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

Background: The association of postprocedural high-sensitivity troponin T (hs-TnT) with prognosis of non-ST-segment elevation myocardial infarction (NSTEMI) patients is incompletely investigated.Aim: To assess the prognostic value of hs-TnT in NSTEMI patients undergoing early percutaneous coronary intervention (PCI).Methods: This study included 3783 patients with NSTEMI undergoing early PCI. Preprocedural and peak postprocedural hs-TnT was measured. Patients were divided into 3 groups: a group with postprocedural hs-TnT in the 1st tertile (hs-TnT <105ng/L; n=1264), a group with postprocedural hs-TnT in the 2nd tertile (hs-TnT ≥105ng/L to 470ng/L; n=1258) and a group with postprocedural hs-TnT in the 3rd tertile (hs-TnT >470ng/L; n=1261). The primary outcome was 1-year all-cause mortality.Results: Overall, there were 299 deaths: 59 (5.5%), 98 (8.2%) and 142 deaths (12.6%) among patients of the 1st, 2nd and 3rd postprocedural hs-TnT tertiles (unadjusted hazard ratio [HR]=1.65, 95% confidence interval [CI] 1.20 to 2.67; P=0.002 for tertile 2 vs tertile 1 and unadjusted HR=2.41 [1.79-3.25]; P<0.001 for tertile 3 vs tertile 1). After adjustment postprocedural hs-TnT was independently associated with the risk of all-cause mortality (adjusted [HR]=1.22 [1.13-1.33], P<0.001 for 1 unit higher log hs-TnT). Postprocedural hs-TnT improved the risk prediction of the model of all-cause mortality (the C statistic of the model without [with baseline variables only] and with incorporation of postprocedural hs-TnT was 0.759 [0.732-0.782] and 0.772 [0.746-0.794], respectively; P<0.001).Conclusions: In patients with NSTEMI undergoing early PCI, postprocedural hs-TnT is independently associated with increased risk of mortality up to 1year after PCI. [ABSTRACT FROM AUTHOR]

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

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

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

Objective: Acute high levels of anger and anxiety are associated with an elevated risk of myocardial infarction (MI) in the following two hours. MIs preceded by these acute negative emotions may also have a poor long-term prognosis, but information about high-risk patients is lacking. We examined whether young age and female sex are associated with MIs that are preceded by negative emotions and whether age and sex moderate the subsequent increased mortality risk following MI preceded by negative emotions.Methods: We conducted a secondary analysis of the Determinants of Myocardial Infarction Onset Study (N=2176, mean age=60.1±12.3years, 29.2% women). Anxiety and anger immediately prior to (0-2h) MI and the day before (24-26h) MI were assessed using a structured interview. Subsequent 10-year all-cause mortality was determined using the US National Death Index.Results: Anxiety during the 0-2h pre-MI period was associated with younger age (OR=0.98,95% CI=0.96-0.99 per year) and female sex (OR=1.50,95% CI=1.11-2.02). Anger in the 0-2h pre-MI period was also associated with younger age (OR=0.95,95% CI=0.94-0.96) but not with sex (OR=0.93,95% CI=0.67-1.28). During follow-up, 580 (26.7%) patients died. Mortality rate was higher if MI occurred immediately after high anxiety, particularly in patients ≥65years (HR=1.80,95% CI=1.28-2.54) vs. younger patients (HR=0.87,95% CI=0.55-1.40; p-interaction=0.015). Other interactions with sex or anger were not significant.Conclusions: Patients with high anxiety or anger levels in the critical 2-hour period prior to MI are younger than those without such emotional precipitants. In addition, pre-MI anxiety is associated with an elevated 10-year mortality risk in patients aged ≥65years. [ABSTRACT FROM AUTHOR]

Background: The Bleeding Academic Research Consortium (BARC) scale has been proposed to standardize bleeding endpoint definitions and reporting in cardiovascular trials. Validation in large cohorts of patients is needed.Objectives: This study sought to investigate the relationship between BARC-classified bleeding and mortality and compared its prognostic value against 2 validated bleeding scales: TIMI (Thrombolysis In Myocardial Infarction) and GUSTO (Global Use of Strategies to Open Occluded Arteries).Methods: We analyzed bleeding in 12,944 patients with acute coronary syndromes without ST-segment elevation, with or without early invasive strategy. The main outcome measure was all-cause death.Results: During follow-up (median: 502 days), noncoronary artery bypass graft (CABG) bleeding occurred in 1,998 (15.4%) patients according to BARC (grades 2, 3, or 5), 484 (3.7%) patients according to TIMI minor/major, and 514 (4.0%) patients according to GUSTO moderate/severe criteria. CABG-related bleeding (BARC 4) occurred in 155 (1.2%) patients. Patients with BARC (2, 3, or 4) bleeding had a significant increase in risk of death versus patients without bleeding (BARC 0 or 1); the hazard was highest in the 30 days after bleeding (hazard ratio: 7.35; 95% confidence interval: 5.59 to 9.68; p < 0.0001) and remained significant up to 1 year. The hazard of mortality increased progressively with non-CABG BARC grades. BARC 4 bleeds were significantly associated with mortality within 30 days (hazard ratio: 10.05; 95% confidence interval: 5.41 to 18.69; p < 0.0001), but not thereafter. Inclusion of BARC (2, 3, or 4) bleeding in the 1-year mortality model with baseline characteristics improved it to an extent comparable to TIMI minor/major and GUSTO moderate/severe bleeding.Conclusions: In patients with acute coronary syndromes without ST-segment elevation, bleeding assessed with the BARC scale was significantly associated with risk of subsequent death up to 1 year after the event and risk of mortality increased gradually with higher BARC grades. Our results support adoption of the BARC bleeding scale in ACS clinical trials. (Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER] [Study P04736]; NCT00527943). [ABSTRACT FROM AUTHOR]

Background: Takotsubo stress cardiomyopathy (TSC) is a syndrome characterized by transient myocardial dysfunction with unknown etiology. Although recent studies have suggested that the syndrome is associated with comorbidity and has a dismal prognosis, there is a lack of comprehensive data describing the epidemiology and prognosis of TSC.Objectives: This study compared risk markers and mortality in patients with TSC with that of individuals with or without coronary artery disease (CAD).Methods: Patients with TSC and control subjects were identified from the Swedish Coronary Angiography and Angioplasty Register between 2009 and 2013 and linked with the Swedish national patient registry, cause of death registry, prescription drug registry, and education and income registries.Results: Patients with TSC were characterized by a low cardiovascular risk factor profile but with increased chronic obstructive pulmonary disease, migraine, and affective disorders. The use of beta-blockers was less common but use of β2-adrenergic agonist agents was more common in patients with TSC compared with either of the control groups. Being a patient with TSC was associated with a hazard ratio of 2.1 for death compared with the control subjects without CAD (95% confidence interval: 1.4 to 3.2). This was similar to the excess mortality risk seen among the CAD control subjects compared with control subjects without CAD (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.3). These associations remained significant after adjusting for CAD risk factors and risk markers for TSC.Conclusions: The findings of increased risk associated with β2-adrenergic agonist agents together with stress related to affective disorders emphasize the pathogenic role of sympathetic stimulation. The prognosis regarding mortality is worse than in control subjects without CAD and similar to patients with CAD emphasizing the urgent need for studies on optimal treatment of TSC. [ABSTRACT FROM AUTHOR]

Background: Acute myocardial infarction (AMI) has poorer outcomes in disadvantaged populations such as those in regional and remote locations. We compared long-term outcomes associated with presentation to regional or remote hospitals among AMI patients.Methods and Results: Administrative claims data from New South Wales (27% regional and remote residents) was used to identify patients >18 years admitted to any NSW hospital with a principal diagnosis of AMI (ICD10 codes: I21·0-I21·4) between 01/07/2004 and 30/06/2008. Hospital of presentation location with a population of <250,000 was defined as regional and remote while hospitals with a population >250,000 were deemed urban. Receipt of revascularisation and mortality were analysed and adjusted for age, comorbidities and previous revascularisation. Patients were censored at death or end of the follow-up period (31 December 2009). 39,798 patients were identified with 9,393 (23.6%) regional and remote presenters. In multivariable models, regional and remote presentation was associated with reduced rates of revascularisation (OR 0.30 95%CI 0.28-0.32; p<0.001), no impact on overall mortality (HR 1.04 95%CI 0.99-1.02; p=0.11), but with increased mortality for patients presenting with STEMI (HR 1.14; 95% CI 1.06-1.23; p<0.001). The propensity analysis was consistent with these findings.Conclusions: Presentation to a regional and remote hospital was associated with lower revascularisation rates following AMI, but with a higher long-term mortality if presenting with ST segment elevation. [ABSTRACT FROM AUTHOR]

Background: Post-myocardial infarction (MI) depression is associated with reduced adherence to cardiac rehabilitation (CR) and increased mortality risk. The present study investigated whether all-cause mortality reduction associated with CR is different for MI-patients with and without depressive symptoms.Methods: Data of 2198 post-MI patients from the Depression after Myocardial Infarction (DepreMI) study and Myocardial Infarction and Depression Intervention Trial (MIND-IT) was used. Depression was assessed at hospitalization, defined as a score≥10 on the Beck Depression Inventory (BDI). Participation in CR was assessed with a self-report questionnaire, 12 months post-MI. Cox regression was used to estimate hazard ratios (HR) for all-cause mortality, up till 10 years post-MI. Missing data was imputed, using multiple imputation.Results: 878 (52%) Patients attended CR, 517 (26%) patients had a BDI score ≥10, and 379 (18%) patients died during the follow-up period. Overall, CR was not associated with a lower mortality risk (HR: 0.83; 0.54-1.30; p=0.41), adjusted for age, sex, left ventricle ejection fraction, previous MI, and past or current heart failure. However, there was a significant interaction between depression and CR on mortality (HR: 0.49; 0.27-0.90; p=0.02). CR was significantly associated with reduced mortality in depressed patients (HR: 0.48; 0.28-0.84; p=0.01), but not in non-depressed patients (HR: 1.09; 0.63-1.89; p=0.74).Limitations: Patients were not randomized to CR. We had no information about the specific reasons of clinicians to offer CR and about the patients' motives to participate.Conclusions: CR was associated with reduced mortality risk only for MI-patients with depression. Clinicians should therefore particularly encourage MI-patients with depression to participate in CR. [ABSTRACT FROM AUTHOR]

Objectives To compare outcome in patients with acute myocardial infarction (MI) and cardiogenic shock (CS) presenting with and without out-of-hospital cardiac arrest (OHCA). Background Despite general improvement in outcome after acute MI, CS remains a leading cause of death in acute MI patients with a high 30-day mortality rate. OHCA on top of cardiogenic shock may further increase mortality in these patients resulting in premature withdrawal of supportive therapy, but this is not known. Methods and results In a retrospective study from 2008 to 2013, 248 consecutive patients admitted alive to a tertiary centre with the diagnosis of CS and acute MI were enrolled, 118 (48%) presented with OHCA and 130 (52%) without (non-OHCA patients). Mean lactate level at admission was significantly higher in OHCA patients compared with non-OCHA patients (9 mmol/l (SD 6) vs. 6 mmol/l (SD 4) p < 0.0001). Co-morbidities were more prevalent in the non-OHCA group. By univariate analysis age (Hazard ratio (HR) = 1.02 [CI 1.00–1.03], p = 0.01) and lactate at admission (HR = 1.06 [CI 1.03–1.09], p < 0.001), but not OHCA (HR = 1.1 [CI 0.8–1.4], p = NS) was associated with mortality. In multivariate analysis, only age (HR = 1.02 [CI 1.01–1.04], p = 0.003) and lactate level at admission (HR = 1.06 [1.03–1.09], p < 0.001) were independent predictors of mortality. One-week mortality was 63% in the OHCA group and 56% in the non-OHCA group, p = NS. Conclusion OHCA is not an independent predictor of mortality in patients with acute MI complicated by cardiogenic shock. This should encourage active intensive treatment of CS patients regardless of OHCA. [ABSTRACT FROM AUTHOR]

Objective To analyze the burden of institutionalizations after femoral fracture and compare it with other “catastrophic” disease entities like stroke, myocardial infarction, or pneumonia. Design/Setting/Participants Routine data of 414,000 hospitalized German patients aged 66 years and older were used to calculate institutionalization risks after femoral fracture, stroke, myocardial infarction, pneumonia or a combined group of “all other hospitalizations.” Measurements Institutionalization was defined as nursing home admission within 6 months after discharge from hospital. Age- and sex-specific incidence and incidence rates of institutionalization were calculated. To compare the risk of institutionalization between the disease entities, age-standardized rates were computed and proportional hazards models were applied. In-house mortality and mortality after discharge from hospital were also calculated. Results The risk of institutionalization increased exponentially with age in all disease entities. For example, the risk of institutionalization after femoral fracture increased from 3.6% in women aged 65 to 69 years to 34.8% in women aged 95 years and older. The highest institutionalization rates were observed in patients with stroke, followed by femoral fracture, pneumonia, and myocardial infarction. In men, the age-standardized risk of institutionalization was almost as high after femoral fracture as after stroke (7.5% vs 8.0%). In contrast to myocardial infarction and pneumonia, femoral fracture and stroke were more likely to be followed by institutionalization rather than death. Conclusion Femoral fractures result in high burden of institutionalizations. Prevention of falls, diagnosis and treatment of osteoporosis, and high-quality rehabilitation are challenges to tackle the burden of institutionalization in these patients in the future. [ABSTRACT FROM AUTHOR]