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Abstract Aims Recent genome-wide association studies (GWAS) have identified several single nucleotide polymorphisms (SNPs) that were associated with blood lipid levels in Europeans. However, little is known about such association in the Chinese populations. The present study was to determine the association of lipid levels susceptibility loci with the risk of China myocardial infarction (MI) patients. Methods A total of 401 patients with MI and 409 controls were included in the study. Five SNPs (including HNF1A rs1169286 and rs2244608, C12orf43 rs2258287, LIPA rs2246833 and TRPS1 rs2293889) were selected using a tagging single nucleotide polymorphism (tSNP) strategy. The SNP genotyping work was performed using an improved multiplex ligation detection reaction (iMLDR) technique. Results The subjects with rs1169286 CT genotype in MI cases had lower FBG levels than the subjects with rs1169286 CC/TT genotypes (P = 0.002). The subjects with rs2246833 TT genotype in MI patients had higher LDL-C levels than the subjects with rs2246833 CC/CT genotypes (P = 0.006). Several SNPs interacted with sex and age to modify TC, TG, LDL-C, CRE and FBG levels, and the risk of MI (P < 0.01 for all). However, our results disclosed no association between the SNPs and susceptibility to MI (P > 0.05 for all). Conclusions Taken together, this study provides additional evidence that functional genetic variation of the lipid related mutations can mediate atherogenic processes and the risk of MI in humans. Highlights • 810 participants, including 401 MI patients and 409 control subjects from China • Those with rs1169286 CT genotype in MI cases had lower FBG levels than those with rs1169286 CC/TT genotypes (P =0.002). • Those with rs2246833 TT genotype in MI cases had higher LDL-C levels than those with rs2246833 CC/CT genotypes (P =0.006). • Several SNPs (rs1169286, rs2244608, rs2258287 and rs2246833) interacted with age to influence TC, TG and LDL-C levels. • Several SNPs interacted with sex to modulate CRE (rs1169286, rs2244608 and rs2293889) and FBG (rs2293889) levels. • The SNP of rs2258287 interacted with hypertension to influence TG levels. [ABSTRACT FROM AUTHOR]

Background: Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.Objectives: This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.Methods: The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.Results: We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.Conclusions: Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703). [ABSTRACT FROM AUTHOR]

Background: Recent trials demonstrated a benefit of multivessel percutaneous coronary intervention (PCI) for noninfarct-related artery (non-IRA) stenosis over IRA-only PCI in patients with ST-segment elevation myocardial infarction (STEMI) multivessel disease. However, evidence is limited in patients with cardiogenic shock.Objectives: This study investigated the prognostic impact of multivessel PCI in patients with STEMI multivessel disease presenting with cardiogenic shock, using the nationwide, multicenter, prospective KAMIR-NIH (Korea Acute Myocardial Infarction-National Institutes of Health) registry.Methods: Among 13,104 consecutive patients enrolled in the KAMIR-NIH registry, we selected patients with STEMI with multivessel disease presenting with cardiogenic shock and who underwent primary PCI. Primary outcome was 1-year all-cause death, and secondary outcomes included patient-oriented composite outcome (a composite of all-cause death, any myocardial infarction, and any repeat revascularization) and its individual components.Results: A total of 659 patients were treated by multivessel PCI (n = 260) or IRA-only PCI (n = 399) strategy. The risk of all-cause death and non-IRA repeat revascularization was significantly lower in the multivessel PCI group than in the IRA-only PCI group (21.3% vs. 31.7%; hazard ratio: 0.59; 95% confidence interval: 0.43 to 0.82; p = 0.001; and 6.7% vs. 8.2%; hazard ratio: 0.39; 95% confidence interval: 0.17 to 0.90; p = 0.028, respectively). Results were consistent after multivariable regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences. In a multivariable model, multivessel PCI was independently associated with reduced risk of 1-year all-cause death and patient-oriented composite outcome.Conclusions: Of patients with STEMI and multivessel disease with cardiogenic shock, multivessel PCI was associated with a significantly lower risk of all-cause death and non-IRA repeat revascularization. Our data suggest that multivessel PCI for complete revascularization is a reasonable strategy to improve outcomes in patients with STEMI with cardiogenic shock. [ABSTRACT FROM AUTHOR]

Background: Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease.Objectives: This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI.Methods: Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI.Results: Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74).Conclusions: Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients. [ABSTRACT FROM AUTHOR]

Background: Early outcomes of patients in the PRAGUE-18 (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction) study did not find any significant differences between 2 potent P2Y12 inhibitors.Objectives: The 1-year follow-up of the PRAGUE-18 study focused on: 1) a comparison of efficacy and safety between prasugrel and ticagrelor; and 2) the risk of major ischemic events related to an economically motivated post-discharge switch to clopidogrel.Methods: A total of 1,230 patients with acute myocardial infarction (MI) treated with primary percutaneous coronary intervention were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The combined endpoint was cardiovascular death, MI, or stroke at 1 year. Because patients had to cover the costs of study medication after hospital discharge, some patients decided to switch to clopidogrel.Results: The endpoint occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; 95% confidence interval: 0.742 to 1.835; p = 0.503). No significant differences were found in: cardiovascular death (3.3% vs. 3.0%; p = 0.769), MI (3.0% vs. 2.5%; p = 0.611), stroke (1.1% vs. 0.7%; p = 0.423), all-cause death (4.7% vs. 4.2%; p = 0.654), definite stent thrombosis (1.1% vs. 1.5%; p = 0.535), all bleeding (10.9% vs. 11.1%; p = 0.999), and TIMI (Thrombolysis In Myocardial Infarction) major bleeding (0.9% vs. 0.7%; p = 0.754). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n = 216) for prasugrel and 44.4% (n = 265) for ticagrelor (p = 0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major cardiovascular events; however, they also had lower ischemic risk.Conclusions: Prasugrel and ticagrelor are similarly effective during the first year after MI. Economically motivated early post-discharge switches to clopidogrel were not associated with an increased risk of ischemic events. (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction [PRAGUE-18]; NCT02808767). [ABSTRACT FROM AUTHOR]

Objectives: The goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events. Background: Early IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI). Methods: The METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up. Results: Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046). Conclusions: In patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The METOCARD-CNIC Trial; NCT01311700) [ABSTRACT FROM AUTHOR]

Background: The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate.Objectives: The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.Methods: The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.Results: A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001).Conclusions: Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Population-based studies generally show J-shaped associations between alcohol intake and mortality from cardiovascular disease (CVD). Little is known about alcohol and long-term mortality risk after myocardial infarction (MI). Objectives We examined alcohol intake in relation to all-cause, CVD, and ischemic heart disease (IHD) mortality in Dutch post-MI patients of the Alpha Omega Cohort. Methods The analysis comprised 4365 patients (60–80 years; 79% male) with an MI  ≤ 10 years before study enrolment. We used a 203-item FFQ to assess alcohol (total ethanol) and dietary intakes over the past month. Patients were classified as nondrinkers (0 g/d; n  = 956) or very light (>0 to 2 g/d; n  = 385), light (M: >2 to 10 g/d; F: >2 to 5 g/d; n  = 1125), moderate (M: >10 to 30 g/d; F: >5 to 15 g/d; n  = 1207), or heavy drinkers (M: >30 g/d; F: >15 g/d; n  = 692). HRs of mortality for alcohol intake were obtained from Cox models, adjusting for age, sex, education, smoking, BMI, physical activity, and dietary factors. Results Alcohol was consumed by 83% of males and 61% of females. During ∼12 years of follow-up, 2035 deaths occurred, of which 903 were from CVD and 558 were from IHD. Compared to the (combined) reference group of nondrinkers and very light drinkers, HRs for all-cause mortality were 0.87 (95% CI, 0.78–0.98), 0.85 (95% CI, 0.75–0.96), and 0.91 (95% CI, 0.79–1.04) for light, moderate, and heavy drinkers, respectively. For CVD mortality, corresponding HRs were 0.80 (95% CI, 0.67–0.96), 0.82 (95% CI, 0.69–0.98), and 0.87 (95% CI, 0.70–1.08) for light, moderate, and heavy drinkers, respectively. Findings for IHD mortality were similar. HRs did not materially change when nondrinkers or very light drinkers were taken as the reference, or after exclusion of former drinkers or patients with diabetes or poor/moderate self-rated health. Conclusions Light and moderate alcohol intakes were inversely associated with mortality risk in stable post-MI patients. These observational findings should be cautiously interpreted in light of the total evidence on alcohol and health. The Alpha Omega Cohort is registered at clinicaltrials.gov as NCT03192410. [ABSTRACT FROM AUTHOR]

Objectives: Using optical coherence tomography, we assessed the proportion of uncovered struts at 6-month follow-up in zotarolimus-eluting stents (ZES), specifically Endeavor (Medtronic CardioVascular, Santa Rosa, California) stents, and identical bare-metal stents (BMS) implanted in patients with ST-segment elevation myocardial infarction (STEMI). Background: Sirolimus- and paclitaxel-eluting stents implanted in STEMI have been associated with delayed healing and incomplete strut coverage. ZES are associated with a more complete and uniform strut coverage in stable patients, but whether this holds true also after STEMI is unknown. Methods: Forty-four patients with STEMI who underwent primary PCI were randomized to ZES or BMS (3:1 randomization). Angiographic, intravascular ultrasound, and optical coherence tomography follow-up was conducted at 6 months and clinical follow-up at 1 year. All images were analyzed by an independent core laboratory that was blind to stent assignments. Results: There were no differences between ZES and BMS in percentage of uncovered struts (median: 0.00% [interquartile range (IQR): 0.00% to 1.78%] vs. 1.98% [IQR: 0.21% to 7.33%], p = 0.13), maximum length of uncovered segments (0.00 [IQR: 0.00 to 1.19] mm vs. 1.38 [IQR: 0.65 to 3.30] mm, p = 0.10), percentage of malapposed struts (0.00% [IQR: 0.00% to 0.23%] vs. 0.15% [IQR: 0.00% to 5.81%], p = 0.16), and maximum length of malapposed segments (0.00 [IQR: 0.00 to 0.67] mm vs. 0.33 [IQR: 0.00 to 2.55] mm, p = 0.20). Neointimal response was similar between ZES and BMS (332 [IQR: 240 to 429] μm vs. 186 [IQR: 136 to 348] μm, p = 0.99) and evenly distributed. No late acquired malapposition was observed in both groups. There were no deaths, myocardial infarction, or stent thromboses at 1 year. Conclusions: This optical coherence tomography study found no difference in strut coverage and similar vessel response to ZES, when compared with identical BMS, implanted during primary percutaneous coronary intervention in STEMI patients. (Six-Month Coverage and Vessel Wall Response of the Zotarolimus Drug-Eluting Stent Implanted in AMI Assessed by Optical Coherence Tomography [OCTAMI]; NCT00704561) [Copyright &y& Elsevier]

Objectives: The aim of this randomized, single-blind, controlled trial was to assess N-acetylcysteine effects on contrast-induced nephropathy and reperfusion injury in ST-segment elevation myocardial infarction patients undergoing primary angioplasty with moderate contrast volumes. Background: High-dose N-acetylcysteine reduced the incidence of contrast-induced nephropathy in patients with high contrast volumes and reduced reperfusion injury in animal trials. Methods: Patients undergoing primary angioplasty were randomized to either high-dose N-acetylcysteine (2 × 1,200 mg/day for 48 h; n = 126) or placebo plus optimal hydration (n = 125). The 2 primary end points were: 1) the occurrence of >25% increase in serum creatinine level <72 h after randomization; and 2) a reduction in reperfusion injury measured as myocardial salvage index by magnetic resonance imaging. Results: The median volume of an iso-osmolar contrast agent during angiography was 180 ml (interquartile range [IQR] 140 to 230 ml) in the N-acetylcysteine and 160 ml (IQR 120 to 220 ml) in the placebo group (p = 0.20). The primary end point contrast-induced nephropathy occurred in 14% of the N-acetylcysteine group and in 20% of the placebo group (p = 0.28). The myocardial salvage index was also not different between both treatment groups (43.5; IQR 25.4 to 71.9 vs. 51.5; IQR 29.5 to 75.3; p = 0.36). Activated oxygen protein products and oxidized low-density lipoprotein as markers for oxidative stress were reduced by as much as 20% in the N-acetylcysteine group (p < 0.05), whereas no change was evident in the placebo group. Conclusions: High-dose intravenous N-acetylcysteine reduces oxidative stress. However, it does not provide an additional clinical benefit to placebo with respect to CIN and myocardial reperfusion injury in nonselected patients undergoing angioplasty with moderate doses of contrast medium and optimal hydration. (Myocardial Salvage and Contrast Dye Induced Nephropathy Reduction by N-Acetylcysteine [LIPSIA-N-ACC]; NCT00463749) [Copyright &y& Elsevier]

Objectives: The aim of this study was to evaluate whether thrombectomy during primary percutaneous coronary intervention (pPCI) in patients with high thrombus burden improves myocardial reperfusion and reduces infarct size. Background: Thrombectomy aims at reducing distal thrombotic embolization during pPCI, improving myocardial reperfusion and clinical outcome. Methods: We randomized 208 patients with high thrombus burden in a 1:1 ratio to either pPCI with thrombectomy (Group T) or standard pPCI (Group S). Thrombectomy was performed with either rheolytic or manual aspiration catheters. Three-month magnetic resonance imaging was performed to assess infarct size and transmurality and microvascular obstruction (MVO). The primary endpoints were ST-segment elevation resolution (STR) >70% at 60 min and 3-month infarct size. Results: The baseline profile was similar between groups, except for a higher rate of initial Thrombolysis In Myocardial Infarction flow grade 3 in Group S (p = 0.002). Group T showed a significantly higher rate of STR (57.4% vs. 37.3%; p = 0.004) and of final myocardial blush 3 (68.3% vs. 52.9%; p = 0.03). Group T and Group S did not differ with regard to infarct size (20.4 ± 10.5% vs. 19.3 ± 10.6%; p = 0.54) and transmurality (11.9 ± 12.0% vs. 11.6 ± 12.7%; p = 0.92), but Group T showed significantly less MVO (11.4% vs. 26.7%; p = 0.02) and a higher prevalence of inhomogeneous scar (p < 0.0001). One-year freedom from major adverse cardiac events was similar between groups. Conclusions: Thrombectomy as an adjunct to pPCI in patients with high thrombus load yielded better post-procedural STR and reduced MVO at 3 months but was not associated with a reduction in infarct size and transmurality. Thromboaspiration in Patients With High Thrombotic Burden Undergoing Primary Percutaneous (Coronary Intervention; NCT01472718) [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this trial was to study the effect of a high bolus dose (HBD) of tirofiban on clinical outcome in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). Background: The On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2) placebo-controlled, double-blind, randomized trial showed that early administration of HBD tirofiban in the ambulance improves ST-segment resolution in patients with STEMI undergoing primary percutaneous coronary intervention. The effect of early tirofiban treatment on clinical outcome is unclear. Methods: The On-TIME 2 trial consisted of 2 phases: an open-label phase, followed by a double-blind, placebo-controlled phase. STEMI patients were randomized to either HBD tirofiban or no tirofiban (phase 1) or placebo (phase 2) in addition to aspirin, heparin, and high-dose clopidogrel. The protocol pre-specified a pooled analysis of the 2 study phases to assess the incidence of major adverse cardiac events at the 30-day follow-up and on total mortality at the 1-year follow-up. Results: During a 3-year period, 1,398 patients were randomized, 414 in phase 1 and 984 in phase 2. Major adverse cardiac events at 30 days were significantly reduced (5.8% vs. 8.6%, p = 0.043). There was a strong trend toward a decrease in mortality (2.2% vs. 4.1%, p = 0.051) in patients who were randomized to tirofiban pre-treatment, which was maintained during the 1-year follow-up (3.7% vs. 5.8%, p = 0.08). No clinically relevant difference in bleeding was observed. Conclusions: Early, pre-hospital initiation of HBD tirofiban, in addition to high-dose clopidogrel, improves the clinical outcome after primary percutaneous coronary intervention in patients with STEMI. (Ongoing 2b/3a inhibition In Myocardial infarction Evaluation; ISRCTN06195297) [Copyright &y& Elsevier]

Objectives: Early identification of myocardial infarction in chest pain patients is crucial to identify patients at risk and to maintain a fast treatment initiation. Background: The aim of the current investigation is to test whether determination of copeptin, an indirect marker for arginin-vasopressin, adds diagnostic information to cardiac troponin in early evaluation of patients with suspected myocardial infarction. Methods: Between January 2007 and July 2008, patients with suspected acute coronary syndrome were consecutively enrolled in this multicenter study. Copeptin, troponin T (TnT), myoglobin, and creatine kinase-myocardial band were determined at admission and after 3 and 6 h. Results: Of 1,386 (66.4% male) enrolled patients, 299 (21.6%) had the discharge diagnosis of acute myocardial infarction, 184 (13.3%) presented with unstable angina, and in 903 (65.2%) an acute coronary syndrome could be excluded. Combined measurement of copeptin and TnT on admission improved the c-statistic from 0.84 for TnT alone to 0.93 in the overall population and from 0.77 to 0.9 in patients presenting within 3 h after chest pain onset (CPO) (p < 0.001). In this group the combination of copeptin with a conventional TnT provided a negative predictive value of 92.4%. Conclusions: In triage of chest pain patients, determination of copeptin in addition to troponin improves diagnostic performance, especially early after CPO. Combined determination of troponin and copeptin provides a remarkable negative predictive value virtually independent of CPO time and therefore aids in early and safe rule-out of myocardial infarction. [Copyright &y& Elsevier]

Background The benefits and risks of prolonged dual antiplatelet therapy may be different for patients with acute myocardial infarction (MI) compared with more stable presentations. Objectives This study sought to assess the benefits and risks of 30 versus 12 months of dual antiplatelet therapy among patients undergoing coronary stent implantation with and without MI. Methods The Dual Antiplatelet Therapy Study, a randomized double-blind, placebo-controlled trial, compared 30 versus 12 months of dual antiplatelet therapy after coronary stenting. The effect of continued thienopyridine on ischemic and bleeding events among patients initially presenting with versus without MI was assessed. The coprimary endpoints were definite or probable stent thrombosis and major adverse cardiovascular and cerebrovascular events (MACCE). The primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries) moderate or severe bleeding. Results Of 11,648 randomized patients (9,961 treated with drug-eluting stents, 1,687 with bare-metal stents), 30.7% presented with MI. Between 12 and 30 months, continued thienopyridine reduced stent thrombosis compared with placebo in patients with and without MI at presentation (MI group, 0.5% vs. 1.9%, p < 0.001; no MI group, 0.4% vs. 1.1%, p < 0.001; interaction p = 0.69). The reduction in MACCE for continued thienopyridine was greater for patients with MI (3.9% vs. 6.8%; p < 0.001) compared with those with no MI (4.4% vs. 5.3%; p = 0.08; interaction p = 0.03). In both groups, continued thienopyridine reduced MI (2.2% vs. 5.2%, p < 0.001 for MI; 2.1% vs. 3.5%, p < 0.001 for no MI; interaction p = 0.15) but increased bleeding (1.9% vs. 0.8%, p = 0.005 for MI; 2.6% vs. 1.7%, p = 0.007 for no MI; interaction p = 0.21). Conclusions Compared with 12 months of therapy, 30 months of dual antiplatelet therapy reduced the risk of stent thrombosis and MI in patients with and without MI, and increased bleeding. (The Dual Antiplatelet Therapy Study [The DAPT Study]; NCT00977938 ) [ABSTRACT FROM AUTHOR]

BACKGROUND Public reporting of procedural outcomes may create disincentives to provide percutaneous coronary intervention (PCI) for critically ill patients. OBJECTIVES This study evaluated the association between public reporting with procedural management and outcomes among patients with acute myocardial infarction (AMI). METHODS Using the Nationwide Inpatient Sample, we identified all patients with a primary diagnosis of AMI in states with public reporting (Massachusetts and New York) and regionally comparable states without public reporting (Connecticut, Maine, Maryland, New Hampshire, Rhode Island, and Vermont) between 2005 and 2011. Procedural management and in-hospital outcomes were stratified by public reporting. RESULTS Among 84,121 patients hospitalized with AMI, 57,629 (69%) underwent treatment in a public reporting state. After multivariate adjustment, percutaneous revascularization was performed less often in public reporting states than in nonreporting states (odds ratio [OR]: 0.81, 95% confidence interval [Cl]: 0.67 to 0.96), especially among older patients (OR: 0.75, 95% Cl: 0.62 to 0.91), those with Medicare insurance (OR: 0.75, 95% Cl: 0.62 to 0.91), and those presenting with ST-segment elevation myocardial infarction (OR: 0.63, 95% Cl: 0.56 to 0.71) or concomitant cardiac arrest or cardiogenic shock (OR: 0.58, 95% Cl: 0.47 to 0.70). Overall, patients with AMI in public reporting states had higher adjusted in-hospital mortality rates (OR: 1.21, 95% Cl: 1.06 to 1.37) than those in nonreporting states. This was observed predominantly in patients who did not receive percutaneous revascularization in public reporting states (adjusted OR: 1.30, 95% Cl: 1.13 to 1.50), whereas those undergoing the procedure had lower mortality (OR: 0.71, 95% Cl: 0.62 to 0.83). CONCLUSIONS Public reporting is associated with reduced percutaneous revascularization and increased in-hospital mortality among patients with AMI, particularly among patients not selected for PCI. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to investigate whether FX06 would limit infarct size when given as an adjunct to percutaneous coronary intervention. Background: FX06, a naturally occurring peptide derived from human fibrin, has been shown to reduce myocardial infarct size in animal models by mitigating reperfusion injury. Methods: In all, 234 patients presenting with acute ST-segment elevation myocardial infarction were randomized in 26 centers. FX06 or matching placebo was given as intravenous bolus at reperfusion. Infarct size was assessed 5 days after myocardial infarction by late gadolinium enhanced cardiac magnetic resonance imaging. Secondary outcomes included size of necrotic core zone and microvascular obstruction at 5 days, infarct size at 4 months, left ventricular function, troponin I levels, and safety. Results: There were no baseline differences between groups. On day 5, there was no significant difference in total late gadolinium enhanced zone in the FX06 group compared with placebo (reduction by 21%; p = 0.207). The necrotic core zone, however, was significantly reduced by 58% (median 1.77 g [interquartile range 0.0, 9.09 g] vs. 4.20 g [interquartile range 0.3, 9.93 g]; p < 0.025). There were no significant differences in troponin I levels (at 48 h, −17% in the FX06 group). After 4 months, there were no longer significant differences in scar size. There were numerically fewer serious cardiac events in the FX06-treated group, and no differences in adverse events. Conclusions: In this proof-of-concept trial, FX06 reduced the necrotic core zone as one measure of infarct size on magnetic resonance imaging, while total late enhancement was not significantly different between groups. The drug appears safe and well tolerated. (Efficacy of FX06 in the Prevention of Myocardial Reperfusion Injury [F.I.R.E.]; NCT00326976) [Copyright &y& Elsevier]

Background: It is generally considered that patients with prior myocardial infarction (PMI) have worse outcomes than those without PMI after coronary artery bypass grafting (CABG). However, any difference in outcomes of patients with anterior or inferior PMI undergoing CABG has never been determined. Methods: We retrospectively reviewed the records of 310 patients with anterior or inferior PMI who underwent isolated CABG between September 2004 and September 2008. Of these, 151 patients had anterior PMI (anterior group), and 159 patients had inferior PMI (inferior group). Preoperative and postoperative variables were compared between the groups. Multivariate logistic regression analysis was used to identify independent predictors of major postoperative complications including death. Results: Patients of the inferior group were significantly older (68.3 ± 9.2 vs 65.5 ± 11.0; p = 0.015) and had more diseased vessels per patient (2.9 ± 0.3 vs 2.8 ± 0.5; p = 0.009) than the anterior group. A higher rate of mild or moderate mitral regurgitation was observed in the inferior group (18.2% vs 8.6%; p = 0.0209). The operative mortality was higher in the inferior group (5.0% vs 0%; p = 0.0073). Rates of respiratory failure (6.9% vs 0.7%; p = 0.0199) and requirement for hemodialysis (5.7% vs 0.7%; p = 0.0056) were higher in the inferior group. Multivariate analysis revealed inferior PMI (p = 0.0068) as the only independent predictor of major postoperative complications including death. Conclusions: The present study indicates that patients with inferior PMI have poorer outcomes after isolated CABG than those with anterior PMI. [Copyright &y& Elsevier]

Objectives: In the present study, we investigated the association of pathological Q waves with infarct size. Furthermore, we investigated whether Q-wave regression was associated with improvement of left ventricular ejection fraction (LVEF), infarct size, and left ventricular dimensions in ST-segment elevation myocardial infarction (STEMI) patients with early Q-wave formation compared with patients without or persistent pathological Q waves. Background: The criteria for pathological Q waves after acute myocardial infarction (MI) have changed over the years. Also, there are limited data regarding correlation of Q-wave regression and preservation of LVEF in patients with an initial Q-wave MI. Methods: Standard 12-lead electrocardiograms (ECGs) were recorded in 184 STEMI patients treated with primary percutaneous coronary intervention (PCI). ECGs were recorded before and following PCI, as well as at 1, 4, 12, and 24 months of follow-up. An ECG was scored as Q-wave MI when it showed Q waves in 2 or more contiguous leads according to the 4 readily available clinical definitions used over the years: “classic” criteria, Thrombolysis In Myocardial Infarction criteria, and 2000 and 2007 consensus criteria. Cardiac magnetic resonance (CMR) examination was performed at 4 ± 2 days after reperfusion and repeated after 4 and 24 months. Contrast-enhanced CMR was performed at baseline and 4 months. Results: The classic ECG criteria showed strongest correlation with infarct size as measured by CMR. The incidence of Q-wave MI according to the classic criteria was 23% 1 h after PCI. At 24 months of follow-up, 40% of patients with initial Q-wave MI displayed Q-wave regression. Patients with a Q-wave MI had larger infarct size and lower LVEF on baseline CMR (24 ± 10% LV mass and 37 ± 8%, respectively) compared with patients with non–Q-wave MI (17 ± 9% LV mass, p < 0.01, and 45 ± 8%, p < 0.001, respectively). Patients with Q-wave regression displayed significantly larger LVEF improvement in 24 months (9 ± 11%) as compared with both persistent Q-wave MI (2 ± 8%) as well as non–Q-wave MI (3 ± 8%, p = 0.04 for both comparisons). Conclusions: Association of Q waves with infarct size is strongest when using the classic Q-wave criteria. Q-wave regression is associated with the largest improvement of LVEF as assessed with CMR. [Copyright &y& Elsevier]

Objectives: Our aim was to investigate cardiac expression of placental growth factor (PlGF) and its clinical significance in patients with acute myocardial infarction (AMI). Background: Placental growth factor is known to stimulate wound healing by activating mononuclear cells and inducing angiogenesis. The clinical significance of PlGF in AMI is not yet known. Methods: Fifty-five AMI patients and 43 control subjects participated in the study. Peripheral blood sampling was performed on days 1, 3, and 7 after AMI. Blood was also sampled from the coronary artery (CAos) and the coronary sinus (CS), before and after acute coronary recanalization. Cardiac expression of PlGF was analyzed in a mouse AMI model. Results: In AMI patients, peripheral plasma PlGF levels on day 3 were significantly higher than in control subjects. Plasma PlGF levels just after recanalization were significantly higher in the CS than the CAos, which indicates cardiac production and release of PlGF. Peripheral plasma levels of PlGF on day 3 were negatively correlated with the acute phase left ventricular ejection fraction (LVEF), positively correlated with both acute phase peak peripheral monocyte counts and chronic phase changes in LVEF. Placental growth factor messenger ribonucleic acid expression was 26.6-fold greater in a mouse AMI model than in sham-operated mice, and PlGF was expressed mainly in endothelial cells within the infarct region. Conclusions: Placental growth factor is rapidly produced in infarct myocardium, especially by endothelial cells during the acute phase of myocardial infarction. Placental growth factor might be over-expressed to compensate the acute ischemic damage, and appears to then act to improve LVEF during the chronic phase. [Copyright &y& Elsevier]

Objectives: The purpose of this study was to investigate the hypothesis that circulation via collateral vessels to an infarct-related artery (IRA) is impaired with aging in patients with acute myocardial infarction (AMI).Background: Animal experiments have shown that advanced age blunts the development of new vessels in response to angiogenic cytokines.Methods: Of 3,573 consecutive patients with AMI, 1,934 patients who fulfilled the following criteria were enrolled in this study: 1) coronary angiograms were obtained within 72 h after the onset of AMI; and 2) IRA showed complete occlusion (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 or 1). Collaterals to the IRA were angiographically evaluated using the Rentrop score. Rentrop scores 1 to 3 were defined as demonstrating significant collaterals.Results: The prevalence of collaterals decreased with age, from 47.9%, 45.8%, 43.4%, to 34.0% in patients <50 years, 50 to 59 years, 60 to 69 years, ≥70 years, respectively (p < 0.001). Advanced age was an independent factor predicting the absence of collateral circulation to the IRA. In contrast, time to catheterization, history of angina pectoris, and preinfarction angina were independent predictors for the presence of collaterals. Multivariate analysis showed that the absence of collaterals was an independent predictor of in-hospital mortality in elderly patients ≥70 years (odds ratio, 15.6; 95% confidence interval, 3.5 to 69.6), although this finding was not significant in patients <70 years.Conclusions: Advanced age is associated with decreased angiographic presence of collaterals to the IRA in patients with AMI. This abnormality may contribute to the poor prognosis of elderly patients with AMI. [Copyright &y& Elsevier]

Background: Circadian variation has been accepted as a factor in acute myocardial infarction (AMI). An increased incidence of cardiac events in the morning has been reported for a long time. Recent reports have indicated that the onset of AMI shows two peaks, which occur in the morning and evening. It has also been demonstrated that circadian pattern of AMI may vary with sex and age. Methods and results: We investigated 522 consecutive patients who underwent primary per-cutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) between 2000 and 2010. The patients were classified into 3 age groups: younger (≤59 years old), intermediate (60-79 years old), and older (≥80 years old). Clinical data were investigated, including the age and sex, angiographic characteristics, and time of onset of STEMI. There were two peaks in the onset of STEMI throughout the day, which were at 7:00-10:00 and 19:00-21:00h, among all patients (male and female). Stratified analysis showed that older females formed the main part of the second peak. Conclusions: There were two peaks in the onset of STEMI in a Japanese population in Tokyo. The second peak was significantly dominated by the older female group. Age and gender influenced the second peak in the circadian variation of AMI in a Japanese population in Tokyo. [ABSTRACT FROM AUTHOR]

Objectives: This study examined the degree to which hospital performance for acute myocardial infarction (AMI) and heart failure (HF) care processes are correlated. Background: Although AMI and HF care processes may be amenable to similar quality improvement interventions, whether these are indeed correlated and whether hospitals with consistently superior performance for both care metrics have the best outcomes remains unknown. Methods: We compared hospital performance of the Centers for Medicare & Medicaid Services AMI and HF core measures in 283 hospitals submitting 10 or more patients to the Get With The Guidelines AMI and HF programs between January 2005 and April 2009. Results: Median hospital adherence to AMI and HF composite measures were 93% (interquartile range: 87% to 97%) and 92% (interquartile range: 85% to 96%), respectively, with only a modest correlation between hospital performance on these 2 composite metrics (r = 0.50; 95% confidence interval: 0.41 to 0.58). Hospitals with superior performance to both AMI and HF processes had significantly longer duration of Get With The Guidelines participation and lower adjusted in-hospital mortality (odds ratio: 0.79; 95% confidence interval: 0.63 to 0.99) for AMI and HF patients, whereas hospitals with superior adherence to either alone had similar mortality rates as hospitals with superior adherence to neither measure. Conclusions: Hospitals that had consistent, superior performance for both AMI and HF care had significantly lower risk-adjusted mortality than those with superior performance either alone or for neither measure. Whether a single scoring system to assess global, rather than condition-specific, quality of cardiovascular care would facilitate care quality improvement more consistently and would optimize patient outcomes merits further investigation. [ABSTRACT FROM AUTHOR]

Objectives: We hypothesized that infarct transmurality assessed with late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) predicts arrhythmic events in patients with chronic myocardial infarction. Background: Patients with decreased left ventricular function due to chronic myocardial infarction are at increased risk for life-threatening arrhythmias related to infarcted tissue. LGE-CMR accurately detects infarct morphology. Methods: We prospectively enrolled 52 patients with chronic myocardial infarction referred for primary preventive implantable cardioverter-defibrillator (ICD) implantation following MADIT (Multicenter Automatic Defibrillator Implantation Trial) study criteria. Using LGE-CMR, left ventricular volumes, function, and infarct morphology were assessed including calculation of total and relative infarct mass, infarct border, infarct border zone, and infarct transmurality. Results: Patients were followed for 1,235 ± 341 days. The primary combined endpoint including appropriate device therapy (ICD discharge or antitachycardia pacing) or death from cardiac cause occurred in 16 individuals resulting in an annual event rate of 4.7%. Six patients received an appropriate shock, 7 patients received recurrent appropriate antitachycardia pacing for sustained ventricular tachycardia, and 3 patients died of cardiac cause. There was a significant association to relative infarct mass (38 ± 8% vs. 28 ± 14%, p = 0.02), infarct transmurality (24 ± 8 g vs. 16 ± 12 g, p = 0.02), and relative infarct transmurality (RIT) (63 ± 12% vs. 48 ± 23%, p = 0.01). In separate logistic regression models, no variable emerged as significant when combined with RIT. As a single effect, RIT emerged as a predictor of the primary endpoint (p = 0.02). A RIT cutoff at 43% resulted in a sensitivity of 88%, a specificity of 50%, a positive predictive value of 44%, and a negative predictive value of 90%. Conclusions: In patients with chronic myocardial infarction scheduled for primary preventive ICD implantation, infarct transmurality as defined by LGE-CMR identifies a subgroup with increased risk for life-threatening arrhythmias and cardiac death. [Copyright &y& Elsevier]

Objectives: The purpose of this study was to examine the association between lower socioeconomic status (SES), as ascertained by years of education, and outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI). Background: Previous studies have shown an inverse relationship between SES and coronary heart disease and mortality. Whether a similar association between SES and mortality exists in STEMI patients is unknown. Methods: We evaluated 11,326 patients with STEMI in the GUSTO-III (Global Use of Strategies to Open Occluded Coronary Arteries) trial study from countries that enrolled >500 patients. We evaluated clinical outcomes (adjusted using multivariate regression analysis) according to the number of years of education completed. Results: One-year mortality was inversely related to years of education and was 5-fold higher in patients with <8 years compared with those with >16 years of education (17.5% vs. 3.5%, p < 0.0001). The strength of the relationship between education and mortality varied among different countries. Nonetheless, years of education remained an independent correlate of mortality at day 7 (hazard ratio per year of increase in education: 0.86; 95% confidence interval: 0.83 to 0.88) and also between day 8 and 1 year (hazard ratio per year of increase in education: 0.96; 95% confidence interval: 0.94 to 0.98), even after adjustment for baseline characteristics and country of enrollment. Conclusions: When the number of years of education was used as a measure of SES, there was an inverse relationship such that significantly higher short-term and 1-year mortality existed beyond that accounted for by baseline clinical variables and country of enrollment. Future studies should account for and investigate the mechanisms underlying this link between SES and cardiovascular disease outcomes. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to evaluate the impact of SYNTAX score (SXscore), and compare its performance in isolation and combination with the PAMI (The Primary Angioplasty in Myocardial Infarction Study) score, for the prediction of 1-year clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. Background: Patients with STEMI were excluded from the original SYNTAX score (SXscore) algorithm. Therefore, the utility of using the SXscore in this patient group remains undefined. Methods: SXscore was calculated retrospectively in 807 patients with STEMI enrolled in the randomized STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute Myocardial Infarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute Myocardial Infarction Study) clinical trials. Clinical outcomes of all-cause death, reinfarction, and clinically driven target vessel revascularization were subsequently stratified according to SXscore tertiles: SXLOW ≤9 (n = 311), 9 < SXMID ≤16 (n = 234), SXHIGH >16 (n = 262). Results: At 1-year follow-up, all clinical outcomes including mortality, mortality/reinfarction, major adverse cardiac events (MACE) (a composite of all-cause death, reinfarction and target vessel revascularization), and definite, definite/probable, and any stent thrombosis were all significantly higher in patients in the highest SXscore tertile. SXscore was identified as an independent predictor of mortality, MACE, and stent thrombosis out to 1-year follow-up. The combination SYNTAX-PAMI score led to a net reclassification improvement of 15.7% and 4.6% for mortality and MACE, respectively. The C-statistics for the SXscore, PAMI score, and the combined SYNTAX-PAMI score were 0.65, 0.81, and 0.73 for 1-year mortality, and 0.68, 0.64, and 0.69 for 1-year MACE, respectively. Conclusions: SXscore does have a role in the risk stratification of patients with STEMI having primary percutaneous coronary intervention; however, this ability can be improved through a combination with clinical variables. (Multicentre 2×2 Factorial Randomised Study Comparing Tirofiban Versus Abciximab and SES Versus BMS in AMI; NCT00229515) [Copyright &y& Elsevier]

Objectives: These studies sought to investigate the impact on mortality of coronary flow after passage of the wire through the culprit vessel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing mechanical reperfusion. Background: Reduced spontaneous coronary flow before percutaneous coronary intervention influences mortality in patients with STEMI. Response to vessel wiring in patients with an occluded coronary artery before intervention might further discriminate outcomes irrespective of pre- and post-intervention coronary flow. Methods: Data from the STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute Myocardial Infarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute Myocardial Infarction Study) trials were pooled: of 919 index procedures, 902 films (98%) were technically adequate for core laboratory TIMI (Thrombolysis In Myocardial Infarction) flow determination. Results: TIMI flow grade 0 was present before percutaneous coronary intervention in 59% of infarct vessels, TIMI flow grade 1 to 2 was found in 21%, whereas the remainder of infarct arteries presented with TIMI flow grade 3. In 49% of patients who showed persistent TIMI flow grade 0 after wire insertion (AWI), mortality was higher at 30 days (5.3%) and 1 year (9.4%) compared with patients in whom TIMI flow grade before percutaneous coronary intervention was either >0 (0.8%; p < 0.003 and 3.6%, p < 0.008) or improved from 0 AWI (1.5%, p < 0.04 and 3.6%, p < 0.02). After correcting for multiple imbalances, including baseline and final flow, persistent TIMI flow grade 0 AWI remained associated at 30 days to 2-fold (risk ratio [RR]: 2.1, 95% confidence interval [CI]: 1.08 to 5.00; p = 0.038) and at 1 year to almost 3-fold increases of mortality (RR: 2.7, 95% CI: 1.3 to 5.6; p = 0.008). Conclusions: STEMI patients displaying persistent no-flow AWI have a lower survival rate despite an apparently successful mechanical intervention. As an early marker for high residual mortality risk, persistent no-flow AWI may qualify STEMI patients for dedicated pharmacomechanical treatment strategies. [Copyright &y& Elsevier]

Objectives: We investigated the reliability of fractional flow reserve (FFR) of nonculprit coronary stenoses during percutaneous coronary intervention (PCI) in acute myocardial infarction. Background: Assessing the hemodynamic severity of the nonculprit coronary artery stenoses at the acute phase of a myocardial infarction could improve risk stratification and shorten the diagnostic work-up. Methods: One hundred one patients undergoing PCI for an acute myocardial infarction (n = 75 with ST-segment elevation myocardial infarction [STEMI], and n = 26 with non–ST-segment elevation myocardial infarction) were prospectively recruited. The FFR measurements in 112 nonculprit stenoses were obtained immediately after PCI of the culprit stenosis and were repeated 35 ± 4 days later. In addition, left ventricular ejection fraction, quantitative coronary angiographic measurements of the nonculprit stenoses, Thrombolysis In Myocardial Infarction (TIMI) flow, corrected TIMI frame count (cTFC), and the index of microcirculatory resistance (n = 14) of the nonculprit vessels were assessed in the acute phase and at control angiogram. Results: The FFR value of the nonculprit stenoses did not change between the acute and follow-up (0.77 ± 0.13 vs. 0.77 ± 0.13, respectively, p = NS). In only 2 patients, the FFR value was higher than 0.8 at the acute phase and lower than 0.75 at follow-up. The TIMI flow, cTFC, percentage diameter stenosis, minimum lumen diameter, and index of microcirculatory resistance did not change. Left ventricular ejection fraction increased significantly in patients with STEMI (from 54 ± 13% to 57 ± 13%, p = 0.03). Conclusions: During the acute phase of acute coronary syndromes, the severity of nonculprit coronary artery stenoses can reliably be assessed by FFR. This allows a decision about the need for additional revascularization and might contribute to a better risk stratification. [ABSTRACT FROM AUTHOR]

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Summary: Background: The risk benefit of percutaneous coronary intervention (PCI) in very elderly patients with acute myocardial infarction (AMI) is currently unclear. Here, we aim to identify the characteristics of these patients and clarify their mid-term mortality rate with or without PCI. Methods and results: 77 patients (≥80 years) were chosen from 506 patients with AMI, and treated with (n =32) or without (n =45) PCI. The mean age and time from onset to admission increased in patients having undergone no PCI. The reasons for PCI refusal were patient/family preference (40%), renal dysfunction (17.8%), or cognitive impairment (13.3%). Patients treated with PCI had lower mid-term mortality than those without PCI (34.4% vs 62.2%; p =0.02), while patients taking β-blockers displayed a significantly lower mortality rate than those without (18.2% vs 63.6%; p =0.0003). Cognitively impaired patients had a higher mortality rate compared with cognitively normal patients (80.0% vs 46.3%; p =0.005). Multivariate analysis indicated that systolic blood pressure on admission, PCI, and β-blocker therapy independently decreased mid-term mortality in these patients. Conclusions: PCI and β-blocker therapy displayed significantly beneficial effects on mid-term mortality in very elderly AMI patients. Elderly-specific trials concerning coexisting disorders are needed to further examine the treatment-related benefits. [Copyright &y& Elsevier]

Objectives: The purpose of this study was to determine whether statin treatment is effective and safe in very elderly (80 years and older) acute myocardial infarction (AMI) patients. Background: Elderly individuals constitute an increasing percentage of patients admitted to hospitals for AMI. Despite that these patients have a higher mortality risk, the application of evidence-based medicine remains much lower than for younger patients. Methods: We included all patients 80 years and older who were admitted with the diagnosis of AMI in the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions between 1999 and 2003 (n = 21,410). Of these, complete covariate and follow-up data were available for 14,907 patients (study population A). To limit the bias related comorbidity on statin therapy, we also performed analyses excluding patients who died within 14 days of the acute event (study population B) and all patients who died within 365 days (study population C). A propensity score was used to adjust for initial differences between treatment groups. Results: All-cause mortality was significantly lower in patients receiving statin treatment at discharge in study population A (relative risk: 0.55, 95% confidence interval: 0.51 to 0.59), in study population B (relative risk: 0.65; 95% confidence interval: 0.60 to 0.71), and in study population C (relative risk: 0.66; 95% confidence interval: 0.59 to 0.76). Similar observations were made for cardiovascular mortality as well as for AMI mortality. There was no increase in cancer mortality in statin-treated patients. Conclusions: Statin treatment is associated with lower cardiovascular mortality in very elderly post-infarction patients without increasing the risk of the development of cancer. [Copyright &y& Elsevier]

Objectives: We tested the hypothesis that residual platelet reactivity after clopidogrel correlates with the extent and severity of coronary atherosclerosis in patients undergoing elective percutaneous coronary intervention (PCI). Background: Platelets are actively involved in vascular atherosclerosis. Methods: We prospectively enrolled 338 patients undergoing PCI for stable angina, loaded with 600-mg clopidogrel. Platelet reactivity was assessed 12 h later by measuring P2Y12 reactivity unit (PRU) with VerifyNow P2Y12 assay (Accumetrics, San Diego, California). High platelet reactivity (HPR) was defined as PRU value ≥240. Presence of multivessel disease (MVD) and total stent length (TSL) were used as surrogate markers of atherosclerosis severity and extension. Results: Patients with MVD showed higher PRU compared with single-vessel disease (SVD) patients (222 ± 85 vs. 191 ± 73; p < 0.001). The PRU increased with the number of stenotic coronaries (1-vessel disease: 191 ± 73; 2-vessel disease: 220 ± 88; 3-vessel disease: 226 ± 80; p = 0.002). The PRU was higher in the third TSL tertile compared with first tertile (217 ± 83 vs. 191 ± 73; p = 0.048). The HPR was most frequently observed among MVD patients (40.5% vs. 21.6% in patients with SVD, respectively; p < 0.001) and those in the third TSL tertile (35.8% vs. 22.2% first tertile; p = 0.028). Higher incidence of periprocedural myocardial infarction was observed in patients with HPR (41.2% vs. 26.7% in patients without HPR; p = 0.008) and in those in the third tertile TSL (37.7% vs. 23.1% first tertile; p = 0.020). By multivariate analysis, HPR was the only independent predictor of periprocedural myocardial infarction (p = 0.034). Conclusions: Patients with more extensive coronary atherosclerosis have a higher rate of HPR, which might partly account for higher risk of periprocedural MI. [Copyright &y& Elsevier]

Objectives: The purpose of the study was to understand determinants of infarct size in a primary percutaneous intervention (PCI) population treated with pexelizumab compared with placebo. Background: In the multicenter APEX-AMI (Pexelizumab in Conjunction With Angioplasty in Acute Myocardial Infarction) trial, pexelizumab did not reduce 90-day mortality. Cardiac magnetic resonance (CMR) with delayed enhancement was used in a substudy evaluating infarct size and left ventricular ejection fraction (LVEF). Methods: Consecutive patients undergoing primary PCI for first myocardial infarction (MI) as part of the APEX-AMI trial were enrolled in this substudy at 5 centers. The CMR was completed on days 3 to 5 (n = 99) and day 90 (n = 83) following PCI. Central core lab-masked analyses for quantified LVEF, volumes, and infarct size by planimetry were performed. Results: Patients were 60 ± 12 years of age, male (n = 83 [84%]), had similar time from symptom onset to presentation (median 2.6 h vs. 2.5 h; p = 1.0), and similar baseline ST-segment deviation (13.5 mm vs. 14 mm; p = 0.59) in both groups. Pexelizumab-treated patients had smaller infarct size (day 3 LV 10.5% vs. 16.2%, p = 0.022; day 90 LV 5.9% vs. 12.4%, p = 0.015) and higher LVEF (day 3 50.3% vs. 46.2%, p = 0.073; day 90 53.9% vs. 49.3%, p = 0.036) compared with placebo-treated patients. The median peak creatine kinase in the pexelizumab group was also significantly less than placebo (922 mg/dl vs. 1,973 mg/dl; p = 0.03). Notably, the pexelizumab group had lower Thrombolysis In Myocardial Infarction (TIMI) flow grade pre-PCI (46.9% vs. 75.0%; p = 0.018), a difference not seen in the overall APEX-AMI study. A multivariate model including baseline features and pexelizumab treatment found anterior MI location and pre-PCI TIMI flow to be significant independent predictors infarct size (p = 0.001), whereas pexelizumab was not (p = 0.29). No death, heart failure, or shock was noted in either substudy group at 90 days. Conclusions: In a CMR substudy of pexelizumab in MI, baseline TIMI flow grade and anterior location were the only predictors of infarct size, with a reduction of pre-PCI TIMI flow grade 0 by 28%, leading to a 35% reduction in infarct size. (The APEX-AMI Trial; NCT00091637) [Copyright &y& Elsevier]

Objectives: Our aim was to examine the prognostic importance of hemorrhagic and ischemic complications after percutaneous coronary intervention (PCI) in unselected patients. Background: In randomized trials of PCI, major bleeding and periprocedural myocardial infarction (pMI) have been associated with increased mortality. Whether similar associations exist among un-selected PCI patients is unknown. Methods: We used data from the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) registry—a multicenter registry of unselected patients undergoing PCI—to examine the association between both in-hospital bleeding and pMI and 1-year mortality. Cardiac enzyme levels were assessed in all patients, and pMI was defined as a peak creatine kinase-MB value ≥3× the upper limit of normal. Post-PCI bleeding was classified by Thrombolysis In Myocardial Infarction criteria. Results: After excluding patients with elevated pre-PCI creatine kinase-MB values and ST-segment elevation myocardial infarction at presentation (n = 1,626), a total of 5,961 patients were available for evaluation. Rates of post-PCI bleeding and pMI were 3.0% and 7.1%, respectively; 1-year all-cause mortality was 2.8%. After multivariable adjustment, both post-PCI bleeding (adjusted hazard ratio [HR]: 3.83, 95% confidence interval: 2.48 to 5.90, p < 0.001) and pMI (adjusted HR: 1.84, 95% confidence interval: 1.17 to 2.89, p = 0.009) were independently associated with 1-year mortality. Time period-specific analyses demonstrated that the adjusted HR for bleeding was similar for 30-day mortality and mortality between 1 month and 1 year, while the adjusted HR for pMI was greater for 30-day mortality as compared with mortality between 1 month and 1 year. Conclusions: Among unselected PCI patients, both post-PCI bleeding and pMI are independently associated with increased 1-year mortality. Continued efforts to reduce these complications after PCI are warranted. [Copyright &y& Elsevier]

Objectives: The goals of this analysis were: 1) to evaluate outcomes among non–ST-segment elevation myocardial infarction (NSTEMI) patients presenting to hospitals with on-site cardiac surgery (OHS hospitals) and without on-site cardiac surgery (No-OHS hospitals); and 2) to specifically examine outcomes among the subset of NSTEMI patients undergoing percutaneous coronary intervention (PCI). Background: Whether backup cardiac surgery improves outcomes among NSTEMI patients or is simply a marker of better adherence to guideline recommendations is unknown. Methods: The NRMI (National Registry of Myocardial Infarction) enrolled 100,071 NSTEMI patients from 2004 to 2006. Outcomes were evaluated in the population as a whole and in propensity-matched analyses in the entire population and in the subset of patients undergoing PCI. Results: In-hospital mortality was significantly lower at OHS hospitals (5.0% vs. 8.8%, p < 0.001). Patients presenting to OHS hospitals were significantly more likely to receive aspirin, beta-blockers, and statins (p < 0.05 for all) and to undergo PCI (38.4% vs. 14.1%, p < 0.001). In the propensity-matched model, the difference in mortality remained significant (5.9% vs. 8.5%, p < 0.001). After adjusting for differences in medications administered within 24 h of arrival and hospital characteristics, the difference in mortality was nearly attenuated (hazard ratio: 0.89, 95% confidence interval: 0.79 to 1.00, p = 0.050). When the propensity-matched model was restricted to patients undergoing PCI, there was no significant difference in mortality (1.3% vs. 1.0%, p = 0.51). Conclusions: NSTEMI patients presenting to No-OHS hospitals have significantly higher mortality. This appears to be due to both modifiable (lower use of guideline-recommended medications) and nonmodifiable factors (hospital size, myocardial infarction volume). In a propensity-matched analysis of patients undergoing PCI for NSTEMI, there was no significant difference in mortality. [Copyright &y& Elsevier]

Objectives: The purpose of this study was to evaluate the effectiveness of combined proximal embolic protection with thrombus aspiration (Proxis Embolic Protection System [St. Jude Medical, St. Paul, Minnesota]) in ST-segment elevation myocardial infarction patients. Background: Embolization during primary percutaneous coronary intervention (PCI) may result in microvascular obstruction, reduced myocardial perfusion, and impaired prognosis. Methods: Two hundred eight-four patients were randomized to primary PCI with the Proxis system versus primary PCI alone after angiography. The primary end point was the occurrence of complete (≥70%) ST-segment resolution (STR) at 60 min measured by continuous ST-segment Holter. Results: There was no significant difference in the occurrence of the primary end point (80% vs. 72%, p = 0.14). However, immediate complete STR (at time of last contrast) occurred in 66% of Proxis-treated patients and 50% in control patients (absolute difference, 16.3%; 95% confidence interval: 4.3% to 28.2%; p = 0.009). A significant lower ST-segment curve area (0 to 3 h after primary PCI) was observed in the Proxis arm (5,192 μV/min vs. 6,250 μV/min, p = 0.037). Major adverse cardiac and cerebral events at 30 days occurred with similar frequency in both groups (6 vs. 10). Conclusions: There was no significant difference in complete STR at 60 min in this proof-of-concept study. However, we observed a significant difference in immediate complete STR in Proxis-treated patients, better STR at later time points, and a reduction of electrocardiogram injury current over time, compared with control patients. The results suggest that primary PCI with the Proxis system may lead to better immediate microvascular flow in ST-segment elevation myocardial infarction patients. (The PREPARE Study; ISRCTN71104460) [Copyright &y& Elsevier]

Objectives: We hypothesized that patients most likely to benefit would be those at high risk with a shorter duration of acute ischemia and who required transfer for percutaneous coronary intervention (PCI). Background: The FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) study failed to demonstrate an improvement in the 90-day composite clinical end point of early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or abciximab alone. Methods: We performed a retrospective analysis of 2,452 patients in this double-blind, placebo-controlled study. Patients were stratified by Thrombolysis In Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI), presentation to a spoke (no PCI available) or hub site, and symptom-to-randomization time. Outcomes included the primary composite end point of death, ventricular fibrillation after 48 h, cardiogenic shock, and congestive heart failure through day 90 as well as 1-year mortality. Results: Mortality for all patients at 1 year was directly related to TIMI risk score (23 of 1,223 = 1.9% in patients with score <3 and 145 of 1,229 = 11.8% with score ≥3, p < 0.001). Patients with TIMI risk score ≥3 and presentation to a spoke site with a symptom-to-randomization time ≤4 h had significantly better 1-year survival if treated with combination-facilitated PCI (hazard ratio [HR]: 0.351, p = 0.01) as well as 90-day composite outcome (HR: 0.45, p = 0.009). A trend for improved survival was also observed in patients with TIMI score ≥3 and spoke site alone (HR: 0.549, p = 0.06). Conclusions: Facilitation of PCI with a combination of abciximab and half-dose reteplase improved survival at 1 year in high-risk patients presenting to a spoke hospital with symptom-to-randomization time ≤4 h. Further prospective study of facilitated PCI in this subgroup of patients is warranted. [Copyright &y& Elsevier]

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Objectives: We examined whether distinct monocyte subsets contribute in specific ways to myocardial salvage in patients with acute myocardial infarction (AMI). Background: Recent studies have shown that monocytes in human peripheral blood are heterogeneous. Methods: We studied 36 patients with primary AMI. Peripheral blood sampling was performed 1, 2, 3, 4, 5, 8, and 12 days after AMI onset. Two monocyte subsets (CD14+CD16− and CD14+CD16+) were measured by flow cytometry. The extent of myocardial salvage 7 days after AMI was evaluated by cardiovascular magnetic resonance imaging as the difference between myocardium at risk (T2-weighted hyperintense lesion) and myocardial necrosis (delayed gadolinium enhancement). Cardiovascular magnetic resonance imaging was also performed 6 months after AMI. Results: Circulating CD14+CD16− and CD14+CD16+ monocytes increased in AMI patients, peaking on days 3 and 5 after onset, respectively. Importantly, the peak levels of CD14+CD16− monocytes, but not those of CD14+CD16+ monocytes, were significantly negatively associated with the extent of myocardial salvage. We also found that the peak levels of CD14+CD16− monocytes, but not those of CD14+CD16+ monocytes, were negatively correlated with recovery of left ventricular ejection fraction 6 months after infarction. Conclusions: The peak levels of CD14+CD16− monocytes affect both the extent of myocardial salvage and the recovery of left ventricular function after AMI, indicating that the manipulation of monocyte heterogeneity could be a novel therapeutic target for salvaging ischemic damage. [Copyright &y& Elsevier]

Objectives: The aim of this study was to investigate the quantitative amount of improvement of ventricular hemodynamic status, geometry, and contractility as well as the long-term clinical outcome of cell-treated patients after acute myocardial infarction (AMI). Background: Animal experiments as well as clinical studies have demonstrated that autologous bone marrow cell (BMC) transplantation might improve ventricular function and prevent remodeling. Methods: Sixty-two patients underwent intracoronary autologous BMC transplantation 7 ± 2 days after AMI. Cells were infused directly into the infarct-related artery. The control group consisted of 62 patients with comparable left ventricular (LV) ejection fraction (EF) and diagnosis. All patients had several examinations (e.g., coronary angiography, right heart catheterization, biplane left ventriculography, electrocardiogram [ECG] at rest and exercise, echocardiography, late potential [LP], heart rate variability [HRV], and 24-h Holter ECG). The therapeutic follow-up was performed 3, 12, and 60 months after BMC therapy. Results: Three months after BMC therapy there was significant improvement of EF and stroke volume index. The infarct size was significantly reduced by 8%. Contraction velocities (lengths/second, volumes/second) increased significantly and the slope of the ventricular function curve (systolic pressure/end-systolic volume) became steeper. There was significant improvement of contractility in the infarct zone, as evidenced by a 31% increase of LV velocity of shortening (VCF), preferably in the border zone of the infarct zone. In contrast, the noninfarcted area showed no difference in VCF before and after BMC therapy. Furthermore, decreases of abnormal HRV, LP, and ectopic beats were documented after BMC therapy. Twelve and 60 months after BMC therapy the parameters of contractility, hemodynamic status, and geometry of the LV were stable. The exercise capacity of treated patients was significantly augmented, and the mortality was significantly reduced in comparison with the control group. Conclusions: BMC therapy leads to significant and longstanding improvements of LV performance as well as quality of life and mortality of patients after AMI. After BMC therapy, no side effects were observed, showing that BMC therapy is safe. [Copyright &y& Elsevier]

Objectives: This study sought to assess of the mobilization of nonhematopoietic very small embryonic-like stem cells (VSELs) in acute myocardial infarction (MI). Background: Acute MI induces mobilization of bone marrow stem cells. Recently, a rare population of VSELs, expressing markers of embryonic pluripotent stem cells (PSCs), was identified in adult murine bone marrow and human umbilical cord blood. Methods: Thirty-one patients with acute MI and 30 healthy subjects were enrolled. Blood was sampled on admission, after 24 h, and 5 days later. Erythrocytes were lysed and lin−CD45− VSELs were isolated using a live cell sorting system (FACSAria, Beckton Dickinson, San Jose, California). Results: In healthy subjects the median number of circulating VSELs was very low (median 0.8 [range 0 to 1.3]) cells/μl. In acute MI, VSELs were mobilized early (median 2.7 [range 0.2 to 3.9] cells/μl; p < 0.001) and remained elevated after 24 h and 5 days (median 4.7 [range 0.2 to 6.4] cells/μl; p < 0.003, and median 2.6 [range 0.3 to 3.6] cells/μl; p < 0.03, respectively). The mobilization of VSEL was significantly reduced in patients older than 50 years and with diabetes in comparison with younger and nondiabetic patients. Circulating VSELs were small (7 to 8 μm) and enriched in the messenger ribonucleic acid of PSC markers (Oct-4, Nanog), cardiac lineage (GATA-4, Nkx2.5/Csx, MEF2C), and endothelial (VE-cadherin) markers. The presence of PSC markers (Oct-4, SSEA-4) and the chemokine receptor CXCR4 in circulating VSELs was confirmed at the protein level by immunofluorescent staining and ImageStream system (Amnis Corporation, Seattle, Washington) analysis. Conclusions: Acute MI induced mobilization of VSELs expressing pluripotent markers, early cardiac and endothelial markers, and chemokine receptor CXCR4. [Copyright &y& Elsevier]

Background Although the prognostic value of findings from cardiac magnetic resonance (CMR) imaging has been established in single-center center studies in patients with ST-segment elevation myocardial infarction (STEMI), a large multicenter investigation to evaluate the prognostic significance of myocardial damage and reperfusion injury is lacking. Objectives The aim of this study was to assess the prognostic impact of CMR in an adequately powered multicenter study and to evaluate the most potent CMR predictor of hard clinical events in a STEMI population treated by primary percutaneous coronary intervention (PCI). Methods We enrolled 738 STEMI patients in this CMR study at 8 centers. The patients were reperfused by primary PCI <12 h after symptom onset. Central core laboratory–masked analyses for quantified left ventricular (LV) function, infarct size (IS), microvascular obstruction (MO), and myocardial salvage were performed. The primary clinical endpoint of the study was the occurrence of major adverse cardiac events. Results Patients with cardiovascular events had significantly larger infarcts (p < 0.001), less myocardial salvage (p = 0.01), a larger extent of MO (p = 0.009), and more pronounced LV dysfunction (p < 0.001). In a multivariate model that included clinical and other established prognostic parameters, MO remained the only significant predictor in addition to the TIMI (Thrombolysis In Myocardial Infarction) risk score. IS and MO provided an incremental prognostic value above clinical risk assessment and LV ejection fraction (c-index increase from 0.761 to 0.801; p = 0.036). Conclusions In a large, multicenter STEMI population reperfused by primary PCI, CMR markers of myocardial damage (IS and especially MO) provide independent and incremental prognostic information in addition to clinical risk scores and LV ejection fraction. (Abciximab i.v. Versus i.c. in ST-elevation Myocardial Infarction [AIDA STEMI]; NCT00712101 ). [ABSTRACT FROM AUTHOR]

Objectives: This study sought to evaluate if an undetectable (<5 ng/l) high-sensitivity cardiac troponin T (hs-cTnT) level and an electrocardiogram (ECG) without signs of ischemia can rule out myocardial infarction (MI) in the emergency department (ED). Background: Chest pain is a common symptom often associated with benign conditions, but may be a sign of MI. Because there is no rapid way to rule out MI, many patients are admitted to the hospital. Methods: All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. We calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. Results: We included 14,636 patients, of whom 8,907 (61%) had an initial hs-cTnT of <5 ng/l; 21% had 5 to 14 ng/l, and 18% had >14 ng/l. During 30-day follow-up, 39 (0.44%) patients with undetectable hs-cTnT had a MI, of whom 15 (0.17%) had no ischemic ECG changes. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). Conclusions: All patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED. [Copyright &y& Elsevier]

Background: Treatment of ST-elevation myocardial infarction has undergone great evolution since introduction of percutaneous coronary intervention (PCI). The purpose was therefore to assess the outcome of patients with ST-elevation myocardial infarction undergoing surgical revascularization with coronary artery bypass grafting (CABG). Methods: A total of 138 consecutive patients with ST-elevation myocardial infarction underwent CABG therapy between January 2000 and January 2007 at our institution. Prospectively recorded preoperative, intraoperative, and postoperative data were retrospectively screened for in-hospital mortality and major adverse cardiac events (MACE). Results: The delay between the onset of ST-elevation myocardial infarction symptoms and CABG procedures was within 6 hours in 37 patients, 7 to 24 hours in 21, 1 to 3 days in 15, 4 to 7 days in 24, and 8 to 14 days in 41 patients. Cardiogenic shock (Killip class ≥III) was present in 38 patients (28%), and 37 patients (27%) were referred for CABG after failed PCI. Overall in-hospital mortality was 8.7%, but mortality varied between 10.8% (≤6 hours), 23.8% (7 to 24 hours), 6.7% (1 to 3 days), 4.2% (4 to 7 days), and 2.4% (8 to 14 days), depending on time interval from symptom onset to operation. Overall, more nonsurvivors were women (58% versus 23%; p < 0.01), had higher preoperative cardiac troponin I levels (13.2 ± 9.8 versus 4.5 ± 4.2 ng/ml; p < 0.0001), and were more frequently in cardiogenic shock (83% versus 22%; p < 0.0001). Unadjusted univariable and risk-adjusted multivariable logistic regression analysis revealed age, female sex, preoperative cardiac troponin I levels, and cardiogenic shock to be the most potent predictors of in-hospital death and MACE. Conclusions: CABG in ST-elevation myocardial infarction can be performed with acceptable risk by incorporating adequate management strategies. However, female sex, preoperative cardiac troponin I level, preoperative cardiogenic shock, and time to operation are major variables of mortality and morbidity results. [Copyright &y& Elsevier]

Abstract: Objective: Uncontrolled hypertension (HTN) results in strokes, myocardial infarction (MI), and other complications, which are the leading cause of disability, death, and severe economic consequence. We conducted an economic evaluation to determine the costs and quality-adjusted life-years (QALYs) associated with amlodipine (Norvasc) and the angiotensin II receptor blockers (ARBs) in preventing stroke and MI among Chinese HTN patients. Methods: A cost-utility analysis was conducted from the third-party payer perspective. A Markov model was constructed to estimate 5-year costs and health consequences of amlodipine and valsartan. Effectiveness data were based on a published meta-analysis. Utility data were retrieved from the published literature. Costs of MI were retrieved from China Health Statistics Yearbook. Costs of stroke were obtained from retrospective chart review and follow-up interviews in Chinese tertiary hospitals. Costs included costs of drugs, direct medical costs of HTN management, stroke/MI treatment, and follow-up management. Discounting rate used for costs and QALYs was 3%. Results: Total direct medical and drug costs of amlodipine and valsartan (ARB) users were ¥111,731,716 and ¥132,058,611, respectively; total QALYs of amlodipine and valsartan users were 30,648.5 and 30,520.8, respectively. Amlodipine is dominant with lower costs and higher QALYs. This demonstrated that compared with valsartan, amlodipine is a cost-saving therapy with better QALY outcome. When irbesartan data were used in the comparison, the magnitude of cost saving changed but the overall conclusion remained the same. Conclusion: Amlodipine is a cost-saving therapy compared with ARBs in preventing stroke and MI for Chinese HTN patients. [Copyright &y& Elsevier]

Background: Recent clinical studies suggest preoperative anemia may increase mortality and morbidity after cardiac surgery. Anemic patients are potentially even more vulnerable in the setting of a recent myocardial infarction (MI). The objective of this study was to investigate the impact of preoperative anemia on short-term outcomes after coronary bypass surgery in patients with a recent MI. Methods: We conducted a retrospective cohort study of 655 patients who underwent an isolated coronary bypass procedure within 21 days of MI, 432 of whom were anemic preoperatively, defined as a hemoglobin less than 13 g/dL for men and less than 12 g/dL for women. The primary outcomes were in-hospital mortality and major adverse events (MAE), which included MI, stroke, and renal failure requiring dialysis. Results: Before risk adjustment, in-hospital mortality and the incidence of MAE were significantly higher in patients with anemia versus no anemia (mortality, 5.1% versus 1.4%, p = 0.02; MAE, 8.6% versus 3.1%, p = 0.009). After risk adjustment, the association between preoperative anemia and mortality or MAE became insignificant (mortality odds ratio 2.34, 95% confidence interval: 0.56 to 9.87, p = 0.25; MAE odds ratio 1.13, 95% confidence interval: 0.46 to 2.79, p = 0.78). Preoperative hemoglobin, treated as a continuous variable, yielded similar results. Conclusions: Preoperative anemia does not directly increase risks of surgical revascularization performed within 21 days of MI. [ABSTRACT FROM AUTHOR]

Background Troponins may be elevated in patients with pneumonia, but associations with myocardial infarction (MI) and with platelet activation are still undefined. Objectives The aim of this study was to investigate the relationship between troponin elevation and in vivo markers of platelet activation in the early phase of hospitalization of patients affected by community-acquired pneumonia. Methods A total of 278 consecutive patients hospitalized for community-acquired pneumonia, who were followed up until discharge, were included. At admission, platelet activation markers such as plasma soluble P-selectin, soluble CD40 ligand, and serum thromboxane B 2 (TxB 2 ) were measured. Serum high-sensitivity cardiac troponin T levels and electrocardiograms were obtained every 12 and 24 h, respectively. Results Among 144 patients with elevated high-sensitivity cardiac troponin T, 31 had signs of MI and 113 did not. Baseline plasma levels of soluble P-selectin and soluble CD40 ligand and serum TxB 2 were significantly higher in patients who developed signs of MI. Logistic regression analysis showed plasma soluble CD40 ligand (p < 0.001) and soluble P-selectin (p < 0.001), serum TxB 2 (p = 0.030), mean platelet volume (p = 0.037), Pneumonia Severity Index score (p = 0.030), and ejection fraction (p = 0.001) to be independent predictors of MI. There were no significant differences in MI rate between the 123 patients (45%) taking aspirin (100 mg/day) and those who were not aspirin treated (12% vs. 10%; p = 0.649). Aspirin-treated patients with MIs had higher serum TxB 2 compared with those without MIs (p = 0.005). Conclusions MI is an early complication of pneumonia and is associated with in vivo platelet activation and serum TxB 2 overproduction; aspirin 100 mg/day seems insufficient to inhibit thromboxane biosynthesis. (MACCE in Hospitalized Patients With Community-acquired Pneumonia; NCT01773863 ) [ABSTRACT FROM AUTHOR]

We aimed to investigate the association of 12 extensively studied polymorphisms in adiponectin ( ADIPOQ ), adiponectin receptor-1 ( ADIPOR1 ) and adiponectin receptor-2 ( ADIPOR2 ) genes with myocardial infarction in Han Chinese. This is a hospital-based, cross-sectional, case-control study, including 717 myocardial infarction patients and 612 controls. Myocardial infarction was confirmed through electrocardiogram/anatomopathological examinations. All polymorphisms met the Hardy-Weinberg equilibrium ( p  > 0.05). The genotype/allele counts of ADIPOQ gene rs2241766 ( p  = 0.001/0.003) and ADIPOR2 gene rs10773989 ( p  < 0.001/=0.008) differed significantly between patients and controls. Under the recessive model, rs2241766 (odds ratio [OR] = 4.16, 95% confidence interval [CI]: 1.83–9.49, p  = 0.001) and rs10773989 (OR = 8.40, 95% CI: 2.54–27.8, p  < 0.001) were associated with the significantly increased risk of myocardial infarction. Haplotype analysis revealed none or marginal significance, and there was no likelihood of genetic interaction as indicated by multifactor dimensionality reduction (MDR). Logistic regression analysis indicated that age, total cholesterol, hypertension, rs2241766, rs1342387, rs10773989 and rs1044471 were significant contributors, and a nomogram based on these contributors exhibited a good predictive utility (C-index: 0.795, p  < 0.001). Our findings demonstrate that two polymorphisms, rs2241766 in ADIPOQ gene and rs10773989 in ADIPOR2 gene, especially under the recessive model of inheritance, played independent leading roles in susceptibility to myocardial infarction in Han Chinese. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times. Background: Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness. Methods: Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics. Results: A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p < 0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p < 0.0001). Conclusions: The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion. [Copyright &y& Elsevier]

Objectives: This study is a prospective randomized trial investigating clinical outcomes of patients with acute myocardial infarction (AMI) treated with abciximab (ReoPro)-coated stents. Background: Recently we have demonstrated that abciximab-coated stents have inhibitory effects in the prevention of coronary restenosis. Methods: Ninety-six patients with AMI were randomly allocated into two groups; group I received abciximab-coated stents (n = 48, 57.1 ± 12.0 years), and group II received bare metal control stents (n = 48, 58.4 ± 11.6 years). Results: At baseline, clinical characteristics, percent diameter stenosis, and minimal luminal diameter were no different between the two groups. One patient in group II had reinfarction and target lesion reintervention during hospital stay. Follow-up coronary angiography was obtained in 77.1% (37 of 48) in group I and 75.0% (36 of 48) in group II. Percent diameter stenosis and late loss were significantly lower in group I than group II (18.9 ± 5.54% vs. 37.9 ± 6.25%, p = 0.008; and 0.39 ± 0.29 mm vs. 0.88 ± 0.45 mm; p = 0.008, respectively). At follow-up intravascular ultrasound, intrastent lumen area and intrastent neointimal hyperplasia (NIH) area were 5.4 ± 1.8 mm2 and 2.2 ± 1.5 mm2, respectively, in group I and 4.3 ± 1.6 mm2 and 3.4 ± 1.8 mm2, respectively, in group II (p = 0.045). And, in-stent restenosis rate was lower in group I than group II (p = 0.011 and p = 0.008, respectively). During 1-year follow-up, two patients in group II (4.1%) had AMI, whereas no patient in group I suffered AMI. Target lesion revascularization and total major adverse cardiac events rates were relatively lower in group I compared with those in group II (10.4% [5 of 48] vs. 20.8% [10 of 48], p = 0.261, and 10.4% vs. 25.0%, p = 0.107, respectively). Conclusions: Abciximab-coated stent implantation was safe and effective without stent thrombosis in AMI patients. [Copyright &y& Elsevier]

Background: Mortality in cardiogenic shock (CS) remains high. Early risk stratification is crucial to make adequate treatment decisions.Objectives: This study sought to develop an easy-to-use, readily available risk prediction score for short-term mortality in patients with CS, derived from the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock) trial.Methods: The score was developed using a stepwise multivariable regression analysis.Results: Six variables emerged as independent predictors for 30-day mortality and were used as score parameters: age >73 years, prior stroke, glucose at admission >10.6 mmol/l (191 mg/dl), creatinine at admission >132.6 μmol/l (1.5 mg/dl), Thrombolysis In Myocardial Infarction flow grade <3 after percutaneous coronary intervention, and arterial blood lactate at admission >5 mmol/l. Either 1 or 2 points were attributed to each variable, leading to a score in 3 risk categories: low (0 to 2), intermediate (3 or 4), and high (5 to 9). The observed 30-day mortality rates were 23.8%, 49.2%, and 76.6%, respectively (p < 0.0001). Validation in the IABP-SHOCK II registry population showed good discrimination with an area under the curve of 0.79. External validation in the CardShock trial population (n = 137) showed short-term mortality rates of 28.0% (score 0 to 2), 42.9% (score 3 to 4), and 77.3% (score 5 to 9; p < 0.001) and an area under the curve of 0.73. Kaplan-Meier analysis revealed a stepwise increase in mortality between the different score categories (0 to 2 vs. 3 to 4: p = 0.04; 0 to 2 vs. 5 to 9: p = 0.008).Conclusions: The IABP-SHOCK II risk score can be easily calculated in daily clinical practice and strongly correlated with mortality in patients with infarct-related CS. It may help stratify patient risk for short-term mortality and might, thus, facilitate clinical decision making. (Intraaortic Balloon Pump in Cardiogenic Shock II [IABP-SHOCK II]; NCT00491036). [ABSTRACT FROM AUTHOR]