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The potential role of the hormone testosterone in the risk for myocardial infarction is investigated in this study of middle-aged men and women compared with a large random control sample from the general population. Radioimmunoassay was used to measure testosterone levels in hair, approximately 1 month and 3 months before an ST-elevation or non-ST-elevation acute myocardial infarction. Mean testosterone levels were measured for middle-aged men and women (n = 168) with diagnosed myocardial infarction (the acute myocardial infarction [AMI] cases). As controls, n = 3,150 randomly selected subjects from the general population of similar age were measured at 1 time point. No significant difference in testosterone levels in hair was found 3 months before AMI for men and women compared with the controls. However, 1 month before AMI, the testosterone levels were decreasing (p0.001) for both men (from 2.84 to 2.10 pg/mg) and women (from 1.43 to 1.10 pg/mg), indicating that a decrease in testosterone concentrations precedes a severe cardiac event. Conventional cardiovascular risk factors were tested as confounders but did not alter this tendency. The AMI cases were also compared with a randomly selected second control group from the general population (n = 205), for whom comparable segmental hair analyses were conducted. A tendency of some decreasing testosterone levels, also in the small control group, was only significant for men. This control group was a small sample, and there might be some natural biologic variation in testosterone levels over time. This study indicates that decreased testosterone levels may be among the pathophysiological processes preceding myocardial infarction and merits further investigation.

Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I

Recent studies suggested that early repolarization (ER)/J wave at the electrocardiogram (ECG) is associated with increased risk of sudden death and ventricular arrhythmias in patients with acute myocardial infarction. In this study, we prospectively assessed whether ER/J wave has any long-term prognostic implications in patients with stable ischemic heart disease (IHD). We enrolled consecutive clinically stable patients with documented IHD, referred to undergo a routine ECG. ER (typical concave ST-segment elevation) and J wave were diagnosed according to prospectively defined criteria. The final population included 617 patients with documented IHD (455 men; age 68.1 ± 11 years). ER/J wave was found in 138 patients (22.4%), 13 of whom (2.1%) showed ER and 133 (21.6%) a J wave. At a follow-up of 8.1±2.9 years, 160 deaths occurred (25.9%), 60 (9.7%) attributed to cardiovascular causes. Total mortality was lower in patients with versus those without ER/J wave (18.8% vs 28.0%; hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40 to 0.93, p = 0.02). The difference, however, was not significant after adjustment for confounding clinical variables (HR 0.78, 95% CI 0.51 to 1.19, p = 0.25). No significant difference was found in cardiovascular death between patients with (7.2%) and those without (10.4%) ER/J wave (adjusted HR 0.78, 95% CI 0.40 to 1.55, p = 0.48). Similar results were obtained for ER and J wave separately, and for ECG location of ER/J wave (inferior or lateral/precordial) and type of J wave (notched or slurred). The ER/J wave pattern at the ECG is not associated with increased risk of long-term mortality in clinically stable patients with a documented history of IHD.

The optimal technique for bifurcation of left main coronary artery (LMCA) stenting has been a subject of controversy since the inception of drug-eluting stents. We searched PubMed, Clinical Trials Registry, and the Cochrane Central Register of Controlled Trials from January 2002 through October 2021. A total of 13 studies comparing the use of provisional versus dual stenting in patients with LMCA bifurcation lesions were included. Any major adverse cardiac event (MACE) was considered the primary composite end point. The secondary end points included individual components of MACE, including death, myocardial infarction, and target lesion revascularization. The treatment effect was defined as the log odds ratio (OR) of provisional over dual stenting for cumulative event rate at 3 years. In 12 studies with 8,377 patients included for MACE, the use of a provisional-stenting strategy was associated with a significant reduction of 3-year MACE (OR 0.64, 95% confidence interval [CI] 0.46 to 0.88) compared with a dual-stenting strategy, primarily driven by target lesion revascularization (OR 0.51, 95% CI 0.36 to 0.73). No significant difference was found regarding death (OR 0.88; 95% CI 0.65 to 1.21) or myocardial infarction (OR 0.97, 95% Cl 0.61 to 1.54). In conclusion, our meta-analysis suggests that provisional stenting should be the preferred technique over dual stenting when treating LMCA bifurcation lesions with drug-eluting stents. Further randomized controlled studies compounded with intracoronary imaging comparing the 2 strategies are warranted.

Impella was approved by the Food and Drug Administration in 2015 for use during high-risk percutaneous coronary interventions (PCIs); however, its safety and efficacy compared with intra-aortic balloon pump (IABP) has not been evaluated in contemporary practice and remains debated. We aimed to compare postapproval outcomes and costs of Impella versus IABP support for high-risk PCI in real-world practice across hospitals in the United States. We identified patients from the Premier Healthcare Database undergoing nonemergent Impella- or IABP-supported high-risk PCI. We used propensity adjustment to control baseline, procedure, and post-PCI medical treatment differences between treatment groups. We included patients undergoing nonemergent single-PCI procedures with either Impella or IABP support and excluded patients presenting with acute ST-elevation myocardial infarction or cardiogenic shock or requiring1 mechanical support devices during index hospitalization. Outcomes included in-hospital survival, myocardial infarction (MI), cardiogenic shock, stroke, bleeding requiring transfusion, acute kidney injury, index hospitalization length of stay, and costs. From April 2016 to June 2019, a total of 48,179 patients were treated with Impella or IABP mechanical circulatory support at 304 hospitals in the United States. Among these, we identified 2,156 patients undergoing nonemergent high-risk PCI treated with Impella (n = 1,447) or IABP (n = 709). After propensity adjustment, Impella use was associated with improved survival (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.02 to 2.36) and less MI (OR 0.29, 95% CI 0.18 to 0.46) and cardiogenic shock (OR 0.54, 95% CI 0.39 to 0.74). Stroke, bleeding requiring transfusion, and acute kidney injury were similar between groups. In conclusion, this Premier Healthcare Database propensity-adjusted analysis, Impella use during nonemergent high-risk PCI was associated with improved survival and reduced in-hospital MI and cardiogenic shock compared with IABP.

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings. This study sought to assess the clinical implications of the "broken line" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry (NCT03607981) prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p0.05), presented more often as intramural hematoma (83 vs 58%, p0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p0.01), and had severe tortuosity (25 vs 10%, p0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p0.05). In conclusion, patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis (NCT03607981).

QRS duration (QRSd) is ill-defined and under-researched as a prognosticator in patients with non-ST-segment myocardial infarction (NSTEMI). We analyzed 240,866 adult (≥18 years) hospitalizations with non-ST-segment elevation myocardial infarction using data from the United Kingdom Myocardial Infarction National Audit Project. Clinical characteristics and all-cause in-hospital mortality were analyzed according to QRSd, with 38,023 patients presenting with a QRSd120 ms and 202,842 patients with a QRSd120 ms. Patients with a QRSd120 ms were more frequently older (median age of 79 years vs 71 years, p0.001), and of white ethnicity (93% vs 91%, p0.001). Patients with a QRSd120 ms had higher frequency of use of aspirin (97% vs 95%, p0.001), P2Y12 inhibitor (93% vs 89%, p0.001), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (82% vs 81%, p0.001) and β blockers (83% vs 78%, p0.001). Invasive management strategies were more likely to be used in patients with QRSd120 ms including invasive coronary angiography (72% vs 54%, p0.001), percutaneous coronary intervention (46% vs 33%, p0.001) and coronary artery bypass graft surgery (8% vs 6%, p0.001). In a propensity score matching analysis, there were no differences between the 2 groups in the adjusted rates of in-hospital all-cause mortality (odds ratio 0.94, 95% confidence interval 0.86 to 1.01) or major adverse cardiac events (odds ratio 0.94, 95% confidence interval 0.85 to 1.02) during the index admission. In conclusion, prolonged QRSd120 ms in the context of non-ST-segment myocardial infarction is not associated with worse in-hospital mortality or the outcomes of major adverse cardiac events.

New-generation drug-eluting stents (DES) strongly reduce restenosis and repeat revascu- larization compared with bare-metal stents (BMS) for percutaneous coronary interven- tion. There is residual uncertainty as to whether other prognostically relevant outcomes are affected by DES versus BMS concerning initial presentation (chronic coronary syn- drome [CCS] vs acute coronary syndrome [ACS]). We performed an individual patient data meta-analysis of randomized trials comparing new-generation DES versus BMS (CRD42017060520). The primary outcome was the composite of cardiac death or myocar- dial infarction (MI). Outcomes were examined at maximum follow-up and with a 1-year landmark. Risk estimates are expressed as hazard ratio (HR) with 95% confidence inter- val (CI). A total of 22,319 patients were included across 14 trials; 7,691 patients (34.5%) with CCS and 14,628 patients (65.5%) with ACS. We found evidence that new-generation DES versus BMS consistently reduced the risk of cardiac death or MI in both patients with CCS (HR 0.83, 95% CI 0.70 to 0.98, p

Multivessel coronary disease is frequent in older patients who underwent coronary angiography for acute coronary syndrome. Whether a complete revascularization or a culprit-only approach is preferable in these patients is still debated. We included consecutive patients aged ≥85 years, presenting with acute coronary syndrome and showing multivessel coronary disease at coronary angiography. Patients were grouped according to complete (residual SYNTAX score [RSS] 0 to 8) or incomplete (RSSgt;8) revascularization. Primary end point was the rate of major adverse cardiovascular events (MACEs, the composite of cardiovascular death, re-myocardial infarction [re-MI], clinically driven percutaneous coronary intervention, and rehospitalization because of cardiac disease) at 2 years follow-up. A total of 166 patients met the criteria for enrollment; 108 patients had a final RSS 0 to 8 (complete revascularization) and 58 patients had a final RSSgt;8 (incomplete revascularization). The rate of MACE was reduced in patients who underwent complete revascularization (35.2% vs 51.7%, p = 0.039, adjusted hazard ratio 0.60, 95% confidence interval 0.37 to 0.98, p = 0.04), a difference mainly driven by a reduction in re-MI (8.3% vs 19.0%, p = 0.045), clinically driven percutaneous coronary intervention (2.8% vs 19.0%, plt;0.001), and rehospitalization for cardiac disease (9.3% vs 24.1%, p = 0.009). Other independent predictors of MACE were active malignancy, previous MI, left ventricle ejection fractionlt;35% (increasing risk of events), and radial access (reducing risk of events). In conclusion, in patients aged ≥85 years, a complete revascularization is associated with a better prognosis, especially in terms of nonfatal events.

The relation between serial high-sensitivity C-reactive protein (hsCRP) and long-term major cardiovascular events (MACEs; cardiovascular death, myocardial infarction, stroke, coronary revascularization, hospitalization for unstable angina) has not been explored in optimally-treated patients with atherosclerotic cardiovascular disease. We tested the hypothesis that longitudinal follow-up hsCRP (repeated measures over time) would associate with 30-month MACE rates. We performed a post hoc analysis of ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibitor with Evacetrapib in Patients with High-Risk for Vascular Outcomes), involving optimally-treated patients with high-risk vascular disease, with available baseline and at least 1 follow-up hsCRP level. Using multivariable Cox proportional hazard models, we determined the association of longitudinal follow-up hsCRP with MACE at 30 months among 8,563 patients (aged 64.6 ± 9 years, 22% women). Patients with incident MACE (n = 961) had higher baseline hsCRP levels (1.77 vs 1.46 mg/L, plt;0.0001 for patients with and without MACE, respectively) and showed an upward trajectory during follow-up, whereas median hsCRP levels remainedlt;2 mg/L at all time points (1.83 vs 1.53 mg/L, 1.91 vs 1.53 mg/L, 1.76 vs 1.37 mg/L, at 3, 12, and 24 months, respectively). In a multivariable analysis, higher longitudinal hsCRP levels were independently associated with MACE (hazard ratio [95% confidence interval] per SD 1.19 [1.10 to 1.29], plt;0.001), the majority of its individual components and all-cause death. Multivariable models containing longitudinal hsCRP provided improved predictive ability of MACE over baseline hsCRP. In the setting of established medical therapies, longitudinal follow-up hsCRP was independently associated with long-term MACE. In conclusion, these findings suggest that longitudinal hsCRP represents a novel approach of residual cardiovascular risk even when on-treatment hsCRP levels remainlt;2 mg/L.

Exercise capacity (EC) is inversely related to the risk of cardiovascular disease and incident heart failure (HF) in healthy subjects. However, there are no present studies that exclusively evaluate EC and the risk of incident HF in patients with known coronary heart disease (CHD). We aimed to determine the relation between EC and incident HF in patients with an established clinical diagnosis of CHD. We retrospectively identified 8,387 patients (age 61 ± 12 years; 30% women; 33% non-White) with a history of myocardial infarction (MI) or coronary revascularization procedure and no history of HF at the time of a clinically indicated exercise stress test completed between 1991 and 2009. EC was quantified in metabolic equivalents of task (METs) estimated from treadmill testing. Incident HF was identified through June 2010 from administrative databases based on ≥3 encounters with International Classification of Diseases, Ninth Revision 428.x. Cox regression analysis was used to evaluate the risk of incident HF associated with METs. Covariates included age; gender; race; hypertension, diabetes, hyperlipidemia, smoking, and MI; medications for CHD and lung diseases; and clinical indication for treadmill testing. During a median follow-up of 8.2 years (interquartile range 4.7 to 12.4 years) after the exercise test, 23% of the cohort experienced a new HF diagnosis. Lower EC categories were associated with higher HF incidence compared with METs ≥12, with nearly fourfold greater adjusted risk among patients with METslt;6. Per unit increase in METs of EC was associated with a 12% lower adjusted risk for HF. There was no significant interaction based on race (p = 0.06), gender (p = 0.88), age ≤61 years (p = 0.60), history of MI (p = 0.31), or diabetes (p = 0.38). This study reveals that among men and women with CHD and no history of HF, EC is independently and inversely related to the risk of future HF.

Data on myocardial infarction (MI) treatment in patients with previous coronary artery bypass grafting (CABG) is limited. We queried the Nationwide Readmissions Database to identify hospitalizations of patients with MI from 2016 to 2019. Among hospitalized patients presenting with MI, 10.3% had previous CABG. Patients with MI who had previous CABG were less likely to be revascularized than those without previous CABG for both ST-segment elevation MI (STEMI) (46.4% vs 68.4%) and non-ST-segment elevation MI (NSTEMI) (30.8% vs 36.7%). CABG was associated with a lower risk of death in NSTEMI patients (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.82 to 0.86), but a higher risk in STEMI patients (OR 1.06, 95% CI 1.01 to 1.13). Revascularization was associated with a lower risk of in-hospital death in patients with previous CABG presenting with STEMI (OR 0.30, 95% CI 0.26 to 0.35) and NSTEMI (OR 0.21, 95% CI 0.19 to 0.23).

Peripheral artery disease (PAD) prevalence increases with age, but the relation between age at PAD diagnosis and outcomes is unclear. We investigated the cardiovascular and limb outcomes of patients diagnosed with PAD at different ages. We studied patients with PAD aged ≥18 years who were diagnosed between 1996 and 2020 at Mayo Clinic. Patients were grouped by diagnosis age (50, 50 to 59, 60 to 69, ≥70 years) and ankle brachial index (ABI): low ABI (1.0) or elevated ABI (1.4). Primary outcomes were cardiovascular events (CVEs; myocardial infarction or ischemic stroke) and limb events (LEs; critical limb ischemia or amputation). Competing risk analysis was performed to calculate adjusted hazard ratios. The cohort included 22,073 patients with PAD (low ABI: 77.1%; elevated ABI: 22.9%). CVEs were observed in 8.2% of patients and LEs in 15.6%. The highest CVE risk was observed in patients diagnosed with PAD before age 50 (compared with patients diagnosed after age 70; hazard ratio 2.33 [95% confidence interval 1.95 to 2.78]). CVE risk decreased with older age at diagnosis. Although younger groups demonstrated higher LE risk, there was no clear association with diagnosis age. These patterns of risk were seen both in low and elevated ABI subgroups but in greater magnitude with elevated ABI. Younger patients diagnosed with PAD face increased risk of myocardial infarction and ischemic stroke compared with patients diagnosed at an older age. CVE risk notably exceeds LE risk. In conclusion, younger age at PAD diagnosis may be an important risk factor, which warrants more aggressive interventions focused on CVE prevention.

The association between vascular disease and outcomes of patients with acute myocardial infarction (AMI) has not been well-defined in the diabetes mellitus (DM) population. All patients with DM presenting with AMI between October 2015 and December 2018 in the National Inpatient Sample database were stratified by number and site of extracardiac vascular comorbidity (cerebrovascular [CVD], renovascular, neural, retinal and peripheral [PAD] diseases). Multivariable logistic regression was used to determine the adjusted odds ratios (aORs) of in-hospital adverse outcomes and procedures. Of 1,116,670 patients with DM who were hospitalized for AMI, 366,165 had ≥1 extracardiac vascular comorbidity (32.8%). Patients with vascular disease had an increased aOR for mortality (aOR 1.05, 95% confidence interval [CI] 1.04 to 1.07), major adverse cardiovascular and cerebrovascular events (MACCEs) (aOR 1.19, 95% CI 1.18 to 1.21), stroke (aOR 1.72, 95% CI 1.68 to 1.76), and major bleeding (aOR 1.11, 95% CI 1.09 to 1.13) and had lower odds of receiving coronary angiography (CA) (aOR 0.90, 95% CI 0.90 to 0.91) and percutaneous coronary intervention (PCI) (aOR 0.82, 95% CI 0.82 to 0.83) than patients without extracardiac vascular disease. Patients with PAD had the highest odds of mortality (aOR 1.29, 95% CI 1.27 to 1.32), whereas patients with CVD had the greatest odds of MACCEs, stroke, and major bleeding (aOR 1.82, 95% CI 1.78 to 1.87, aOR 4.25, 95% CI 4.10 to 4.40, and aOR 1.51, 95% CI 1.45 to 1.57, respectively). Patients with DM presenting with AMI and concomitant extracardiac vascular disease were more likely to develop clinical outcomes and less likely to undergo CA or PCI. Patients with PAD had the highest risk of mortality, whereas patients with CVD had the greatest risk of MACCEs, stroke, and major bleeding.

Smoking is associated with increased risk for acute ST-elevation myocardial infarction (STEMI) at a young age. Although smoking is a modifiable risk factor, smoking cessation rates after STEMI are suboptimal. We investigated the association between smoking status 1 year after STEMI and adverse events in patients (n = 765) aged ≤60 years. Patients were categorized as: (1) nonsmokers, (2) quit smoking, and (3) continued/resumed smoking. The association between smoking status and risk for major adverse cardiovascular events (MACEs) was analyzed during a median follow-up of 8 years. At presentation with STEMI, the mean age was 51 ± 7 years (88% men) and 427 (56%) were smokers. A year after STEMI, 272 continued smoking, 35 quit but later resumed smoking (summed to a single group; n = 307), and 120 quit smoking. Continued smoking was associated with younger age, male gender, lower weight, and low socioeconomic status. Compared with nonsmokers, the adjusted hazard ratio (95% confidence interval) for myocardial infarction, stroke, unstable angina, death, and MACE was 2.51 (1.67 to 3.73), 2.07 (0.94 to 4.56), 3.73 (1.84 to 7.58), 2.52 (1.53 to 4.13), and 2.40 (1.80 to 3.22), accordingly, in those who continued to smoke. However, the adjusted hazard ratio was not significantly associated with these outcomes in patients who quit smoking (MACE: 1.20 [0.77 to 1.87], p=0.414; nonsignificant for individual end points). In conclusion, the prevalence of smoking in young and middle-aged patients presenting with STEMI is high and smoking cessation rates are low. A year after STEMI, those who continued to smoke had worse cardiovascular outcomes and death compared with nonsmokers; however, the long-term outcomes among those who quit smoking appear to be comparable with nonsmokers. The results highlight the contrast between health benefits of quitting smoking after STEMI and low abstinence rates in clinical practice.

Septic shock is a life-threatening host response to infection and a significant contributor to cost burden in the United States. Furthermore, sepsis-related inflammation has been linked to myocardial infarction (MI). We sought to examine the association of type 1 and type 2 MI with outcomes in hospitalizations admitted with septic shock. The National Readmission Database 2018 was queried to identify hospitalizations with hospital discharge diagnoses of septic shock without MI, septic shock with type 1 MI, or septic shock with type 2 MI. Complex-sample multivariable logistic and linear regression models were used to determine the association of these conditions with clinical outcomes. Of 354,528 hospitalizations with septic shock, 11,519 had type 1 MI (3.2%) and 13,970 had type 2 MI (3.9%). Compared with septic shock without MI, type 1 MI was associated with higher mortality (adjusted odds ratio [OR] 1.67, 95% confidence interval [CI] 1.57 to 1.77), costs (adjusted parameter estimate $4,571, 95% CI 3,020 to 6,122), and discharge to facility (adjusted OR 1.09, 95% CI 1.01 to 1.17). In contrast, septic shock with type 2 MI was associated with similar mortality and discharge to nursing facility and higher costs (adjusted parameter estimate 1,798, 95% CI 549 to 3,047). Septic shock hospitalizations with type 1 MI had higher in-hospital mortality (adjusted OR 1.74, 95% CI 1.60 to 1.90, p0.001) compared with type 2 MI. In conclusion, type 1 MI is associated with higher mortality and resource utilization among septic shock hospitalizations. Furthermore, type 2 MI was associated with higher resource utilization.

Cardiovascular (CV) disease accounts for 1/3 of deaths worldwide and 1/4 of deaths nationwide. Socioeconomic status (SES) affects CV health and outcomes. Previous studies that examined the association of SES and CV outcomes have yielded mixed results. Using a large-scale database, the aim of this study was to assess the magnitude of the association between categorized median household income, an indicator for SES, and nonfatal or fatal acute myocardial infarction (AMI). Using logistic regression models, zip code median household income data from the United States Census Bureau were matched to 1-year rates of hospital readmission for AMI and CV death. Patient outcomes were obtained from the Myocardial Infarction Data Acquisition System, a comprehensive database that includes all patient CV disease admissions to acute care New Jersey hospitals. Our main results indicate that compared with those in the highest household income level ($68,000), patients in the lowest-income group ($43,000) had significantly higher risk for AMI readmission (adjusted odds ratio 1.1388, 95% confidence interval 1.0905 to 1.1893, p = 0) and CV death (odds ratio 1.0479, 95% confidence interval 1.0058 to 1.0917, p = 0.0254) after 1 year. This study also found that the likelihood of AMI readmission increased as household income levels decreased. Our findings suggest that healthcare professionals and policy makers should allocate additional resources to low-income communities to reduce disparities in AMI hospital readmissions and AMI case fatalities.

This study analyzed the characteristics, management, and outcomes of patients with poly- myalgia rheumatica (PMR) hospitalized with acute myocardial infarction (AMI), including sensitivity analysis for presence of giant cell arteritis (GCA). Using the National Inpatient Sample (January 2004 to September 2015) and International Classification of Diseases, Ninth Revision, all AMI hospitalizations were stratified into main groups: PMR and no-PMR ; and subsequently, PMR, PMR with GCA, and GCA and no-PMR. Outcomes were all- cause mortality, major adverse cardiovascular/cerebrovascular events (MACCEs), major bleeding, and ischemic stroke as well as coronary angiography (CA) and percutaneous coronary intervention (PCI). Multivariable logistic regression was used to determine adjusted odds ratios with 95% confidence interval (95% CI). A total of 7, 622, 043 AMI hospitalizations were identified, including 22, 597 patients with PMR (0.3%) and 5, 405 patients with GCA (0.1%). Patients with PMR had higher rates of mortality (5.8% vs 5.4%, p = 0.013), MACCEs (10.2% vs 9.2%, p

The optimal timing of postinfarction ventricular septal defect (PI-VSD) repair is subject to debate. Patients with ventricular septal defect (VSD) and ST-elevation myocardial infarction (STEMI) were queried using appropriate International Classification of Diseases, Ninth and Tenth Revision Clinical Modification codes from the National Inpatient Sample (2003 to 2018). VSD repair was identified using appropriate International Classification of Diseases, Ninth and Tenth Revision Procedure Coding System codes. Data were stepwise stratified by cardiogenic shock (CS) and time of repair from admission to create 6 clinically relevant groups: shock 1 (CS; 0 to 7 days), shock 2 (CS; 8 to 14 days), and shock 3 (CS;14 days). Nonshock groups were classified similarly. The primary outcome was in-hospital mortality. Multilevel hierarchical logistic regression was used to adjust for confounders for each group. We identified 10,902 patients with PI-VSD. In shock 1 (n = 5,794), VSD repair was associated with lower mortality (OR 0.76; 95% CI 0.68 to 0.86, p0.001) compared to no VSD repair. In shock 2 (n=1,009) mortality was numerically lower in those who received VSD repair, but not statistically different. In shock 3 (n=483), mortality was numerically higher in those who received VSD repair, but not statistically different. In nonshock 1 (n=5,108), VSD repair was associated with higher mortality (odds ratio [OR] 1.59; 95% confidence interval [CI] 1.33 to 1.90; p0.001). In nonshock 2 (n = 1,265), mortality was numerically higher in patients with VSD repair, although not statistically different. In nonshock 3 (n = 472), mortality was numerically lower in patients with VSD repair, although not statistically different. Mechanical circulatory support use increased over the 16 years (relative change + 18%, p0.001), with no significant change in mortality among patients with PI-VSD. In conclusion, in patients with CS, early PI-VSD repair was associated with lower mortality. However, in patients without CS, early PI-VSD repair was associated with higher mortality.

The optimal coronary artery disease surveillance strategy for end-stage renal disease patients being evaluated for kidney transplantation is unknown. It is unclear what risk factors are associated with the development of new-onset perfusion abnormalities on serial myocardial perfusion imaging. Potential kidney transplant recipients who underwent 2 myocardial perfusion imaging studies at Emory University Hospital between January 2010 and December 2019 were identified. We assessed the frequency of development of any new perfusion defect and development of moderate to severe ischemia (reversible perfusion defect10%) on serial imaging. Finally, we identified the clinical and imaging factors associated with new perfusion defects and explored the association between new perfusion defects and all-cause mortality. History of myocardial infarction (MI) and peripheral artery disease was associated with an increased risk of developing a new perfusion defect. History of MI was also associated with the risk of developing moderate-severe ischemia. Female patients were less likely to develop new perfusion defects or moderate-severe ischemia. There was no association between either outcome and all-cause mortality. In conclusion, a history of MI, peripheral artery disease, and male gender are risk factors for developing new perfusion defects, although only the history of MI and male gender predict moderate to severe ischemia. Interval development of any abnormal perfusion is not associated with increased mortality.

The relation of high-sensitivity cardiac troponin I (hs-cTnI) concentration and presence of obstructive coronary artery disease (CAD) in patients without myocardial infarction (MI) is unclear. Study participants selected from patients free of MI who underwent coronary angiography with or without intervention were enrolled, and hs-cTnI measured. A gradient boosting model was implemented to build a model for detection of CAD. Cox proportional hazard regression was used to assess the association of hs-cTnI and adverse cardiovascular (CV) outcome. Among 978 study participants, 607 patients (62%) had CAD. Higher concentrations of hs-cTnI were associated with chronic kidney disease, heart failure, CAD, male gender, current tobacco use, anemia, age, and low-density lipoprotein cholesterol. History of CAD, male gender, type 2 diabetes mellitus, hs-cTnI, anemia, age, and high-density lipoprotein cholesterol were the most influential factors for detection of CAD. The gradient boosting model had an area under the curve of 0.82, accuracy of 75%, sensitivity of 88%, specificity of 52%, positive predictive value of 76%, and negative predictive value of 72% for detection of CAD. Increase in 1 log unit of hs-cTnI was significantly associated with increased risk of incident MI (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.22 to 1.47, p0.001), CV mortality (HR 1. 24, 95% CI 1.11 to 1.39, p0.001), and composite of incident MI or CV mortality (HR 1.29, 95% CI 1.20 to 1.40, p0.001). In conclusion, among patients without acute MI and CAD, higher concentrations of hs-cTnI were associated with the presence of CAD and linked to increased risk of future CV events. ClinicalTrials.gov Identifier: NCT00842868.

Data on depression and stress among patients with spontaneous coronary artery dissection (SCAD) are limited. Using data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which prospectively enrolled 3,572 acute myocardial infarction (AMI) patients between 18 and 55 years of age, we identified 67 SCAD cases. We compared Patient Health Questionnaire-9 (PHQ-9) and 14-item Perceived Stress Scale (PSS-14) scores obtained at baseline, 1 month, and 12 months between SCAD and AMI of all other causes. Using longitudinal linear mixed-effects analysis, we compared depression and stress scores between SCAD and other AMI, adjusting for time and selected covariates. Patients with SCAD had lower baseline PHQ-9 scores (6.1 ± 6.0 vs 7.7 ± 6.4 for other patients with AMI, p = 0.03), similar 1-month scores, and lower 12-month scores (3.2 ± 4.3 vs 4.9 ± 5.5, p = 0.004). At baseline and 1 month, patients with SCAD had similar PSS-14 scores to those of other patients with AMI. At 12 months, patients with SCAD had lower scores (18.4 ± 8.8 vs 21.5 ± 9.3 for other patients with AMI, p = 0.009). After adjustment for cardiovascular risk factors, co-morbidities, and clinical acuity, no differences in PHQ-9 or PSS-14 scores remained between SCAD and other AMI. Similar results were obtained in a subgroup analysis of only women with SCAD and other AMI. In conclusion, patients with SCAD had a relatively lower burden of depression and perceived stress than other patients with AMI, potentially because of fewer co-morbidities and favorable socioeconomic factors. However, given high depression and stress burden in both SCAD and other patients with AMI, routine screening can help identify and treat these patients.

Gender-related differences after ST-segment elevation myocardial infarction (STEMI) have been reported, but studies have generally focused on high-risk groups and results are inconsistent. This study aims to determine gender-related differences in the treatment of STEMI and in-hospital mortality in a contemporary cohort of young patients. We included patients aged55 years admitted to the Acute Cardiac Care Unit with STEMI during an 11-year period. We retrospectively reviewed the clinical charts to register information on demographics, clinical and laboratory data, angiography, treatment received, complications, and in-hospital mortality. A total of 812 patients were included (712 men and 100 women). There were no gender-related differences in age or prevalence of cardiovascular risk factors. Women, as compared with men, had higher incidence of nonobstructive angiography (14.0% vs 2.4%) and coronary tortuosity (4.0% vs 0.8%), and lower incidence of multivessel disease (35.0% vs 49.6%) (p0.05). Less frequently than men, women received percutaneous transluminal coronary angioplasty (94.0% vs 98.2%), and stent placement (82.0% vs 93.8%), inotropic agents (2.0% vs 8.3%), hypothermia after cardiac arrest (25.0% vs 84.0%), and mechanical ventilation (4.0% vs 11.0%) (p0.05). These differences were not explained by the different angiographic findings. In-hospital mortality was 2.0% and 3.4%, in women and men, respectively (adjusted odds ratio 0.712, 95% confidence interval 0.164 to 3.093, p = 0.650). In conclusion, women aged55 years with STEMI were held to different treatment standards than men.

Patients with acute myocardial infarction (AMI) with chronic total occlusion (CTO) in nonculprit arteries had worse prognosis than patients with AMI without CTO in nonculprit arteries. However, the reason was not clearly explained. This retrospective study aimed to compare the clinical outcomes between patients with AMI with CTO versus those with severe stenosis (90% to 99% stenosis) in nonculprit arteries, which would help to elucidate the role of CTO in nonculprit arteries. We included 643 patients with AMI and divided those into the CTO group (n = 188) and 90% to 99% stenosis group (n = 455). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and readmission for heart failure. During the median follow-up duration of 431 days (Q1:178 days to Q3:950 days), a total of 189 MACE was observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the CTO group than in the 90% to 99% stenosis group (p0.001). The multivariate Cox hazard analysis revealed that CTO in nonculprit arteries (vs 90% to 99% stenosis) was significantly associated with MACE (hazard ratio 1.410, 95% confidence interval 1.042 to 1.907; p = 0.026) after controlling known confounding factors. In conclusion, patients with AMI with CTO in nonculprit arteries had worse clinical outcomes than those with 90% to 99% stenosis in nonculprit arteries. Patients with AMI with CTO could be recognized as a high-risk group rather than those with 90% to 99% stenosis and should be carefully managed to prevent cardiovascular events.

Fewer ST-elevation myocardial infarctions (STEMIs) presentations and increased delays in care occurred during the COVID-19 pandemic in urban areas. Whether these associations occurred in a more rural population has not been previously reported. Our objective was to evaluate the impact of COVID-19 on time-to-presentation for STEMI in rural locations. Patients presenting to a large STEMI network spanning 27 facilities and 13 predominantly rural counties between January 1, 2016 and April 30, 2020 were included. Presentation delays, defined as time from symptom onset to arrival at the first medical facility, classified as ≥12 and ≥24 hours from symptom onset were compared among patients in the pre–COVID-19 and the early COVID-19 eras. To account for patient-level differences, 2:1 propensity score matching was performed using binary logistic regression. Among 1,286 patients with STEMI, 1,245 patients presented in the pre–COVID-19 era and 41 presented during the early COVID-19 era. Presentation delays ≥12 hours (19.5% vs 4.0%) and ≥24 hours (14.6% and 0.2%) were more common in COVID-19 than pre–COVID-19 cohorts (p

Risk prediction models for cardiovascular disease (CVD) death developed from patients without vascular disease may not be suitable for myocardial infarction (MI) survivors. Prediction of mortality risk after MI may help to guide secondary prevention. Using national electronic record data from the Veterans Health Administration 2002 to 2012, we developed risk prediction models for CVD death and all-cause death based on 5-year follow-up data of 100,601 survivors of MI using Cox proportional hazards models. Model performance was evaluated using a cross-validation approach. During follow-up, there were 31,622 deaths and 12,901 CVD deaths. In men, older age, current smoking, atrial fibrillation, heart failure, peripheral artery disease, and lower body mass index were associated with greater risk of death from CVD or all-causes, and statin treatment, hypertension medication, estimated glomerular filtration rate level, and high body mass index were significantly associated with reduced risk of fatal outcomes. Similar associations and slightly different predictors were observed in women. The estimated Harrell's C-statistics of the final model versus the cross-validation estimates were 0.77 versus 0.77 in men and 0.81 versus 0.77 in women for CVD death. Similarly, the C-statistics were 0.75 versus 0.75 in men, 0.78 versus 0.75 in women for all-cause mortality. The predicted risk of death was well calibrated compared with the observed risk. In conclusion, we developed and internally validated risk prediction models of 5-year risk for CVD and all-cause death for outpatient survivors of MI. Traditional risk factors, co-morbidities, and lack of blood pressure or lipid treatment were all associated with greater risk of CVD and all-cause mortality.

There are limited contemporary data evaluating the relation between hospital characteristics and outcomes of patients with cardiac arrest complicating acute myocardial infarction (AMI-CA). As such, we used the National Inpatient Sample database (2000 to 2017), to identify adult admissions with primary diagnosis of AMI and concomitant CA. Interhospital transfers were excluded, and hospitals were classified based on location and teaching status (rural, urban nonteaching, and urban teaching) and bed size (small, medium, and large). Among 494,083 AMI-CA admissions, 9.3% received care at rural hospitals, 43.4% at urban nonteaching hospitals, and 47.3% at urban teaching hospitals. Compared with urban nonteaching and teaching hospitals, AMI-CA admissions at rural hospitals received lower rates of cardiac and noncardiac procedures. Admissions to urban teaching hospitals had higher rates of acute organ failure, concomitant cardiogenic shock, and cardiac and noncardiac procedures. When hospitals were stratified by bed size, 9.8% of AMI-CA admissions were admitted to small capacity hospitals, 26.0% to medium capacity, and 64.2% to large capacity hospitals. The use of cardiac and noncardiac procedures was lower in small hospitals with higher rates of use in medium and large hospitals. In-hospital mortality was higher in urban nonteaching (adjusted odds ratio [OR] 1.17; 95% confidence interval [CI]1.14 to 1.20; p0.001) and urban teaching hospitals (adjusted OR 1.36; 95% CI 1.32 to 1.39; p0.001) compared with rural hospitals. Compared with small hospitals, medium (adjusted OR 1.11; 95% CI 1.08 to 1.14; p0.001) and large hospitals (adjusted OR 1.22; 95% CI 1.19 to 1.25; p0.001) were associated with higher in-hospital mortality. In conclusion, AMI-CA admissions to large and urban hospitals had higher in-hospital mortality compared with small and rural hospitals potentially owing to greater acuity.

Coronary procedures predispose patients to adverse events. To improve our understanding of the genetic factors underlying postoperative prognosis, we studied the association of polygenic risk scores (PRSs) with postprocedural complications in coronary patients who underwent revascularization. The study sample comprised 8,296, 6,132, and 13,082 patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or any revascularization, respectively. We genotyped all subjects and identified adverse events during follow-up of up to 30 years by record linkage with nationwide healthcare registers. We computed PRSs for each postoperative adverse outcome (atrial fibrillation [AF], myocardial infarction, stroke, and bleeding complications) for all participants. Cox proportional hazards models were used to examine the association between PRSs and outcomes. A 1-SD increase in AF-PRS was associated with greater risk of postoperative AF with hazard ratios of 1.22 (95% confidence interval [CI] 1.16 to 1.28), 1.15 (95% CI 1.10 to 1.20) and 1.18 (95% CI 1.14 to 1.22) after percutaneous coronary intervention, coronary artery bypass grafting, and any revascularization, respectively. In contrast, the association of each PRSs with other postoperative complications was nonexistent to marginal. Inclusion of the AF-PRS in a model with a clinical risk score resulted in significant model improvement (increase in model c-statistic 0.0059 to 0.0098 depending on procedure; p0.0002 for all). In conclusion, our results demonstrate that PRS can be used for AF risk-prediction in patients who underwent revascularization. The AF-PRS could potentially be used to improve AF prevention and outcomes in patients who underwent revascularization.

In contrast to atherosclerotic acute myocardial infarction (AMI), conservative therapy is considered preferable in the acute management of spontaneous coronary artery dissection (SCAD) if clinically possible. The present study aimed to investigate factors associated with treatment strategy for SCAD. Women aged ≤60 years with AMI and SCAD were retrospectively identified in the Nationwide Readmissions Database 2010 to 2015 and were divided into revascularization and conservative therapy groups. The revascularization group (n = 1,273, 68.0%), compared with the conservative therapy group (n = 600, 32.0%), had ST-elevation AMI (STEMI) (anterior STEMI, 20.3% vs 10.5%; inferior STEMI, 25.1% vs 14.5%; p0.001) and cardiogenic shock (10.8% vs 1.8%; p0.001) more frequently. Multivariable logistic regression analysis demonstrated that anterior STEMI (vs non-STEMI, odds ratio 2.89 [95% confidence interval 2.08 to 4.00]), inferior STEMI (2.44 [1.85 to 3.21]), and cardiogenic shock (5.13 [2.68 to 9.80]) were strongly associated with revascularization. Other factors associated with revascularization were diabetes mellitus, dyslipidemia, smoking, renal failure, and pregnancy/delivery-related conditions; whereas known fibromuscular dysplasia and admission to teaching hospitals were associated with conservative therapy. Propensity-score matched analyses (546 pairs) found no significant difference in in-hospital death, 30-day readmission, and recurrent AMI between the groups. In conclusion, STEMI presentation, hemodynamic instability, co-morbidities, and setting of treating hospital may affect treatment strategy in women with AMI and SCAD. Further efforts are required to understand which patients benefit most from revascularization over conservative therapy in the setting of SCAD causing AMI.

The 2016 European Society of Cardiology Guidelines introduced a new term, mid-range left ventricular ejection fraction (mrEF) heart failure, however, the clinical characteristics and short-term outcomes in cardiogenic shock patients with mrEF after acute myocardial infarction remain unclear. This retrospective study analyzed the baseline characteristics, management, and outcomes according to the left ventricular ejection fraction (LVEF), reduced LVEF (rEF) ≤40%, mrEF 41% to 49%, and preserved LVEF (pEF) ≥50% in patients with acute myocardial infarction complicated by cardiogenic shock. The primary end point was 30-day all-cause mortality and the secondary end point was the composite events of major adverse cardiovascular events (MACEs). In 218 patients, 71 (32.6%) were patients with mrEF. Compared with those with pEF, patients with mrEF had some similar clinical characteristics to that of rEF. The 30-day all-cause mortality in patients with rEF, mrEF, and pEF were 72.7%, 56.3%, and 32.0%, respectively (p = 0.001). The 30-day MACE were 90.9%, 69.0%, and 60.2%, respectively (p = 0.001). After multivariable adjustment, patients with mrEF and rEF had comparable 30-day all-cause mortality (hazard ratio [HR] = 0.81, 95% confidence interval [CI] 0.50 to 1.33, p = 0.404), and pEF was associated with decreased risk of 30-day all-cause mortality compared with rEF (HR = 0.41, 95% CI 0.24 to 0.71, p = 0.001). In contrast, the risk of 30-day MACE in mrEF and pEF were lower than that of rEF (HR = 0.62, 95% CI 0.40 to 0.96, p = 0.031 and HR = 0.53, 95% CI 0.34 to 0.80, p = 0.003, respectively). In conclusion, 1/3 of patients with acute myocardial infarction complicated by cardiogenic shock were mrEF. The clinical characteristics and short-term mortality in patients with mrEF were inclined to that of rEF and the occurrence of early left ventricular systolic dysfunction is of prognostic significance.

The MacNew questionnaire is a disease-specific quality of life measure that has been used in patients with myocardial infarction and heart failure. We aimed to investigate the impact of transcatheter aortic valve implantation (TAVI) on health-related quality of life (HRQoL) using MacNew Questionnaire and identify predictors associated with a change in its score. This was a prospective multi-center study performed across 5 National Health Service hospitals in the United Kingdom performing TAVI between 2016 and 2018. HRQoL was assessed using MacNew Questionnaire, Euro Quality of Life-5D-5L, and Short Form 36 questionnaires collected at baseline, 3-, 6- and 12 months after the procedure. Out of 225 recruited patients, 19 did not have TAVI and 4 withdrew their consent, and hence 202 patients were included. HRQoL was assessed in 181, 161, and 147 patients at 3, 6, and 12 months, respectively. Using MacNew, there was a significant improvement in all domains of HRQoL as early as 3 months after TAVI which was sustained up to 12 months with improved discrimination of change in HRQoL compared with other scales. Poor mobility at baseline and history of myocardial infarction were independent predictors of reduced improvement in HRQoL at 3 months. HRQoL increased in all subgroups of patients including frail ones. In conclusion, the MacNew assessment tool performed well in a representative TAVI cohort and could be used as an alternative disease-specific method for assessing HRQoL change after TAVI.

There have been mixed results regarding the efficacy and safety of various percutaneous coronary intervention bifurcation techniques. An electronic search of Medline, Scopus, and Cochrane databases was performed for randomized controlled trials that compared the outcomes of any bifurcation techniques. We conducted a pairwise meta-analysis comparing the 1-stent versus 2-stent bifurcation approach, and a network meta-analysis comparing the different bifurcation techniques. The primary outcome was major adverse cardiac events (MACEs). The analysis included 22 randomized trials with 6,359 patients. At a weighted follow-up of 25.9 months, there was no difference in MACE between 1-stent versus 2-stent approaches (risk ratio [RR] 1.20, 95% confidence interval [CI] 0.92 to 1.56). Exploratory analysis suggested a higher risk of MACE with a 1-stent approach in studies using second-generation drug-eluting stents, if side branch lesion length ≥10 mm, and when final kissing balloon was used. There was no difference between 1-stent versus 2-stent approaches in all-cause mortality (RR 0.95, 95% CI 0.69 to 1.30), cardiovascular mortality (RR 1.07, 95% CI 0.68 to 1.68), target vessel revascularization (TVR) (RR 1.22, 95% CI 0.90 to 1.65), myocardial infarction (MI) (RR 1.04, 95% CI 0.69 to 1.56) or stent thrombosis (RR 1.10, 95% CI 0.68 to 1.78). Network meta-analysis demonstrated that double kissing crush technique was associated with lower MACE, MI, TVR, and target lesion revascularization, whereas culotte technique was associated with higher rates of stent thrombosis. In this meta-analysis of randomized trials, we found no difference between 1-stent versus 2-stent bifurcation percutaneous coronary intervention approaches in the risk of MACE during long-term follow-up. Among the various bifurcation techniques, double kissing crush technique was associated with lower rates of MACE, target lesion revascularization, TVR, and MI.

ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6 months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF)50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF50% independently predicted the development of HF and all-cause death.

Recently, one observational study showed that patients with ST-segment elevation myocardial infarction (STEMI) without standard cardiovascular risk factors were associated with increased mortality compared with patients with risk factors. This unexpected result should be evaluated in other populations including those with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and chronic coronary syndrome (CCS). Among 30,098 consecutive patients undergoing first coronary revascularization in the CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Grafting) registry cohort-2 and 3, we compared clinical characteristics and outcomes between patients with and without risk factors stratified by their presentation (STEMI n = 8,312, NSTE-ACS n = 3,386, and CCS n = 18,400). Patients with risk factors were defined as having at least one of the following risk factors: hypertension, dyslipidemia, diabetes, and current smoking. The proportion of patients without risk factors was low (STEMI: 369 patients [4.4%], NSTE-ACS: 110 patients [3.2%], and CCS: 462 patients [2.5%]). Patients without risk factors compared with those with risk factors more often had advanced age, low body weight, and malignancy and less often had history of atherosclerotic disease and prescription of optimal medical therapy. In patients with STEMI, patients without risk factors compared with those with risk factors were more often women and more often had atrial fibrillation, long door-to-balloon time, and severe hemodynamic compromise. During a median of 5.6 years follow-up, patients without risk factors compared with those with risk factors had higher crude incidence of all-cause death. After adjusting confounders, the mortality risk was significant in patients with CCS (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.01 to 1.49, p = 0.04) but not in patients with STEMI (HR 1.06, 95% CI 0.89 to 1.27, p = 0.52) and NSTE-ACS (HR 1.07, 95% CI, 0.74 to 1.54, p = 0.73). In conclusion, among patients undergoing coronary revascularization, patients without standard cardiovascular risk factors had higher crude incidence of all-cause death compared with those with at least one risk factor. After adjusting confounders, the mortality risk was significant in patients with CCS but not in patients with STEMI and NSTE-ACS.

ST-elevation myocardial infarction (STEMI)–related mortality has been decreasing within the United States because of improvements in management and preventive efforts; however, persistent disparities in demographic subsets such as race may exist. In this study, the nationwide trends in mortality related to STEMI in adults in the United States from 1999 to 2019 are described. Trends in mortality related to STEMI were assessed through a cross-sectional analysis of the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100,000 people and associated annual percentage change and average annual percentage changes with 95% confidence intervals (CIs) were determined. Joinpoint regression was used to assess the trends in the overall, demographic (gender, race/ethnicity, age), and regional groups. Between 1999 and 2019, a total of 3,655,274 deaths related to STEMI occurred. In the overall population, age-adjusted mortality rates decreased from 134.7 (95% CI 134.2 to 135.3) in 1999 to 48.5 (95% CI 48.3 to 48.8) in 2019 with an average annual percentage change of −5.0 (95% CI −5.5 to −4.6). Higher mortality rates were seen in Black men living in the Southern United States. Patients older than 85 years experienced substantial decreases in mortality. In addition, rural counties had persistently higher mortality rates in comparison with urban counties. In conclusion, despite decreasing mortality rates in all groups, persistent disparities continued to exist throughout the study period.

The optimal timing of coronary artery bypass grafting (CABG) in patients after an acute myocardial infarction (MI) is unknown. We performed a systematic review and meta-analysis of studies comparing mortality rates in patients who underwent CABG at different time intervals after acute MI. Bias assessments were completed for each study, and summary of proportions of all-cause mortality were calculated based on CABG at various time intervals after MI. A total of 22 retrospective studies, which included a total of 137,373 patients were identified. The average proportion of patients who died when CABG was performed within 6 hours of MI was 12.7%, within 6 to 24 hours of MI was 10.9%, within 1 day of MI was 9.8%, any time after 1 day of MI was 3.0%, within 7 days of MI was 5.9%, and any time after 7 days of MI was 2.7%. Interstudy heterogeneity, assessed using I2 values, showed significant heterogeneity in death rates within subgroups. Only 1 study accounted for immortal time bias, and there was a serious risk of selection bias in all other studies. Confounding was found to be a serious risk for bias in 55% of studies because of a lack of accounting for type of MI, MI severity, or other verified cardiac risk factors. The current publications comparing timing of CABG after MI is at serious risk of bias because of patient selection and confounding, with heterogeneity in both study populations and intervention time intervals.

This study aimed to assess long-term resource utilization and outcomes in patients with acute chest pain who underwent coronary computed tomography angiography (CCTA) and stress echocardiography (SE). This was a retrospective, propensity-matched analysis of health insurance claims data for a national sample of privately insured patients over the period January 1, 2011, to December 31, 2014. There were 3,816 patients matched 1:1 who received either CCTA (n = 1,908) or SE (n = 1,908). Patients were seen in the emergency department (ED) between January 1, 2011, and December 31, 2011 with a primary diagnosis of chest pain and received either CCTA or SE within 72 hours as the first noninvasive test and maintained continuous enrollment in the database from the time of the ED encounter through December 31, 2014. All individual patient data were censored at 3 years. Compared with SE, CCTA was associated with higher odds of downstream cardiac catheterization (9.9% vs 7.7%, adjusted odds ratio [AOR] 1.28, 95% confidence interval (CI) 1.00 to 1.63), future noninvasive testing (27.7% vs 22.3%, AOR 1.22, 95% CI 1.05 to 1.42), and return ED visits or hospitalization for chest pain at 3 years (33.1% vs 24.2%, AOR 1.37, 95% CI 1.19 to 1.59). There were no statistically significant differences in new statin use (15.5% vs 14.9%, AOR 1.04, 95% CI 0.85 to 1.28), coronary revascularization (2.7% vs 2.2%, AOR 1.25, 95% CI 0.77 to 2.01) or hospitalization for acute myocardial infarction (0.9% vs 0.9%, AOR 0.96, 95% CI 0.47 to 1.99). In conclusion, in patients who present to the ED with chest pain, CCTA is associated with increased downstream resource utilization compared with SE with no differences in long-term cardiovascular outcomes.

J waves may be observed during coronary angiography (CAG), but they have not been fully studied. We investigated the characteristics of J waves in 100 consecutive patients during CAG. The patients and their family members had no history of cardiac arrest. Approximately 60% of patients had ischemic heart disease, previous myocardial infarction, or angina pectoris, but at the time of this study, the right coronary artery was shown to be normal or patent after stenting. Electrocardiogram was serially recorded to monitor J waves and alteration of the QRS complex during CAG. In 12 patients (12%), J waves (0.249 ± 0.074 mV) newly appeared during right CAG, and in another 13 patients (13%), preexisting J waves increased from 0.155 ± 0.060 mV to 0.233 ± 0.133 mV during CAG. Left CAG induced no J waves or augmentation of J waves. Distinct alterations were observed in the QRS complex during CAG of both coronary arteries. Mechanistically, myocardial ischemia induced by contrast medium was considered to result in a local conduction delay, and when it occurred in the inferior wall, the site of the late activation of the ventricle, the conduction delay was manifested as J waves. In conclusion, J waves were confirmed to emerge or increase during angiography of the right but not the left coronary artery. Myocardial ischemia induced by contrast medium caused a local conduction delay that was manifested as J waves in the inferior wall, the site of the late activation of the ventricle.

We aimed to investigate a causal effect of functional sarcopenia status, including poor handgrip strength and slow walking pace, on cardiovascular diseases. This study was an observational cohort study including observational analysis and Mendelian randomization. We studied the UK Biobank prospective cohort (n = 324,486) for observational analysis with poor handgrip strength or self-reported slow walking pace as the exposures, investigating risk of myocardial infarction or mortality. Genetic instruments for the exposures were developed in 337,138 individuals of white British ancestries, and coronary artery disease outcome (60,801 cases/123,504 controls) from the independent CARDIoGRAMplustC4D cohort was studied by two-sample Mendelian randomization. The findings were replicated by one-sample analysis by polygenic risk score analysis within the UK Biobank. Both slow walking pace and poor handgrip strength were significantly associated with higher risks of incident myocardial infarction and mortality, particularly from cardiovascular deaths, in the observational investigation. Genetically predicted poor handgrip strength (odds ratio: 1.128 [1.041 to 1.222]) and slow walking pace (odds ratio: 1.171 [1.022 to 1.342]) showed causal effects on the coronary artery disease risks in the independent cohort. The results were again identified by the one-sample Mendelian randomization, as the higher polygenic risk score for poor handgrip strength and slow walking pace was associated with a higher risk of mortality. In conclusion, this study supports the causal effects of slow walking pace and poor handgrip strength on the risks of cardiovascular disease and mortality. The functional sarcopenia status are targetable causative factors for interventions aiming to reduce risks of cardiovascular disease or mortality.

Early ventricular tachycardia (VT) and ventricular fibrillation (VF) are associated with increased in-hospital mortality but do not influence the long-term prognosis in ST-elevation myocardial infarction (STEMI). Recent data advocate a differential approach to the type of arrhythmia and indicate long-term mortality hazard associated with monomorphic VT. We aimed to evaluate the prognostic value of early monomorphic VT compared to nonmonomorphic VT/VF in a nonselected cohort of STEMI patients. Consecutive STEMI patients admitted for primary percutaneous coronary intervention from 2007 to 2010 were included. Clinical characteristics were obtained from the Swedish national SWEDEHEART registry. The occurrence and type of early VT/VF were verified in medical records. All-cause mortality 8 years after STEMI was assessed using the Swedish Cause of Death Register. A total of 2,277 STEMI patients were included (age 66 ± 12 years, 70% male), among them 35 (1.5%) with early monomorphic VT and 115 (5.1%) with nonmonomorphic VT/VF. Patients with monomorphic VT had similar clinical characteristics compared to those with nonmonomorphic VT/VF. In total, 22 patients (63%) with monomorphic VT and 43 (37%) with nonmonomorphic VT/VF died by 8 years of follow-up (p = 0.011). Monomorphic VT was associated with a higher risk of all-cause mortality compared to nonmonomorphic VT/VF in univariate analysis (HR 2.03, 95% CI 1.21 to 3.39, p = 0.007) and after adjustment for age and history of myocardial infarction (MI) (HR 1.74, 95% CI 1.02 to 2.97, p = 0.041). Early monomorphic VT in STEMI is associated with a higher risk of all-cause mortality compared to nonmonomorphic VT/VF and deserves further studies to refine risk stratification strategies.