVP. The higher MODS score, RVB(P=0.017) and RVP(P=0.029). The number of vasoactives was higher in RVB(P=0.031) RVP(P=0.009). Finally, the phenotypic characterization revealed a significant association with RVB(P=0.001) and RVP(P=0.032) more cardio-metabolic. The SCAI-CSWG classification indicated a higher proportion in the E category for both RVB(P=0.046) and not significant in RVP(P=0.405). Overall, mortality rates did not differ significantly between in RVB(P=0.174) or RVP(P=0.117), although there was a trend towards higher mortality in patients with RVi. Age, sex, DM, HTN, previous MI, PCI, CABG, stroke, and type of MI, primary reperfusion, LVEF, and laboratory parameters did not differ. RVB had higher heart rate(P=0.036), RAP, PASP(both P<0.001), lower SBP(P=0.049), cardiac output(P=0.004), index(P=0.001), power(P=0.012), power index(P=0.002), CPI(RAP), perfusion pressure, PAPi(both P<0.001), Stroke volume(SV, P=0.001), SVi(P<0.001), LVSWi(P=0.001), and RVSWi(P<0.001). RVP higher RAP(<0.001), and lower cardiac output(P=0.008), index(P=0.005), power(P=0.034), power index(P=0.029), CPI(RAP)(P=0.002), perfusion pressure(P=0.035), PAPi(P<0.001), SV(P=0.018), SVi(P=0.011), LVSWi(P=0.034) RVSWi(P<0.001). Importantly interaction between group*time was found in RVB in RAP(P<0.001), mPAP(P=0.038), perfusion pressure(P=0.002) and RVSWi(P<0.001) and in RVP in SV(P=0.014), SVi(P=0.013) and LVSWi(P=0.028) suggest that RVi had different hemodynamic response. For RVB a reduction of -4.16 days in survival time (-7.79, -0.54, P=0.024); Logrank P=0.035. Similarly, for RVP demonstrated a significant reduction of -7.27 days (-14.08, -0.47, P=0.036); Logrank P=0.017. No significant of the culprit artery in RVB, RVP (P>0.05) was observed. RVB and RVP was strongly associated with a higher prevalence of RVi (STe-V3/4R) on ECG (35.1 vs. 11.7%, and 61.5 vs. 13.7%, P<0.001). Conclusion In AMI-CS, RVi, whether baseline or persistent, is associated with distinct hemodynamic profiles and a trend toward higher mortality.Figure 1.Hemodynamics of RVB(A-C) & RVP(D-F)Figure 2.Survival of RVB, RVP (A, B) & HR(C)

The association of the basal TIMI flow, post-PCI TIMI flow and thrombus grade with HbA1c levels in non-diabetic patients with acute ST segment elevation myocardial infarction undergoing primary PCI

Abstract Objectives The acute phase of ST-segment elevation myocardial infarction (STEMI), as determined by TIMI angiographic criteria, is influenced by various factors that impact the patient’s clinical outcome. However, the modifiable risk factors of impaired TIMI flow (TIMI<3) and its effective treatment are not fully understood. Hyperglycemia may induce a pro thrombotic state and thus affect TIMI flow before or after PCI. This study investigates the correlation between hemoglobin A1c levels, TIMI flow grade, and thrombus grade in infarct-related arteries, assessing its predictive value in non-diabetic patients with STEMI. Methods The 265 patients selected based on the hemoglobin A1c level lower than 6.5 % and were divided into three groups based on HbA1c level. Comparison between three groups in terms of risk factors, troponin level, blood glucose level, lipid profile, kidney function, number of involved vessels, type of MI, left ventricular ejection fraction, TIMI flow before and after primary angioplasty, thrombus burden, complications and hospital mortality was made. Results With the increase in HbA1c level, the prevalence of TIMI 3 flow after primary PCI decreased. The prevalence of TIMI flow 2–3 before angioplasty also decreased with the increase in HbA1c level. Increased hemoglobin A1c was also significantly related to large thrombus burden (p=0.021). Morover, hemoglobin A1c remained an independent predictor of post-PCI TIMI flow and thrombus burden. Conclusions Elevated hemoglobin A1c is a predictor of TIMI flow less than 3 after primary PCI and high thrombus burden, in STEMI patients without a history of diabetes mellitus.

Pattern of atherosclerotic plaque and type of MI in the patients of cardiovascular disease with and without standard modifiable cardiovascular risk factors (SMuRF)

Pattern of atherosclerotic plaque and type of MI in the patients of cardiovascular disease with and without standard modifiable cardiovascular risk factors (SMuRF)

Higher number vasopressor usage linked to poorer outcomes despite obtaining hemodynamic goals in acute myocardial infarction complicated by cardiogenic shock

Abstract Introduction Despite using vasoactive drugs to achieve hemodynamic goals in AMI-CS, the outcome of patients that achieve these goals and its relation with the number of drugs is uncertain. Methods 309 AMI-CS+PAC patients, divided by vasoactives 0-1, 2, or >2. Repeated measures ANOVA was used to compare 24-h hemodynamic data. The primary outcome was in-hospital mortality, and univariate and multivariate analyses were performed, adjusting for age, sex, type of MI, SCAI, multiorgan failure (MOF), and type of reperfusion. We also examined patients who achieved hemodynamic goals and analyzed the high achievers(≥5 goals) based on: MAP, CI, CPI, RAP, PCWP, and PAPI. Results 57 had 0-1, 76 =2, and 176 >2 vasoactives. Most patients were male(82%) with a median age 61(53-67) and had STEMI(82.8%). No differences in age, diabetes, previous HF, MI, PCI, CABG, smoking history, OHCA, or type of AMI. Killip-Kimball was overall worse in 2 and >2 groups(P<0.001). LVEF decreased as drugs increased (>2=30, 2=35, 0-1=40%; P<0.001). Higher leucocyte count, Cr, AST, ALT, LDH, and lactate with lower platelets, eGFR, and pH were seen as the number of drugs increased. No differences in Hb, electrolytes, albumin, C-reactive protein, primary reperfusion, angiography, number of vessels, or revascularization were noted. The use of mechanical ventilation and hemodialysis was lower in the 0-1 group. SCAI, MODS, MOF, and AKI were higher in 2 and >2 group. Mortality was higher in the>2 group(67.6) compared to 2 (31.6) and 0-1 (12.3%; P<0.001). In the serial measures, CI (Fig1A), CPO, CPI (Fig1B), CPIRAP, SBP, MAP, and PAPI(Fig1D,C) had lower values in the >2 group compared with the 2 or 0-1(P<0.001), whereas higher RAP and PCWP were seen in the >2 group(P<0.001, 0.009, Fig1E,F). The number of vasoactives was an independent predictor of mortality, and the estimated probability of mortality was higher as the number of drugs increased, despite achieving hemodynamic goals(Fig1; blue= 0-1, green=2, red >2). In the global cohort, patients receiving 2 or more vasoactive drugs had an increased hazard ratio compared to those receiving 0-1 drugs (Fig2C-D). Among high hemodynamic goal achievers (n=115), a difference in the Kaplan-Meier analysis was observed when compared with the 0-1 group, but no difference was seen with 2 drugs(HR 2.31[0.55-9.7; 0.252], HRadj 2.12[0.43-10.46; 0.358]). However, differences were observed when >2 drugs were used(HR 6.85[3.57-22.51; 0.002] and HRadj 7.38[1.96-27.77; 0.003])(Fig2B). In addition, a comparison of each variable subgroup achiever showed differences between the 0-1 and >2 vasoactives even after adjustment. In contrast, when compared vs 2 vasoactives, only CI, CPI, CPIRAP, and PAPI retained significance after adjustment(Fig2C-D). Conclusion Despite achieving hemodynamic goals in AMI-CS, the use of more vasoactive drugs may result in poorer outcomes. Furthermore, investigating strategies to reduce vasoactives, such as upfront MCS is warranted.Fig 1.Blue=0-1 Green=2 Red=>2 vasoactiveFig 2.

Fagerstrom score predicts smoking status six months after hospitalization for acute myocardial infraction:a prospective study

Abstract Backround Cardiovascular patients who quit smoking reduce their risk for future disease and mortality by 1/3 after 2 years. Despite this, more than half of all cardiac patients continue to smoke after being discharged from the hospital. Fagerstrom score is a validated marker of nicotine addiction in smokers. Purpose The aim of this study is to investigate the predictive value of the Fargestrom score (F.Sc) as a smoking cessation tool in patients with acute myocardial infarction (AMI) at 3 and 6 months after discharge. Methods We investigated a) the predictive value of F.Sc for the smoking status in patients early after AMI and b) the effectiveness of medically assisted smoking cessation programs in the prevention of relapsing to smoking post discharge. In 103 smokers (58±12 years,79.6% males) we assessed F.Sc during hospitalization for AMI. Patients filled a questionnaire during a face-to-face interview were followed-up at 3 and 6 months. The questionnaire was divided into the following sections: demographics, habits related to smoking, knowledge of smoking risks to health and methods to quit smoking. We recorded the type of MI, number and type of diseased coronary vessels, peak cardiac enzymes levels, left ventricular ejection fraction by echocardiography, intervention during hospitalization, previous medical history. The hospital anxiety and depression scale (HADS) were used to assess the patient’s mental health condition. For the evaluation of nicotine addiction, we use F.Sc. Results 59 people were hospitalized for STEMI and 44 for NSTEMI. The peak levels of high-sensitivity (hs)-troponin T during hospitalization were 3843.2 [991.3–9338.8] ng/mL. 100 AMI patients underwent PCI and 3 received thrombolysis. All patients were smoking conventional cigarettes before admission for AMI. 29 (28.2%) οf participants had a previous diagnosis of CAD, 55 (53.4%) had hypertension, 49 (47.6%) had hyperlipidemia. The mean HADS-D value was 7.4 ± 1.6, and only 20/103 (19.41%) participants had HADS-D score equal or greater than 10. 28 patients (27.2%) did not quit smoking throughout the 6 months of follow-up (F.Sc: 8.1±1.6), 39 patients (37.8%) ceased smoking at 3 months but relapsed to smoking at 6 months (score:6.8±2.1) and only 34 (33%) had ceased smoking for 6 consecutive months (F.Sc:5.2±2 P<0.05 for all comparisons between subgroups). Out of 73 patients that abstained from smoking the first 3 months post-AMI, those who participated in a smoking cessation program displayed lower rate of relapsing to smoking compared with those who opted to cease smoking without any support(33.3% vs 61.8% p=0.012). Conclusion Fagerstrom score was found to be a valid quantitative predictor of smoking cessation in the period of 6-months follow-up AMI. Patients who participated in a smoking cessation program displayed lower relapse rates suggesting the effectiveness of these programs for smoking cessation in AMI patients.F.Sc and different smoking behaviorsAssociation of F.Sc with smoking status

Clinical outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention stratified according to duration of pain-to-balloon time and type of myocardial infarction.

Based on the clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), treated with primary percutaneous coronary intervention (pPCI), this study intended to assess mortality and major adverse cardiac and cerebrovascular event (MACCE) rates according to duration of pain-to-balloon (PTB) time and type of MI. This is a retrospective cohort study based on the prospectively collected ORPKI registry which covers PCIs performed in Poland chosen between January 2014 and December 2017. Under assessment were 1,994 STEMI and 923 NSTEMI patients. Study endpoints included mortality and MACCE rates (in-hospital, 30-day, 12- and 36-month). Predictors of all-cause mortality in the overall group, STEMI and NSTEMI were assessed by multivariable analysis. Kaplan-Meier survival curve analysis did not reveal significant differences between the STEMI and NSTEMI group for all-cause mortality or MACCE at the 36-month follow-up. While in the long PTB time group, MACCE rate was significantly greater in STEMI patients when compared to NSTEMI (p = 0.004). Among STEMI patients, the short, medium and long PTB time groups differed significantly in the rate of all-cause mortality (p = 0.006) and MACCE (p = 0.04) at 1,095 days of follow-up, which were the greatest in the long PTB time group. Before considering the length of PTB time, there were no statistically significant differences in mortality or MACCE frequency between the STEMI and NSTEMI group at 36-month follow-up. Longer PTB times are related to significantly greater mortality at the 36-month follow-up in the STEMI, but not in the NSTEMI group.

Myocardial Infarction Prevalence and Management at Medical Teaching Institute, Hayatabad Medical Complex, Peshawar, KPK, Pakistan.

Myocardial infarction focuses on the sudden deprivation of circulating blood including variation in myocardial tissue necrosis. Where it is an irretrievable death of ischemia. Annually, compared with other diseases, cardiac disease is the top contributor to human fatalities. The prevalence studies show that the rate has been increased in many countries. To discuss the myocardial infarction prevalence and management in 31 MI-diagnosed patients of Cardiology Ward, MTI, Hayatabad Medical Complex, Peshawar, KPK, Pakistan. A descriptive study was carried out based on clinical clerkship of 31 myocardial infarction diseased patients. The whole data was collected during a six days per week visit routine with the help of proforma containing i.e. questions about the patient’s history. The data was analyzed properly by utilizing SPSS software version 21 and Microsoft Excel to draw results regarding the prevalence and management of myocardial infarction. Discussing the prevalence of myocardial infarction, in 31 MI-diagnosed patients 64.4% were male while in city-wise contribution Peshawar was ranked 1st among other KPK cities with a value of 45.02%. The mean average value was 62 years for all patients. In the management of MI, hypertension was the leading risk factor having a percentage of 48% among others. Chest pain was found in almost all MI-diseased patients. 129.45 mmHg, and 81 mmHg were the systolic and diastolic blood pressure mean values respectively. It was found that the MI rate is higher in males compared to females. AWMI was the most commonly diagnosed type of MI. The suggested drug prescriptions at the said hospital were mostly clopidogrel, aspirin, rosuvastatin, and Enoxaparin. Keywords: Ischemia, tissue necrosis, acute anterior wall myocardial infarction, chest pain, hypertension

Association of Acute Coronary Syndromes with Blood Groups: A Single-Center, Observational Study

Background: Evidence suggests an association between ABO blood groups and cardiovascular diseases; particularly acute coronary syndromes, a major reason for hospitalization and mortality. Aim: To investigate the association between ABO blood groups and acute coronary syndrome (ACS) frequency. Study design: Cross-sectional study. Place and duration of study: United Hospital, Karachi from 1st June 2022 to 31st December 2022. Methods: Two hundred and five participants with a diagnosis of ACS were enrolled in this study. A structured questionnaire was used to gather the data regarding the demographics and clinical characteristics of the patients. By utilizing specific antibodies and the agglutination approach, blood types were identified. ECG, coronary angiography, echocardiography and troponin-I were performed on these patients. Results: Blood groups B+ and O+ among ACS patients had the largest prevalence (35.1 and 28.8%, respectively) and there was a significant association between blood groups and the type of MI (p=0.008). The most frequently diagnosed MI was anterior wall myocardial infarction (AWMI), which is highly prevalent among patients with the type A (+ve) blood group. Moreover, the risk factors were equally prevalent among patients of different blood groups. Conclusions: The frequency of ACS and ABO blood type were significantly correlated and there was no statistically significant correlation between any risk factors under study and blood type. Keywords: Acute coronary syndrome, ABO blood type, Risk factors

Distribution of Myocardial Infarction Regarding Hypertensive, Diabetes and Gender

Background: Coronary artery disease is the leading cause of death throughout the entire world, in Pakistan most common type of coronary disease is the myocardial infarction. Regarding the frequency of risk factors most common location of MI is anterior and inferior wall infarction in male and female, hypertensive and diabetic patients. The aims of this study was to determine the type, site, and risk factors in myocardial infarction patients associated with gender, diabetes and hypertension. Method: cross sectional study was conducted in CCU and in cardiology ward at Lady Reading Hospital Peshawar. The duration of this study was four months i.e from March 2019 to June 2019. From 18 to 100 years old data were collected on the basis of convenient sampling technique. The data was collected through a standard performa and was analyzed through SPSS 23. Results: Highest number of cases were found in age group 51-75 years with 60.4%. Male patients (56.8%) were more affected than females. Married persons were frequently suffered from myocardial infarction with 99.1%. Among total myocardial infarction patients 78.4% were suffered from ST segment elevation. Anterior side of heart were affected more with MI, followed by inferior side. Myocardial infarction were common among hypetensive patients. Family history of hypertension was also higher among the myocardial infarcted patients. Low level of diabetes were also found among myocardial infarcted patients. A total of the 227 infarction patients 75.3% patients having ST segment elevation were recorded on ECG. Conclusion: Frequency of MI is higher in male, hypertensive patients and STEMI were most common type of MI, anterior and inferior wall MI is the most common location of MI among gender, diabetics and hypertensive patients. A risk factor that is extremely powerful in one nation may not be as significant in another due to differences in the incidence of risk factors in various populations. Keywords: Coronary artery disease, myocardial infarction, type of MI, site of MI, Hypertension, Diabetes, Family History.

Predictors of No-Reflow in Patients undergoing Primary Percutaneous Coronary Intervention for Acute ST Elevation Myocardial Infarction at Tabba Heart Institute Karachi

Aim: To determine the predictors of no-reflow in patients undergoing Primary Percutaneous Coronary Intervention (PPCI) for acute ST elevation myocardial infarction (STEMI) at Tabba Heart Institute Karachi. Study duration: The study was carried out from September 2020 to September 2021. Methods: An observational study that was conducted at Tabba heart Institute Karachi. All patients with acute ST elevation myocardial infarction (STEMI) presenting within 12 hours of symptoms who undergoing primary PCI were included in the study. The patients were categorized Angiographically as no –reflow (with Thrombolysis in Myocardial Infarction (TIMI) <3 and reflow (TIMI-3) flow groups. The data regarding age and gender, type of MI, time from symptoms onset, co-morbid conditions like diabetes mellitus, hypertension, smoking, baseline Thrombolysis In Myocardial Infarction Trials (TIMI flow), infarct related artery (IRA), diameter of stent used, and the TIMI flow in IRA after the completion of procedure but before the use of intracoronary adenosine if needed, was recorded on a pre-designed proforma. The data was analyzed using SPSS 20.0. Results: Total 296 patients who underwent primary PCI after acute MI were enrolled in the study. Mean age of the study population was 57±11 years. No reflow was present in 31.4% of patients. No reflow was more common in patients with age more than 60 years, females, symptom onset to primary PCI time of more than 6 hours, LAD infarct, and baseline TIMI flow < 2. Conclusion: During primary PCI, no reflow occurs in a significant percentage of patients and is predictable by a number of factors which should be kept in mind to minimize the incidence of no reflow. Key words: No reflow, acute myocardial infarction, primary PCI

P340 PARADOXICAL DIVERGENCE BETWEEN RATE OF SURVIVAL AND QUALITY INDICATOR OF CARE IN MYOCARDIAL INFARCTION ACCORDING TO PNE–AGENAS (ITALIAN NATIONAL HEALTHCARE OUTCOMES PROGRAM)

Abstract Background The Italian National Healthcare Outcomes Program (PNE – AGENAS) each year provides quality performance measures for our Hospitals. Some measures refer directly to hard events such as mortality, others are focused over procedures that should be related to subsequent events, including mortality. The rate of PCI performed within 48 hours (48h–PCI) in patients with acute myocardial infarction (AMI) is currently used as a performance measures. An arbitrary standard of 35–40% of 48h–PCI for patients with AMI is considered the goal for a satisfactory practice. Methods We analyzed the PNE–AGENAS performance measures for the year 2020. Overall 1652 MI have been recorded in 2020 in Tuscany. We considered those Hospitals with > 100 AMI. We related the 30 day and one–year mortality with the 48h–PCI of the 20 Hospitals identified. Of these latter 13 are Hospitals with a 24h PCI service. Results All the hospitals hosting a catheterization laboratory largely overcame the 48h–PCI quality standard although with a wide variation among sites (70,8 – 90.4%). On the contrary all the Hospitals without a cath–lab did not even approach the standard (0–33.%). The analysis of the mortality data both at 30 day and at 1 year showed a wide variability among Hospitals without an appreciable difference. The 30–day mortality rate ranged from 2 to 15% without any relationship with the 48h–PCI. In some cases better survival rates were recorded for those Hospitals with the worse 48h–PCI. Conclusions Several factors makes 48h–PCI a useless and even confounding measure of performance. As a matter of fact this measure does not consider the type of MI treated (STEMI vs NSTEMI), nor the presence or not of a cath lab. Also it does not take account for the case mix of the population of AMI treated. Patients with STEMI represents about 30% of the activity of an Hospital with a 24h cath –lab. It is obviously easy for such an Hospital to satisfy the proposed standard as these patients should receive their PCI well before 24 hours. The contemporary organizations do cooperate and are organized as networks. The 48h–PCI should be only used to evaluate these networks, not the single hospitals. In conclusion our analysis by showing the divergent and paradoxical phenomena of better or similar survival in spite of longer or similar 48hPCI highlights the need to abandon this useless and even confounding measure to evaluate the Cardiology practice in the Italian Hospital.

Factors leading to delayed presentation among patients presenting with ST-elevation Myocardial Infarction in Emergency Department of a tertiary care hospital.

The duration between the onset of myocardial infarction and first intervention plays a pivotal role in saving the life of the patients. Objective: To determine the frequency of various pre-hospital factors causing delay among patients presenting with STEMI in the emergency department of a teaching hospital. Methods: This is a descriptive observational study conducted at the Cardiology Department, Rawalpindi Institute of Cardiology (RIC), Rawalpindi from March to August 2019. A total of 142 patients presenting with ST-elevation myocardial infarction (STEMI) to the Emergency Department (ED) of RIC were enrolled. Electrocardiograms (ECGs) were reviewed for confirmation of STEMI and find the type of MI. Echo-cardiography was done to find out the ejection fraction (EF) of the left ventricle. Type of reperfusion therapy either thrombolytic therapy or primary percutaneous coronary intervention (PCI), time of symptom onset, and time of presentation in ED of RIC were noted. Patients were divided into four major groups depending upon the possible factors for delayed presentation: 1) Misinterpretation of symptoms, 2) Ignorance Of reporting urgently or waiting for symptoms to resolve, 3) Transportation problem and 4) First presentational facility where thrombolytic unavailable. Data were analyzed using the Statistical Package for Social Sciences (SPSS) v.23.0 (IBM, Armonk, U.S.). Results: The mean age was 53.2(SD=15.5). Out of 142 patients, most of them were males 130(91.5%). In our study, the majority 46.5% had a primary level of education. Transportation problems were the main reason for delayed presentation accounting for 45(34.5%), followed by misinterpretation of symptoms 40(28.2%), patients first presented at a facility where thrombolytic therapy was unavailable 27(19%) and patients were either ignorant of reporting urgently to a hospital or they waited for symptoms to resolve 26(18.3%). There was a significant difference in point of the first consultation, MI type, and time duration of delayed presentation among groups (P<.05). Conclusion: Transportation problems and misinterpretation of symptoms are the main reasons for the delay in getting reperfusion treatment for ST-elevation MI. Providing better primary care facilities available to rural areas as well as targeted awareness campaigns will greatly help in this regard.

Detection and Localization of Myocardial Infarction Based on Multi-Scale ResNet and Attention Mechanism.

PurposeMyocardial infarction (MI) is one of the most common cardiovascular diseases, frequently resulting in death. Early and accurate diagnosis is therefore important, and the electrocardiogram (ECG) is a simple and effective method for achieving this. However, it requires assessment by a specialist; so many recent works have focused on the automatic assessment of ECG signals.MethodsFor the detection and localization of MI, deep learning models have been proposed, but the diagnostic accuracy of this approaches still need to be improved. Moreover, with deep learning methods the way in which a given result was achieved lacks interpretability. In this study, ECG data was obtained from the PhysioBank open access database, and was analyzed as follows. Firstly, the 12-lead ECG signal was preprocessed to identify each beat and obtain each heart interval. Secondly, a multi-scale deep learning model combined with a residual network and attention mechanism was proposed, where the input was the 12-lead ECG recording. Through the SENet model and the Grad-CAM algorithm, the weighting of each lead was calculated and visualized. Using existing knowledge of the way in which different types of MI gave characteristic patterns in specific ECG leads, the model was used to provisionally diagnose the type of MI according to the characteristics of each of the 12 ECG leads.ResultsTen types of MI anterior, anterior lateral, anterior septal, inferior, inferior lateral, inferior posterior, inferior posterior lateral, lateral, posterior, and posterior lateral were diagnosed. The average accuracy, sensitivity, and specificity for MI detection of all lesion types was 99.98, 99.94, and 99.98%, respectively; and the average accuracy, sensitivity, and specificity for MI localization was 99.79, 99.88, and 99.98%, respectively.ConclusionWhen compared to existing models based on traditional machine learning methods, convolutional neural networks and recurrent neural networks, the results showed that the proposed model had better diagnostic performance, being superior in accuracy, sensitivity, and specificity.

Risk Factors and Outcomes of Heart Failure Following First-Episode of Acute Myocardial Infarction-A Case Series Study of 161,384 Cases.

Background: Heart failure (HF) is one of the important complications of acute myocardial infarction (AMI), but the epidemiology, associated risks and outcomes have not been well investigated in the era of broad use of fluoroscopy-guided angiographic intervention. Methods: We analysed 161,384 subjects who had experienced the first episode of AMI during 1 January 2000 and 31 December 2012 using the Taiwan National Health Insurance Research Database. Results: During the index AMI hospitalization, 23.6% of cases developed HF. Female, ≥65 years-old, non-ST-segment elevation type of MI, diabetes mellitus (DM), peripheral vascular occlusion disease (PAOD), chronic obstructive pulmonary disease (COPD), atrial fibrillation, and ventricular tachycardia/fibrillation (VT/VF) were associated with higher risks of developing HF. HF cases had inferior survival outcomes compared to non-HF cases in both the short and long term. Among those HF patients, ≥65 years, DM, PAOD, and VT/VF were associated with worse outcomes. On the contrary, coronary reperfusion intervention and treat-to-target pharmacologic treatment were associated with favourable survival outcomes. Conclusions: HF remains common in the modern age and poses negative impacts in survival of AMI patients. It highlights that prudent prevention and early treatment of HF during AMI hospitalization is an important medical issue.

New onset atrial fibrillation in STEMI patients: main prognostic factors and clinical outcome

Abstract Background New onset atrial fibrillation (NOAF) is not a so rare condition among patients hospitalized for ST-segment elevation myocardial infarction (STEMI). Several studies showed that NOAF during an acute coronary syndrome (ACS) leads to increased mortality, both at short and long term. The indications for the treatment of patients with known AF undergoing percutaneous coronary interventions (PCI) are clear, while less is available about the management of NOAF during ACS and in particular during STEMI. The purpose of this study is therefore to evaluate mortality and clinical outcome of this high risk subgroup of patients. Methods We analysed 1455 consecutive patients undergoing coronary angiography and/or PCI for STEMI. CHA2DS2-VASc and HAS-BLED scores were calculated for all patients. In-hospital, 1-year and long-term follow up mortality was evaluated for all patients. Cerebral ischemic and hemorrhagic events were also evaluated as clinical endpoints at 1 year. Results NOAF was detected in 102 subjects, 62.7% males, with a mean age of 74.8±10.6 years. We found a high prevalence of main cardiovascular risk factors such as hypertension, dyslipidemia, smoke and renal failure. Mean ejection fraction (EF) was 43.5±12.1% and the mean atrial volume was increased (58±20.9 ml). The most represented type of MI at admission was anterior STEMI (46%). NOAF occurred mainly in the peri-acute phase and had a very variable duration (8.1±12.5 min). During hospitalization all patients were treated with Enoxaparin, but only 25.2% of them were discharged with long term oral anticoagulation (16.7% warfarin, 4.9% direct oral anticoagulant). The majority of patients had a CHA2DS2-VASc score >2 and a HAS-BLED score of 2 or 3. In-hospital mortality was 14.2%, while 1-year mortality was 17.2% and long term mortality 32.1% (median follow-up time 1820 days, range 341 to 3985). Through a logistic regression analysis we identified age as an independent predictor of mortality both at short and long term follow up, while EF was the only independent predictor for in-hospital mortality and arrhythmia duration for 1-year mortality. At 1-year follow up we recorded three ischemic strokes, while no bleeding complications. Conclusions STEMI patients who develop NOAF are a very high-risk population and are characterized by increased short and long term mortality. NOAF should be diagnosed and treated as soon as possible with a correct indication to long term OAC based on the ratio between ischemic and hemorrhagic risk. Funding Acknowledgement Type of funding sources: None.

English

BACKGROUND Acute Myocardial Infarction (AMI) can lead to death, and thrombolytic therapy (TLT) is a common treatment protocol. However, thrombolysis is not always successful, and there are numerous contributing factors. We wanted to compare and contrast the coronary angiographic profile of patients with successful and failed thrombolysis with tenecteplase. METHODS Cases of AMI receiving tenecteplase were categorized as successful and failed thrombolysis groups. Fifty patients in each group were compared for various characteristics such as age, sex, risk factors, time to thrombolysis, LV function, number of coronary vessels involved, angiographic lesion characteristics, thrombolysis in myocardial infarction (TIMI) flow, and to look for features that may predispose to thrombolysis failure. To determine the association between variables, chi-square test and logistic regression were used. RESULTS The mean age in the successful & failed thrombolysis group was 50.72 years and 53.48 years. Gender, diabetes, hypertension, smoking, alcohol, type of MI were not statistically significant for failed thrombolysis. All patients with window period < 3 hrs had successful thrombolysis and most patients with window period > 6 hrs had failed thrombolysis (87.2 %). (P < 0.001). Most patients (75.9 %) with Type A lesions had successful thrombolysis and patients with Type B & C lesions (88.1 %) had failed thrombolysis. (P < 0.001). CONCLUSIONS In patients with longer window periods, failed thrombolysis was more common and was associated with complex coronary lesion morphology. This study reemphasizes the value of early thrombolysis for effective reperfusion and clinical outcome improvement. KEYWORDS Failed Thrombolysis, Tenecteplase, Angiographic Profile

CORRELATION OF ANKLE-BRACHIAL INDEX WITH SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS HOSPITALIZED FOR ACUTE MYOCARDIAL INFARCTION

Objective: Ankle-brachial index (ABI) is an stablished predictor of cardiovascular events in different clinical setting including hypertension Purpose: To assess the usefulness of ABI evaluation for identifying multivessel CAD in patients with acute myocardial infraction (AMI). Design and method: We studied 101 patients [77.2% male; mean age 60.9 years; 63.4% hypertensives; 24.8% with diabetes mellitus (DM)] who were hospitalized because of ST-elevation MI (STEMI, 51.5%) and Non-ST–elevation MI (NSTEMI). All patients underwent baseline estimation of clinical and laboratory parameters during their hospitalization. The ABI was measured according to established methodology using a certified automated device and abnormal ABI was defined as a value <0.9. Severity of CAD was estimated by the number of affected main vessels. Results: In the entire population, mean ABI was 1.11 ± 0.17, while 15.8% of patients had abnormal ABI. NSTEMI patients compared to those with STEMI demonstrated a trend forlower ABI (1.07 ± 0.18 vs 1.12 ± 0.16; p = 0.144) and more often abnormal ABI (22.4% vs 9.6%; p = 0.103). Using univariate analysis in the entire population, severity of CAD was correlated with age (r = 0.133; p = 0.053), history of DM (r = 0.225; p = 0.01), ABI value (r = 0.214; p = 0.029) and abnormal ABI (r = 0.242; p = 0.015). In multivariate regression models, both ABI value (b = 0.258; p = 0.014) and abnormal ABI (b = 0.218; p = 0.036) remained significant predictors of CAD severity independently of gender, age, DM, smoking, low density lipoprotein (LDL-C), 24-h systolic blood pressure and the type of MI. Conclusions: An impaired ABI is associated with greater risk of multivessel CAD in patients with AMI. This finding in patients with acute coronary syndromes may thusraise the suspicion of advanced disease, alerting to the need for moreaggressive diagnostic and therapeutic strategies.

The Diagnostic Challenges Associated with Type 2 Myocardial Infarction.

The diagnostic challenges associated with type 2 myocardial infarction (T2MI) evolve around an extensive evidence base. T2MI is a type of MI that occurs secondary to ischemia due to increased demand or decreased oxygen supply. This classification has been used for the last 5 years, yet there is little understanding of the characteristics and clinical outcomes. According to a survey, T2M1 can be caused mainly by different factors such as anemia (31%), sepsis (24%), and arrhythmia (17%). Other associated factors, such as age and gender, also play a part in the disease. The pathology behind T2MI is the rise and fall of cardiac troponin values with at least one value above the 99 percentile and evidence of an imbalance unrelated to coronary thrombosis. The diagnosis of the condition is evidence-based backed up with imaging techniques. The treatment of T2MI may involve blood pressure management, administration of blood products, heart rate control, and respiratory support. Depending on the clinical presentation, coronary evaluations can be used to assess the likelihood of coronary artery disease (CAD). If indicated, the MI guidelines may apply to CAD. If it shows, the MI guidelines may use electrocardiography findings of ST-segment elevation myocardial infarction (STEMI) or non-STEMI. However, the absence of CAD indicates that the benefits of cardiovascular risk reduction strategies with T2MI remain uncertain.

Compared presentation, management and long-term outcomes after acute myocardial infraction in men and women <50 years of age. The FAST-MI programme

Abstract The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme. Methods FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%). Results Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08). All in-hospital complications except reinfarction (1.8 vs 0.6%, p<0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P<0.001); PCI was less often used (74% vs 85.5%, P<0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P<0.001), even in patients with significant CAD (46% vs 55%, P=0.004). Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke. Conclusion There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender. Five-year mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca