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Empagliflozin reduces the risk of heart failure (HF) hospitalizations but not all-cause mortality when started within 14 days of acute myocardial infarction (AMI). This study sought to evaluate the association of left ventricular ejection fraction (LVEF), congestion, or both, with outcomes and the impact of empagliflozin in reducing HF risk post-AMI. In the EMPACT-MI (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction) trial, patients were randomized within 14 days of an AMI complicated by either newly reduced LVEF<45%, congestion, or both, to empagliflozin (10 mg daily) or placebo and were followed up for a median of 17.9 months. Among 6,522 patients, the mean baseline LVEF was 41 ± 9%; 2,648 patients (40.6%) presented with LVEF <45% alone, 1,483 (22.7%) presented with congestion alone, and 2,181 (33.4%) presented with both. Among patients in the placebo arm of the trial, multivariable adjusted risk for each 10-point reduction in LVEF included all-cause death or HF hospitalization (HR: 1.49; 95% CI: 1.31-1.69; P < 0.0001), first HF hospitalization (HR: 1.64; 95% CI: 1.37-1.96; P < 0.0001), and total HF hospitalizations (rate ratio [RR]: 1.89; 95% CI: 1.51-2.36; P < 0.0001). The presence of congestion was also associated with a significantly higher risk for each of these outcomes (HR: 1.52, 1.94, and RR: 2.03, respectively). Empagliflozin reduced the risk for first (HR: 0.77; 95% CI: 0.60-0.98) and total (RR: 0.67; 95% CI: 0.50-0.89) HF hospitalizations, irrespective of LVEF or congestion, or both. The safety profile of empagliflozin was consistent across baseline LVEF and irrespective of congestion status. In patients with AMI, the severity of left ventricular dysfunction and the presence of congestion was associated with worse outcomes. Empagliflozin reduced first and total HF hospitalizations across the range of LVEF with and without congestion. (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction [EMPACT-MI]; NCT04509674) [Display omitted] [ABSTRACT FROM AUTHOR]

The recent guidelines from the European Society of Cardiology recommends using high-sensitivity cardiac troponin (hs-cTn) in either 0/1-h or 0/2-h algorithms to identify or rule out acute myocardial infarction (AMI). Several studies have reported good diagnostic accuracy with both algorithms, but few have compared the algorithms directly. We aimed to compare the diagnostic accuracy of the algorithms head-to-head, in the same patients. This was a secondary analysis of data from a prospective observational study; 1167 consecutive patients presenting with chest pain to the emergency department at Skåne University Hospital (Lund, Sweden) were enrolled. Only patients with a hs-cTnT sample at presentation AND after 1 AND 2 h were included in the analysis. We compared sensitivity, specificity, and negative (NPV) and positive predictive value (PPV). The primary outcome was index visit AMI. A total of 710 patients were included, of whom 56 (7.9%) had AMI. Both algorithms had a sensitivity of 98.2% and an NPV of 99.8% for ruling out AMI, but the 0/2-h algorithm ruled out significantly more patients (69.3% vs. 66.2%, p < 0.001). For rule-in, the 0/2-h algorithm had higher PPV (73.4% vs. 65.2%) and slightly better specificity (97.4% vs. 96.3%, p = 0.016) than the 0/1-h algorithm. Both algorithms had good diagnostic accuracy, with a slight advantage for the 0/2-h algorithm. Which algorithm to implement may thus depend on practical issues such as the ability to exploit the theoretical time saved with the 0/1-h algorithm. Further studies comparing the algorithms in combination with electrocardiography, history, or risk scores are needed. [ABSTRACT FROM AUTHOR]

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review. [Display omitted] • Ventricular free-wall rupture is a rare, but potentially fatal, complication of acute myocardial infarction, requiring prompt surgical intervention. • Pseudoaneurysm formation results from contained rupture; characterization by multimodality imaging can enhance risk stratification and guide the surgical strategy. • Developments in transcatheter therapeutics have introduced percutaneous approaches for high-risk or inoperable patients with suitable pathoanatomy, but experience with these options is limited. [ABSTRACT FROM AUTHOR]

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias. [Display omitted] • Acute myocardial infarction is the most frequent cause of left ventricular aneurysm formation, although genetic, metabolic, inflammatory, and traumatic conditions are additional etiologies. • Angina, heart failure, thromboembolism, and ventricular arrhythmias are potential complications requiring specific therapies, including surgical reconstruction, anticoagulation, ablation of arrhythmias, implantable devices, and pharmacological therapy. • In patients with ventricular aneurysm complicated by ventricular tachycardia, implanted cardioverter-defibrillators may reduce the risk of sudden death. Electrophysiological mapping is critical to determining whether to pursue surgical or percutaneous ablation. [ABSTRACT FROM AUTHOR]

This review summarizes the current evidence regarding efficacy and safety of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of cardiogenic shock. Currently, there is evidence from 4 randomized controlled trials which all do not support a mortality benefit and increased complication rates by VA-ECMO. Based on current evidence, possible subgroups will be discussed and indications in selected very small patient groups be discussed. [ABSTRACT FROM AUTHOR]

The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction–cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined. We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters. Ten patients (eight male, two female; aged 43–70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C–E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4–48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%. A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol. [ABSTRACT FROM AUTHOR]

Patients who sustain an acute myocardial infarction (AMI), including ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation myocardial infarction (NSTEMI), remain at high risk for heart failure (HF), coronary events, and death. Angiotensin-converting enzyme inhibitors have been shown to significantly decrease the risk for cardiovascular events in both STEMI and NSTEMI patients. The objectives were to determine whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan, compared with ramipril, has impact on reducing cardiovascular events according to the type of AMI. The PARADISE-MI (Prospective ARNI versus ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction) trial enrolled patients with AMI complicated by left ventricular dysfunction and/or pulmonary congestion and at least 1 risk-enhancing factor. Patients were randomized to either sacubitril/valsartan or ramipril. The primary endpoint was death from cardiovascular causes or incident HF. In this prespecified analysis, we stratified patients according to AMI type. Of 5,661 enrolled patients, 4,291 (75.8%) had STEMI. These patients were younger and had fewer comorbidities and cardiovascular risk factors than NSTEMI patients. After adjustment for potential confounders, the risk for the primary outcome was marginally higher in NSTEMI vs STEMI patients (adjusted HR: 1.19; 95% CI: 1.00-1.41), with borderline statistical significance (P = 0.05). The primary composite outcome occurred at similar rates in patients randomized to sacubitril/valsartan vs ramipril in STEMI (10% vs 12%; HR: 0.87; 95% CI: 0.73-1.04; P = 0.13) and NSTEMI patients (17% vs 17%; HR: 0.97; 95% CI: 0.75-1.25; P = 0.80; P interaction = 0.53). Compared with ramipril, sacubitril/valsartan did not significantly decrease the risk for cardiovascular death and HF in patients with AMI complicated by left ventricular dysfunction, irrespective of the type of AMI. (Prospective ARNI vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI; NCT02924727) [Display omitted] [ABSTRACT FROM AUTHOR]

• Killip classification is a useful clinical tool for risk stratification in MINOCA. • High Killip class is an independent predictor of MACE and death in MINOCA. • High Killip class MINOCA show a higher risk of HF than MIOCA counterparts. Killip classification is a practical clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) is still poorly explored. Our purpose was to evaluate the prognostic role of high Killip class in the specific setting of MINOCA and compare the results with a cohort of patients with obstructive coronary arteries myocardial infarction (MIOCA). This study included 2455 AMI patients of whom 255 were MINOCA. We compared the Killip classes of MINOCA with those of MIOCA and evaluated the prognostic impact of a high Killip class, defined if greater than I, on both populations' outcome. Short-term outcomes included in-hospital death, re-AMI and arrhythmias. Long-term outcomes were all-cause mortality, re-AMI, stroke, heart failure (HF) hospitalization and the composite endpoint of MACE. Killip class >1 occurred in 25 (9.8%) MINOCA patients compared to 327 (14.9%) MIOCA cases. In MINOCA subjects, a high Killip class was associated with a greater in-hospital mortality (p = 0.002) and, at long term follow-up, with a three-fold increased mortality (p = 0.001) and a four-fold risk of HF hospitalization (p = 0.003). Among MINOCA, a high Killip class was identified as a strong independent predictor of MACE occurrence [HR 2.66, 95% CI (1.25–5.64), p = 0.01] together with older age and worse kidney function while in MIOCA population also left ventricular ejection fraction and troponin value predicted MACE. Killip classification confirmed its prognostic impact on short- and long-term outcomes also in a selected MINOCA population, which still craves for a baseline risk stratification. [Display omitted] [ABSTRACT FROM AUTHOR]

This paper examines the role of socioeconomic status (SES) in affecting access to care and the survival of acute myocardial infarction (AMI) patients in Australia's universal health care system. We jointly model the probabilities of patients being admitted to a catheterisation-capable hospital, receiving invasive coronary angiography (ICA), and surviving 30 days post discharge as a recursive system of probit equations. We further investigate the role of capacity and whether the access gap between SES groups widens when capacity becomes limited. Our study shows that SES plays a significant role in affecting the survival of AMI patients, both directly and indirectly through healthcare access. We find that socioeconomically disadvantaged patients are less likely to gain access to crucial services like catheterisation hospitals and ICA, which indirectly affects their survival probability in addition to the adverse direct impact of SES. While healthcare capacity showed no overall effect on access, its interplay with SES exacerbates the access disparity in situations of limited capacity. Our findings suggest that, to reduce inequality in health outcomes, public health strategy needs to focus not only on enhancing access but also addressing the direct consequences of SES. [ABSTRACT FROM AUTHOR]

• 4S-AF scheme score is distributed normally in post-MI NOAF. • High 4S-AF scheme score is associated poor survival in patients with post-MI NOAF. • 4S-AF scheme score improves the prognostic predictive performance of GRACE score in post-MI NOAF. The 4S-AF scheme (Stroke risk [St], Symptom severity [Sy], Severity of atrial fibrillation burden [Sb], Substrate [Su]) is a novel approach for the holistic characterization of AF. We aimed to investigate the prognostic implications of the 4S-AF scheme score in acute myocardial infarction (AMI) patients with new-onset atrial fibrillation (NOAF). We included 262 patients with post-MI NOAF who had complete data for the 4S-AF scheme evaluation between February 2014 and March 2018. The 4S-AF scheme score was calculated as a sum of each domain with a maximum of 9. The primary outcome was all-cause death. Of 262 patients (66.0% males, mean age 74.5 ± 10.4 years) were analyzed. The mean 4S-AF scheme score was 5.0 ± 1.6. There were 62 (27.3%) all-cause deaths within a median follow-up of 2.6 years. According to multivariable Cox regression models, each 1-point increase in the 4S-AF scheme score was significantly associated with 39% increased all-cause mortality (HR: 1.39, 95% CI: 1.16–1.67, P <0.001), which was mainly driven by the Sb (HR: 1.43, 95%CI: 1.05–1.95, P = 0.025) and Su (HR: 1.53, 95%CI: 1.17–2.02, P = 0.002) domains. Adding the 4S-AF scheme score on top of the Global Registry of Acute Coronary Events score could significantly improve its discriminative capability (C-index from 0.713 to 0.761, P = 0.039) and reclassification performance (continuous net reclassification improvement: 41.0% [95%CI: 12.5–69.6]; integrated discrimination improvement: 5.1% [95%CI: 2.2–8.1]) for all-cause mortality. Characterization of NOAF using the 4S-AF scheme aids in the risk stratification of AMI patients with NOAF. [Display omitted] [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality worldwide and the primary underlying risk factor for heart failure. Despite decades of research and clinical trials, there are no drugs currently available to prevent organ damage from acute ischaemic injuries of the heart. In order to address the increasing global burden of heart failure, drug, gene, and cell-based regeneration technologies are advancing into clinical testing. In this review we highlight the burden of disease associated with AMI and the therapeutic landscape based on market analyses. New studies revealing the role of acid-sensitive cardiac ion channels and other proton-gated ion channels in cardiac ischaemia are providing renewed interest in pre- and post-conditioning agents with novel mechanisms of action that may also have implications for gene- and cell-based therapeutics. Furthermore, we present guidelines that couple new cell technologies and data resources with traditional animal modelling pipelines to help de-risk drug candidates aimed at treating AMI. We propose that improved preclinical pipelines and increased investment in drug target identification for AMI is critical to stem the increasing global health burden of heart failure. [ABSTRACT FROM AUTHOR]

Diabetes mellitus (DM) is an important risk factor for adverse outcomes following acute myocardial infarction (AMI), but large-scale studies investigating the differential impact of Type 1 DM (T1DM) and Type 2 DM (T2DM) on AMI outcomes are lacking. All adult discharges for AMI in the National Inpatient Sample (October 2015 to December 2018) were included and stratified into T1DM, T2DM and non-DM (NDM) groups. Outcomes of interests were all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and acute ischemic stroke, as well as invasive management. Binomial hierarchical multilevel multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was used to investigate the association between DM and its subtypes with the AMI outcomes. Out of 2,587,615 patients, there were 29,250 (1.1 %) T1DM and 1,032,925 (39.9 %) T2DM patients. After multivariable adjustment, patients with T1DM had increased odds of MACCE (aOR 1.20, 95 % CI 1.09–1.31), all-cause mortality (aOR 1.20, 95 % CI 1.08–1.33) and major bleeding (aOR 1.28, 95 % CI 1.13–1.44), whilst T2DM patients had increased odds of MACCE (aOR 1.03, 95 % CI 1.01–1.05) and ischemic stroke (aOR 1.09, 95 % CI 1.05–1.13), compared to NDM patients. The adjusted odds of receiving percutaneous coronary intervention were lower in both T1DM and T2DM patients (aOR 0.70, 95 % CI 0.66–0.75 and aOR 0.95, 95 % CI 0.94–0.96, respectively), but T2DM patients showed higher utilization of composite percutaneous and surgical revascularization (aOR 1.03, 95 % CI 1.03–1.04) compared to NDM patients. DM patients presenting with AMI have worse in-hospital clinical outcomes compared to NDM patients. There are important DM type-related differences with T1DM patients having overall worse outcomes and receiving less overall revascularization. [Display omitted] • Differential impact of diabetes mellitus (DM) types on acute myocardial infarction (AMI) outcomes is not well-defined. • DM patients with AMI have lower adjusted utilization of invasive management compared to patients without DM. • DM patients with AMI have worse adjusted clinical outcomes compared to patients without DM. • There are important DM type-related differences with Type 1 DM patients having overall worse outcomes. [ABSTRACT FROM AUTHOR]

Despite early and currently effective epicardial coronary recanalization, the mortality rate after mechanical complication (MC) remains high, especially in cardiogenic shock. There is an increase in the use of mechanical circulatory support in patients with cardiogenic shock and MC, however, evidence is still scarce and most studies exclude patients with mechanical complications. Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the predictors and outcomes of patients with MC, subtypes and the use of MCS. We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC and of them 1320 (56.3 %) received MCS. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture (FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582–12.855, p < 0.001) in patients with MC compared to patients without MC (49.7 % vs. 4.6 %, p < 0.001) and all subtypes of MC showed a significant increase in mortality. The use of MCS was associated with decreased mortality in PMR (46.2 % to 34.8 %, p = 0.009) and pseudoaneurysm (64.7 % to 42.1 %, p < 0.001), however, with higher mortality in VSR. The incidence of MC after an AMI is very low, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and with fewer comorbidities. The subtype with the highest frequency and highest mortality was VSR. The use of mechanical circulatory support was associated with better survival in PMR and pseudoaneurysm, but not overall survival. • Currently, despite rapid and effective epicardial coronary reperfusion, mechanical complications following AMI continue to be the most devastating and frightening complications, albeit with a very low incidence of 0.1%. • Positive predictors of having a mechanical complication are older age, female sex, fewer medical comorbidities, STEMI presentation, heart failure and nonischemic heart conditions such as valve disease and atrial fibrillation. • The mortality of patients with AMI and MC is 12 times higher than that of patients without MC (49.7 % vs. 4.6 %) and all subtypes of MC showed a significant increase in mortality. • The use of mechanical circulatory support is associated with decreased mortality in papillary muscle rupture and pseudoaneurysm, with no difference in free wall rupture, however, with higher mortality in ventricular septal rupture. [ABSTRACT FROM AUTHOR]

Quality measures within Emergency Medicine (EM) were developed to standardize and improve care. Their development has been limited by lack of consideration of sex- and gender-based differences. Research has suggested that sex and gender can impact clinical care and treatment. Inclusion of sex and gender differences is needed to create EM quality measures that are equitable to all. The aim of the review is to provide a brief history of EM quality measures and the value of considering sex- and gender-based evidence in their development to ensure equity, using acute myocardial infarction (AMI) as an example. Current quality measures related to AMI, such as time-to-electrocardiogram and door-to-balloon time in percutaneous coronary intervention, may have important and modifiable disparities when stratified by sex. Even when presenting with signs and symptoms of AMI, women experience delayed time to diagnosis and treatment. Few studies have considered interventions to mitigate these differences. However, the data available suggest that sex-based disparities can be minimized by implementation of strategies such as a quality control checklist. Quality measures were created to deliver high-quality, evidence-based, and standardized care, but without the inclusion of sex and gender metrics, they may not advance care to an equitable level. [ABSTRACT FROM AUTHOR]

• In real-world clinical practice, the initiation and up-titration of sacubitril/valsartan prescription remain challenging in patients with AMI. • Early use or high dosage of sacubitril/valsartan is associated with an improvement in primary composite endpoints as well as the incidence of new-onset HFrEF or HFpEF. • The low dose of sacubitril/valsartan is well tolerated and may be associated with similar outcomes compared with high dose in some circumstances (LVEF>50% or HF at baseline). In real-world clinical practice, the initiation and up-titration of sacubitril/valsartan remain challenging due to symptomatic hypotension in patients with acute myocardial infarction(AMI). The purpose of this study was to investigate the efficacy of different initial timing and dosage of sacubitril/valsartan in AMI patients. This prospective and observational cohort study enrolled AMI patients treated with percutaneous coronary intervention(PCI), and were categorized according to the initial timing and average daily doses of sacubitril/valsartan prescription. The primary endpoint was defined as a composite of cardiovascular death, recurrent AMI, coronary revascularization, heart failure(HF) hospitalization and ischaemic stroke. Secondary outcomes included the new-onset HF, and the composite endpoints in AMI patients complicated with HF at baseline. The study population consisted of 915 AMI patients. After a median follow-up of 38 months, early use or high dosage of sacubitril/valsartan was associated with an improvement in primary endpoint as well as the incidence of new-onset HF. Early use of sacubitril/valsartan also ameliorated the primary endpoint in AMI patients with left ventricular ejection fraction(LVEF) ≤50% as well as LVEF>50%. Besides, early use of sacubitril/valsartan improved the clinical outcomes in AMI patients complicated with HF at baseline. The low dose was well tolerated and may be associated with similar outcomes compared with high dose under some circumstances(LVEF>50% or HF at baseline). Early use or high dosage of sacubitril/valsartan medication is associated with an improvement in clinical outcome. The low dose of sacubitril/valsartan is well tolerated and may be an acceptable alternative strategy. [ABSTRACT FROM AUTHOR]

We aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). We conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. During the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94–1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82–1.23; p = 0.995). In this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock. [Display omitted] • 90-day mortality in AMI complicated by cardiogenic shock requiring VA ECMO was 64%. • Early VA ECMO implantation did not show a survival advantage in 90-day mortality. • VA ECMO implantation at high-volume centers did not show a survival advantage. [ABSTRACT FROM AUTHOR]

Patients with acute myocardial infarction (AMI) commonly have multiple comorbidities, and some die in hospitals due to causes other than cardiac complications. However, limited information is available on noncardiac death in patients hospitalised for AMI. Therefore, the present study was performed to determine the incidence, annual trend, clinical characteristics, and predictors of in-hospital non-cardiac death in patients with AMI using the Tokyo Cardiovascular Care Unit (CCU) network registry. The registry included 38,589 consecutive patients with AMI who were admitted to the CCU between 2010 and 2019. The primary endpoint was in-hospital noncardiac death. Further, predictors of cardiac and non-cardiac death were identified. The incidence of all-cause in-hospital mortality was 7.0% (n = 2700), and the proportion of mortality was 15.6% (n = 420) and 84.4% (n = 2280) for noncardiac and cardiac causes, respectively. The proportion of noncardiac deaths did not change annually over the last decade (p = 0.66). After adjusting for all variables, age, Killip classification grade, peak creatine kinase, hemoglobin, serum creatinine, and C-reactive protein were common predictors of cardiac and non-cardiac deaths. Indicators of malnutrition, such as lower body mass index (kg/m2) [odds 0.94, 95%CI (0.90–0.97), p < 0.001] and serum low-density lipoprotein cholesterol level (per 10 mg/dl) [odds 0.92, 95%CI (0.89–0.96), p < 0.001] were the specific predictors for non-cardiac deaths. The incidence of in-hospital noncardiac death was significant in patients with AMI, accounting for 15.6% of all in-hospital mortalities. Thus, prevention and management of non-cardiac complications are vital to improve acute-phase outcomes, especially those with predictors of non-cardiac death. Clinical Features and Predictors of Non-cardiac Death in Patients Hospitalised for Acute Myocardial Infarction. AMI acute myocardial infarction; CCU Cardiovascular Care Unit; BMI body mass index; LDL-C low-density lipoprotein cholesterol; CRP C-reactive protein; CK creatine kinase; CPA cardiopulmonary arrest; WBC white blood cell; LMCA left main coronary artery; BNP B-type natriuretic peptide. [Display omitted] • This study demonstrates the clinical importance of noncardiac death in AMI. • No previous study has focused on noncardiac death in patients hospitalised for AMI. • Incidence of non-cardiac death was high and has not changed over the last decade. • The management of non-cardiac complications with a comprehensive approach is vital. • Malnutrition may be a key factor for additional care in patients with AMI. [ABSTRACT FROM AUTHOR]

Optical coherence tomography (OCT) may provide a method for detecting histologically defined high-risk plaques in vivo. The authors aimed to investigate the prognostic value of OCT for identifying patients and lesions that are at risk for adverse cardiac events. Between January 2017 and May 2019, OCT of all the 3 main epicardial arteries was performed in 883 patients with acute myocardial infarction (MI) who were referred for primary percutaneous coronary intervention. The primary endpoint was the composite of cardiac death, nonculprit lesion–related nonfatal MI, and unplanned coronary revascularization. Patients were followed for up to 4 years (median 3.3 years). The 4-year cumulative rate of the primary endpoint was 7.2%. In patient-level analysis, thin-cap fibroatheroma (TCFA) (adjusted HR: 3.05; 95% CI: 1.67-5.57) and minimal lumen area (MLA) <3.5 mm2 (adjusted HR: 3.71; 95% CI: 1.22-11.34) were independent predictors of the primary endpoint. In lesion-level analysis, nonculprit lesions responsible for subsequent events were not angiographically severe at baseline (mean diameter stenosis 43.8% ± 13.4%). TCFA (adjusted HR: 8.15; 95% CI: 3.67-18.07) and MLA <3.5 mm2 (adjusted HR: 4.33; 95% CI: 1.81-10.38) were predictive of events arising from each specific lesion. TCFAs with an MLA <3.5 mm2 carried a higher risk and were sufficient for identifying patients at risk for the composite of cardiac death and nonculprit lesion–related nonfatal MI. OCT imaging of angiographically nonobstructive territories in patients with acute MI can aid in identifying patients and lesions at increased risk for adverse cardiac events. [Display omitted] [ABSTRACT FROM AUTHOR]

Aim: Safety-net hospitals (SNHs) look after a higher proportion of uninsured patients and are often located in deprived areas. This study aimed to determine whether there are differences in the clinical characteristics, treatments and outcomes of patients presenting with acute myocardial infarction (AMI) in SNHs versus non-SNHs (N-SNHs).Methods: All hospitalizations with a principal diagnosis of AMI in the United States' National Inpatient Sample between 2016 and 2019 were stratified by safety-net hospital status. Multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was conducted to investigate invasive management and clinical outcomes.Results: A total of 2,544,009 weighted discharge records were analyzed, including 601,719 records from SNHs (23.7 %). Compared with N-SNHs, SNH AMI patients were younger (median 66 years vs. 67 years, p < 0.001), and had a higher proportion in the lowest quartile of median household income (37.3 % vs. 28.5 %, p < 0.001). Patients from SNHs were less likely to receive coronary angiography (aOR 0.92, 95 % CI 0.91-0.93, p < 0.001), percutaneous coronary intervention (aOR 0.94, 95 % CI 0.93-0.95, p < 0.001), and coronary artery bypass grafting (aOR 0.93, 95 % CI 0.92-0.94, p < 0.001). In addition, they had increased all-cause mortality (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), major adverse cardiovascular/cerebrovascular events (composite of mortality, stroke and reinfarction) (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), and stroke (aOR 1.11, 95 % CI 1.08-1.14, p < 0.001), while there was no difference in major bleeding (aOR 1.02, 95 % CI 1.00-1.04, p = 0.107).Conclusion: Among AMI patients, treatment in SNHs was associated with lower utilization of coronary angiography and revascularization and worse clinical outcomes. [ABSTRACT FROM AUTHOR]

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• The VENUS Study is the first platform in Japan to evaluate vaccine effectiveness. • Pneumococcal vaccination reduces cardiovascular risk in Japanese older adults. • The protective effect was high for six months after pneumococcal vaccination. The protective effect of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) against cardiovascular disease has been investigated in the United States and Europe; however, its effect has not been fully established. This study aimed to investigate the protective effect of PPSV23 on cardiovascular events in adults aged ≥ 65 years. This population-based nested case-control study was conducted using the claims data and vaccine records between April 2015 and March 2020 from the Vaccine Effectiveness, Networking, and Universal Safety (VENUS) Study. PPSV23 vaccination was identified using vaccination records in each municipality. The primary outcome was acute myocardial infarction (AMI) or stroke. The adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for PPSV23 vaccination were calculated using conditional logistic regression. Among 383,781 individuals aged ≥ 65 years, 5,356 and 25,730 individuals with AMI or stroke were matched with 26,753 and 128,397 event-free controls, respectively. Individuals who were PPSV23 vaccinated, compared with the unvaccinated individuals, had significantly lower odds of AMI or stroke events (aOR, 0.70 [95% CI, 0.62–0.80] and aOR, 0.81 [95% CI, 0.77–0.86], respectively). More recent PPSV23 vaccination was associated with lower odds ratios (AMI, aOR 0.55 [95% CI, 0.42–0.72] for 1–180 days and aOR 1.11 [95% CI, 0.84–1.47] for 720 days or longer; stroke, aOR 0.83 [95% CI, 0.74–0.93] for 1–180 days and aOR 0.90 [95% CI, 0.78–1.03] for 720 days or longer). Among Japanese older adults, individuals who were PPSV23 vaccinated, compared with unvaccinated individuals, had significantly lower odds of AMI or stroke events. [ABSTRACT FROM AUTHOR]

Few studies have analyzed the incidence and the risk of acute myocardial infarction (AMI) during the post-acute phase of COVID-19 infection. To assess the incidence and risk of AMI in COVID-19 survivors after SARS-CoV-2 infection by a systematic review and meta-analysis of the available data. Data were obtained searching MEDLINE and Scopus for all studies published at any time up to September 1, 2022 and reporting the risk of incident AMI in patients recovered from COVID-19 infection. AMI risk was evaluated using the Mantel–Haenszel random effects models with Hazard ratio (HR) as the effect measure with 95% confidence interval (CI) while heterogeneity was assessed using Higgins and Thomson I2 statistic. Among 2765 articles obtained by our search strategy, four studies fulfilled the inclusion criteria for a total of 20,875,843 patients (mean age 56.1 years, 59.1% males). Of them, 1,244,604 had COVID-19 infection. Over a mean follow-up of 8.5 months, among COVID-19 recovered patients AMI occurred in 3.5 cases per 1.000 individuals compared to 2.02 cases per 1.000 individuals in the control cohort, defined as those who did not experience COVID-19 infection in the same period). COVID-19 patients showed an increased risk of incident AMI (HR: 1.93, 95% CI: 1.65–2.26, p < 0.0001, I2 = 83.5%). Meta-regression analysis demonstrated that the risk of AMI was directly associated with age (p = 0.01) and male gender (p = 0.001), while an indirect relationship was observed when the length of follow-up was utilized as moderator (p < 0.001). COVID-19 recovered patients had an increased risk of AMI. • Recovered COVID-19 infection is associated with higher risk of myocardial infarction • The risk of acute myocardial infarction was 93% higher in COVID-19 recovered patients compared to the general population. • The risk was higher in the early phase after the infection [ABSTRACT FROM AUTHOR]

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Coronary microthromboembolism after acute myocardial infarction (AMI) requires urgent and effective treatment. Early and effective recovery of coronary microcirculation perfusion for the management of AMI would be crucial for better prognosis. Ultrasound assisted thrombolysis in the in-vitro experiments have great potential for the elimination of acute coronary microthromboembolism, especially with stable cavitation using low-intensity focused ultrasound (LIFU) and dodecafluoropentane-loaded acoustic phase-change nanoparticles (DDFP@NPs). Therefore, our study sought to perform animal experiments using this novel treatment method in a porcine model with acute coronary microthromboembolism for further investigation of potential therapeutic values. Porcine model with acute coronary thromboembolism was established using percutaneous coronary intervention and autologous thrombus injection. For ultrasound assisted thrombolysis, DDFP@NPs were prepared by rotary evaporation and sonication process, and LIFU was optimized. Echocardiography and TTC staining were performed for the evaluation of porcine model establishment and treatment effect. The treatment using LIFU guided DDFP@NPs had almost completely recanalized culprit coronary branch after treatment procedure, and smaller infarcted size (5.4 ± 1.0%), better LVEF (52.5 ± 1.8%) and better coronary microcirculation after 28 days of treatment, which outperformed treatments using LIFU+SonoVue microbubbles (infarcted size: 26.4 ± 3.5% and LVEF: 37.2 ± 3.1%) and LIFU only (infarcted size: 32.2 ± 3.1% and LVEF: 32.2 ± 0.4%) (all P < 0.05), while the treatment effect were similar to treatment using intravenous tissue-plasminogen activator (infarcted size: 4.9 ± 0.9% and LVEF: 53.1 ± 1.1%) (all P > 0.05). Our study has innovatively established a treatment method using DDFP@NPs combined with LIFU irradiation for coronary thrombolysis and verified its treatment effect with high-efficient thrombolysis in the in-vivo experiments, which can be considered as powerful experimental evident of the novel method for potential clinical use of acute coronary thrombolysis. Multidimensional experimental investigations and cautious verification may need before the method could be used as treatment before preliminary clinical trials. • Ultrasound assisted thrombolysis have great potential for the elimination of acute coronary microthromboembolism. • DDFP-loaded nanoparticles combined with ultrasound irradiation can dissolve thrombolysis in the in-vivo experiments. • The thrombolysis mechanism relies on the stable cavitation effect of acoustic phase-change nanoparticles. [ABSTRACT FROM AUTHOR]

Whilst it is known patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI), the relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalised with T2AMI based on the presence of SMuRF. Using the National Inpatient Sample, all hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). Among 17,595 included hospitalizations, 1345 (7.6%) were SMuRF-less and 16,250 (92.4%) were SMuRF. On adjusted analysis, SMuRF-less patients had increased odds of all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts. Secondary diagnoses among both cohorts were similar, with respiratory disorders most prevalent followed by cardiovascular and renal disorders. T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. There was no SMuRF-based difference in the secondary diagnoses with the most common being respiratory, cardiovascular, and renal disorders. Further studies are warranted to improve overall care and outcomes of SMuRF-less patients. [Display omitted] • SMuRF-less patients represent 7.6% of T2AMI admissions. • SMuRF-less patients admitted with T2AMI experience more adverse outcomes. • There was no SMuRF-based difference in secondary diagnoses between each group. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the relationship between day-1 urine cadmium excretion and 30-day mortality in patients with acute myocardial infarction (AMI) at two centers. A total of 286 patients (222 males and 64 females) with AMI from Huashan Hospital, Shanghai and Chang Gung Memorial Hospital, Taiwan were enrolled. Basic vital signs, history, laboratory results, and day-1 urine excretion of cadmium (D1UECd) were recorded. Disease severity was assessed during the first hospitalization using Killip score, APACHE II score, and SOFA score. The main endpoint was 30-day mortality. Among the 286 patients, 218 were from Chung Gung Memorial Hospital and 68 were from Huashan Hospital with an average age of 64.2 years. Forty (14%) patients died within 30 days after AMI. The average 24-h urine cadmium level among the Chung Gung Memorial Hospital cohort was 1.5 ± 2.4 μg compared to 1.7 ± 1.7 μg among Huashan Hospital cohort, both higher than the local populations. A higher D1UECd level was significantly associated with a greater risk of 30-day mortality (odds ratio 1.68, 95% confidence interval 1.30–2.16) after controlling for a number of covariates. The ability of D1UECd to discriminate 30-day mortality was excellent, with a very high area under the curve (87.2%, 95% CI 82.0–92.5%). D1UECd was positively correlated and an independent predictor of 30-day mortality in the enrolled AMI patients. D1UECd may be a simple, objective prognostic scoring system in AMI patients. • Day-1 urine excretion of cadmium is positively correlated and an independent predictor of 30-day mortality in the enrolled AMI patients. • The prognosis predictive value of Day-1 urine excretion of cadmium is better than Killip, APACHE II and SOFA. [ABSTRACT FROM AUTHOR]

Background: Air pollution is a consequence of industrial development that is exacerbated as a result of population growth, and urbanisation.Aim: The goal of the study is to investigate the effects of air pollution on the number of cases of acute myocardial infarction (AMI) according to gender using the Zero-inflated Poisson Regression model in Hamadan, Iran.Methods: The study used an ecological design, and data collected from March 2016 to September 2020 in Hamadan were included. The intended response was the number of cases of AMI recorded in the investigated period. The time lag of the pollutants was used to investigate the effect of air pollution on the number of AMIs.Results: The number of AMI recorded for men and women was 1,195 and 553, respectively. The average age (±SD) for men and women was 64.60 (±12.27) and 70.98 (±11.79) years, respectively. According to the air quality index in Hamadan, the values of particulate matter (PM)2.5, SO2, O3, and CO were below moderate levels. Also, according to NO2 and PM10, the air quality index of Hamadan was in the very unhealthy mode just for 2 and 3 days, respectively. The O3 and NO2 are significant positive effects on AMI among men. But, PM2.5, PM10, and SO2 are negative impacts on hospitalisation in men due to AMI. For women, PM2.5 and O3 had positive effects on AMI. But, NO2 and PM10 had a significant negative impact on hospitalisation in women during different time lags.Conclusions: The results of the study showed that if the analyses are based on gender, the responses to pollutants are different and hence the stratified analysis is important. [ABSTRACT FROM AUTHOR]

To identify the best strategy to achieve complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD). We systematically reviewed the literature for randomized controlled trials (RCTs) comparing IRA-only PCI and CR guided by angiography or fractional flow reserve (FFR) in MVD-STEMI. Both frequentist (classical) and Bayesian network meta-analysis were performed, including a comparative hierarchy estimation of the probability to reduce the primary composite endpoint of all-cause death and new myocardial infarction (MI). We identified 11 RCTs, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the primary endpoint (OR: 0.73; 95%CI0.55–0.97). We observed non-significant difference between angiography and FFR guidance in reducing the primary endpoint (OR: 0.73, 95% CI 0.35–1.57). The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of all-cause death or new MI (SUCRA92%). In patients with MVD-STEMI, CR is associated with a reduction in all-cause mortality and new MI compared with IRA-only PCI. Angio-guided CR is associated with the lowest risk of all-cause death or new MI, therefore the role of FFR-guidance in this setting is questionable. Both frequentist and Bayesian network meta-analysis were performed to compare infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) and complete revascularization (CR) guided by angiography or fractional flow reserve (FFR) in multivessel disease (MVD) and acute ST-elevation myocardial infarction (STEMI). Eleven randomized controlled trials were identified, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the incidence of the composite endpoint of all-cause death and new myocardial infarction without significant difference in angio-guided and FFR-guided CR. The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of the composite endpoint and, therefore the role of FFR-guidance in this setting is questionable. • A meta-analysis of 11 trials compared angio-guided vs FFR-guided revascularization in STEMI. • Complete revascularization significantly reduced the incidence of all-cause death and new myocardial infarction • The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk [ABSTRACT FROM AUTHOR]

To quantitatively evaluate the associations of infarct size, regional myocardial function examined by cardiac magnetic resonance feature tracking (CMR-FT) strain analysis with infarct location in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention. Cardiac magnetic resonance images were retrospectively analyzed in 95 consecutive STEMI patients with successful reperfusion. The patients were divided into the anterior wall myocardial infarction (AWMI) and nonanterior wall myocardial infarction (NAWMI) groups. Infarct characteristics were assessed by late gadolinium enhancement. Global and regional strains and associated strain rates in the radial, circumferential and longitudinal directions were assessed by CMR-FT based on standard cine images. The associations of infarct size, regional myocardial function examined by CMR-FT strain analysis with infarct location in STEMI patients were evaluated by the Spearman or Pearson method. There were 44 patients in the AWMI group and 51 in the NAWMI group. The extent of left ventricular enhanced mass was significantly larger in patients with AWMI compared with the NAWMI group (24.47+11.89, 21.06+12.08 %LV; t = 3.928, P = 0.008). In infarct zone analysis, strains in the radial, circumferential and longitudinal directions were remarkably declined in the AWMI group compared with the NAWMI group (z = -20.873, -20.918, -10.357, all P < 0.001). The volume (end-systolic volume index), total enhanced mass and extent of enhanced mass of the left ventricular were correlated best with infarct zone strain in the AWMI group (all P < 0.001). In STEMI patients treated by percutaneous coronary intervention, myocardial damage is more extensive and regional myocardial function in the infarct zone is lower in the AWMI group compared with the NAWMI group. [ABSTRACT FROM AUTHOR]

Observational and trial data have revealed significant improvement in cardiogenic shock (CS) mortality due to acute myocardial infarction (AMI) after introducing early coronary revascularization. Less is known about CS mortality due to heart failure (HF), which is increasingly recognized as a distinct entity from AMI-CS. In this nationwide observational study, the CDC WONDER database was used to identify national trends in age-adjusted mortality rates (AAMR) due to CS (HF vs. AMI related) per 100,000 people aged 35–84. AAMR from AMI-CS decreased significantly from 1999 to 2009 (AAPC: -6.9% [95%CI -7.7, −6.1]) then stabilized from 2009 to 2020. By contrast, HF-CS associated AAMR rose steadily from 2009 to 2020 (AAPC: 13.3% [95%CI 11.4,15.2]). The mortality rate was almost twice as high in males compared to females in both AMI-CS and HF-CS throughout the study period. HF-CS mortality in the non-Hispanic Black population is increasing more quickly than that of the non-Hispanic White population (AAMR in 2020: 4.40 vs. 1.97 in 100,000). The AMI-CS mortality rate has been consistently higher in rural than urban areas (30% higher in 1999 and 28% higher in 2020). These trends highlight the fact that HF-CS and AMI-CS represent distinct clinical entities. While mortality associated with AMI-CS has primarily declined over the last two decades, the mortality related to HF-CS has increased significantly, particularly over the last decade, and is increasing rapidly among individuals younger than 65. Accordingly, a dramatic change in the demographics of CS patients in modern intensive care units is expected. • Among US adults, AMI-CS mortality decreased substantially from 1999 to 2009 then stabilized from 2009 to 2020. • Conversely, HF-CS mortality was stable from 1999 until 2009, and rose steadily from 2009 to 2020. • Males had consistently higher mortality rates than females in both AMI-CS and HF-CS across all years. • HF-CS mortality has been consistently higher in non-Hispanic Black individuals compared to Non-Hispanic White individuals. • AMI-CS mortality has been comparable between non-Hispanic Black and White individuals. [ABSTRACT FROM AUTHOR]

Background: Early inflammation following acute ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) affects myocardial infarct (MI) size and left ventricular remodeling. The mammalian target of rapamycin (mTOR) is involved in the enhanced inflammatory response and its inhibition has exerted beneficial effects on MI size in preclinical models of acute MI.Objectives: The CLEVER-ACS (Controlled Level Everolimus in Acute Coronary Syndromes) trial evaluated the effects of targeting inflammation by mTOR inhibition in patients with STEMI undergoing PCI.Methods: CLEVER-ACS was a randomized, multicenter, international, double-blind, placebo-controlled trial. A total of 150 patients with STEMI undergoing PCI were randomly assigned to oral everolimus (days 1-3: 7.5 mg daily; days 4-5: 5.0 mg daily) or placebo for 5 days. The primary endpoint was the change in MI size. The secondary endpoint was the change in microvascular obstruction (MVO) from baseline (12 hours to 5 days after PCI) to 30 days as assessed by cardiac magnetic resonance imaging.Results: The changes in MI size from baseline to 30 days, the primary endpoint, were -14.2 g (95% CI: -17.4 to -11.1 g) and -12.3 g (95% CI: -16.0 to -8.7 g) in the everolimus and placebo groups (P = 0.99). Corresponding changes in MVO were -4.8 g (95% CI: -6.7 to -2.9 g) and -6.3 g (95% CI: -8.7 to -4.0 g) in the everolimus and placebo groups (P = 0.14). Adverse events did not differ between the study groups.Conclusions: Among STEMI patients undergoing PCI, early mTOR inhibition with everolimus did not reduce MI size or MVO at 30 days. (CLEVER-ACS [Controlled Level Everolimus in Acute Coronary Syndromes; NCT01529554). [ABSTRACT FROM AUTHOR]

The optima revascularization strategy for senior patients admitted with acute myocardial infarction (AMI) in the context of multivessel coronary artery disease (MVCAD) remains unclear. We aimed to compare a strategy of culprit-vessel (CV) vs. multi-vessel percutaneous coronary intervention (MV-PCI) in older adults (≥75 years) with AMI. We analyzed four randomized controlled trials designed to include older adults with AMI. The primary endpoint was all-cause death. The secondary endpoint was the composite of all-cause death, myocardial infarction, stroke and major bleeding (Net Adverse Clinical Events, NACE). A non-parsimonious propensity score and nearest-neighbor matching was performed to account for bias. A total of 1,334 trial participants were included; of them, 770 (57.7%) underwent CV-PCI and 564 (42.3%) a MV-PCI strategy. After a median follow-up of 365 days, patients treated with MV-PCI experienced a lower rate of death (6.0% vs. 9.9%; p = 0.01) and of NACE (11.2% vs. 15.5%; p = 0.016). After multivariable analysis, MV-PCI was independently associated with a lower hazard of death (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42–0.96; p = 0.03) and NACE (NACE 0.72[0.53–0.98]; p = 0.04). These results were confirmed in a matched propensity analysis, were consistent throughout the spectrum of older age and when analyzed by subgroups and when immortal-time bias was considered. In the setting of older adults with MVCAD who were managed invasively for AMI, a MV-PCI strategy to pursue complete revascularization was associated with better survival and lower risk of NACE compared to a CV-PCI. Adequately sized RCTs are required to confirm these findings. Survival analysis and occurrence of clinical events at 2 years. Kaplan-Meier curves for all-cause deaths (A) and NACE (B) are shown. In (C) number of events and (%) are reported. Log-rank p and number of patients at risk are shown. CV, Culprit-vessel; MV, Multivessel; NACE, Net Adverse Clinical Events; PCI, Percutaneous Coronary Intervention. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: There is limited data on the impact of chronic total occlusions (CTOs) on the outcomes of patients presenting with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) in the contemporary era.Methods: We queried the National Inpatient Sample between October 2015 and December 2017 using the International Classification of Diseases, Tenth revision codes to identify hospitalized AMI patients undergoing PCI. A 1:1 propensity-score matched analysis was performed to compare in-hospital outcomes of patients with and without CTOs.Results: Among 576,760 admissions identified during the study period, 51,225(8.8 %) had CTO and 525,535 (91.1 %) did not. After 1:1 propensity-score matching, each matched group contained 51,210 admissions. In-hospital mortality was significantly higher in the CTO group compared with the non-CTO group (4.7 % vs 3 %, p < 0.0001). In the CTO group, hospital length of stay was longer (median 3 vs 2 days, p = 0.001) and lower percentage of patients were discharged to home (78.8 % vs 81.1 %, p < 0.0001), compared with the non-CTO group. Median cost of hospital stay was also higher in the CTO group compared with the non-CTO group ($20,921 vs $19,856, p < 0.0001).Conclusions: In this propensity-score matched analysis of a large US inpatient database, the presence of CTOs in AMI patients undergoing PCI identified a higher risk cohort with in higher in-hospital mortality, longer hospital length of stay and higher hospitalization cost. [ABSTRACT FROM AUTHOR]

Background: Clonal hematopoiesis of indeterminate potential (CHIP) is common in elderly individuals and is associated with an increased risk of both hematologic malignancies and cardiovascular disease. The impact of CHIP on the outcomes for patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains undetermined.Objectives: The purpose of this study was to determine the prognostic impact of CHIP in CS after AMI.Methods: Blood samples were obtained at randomization from 446 patients included in the CULPRIT-SHOCK (Culprit Lesion Only vs Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock; NCT01927549) trial. CHIP was assessed using a next-generation sequencing approach targeting the most commonly mutated genes; the primary outcome at 30 days comprised all-cause mortality and renal replacement therapy.Results: CHIP variants at ≥2% variant allele frequency were detected in 29% (n = 129), most commonly in the DNMT3A or TET2 genes, which harbored 47% and 36% of all mutations, respectively. Compared to non-CHIP patients, CHIP carriers were older and had decreased renal function and increased levels of N-terminal pro-B-type natriuretic peptide and inflammatory biomarkers. CHIP carriers had worse short-term outcomes measured either as mortality or as the combined clinical endpoint of mortality or severe renal failure within 30 days. Association of CHIP with the combined endpoint was independent of age and biomarkers reflecting kidney function, heart failure severity, and inflammation (OR: 1.83; 95% CI: 1.05-3.21; P = 0.03) but not significant regarding all-cause mortality (OR: 1.67; 95% CI: 0.96-2.90; P = 0.069).Conclusions: CHIP is frequent among AMI and CS patients and is associated with impaired clinical outcome. CHIP assessment may facilitate risk stratification in patients with CS and imply novel treatment targets. (Culprit Lesion Only vs Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock [CULPRIT-SHOCK]; NCT01927549). [ABSTRACT FROM AUTHOR]

Background: Acute myocardial infarction (AMI), a medical condition caused by the ischemic necrosis of cardiac tissues, is due to sudden occlusion of the coronary arteries in patients including transplant recipients. It is the leading reason for death and disability worldwide. This study aimed to search potential biomarkers related to the progression of AMI and identify the related immune-related pathways, as also examine their association with the immune cell infiltration and diagnostic value for AMI. Methods: Datasets of gene microarray were extracted from (www.ncbi.nlm.nih.gov/geo) the Gene Expression Omnibus (GEO) database and AMI-related biomarkers were obtained by differential expression analysis and weighted correlation network analysis (WGCNA). Subsequently, the support vector machine-recursive feature elimination (SVM-RFE) and the least absolute shrinkage and selection operator (LASSO) regression analyses were used to mine AIM-related hub markers. For the assessment of the diagnostic value of these markers for AMI, the receiver operator characteristic (ROC) curves were plotted. Additionally, the single-sample gene set enrichment analysis (ssGSEA) was performed to determine the immune cell infiltration. Results: A total of 1273 differentially expressed genes (DEGs) were obtained. Nine co-expression modules were obtained after WGCNA. Among them, the brown-colored module was identified as the hub for AMI (correlation [cor] = 0.73, P = 1.1e-87), and intersected with the DEGs yielded a total of 88 shared genes. Subsequently, five hub genes were obtained from the analysis of the LASSO regression and SVM-RFE algorithm. Ultimately, using the ROC curves, the diagnostic values of these genes for AMI were confirmed. The five hub genes were also found to be significantly associated with the infiltration levels of multiple immune cells. Moreover, the DEGs were mainly enriched in the inflammatory and immune-related gene sets evidenced by the functional enrichment analysis. Conclusion: The five hub genes may serve as potential markers for AMI diagnosis and the findings have implications for further investigations on the molecular mechanisms underlying AMI. [ABSTRACT FROM AUTHOR]

Background: Low ankle-brachial index (ABI) is an established risk factor for long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI), and brachial-ankle pulse wave velocity (ba-PWV) may also be a risk factor. However, there is a significant overlap between low ABI and high ba-PWV. The purpose of this retrospective study was to examine whether increased ba-PWV was associated with long-term clinical outcomes in AMI patients with normal ABI.Methods: We included 932 AMI patients with normal ABI and divided them into the high PWV group (≥1,400 cm/s; n=646) and the low PWV group (<1400 cm/s; n=286) according to the ba-PWV values measured during the AMI hospitalisation. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and hospitalisation for heart failure.Results: During the median follow-up duration of 541 days (Q1: 215 days-Q3: 1,022 days), a total of 154 MACE were observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the high PWV group than in the low PWV group (p<0.001). The multivariate Cox hazard analysis revealed that high ba-PWV was significantly associated with MACE (hazard ratio [HR] 1.587; 95% CI 1.002-2.513; p=0.049) after controlling multiple confounding factors.Conclusions: High ba-PWV was significantly associated with long-term adverse events in AMI patients with normal ABI. Our results suggest the usefulness of PWV as a prognostic marker in AMI with normal ABI. [ABSTRACT FROM AUTHOR]

Contemporary data on the epidemiology of acute myocardial infarction (AMI) in Vietnam are extremely limited. We established population-based registries of residents from 2 provinces in a northern urban (Hai Phong), and a central rural (Thanh Hoa), province of Vietnam hospitalized with a validated first AMI in 2018. We described patient characteristics, in-hospital management and clinical complications, and estimated incidence rates of AMI in these two registries. A total of 785 patients (mean age = 71.2 years, 64.7% men) were admitted to the two hospitals with a validated first AMI. Approximately 64% of the AMI cases were ST-segment-elevation AMI. Patients from Thanh Hoa compared with Hai Phong were more likely to delay seeking acute hospital care. The incidence rates (per 100,000 population) of initial AMI in Thanh Hoa and Hai Phong were 16 and 30, respectively. Most patients were treated with aspirin (Thanh Hoa: 96%; Hai Phong: 90%) and statins (both provinces: 91%) during their hospitalization. A greater proportion of patients in Hai Phong (69%) underwent percutaneous revascularization than those in Thanh Hoa (58%). The most common in-hospital complications were heart failure (both provinces:12%), cardiogenic shock (Thanh Hoa: 10%; Hai phong: 7%); and cardiac arrest (both provinces: 9%). The in-hospital case-fatality rates for patients from Thanh Hoa and Hai Phong were 6.8% and 3.8%, respectively. The incidence and hospital case-fatality rates of AMI were low in two Vietnamese provinces. Extent of pre-hospital delay and in-hospital use of evidence-based therapies were suboptimal, being more prominent in the rural province. • Contemporary data on the epidemiology of acute myocardial infarction (AMI) in Vietnam are extremely limited. • A registry of residents from 2 provinces in northern and central Vietnam hospitalized with an AMI during 2018 was established. • The incidence and hospital case-fatality rates of AMI were low in two large Vietnamese provinces. • Extent of pre-hospital delay and in-hospital use of evidence-based therapies were suboptimal. [ABSTRACT FROM AUTHOR]

• De Ritis ratio predicts 3-year all-cause mortality after acute myocardial infarction. • De Ritis ratio predicts 3-year cardiac mortality after acute myocardial infarction. • De Ritis ratio predicts 30-day risk of bleeding after percutaneous coronary intervention. • De Ritis ratio has a moderate sensitivity regarding prediction of mortality. The association between aspartate aminotransferase to alanine aminotransferase ratio (De Ritis ratio) and prognosis of patients with acute myocardial infarction (AMI) remains poorly investigated. This study included 3000 patients with AMI undergoing percutaneous coronary intervention. Patients were categorized in groups according to tertiles of the De Ritis ratio: tertile 1 (De Ritis ratio < 1.11; 905 patients), tertile 2 (De Ritis ratio 1.11 to 1.95; 1003 patients) and tertile 3 (De Ritis ratio > 1.95; 1002 patients). The primary endpoint was 3-year all-cause mortality. At 3 years, all-cause deaths occurred in 487 patients: 119 deaths (13.2%) in patients of 1st tertile, 164 deaths (17.8%) in patients of 2nd tertile and 204 deaths (21.9%) in patients of 3rd tertile of the De Ritis ratio (adjusted hazard ratio [HR] = 1.16, 95% confidence interval [CI] 1.02 to 1.31], P = 0.023 per unit increment in the logarithmic scale of the De Ritis ratio); cardiac deaths occurred in 328 patients: 76 deaths (8.2%) in patients of 1st tertile, 110 deaths (12.0%) in patients of 2nd tertile and 142 deaths (15.4%) in patients of 3rd tertile of the De Ritis ratio (adjusted HR = 1.20 [1.04–1.40], P = 0.014 per unit increment in the logarithmic scale of De Ritis ratio). The C-statistic of the multivariable model(s) with baseline data without and with De Ritis ratio was 0.822 [0.805–0.839] and 0.823 [0.805–0.840], (P = 0.419) for all-cause mortality and 0.831[0.811–0.852] and 0.832 [0.811–0.853], P = 0.621) for cardiac mortality. In patients with AMI, elevated De Ritis ratio was associated with increased risk of 3-year mortality. [ABSTRACT FROM AUTHOR]

• Tenascin-C is expressed in diseased hearts, not in normal hearts. • Clinical utility of Tenascin-C in diseased heart is unclear. • Tenascin-C was independently associated with acute myocardial infarction, cardiomyopathy, diabetic retinopathy. • Tenascin could predict cardiovascular outcomes in patient with stable coronary heart disease. We investigated the prognostic value of tenascin-C in patients with stable coronary heart disease. A total of 666 patients were enrolled and followed for 72 months. The primary outcome was a composite of cardiac events. The secondary outcomes were all-cause death, cardiovascular death, acute myocardial infarction (AMI), and heart failure hospitalization. Results: The area under the curve of tenascin-C to discriminate the occurrence of composite cardiac events was 70 % (95 % CI: 64.2 % to 75.8 %), and the corresponding optimal cutoff value was 19.91 ng/ml. A higher concentration of tenascin-C was associated with a greater risk of composite cardiac events (P trend < 0.001). Similar results were observed in all-cause death, AMI, and heart failure hospitalization. Tenascin-C was found to be an independent predictor of total cardiovascular events in patients with stable coronary heart disease at 72 months, and also for all-cause death, AMI, and heart failure hospitalization. [ABSTRACT FROM AUTHOR]

Background: Recently, the impact of the lack of standard modifiable risk factors, including hypertension, diabetes, dyslipidaemia, and current smoking, has been investigated in ST-segment elevation myocardial infarction (MI). The present study aimed to evaluate clinical characteristics and prognosis of the patients with no standard risk factors in acute MI.Methods: This bi-centre registry included 1,093 patients with acute MI undergoing percutaneous coronary intervention. The participants were divided into two groups: patients having at least one of the four standard risk factors and those having none of the risk factors. The study endpoints included major adverse cardiovascular events (MACE) (death, recurrent MI, and stroke) and major bleeding events during hospitalisation. Any MACE and major bleeding events after discharge were also evaluated as an exploratory analysis.Results: Of 1,093 patients, 64 (5.9%) had none of the four standard risk factors. The patients with no standard risk factors were likely to present with Killip class IV and cardiac arrest. The rate of in-hospital MACE was higher in patients with no risk factors than in their counterparts (25.0% vs 9.9%; p<0.001), whereas the incidence of in-hospital major bleeding was not significantly different between the two groups (9.4% vs 6.7%; p=0.44). Active cancer and autoimmune/inflammatory diseases were often found in patients with no standard risk factors. After discharge, no significant differences were observed in the risks of MACE and major bleeding events between the two groups.Conclusions: No standard modifiable risk factors were not uncommon and were associated with poor short-term outcomes in patients with acute MI. [ABSTRACT FROM AUTHOR]

The timing of hemodynamic support in acute myocardial infarction complicated by cardiogenic shock (AMICS) has yet to be defined. The aim of this meta-analysis was to evaluate the impact of timing of Impella initiation on early and midterm mortality. A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting short-term mortality rates and timing of Impella placement in AMICS were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, short-term mortality (≤30 days), and secondary endpoints (midterm mortality, device-related bleeding, and limb ischemia). Of 1289 studies identified, 13 studies (6810 patients; 2970 patients identified as receiving Impella pre-PCI and 3840 patients receiving Impella during/post-PCI) were included in this analysis. Median age was 63.8 years (IQR 63–65.7); 76% of patients were male, and a high prevalence of cardiovascular risk factors was noted across the entire population. Short-term mortality was significantly reduced in those receiving pre-PCI vs. during/post-PCI Impella support (37.2% vs 53.6%, RR 0.7; CI 0.56–0.88). Midterm mortality was also lower in the pre-PCI Impella group (47.9% vs 73%, RR 0.81; CI 0.68–0.97). The rate of device-related bleeding (RR 1.05; CI 0.47–2.33) and limb ischemia (RR 1.6; CI 0.63–2.15) were similar between the two groups. This analysis suggests that Impella placement prior to PCI in AMICS may have a positive impact on short- and midterm mortality compared with post-PCI, with similar safety outcomes. Due to the observational nature of the included studies, further studies are needed to confirm this hypothesis (CRD42022300372). • Impella placement before PCI in ACS complicated by CS is associated with a reduced mortality compared with the post-PCI group. • The meta-regression analysis suggested that male gender and age were associated with the primary outcome. • Complication rate was comparable between the two strategies regarding device-related bleeding and limb ischemia. [ABSTRACT FROM AUTHOR]

• New-onset AF(NOAF) after acute myocardial infarction(AMI) is common and is associated with worse outcomes. • Atrial cardiomyopathy markers including PTFV1, LAD, and BNP were strongly associated with NOAF after AMI. • The prediction performance of the ESC model for NOAF was increased by the addition of these markers. New-onset atrial fibrillation (NOAF) after acute myocardial infarction (AMI) is common and independently correlated with poor prognosis. The purpose of this study is to explore whether atrial cardiomyopathy (ACM) markers improve NOAF risk assessment and contribute to therapy decision-making to improve prognosis. We retrospectively analyzed 4713 patients with AMI without a documented history of atrial fibrillation (AF). We measured markers of ACM including P-wave terminal force in ECG lead V1 (PTFV1), Left atrial dimension (LAD), and B-type natriuretic peptide (BNP). Patients were stratified into tertiles of PTFV1, LAD, and BNP levels. Associations between markers and NOAF were evaluated using logistic regression analysis. Overall, 222 (4.71%) patients had NOAF out of 4713 patients. The prevalence of NOAF increased gradually with PTFV1, LAD, and BNP tertiles. On multivariable regression analysis with potential confounders, elevated PTFV1, LAD, and BNP markers were significantly associated with an increased risk of NOAF. The addition of PTFV1, LAD, and BNP to the AF risk factors recommended by the 2020 ESC Guidelines significantly improved risk discrimination for NOAF. Atrial cardiomyopathy markers including PTFV1, LAD, and BNP were strongly associated with NOAF after AMI. The prediction performance of the clinical model for NOAF was increased by the addition of these markers. [ABSTRACT FROM AUTHOR]

Opioids are used for pain relief in patients suffering from acute myocardial ischemia or infarction. Clinical and laboratory studies demonstrate that morphine treated patients or the experimental animal model suffering acute myocardial ischemia and reperfusion, may worsen myocardial viability. As transient receptor potential vanilloid 1 (TRPV1) plays important roles in pain sensation and cardio-protection, we query whether opioids may exacerbate myocardial viability via interaction with TRPV1 activity in the pain relief. We found the co-expressions of TRPV1 and opioid μ, δ and κ receptors in adult rat cardiomyocytes. Intravenous injection of morphine (0.3 mg/kg) at 20 min after induction of myocardial ischemia, in the rat model of acute myocardial ischemia and reperfusion, induced significant reduction of phosphorylated TRPV1 (p-TRPV1) in the ventricular myocardium and increase in serum cardiac troponin I (cTnI), compared with the ischemia/reperfusion controls (all P < 0.05). The effects of morphine were completely reversed by selective opioid μ, δ and κ receptor antagonists. While significant upregulation of p-TRPV1 (P < 0.05) and improvement of ±dP/dt max (all P < 0.05) were detected in the animals giving the same dose of morphine before induction of myocardial ischemia. The changes in p-TRPV1 correlate with the alterations of cTnI (r = −0.5840, P = 0.0283) and ±dP/dt max (r = 0.8084, P = 0.0005 and r = −0.8133, P = 0.0004, respectively). The findings of this study may indicate that potentiation and attenuation of TRPV1 sensitivity correlate with the improvement of the cardiac performance and the aggravation of myocardial viability, respectively, by giving morphine before and during myocardial ischemia and reperfusion. [ABSTRACT FROM AUTHOR]

[Display omitted] • Review of the most specific cardiac biomarker, troponin I and T. • Introduction of SPR biosensors to detection the cardiac troponin I and T biomarker. • Immunosensor, aptasensor, and imprinting SPR based biosensor was introduced. • Expressing the SPR biosensors as a useful platform for early detection of troponin. Acute myocardial infarction (AMI) is one of the life-threatening causes that decrease blood flow to the heart, leading to increased mortality and related complications. Recently, the measure of blood concentration of cardiac biomarkers has been suggested to overcome the limitations of electrocardiography (ECG) analyses for early diagnosis of this disease. Troponins, especially cardiac troponin I and cardiac troponin T, with high sensitivity and specificity, are considered the gold standards in myocardial diagnosis. Recently, the use of new biosensors such as surface plasmon resonance (SPR) for early detection of these biomarkers has been greatly appreciated. Due to the rapid, sensitive, real-time, and label-free detection of SPR-based biosensors, they can be applied for selective and nonspecific absorption that is intended to be used as an in situ cardiac biosensor. Here, we exclusively discussed the updated developments of these valuable predictors for the possible occurrence of AMI detected by SPR. [ABSTRACT FROM AUTHOR]

Sodium valproate (VPA), a histone deacetylase (HDAC) inhibitor, could be a promising candidate to treat acute myocardial infarction (AMI). In this study, AMI was induced in New Zealand White rabbits by occluding the left circumflex coronary artery for 1 h, followed by reperfusion. The animals were distributed into three experimental groups: the sham-operated group (SHAM), the AMI group and the AMI + VPA group (AMI treated with VPA 500 mg/kg/day). After 5 weeks, abdominal aorta was removed and used for isometric recording of tension in organ baths or protein expression by Western blot, and plasma for the determination of nitrate/nitrite (NOx) levels by colorimetric assay. Our results indicated that AMI induced a reduction of the endothelium-dependent response to acetylcholine without modifying the endothelium-independent response to sodium nitroprusside, leading to endothelial dysfunction. VPA treatment reversed AMI-induced endothelial dysfunction and even increased NO sensitivity in vascular smooth muscle. This response was consistent with an antioxidant effect of VPA, as it was able to reverse the superoxide dismutase 1 (SOD 1) down-regulation induced by AMI. Our experiments also ruled out that the VPA mechanism was related to eNOS, iNOS, sGC and arginase expression or changes in NOx plasma levels. Therefore, we conclude that VPA improves vasodilation by increasing NO bioavailability, likely due to its antioxidant effect. Since endothelial dysfunction was closely related to AMI, VPA treatment could increase aortic blood flow, making it a potential agent in reperfusion therapy that can prevent the vascular damage. [Display omitted] • VPA treatment reverses AMI-induced endothelial dysfunction in rabbit aorta. • VPA increases NO bioavailability in response to acetylcholine. • VPA mechanism is independent of eNOS-sGC, iNOS or arginase protein expression. • AMI decreases SOD1 protein expression in aorta. • Enhancement of VPA in AMI may be related to the ability to restore SOD1. [ABSTRACT FROM AUTHOR]

Background: Risk-stratifying patients with cardiogenic shock (CS) is a major unmet need. The recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) staging system for CS severity lacks uniform criteria defining each stage.Objectives: The purpose of this study was to test parameters that define SCAI stages and explore their utility as predictors of in-hospital mortality in CS.Methods: The CS Working Group registry includes patients from 17 hospitals enrolled between 2016 and 2021 and was used to define clinical profiles for CS. We selected parameters of hypotension and hypoperfusion and treatment intensity, confirmed their association with mortality, then defined formal criteria for each stage and tested the association between both baseline and maximum Stage and mortality.Results: Of 3,455 patients, CS was caused by heart failure (52%) or myocardial infarction (32%). Mortality was 35% for the total cohort and higher among patients with myocardial infarction, out-of-hospital cardiac arrest, and treatment with increasing numbers of drugs and devices. Systolic blood pressure, lactate level, alanine transaminase level, and systemic pH were significantly associated with mortality and used to define each stage. Using these criteria, baseline and maximum stages were significantly associated with mortality (n = 1,890). Lower baseline stage was associated with a higher incidence of stage escalation and a shorter duration of time to reach maximum stage.Conclusions: We report a novel approach to define SCAI stages and identify a significant association between baseline and maximum stage and mortality. This approach may improve clinical application of the staging system and provides new insight into the trajectory of hospitalized CS patients. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483). [ABSTRACT FROM AUTHOR]

We evaluated the diagnostic performance of a whole blood, point of care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay for myocardial infarction (MI) compared to central laboratory assays. Consecutive patients presenting to the emergency department with symptoms of ischemia were studied. Serial hs-cTnI testing was based on clinical indication at presentation. Parallel measurements were made using fresh whole blood on Siemens Atellica VTLi POC assay, EDTA plasma on Abbott ARCHITECT i2000 used in practice, and heparin plasma on Siemens Atellica. MI was determined according to the Fourth Universal Definition of MI using 99th percentiles. Sensitivities and negative predictive values (NPV) were calculated using 99th percentile URLs. 1089 Patients, 418 females and 671 males, were enrolled. There were 91 (8.4%) MIs. At baseline (0 h), POC hs-cTnI assay had a sensitivity of 65.7% (95% CI 47.8–80.9) for females and 67.9% (54.0–79.7) for males and NPV of 96.4% (93.9–98.1) for females and 96.7% (94.9–98.0) for males. At 2 h, sensitivity improved to 82.9% (66.4–93.4) for females and 80.4% (67.6–89.8) for males, while NPV improved to 98.2% (96.1–99.3) and 97.9% (96.3–99.0), respectively. For central laboratory assays, comparable diagnostics were observed at 2 h: females - sensitivity 94.3% (80.8–99.3) for ARCHITECT and 79.4% (62.1–91.3) for Atellica, and NPV 99.3% (97.6–99.9) and 98.0% (95.8–99.2), respectively; males - sensitivity 87.5% (75.9–94.8) for ARCHITECT and 80.4% (67.6–89.8) for Atellica, NPVs of 98.7% (97.3–99.5) and 97.9% (96.3–99.0), respectively. The POC, whole blood Atellica VTLi hs-cTnI assay demonstrated comparable diagnostic accuracy for MI to central laboratory assays using 99th percentiles. [ABSTRACT FROM AUTHOR]

Background: Left ventricular unloading with Impella may improve survival outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). However, the optimal timing to initiate left ventricular unloading has yet to be established. Therefore, we conducted a systematic review and meta-analysis to compare survival in patients with AMI-CS who were supported with Impella prior to PCI (pre-PCI) to those in whom support was initiated following PCI (post-PCI).Methods: All studies that evaluated the impact of pre-PCI versus post-PCI Impella placement in patients with AMI-CS were included. Primary endpoints included in-hospital, 30-day, and 6-month survival rates.Results: We identified five observational studies comparing outcomes in 432 patients with AMI-CS, of which 173 patients were treated with Impella pre-PCI and 259 patients post-PCI. Patients in the pre-PCI group had lower in-hospital mortality compared to patients in the post-PCI group (RR 0.62, 95% CI: 0.50-0.76, I2 = 0%). The lower mortality rate in the pre-PCI group remained evident at 30 days (HR 0.60, 95% CI: 0.47-0.78, I2 = 0%) and at 6 months (HR 0.66, 95% CI: 0.44-0.97, I2 = 0%). There was no difference in the risk of adverse events including reinfarction, stroke, major bleeding, acute ischemic limb, access site bleeding, and hemolysis.Conclusions: In this meta-analysis of studies evaluating survival among AMI-CS patients with left ventricular unloading initiated pre- versus post-PCI, Impella placement prior to PCI was associated with improved survival. [ABSTRACT FROM AUTHOR]