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Abstract Background While preinfarction angina pectoris (pre-IA) is recognized as favorable effects on acute myocardial infarction (AMI), the detail has not been fully investigated. The aims of the current study were to clarify patient characteristics, lesion morphologies determined by optical coherence tomography (OCT), and cardiac outcomes related to pre-IA in patients with AMI. Methods Clinical data and outcomes were compared between AMI patients with pre-IA (pre-IA group, n = 507) and without pre-IA (non-pre-IA group, n = 653). Angiography and OCT findings were analyzed in patients with pre-intervention OCT and compared between groups of pre-IA (n = 219) and non-pre-IA (n = 269). Results ST-segment elevation myocardial infarction (61% vs. 75%, p < 0.001) and cardiogenic shock (8% vs. 14%, p = 0.001) were less prevalent in pre-IA group. Peak creatine kinase-MB levels were lower in pre-IA group (median 83 IU/mL vs. 126 IU/mL, p < 0.001). In pre-intervention coronary angiography findings, initial TIMI flow grade 0/1 (43% vs. 56%, p = 0.019) and Rentrop collateral circulation 0/1 (69% vs. 79%, p = 0.018) were less frequently observed in pre-IA than in non-pre-IA patients. In post-thrombectomy OCT images, plaque rupture (39% vs. 56%, p = 0.003) and red thrombi (42% vs. 54%, p = 0.027) were also less frequently observed in pre-IA group. Kaplan–Meier estimate survival curves showed that cardiac death at 12-months was lower in pre-IA group than in non-pre-IA group (6.9% vs. 10.1%, p = 0.036). Conclusions Patients with pre-IA had less severe AMI on admission, smaller infarction size, and more favorable long-term survival, which may be caused by difference of lesion morphology between patients with and without pre-IA. Highlights • Features of AMI with preinfarction angina (pre-IA) have not been fully examined. • Clinical presentation on admission was less severe in patients with pre-IA. • Initial TIMI flow grade and Rentrop collateral grade were more favorable in pre-IA. • Plaque rupture and red thrombi determined by OCT were less prevalent in pre-IA. • Cardiac mortality at 12 months was more favorable in patients with pre-IA. [ABSTRACT FROM AUTHOR]

Highlights • A predicted prognosis for patients with STEMI is considered to be a necessary instrument for stratifying risk for these patients • The FASTEST risk score was validated and can be used in patients with STEMI • The FASTEST appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 h of admission • FASTEST added prognostic value over GRACE and ZWOLLE score in STEMI patients. [ABSTRACT FROM AUTHOR]

Abstract Background Left Anterior Fascicular Block (LAFB) occurs frequently among the elderly, and have a correlation with coronary artery disease (CAD), yet controversies regarding its clinical significance still remain. Methods We carried on a retrospective study involving 92 LAFB and 478 non-LAFB patients, in which anatomic, clinical and electrocardiographic characteristics were compared. Results LAFB subjects had more pathological CAD (66.3% vs 54.6%, P = 0.039), myocardial infarction (MI) (53.3% vs 37.9%, P = 0.007) and myocarditis (5.4% vs 1.7%, P = 0.043). Among the LAFB group, 58.1% of patients with CAD and 30.2% of patients with MI were clinically misdiagnosed, while 42.9% of patients with MI were clinically missed. Logistic regression showed CAD had no independent relevance with LAFB. LAFB subjects displayed heavier hearts [(451.1 ± 101.3)g vs (407.1 ± 102.3)g, P < 0.001], thicker left ventricular walls [(1.6 ± 0.4)cm vs (1.4 ± 0.3)cm, P = 0.001]. Kaplan-Meier survival analysis indicated significant differences in long-term survival time (χ2 = 12.223, P < 0.001) and cardiac mortality (χ2 = 20.982, P < 0.001) between LAFB and non-LAFB group. Cox multivariate analysis demonstrated LAFB was an independent risk factor of all-cause death (HR = 1.552, 95% CI = 1.208–1.994, P = 0.001) and cardiac death (HR = 2.287, 95% CI = 1.545–3.386, P < 0.001). The major death cause of LAFB was cardiac death (46.7%), including more MI (28.3% vs 13.4%, P = 0.008), myocarditis (4.3% vs 1.0%, P = 0.042) and cardiac rupture (6.7% vs 1.9%, P = 0.022). Conclusions LAFB subjects had more pathological CAD and MI, but LAFB was not an independent relevant factor of CAD. LAFB lowered the accuracy to clinically diagnose CAD. LAFB patients gained heavier hearts, thicker left ventricular walls, and suffered increased risk of death and cardiac death. Highlights • Left anterior fascicular block (LAFB) increased all-cause death and cardiac death. • LAFB was not independently relevant with coronary artery disease (CAD). • LAFB lowered the accuracy to clinically diagnose CAD. • LAFB patients had greater heart mass and more left ventricle hypertrophy. • The CAD, cardiac structure and death cause were determined precisely by autopsy. [ABSTRACT FROM AUTHOR]

Background Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCAs) is an increasingly recognized entity. No previous study has evaluated predictors for new major adverse cardiacvascular events (MACEs) and death in patients with MINOCA. Methods We conducted an observational study of MINOCA patients recorded between July 2003 and June 2013 and followed until December 2013 for outcome events. Out of 199,163 MI admissions, 9092 consecutive unique patients with MINOCA were identified. The mean age was 65.5 years and 62% were women. MACE was defined as all-cause mortality, rehospitalization for acute MI, ischemic stroke and heart failure. Hazard ratio and 95% confidence interval (HR; 95% CI) was calculated using Cox-regression. Results A total of 2147 patients (24%) experienced a new MACE and 1254 patients (14%) died during the mean follow-up of 4.5 years. Independent predictors for MACE after adjustment, were older age (1.05; 1.04–1.06), diabetes (1.44; 1.21–1.70), hypertension (1.25; 1.09–1.43), current smoking (1.38; 1.15–1.66), previous myocardial infarction (1.38; 1.04–2.82), previous stroke (1.69; 1.35–2.11), peripheral vascular disease (1.55; 1.97–2.23), chronic obstructive pulmonary disease (1.63; 1.32–2.00), reduced left ventricular ejection fraction (2.00; 1.54–2.60), lower level of total cholesterol (0.88; 0.83–0.94) and higher level of creatinine (1.01; 1.00–1.03). Independent predictors for all cause death were age, current smoking, diabetes, cancer, chronic obstructive pulmonary disease, previous stroke, reduced left ventricular fraction, lower level of total cholesterol and higher levels of creatinine and CRP. Conclusions The clinical factors predicting new MACE and death of MINOCA patients seem to be strikingly similar to factors previously shown to predict new cardiovascular events in patients with MI and obstructive coronary artery disease. [ABSTRACT FROM AUTHOR]

Background A variety of risk models have been developed to predict acute myocardial infarction (AMI) in-hospital mortality risk. As a distinct, higher-risk population, women with AMI have different risk profiles from their men counterparts. Published researches have indicated that the interaction between variables in these models for in-hospital mortality and gender are significant. Due to the interaction and gender differences, the predicting value of these risk models for women could be controversial. Methods Databases from the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) Retrospective AMI Study were utilized for model derivation ( n = 16,100, women were 4896) and databases from the China PEACE Prospective AMI Study for model validation ( n = 6207, women were 2090). A multivariable backward stepwise logistic regression was used to examine correlates of in-hospital mortality, and the variables were subsequently weighted and integrated into a scoring system. Results We constructed a novel risk-predicting tool to estimate the baseline risk of in-hospital mortality among women with AMI. The risk score includes 8 variables [age, systolic blood pressure, heart rate, initial glomerular filtration rate (GFR), serum glucose, Killip class, cardiac arrest, ventricular tachycardia/ventricular fibrillation (VT/VF)]. The prognostic discriminatory capacity of the Women Acute Myocardial Infarction in-Hospital Mortality (WAMI) risk score was excellent (c statistic 0.84, 95% confidence interval [CI]: 0.83 to 0.86, p < 0.001). External validation of the model showed better prognostic capacity (c statistic 0.87, 95% CI: 0.84 to 0.90, p < 0.001) than the GRACE risk score (0.77, 95% CI 0.72–0.82, p < 0.001) and TIMI risk score (0.72, 95% CI 0.68–0.77, p < 0.001). Conclusions The WAMI Score is a simple robust tool for predicting the in-hospital mortality risk of women with AMI. Trial registration “China PEACE-Retrospective AMI Study”, NCT01624883, retrospectively registered: April 2012. Date of enrolment of the first participant to the trial: June 17, 2012. “China PEACE-Prospective AMI Study”, NCT01624909, prospectively registered: December 2012. Date of enrolment of the first participant to the trial: June 17, 2012. [ABSTRACT FROM AUTHOR]

Background Recent experimental studies have shown a dynamic time course of myocardial edema with an initial wave of edematous reaction within hours after reperfusion which almost resolved at 24 h. However, this dynamic pattern appears to be absent in clinical cohort studies. Thus far, no studies have combined a quantitative and qualitative assessment of acute myocardial injury in a large clinical cohort to explain these divergent findings. Methods A cohort of 225 patients (59 ± 11 years, 83% men) with successfully reperfused STEMI within 12 h of symptom onset were included. Quantitative measurements of myocardial damage such as T1 mapping and T2 triple short-tau inversion recovery (STIR), contrast-to-noise ratio (CNR) and their impact on area-at-risk (AAR), infarct size (IS), and myocardial salvage index (MSI) were assessed at different time points. One-way analysis of variance (ANOVA) and linear regression analysis was used to compare myocardial damage at the different time points. Results A small fraction of patients underwent CMR within 24 h of reperfusion (17/225, 7.6%). No significant variations in AAR, IS, MSI, T2 STIR CNR, or native T1 maps were observed between the different time points after reperfusion. Time of CMR was not a significant predictor of AAR ( P  = 0.90), IS ( P  = 0.27), MSI ( P  = 0.23) or T2 STIR CNR ( P  = 0.23). Conclusions The majority of CMR exams in STEMI patients are performed outside the dynamic time window of early post-MI edema. The stable pattern of markers of acute myocardial damage at different time points suggests these markers are reliable for the prognostication of patients after STEMI. [ABSTRACT FROM AUTHOR]

Background Identification of patients at risk of poor outcome after acute myocardial infarction (MI) would allow tailoring healthcare to each individual. However, lack of prognostication tools renders this task challenging. Previous investigations suggested that blood transcriptome analysis may inform about prognosis after MI. We aim to independently confirm the value of gene expression profiles in the blood to predict left ventricular (LV) dysfunction after MI. Methods and results Five genes (LMNB1, MMP9, TGFBR1, LTBP4 and TNXB) selected from previous studies were measured in peripheral blood samples obtained at reperfusion in 449 MI patients. 79 patients had LV dysfunction as attested by an ejection fraction (EF) ≤ 40% at 4-month follow-up and 370 patients had a preserved LV function (EF > 40%). LMNB1, MMP9 and TGFBR1 were up-regulated in patients with LV dysfunction and LTBP4 was down-regulated, as compared with patients with preserved LV function. The 5 genes were significant univariate predictors of LV dysfunction. In multivariable analyses adjusted with traditional risk factors and corrected for model overfitting, a panel of 3 genes − TNXB, TGFBR1 and LTBP4 – improved the prediction of a clinical model ( p = 0.00008) and provided a net reclassification index of 0.45 [0.23–0.69], p = 0.0002 and an integrated discrimination improvement of 0.05 [0.02–0.09], p = 0.001. Bootstrap internal validation confirmed the incremental predictive value of the 3-gene panel. Conclusion A 3-gene panel can aid to predict LV dysfunction after MI. Further independent validation is required before considering these findings for molecular diagnostic assay development. [ABSTRACT FROM AUTHOR]

Background The prevalence and associated-risk of asymptomatic multisite artery disease (MSAD) in high risk coronary patients are unknown. Whether systematic identification and aggressive management of asymptomatic MSAD is clinically relevant in high risk coronary patients has not been evaluated. Methods We randomly assigned 521 high risk coronary patients defined by the presence of three-vessel coronary disease ( n = 304) or recent acute coronary syndrome beyond the age of 75 years ( n = 215) to either a strategy of systematic detection of asymptomatic MSAD combined with an aggressive secondary prevention ( n = 263) or to a more conventional strategy based on treatment of coronary artery disease only with standard of care ( n = 258). The primary end point was the time to first occurrence of death, any organ failure or ischemic event leading to re-hospitalization through two years of follow-up. Results The pro-active strategy identified asymptomatic MSAD in 21.7% of patients with few revascularizations (3.6%); the pro-active pharmacological secondary prevention was obtained in > 85% of patients and life-style changes in < 60% of patients. At 2-year follow-up, the primary end point occurred in 44.9% of patients in the pro-active group and 43.0% of patients in the conventional group (HR 1.03; 95% confidence interval [CI], 0.80 to 1.34]. The rate of major bleeding did not differ significantly between groups (4.6% vs 5.0%; HR, 0.97; 95% CI, 0.40 to 1.91). Conclusion In high risk coronary patients, there is no apparent benefit of a systematic detection of asymptomatic extra-coronary atherothrombotic disease and intensified treatment over a 2-year follow-up period. (Funded by the Academic Allies in Cardiovascular Trials Initiatives and Organized Networks and Institut de l'Athérothrombose; AMERICA ClinicalTrials.gov number, NCT00445835 ). [ABSTRACT FROM AUTHOR]

Background A longer QTc interval has been associated with more adverse cardiovascular events and death in the general population. Little evidence is available on these relationships among patients with atrial fibrillation (AF). Methods We performed a prospective observational multicenter cohort study of 1413 patients with AF. A resting 12‑lead electrocardiogram (ECG) was performed at baseline. QT interval was corrected for heart rate using the Bazett formula (QTc). Endpoints for this study included hospitalizations for congestive heart failure (CHF), a combination of cardiovascular death, myocardial infarction, stroke, systemic arterial embolism (MACE) and all-cause mortality. Results Mean age of our population was 68 ± 12 years and 420 (30%) participants were female. Median QTc was 432 ms (interquartile range 409; 457). The mean follow-up time was 3.6 ± 1.5 years. After multivariable adjustment, there was a linear increase in risk with increasing QTc interval for incident CHF (hazard ratio (HR) per 1-SD increase in QTc 1.3 [95% CI 1.1; 1.6], p = 0.008), MACE (HR 1.2 [1.0; 1.4], p = 0.02) and all-cause mortality (HR 1.3 [1.0; 1.6], p = 0.002). Results were consistent whether or not patients were in sinus rhythm on the baseline ECG (HR for CHF 1.7 versus 1.3, p interaction 0.08; HR for MACE 1.3 versus 1.2, p interaction 0.9; HR for all-cause mortality 1.4 versus 1.4, p interaction 0.9). Conclusions In this large well-characterized cohort of AF patients, QTc interval was independently associated with adverse outcomes. These results were independent of the rhythm on the baseline ECG. [ABSTRACT FROM AUTHOR]

Aims To assess the possible merits of optical coherence tomography (OCT) guidance in primary percutaneous coronary intervention (pPCI). Methods and results 201 patients with ST-elevation myocardial infarction (STEMI) were enrolled in this study. Patients were randomized either to pPCI alone (angio-guided group, n = 96) or to pPCI with OCT guidance (OCT-guided group, n = 105) and also either to biolimus A9 or to everolimus-eluting stent implantation. All patients were scheduled for nine months of follow-up angiography and OCT study. OCT guidance led to post-pPCI optimization in 29% of cases (59% malapposition and 41% dissections). No complications were found related to the OCT study. OCT analysis at nine months showed significantly less in-segment area of stenosis (6% [− 11, 19] versus 18% [3, 33]; p = 0.0002) in favor of the OCT-guided group. The rate major adverse cardiovascular events were comparable at nine months in both groups (3% in the OCT group versus 2% in the angio-guided group; p = 0.87). Conclusions This study demonstrates the safety of OCT guidance during pPCI. The use of OCT optimized stent deployment in 1/3 of patients in this clinical scenario and significantly reduced in-segment area of stenosis at nine months of follow-up. Whether such improvements in OCT endpoints will have a positive impact on late clinical outcomes, they demand both a larger and longer-term follow-up study. [ABSTRACT FROM AUTHOR]

Background Patients who have had a prior myocardial infarction (MI) are at increased risk for adverse outcomes after subsequent percutaneous coronary intervention (PCI). Objective The objective of this study is to examine the efficacy and safety of cangrelor, a potent intravenous P2Y 12 inhibitor, in patients with prior MI. Methods Pooled data from the CHAMPION trials were examined. Prior MI was defined as a history of MI, excluding MI events at baseline. The primary endpoint was a composite of death, MI, ischemia-driven revascularization, or stent thrombosis at 48-h post-randomization. The primary safety endpoint was GUSTO-defined severe bleeding at 48 h. Results Out of 24,691 patients, 5699 (23%) had a prior MI. The primary endpoint was higher in patients with vs. without prior MI (4.9% vs. 4.0%, p = 0.002). The primary endpoint was 4.2% with cangrelor vs. 5.7% with clopidogrel (absolute risk reduction = 1.5%; OR 0.72 [95%CI 0.57–0.92]) in patients with prior MI and 3.7% with cangrelor vs. 4.3% with clopidogrel (absolute risk reduction = 0.6%; OR 0.85 [95%CI 0.74–0.99]) in patients without prior MI ( P -interaction = 0.25). The rate of GUSTO-defined severe bleeding was 0.1% with cangrelor vs. 0.1% with clopidogrel (OR 1.39 [95%CI 0.31–6.24]) in patients with prior MI, and 0.2% with cangrelor vs. 0.2% with clopidogrel (OR 1.18 [95%CI 0.65–2.14]) in patients without prior MI ( P -interaction = 0.84). Conclusion In the CHAMPION trials, patients with prior MI had higher rates of ischemic outcomes within 48 h after PCI. Cangrelor reduced ischemic events with no significant increase in GUSTO-defined severe bleeding in patients with or without prior MI. [ABSTRACT FROM AUTHOR]

Background Percutaneous coronary intervention (PCI) reduces mortality in most myocardial infarction (MI) patients but the effect on elderly patients with comorbidities is unclear. Our aim was to analyse the effect of PCI on in-hospital mortality of MI patients, by age, sex, ST elevation on presentation, diabetes mellitus (DM) and chronic kidney disease (CKD). Methods Cohort study of 79,791 MI patients admitted at European hospitals during 2000–2014. The effect of PCI on in-hospital mortality was analysed by age group (18–74, ≥ 75 years), sex, presence of ST elevation, DM and CKD, using propensity score matching. The number needed to treat (NNT) to prevent a fatal event was calculated. Sensitivity analyses were conducted. Results PCI was associated with lower in-hospital mortality in ST and non-ST elevation MI (STEMI and NSTEMI) patients. The effect was stronger in men [Odds ratio (95% confidence interval) 0.30 (0.25–0.35)] than in women [0.46 (0.39–0.54)] aged ≥ 75 years, and in NSTEMI [0.22 (0.17–0.28)] than in STEMI patients [0.40 (0.31–0.5)] aged < 75 years. PCI reduced in-hospital mortality risk in patients with and without DM or CKD (54–72% and 52–73% reduction in DM and CKD patients, respectively). NNT was lower in patients with than without CKD [≥ 75 years: STEMI = 6(5–8) vs 9(8–10); NSTEMI = 10(8–13) vs 16(14–20)]. Sensitivity analyses such as exclusion of hospital stays < 2 days yielded similar results. Conclusions PCI decreased in-hospital mortality in MI patients regardless of age, sex, and presence of ST elevation, DM and CKD. This supports the recommendation for PCI in elderly patients with DM or CKD. [ABSTRACT FROM AUTHOR]

Background In addition to thromboembolism, atrial fibrillation (AF) may also predispose to major adverse cardiovascular events (MACE) attributable to coronary artery disease (CAD), including myocardial infarction (MI). The 2MACE score (2 points - Metabolic syndrome and Age ≥ 75 years, 1 point - MI/revascularization, Congestive heart failure/ejection-fraction < 40%, and thrombo-Embolism) was recently proposed to help identify AF patients at risk of MACE. We assessed the predictive validity of the 2MACE score for MACE occurrence in AF patients free of CAD at baseline. Methods Non-valvular AF patients (n = 794) without CAD (mean-age, 62.5 ± 12.1 years, metabolic syndrome, 34.0%; heart failure/ejection-fraction < 40%, 25.7%; thromboembolism, 9.7%) were prospectively followed for 5 years, or until MACE (composite of non-fatal/fatal MI, revascularization and cardiovascular death). At inclusion, CAD was excluded by medical history, exercise-stress testing and/or coronary angiography. Also, the 2MACE score was determined. Results At follow-up, 112 patients experienced MACE (2.8%/year). The 2MACE score demonstrated adequate discrimination (C-statistic, 0.699; 95% confidence interval [CI], 0.648–0.750; P < 0.001) and calibration (Hosmer-Lemeshow P = 0.79) for MACE. The score was significantly associated with MACE, with the adjusted Hazard Ratio (aHR) of 1.56 (95%CI, 1.35–1.73; P < 0.001). As for individual outcomes, the score predicted MI (n = 46; aHR, 1.49; 95%CI 1.23–1.80), revascularization (n = 32; aHR, 1.41; 95%CI, 1.11–1.80) and cardiovascular death (n = 34; aHR, 1.43; 95%CI, 1.14–1.81), all P < 0.001. Conclusions The 2MACE score successfully predicts future MACE, including incident MI, coronary revascularization and cardiovascular death in AF patients free of CAD at baseline. It may have a role in risk-stratification and primary prevention of MACE in AF patients. [ABSTRACT FROM AUTHOR]

Aim Most deaths after myocardial infarction (MI) occur in patients with normal or moderately reduced left ventricular ejection fraction (LVEF > 35%). Periodic repolarization dynamics (PRD) and deceleration capacity (DC) are novel ECG-based markers related to sympathetic and vagal cardiac autonomic nervous system activity. Here, we test the combination of PRD and DC to predict risk in post-infarction patients with LVEF > 35%. Methods and results We included 823 survivors of acute MI with LVEF > 35%, aged ≤ 80 years and in sinus rhythm. PRD and DC were obtained from 30-min ECG-recordings within the second week after index infarction and dichotomized at established cut-off values of ≥ 5.75 deg 2 and ≤ 2.5 ms, respectively. Patients were classified as having normal (CAF 0), partly abnormal (DC or PRD abnormal; CAF 1) or abnormal cardiac autonomic function (DC and PRD abnormal; CAF 2). Primary endpoint was 5-year all-cause mortality. Within the first 5 years of follow-up, 51 patients died (6.2%). PRD and DC effectively stratified patients into low-risk (CAF 0; n = 562), intermediate-risk (CAF 1; n = 193) and high-risk patients (CAF 2; n = 68) with cumulative 5-year mortality rates of 2.9%, 9.4% and 25.2%, respectively (p < 0.001). On multivariable analyses, CAF was independent from established risk factors (GRACE-score, diabetes mellitus, mean heart rate, heart rate variability). Addition of CAF significantly improved the model (increase of C-statistics from 0.732 (0.651–0.812) to 0.777 (0.703–0.850), p = 0.047; continuous NRI (0.400, 95% CI 0.230–0.560, p < 0.001); IDI (0.056, 95% CI 0.022–0.122, p < 0.001)). Conclusion CAF identifies new high-risk post-MI patients with LVEF > 35% which might benefit from prophylactic strategies. [ABSTRACT FROM AUTHOR]

Background A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T is recommended by the European Society of Cardiology. However, Asian data are not available. Methods This prospective cohort study included 413 patients with suspected non-ST elevation myocardial infarction in 3 hospitals in Japan and Taiwan from November 2014 to April 2017. Patients were divided into 3groups—rule-out, observe, and rule-in—according to the algorithm. Major adverse cardiovascular events were evaluated at the 30-dayfollow-up. Results The algorithm ruled out acute myocardial infarction (AMI) in 171 patients with a negative predictive value and sensitivity of 100% (95% confidential interval [CI], 96.8%–100%) and 100% (95% CI, 88.0%–100%), respectively, in the rule-out group. None of the patients were diagnosed with AMI. Among the 127 patients classified into the rule-in group, 47 were diagnosed as having AMI. The positive predictive value and specificity were 33.1% (95% CI, 25.1%–41.9%) and 66.3% (95% CI, 60.2%–72.0%), respectively. Elective catheter intervention was required in 13 patients (5 in the rule-out group, 8 in the observe group) by the 30-dayfollow-up. The Framingham Risk Score (FRS) identified moderate risk in 5 patients and high risk in 8, while the Global Registry of Acute Coronary Events (GRACE) 2.0 risk score identified low risk in 6 patients and moderate risk in 7. Conclusion The ESC0-hour/1-hour algorithm could be sufficient in Asian patients. The combination with FRS may be more precise than that with the GRACE 2.0 risk score. [ABSTRACT FROM AUTHOR]

Background Although octogenarians constitute a fast-growing portion of cardiovascular patients, few data are available on the outcome of patients aged ≥ 85 years with ST-Elevation Myocardial Infarction (STEMI). Methods and Results We analyzed 126 consecutive patients aged ≥ 85 years (age 88 ± 2 years) with STEMI, undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from symptoms onset. Long-term follow-up (median 898 days) was obtained for the 102 patients surviving the index-hospitalization. In-hospital mortality rate was 19%. Nonagenarians, diabetes mellitus, severe left ventricular systolic dysfunction and intra-aortic balloon pumping were significantly and independently correlated to in-hospital mortality at the multivariate analysis. A low rate of complications was detected. Among patients surviving the index hospitalization, 32 (31%) patients died during follow-up. 55 patients (54%) had re-hospitalization due to cardiovascular causes. The univariate analysis identified chronic renal failure, Killip class ≥ 3, TIMI Risk Score > 8 and very high risk of bleeding as predictors of long-term overall mortality. At the multivariate analysis only chronic renal failure and very high risk of bleeding were significantly and independently correlated to long-term all-cause mortality. Renal function and anterior myocardial infarction were significantly and independently associated with the combined end-point of cardiac mortality and re-hospitalization due to cardiovascular disease at the multivariate analysis. Conclusions PPCI in patients ≥ 85 years old is relatively safe. In this population, pPCI is associated with a good long-term survival, although still worse than in younger patients, despite a considerable incidence of re-hospitalization due to cardiovascular events. [ABSTRACT FROM AUTHOR]

Background QRS duration has previously shown association with mortality in patients with acute myocardial infarction treated with thrombolytics, less is known in patients with suspected ST segment elevation myocardial infarction (STEMI) when assessing QRS duration on prehospital ECG. Thus, the objective was to investigate the prognostic effect of QRS duration on prehospital ECG and presence of classic left and right bundle branch block (LBBB/RBBB) for all-cause mortality in patients with suspected STEMI. Method In total 2105 consecutive patients (mean age 64 ± 13 years, 72% men) with suspected STEMI were prospectively included. QRS duration was registered from automated QRS measurement on prehospital ECG and patients were divided according to quartiles of QRS duration (< 89 ms, 89–98 ms, 99–111 ms and > 111 ms). Primary endpoint was all-cause 30-day mortality. Predictors of all-cause mortality were assessed using Cox proportional hazards analysis. Results Among all patients median QRS duration was 98 ms (IQR 88–112 ms). RBBB-morphology was seen in 126 patients (6.0%) and LBBB in 88 patients (4.2%), 80% were treated with percutaneous coronary intervention and the final diagnosis was STEMI in 1777 patients (84%). Thirty-day mortality was 7.6% in patients with suspected STEMI. In multivariable analysis, QRS duration > 111 ms (hazard ratio (HR) 3.08; 95% confidence interval (CI): 1.71–5.57, p = 0.0002), LBBB – morphology (HR 3.0; 95% CI: 1.38–6.53, p = 0.006) and RBBB (HR 3.68; 95% CI: 1.95–6.95, p < 0.0001) were associated with 30 day all-cause mortality. Conclusion In patients with suspected STEMI, QRS prolongation, LBBB, and RBBB on prehospital ECG are associated with increased risk of death. [ABSTRACT FROM AUTHOR]

Background Sleep apnea (SA) is associated with intermittent hypoxemia that may lead to ischemic preconditioning in the myocardium. This potential cardioprotective effect of SA may play a role in the development of non-ST-elevation myocardial infarction (NSTEMI) versus ST-elevation myocardial infarction (STEMI) during acute ischemia. However, there is limited evidence about the relative prevalence of NSTEMI versus STEMI in SA patients. We therefore prospectively investigated the prevalence of these two types of MI in patients with SA. Methods We prospectively studied 782 consecutive patients admitted with the diagnosis of acute MI (both NSTEMI and STEMI). All subjects underwent sleep evaluations using a portable diagnostic device after at least 48 h post-admission, provided they were in stable condition. Six hundred and seven out of 782 patients had technically adequate sleep studies, and therefore were included in the final analysis. Results SA was present in 65.7% (n = 399) and NSTEMI in 30% (n = 182) of patients. Increasing severity of SA was associated with increasing likelihood of NSTEMI, and with decreasing likelihood of STEMI (p < 0.001). Relative frequency of NSTEMI in the moderate to severe SA group (AHI ≥ 15 events/h) was 40.6% versus 29.9% for STEMI (p = 0.01). Conclusion The prevalence of NSTEMI increases with increasing severity of SA. This finding may suggest a cardioprotective role of SA, which may attenuate the development of STEMI, perhaps through ischemic preconditioning. [ABSTRACT FROM AUTHOR]

Background Coronary artery disease (CAD) is the leading cause of mortality around the world. We sought to study changes in the risk profile of patients presenting with ST elevation myocardial infarction (STEMI). Methods We retrospectively studied all patients presenting with STEMI to our center between 1995 and 2014. Patients were divided into four quartiles, 5 years each. Baseline risk factors and comorbidities were recorded. Sub-analysis was done for patients with established CAD and their household incomes. Results A total of 3913 patients (67.9% males) were included; 42.5% presented with anterior STEMI and 57.5% inferior STEMI. Ages were 64 ± 12, 62 ± 13, 61 ± 13 and 60 ± 13 in the four quartiles respectively. Obesity prevalence was 31, 37, 38 and 40% and diabetes mellitus prevalence was 24, 25, 24 and 31%, while hypertension was 55, 67, 70 and 77%, respectively, p < 0.01 for all. Smoking prevalence was 28, 32, 42 and 46, p < 0.01. When subgroup analysis was done for patients with history of CAD, prevalence of smoking, obesity, diabetes and hypertension significantly increased across the four quartiles. When patients were divided to four groups based on household income (poor, low middle, middle and high income), prevalence of diabetes, hypertension, smoking and obesity were significantly higher in patients with low income. Conclusion Despite better understanding of cardiovascular risk factors and more focus on preventive cardiology, patients presenting with STEMI over the past 20 years are getting younger and more obese, with more prevalence of smoking, hypertension, and diabetes mellitus. This trend is greater in the lower income population. [ABSTRACT FROM AUTHOR]

Background Data are scarce regarding the risk, temporal trends and predictors of late-onset heart failure (LOHF) after acute myocardial infarction (AMI). We aimed at studying the risk and predictors of LOHF and the composite event of LOHF or death after AMI. Methods AMI patients first entered in the nationwide SWEDEHEART registry between 2004 and 2013 were included. Patients with a prior history of heart failure (HF) and those who died in-hospital were excluded. Dates and ICD-codes for LOHF in the national patient and death registries were used to determine time to first readmission due to LOHF and/or death. Results A total of 150,566 AMI patients were included in the analysis. The 1-year, 2-year and 5-year cumulative risk of developing LOHF were 11.4%, 14.6% and 21.8% respectively. The risk of LOHF within 2 years decreased from 15.5% to 14.4% (2004–2005 vs 2010–2011), p < 0.001. Calendar year was protective of LOHF/death after adjustment (HR 0.96, 95% CI 0.94–0.98, p < 0.001). In-hospital HF, age, diabetes mellitus, chronic kidney disease, peripheral arterial disease, chronic obstructive pulmonary disease and atrial fibrillation, were strong predictors of LOHF. Risk profile improved and use of evidence based therapies increased during the time period. Conclusions Survivors of AMI remain at a continued risk of LOHF. However, the overall risk of LOHF shows a decreasing trend after an index AMI over time. Lower risk of LOHF may relate to decreasing burden of comorbidities and increasing use of evidence based treatments. [ABSTRACT FROM AUTHOR]

Background/Introduction Outcome after ST segment elevation myocardial infarction (STEMI), has improved but patients with high Killip class still have a poor prognosis, and those ≥ II need a closer monitoring in a specialized cardiac care unit. Purpose We aimed to determine the predictors of Killip class in a group of patients admitted for acute STEMI. Methods Non-interventional registry in a Cardiac Intensive Care Unit. Patients were consecutively included from January 2010 to April 2015, and multivariate analysis was performed to determine independent predictors of high Killip Class. Results We included 1111 patients, mean age was 64.0 ± 14.0 years and 258 (23.2%) were female. Primary percutaneous coronary intervention was performed in 991 (89.2%), and 120 (10.8%) only received thrombolysis as acute reperfusion therapy. A total of 230 (20.7%) were in class II or higher. The independent predictors of Killip ≥ II were (odds ratio [95% confidence interval]): older age (2.1 [1.4–3.0]), female sex (1.6 [1.1–2.2]), diabetes (1.4 [1.0–2.1]), prior heart failure (3.2 [1.4–7.2]), chronic kidney disease (2.0 [1.1–3.6]), anaemia (3.0 [2.0–4.5]), multivessel disease (1.6 [1.1–2.2]), anterior location (2.4 [1.8–3.4]), time of evolution > 2 h (1.6 [1.1–2.4]), and TIMI flow-grade < 3 (1.8 [1.2–2.7]). In-hospital mortality increased with Killip class (I 1.5%, II 3.7%, III 16.7%, IV 36.7%). Conclusion In patients with STEMI Killip class can be predicted with variables available when primary percutaneous coronary intervention is performed and is strongly associated with in-hospital prognosis. [ABSTRACT FROM AUTHOR]

Aims To describe the clinical characteristics, contemporary trends of in-hospital management and outcome of patients admitted for an acute coronary syndrome (ACS) with associated atrial fibrillation (AF). Methods We analyzed data from four Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive ACS patients. Results Out of 16,803 ACS patients, 1019 (6.1%) presented with concomitant AF: 668 with non-ST elevation (NSTE)-ACS and 351 with ST-elevation myocardial infarction (STEMI). As compared to no-AF patients, those with AF were older and had significantly more prior cardiac events and comorbidities (all p < 0.005). A progressive increase occurred over time in the rates of coronary angiography and percutaneous coronary intervention, both in NSTE-ACS (p for trend = 0.0002 and 0.0008, respectively) and STEMI patients with AF at admission (both p for trend < 0.0001), with trends similar to those observed in non-AF patients. Among STEMI patients, in-hospital mortality decreased by 50% in those without AF (7.5% in 2001 to 3.3% in 2014, p < 0.0001), with a similar decrease in those with AF (20% vs 10.7%, p = 0.20), even though not statistically significant. At multivariable analysis, AF on admission was not an independent predictor of in-hospital mortality [odds ratio (OR): 0.82; 95% confidence intervals (CI): 0.52–1.30; p = 0.41 for NSTE-ACS, and OR: 1.07; 95% CI: 0.73–1.57; p = 0.74 for STEMI]. Conclusions Over the last 14 years, the in-hospital management of ACS patients with AF has significantly improved as for patients without AF, with comparable effect in terms of outcome. [ABSTRACT FROM AUTHOR]

Background There is a shortage of information on regional variations in ST-segment elevation myocardial infarction (STEMI) management and prognosis at a global level. We aimed to compare patient profiles, in-hospital management and post-discharge mortality across several world regions. Methods In total, 11,559 patients with STEMI were enrolled in two prospective studies of acute coronary syndrome survivors: EPICOR (4943 patients from 555 hospitals in 20 countries in Europe and Latin America recruited between September 2010 and March 2011) and EPICOR Asia (6616 patients from 218 hospitals in eight Asian countries recruited between June 2011 and May 2012). Comparisons were performed by eight pre-defined regions: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE), Latin America (LA), China (CN), India (IN), Southeast Asia (SA), and South Korea/Hong Kong/Singapore (KS). Results Reperfusion therapy rates ranged between 53.9% (IN) and 81.2% (SE), primary percutaneous coronary intervention (PCI) between 24.8% (IN) and 65.6% (NE) and fibrinolysis between 8.1% (CN) and 34.2% (SA). Median time to primary PCI (h) ranged from 3.9 (NE) to 20.9 (IN) and to fibrinolysis from 2.4 (SE) to 6.3 (IN). Two-year mortality ranged between 2.5% in NE and 7.4% in LA. Regional variations in mortality persisted after adjustment for reperfusion therapy and known prognostic factors. Conclusions Among patients with STEMI, there is a wide regional variation in clinical profiles, hospital care and mortality. Substantial room for improvement remains at a global level for increasing reperfusion rates, reducing delays and post-discharge mortality in patients with STEMI. [ABSTRACT FROM AUTHOR]

Background It is uncertain how the implementation of high-sensitivity cardiac troponin T (hs-cTnT) has affected the survival of patients with chest pain in the emergency department (ED). We studied prognosis and resource utilization in terms of coronary angiographies and revascularizations (percutaneous coronary intervention or coronary artery bypass grafting) in patients evaluated with hs-cTnT compared with conventional troponin T (cTnT). Methods All patients > 25 years presenting with chest pain and at least one troponin level analyzed in the ED at the Karolinska University Hospital, Sweden, were included. Hazard ratios (HR) for all-cause mortality, coronary angiographies and revascularizations were adjusted for age, sex and comorbidities during 1 year of follow-up comparing patients tested with hs-cTnT (December 10, 2010 to December 31, 2013) with patients tested with cTnT (January 1, 2009 to December 9, 2010). Results In total, 31,904 patients were included ( n = 12,485 tested with cTnT and n = 24,729 using hs-cTnT). Patient characteristics, comorbidities, and medications were similar during the study period. The absolute risk of all-cause mortality was 3.7% for those tested with cTnT compared with 3.4% for hs-cTnT. After adjustment for confounders, an increased all-cause mortality was observed for patients tested with hs-cTnT (HR 1.15; 95% confidence interval (CI) 1.02–1.29). Coronary angiographies increased by 13% (HR 1.13; 95% CI 1.00–1.28) and revascularizations by 18% (HR 1.18; 95% CI 1.01–1.37) when using hs-cTnT. Conclusions In an observational cohort study including patients with chest pain in the ED we found a small increase in mortality, coronary angiographies and revascularizations after the introduction of hs-cTnT. [ABSTRACT FROM AUTHOR]

Background Few studies have explored prognosis in patients with previous myocardial infarction (MI) with mild-moderate (MM) left ventricular (LV) dysfunction (D). The aim of our study was to investigate whether combining LV parameters obtained by cardiac magnetic resonance (CMR) improves risk stratification of patients with previous MI and MM-LV-D. Methods In 418 consecutive patients (63.3 ± 11.3 years old, female 12.9%) with previous MI, we quantified LVEF, volumes and wall motion score index (WMSI) and measured the infarct extent by late gadolinium enhancement (LGE). According to LVEF, patients were considered with normal LVEF (> 55%), MM-LV-D (LVEF > 30 and ≤ 55%) and severe (S) LV-D (LVEF ≤ 30). Results During follow-up (median, 39.7 months) cardiac events (cardiac death or appropriate intra-cardiac defibrillator shocks) occurred in 17/99 of patients with S-LV-D, in 15/201 with MM-LV-D, and in only 1/118 of those with normal LV-EF. After adjustment for age, an extent of LGE > 11.3%, a dilated LV (male > 112 ml/m 2 ; female > 92 ml/m 2 ) and a WMSI > 1.59 were associated with adverse cardiac events in patients with MM-LV-D. In patients with MM-LV-D, when each of these 3 factors was observed, the prognosis was worse respect to those with 1–2 factors and no factor ( p = 0.035 and p = 0.004, respectively). Prognosis was similar ( p = 0.61) between MM-LV-D patients with all 3 factors and those with S-LV-dysfunction. CONCLUSIONS. A multiparametric CMR approach, which includes LGE, dilated LV and WMSI, permits to identify post MI patients with MM-LV-D with a risk of cardiac events similar to those with S-LV-D. Further multicenter studies are needed to confirm our data. [ABSTRACT FROM AUTHOR]

Introduction Impaired renal function, reflected by estimated glomerular filtration rate (eGFR) or cystatin C, is a strong risk predictor in the presence of acute myocardial infarction (AMI). Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is an early marker of acute kidney injury. uNGAL might also be a good predictor of outcome in patients with cardiovascular disease. Aim of the present study was to evaluate the prognostic value of uNGAL compared to eGFR and cystatin C in patients with suspected AMI. Methods 1818 patients were enrolled with suspected AMI. Follow-up information on the combined endpoint of death or non-fatal myocardial infarction was obtained 6 months after enrolment and was available in 1804 patients. 63 events (3.5%) were registered. Results While cystatin C and eGFR were strong risk predictors for the primary endpoint even adjusted for several variables, uNGAL was not independently associated with outcome: When applied continuously uNGAL was associated with outcome but did not remain a statistically significant predictor after several adjustments (i.e. eGFR). By adding cystatin C or uNGAL to GRACE risk score variables, only cystatin C could improve the predictive value while uNGAL showed no improvement. Conclusion We could show that cystatin C is an independent risk predictor in patients with suspected AMI and cystatin C can add improvement to the commonly used GRACE risk score. In contrast uNGAL is not independently associated with outcome and seems not to add further prognostic information to GRACE risk score. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is a well-known complication in the setting of ST elevation myocardial infarction (STEMI). Data on the long-term prognostic implications of New-Onset AF (NOAF) complicating STEMI in the era of complete revascularization remains controversial. Our aim therefore was to evaluate the long-term prognosis of prior AF (pAF) and new-onset AF (NOAF) in STEMI patients undergoing percutaneous coronary intervention (PCI). Methods We studied 1657 consecutive STEMI patients hospitalized in the cardiac intensive care unit during 2008–2014. We reviewed patient records for the occurrence of pAF and NOAF. NOAF was defined as AF occurring within 30 days of the STEMI episode. Patients were followed for a mean period of 3.4 ± 2.1 years. Results Within our cohort 77 (4.6%) patients had pAF and 47 (2.8%) had NOAF. Patients with any AF were older and had a reduced systolic ejection fraction. Thirty-day mortality and all-cause mortality rates were significantly higher in patients with pAF in comparison to those without AF (9.1% vs. 2.2% p < 0.001 and 31.2% vs. 9.4%, p < 0.001, respectively). NOAF showed a trend for increased all-cause mortality (17% vs. 9.1%, p = 0.07) and 30-days mortality (6.4% vs. 2.1%. p = 0.09). In a multivariate regression model, pAF but not NOAF was a predictor of mortality throughout the follow-up period (HR 2.02, 95% CI 1.2 to 3.1, p = 0.005 and HR 1.1, 95% CI 0.56 to 2.2, p = 0.75, respectively). Conclusions Prior AF and not new-onset AF is an independent predictor of both short and long term mortality in patients treated with PCI. [ABSTRACT FROM AUTHOR]

Background Acute hyperglycemia on admission is common in acute myocardial infarction (AMI) patients regardless of diabetic status, and is known as one of prognostic factors. However, the effect of hyperglycemia on non-diabetic patients is still on debate. Methods A total of 12,625 AMI patients (64.0 ± 12.6 years, 26.1% female) who were enrolled in Korea Acute Myocardial Infarction Registry-National Institute of Health between November 2011 and December 2015, were classified into 4367 diabetes (65.4 ± 11.6 years, 30.4% female) and 8228 non-diabetes (63.3 ± 13 years, 23.9% female). Patients were analyzed for in-hospital clinical outcome according to admission hyperglycemic status. Results In diabetic patients, independent predictors of in-hospital mortality were old age, high HbA 1 C, pre-Thrombolysis In Myocardial Infarction (TIMI) flow 0, left ventricle ejection fraction < 40%, cardiogenic shock and ventricular tachycardia. In non-diabetic patients, independent predictors of in-hospital mortality were old age, high admission glucose (≥ 200 mg/dL), pre TIMI flow 0, failed percutaneous coronary intervention, low left ventricle ejection fraction < 40%, cardiogenic shock, stent thrombosis and decreased Hb ≥ 5 g/dL. In hospital mortality was significantly higher in diabetic patients compared to non-diabetic patients (5.0% vs. 3.4%, p < 0.001). However, non-diabetic patients with hyperglycemia have significantly higher mortality compared to diabetic patients (17.4% vs. 7.2%, p < 0.001). Comorbidity including cardiogenic shock ( p < 0.001), cerebral hemorrhage ( p = 0.012), decreased Hb ≥ 5 g/dL ( p = 0.013), atrioventricular block ( p < 0.001) and ventricular tachycardia ( p = 0.007) was higher in non-diabetic with hyperglycemia than in diabetic patients. Conclusions These findings underscore clinical significance of admission hyperglycemia on in-hospital mortality in non-diabetic AMI patients. [ABSTRACT FROM AUTHOR]

Aim To evaluate the association of post-acute myocardial infarction (AMI) plasma haptoglobin (Hp) levels with long-term overall survival in AMI patients. Methods and results Patients who were diagnosed of AMI were recruited and their Hp phenotypes and plasma levels were determined. According to previously reported cutoff point for Hp level (288.4 ng/ml), patients were classified as higher Hp group (> 288.4 ng/ml) and lower Hp group (≤ 288.4 ng/ml). The primary outcome was overall survival. This study recruited and followed a total of 117 patients for a median of 11.0 (3.2–17.6) years. Higher Hp group had 46 patients (39.3%) and lower Hp group had 71 patients (60.7%). Twelve patients had Hp 1-1 (10.3%), 50 with Hp 2-1 (42.7%), and 55 with Hp 2-2 (47.0%). The lower Hp group had significantly better overall survival (174.1 [51.6–212.5] vs. 106.5 [22.2–209.1], P = 0.037). There was no significant difference in overall survival between the three phenotype groups ( P = 0.477). Multivariate regression analysis revealed that increased age (adjusted HR = 1.06, 95% CI: 1.03–1.10, P < 0.001) and higher Hp level (adjusted HR = 1.65, 95% = 1.02–2.67, P = 0.040) were significantly associated with poor overall survival. Conclusion Higher post-AMI plasma Hp level was independently associated with poor overall survival in AMI patients. No significant difference in overall survival was noted between three Hp phenotype groups. Acute phase Hp level might reflect the severity of oxidative stress during inflammation process. [ABSTRACT FROM AUTHOR]

Background Remote ischemic preconditioning (RIPC) has two time windows for organ protection: acute and delayed. Previous studies have mainly focused on the acute time window to evaluate organ protection by RIPC. We evaluated myocardial protection by delayed RIPC in adult patients undergoing cardiac surgery. Methods A total of 160 adult patients undergoing cardiac surgery with cardiopulmonary bypass were randomized to receive either delayed RIPC (four cycles of 5 min of ischemia followed by 5 min of reperfusion by inflation to 200 mm Hg and deflation of a blood pressure cuff on the upper arm) or the control treatment 24–48 h before surgery. The primary endpoint was post-operative troponin I levels serially measured for 72 h. Secondary endpoints included post-operative serum creatinine levels, acute kidney injury, and composite complications. Results There were no significant differences in post-operative troponin I values. The incidence of acute kidney injury, defined by the Acute Kidney Injury Network staging system, was lower in the delayed RIPC group compared to the control group (30.0% vs. 47.5%; relative risk, 0.768; 95% confidence interval, 0.599–0.985; p = 0.023). Moreover, the occurrence of composite complications was lower in the delayed RIPC group compared with the control group (65.0% vs. 81.3%; relative risk, 0.536; 95% confidence interval, 0.311–0.924; p = 0.020). Conclusions While RIPC did not provide cardioprotective effects in patients undergoing cardiac surgery, it appeared to reduce acute kidney injury, as well as the rate of composite complications. [ABSTRACT FROM AUTHOR]

Background There is conflicting information regarding the association between hyperuricemia and survival in STEMI patients. Our study examined the interaction between hyperuricemia and Killip class on mortality of STEMI patients. Methods We analyzed 951 consecutive STEMI patients between February 2006 and September 2012. Hyperuricemia was defined as SUA of at least 7 mg/dL in males and 6 mg/dL in females. Killip class I patients were divided into hyperuricemia and normouricemia groups. Results The Killip class I hyperuricemia and normouricemia groups had similar baseline and procedural characteristics, but the hyperuricemia group had significantly greater BMI, serum creatinine, and SUA, and a lower TIMI risk score (2, IQR: 1–4 vs. 3, IQR: 2–4, p = 0.019). The hyperuricemia group also had greater 30-day and 1-year mortality rates (2.9% vs. 0.3%, p = 0.022; 6.5% vs. 1.1%, p = 0.002, respectively). However, hyperuricemia was not associated with mortality of patients in Killip classes II–IV or in the overall study population. Hyperuricemia was associated with increased mortality in subgroups of patients who were at least 65 years-old, male, had BMI of 25 kg/m 2 or less, were in Killip class I, without diabetes, and who did not receive intra-aortic balloon pump support. Hyperuricemia interacted with Killip class I in increasing the risk for 1-year mortality ( p for interaction = 0.038). Conclusions Hyperuricemia increased the 1-year mortality of STEMI patients in Killip class I, but not of patients in Killip classes II–IV. An interaction of hyperuricemia and Killip class significantly affects the mortality of STEMI patients. [ABSTRACT FROM AUTHOR]

Background It is unclear whether simvastatin–ezetimibe could be an alternative therapy to high-intensity statin therapy in high-risk patients. The aim of this study was to compare the clinical outcomes of simvastatin–ezetimibe and high-intensity statin therapy in patients with acute myocardial infarction (AMI), and especially in those with high-risk factor. Methods A total of 3520 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were classified into simvastatin–ezetimibe group (n = 1249) and high-intensity statin group (n = 2271). Multivariate analysis and propensity-score matching analysis were performed. The primary endpoint was major adverse cardiac events (MACE) at 12-months follow-up. Results In overall AMI patients, MACE occurred in 116 patients (9.3%) in simvastatin–ezetimibe group and 116 patients (5.1%) in high-intensity statin group. The difference in MACE between groups was driven by repeat revascularization (5.9% vs. 2.2%). After propensity matching analysis, simvastatin–ezetimibe was associated with a higher incidence of MACE than high-intensity statin therapy (adjusted hazard ratio: 3.090, 95% confidence interval: 1.715 to 5.566, p < 0.001). However, in patients with high-risk factors, such as diabetes, old age, or heart failure, simvastatin-ezetimibe had similar incidence of MACE compared with high-intensity statin therapy in further adjusted analysis. Conclusions In overall AMI patients, high-intensity statin therapy had better clinical outcomes than simvastatin–ezetimibe. However, in patients with high-risk factor, simvastatin–ezetimibe had comparable clinical outcomes to high-intensity statin therapy. Therefore, simvastatin–ezetimibe could be used as an alternative to high-intensity statin therapy in such patients. [ABSTRACT FROM AUTHOR]

Background Autonomic imbalance with increased sympathetic and decreased parasympathetic activities is observed in patients after myocardial infarction (MI). We aimed to investigate sleep-related changed in autonomic regulation in left coronary artery (LCA) ligation rats. Methods Wireless transmission of polysomnographic recording was performed in sham and LCA ligation male rats during normal daytime sleep with and without atenolol treatment. Spectral analyses of the electroencephalogram (EEG) and electromyogram (EMG) were evaluated to define active waking (AW), quiet and paradoxical sleeps (QS, PS). Cardiac autonomic activities were measured by analyzing the power spectrum of heart rate variability (HRV). EEG, EMG and HRV were recorded over 6 h for consecutive 3 days in all groups. Results In LCA ligation group, there were higher LF and LF/HF ratio on QS phase, but not AW and PS phases, compared to atenolol treated sham and LCA ligation groups, respectively. The HF component was not significantly changed on all groups in both sleep and awake phases. Sleep interruption was more frequent in LCA ligation rats compared to sham, and it was not found in LCA ligation with atenolol treatment group. Increased AW, PS and decreased QS time were noted in LCA ligation group, compared to sham and it was restored to baseline in LCA ligation with atenolol treatment group. Conclusions Our results demonstrate significant sleep fragmentations with sympathetic hyperactivity during QS stages after MI, and atenolol could restore the autonomic dysfunction and sleep disturbance. The finding explains the cause of sleep-related fetal arrhythmia and sudden cardiac death after MI. [ABSTRACT FROM AUTHOR]

Background Depressed heart rate variability (HRV) is usually considered a negative long-term prognostic factor after acute myocardial infarction. Anyway, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention (PCI). Main aim of this study was to evaluate if HRV still retains prognostic significance in our era of immediate PCI. Methods and results Two weeks after STEMI treated by primary PCI, time-domain HRV was assessed from 24-h Holter recordings in 186 patients: markedly depressed HRV (SDNN < 70 ms or < 50 ms) was present in 16% and in 5% of cases, respectively; patients with left ventricle ejection fraction (LVEF) < 40% presented more often SDNN values in the lowest quartile. Physical performance was also assessed, by 6-minute walk tests (6MWT) and by cardiopulmonary exercise test (CPET). After > 2 years from infarction, occurrence of major clinical events (MCE) was investigated. Cases with or without MCE did not differ by initial HRV parameters; Kaplan–Meier events-free survival curves were similar between patients with lowest quartile SDNN and the remaining ones (χ 2 0.981, p = 0.322). By the contrary, events-free survival was worse if patients walked shorter distances at 6MWT (χ 2 6.435, p = 0.011), developed poorer ventilatory efficiency at CPET (χ 2 10.060, p = 0.002), or presented LVEF < 40% (χ 2 7.085, p = 0.008). Conclusions In primary-PCI STEMI patients, markedly abnormal HRV was found in a small percentage of cases. HRV seems to have lost its prognostic significance, while parameters indicating LV function (LVEF and physical performance) could allow better prognostication in primary-PCI STEMI patients. [ABSTRACT FROM AUTHOR]

Background Limited data are available on the efficacy of statin therapy for secondary prevention in patients with vasospastic angina (VSA). We investigated the association of statin therapy with long-term clinical outcomes in VSA patients without significant coronary artery disease. Methods From January 2003 to June 2014, we enrolled a total of 804 patients with VSA proven by an ergonovine provocation test without significant (≥ 70% diameter stenosis) coronary artery disease. We classified patients into a statin group (n = 330) and a no-statin group (n = 474) according to the use of statin. Primary outcome were major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, myocardial infarction, and any revascularization. Results Median follow-up duration was 4.5 years (interquartile range: 2.0 to 7.3 years). MACE occurred in 14 patients (4.2%) in the statin group, and 21 patients (4.4%) in the no-statin group. There were no differences between the two groups (p = 0.97). After 1:1 propensity-score matching (281 pairs), MACE (statin versus [vs.] no-statin; 3.2% vs. 4.3%, hazard ratio [HR]; 0.80, 95% confidence interval [CI]; 0.34–1.89, p = 0.60) and readmission due to chest pain (17.1% vs. 17.4%, HR; 1.08, 95% CI; 0.72–1.06, p = 0.72) were not statistically different between the two groups. Conclusion Our results suggest that statin therapy could not improve long-term clinical outcomes in VSA patients without significant coronary artery disease. [ABSTRACT FROM AUTHOR]

Background The aim is to know the factors related to the evolution of Health Related Quality of Life (HRQL) in Coronary Patients (CP) from a longitudinal perspective using an appropriate method that handles missing data adequately when the mechanism of missingness is uncertain. Methods Prospective study with repeated measures at baseline, 3 and 6 months. 250 patients with acute myocardial infarction or unstable angina were studied. Sociodemographic and clinical data were collected at baseline. Mental health (GHQ-28) and HRQL (SF-36v1) were assessed during the follow-up. The missingness mechanism was tested. Friedman test and partial eta-squared were used to analyse changes in SF-36 scores and WGEE were used to identify the predictors of the evolution of HRQL. Results 95 dropped out after 3 months and 72 after 6 months. The missingness was likely to be at random. All the dimensions of the SF-36 improved over time, except PF. The factors related to the evolution of HRQL were: being woman (B = − 23.9 in RE; B = − 6.9 in MCS), older age (B = − 0.5 in BP; B = − 0.3 in VT), being single/separated (B = − 14.5 in GH; B = − 14.1 in SF; B = − 23.3 in MH) and widow(er) (B = − 23.2 PF; B = − 29.8 in SF), hypertensive (B = − 19.8 in RP; B = − 8.9 in VT), worse mental health (B = − 3 in PF; B = − 2.8 in RP; B = − 3.1 in BP; B = − 1.2 in PCS; B = − 3.8 in VT; B = − 2.6 in SF), previous history of CHD (B = − 12.5 in PF; B = − 5.2 in PCS), and performing heart-healthy physical activities (B = 13.9 in PF). Conclusions HRQL improves over time. A global approach, including age, marital status, performing physical activities or hypertension, is required to improve HRQL in CP. [ABSTRACT FROM AUTHOR]

Copeptin, a neuropeptide of unknown pathophysiological function that is stoichiometrically secreted with the antidiuretic hormone, is a non-specific marker of endogenous stress which has recently gained interest for its use within a dual-marker strategy in combination with cardiac troponin for the early rule-out of non-ST-elevation myocardial infarction (NSTEMI) in emergency department patients with suspected MI. Based on methodologically strong and consistent evidence from large diagnostic studies and even one randomized intervention study, current European Society of Cardiology Guidelines recommend copeptin and the dual-marker strategy for the early rule-out of MI when high-sensitivity cardiac troponin (hs-cTn) assays are not available. When used with conventional cTn assays, the incremental value of copeptin is large. When used with hs-cTn, the incremental value is very small and does not justify routine clinical use. This review aims to describe the structure, function, and release mechanism of copeptin; as well as to provide an explanation on why this biomarker should be used in the rule-out, and not in the rule-in, of NSTEMI. [ABSTRACT FROM AUTHOR]

Aims ST-segment elevation myocardial infarction (STEMI) triggers remote extracellular matrix expansion. Myocardial extracellular volume fraction (ECV), determined by cardiovascular magnetic resonance, permits quantification of interstitial space expansion. Our aim was to determine the relationship between early serum fibrosis biomarkers and 180-day post-infarct remote myocardium remodeling using ECV. Methods and results In 26 patients with STEMI, functional imaging, T1-mapping, and late-gadolinium-enhancement were performed on a 3-T CMR scanner at baseline (days 3 to 5) and 180 days. Biomarkers were measured at days 1, 3, and 7 after STEMI. The mean initial and follow-up left ventricular ejection fraction (LVEF) were 48.3 ± 18.1% and 52.6 ± 12.3%, respectively. Initial infarct size was 11.6 ± 16.8% of LV mass. ECV in the remote myocardium at 180 days correlated with indexed end-systolic volume (r = 0.4, p = 0.045). A significant correlation was observed between galectin-3 at day 7 and ECV at 6 months (r = 0.428, p = 0.037). A trend towards a direct correlation was found for BNP (r = 0.380, p = 0.059). Multivariate analysis revealed that BNP and galectin-3 were independent predictors of long-term changes in ECV and explained nearly 30% of the variance in this parameter (r 2 = 0.34; p = 0.01). A galectin-3 cutoff value of 10.15 ng/mL was the most powerful predictor of high ECV values (≥ 28.5%) at follow-up. Galectin-3 at day 7 was an independent predictor of high ECV values at follow-up (OR = 22.51; CI 95%: 2.1–240.72; p = 0.01) with 0.76 AUC (CI: 0.574–0.964; p = 0.03). Conclusions Galectin-3 measured acutely after STEMI is an independent predictor of increased ECV at 6-month follow-up that might be useful for long-term risk stratification. [ABSTRACT FROM AUTHOR]

Background While beta-blockers have been widely used for patients with stable coronary artery disease (CAD), some concerns have been raised that beta blockers do not have survival benefit in this population. We conducted a meta-analysis to determine the effects of beta blockers on all-cause and cardiac mortality in adults with CAD without previous myocardial infarction (MI) or reduced ejection fraction. Methods A systematic search of PubMed, Web of Science, Medline/Ovid and Google Scholar through March 2016 identified 4 studies that reported angiographic CAD without previous myocardial infarction or reduced ejection fraction. Fixed-effects pooled odds ratios and 95% confidence intervals of all-cause and cardiac mortality were estimated. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess overall quality of evidence. Results A total of 17,397 patients were analyzed. In both all-cause and cardiac mortality analysis, no serious limitation was identified. Beta-blockers were not associated with reductions in all-cause mortality (odds ratios = 0.910, 95% confidence intervals 0.797–1.039, p = .163) or cardiac mortality (odds ratio = 0.926, 95% confidence interval 0.773–1.110, p = .407). Conclusion Beta-blockers do not provide any survival benefit in patients with angiographic CAD without history of MI or reduced ejection fraction. [ABSTRACT FROM AUTHOR]

Background Few clinical trials have focused on populations with a history of distant myocardial infarction (MI). The PEGASUS trial assessed the impact of dual antiplatelet therapy in such patients, selected by enrichment criteria of high cardiovascular risk. Whether the PEGASUS population reflects the risk of a broader post-MI population is questionable. We analyzed whether 4-year mortality of a routine-practice population would differ according to the inclusion and exclusion criteria used in PEGASUS. Methods FAST-MI is a nationwide French registry recruiting acute MI patients in November 2005; 2490 patients alive and without recurrent MI at one year were classified into three groups: Group 1 (“PEGASUS-like” population; n = 1395; 56%), Group 2 (population having ≥ 1 exclusion criterion for the trial; n = 677; 27%), and group 3 (population meeting neither the PEGASUS inclusion nor exclusion criteria; n = 418, 17%). Results Group 1 patients were older than Group 3 patients, with higher GRACE scores, more comorbidity, and less STEMI, but were younger than the PEGASUS trial population. Enrichment criteria successfully defined a population at higher risk: 4-year survival 83% in Group 1, 97% in Group 2, and 68% in Group 3 (P < 0.001). Among risk-enrichment criteria, age alone was highly discriminant: in PEGASUS-like patients, survival was 78% in those ≥ 65 versus 94% in those < 65 years. Conclusions Enrichment criteria used in PEGAGUS succeed in defining a population at increased risk in patients with prior MI, age being the most discriminant factor. The trial population, however, was notably younger and more masculine than the corresponding real-life population in France. Clinicaltrials.gov number: NCT00673036 . [ABSTRACT FROM AUTHOR]

Inflammation plays an important role on every stage of atherosclerosis. Myeloperoxidase (MPO), a leukocyte-derived enzyme that participates in the innate immunity, probably is involved in many stages of atherothrombosis. According to the recent studies, MPO is related with unfavorable outcome in patients with chest pain and acute coronary syndromes. Its role in prediction of outcomes after ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of the study was to assess if elevated MPO level is a predictor of long-term adverse cardiac events in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Material and methods We evaluated data of 127 patients with STEMI. Plasma levels of MPO collected on admission and the 3rd–4th day of hospitalization were measured by ELISA method. C-reactive protein (CRP) and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) were also determined. All patients were followed-up prospectively for the occurrence of major adverse cardiovascular events (MACE) defined as unscheduled coronary revascularization procedure, stroke, reinfarction or all-cause death. Results After 14 months of follow-up 20% of patients developed MACE. Elevated MPO levels collected on the 3rd–4th day of STEMI were the predictor of death, reinfarction, the need for coronary revascularization and all adverse events taken together. In multivariate analysis, MPO and CRP levels assessed on the 3rd–4th day of hospitalization revealed to be significant predictors of MACE. MPO demonstrated to be significantly better predictor of MACE than NT-proBNP level. Conclusions Myeloperoxidase is a prognostic marker in patients with STEMI treated with pPCI. [ABSTRACT FROM AUTHOR]

Background To reduce complications during coronary artery bypass grafting (CABG) off-pump CABG was introduced; however, results have been mixed. The aim of this work was to conduct a systematic review and meta-analysis of off-pump vs. on-pump CABG. Methods To identify potential studies systematic searches were carried out using various databases. The search strategy included the key concepts of “cardiopulmonary bypass” AND “coronary artery bypass grafting” AND “off pump”. This was followed by a meta-analysis investigating post-operative atrial fibrillation, myocardial infarction, ≤ 30 day mortality, stroke, ventilation time, intensive care unit (ICU) stay and hospital stay. Results Fifty four studies (59 intervention groups), totalling 16,261 participants were analysed. Off pump CABG led to a significantly lower incidence of post-operative atrial fibrillation odds ratio (OR) 0.87 (95% confidence interval [CI] 0.78 to 0.97, p = 0.01), but no differences in either myocardial infarction OR 0.98 (95% CI 0.82 to 1.15, p = 0.77) or ≤ 30 day mortality OR 0.85 (95% CI 0.68 to 1.06, p = 0.16). There was a strong trend towards a reduced incidence of stroke OR 0.77 (95% CI 0.59 to 1.00, p = 0.05); however this did not quite reach significance. Ventilation time mean difference (MD) − 3.78 h (95% CI − 4.75 to − 2.82, p < 0.00001); ICU stay MD − 0.34 days (95% CI − 0.50 to − 0.17, p < 0.0001); and hospital stay MD − 0.9 days (95% CI − 1.25 to − 0.56, p < 0.00001) were all significantly shorter in the off-pump group. Conclusions Off-pump CABG has some benefits over on-pump CABG, particularly in relation to post-operative atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background Relatively little is known about the role of phosphatidylserine (PS) in procoagulant activity (PCA) in patients with non-ST-elevated myocardial infarction (NSTEMI) after stent implantation. This study was designed to evaluate whether exposed PS on microparticles (MPs) and blood cells were involved in the hypercoagulable state in NSTEMI patients with stent implantation. Methods NSTEMI patients (n= 90) and healthy controls (n = 20) were included in our study. PS exposure on MPs and blood cells was analyzed with flow cytometer and confocal microscope. PCA was evaluated by clotting time, purified coagulation complex assays and fibrin production assays. Results Baseline levels of MPs and PS + blood cells were significantly higher (P < 0.001) in the patients than in controls. After stent implantation, a remarkable increase was observed in both MPs and PS + blood cells. Specifically, PS + MPs, PS + platelets and erythrocytes peaked at 18 h following stent implantation, while PS + leukocytes peaked on day 2. In addition, circulating MPs (mostly derived from platelets, leukocytes, erythrocytes and endothelial cells) cooperating with PS + blood cells, contributed to markedly shortened coagulation time and markedly increased FXa/thrombin/fibrin (all P < 0.01) generation in patient group. Moreover, blockade of exposed PS on MPs and cells with lactadherin inhibited PCA by approximately 70%. Conclusions Our results suggest that PS + MPs and blood cells play a procoagulant role in NSTEMI patients following stent implantation. Blockade of PS could become a novel therapeutic modality for the prevention of thrombosis in these patients. [ABSTRACT FROM AUTHOR]

Background Previous studies have shown that air pollution particulate matter (PM) is associated with an increased risk for myocardial infarction. The effects of air pollution on the risk of ST-elevation myocardial infarction (STEMI), in particular the role of gaseous air pollutants such as NO 2 and O 3 and the susceptibility of specific populations, are still under debate. Methods All patients entered in the Belgian prospective STEMI registry between 2009 and 2013 were included. Based on a validated spatial interpolation model from the Belgian Environment Agency, a national index was used to address the background level of air pollution exposure of Belgian population. A time-stratified and temperature-matched case-crossover analysis of the risk of STEMI was performed. Results A total of 11,428 STEMI patients were included in the study. Each 10 μg/m 3 increase in PM10, PM2.5 and NO 2 was associated with an increased odds ratio (ORs) of STEMI of 1.026 (CI 95% : 1.005–1.048), 1.028 (CI 95% : 1.003–1.054) and 1.051 (CI 95% : 1.018–1.084), respectively. No effect of O 3 was found. STEMI was associated with PM10 exposure in patients ≥ 75 y.o. (OR: 1.046, CI 95% : 1.002–1.092) and with NO 2 in patients ≤ 54 y.o. (OR: 1.071, CI 95% : 1.010–1.136). No effect of air pollution on cardiac arrest or in-hospital STEMI mortality was found. Conclusion PM2.5 and NO 2 exposures incrementally increase the risk of STEMI. The risk related to PM appears to be greater in the elderly, while younger patients appear to be more susceptible to NO 2 exposure. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (AMI) is an important health problem. Cardiac rehabilitation (CR) programs following AMI have shown to be effective in reducing mortality. We aim to systematically review the existing literature that analyzes the factors that affect participation and adherence to cardiac rehabilitation programs. We reviewed Medline, EMBASE and Cochrane databases from 01/01/2004 to June 2016 using predefined inclusion and exclusion criteria. We classified the results into factors affecting participation and factors influencing adherence to CR programs. We included 29 studies, and there was a general agreement in those factors predicting participation and adherence to CR programs. These factors can be classified into person-related factors and aspects related to CR programs. Older participants, women, patients with comorbidities, unemployed and uncoupled persons, less educated people and those with lower income had a lower participation. A similar pattern was observed for CR adherence. Also, those potential participants who live farther from CR facilities, do not have transportation, or do not drive, attended less to CR programs. These factors were very similar when analyzing adherence to CR programs. These aspects were similar in Europe and the USA. These results clearly show that participation in CR programs follows a determined pattern that is very homogeneous in different settings. Health professionals should also be aware of patients reluctant to participate in CR programs and adapt their messages and redesign CR programs, to promote participation and adherence. [ABSTRACT FROM AUTHOR]

Background There is a controversy surrounding the correlation between fibrinogen (Fib) level and prognosis of coronary artery disease (CAD). We try to investigate the role of the subtypes of CAD in this controversy. Methods A retrospective analysis was conducted from a single center CAD registered database. 3020 consecutive patients with CAD confirmed by coronary angiography were enrolled. The end points were all-cause mortality. Results The mean follow-up time was 27.2 ± 13.1 months and death events occurred in 258 cases. Mortality rates for patients with CAD and those in the stable coronary artery disease (SCAD) and unstable angina pectoris (UAP) groups exhibited an overall rising trend as Fib levels increased (log rank test, all p < 0.05). However, similar trends were not detected in patients with acute myocardial infarction (AMI). The results of a Cox proportional-hazards regression analysis showed that Fib level was independently correlated with the risk of death in patients with CAD as well as those in the SCAD and UAP groups (CAD, HR 1.40, CI 1.16–1.68; SCAD, HR 1.86, CI 1.24–2.79; UAP, HR 1.42, CI 1.06–1.90). In the AMI group, however, no independent correlation was observed between Fib level and mortality. Conclusion The different proportions of subtypes of CAD affected the correlation between Fib level and the clinical prognosis of patients with CAD. This is maybe a clue to explain the controversy. [ABSTRACT FROM AUTHOR]

Background Atrial natriuretic peptide (ANP) therapy has been reported to have beneficial effects in patients with acute myocardial infarction (AMI); however, its impact on in-hospital mortality remains unclear. This study aimed to investigate the effects of ANP therapy on in-hospital mortality in AMI patients undergoing percutaneous coronary intervention (PCI). Methods This was a retrospective cohort study using the Diagnosis Procedure Combination inpatient database in Japan. We identified AMI patients who underwent PCI with stent implantation on the day of admission, between 2010 and 2014. We compared 30-day in-hospital mortality between patients who started ANP therapy on the day of admission (ANP group) and those who received no ANP therapy during hospitalization (control group), using propensity score and instrumental variable methods. Results Of 60,592 eligible patients (8189 ANP group, 52,403 control group) from 850 hospitals, 1:1 propensity score matching created 8027 pairs. There was no significant difference in 30-day in-hospital mortality between the ANP and control groups (3.4% vs. 3.8%, respectively; p = 0.162; risk difference, − 0.42%; 95% confidence interval [CI], − 1.00% to 0.15%) in the propensity score-matched cohort. Logistic regression analysis with adjustment for propensity score deciles found no significant association between ANP therapy and 30-day in-hospital mortality (odds ratio, 0.99; 95% CI, 0.82 to 1.19). Instrumental variable analysis also showed no significant association between ANP therapy and 30-day in-hospital mortality (risk difference, − 0.59%; 95% CI, − 1.24% to 0.05%). Conclusions This study found no significant association between ANP therapy and in-hospital mortality in AMI patients undergoing PCI. [ABSTRACT FROM AUTHOR]

Background Patients presenting with ST-elevation myocardial infarction commonly have multi-vessel coronary artery disease. After the culprit artery is treated, the optimal treatment strategy for the residual disease is not yet defined. Large observational studies suggest that treatment of residual disease should be deferred but smaller randomised controlled trials (RCTs) suggest multi-vessel primary percutaneous coronary intervention (MV-PPCI) at the time of STEMI is safe. We examine if allocation bias of high-risk patients could explain the conflicting results between observational studies and RCTs and aim to resolve the paradox between the two. Methods A meta-analysis of registries comparing culprit-only PPCI to MV-PPCI was performed. We then determined if high-risk patients were more likely to be allocated to MV-PPCI. A meta-regression was performed to determine if any allocation bias of high-risk patients could explain the difference in outcomes between therapies. Results 47,717 patients (19 studies) were eligible. MV-PPCI had higher mortality than culprit-only PPCI (OR 1.59, 95% CI 1.12 to 2.24, p = 0.03). However, higher risk patients were more likely to be allocated to MV-PPCI (OR 1.45, 95% CI 1.18 to 1.78, p = 0.0005). When this was accounted for, there was no difference in mortality between culprit-only PPCI and MV-PPCI (OR 0.99, 95% CI 0.69 to 1.41, p = 0.94). Discussion Clinicians preferentially allocate higher-risk patients to MV-PPCI at the time of STEMI, resulting in observational studies reporting higher mortality with this strategy. When this is accounted for, these large observational studies in ‘real world’ patients support the conclusion of the smaller RCTs in the field: MV-PPCI has equivalent mortality to a culprit-only approach. [ABSTRACT FROM AUTHOR]

Background Cardiac troponin T and I are important diagnostic and prognostic markers in patients with acute coronary syndrome (ACS). Troponin elevations in various non-ACS scenarios have been documented, but few studies have been conducted on the general hospitalized population, none compared the diagnostic performance of troponin I and T. Methods and results Patients aged > 18 years (n = 1097), consecutively admitted to a district hospital, were included in the study. Blood samples were collected at admission and analysed with three different troponin assays. Serum was available in 92.2%, giving a study population of 1012 patients (mean age 61.6 years, 510 (50.4%) female). ACS was diagnosed among 125 (12.4%) of the patients. Remaining patients were admitted with a broad spectrum of medical and surgical conditions. Of the total population, sc-cTnI was above the 99th percentile in 93 (9.2%), hs-cTnI was above the 99th percentile in 80 (7.9%) and hs-cTnT was above the 99th percentile in 400 (39.5%) of the patients (p < 0.001 for all differences). Hs-cTnT was stronger correlated with estimated glomerular filtration rate (r [2] = 0.13 vs r [2] = 0.06) and haemoglobin (r [2] = 0.1 vs r2 = 0.02) than with hs-cTnI, none were correlated with C-reactive protein (r [2] = 0.04 vs r [2] = 0.02). The correlation between ln(hs-cTnT) and ln(hs-cTnI) was better in ACS patients than in non-ACS patients (r [2] = 0.79 vs r [2] = 0.47, p < 0.001). Conclusion Hs-cTnT was elevated above the 99th percentile in more than one third of the non-ACS patients, while hs-cTnI and sc-cTnI were elevated in approximately one tenth. The correlation between hs-cTnT and hs-cTnI concentrations was significantly stronger in ACS patients than in non-ACS patients. [ABSTRACT FROM AUTHOR]

Background To investigate the age-dependent impact of the superfast door-to-balloon (D2B) times of ≤ 60 min as recommended by the new ESC Guideline for patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) on mid-term survival rates based on a single center registry dataset. Patients and methods This study enrolled consecutive STEMI patients who underwent PPCI from Jan 1, 2009 through Sep 30, 2013. We compared demographics, clinical characteristics and the D2B-survival relationships between patients aged ≥ 65 and < 65. Results The younger group comprised 242 patients (68%) aged < 65 and the elder group consisted of 115 patients (32%) aged ≥ 65. In patients aged < 65, the mortality rate decreased linearly with D2B time shortening (> 90 min vs. 61–90 min vs. ≤ 60 min = 14.9% vs. 13.3% vs. 1.2%, P = 0.001). Contrarily, shortening of D2B time was not associated with reduced mortality rate in patients aged ≥ 65 (> 90 min vs. 61–90 min vs. ≤ 60 min = 23.5% vs. 19% vs. 18.9%, P = 0.99). In younger patients but not the elderly, a D2B time of < 60 min has sufficient power to predict mortality with a sensitivity of 0.83, specificity of 0.74, and Youden index of 0.57. Conclusions Our results show that the new ESC Guideline recommendation of D2B time ≤ 60 min is associated with better survival rates in younger STEMI patients undergoing PPCI. Our findings stress the importance of guideline adherence to minimize reperfusion delay to improve survival in these patients. [ABSTRACT FROM AUTHOR]