Uncomplicated Acute Myocardial Infarction Research Articles

Return to Work after Uncomplicated Acute Myocardial Infarction

Return to Work after Uncomplicated Acute Myocardial Infarction

Hospital discharge after uncomplicated ST elevation acute myocardial infarction: How early is safe?

Abstract Background International guidelines recommend that hospital discharge within 48–72h is appropriate in selected low-risk patients admitted for ST elevation acute myocardial infarction (STEMI). Objectives To assess the safety of hospital discharge after 24 hours of admission in patients with uncomplicated STEMI submitted to primary percutaneous coronary intervention (PPCI). Methods We conducted a single-centre retrospective study enrolling consecutive patients admitted for STEMI from 2016 to 2018 submitted to PPCI. We defined clinically uncomplicated STEMI (UMI) as the absence of cardiorespiratory arrest, mechanical complications, tachy- and bradyarrhythmias, heart failure (Killip class > 1 [HF]), reinfarction and types 2 or 3 Bleeding Academic Research Consortium. Additionally, we included the criterion of preserved left preserved ejection fraction (LVEF>50%). Patients referred for coronary surgery (CABG) were excluded. Cumulative rates of death and clinical events defining UMI were reported at days 1, 2, 3, and 4. Death, clinical events defining UMI or repeat coronary revascularization at 1-year were reported after days 1, 2, 3, and 4. Results A total of 356 patients submitted to PPCI were included, with 64±14 years, 73% male. Median in-hospital stay was 4 [3;7] days. Applying UMI criteria we identified 271 patients (76%) in day-1, 249 (70%) in day-2, 244 (69%) in day-3, and 240 (67%) patients in day 4. Using UMI criteria, discharge after day 1 would be associated with 2.0% of early clinical events, 1.6% after day-2, and 1% after day-3. Post-discharge 1-year incidence of death, clinical events defining UMI or repeat coronary revascularization was roughly similar after day-2 (Table). Adding LVEF>50% to UMI, we identified 176 patients (49%) in day-1, 168 (47%) in day-2, 165 (46%) in day-3 and 164 (46%) in day-4. Discharge after day 1 would be associated with 1.8% of early clinical events, 0.6% after day-2 and 0.6% after day-3. Post-discharge 1-year incidence of death, clinical events defining UMI or repeat coronary revascularization was similar after day-2. Conclusions In our cohort of patients with STEMI submitted to PPCI, clinically uncomplicated criteria identified 69% of patients eligible for safe discharge after day-3. The addition of preserved left ventricular ejection fraction criterion can anticipate a safe discharge after day-2 in almost 50% of patients.

Urinary catheterization prior to PCI worsens clinical outcomes in patients with acute myocardial infarction

BackgroundIndwelling urethral catheters (IUCs) are used to measure urine volume, keep patients on bed rest, or keep the groin area clean in patients with acute myocardial infarction (AMI). However, the association between IUC use and in-hospital urinary-related complications is unknown. MethodsThis was a single-center retrospective analysis of 303 patients admitted to our hospital in 2018–2020 who had AMI without cardiogenic shock. An IUC was inserted in the emergency room upon initiation of invasive catheter treatment and removed as soon as possible. The primary outcome was in-hospital adverse urinary event (IHAUE), which consisted of in-hospital urinary tract infection and in-hospital gross hematuria. ResultsOf 303 patients, 243 patients (80.2 %) underwent IUC insertion. A lower proportion of patients with IUCs were male (72 % vs. 85 %, p = 0.044). A higher proportion had Killip classification 2 or 3 (13 % vs. 0 %, p = 0.003) or ST-elevation myocardial infarction (65 % vs. 32 %, p < 0.001). IHAUEs occurred significantly more commonly in patients with IUCs than without IUCs (11 % vs. 2 %, p = 0.023). Kaplan-Meier analysis showed that IHAUEs occurred more frequently in patients with IUCs than patients without IUCs (log-rank test p = 0.033). Furthermore, IUC use longer than the median of 2 days was associated with a higher odds ratio (OR) for IHAUE when compared with those without IUC use (OR, 3.65; 95 % confidence interval, 1.28–10.4; p = 0.015). There were no significant differences in in-hospital mortality by IUC status. ConclusionsIUC use is associated with a higher risk of IHAUEs in patients with uncomplicated AMI. Routine IUC use might not be recommended.

Beta-blocker prescription and outcomes in uncomplicated acute myocardial infarction: Insight from the ePARIS registry

BackgroundSystematic prescription of beta-blockers after myocardial infarction remains an open question in the era of revascularization, especially for patients with uncomplicated myocardial infarction. ObjectiveTo evaluate in a real-life registry the proportion of patients with uncomplicated myocardial infarction (preserved left ventricular ejection fraction and no cardiovascular event within the first 6 months), and to report their characteristics, outcomes and beta-blocker use. MethodsWe included 1887 consecutive patients with ST-segment elevation myocardial infarction from the prospective ePARIS registry. Patients were divided into three groups: the “uncomplicated myocardial infarction” group (n=1060), defined by a left ventricular ejection fraction ≥ 40% and a 6-month period free from cardiovascular events; the “complicated myocardial infarction” group (n=366), defined by a left ventricular ejection fraction ≥ 40% and a recurrent cardiovascular event in the first 6 months; and the “left ventricular dysfunction” group (n=461), defined by a left ventricular ejection fraction<40%. ResultsDuring a median follow-up of 2.7 years (interquartile range 1.0–4.9 years), the “uncomplicated myocardial infarction” group was at low mortality risk compared with the “complicated myocardial infarction” group (hazard ratio 0.38, 95% confidence interval 0.25–0.58; P<0.01) and the “left ventricular dysfunction” group (hazard ratio 0.22, 95% confidence interval 0.15–0.32; P<0.01). Beta-blockers were prescribed at discharge predominantly in the “uncomplicated myocardial infarction” group (93%) compared with 87% in the “complicated myocardial infarction” group and 81% in the “left ventricular dysfunction” group. ConclusionsBeta-blockers are less prescribed in patients who may need them the most. The benefit of beta-blockers–largely prescribed in lower-risk patients–remains to be shown beyond the first 6 months for these patients with no left ventricular dysfunction and no recurrent events.

PREVALENCE, CLINICAL AND FUNCTIONAL CHARACTERISTICS OF PATIENTS WITH ACUTE MYOCARDIAL INFARCTION COMPLICATED BY ACUTE HEART FAILURE.

The aim: The study was designed to establish the prevalence of acute heart failure in patients with acute myocardial infarction, to determine the sex-age characteristics of acute myocardial infarction course in case of complications by acute heart failure of high classes (Killip III and Killip IV). Materials and methods: We analyzed medical records of inpatients of the myocardial infarction department of the municipal non-profit enterprise Vinnytsia Regional Center for Cardiovascular Pathology in 2019. The survey covered 828 medical records of patients with acute myocardial infarction, average age (64.6 ± 0.38), including 569 (64.7%) males and 311 (35.3%) females. Results: 129 (15.6%) patients with acute myocardial infarction were diagnosed high-class acute heart failure. Patients with high-class acute heart failure were statistically significantly elderly individuals of the average age (69.0 ± 1.3), (p <0.001), including 53.7% of males, and 46.3% (p <0.001) female patients. Patients with acute myocardial infarction complicated by acute heart failure were hospitalized within 2 hours of symptoms` onset with statistically significantly higher probability (p = 0.004). Patients with acute myocardial infarction complicated by acute high-class heart failure were statistically significantly more likely diagnosed with concomitant hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease than individuals with uncomplicated acute myocardial infarction. Acute myocardial infarction patients` mortality was 3.4%, while the one in patients with acute heart failure was 38% (p <0.001). Conclusions: Patients with complicated myocardial infarction are characterized by statistically significantly higher comorbidity and increased lethality.

What are the effects of early mobilization (median 6 days) for people with acute uncomplicated myocardial infarction (MI)?

What are the effects of early mobilization (median 6 days) for people with acute uncomplicated myocardial infarction (MI)?

P331Effect of exercise stress test on platelet function in patients with recent acute myocardial infarction

Abstract Background Exercise-based cardiac rehabilitation for coronary artery disease (CAD) is associated with lower cardiovascular mortality. On the other hand, acute strenuous exercise has been linked to cardiovascular complications such as acute myocardial infarction (AMI) and sudden cardiac death. One of the pathophysiological mechanisms involved in these outcomes might be an increase in platelet aggregability after exercise. Although previous studies showed higher platelet aggregability after exercise among stable CAD patients on aspirin treatment, there is no data regarding the effect of exercise on platelet activity in post-AMI patients on dual anti-platelet therapy (DAPT). Purpose To evaluate the effect of high-intensity exercise on platelet aggregability in sedentary post-AMI patients on DAPT. Methods Platelet function was analyzed immediately before and after maximal cardiopulmonary exercise test (CPET) on cycle ergometer utilizing a personalized ramp protocol and aiming to achieving peak exercise in around 10 min. The CPET was done within 31±4 days after uncomplicated AMI. Platelet aggregability was assessed by Multiplate®ADPtest (MP-ADP) and Multiplate® ASPItest (MP-ASPI) measured as area under the curve (AUC). Reticulated platelets were measured concomitantly to MP-ADP e MP-ASPI using a fully automated flow cytometer (Sysmex XN-2000®) to determine absolute immature platelet count (IPC) per 103/microliter. Continuous variables were expressed as means ±standard deviation or as median and 25th–75th percentiles if not Gaussian distributed. Comparisons between the pre- and post-CPET assessments were performed using Wilcoxon signed rank test. Results We analyzed 81 sedentary patients (mean age 58.3±10.1 years-old, 76.5% men) after AMI (50.6% with ST-elevation myocardial infarction, mean left ventricular ejection fraction after index event 55±11.7%, 98.8% on statin and 85.5% on beta-blocker treatment). Platelet aggregability, either by MP-ADP or MP-ASPI, and IPC were significantly increased after CPET (table). Platelet function after CPET Before CPET After CPET p-value Multiplate® ADPtest (AUC) – median (25th–75th percentiles) 32.0 (22.0–48.5) 37.0 (26.0–55.2) 0.003 Multiplate® ASPItest (AUC) – median (25th–75th percentiles) 17.0 (12.7–22.0) 22.0 (16.7–28.0) &lt;0.001 Immature platelet count (103/microliter) – median (25th–75th percentiles) 9.5 (6.8–13.8) 9.6 (6.6–16.5) 0.006 CPET: cardiopulmonary exercise test; AUC: area under the curve. Conclusion On this post-AMI population, platelet was hyperactivated after exercise stress test despite the use of DAPT. These findings suggest that, even when properly treated, post-AMI patients might be at higher risk of ischemic complications after high-intensity exercises, reinforcing the importance of tailoring exercise prescription in this population. Acknowledgement/Funding Sao Paulo Research Foundation, FAPESP

Do Patients need Lifelong β-Blockers after an Uncomplicated Myocardial Infarction?

The lifelong use of β-adrenoceptor antagonists (β-blockers) after a myocardial infarction (MI) has been the standard of care based on trials performed before the era of revascularization, when heart failure was common. Large randomized trials in the mid-1980s demonstrated that β-blockers played a major role in improving the in-hospital and long-term survival of patients admitted for MI. However, the implementation of rapid myocardial reperfusion led to a substantial survival benefit and a reduction of heart failure because of reduced infarct size. Modern large longitudinal registries did not provide sufficient evidence to support long-term β-blocker therapy in patients with uncomplicated acute MI. The long-term prescription of this therapy has become a matter of debate given the lack of contemporary evidence, frequent side effects, and treatment adherence issues. Furthermore, this shift into the reperfusion era led to a downgraded recommendation for the use of β-blockers in post-MI patients (class IIa B recommendation) in the 2017 European Society of Cardiology (ESC) recommendations for the treatment of ST-segment elevation MI (STEMI). Three large ongoing multicenter randomized trials (AβYSS, REDUCE-SWEDEHEART, and REBOOT-CNIC) are evaluating early discontinuation of β-blockers after an uncomplicated acute MI. The tested hypothesis is that β-blocker withdrawal is safe versus major adverse cardiovascular events and improves quality of life by reducing side effects. Thus, the present review summarizes the exhaustive evidence-based data for long-term β-blocker use after uncomplicated MI and the ongoing trials.

Trends in Length of Hospital Stay and the Impact on Prognosis of Early Discharge After a First Uncomplicated Acute Myocardial Infarction

Few studies have examined recent trends in the length of stay (LOS) among patients hospitalized with a first uncomplicated acute myocardial infarction (AMI) and the impact of early hospital discharge on various short-term outcomes in these low-risk patients. We used data from 1,501 residents hospitalized with a first uncomplicated AMI from all central Massachusetts medical centers on a biennial basis between 2001 and 2011. The association between hospital LOS and subsequent hospital readmission or death was examined using logistic regression modeling. The average age of the study population was 63.7 years, 63.0% were men, and 91.4% were non-Hispanic whites. The average hospital LOS declined from 4.1 days in 2001 to 2.9 days in 2011. During the years under study, the average 30-day hospital readmission rate was 11.9%, whereas the 30- and 90-day death rates were 1.5% and 2.9%, respectively. The multivariable adjusted odds ratio of a 30-day hospital readmission (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.52 to 1.41), or 30-day (OR = 0.93, 95% CI = 0.29 to 2.98) and 90-day (OR = 0.89, 95% CI = 0.36 to 2.20) death rates were not significantly different between patients who were discharged from central Massachusetts medical centers during the first 2 days as compared with those discharged thereafter. In conclusion, the average LOS in patients with a first uncomplicated AMI declined during the years under study, and early discharge from the hospital at day 2 or sooner of these low-risk patients does not appear to be associated with an increased risk of adverse events post discharge compared with those discharged at a later time.

Safety of early performance of the six-minute walk test following acute myocardial infarction: a cross-sectional study

BackgroundThe six-minute walk test (6MWT) is a simple, low cost, reliable, and valid method for evaluating the functional capacity of cardiac patients. However, its early use and safety following acute myocardial infarction (AMI) is recent and has been little investigated. ObjectiveTo evaluate and to compare the safety and the cardiac behavior of early performance of the 6MWT in patients following uncomplicated AMI up to 4 days or more than 4 days after the event. MethodsFollowing discharge from the Coronary Care Unit, 152 stable asymptomatic patients diagnosed with uncomplicated AMI performed the 6MWT. During the test, in addition to the distance walked, heart rate (HR), blood pressure (BP), and adverse events were also recorded. Electrocardiography was recorded using a Holter monitor in 105 patients. Patients were allocated considering two groups according to the number of days since AMI: Up to 4 Days Group and After 4 Days Group. ResultsAll patients completed the 6MWT, 66 in the Up to 4 Days Group and 86 in the After 4 Days Group. The walking distance was similar in both groups (85% of the predicted value), as well as the physiological responses (increase in systolic BP and HR), reaching 63% (median) of maximum HR. Only 3.9% of patients had major complications (angina, drop in BP, or ventricular tachycardia), with no difference between the groups. None of the complications regarded as severe led to truly significant complications or death. ConclusionThe 6MWT was proven to be safe and feasible for early functional evaluation following uncomplicated AMI.

Окислительный стресс и гемореология у больных инфарктом миокарда с сахарным диабетом 2 типа

This paper highlights the influence of the intensity of the oxidative stress on hemorheology parameters&#x0D; in complicated and uncomplicated acute myocardial infarction in patients with diabetes type 2. The&#x0D; study was performed by analyzing the results of examination and treatment of 66 patients, men aged 65,6 ± 5,8&#x0D; years old, suffering from coronary heart disease with clinical manifestations of acute myocardial infarction and&#x0D; concomitant diabetes type 2. Depending on the presence of acute heart failure patients were divided into 2&#x0D; groups. 1st group consisted of 34 patients with myocardial infarction without complications, Group 2 - 32 patients&#x0D; who have myocardial infarction complicated by acute heart failure (II-III class classification T.Killip).&#x0D; Condition pro- and antioxidant systems were evaluated for 3 days by determining in the blood of patients&#x0D; diene conjugates, malonic dialdehyde, α-tocopherol, ceruloplasmin, calculated coefficient of oxidative stress.&#x0D; The rheological properties blood evaluated by the blood coagulation time, the hematocrit, amount the fibrinogen&#x0D; in the blood, and blood plasma viscosity, red blood cells deformability index, the aggregation of red blood cells&#x0D; and thrombocytes. The values obtained were compared with data from 32 healthy donors.&#x0D; It is revealed that the development of congestive heart failure in acute myocardial infarction in patients&#x0D; with diabetes type 2 is accompanied by activation of lipid peroxidation (LPO) by maintaining a high level of&#x0D; primary lipid peroxidation products. Insufficient activity of antioxidant defense can limit oxidative processes,&#x0D; and leads to their further growth. The damaging effect of lipid peroxidation in the cell membranes is reflected in violation of aggregation and blood viscosity indexes.

Nonurgent Commercial Air Travel after Acute Coronary Syndrome: A Review of 288 Patient Events

ObjectivesWe studied a population of individuals who experienced an acute coronary syndrome (ACS) event while traveling abroad and required nonurgent commercial air travel to the home region. MethodsThis retrospective study gathered data from 288 patients enrolled in a travel-based medical assistance program. Interventions, complications, and travel home were assessed for trends. Descriptive and comparison statistical analyses were performed. ResultsTwo hundred eighty-eight patients were identified and entered into the review. Of the patients in this study, 77.1% were male with an average age of 67.7 years. One hundred sixteen (40.3%) patients were diagnosed with unstable angina pectoris (USAP), whereas the remaining 172 (59.7%) patients experienced acute myocardial infarction (AMI). Regarding inpatient complications during the initial admission, 121 (42.0%) patients experienced 1 or more adverse event. The average number of days after an ACS event that a patient began to travel home was 10.5 days for the entire patient population (USAP patients = 8.8 days, AMI patients = 11.8 days). Two hundred twenty (76.4%) patients traveled with a medical escort, and 48 (16.7%) patients received supplemental oxygen during air travel. Four (1.4%) in-flight adverse events occurred in the following ACS diagnostic groups: 2 in the complicated AMI group, 1 in the uncomplicated USAP group, and 1 in the uncomplicated AMI group. No in-flight deaths occurred. Nine (3.1%) deaths were noted within 2 weeks after returning to the home region. The deaths after returning to the home region occurred in the following ACS diagnostic groups: 2 in the complicated USAP group, 1 in the uncomplicated USAP group, and 6 in the complicated AMI group. None of the patients who experienced in-flight events died after returning to their home region. ConclusionsUpon discharge, the vast majority of ACS patients who travel to their home region via commercial air do not experience adverse events in-flight; when such adverse events occur in-flight, these events do not result in a poor outcome. No in-flight deaths occurred; death occurred in a minority of patients after returning to their home region, particularly in the complicated USAP and AMI groups, who were planned readmissions to the hospital.

Stent thrombosis: An increased adverse event after angioplasty following resuscitated cardiac arrest

BackgroundThe leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied. ObjectiveThe aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized. MethodsWe analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33°C for 24h) following resuscitation and PCI. ResultsThere was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50.9% vs 98.7%, p<0.001) and aspirin (52.7% vs 99%, p<0.001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0% (p=0.01). None of CA patients had received a dual antiplatelets therapy (0% vs 99%). LVEF at admission was lower in the CA group (40.3% vs 48%; p<0.001), and shock was more frequent (83.6% vs 8.5%; p<0.001). Survival at 28 days was 50.1% in CA group vs 98.0% (p<0.001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR=12.9; 95%CI 1.3–124.6; p=0.027). ConclusionIn CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.

The Th17/Treg imbalance in patients with cardiogenic shock

Type 17 helper T (Th17) cells producing the proinflammatory signature cytokine interleukin (IL)-17 are conterregulated by regulatory T cells (Treg) producing anti-inflammatory cytokines like transforming growth factor (TGF)-β and interleukin-(IL)-10. An imbalance of the Th17/Treg-ratio toward Th17 cell subset was shown to be involved in plaque destabilization and acute myocardial infarction (AMI), while no data exist in infarction-related cardiogenic shock (CS). The objective of this study was to evaluate the role of Th17/Treg and their related cytokines in uncomplicated AMI and infarction-related CS. In an observational monocentric study, blood sample from age-matched healthy controls (HC, n=20), patients with uncomplicated AMI (n=20), patients with CS who survived for at least 28days (CS-survivors, n=20) and CS-non-survivors (n=20) were analyzed. Circulating Th17 and Treg cell subsets and their intracellular cytokine expression were measured by flow cytometry and associated with circulating proinflammatory Th17-derived cytokines IL-6, IL-17 and their anti-inflammatory Treg-derived cytokines TGF-β and IL-10 measured by enzyme immunoassay. According to the severity of ACS, CS-non-survivors showed the highest levels of Th17 (p<0.001) and the lowest levels of Treg cells (p<0.001) favoring a Th17/Treg imbalance toward the proinflammatory Th17 response (p<0.001). Changes of T cell subsets were also associated with a proinflammatory cytokine expression measured by increased IL-6 (p<0.001) and IL-17 levels (p<0.001) and decreased TGF-β (p<0.001) and IL-10 levels (p=0.057). For the Th17/Treg-ratio at admission, a cut-off point of >0.33 had a sensitivity of 90% and a specificity of 80% to determine 28-day mortality in CS (confirmed by ROC analysis, area under the curve: 0.88±0.06, p<0.001). Th17/Treg-ratio >0.33 was observed to be an independent predictor for 1-year mortality in CS confirmed by Cox proportional hazard analysis (hazard ratio (HR): 4.31; 95% confidence interval (CI) 1.44-12.93; p=0.009). The Th17/Treg imbalance toward a Th17 shift might represent a promising candidate as therapeutic target and risk indicator in cardiogenic shock.

Mobilization Patterns of Patients After an Acute Myocardial Infarction

This study was aimed to identify the mobilization patterns of acute myocardial infarction (AMI) patients during their first three days in the coronary care unit (CCU) by performing a prospective observational pilot study design. The study included 31 diagnosed AMI patients admitted to three CCUs. Mobilization patterns classified as bed rest, semi-fowler, transfer to chair, and standing/walking were documented by CCU nurses for 72 consecutive hours after patient admission to the CCU. Of 2,232 possible mobilization periods (72 hr × 31 patients), 1,385 recorded observations of mobilization (62%) were obtained. Bed rest and semi-fowler positions were the most common mobilization patterns; together they accounted for 70% of the documented positions over the first 72 hr in the CCU. Patients who experience an uncomplicated AMI spend the majority of their first 72 hr in CCU in bed.

Can we improve duration of hospital stay in angioplasty treated ST-segment elevation acute myocardial infarction? The Zwolle risk score

Purpose: Optimal duration of stay (DS) in angioplasty (PCI) treated uncomplicated acute ST-segment elevation myocardial infarction (STEMI) remains undetermined. The Zwolle risk score (ZRS) is a simple tool which could help identify patients who can be safely discharged before 72h. We aimed to apply ZRS to our population and assess the variables influencing DS. Methods: 276 consecutive STEMI patients admitted for PCI were studied, between January 2009 and December 2010. ZRS, DS and 30-day mortality were obtained for all patients. Low risk was defined as ZRS≤3 and ROC curves were used for discriminative power. Results: In the 276 patients evaluated (mean age 62±13 years-old, 75% male, 20% Killip>1), ZRS median was 3 (IQR 1-4). 171 patients were classified as low risk. These patients were younger (57.1 vs. 67.6 years-old, p 1.2 mg/dL (37.2 vs 62.8% p=0.001). Total 30-day mortality was 4.7% (13 patients). ZRS correctly predicted this event in 93.7% of cases (C-statistic 0.937; CI95% 0.906-0.968). 30-day mortality, stratified by ZRS, was significantly different in the 2 groups (0 vs. 12.4% p<0.001, Fig.1), corresponding to a positive predictive value of 100% (CI95% 97.0-100%) for safe early discharge. In the low risk subset of patients, mean duration of stay was substantially lower (6.0 vs. 15.1 days, p<0.001). The need for additional revascularization (20 patients, 11.7%) was the most frequent cause for longer DS. ![Figure][1] Figure 1 Conclusions: In our population, a ZRS ≤3 had both high discriminative power and positive predictive value for safe early discharge, translating on the DS. A cost-benefit analysis is warranted to further assess the real impact of these results. [1]: pending:yes

FGF-23 is associated with increased disease severity and early mortality in cardiogenic shock

Despite the increased use of percutaneous interventions, infarction-related cardiogenic shock (CS) is still associated with high mortality. Biomarkers might be helpful to identify patients at risk, and point towards novel therapeutic strategies in CS. The phosphaturic hormone fibroblast growth factor 23 (FGF-23) has recently been introduced as a predictor for mortality in patients with chronic systolic heart failure. However, its predictive role in CS has not been investigated so far. FGF-23 was measured in 51 patients with CS. Eighteen patients with uncomplicated acute myocardial infarction (AMI) and 940 patients with stable coronary artery disease (CAD) undergoing elective coronary angiography included in a previous study served as control groups. Compared with patients with stable CAD, FGF-23 was profoundly elevated in patients with CS, but not in patients with uncomplicated AMI (CAD: 131.1 ± 9.5; AMI: 175.3 ± 57.2; CS: 1684.4 ± 591.7 rU/ml, p<0.0001 CS vs. CAD). In patients with CS, FGF-23 correlated significantly with the SAPS II score (r=0.461, p=0.0003) and NT-pro BNP levels (r=0.489, p=0.001). Patients were stratified as "survivors" and "non-survivors" according to their 28-day mortality. The overall 28-day-mortality-rate was 37%. Non-survivors of CS showed significantly higher FGF-23 levels compared with survivors (3260.1 ± 1514.7 vs. 847.9 ± 182.4 rU/ml, p=0.028). In the ROC curve analysis, FGF-23 levels predicted 28-day mortality (area under the curve (AUC) 0.686, p=0.028), and FGF-23 level of 1180 rU/ml was identified as optimal cut-off value. In a multivariate Cox proportional hazard model adjusted for gender, blood pressure, ejection fraction and levels of creatine kinase, FGF-23 levels above 1180 rU/ml significantly predicted 28-day mortality (hazard ratio (HR) 2.74, 95% CI 1.01-7.04, p=0.037). In CS, a tremendous increase in FGF-23 occurs, and high levels of FGF-23 are associated with poor outcome.

Circulating angiopoietins and cardiovascular mortality in cardiogenic shock

Vascular integrity is disturbed in shock contributing to clinical appearance and serious outcomes. While angiopoietin (Ang)-1 protects from vascular inflammation and leakage, Ang-2 disrupts endothelial barrier function. The imbalance of Ang-1 and Ang-2, their association to haemodynamic deterioration, and their prognostic relevance are not known and, thus, were prospectively evaluated in patients with cardiogenic shock (CS) in this study. Plasma Ang-1 and Ang-2 were determined by the enzyme immunoassay in patients with CS (n = 96), uncomplicated acute myocardial infarction (AMI, n = 20) and age-matched healthy controls (HC, n = 20). Angiopoietin-2 was three-fold elevated in CS compared with HC (P < 0.001), remained elevated in non-survivors, and decreased in survivors (P < 0.001). In contrast, Ang-1 decreased up to 35-fold in CS (P < 0.001). Angiopoietin-1 was correlated and Ang-2 was inversely related to a cardiac power index and mixed venous oxygen saturation, respectively (P < 0.001 for all). To assess the prognostic relevance, two outcome variables were considered: the 28-day mortality and the survival time (follow-up time 1 year). For Ang-2 at admission a cut-off point of 2500 pg/mL had a sensitivity of 61% and a specificity of 80% to determine 28-day mortality in CS (confirmed by receiver operating characteristic analysis, area under the curve = 0.71 ± 0.06, P < 0.001). Angiopoietin-2 levels >2500 pg/mL at admission were observed to be an independent predictor for 1-year mortality in CS confirmed by Cox proportional hazard analysis [hazard ratio (HR) 2.11; 95% confidence interval (CI) 1.03-4.36; P = 0.042]. Circulating Angs are closely related to outcome and severity in CS. Angiopoietin-2 emerged as an independent predictor of 28-day and 1-year mortality in CS. Larger studies are required to define the cut-off and predictive values for Ang-2. Angiopoietins may be prognostic biomarkers for survival in CS and might represent a novel therapeutic target.

Role of receptor for advanced glycation end products in cardiogenic shock*

Activation of the receptor for advanced glycation end products by its ligands promotes inflammatory processes and tissue injury. The available evidence suggests that soluble forms of receptor for advanced glycation end products circulating in the plasma may neutralize the ligand-mediated damage by acting as a decoy. Thus, it is hypothesized that receptor for advanced glycation end products expression might be deleterious, whereas soluble receptor for advanced glycation end products might be beneficial in cardiogenic shock. However, until now, no data exist regarding the role of soluble receptor for advanced glycation end products and receptor for advanced glycation end products in humans with cardiogenic shock complicating myocardial infarction. Prospective observational cohort study. Intensive critical care unit of a university hospital. Forty patients with cardiogenic shock complicating acute myocardial infarction, 20 age-matched patients with acute uncomplicated myocardial infarction and, 20 age-matched healthy volunteers. None. Monocytic receptor for advanced glycation end products expression assessed by flow cytometry was significantly increased in cardiogenic shock nonsurvivors (137.02±7.48 mean fluorescence intensity; n=13) compared to survivors (67.80±8.33 mean fluorescence intensity; n=17; p<.001). Conversely, nonsurvivors had significantly decreased plasma soluble receptor for advanced glycation end products levels (79.87±10.62 arbitrary units; n=13; p=.004) compared to survivors (127.65±10.52 arbitrary units; n=17) as assessed by Western blotting. Receptor for advanced glycation end products expression and soluble receptor for advanced glycation end products levels were determined as independent predictors for 28-day mortality in cardiogenic shock confirmed by receiver-operator characteristics and multivariate analysis (receptor for advanced glycation end products: area under the curve, 0.943±0.05; p<.001; soluble receptor for advanced glycation end products: area under the curve, 0.815±0.08; p<.01). Both receptor for advanced glycation end products>103.6 mean fluorescence intensity or soluble receptor for advanced glycation end products<76.88 arbitrary units independently predicted a 27.87-fold (p<.001) and a 3.97-fold (p=.019) increase in 28-day mortality in cardiogenic shock. Enhanced monocytic receptor for advanced glycation end products expression and decreased plasma soluble receptor for advanced glycation end products levels play a central role in patients with cardiogenic shock associated with proinflammatory and destroying pathways, resulting in an enhanced 28-day mortality-rate. Receptor for advanced glycation end products and soluble receptor for advanced glycation end products may be prognostic biomarkers for survival in cardiogenic shock and might represent a novel therapeutic target in cardiogenic shock.

A randomized controlled trial of oxygen therapy in acute myocardial infarction Air Verses Oxygen In myocarDial infarction study (AVOID Study)

The role of routine supplemental oxygen for patients with uncomplicated acute myocardial infarction (AMI) has recently been questioned. There is conflicting data on the possible effects of hyperoxia on ischemic myocardium. The few clinical trials examining the role of oxygen in AMI were performed prior to the modern approach of emergent reperfusion and advanced medical management. Air Verses Oxygen In myocarDial infarction study (AVOID Study) is a prospective, multi-centre, randomized, controlled trial conducted by Ambulance Victoria and participating metropolitan Melbourne hospitals with primary percutaneous coronary intervention capabilities. The purpose of the study is to determine whether withholding routine supplemental oxygen therapy in patients with acute ST-elevation myocardial infarction but without hypoxia prior to reperfusion decreases myocardial infarct size. AVOID will enroll 490 patients, >18 years of age with acute ST-elevation myocardial infarction of less than 12 hours duration. There is an urgent need for clinical trials examining the role of oxygen in AMI. AVOID will seek to clarify this important issue. Results from this study may have widespread implications on the treatment of AMI and the use of oxygen in both the pre-hospital and hospital settings.