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In the BRIGHT-4 (Bivalirudin With Prolonged Full-Dose Infusion During Primary PCI Versus Heparin Trial-4), anticoagulation with bivalirudin plus a 2- to 4-hour high-dose infusion after percutaneous coronary intervention (PCI) reduced all-cause mortality and bleeding without increasing reinfarction or stent thrombosis compared with heparin alone in patients with ST-segment elevation myocardial infarction (STEMI). These findings require external validation. This study sought to determine outcomes of bivalirudin vs heparin anticoagulation during PCI in STEMI. We performed an individual-patient–data meta-analysis of all large randomized trials of bivalirudin vs heparin in STEMI patients undergoing primary PCI performed before BRIGHT-4. The primary endpoint was all-cause mortality. Six trials randomizing 15,254 patients were included. Pooled across all regimens of bivalirudin and glycoprotein IIb/IIIa inhibitor (GPI) use, bivalirudin reduced 30-day all-cause mortality (2.5% vs 2.9%; adjusted OR: 0.78; 95% CI: 0.62-0.99), cardiac mortality (adjusted OR: 0.69; 95% CI: 0.54-0.88), and major bleeding (adjusted OR: 0.53; 95% CI: 0.44-0.64) but increased reinfarction (adjusted OR: 1.30; 95% CI: 1.02-1.65) and stent thrombosis (adjusted OR: 1.43; 95% CI: 1.05-1.93) compared with heparin. In 4 trials in which 6,244 patients were randomized to bivalirudin plus a high-dose post-PCI infusion vs heparin without planned GPI use (the BRIGHT-4 regimens), 30-day all-cause mortality occurred in 1.8% vs 2.9% of patients, respectively (adjusted OR: 0.74; 95% CI: 0.48-1.12), and bivalirudin reduced cardiac mortality (adjusted OR: 0.62; 95% CI: 0.39-0.97) and major bleeding (adjusted OR: 0.49; 95% CI: 0.35-0.70), with similar rates of reinfarction (adjusted OR: 0.89; 95% CI: 0.58-1.38) and stent thrombosis (adjusted OR: 0.80; 95% CI: 0.41-1.57). In STEMI patients undergoing primary PCI, bivalirudin with a 2- to 4-hour post-PCI high-dose infusion reduced cardiac mortality and major bleeding without an increase in ischemic events compared with heparin monotherapy with provisional GPI use, confirming the BRIGHT-4 results. [ABSTRACT FROM AUTHOR]

Early invasive revascularization guided by moderate to severe ischemia did not improve outcomes over medical therapy alone, underlying the need to identify high-risk patients for a more effective invasive referral. CMR could determine the myocardial extent and matching locations of ischemia and infarction. This study sought to investigate if CMR peri-infarct ischemia is associated with adverse events incremental to known risk markers. Consecutive patients were included in an expanded cohort of the multicenter SPINS (Stress CMR Perfusion Imaging in the United States) study. Peri-infarct ischemia was defined by the presence of any ischemic segment neighboring an infarcted segment by late gadolinium enhancement imaging. Primary outcome events included acute myocardial infarction and cardiovascular death, whereas secondary events included any primary events, hospitalization for unstable angina, heart failure hospitalization, and late coronary artery bypass surgery. Among 3,915 patients (age: 61.0 ± 12.9 years; 54.7% male), ischemia, infarct, and peri-infarct ischemia were present in 752 (19.2%), 1,123 (28.8%), and 382 (9.8%) patients, respectively. At 5.3 years (Q1-Q3: 3.9-7.2 years) of median follow-up, primary and secondary events occurred in 406 (10.4%) and 745 (19.0%) patients, respectively. Peri-infarct ischemia was the strongest multivariable predictor for primary and secondary events (HR adjusted : 1.72 [95% CI: 1.23-2.41] and 1.71 [95% CI: 1.32-2.20], respectively; both P < 0.001), adjusted for clinical risk factors, left ventricular function, ischemia extent, and infarct size. The presence of peri-infarct ischemia portended to a >6-fold increased annualized primary event rate compared to those with no infarct and ischemia (6.5% vs 0.9%). Peri-infarct ischemia is a novel and robust prognostic marker of adverse cardiovascular events. [ABSTRACT FROM AUTHOR]

ST-segment elevation myocardial infarction (STEMI) is associated with high early mortality. However, it remains unclear if patients surviving the early phase have long-term excess mortality. This study aims to assess excess mortality in STEMI patients treated with primary percutaneous coronary intervention (PCI) compared with an age- and- sex-matched general population at landmark periods 0 to 30 days, 31 to 90 days, and 91 days to 10 years. Using the Western Denmark Heart Registry, we identified first-time PCI-treated patients who had primary PCI for STEMI from January 2003 to October 2018. Each patient was matched by age and sex to 5 individuals from the general population. We included 18,818 patients with first-time STEMI and 94,090 individuals from the general population. Baseline comorbidity burden was similar in STEMI patients and matched individuals. Compared with the matched individuals, STEMI was associated with a 5.9% excess mortality from 0 to 30 days (6.0% vs 0.2%; HR: 36.44; 95% CI: 30.86-43.04). An excess mortality remained present from 31 to 90 days (0.9% vs 0.4%; HR: 2.43; 95% CI: 2.02-2.93). However, in 90-day STEMI survivors, the absolute excess mortality was only 2.1 percentage points at 10-year follow-up (26.5% vs 24.5%; HR: 1.04; 95% CI: 1.01-1.08). Use of secondary preventive medications such as statins, antiplatelet therapy, and beta-blockers was very high in STEMI patients throughout 10-year follow-up. In primary PCI-treated STEMI patients with high use of guideline-recommended therapy, patients surviving the first 90 days had 10-year mortality that was only 2% higher than that of a matched general population. [Display omitted] [ABSTRACT FROM AUTHOR]

Les infarctus du myocarde avec lésion coronaire non obstructive (MINOCA) représentent un pourcentage non négligeable de la proportion des infarctus du myocarde (≈6 %). De plus, le pronostic au long cours est péjoratif avec un taux annuel de mortalité de 2 %. Ce taux important de mortalité peut s'expliquer par le fait que les MINOCA représentent un groupe hétérogène et que le diagnostic de la pathologie est méconnu. Il est primordial de bien connaître cette présentation clinique et de respecter les différentes stratégies diagnostiques pour identifier le mécanisme étiologique et ainsi mettre en place un traitement adapté. Pour aider au diagnostic, il existe de nombreux outils à notre disposition qui appartiennent notamment aux domaines de l'imagerie dont les principaux sont : la coronarographie aidée de la physiologie coronaire et des tests pharmacologiques ainsi que de l'imagerie endocoronaire et l'IRM cardiaque. Cette revue fera un point sur la définition, l'épidémiologie, les stratégies diagnostiques et les options de traitement des patients présentant un MINOCA. Myocardial infarction with non-obstructive coronary lesion (MINOCA) represents a non-negligible percentage of the proportion of myocardial infarctions (≈6%). Moreover, the long-term prognosis is poor, with an annual mortality rate of 2%. This high mortality rate may be explained by the fact that MINOCA represents a heterogeneous group, and the diagnosis of pathology is poorly understood. It is essential to be aware of this clinical presentation, and to follow the different diagnostic strategies, in order to identify the etiological mechanism, and thus set up a suitable treatment. Many tools are available to support diagnosis, notably in the fields of imaging, the principal contributors being coronary angiography, coronary physiology and pharmacological testing, as well as endo-coronary imaging and cardiac MRI. This review will provide an update on the definition, epidemiology, diagnostic strategies and treatment options for patients with MINOCA. [ABSTRACT FROM AUTHOR]

The impact on age on the short-term and long-term prognosis in patients with Takotsubo syndrome (TTS) is unclear. We aimed to evaluate whether age has prognostic implications during hospital stay and long-term follow-up of TTS patients. 688 consecutive patients were admitted for TTS in 7 tertiary centers from January-2008 to June-2021. We divided our cohort into two groups (patients <75 years and ≥75 years). Clinical, analytical, and hemodynamic variables as well as in-hospital management were registered and compared between groups. Mortality rates during hospital stay and follow-up were assessed. Adverse cardiovascular events (ACE) were defined as the composite of cardiovascular death, heart failure event, acute myocardial infarction, stroke and symptomatic arrhythmia. Median age was 74.7 years and 49.4 % were ≥75 years. 86.9 % were women and 22.3 % were secondary forms of TTS. In-hospital mortality was 3.6 % (1.5 % cardiovascular). Median clinical follow-up was 4.3 years. Mortality during the follow-up period was 23 % (5.0 % cardiovascular) while ACE were 22.5 %, mainly due to heart failure events. Kaplan-Meier curves showed both higher rates of mortality and ACE in ≥75 years group (30.2 % vs 15.8 %; p < 0.001 and 28.3 % vs 16.7 %; p < 0.001). Age was independently associated with higher rates of overall mortality and ACE in patients with TTS. Hypertension, absence of sinus rhythm, Killip class > I and a more impaired coronary microvascular resistance were also associated to ACE in TTS patients. Advanced age was associated with higher rate of overall mortality and ACE during long-term follow-up in TTS patients. Age as a prognostic variable during the follow-up in Takotsubo patients. A: Cardiac ventriculography in systole of a patient with Takotsubo syndrome showing dyskinesia of midventricular and apical segments (red arrows) with basal hypercontractility (green arrows); B: TTS patients with age ≥ 75 years presented a higher overall mortality during follow-up; C: TTS patients with age ≥ 75 years presented a higher percentage of adverse cardiovascular events during follow-up. [Display omitted] • Adverse cardiovascular events are frequent in Takotsubo syndrome during follow-up. • Age is related to adverse cardiovascular events during the follow-up in Takotsubo. • Increased age is associated with overall mortality during the follow-up in Takotsubo. • Gender, HTN, CKD and secondary forms are also associated to overall mortality. • HTN, sinus rhythm, Killip and CMD are related to cardiac prognosis in Takotsubo. [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]

Mortality rates following cardiogenic shock (CS) have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with CS. Consecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were applied for statistics. From a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756–1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713–1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710–1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677–1.783; p = 0.704). Sex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology. (clinicaltrials.gov identifier: NCT05575856) • The study investigates the prognostic role of sex-related outcomes in patients with cardiogenic shock (CS) • The rates of CS related to acute myocardial infarction (AMI) were higher in males. • In contrast, the risk of 30-day all-cause mortality did not differ among males and females. • Mortality was comparable irrespective of AMI-related CS or non-AMI-related CS. [ABSTRACT FROM AUTHOR]

Current evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT) for patients at high-ischemic risk and low bleeding risk as well as the efficacy and safety of short DAPT in high-bleeding risk (HBR) patients. We evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of the BARC consortium definitions. We included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119 (37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences were observed between the 3 categories beyond the bleeding risk. Median follow-up was 57 months. Multivariate analysis identified higher risk of all-cause mortality (HR: 1.96 95 % CI 1.45–2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI 1.39–3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50–2.02; p < 0.001) and MB (sHR: 3.41 95 % CI 1.45–8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02–1.35; p = 0.027). Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality. [Display omitted] • Among 8252 patients 39 % were candidates for abbreviated DAPT and 37.8 % for prolonged DAPT. • The candidate to abbreviated DAPT had higher risk of all-cause (HR: 1.96) and cardiovascular (HR: 2.10) mortality. • Patients' candidate to short or prolonged DAPT had higher risk of MACE. • Candidates to abbreviated DAPT had higher risk of MB (sHR: 2.84). [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]

We aimed to determine whether newly diagnosed atrial fibrillation (AF) predicted cardiovascular events and death after myocardial infarction (AMI) in a large nationwide cohort of patients. All Medicare beneficiaries aged >65 years who were discharged alive after a diagnosis of AMI between January 1, 2007 and December 31, 2008 were identified. Main exposure was a diagnosis of AF during admission or within 90 days after discharge. Primary outcome was a composite of recurrent AMI, stroke and all-cause mortality. Secondary outcomes were each of recurrent AMI, stroke and all-cause mortality. We used Cox proportional hazards regression to assess the relationship between AF and time-to-event outcomes with follow up ending at 3 years. Of 184,980 patients, 9.1 % had AF; 40.6 % were male; 82.8 % were non-Hispanic whites. Mean age was 79.1 ± 8.1 years. Overall, 15.7 % had subsequent AMI, 5.7 % had stroke and 43.9 % died during a mean follow up of 26.4 months. AF was associated with a significantly increased risk of the primary outcome (Hazard ratio (HR) = 1.10; 95 % confidence interval (CI): 1.07-1.12). AF was also separately associated with significantly increased risk of recurrent AMI (HR = 1.09; 95 % CI: 1.04-1.14), stroke (HR = 1.29; 95 % CI: 1.21-1.37), and death (HR = 1.09; 95 % CI: 1.06-1.12). Neither age, race nor sex modified the effects of AF on primary or secondary outcomes. In conclusion, AF is a significant predictor of adverse cardiovascular outcomes and mortality after AMI. Further studies are needed to understand mechanisms by which AF alters outcomes in survivors of AMI. [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]

Background: Whilst the left ventricular ejection fraction (LVEF) remains the primary echocardiographic measure widely utilised for risk stratification following myocardial infarction (MI), it has a number of well recognised limitations. The aim of this study was to compare the prognostic utility of a composite echocardiographic score (EchoScore) composed of prognostically validated measures of left-ventricular (LV) size, geometry and function, to the utility of LVEF alone, for predicting survival following MI.Methods: Retrospective data on 394 consecutive patients with a first-ever MI were included. Comprehensive echocardiography was performed within 24 hours of admission for all patients. EchoScore consisted of LVEF<50%, left atrial volume index>34 mL/m2, average E/e >14, E/A ratio>2, abnormal LV mass index, and abnormal LV end-systolic volume index. A single point was allocated for each measure to derive a score out of 6. The primary outcome measure was all-cause mortality.Results: At a median follow-up of 24 months there were 33 deaths. On Kaplan-Meier analysis, a high EchoScore (>3) displayed significant association with all-cause mortality (log-rank χ2=74.48 p<0.001), and was a better predictor than LVEF<35% (log-rank χ2=17.01 p<0.001). On Cox proportional-hazards multivariate analysis incorporating significant clinical and echocardiographic predictors, a high EchoScore was the strongest independent predictor of all-cause mortality (HR 6.44 95%CI 2.94-14.01 p<0.001), and the addition of EchoScore resulted in greater increment in model power compared to addition of LVEF (model χ2 56.29 vs 44.71 p<0.001, Harrell's C values 0.83 vs 0.79).Conclusions: A composite echocardiographic score composed of prognostically validated measures of LV size, geometry, and function is superior to LVEF alone for predicting survival following MI. [ABSTRACT FROM AUTHOR]

Background: Heart failure is increasing in prevalence, creating a greater public health and economic burden on our health care system. With a rising proportion of hospitalisations for heart failure with preserved ejection fraction (HFpEF) compared to heart failure with reduced ejection fraction (HFrEF) and lack of proven therapies for HFpEF, patient characterisation and defining clinical outcomes are important in determining optimal management of heart failure patients. There is scarce Australian-specific data with regards to the burden of disease of patients with HFpEF which further limits our ability to appropriately manage this syndrome.Aim: To determine the characteristics, management practices and outcomes of patients with HFpEF compared to patients diagnosed with HFrEF.Method: Data was sourced from the Victorian Cardiac Outcomes Registry-Heart Failure (VCOR-HF) snapshot of patients admitted with acute heart failure to one of 16 Victorian health services between 2014-2017 over one consecutive month annually. Outcomes measured were in-hospital mortality, and 30-day readmission and mortality.Results: Of the 1,132 HF patients, 436 patients were diagnosed with HFpEF and were more likely to be female (59%) and older (81.5±9.8 vs 73.2±14.5 years). They were also more likely to have hypertension (80%), atrial fibrillation (59.9%), chronic obstructive airways disease (36.2%) and chronic kidney disease (68.8%). Patients with HFrEF were more likely to have ischaemic heart disease with a history of previous myocardial infarction (36.6%), percutaneous coronary intervention and cardiac bypass surgery (35.2%). There were no significant differences in 30-day mortality between HFpEF and HFrEF (10.2% vs 7.8%; p=0.19, respectively) and 30-day readmission rates (22.1% vs 25.9%; p=0.15, respectively).Conclusion: VCOR-HF Snapshot data provides important insight into the burden of acute heart failure. Whilst patients with HFpEF and HFrEF have differing clinical profiles, morbidity, mortality and re-admission rates are similar. [ABSTRACT FROM AUTHOR]

Background: Chronic total occlusion (CTO) is common among patients with coronary artery disease. Very few studies have focused on outcomes of patients with CTO and reduced left ventricular ejection fraction (LVEF), according to treatment applied. The aim of our study was to determine the potential influence of the selected treatment on the prognosis in patients with CTO associated with reduced LVEF.Methods: Between June 2010 and October 2013, all consecutive patients with at least one CTO and reduced LVEF (<40%) were enrolled. Major adverse cardiac events (MACE), defined as the composite of cardiac mortality or myocardial infarction (MI) and its individual components, were compared between three treatment groups: medical therapy (MT), percutaneous coronary intervention (PCI), and coronary bypass graft (CABG).Results: In 256 included patients, the follow-up was 1129 ± 556 days. The incidence of MACE was 40% in the MT group, compared with PCI (20.3%) and CABG (16.7%); p < 0.001. All-cause and cardiac mortality were also higher in the MT group (40.7% and 33.3%, respectively) versus the PCI (21.9% and 15.6%) and CABG (11.9% and 9.5%) groups (p < 0.001 for both endpoints); MI rate did not differ among groups. In the adjusted multivariate analysis, CABG had lower MACE risk, compared with MT (HR = 0.39, 0.17-0.91; p = 0.029); successful PCI also trended toward lower risk of MACE, compared with MT.Conclusions: Patients with CTO and reduced LVEF treated with MT had a worse prognosis than those treated with revascularization (either CABG or PCI). Patients with an indication for CABG appeared to perform best during long-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Varying definitions of procedural myocardial infarction (PMI) are in widespread use.Objectives: This study sought to determine the rates and clinical relevance of PMI using different definitions in patients with left main coronary artery disease randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) surgery in the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial.Methods: The pre-specified protocol definition of PMI (PMIProt) required a large elevation of creatine kinase-MB (CK-MB), with identical threshold for both procedures. The Third Universal Definition of MI (types 4a and 5) (PMIUD) required lesser biomarker elevations but with supporting evidence of myocardial ischemia, different after PCI and CABG. For the PMIUD, troponins were used preferentially (available in 49.5% of patients), CK-MB otherwise. The multivariable relationship between each PMI type and 5-year mortality was determined.Results: PMIProt occurred in 34 of 935 (3.6%) patients after PCI and 56 of 923 (6.1%) patients after CABG (difference -2.4%; 95% confidence interval [CI]: -4.4% to -0.5%; p = 0.015). The corresponding rates of PMIUD were 37 (4.0%) and 20 (2.2%), respectively (difference 1.8%; 95% CI: 0.2% to 3.4%; p = 0.025). Both PMIProt and PMIUD were associated with 5-year cardiovascular mortality (adjusted hazard ratio [HR]: 2.18 [95% CI: 1.13 to 4.23] and 2.87 [95% CI: 1.44 to 5.73], respectively). PMIProt was associated with a consistent hazard of cardiovascular mortality after both PCI and CABG (pinteraction = 0.86). Conversely, PMIUD was strongly associated with cardiovascular mortality after CABG (adjusted HR: 11.94; 95% CI: 4.84 to 29.47) but not after PCI (adjusted HR: 1.14; 95% CI: 0.35 to 3.67) (pinteraction = 0.004). Results were similar for all-cause mortality and with varying PMIUD biomarker definitions. Only large biomarker elevations (CK-MB ≥10× upper reference limit and troponin ≥70× upper reference limit) were associated with mortality.Conclusions: The rates of PMI after PCI and CABG vary greatly with different definitions. In the EXCEL trial, the pre-specified PMIProt was associated with similar hazard after PCI and CABG, whereas PMIUD was strongly associated with mortality after CABG but not after PCI. (EXCEL Clinical Trial [EXCEL]; NCT01205776). [ABSTRACT FROM AUTHOR]

An abnormal ankle-brachial pressure index (ABI) is a marker of the risk for increased total and cardiovascular (CV) mortality. However, it is not clear whether it is associated with an even worse prognosis in patients with previous CV events or with cancer mortality. Consecutive subjects undergoing ABI assessment for suspected peripheral artery disease or for stratification of CV risk in ten centers in the Veneto Region (northeast Italy), between 2011 and 2014 were enrolled. The ABI was expressed as normal ≥0.9 to ≤1.3, and abnormal <0.9 or >1.3. All-cause mortality and CV or cancer mortality and hospitalizations for CV disease were collected from administrative databases up to December 2018. The study enrolled 1,177 patients. ABI was abnormal in 57.2%. Median follow-up was 61.6 months (53.4–70.1). All-cause, CV and cancer mortality were higher in patients with abnormal than normal ABI, with hazard ratios (HR) respectively 2.0 (95% CI 1.48–2.69), 1.98 (95% CI 1.24–3.17) and 1.85 (95% CI 1.09–3.15). Among subjects with abnormal ABI, the risk of overall mortality, HR 1.57 (95% CI 1.17–2.12), and CV mortality, HR 2.39 (95% CI 1.43–3.99), was higher in those with previous CV events. These latter also had a higher risk of hospitalization for myocardial infarction and stroke: HR 1.85 (95% CI 1.023.37) and 2.17 (95% CI 1.10–4.28). The co-existence of abnormal ABI and a history of CV events identifies subjects at higher risk, who call for a more aggressive approach. Abnormal ABI is also a predictor of cancer mortality. [ABSTRACT FROM AUTHOR]

Whether the prognostic impact of comorbidity on myocardial infarction (MI) mortality is due to comorbidity alone or/and its interaction effect is unknown. We used Danish medical registries to conduct a nationwide cohort study of all first-time MIs during 1995–2016 (n = 179,515) and a comparison cohort matched on age, sex, and individual comorbidities (n = 880,347). We calculated age-standardized 5-year all-cause mortality rates. Interaction was examined on an additive scale by calculating interaction contrasts (difference in rate differences). Among individuals without comorbidity, the 30-day mortality rate per 1000 person-years was 1851 (95% CI: 1818–1884) for MI patients and 22 (21–24) for comparison cohort members (rate difference = 1829). For individuals with low comorbidity, corresponding baseline mortality rates were 2498 (2436–2560) in the MI and 54 (50–57) in the comparison cohort (rate difference = 2444). The interaction contrast (616) indicated that the interaction accounted for 25% (616/2498) of the total 30-day mortality rate in MI patients with low comorbidity. This percentage increased further for moderate (35%) and severe (45%) comorbidity levels. Absolute and relative interaction effects were largest within the first 30 days and younger individuals. Dose-response patterns were also observed during 31–365 days and 1–5 years of follow-up (p -values for trends<0.002). The interaction differed substantially between individual types of cardiac and non-cardiac comorbidities. Cardiac and non-cardiac comorbidities interact with MI to increase short- and long-term mortality beyond that explained by their additive effects. The interaction had a dose-response relation with comorbidity burden and a magnitude of clinical importance. • The prognostic impact of comorbidity on myocardial infarction (MI) is unclear. • Comorbidity burden interacts with MI to increase short- and long-term mortality. • The interaction effect showed a dose-response relation. • The interaction differed between individual cardiac and non-cardiac comorbidities. • The magnitude of the interaction effect was clinically important. [ABSTRACT FROM AUTHOR]

Background: The vasoactive-inotropic score (VIS) predicts mortality and morbidity after paediatric cardiac surgery. Here we examined whether VIS also predicted outcome in adults after cardiac surgery, and compared predictive capability between VIS and three widely used scoring systems.Methods: This single-centre retrospective cohort study included 3213 cardiac surgery patients. Maximal VIS (VISmax) was calculated using the highest doses of vasoactive and inotropic medications administered during the first 24 h post-surgery. We established five VISmax categories: 0-5, >5-15, >15-30, >30-45, and >45 points. The predictive accuracy of VISmax was evaluated for a composite outcome, which included 30-day mortality, mediastinitis, stroke, acute kidney injury, and myocardial infarction.Results: VISmax showed good prediction accuracy for the composite outcome [area under the curve (AUC), 0.72; 95% confidence interval (CI), 0.69-0.75]. The incidence of the composite outcome was 9.6% overall and 43% in the highest VISmax group (>45). VISmax predicted 30-day mortality (AUC, 0.76; 95% CI, 0.69-0.83) and 1-yr mortality (AUC, 0.70; 95% CI, 0.65-0.74). Prediction accuracy for unfavourable outcome was significantly better with VISmax than with Acute Physiology and Chronic Health Evaluation II (P=0.01) and Simplified Acute Physiological Score II (P=0.048), but not with the Sequential Organ Failure Assessment score (P=0.32).Conclusions: In adults after cardiac surgery, VISmax predicted a composite of unfavourable outcomes and predicted mortality up to 1 yr after surgery. [ABSTRACT FROM AUTHOR]

Background: To describe the long-term mortality of a complete national cohort of acute coronary syndrome (ACS) patients enrolled in 2002, to compare this with a national age, sex and Māori ethnicity matched population, and to assess the influence of baseline factors on the 12-year mortality.Methods: We reviewed 721 patients with a discharge diagnosis of an ACS who were enrolled in the first New Zealand ACS audit group cohort over 14days in May 2002. We matched the cohort to the national mortality database using each patient's unique national identity number.Results: Over a median follow-up of 12.7 years of 721 patients discharged with an ACS, overall mortality was 52%: ST-elevation myocardial infarction (STEMI) (58%), non-ST-elevation myocardial infarction (NSTEMI) (61%) and unstable angina pectoris (UAP) (42%) patients, p<0.0001. In an age-adjusted survival model, males had a 29% increased mortality rate compared to females with a hazard ratio of 1.29 (95% CI 1.04, 1.61, p=0.019). Over 12 years there were 339 (47%) deaths, compared to 284 (39%) deaths observed in the matched population. The standardised mortality ratio for patients admitted with an ACS in New Zealand is 1.3 (95% CI 1.2, 1.5) with eight patients per 100 not surviving to 12 years compared to this matched population.Conclusions: The high mortality rate in this ACS cohort is a stark reminder of the prognostic implications of a presentation with an ACS. It emphasises the on-going need for optimal management of these patients throughout every stage of their initial treatment and subsequent on-going care. [ABSTRACT FROM AUTHOR]

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

Abstract Background and aims Pulse pressure (PP) is a surrogate of aortic stiffness (AS) easily obtainable. The link between AS and cardio-vascular disease is documented, however, data regarding acute coronary syndrome (ACS) patients are scarce and contradictory. We aimed to assess the prognostic value of PP measured at admission, with regard to major adverse outcomes (all-cause mortality, recurrence of MI, and stroke), during the first year following an acute coronary syndrome (ACS). Methods The SPUM–ACS project is a prospective cohort study of patients with ACS conducted in 4 Swiss University hospitals. Patients with no PP at admission or with severe clinical heart failure or cardiogenic shock were excluded. Cox regression analyses were performed to determine associations between PP and outcomes (all-cause mortality, recurrence of myocardial infarction (MI), and stroke). Three multivariate Cox regression models were adjusted for hemodynamic, cardiovascular, and non-cardiovascular confounders, added successively. Results Of 5635 eligible patients, 5070 met the inclusion criteria. Mean patient age was 63 years (range: 54–72), 79.6% were male, and mean blood pressure and PP were 93.9 ± 15.6 and 54 ± 17 mmHg, respectively. Multivariate analyses confirmed the prognostic significance of PP for each 10-mmHg increase for the composite endpoint, hazard ratio (HR) 1.126 [1.051–1.206], p = 0.001; all-cause mortality, HR1.129 [1.013–1.260], p = 0.029; and recurrence of MI, HR1.206 [1.102–1.320], p < 0.001; but not for stroke, HR1.014[0.853–1.205]. Conclusions PP measured at admission is a strong, independent prognostic marker predicting mortality and recurrence of MI after ACS. PP should be considered for the management of secondary prevention. Highlights • Pulse pressure (PP), a surrogate of aortic stiffness, is associated with cardiovascular disease in various populations. • After an acute coronary syndrome (ACS), patients may exhibit a poor outcome despite a modern guideline-based management. • PP measured at admission is a robust and independent prognostic marker after diagnosis of ACS. • PP measurement could be critical to the development of new preventive strategies. • PP measurement could be critical to optimize the use of existing ones. [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 Reports from many countries have shown birthplace-associated disparities in the incidence and mortality following acute myocardial infarction (AMI). The aims of the study were to identify and compare short- and long-term post-AMI mortality according to birthplace. Methods A retrospective analysis of Israeli AMI patients from a tertiary medical center in Southern Israel throughout 2002–2012. Data source: the hospital's computerized systems. Patients were classified according to the country of birth (Israel, Southern Europe/Balkans, Northern Africa, Eastern/Central Europe, India/Pakistan, Middle-East, Yemen, and Ethiopia). Study outcomes: in-hospital and up to 10-years post-discharge all-cause mortality. Results The study included 11,143 patients, age 67.4 ± 13.9 and 67.5% men. Israeli-born patients were significantly younger, with lower rate of diabetes mellitus and hypertension but significantly higher rate of obesity, smoking, history of coronary artery disease and male sex compared with immigrants. The rate of STEMI and administration of percutaneous coronary revascularization was higher, yet extent of coronary findings and severe left ventricular dysfunction was lower in Israeli-born patients. In-hospital as well as post-discharge 1-and 10-year mortality rates were approximately 65% lower in Israeli-born patients compared with immigrants. Following adjustment for potential confounders the inequalities in post-discharge mortality attenuated (Yemen OR = 2.3 [95%CI: 1.4–3.6], Southern Europe/Balkans 1.75 [1.2–2.5], Northern Africa 1.5 [1.3–1.8], Eastern/Central Europe 1.4 [1.2–1.7] and India/Pakistan 1.4 [1.1–1.9], for 10-years mortality, p  < 0.05 for each) and those for in-hospital mortality disappeared. Conclusions Immigrants are at increased risk for post-discharge, yet not in-hospital mortality following AMI. Appropriate targeted preventive programs are required for these groups of patients. [ABSTRACT FROM AUTHOR]

Background: Depression predicts poor prognosis in patients with myocardial infarction (MI). However, individual depressive symptoms may have different prognostic value, and age and sex could be important effect modifiers. This study compared the prognostic value of individual depressive symptoms across age and sex subgroups in post-MI patients.Methods: Individual patient-data were compiled for 6673 post-MI patients from seven studies. Depressive symptoms were measured with 10 items of the Beck Depression Inventory (BDI10). The endpoint was all-cause mortality (mean=3.8 years). Multilevel multivariable Cox regression analysis was used to estimate the mortality risk across age groups (≤55, 56-69 and ≥70 years) and sex for symptoms that potentially interacted with age and sex.Results: At follow-up, 995 (15%) post-MI patients had died. BDI10 depression scores were associated with an increased mortality risk (HR:1.20;95%CI:1.11-1.28,p<.001). Negative self-image (HR:1.53;1.06-2.21;p=.022) and indecisiveness (HR:1.53;1.15-2.04;p=.003) were associated with increased mortality in men <55. Dissatisfaction was associated with increased mortality in men aged 56-69 (HR:1.35;1.07-1.71;p=. 011), and dissatisfaction (HR:1.34;1.10-1.63;p=.003) and fatigue (HR:1.45;1.20-1.74;p<.001) in men >70. Fatigue was associated with mortality in women aged 56-69 (HR:1.54;1.09-2.15;p=.012), and suicidal ideation in women aged >70 (HR:1.58;1.03-2.43;p=.037). Left-ventricular ejection fraction (LVEF) accounted for much of the associations in men ≤55 years and women ≥70 years.Limitations: Findings are sample-specific and need replication in future research; BDI10 items were derived from the original BDI assessment.Conclusions: There is large heterogeneity in the prognostic value of individual depressive symptoms in post-MI patients across sex and age subgroups. LVEF partially explained the depression-prognosis association in specific subgroups. [ABSTRACT FROM AUTHOR]

Background: Emerging evidence suggests that postoperative troponin release is a strong and independent predictor of short-term mortality. However, evaluating elevated troponins in patients with chronic kidney disease (CKD) is still controversial and is often disregarded. This study examines morbidity along with short- and long-term mortality risk associated with elevated high-sensitivity troponin T (hsTnT) in patients with different stages CKD undergoing noncardiac surgery.Methods: This observational cohort comprised 3262 patients aged ≥60 yr who underwent noncardiac surgery. Postoperative hsTnT concentrations were divided into normal [<14 ng l-1 (reference)], low (14-49 ng l-1), moderate (50-149 ng l-1), and high (≥150 ng l-1) groups. A threshold of 50 ng l-1 was used to dichotomize hsTnT. The study endpoints were 30-day and long-term all-cause mortality, and postoperative myocardial infarction.Results: Postoperative hsTnT was associated with a stepwise increase in 30-day and long-term mortality risk: low hsTnT adjusted hazard ratio (HR) 1.4 [95% confidence interval (CI): 1.1-1.7], moderate hsTnT adjusted HR 3.1 (95% CI: 2.3-4.3), high hsTnT adjusted HR 5.5 (95% CI: 3.6-8.4). Postoperative hsTnT ≥50 ng l-1 was associated with 30-day and long-term mortality risk for each stage of CKD. Elevated troponin concentrations in severe CKD (estimated glomerular filtration rate <30 mL min-1 1.73 m-2), however, did not predict short-term death.Conclusions: Elevated postoperative hsTnT is associated with a dose-dependent increase in 30-day and long-term mortality risk in each stage of CKD with an estimated glomerular filtration rate ≥30 ml min-1 1.73 m-2. [ABSTRACT FROM AUTHOR]

Background: Non-invasive cardiac imaging allows detection of cardiac amyloidosis (CA) in patients with aortic stenosis (AS). Our objective was to estimate the prevalence of clinically suspected CA in patients with moderate and severe AS referred for cardiovascular magnetic resonance (CMR) in age and gender categories, and assess associations between AS-CA and all-cause mortality. Methods: We retrospectively identified consecutive AS patients defined by echocardiography referred for further CMR assessment of valvular, myocardial, and aortic disease. CMR identified CA based on typical late-gadolinium enhancement (LGE) patterns, and ancillary clinical evaluation identified suspected CA. Survival analysis with the Log rank test and Cox regression compared associations between CA and mortality. Results: There were 113 patients (median age 74 years, Q1-Q3: 62-82 years), 96 (85%) with severe AS. Suspected CA was present in 9 patients (8%) all >80 years. Among those over the median age of 74 years, the prevalence of CA was 9/57 (16%), and excluding women, the prevalence was 8/25 (32%). Low-flow, low-gradient physiology was very common in CA (7/9 patients or 78%). Over a median follow-up of 18 months, 40 deaths (35%) occurred. Mortality in AS + CA patients was higher than AS alone (56% vs. 20% at 1-year, log rank 15.0, P < 0.0001). Adjusting for aortic valve replacement modeled as a time-dependent covariate, Society of Thoracic Surgery predicted risk of mortality, left ventricular ejection fraction, CA remained associated with all-cause mortality (HR = 2.92, 95% CI = 1.09-7.86, P = 0.03). Conclusions: Suspected CA appears prevalent among older male patients with AS, especially with low flow, low gradient AS, and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation. [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]

Background and Aim: The prognostic impact of poor nutritional status and cardiac cachexia in myocardial infarction is not clearly understood. Recent studies have implied a prognostic value of the prognostic nutritional index (PNI) in colorectal surgeries and postoperative septic complications. The present study aimed to evaluate the prognostic value of PNI in ST-segment elevation myocardial infarction (STEMI) patients.Methods and Results: We evaluated the in-hospital and long-term (3 years) prognostic impact of PNI on 1823 patients with STEMI undergoing primary percutaneous coronary intervention. Patients with lower PNI had significantly higher in-hospital and long-term mortality and major adverse cardiac events. After adjustment for all confounders, the in-hospital mortality rates were 7.9 times higher at the lower PNI level (95% CI: 5.0-15.8) than those at the higher PNI level. The long-term mortality rates were also 6.4 times higher at the lower PNI level (95% CI: 4.4-12.4) than those at the higher PNI level.Conclusion: The present study demonstrated that the PNI, calculated based on the serum albumin level and lymphocyte count, is an independent prognostic factor for mortality in patients with STEMI. [ABSTRACT FROM AUTHOR]

Background Several studies have shown that, after an acute myocardial infarction, women have worse prognosis than males. However, it is not clear if female sex is an independent predictor of mortality risk. Our aim was to analyse sex influence on the prognosis of these patients. Methods Retrospective registry of patients with ST segment elevation myocardial infarction (STEMI) from January 2010 to April 2015. Results From 1111 patients, 258 (23.2%) were women. Compared with men, they presented higher risk profiles with older age (70.1 ± 14.4 years vs. 62.3 ± 13.4, P < 0.001), more cardiovascular risk factors (except smoking), longer time from symptoms onset to hospital arrival (5.2 ± 4.1 h vs . 4.2 ± 3.7), higher Killip classification (1.6 ± 1.1 vs . 1.4 ± 0.8), fewer complete revascularizations (175 [67.8%] vs . 662 [77.9%] in men) and higher in-hospital mortality (26 [10.1%] vs . 34 [4.0%]); all p values < 0.003. At discharge, women less frequently received ACE inhibitors (189 [81.1%] vs . 702 [85.8%], p = 0.045) and presented more major adverse events (death, bleeding, infection, myocardial infarction, stent thrombosis or heart failure) during the first month after discharge (10.5% vs. 4.5%, p < 0.001) and higher long-term mortality (hazard ratio [HR] 1.6, 95% CI 1.1–2.2). After adjusting by age, most of the differences disappeared, and sex was not an independent factor of in-hospital (odds ratio 1.71, 95% CI 0.97–2.99) or long-term mortality (HR 1.0, 95% CI 0.7–1.5). Conclusions In patients with acute STEMI, the association of female sex with poor prognosis is mainly explained by age. Sex does not seem to be an independent prognostic factor. [ABSTRACT FROM AUTHOR]

Background: A large angle between the QRS vector and the T-wave vector (QRS-T angle) in electrocardiograms (ECGs) has recently been introduced as a marker of poor prognosis. The prognostic value in diabetes is unknown. We assessed the long-term predictive power of the frontal plane QRS-T angle in the diabetic population.Methods: In 1992-93, the diabetic population of the municipality of Horsens, Denmark, was delineated by the prescription method, and an age- and gender-stratified sample of 240 diabetic persons was randomly selected. In 2015, 12-lead ECGs taken in 1993-94 were analyzed. Vital statistics were obtained from the Danish Civil Registration System and data regarding hospitalizations taken from The National Patient Registry in July 2015.Results: In total, 178 people agreed to participate (74%) in the study, with the mean (sd) age being 58.9 (10.2) years and 56% being male. The total observation time was 21.5 (0.18) years, during which time 122 (69%) persons died, 32 (18%) suffered a myocardial infarction (MI) and 126 (71%) reached the composite endpoint of non-fatal MI or all-cause death. In Cox regression multivariate analysis a QRS-T angle above 90° was found to be an independent predictor of all-cause death (HR=2.2 (95% CI: 1.3-3.8)), MI (HR=2.95 (95% CI: 1.1-7.7)) and MI or all-cause death (HR=2.0 (95% CI: 1.2-3.5)) (all p<0.05), when adjusting for the effects of co-variates (gender, age, length of diabetes, BMI, total cholesterol, diabetes type, hemoglobin A1c, smoking, hypertension and previous MI).Conclusion: A large QRS-T angle is a strong, independent long-term predictor of all-cause mortality, MI and MI or all-cause death in the diabetic population. [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 Right Ventricular (RV) involvement during inferior acute myocardial infarction (AMI) was known to be associated with poor outcome, but might have been mitigated by recent therapeutics. The aim of study was to determine the characteristics and outcomes of patients with RVAMI compared to isolated inferior AMI. Methods This is an observational study that enrolled consecutive patients with RVAMI; age-sex matched patients with isolated inferior AMI served as controls. Results A total of 51 patients with RVAMI were studied (male 39, age 63 ± 16) and compared to 39 age-sex matched patients with isolated inferior AMI. Atherosclerosis risk factors, previous MI and treatment at presentation were similar in both groups. Primary coronary angioplasty was successful in > 90% in both groups. When compared to patients with isolated inferior AMI, patients with RVAMI had more frequent cardiogenic shock at presentation (35% versus 0%, P < 0.01), and in-hospital mortality (18% versus 0%, P < 0.01). Associated factors with in-hospital mortality included age, sex, RV involvement, delay from onset to management, angioplasty, anti GPIIb-IIIa treatment, ejection fraction, creatinine level but not the severity at presentation (including the presence of cardiogenic shock). After discharge from hospital and during a mean 200 weeks follow-up period, mortality increased similarly in both groups. Conclusion RVAMI is still associated with high in-hospital mortality. The severity of initial presentation is not a prognostic factor. Mortality rates after discharge increased very slowly and similarly in both groups. [ABSTRACT FROM AUTHOR]

Background Mean platelet volume to platelet count ratio (MPV/P ratio) has been demonstrated to be a predictor of adverse outcome in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We aimed to assess whether MPV/P ratio is a useful marker to predict long-term prognosis in NSTEMI patients undergoing PCI. Moreover, the prognostic accuracy of MPV/P ratio was compared with MPV and GRACE score. Methods In a retrospective cohort study, according to the baseline MPV/P values, 887 consecutive NSTEMI patients undergoing PCI were divided into two groups: the high MPV/P group ( n = 296, MPV/P ≥ 0.054) and the low MPV/P group ( n = 591, MPV/P < 0.054). Clinical endpoints were all-cause mortality and all-cause mortality/nonfatal reinfarction. Results Multivariate analysis showed that high MPV/P was an independent predictor of all-cause mortality [HRs: 1.973, 95% CI: 1.528–2.549, P < 0.001], and all-cause mortality/nonfatal myocardial reinfarction [HRs: 1.289, 95% CI: 1.181–1.408, P < 0.001]. MPV/P ratio has good accuracy for predicting clinical endpoints. The discriminatory performance of MPV/P ratio was similar to GRACE score but better than MPV (for all-cause mortality: MPV/P vs. GRACE: z = 0.205, p = 0.837; MPV/P vs. MPV: z = 2.677, p = 0.008; GRACE vs. MPV: z = 3.017, p = 0.003; for all-cause mortality/nonfatal myocardial: MPV/P vs. GRACE: z = 1.098, p = 0.272; MPV/P vs. MPV: z = 4.026, p < 0.001; GRACE vs. MPV: z = 4.962, p < 0.001). Conclusions MPV/P ratio was similar to GRACE score but better than MPV for predicting all-cause mortality and all-cause mortality/nonfatal myocardial reinfarction in NSTEMI patients undergoing PCI. However, MPV/P ratio is easier to calculate than GRACE score. [ABSTRACT FROM AUTHOR]

Background Patient function is a risk factor of mortality following acute myocardial infarction (AMI). Norton scale (NS) was originally developed to estimate the risk for pressure ulcers. It contains 5 domains: mental condition, physical condition, mobility, activity in daily living and incontinence. Objective To evaluate NS as long-term prognostic marker following AMI. Methods A retrospective study based on computerized medical records of AMI patient hospitalized in a tertiary medical center in 2004–2012. NS scores and patients' characteristics were collected from computerized databases. The primary outcome was all-cause long-term (up-to 10-years) mortality. Results Overall 6964 patients were included; mean age 67.3 ± 14.1 years, 68.1% males. Mean NS score was 17.8 ± 3; of which 21.1% had low-NS (≤ 16). Patients with low-NS had increased prevalence of hypertension, diabetes and renal disease, 3-vessel coronary artery disease, more often Non ST-Elevation Myocardial Infarction (NSTEMI) and in-hospital complications. Throughout the follow-up period cumulative mortality rate in patients with low- and high-NS groups were 97.3% and 43% respectively (AdjHR 1.66; 95% CI: 1.521–1.826; p < 0.001). Furthermore, a reduction in one point in the NS score inversely associated with increased risk for mortality (AdjHR 1.10; 95% CI: 1.12–1.22; p < 0.001). Conclusions NS is an independent long-term prognostic marker for all-cause mortality in hospital survivors with a gradual “dose–response” effect. This data emphasizes the importance prognostic implication of the general functional status on the prognosis of AMI patients. [ABSTRACT FROM AUTHOR]

Previous studies found an increase in maximal intimal thickness (MIT) ≥0.5 mm during the first year after heart transplantation (HTx), based on 3-7 select cross-sectional intravascular ultasound (IVUS) images, predicts outcome. Consensus recommendations advise against select image analysis and long vessel (40-50 mm) volumetric evaluation is preferred. However, the prognostic utility of such assessment in HTx is unclear. This study determined the relationship between long vessel volumetric IVUS evaluation early after HTx and long-term outcome. HTx recipients from four institutions underwent IVUS at 12 weeks and one year post-HTx and long vessel volumetric IVUS evaluation was performed. All-cause mortality was the primary and major adverse cardiac events (MACE i.e. composite of cardiac death, re-HTx, myocardial infarction, heart failure or coronary revascularization) was the secondary endpoint. Of 243 HTx recipients (mean follow-up 8.1±3.1 years) those with Percent Atheroma Volume (PAV) increase ≥7.0% (absolute percentage units) had a significantly increased risk of all-cause mortality (34% vs 14%, p=0.01; adjusted hazard ratio (HR) 2.60 (95% CI 1.37-4.93, p<0.01)) and MACE (40% vs 21%, p=0.04; adjusted HR 1.99 (95% 1.15-3.45, p=0.01)). MIT increase ≥0.5 mm was not associated with increased risk of all-cause mortality or MACE. With long-vessel IVUS analysis, PAV increase≥7.0% (absolute percentage units) during the first year post-HTx predicts subsequent all-cause mortality and MACE, whereas the previously established threshold of MIT increase ≥0.5 mm does not. [ABSTRACT FROM AUTHOR]

Introduction: Platelet activation and hyperreactivity plays a pivotal role in developing intravascular thrombus in ST elevation myocardial infarction (STEMI). Mean platelet volume (MPV), which is readily available in clinical settings, has been linked to poor prognosis following STEMI. Recently, platelet-to-lymphocyte ratio (PLR) has emerged as a new marker of worse outcomes linking inflammation and thrombosis. We investigated the prognostic significance of the new marker, MPVLR, in diabetic patients with STEMI undergoing percutaneous coronary intervention (PCI).Methods: A total of 623 patients with diabetes mellitus and STEMI undergoing primary PCI were enrolled and divided based on the median MPVLR on admission into two groups: group 1 (N=266) with an MPVLR ≤4.46 and group 2 (N=257) with an MPVLR >4,46.Results: Despite similar clinical features patients with elevated MPVLR (group 2) had worse angiographic characteristic suggestive of a higher thrombus burden. In-hospital and one-year mortality was higher in group 2. ROC analysis revealed moderate diagnostic value in predicting in-hospital mortality (adjusted HR 1.13; 95% CI 1.04-1.23; P=0.003; MPVLR cut-off >6.13) similar to that of PLR a good diagnostic value in predicting long-term mortality (adjusted HR 1.52; 95% CI 1.42-1.63; P<0.0001; MPVLR cut-off >5.88) better than that of PLR. MPVLR remained an independent risk factor of early and late mortality.Conclusions: To the best of our knowledge, this is the first ever study that has investigated MPVLR. Despite similar clinical characteristics, patients with elevated MPVLR had worse angiographic features which may indicate a greater thrombus burden. Elevated MPVLR is an independent risk factor of early and late mortality following STEMI. In addition, it has similar value to PLR in predicting in-hospital mortality, and a better value than PLR in predicting long-term mortality. [ABSTRACT FROM AUTHOR]

Background: Stress hyperglycemia (SH) is a valid prognosticator of in-hospital complications and mortality in the intensive care unit, and is universally available, simple, and cost-effective. Even small refinements of SH can improve the risk stratification of patients with one of the most important diseases today-acute myocardial infarction (AMI).Objective: The aim of the review was to analyze whether SH nomenclature and methodology have been consistent in the medical literature in order to identify possible methodological faults and to suggest possible solutions.Discussion: SH nomenclature and glycemic targets have been relatively uniform in recent years, but there has been a pronounced variability in the methodology. Recent meta-analysis showed that AMI patients with new hyperglycemia had a 3.6-fold increased risk of mortality during hospitalization in comparison to those who were normoglycemic. Four SH methodological mistakes were identified. First, using one cutoff value for SH instead of two different values (one for patients with diabetes mellitus [DM] and one for patients without DM). Second, analyzing, for example, either tertiles or quintiles without dividing AMI patients into subgroups according to their DM status. Third, studying only two subgroups (with SH and without SH), without determining the presence of DM, when DM is not analyzed. Fourth, failure to measure glycated hemoglobin.Conclusions: The same admission blood glucose (BG) is a marker of different mortality risks in diabetic compared to nondiabetic AMI patients. For example, when admission BG is 108-126 mg/dL (6-7 mmol/L), then the risk of in-hospital mortality is higher in DM patients; however, with an admission BG of 162-180 mg/dL (9-10 mmol/L), the risk is lower in diabetic patients. We can improve the clinical utility of the admission BG in AMI if we analyze four groups of patients (those with and without previously diagnosed DM, and above and below the admission glycemia cutoff values for in-hospital mortality). Those cutoffs should be calculated separately for diabetic and nondiabetic AMI patients. [ABSTRACT FROM AUTHOR]

Background Ethnical disparities in presentation and outcomes following AMI were reported. We evaluated the temporal-trends of AMI hospitalizations and mortality of Bedouins (Muslims) and Jews in Israel. Methods Retrospective analysis of 15,352 AMI admissions (10,652 patients; 11.3% Bedouins, 88.7% Jews) throughout 2002–2012. The trends in admission rates (AR) were compared using direct age–sex adjustment. The trends of in-hospital mortality (IHM) and 1-year post-discharge mortality (PDM) were adjusted for the patients' characteristics. Results Bedouins were younger (61.7 ± 14.3 vs. 68.8 ± 13.7 years, p < 0.001), a higher rate of males. Different prevalence of cardiovascular risk factors was found. STEMI presentation, 3-vessel disease and PCI intervention were more frequently in Bedouins than Jews. Adjusted AR was lower among Jews (4.80/1000 and 3.24/1000 in 2002 and 2012 respectively) than in Bedouins (9.63/1000 and 5.13/1000). A significant decrease of adjusted AR was found in both ethnicities (p-for-trend < 0.001 both), greater in Bedouins (p-for-disparity = 0.017). The overall rate of IHM was higher for Jews (8.7% vs. 5.6%; p = 0.001). The decline of IHM was found in both groups: an increase of one-year resulted in AdjOR = 0.877; (p-for-trend < 0.001) and 0.910 (p-for-trend = 0.052) in Jews and Bedouins respectively (p-for-interaction = 0.793). The rates of PDM were higher for Jews (13.6% vs. 9.9%; p = 0.001). The risk for PDM increased in both groups: AdjOR = 1.118; (p-for-trend < 0.001) and 1.093; (p-for-trend = 0.012) for one-year increase, for Jews and Bedouins respectively (p-for-interaction = 0.927). Conclusions Throughout 2002–2012 Bedouin AMI patients differed from Jews. Adjusted incidence of AMI declined, greater in Bedouins. IHM declined and PDM increased in both groups. A culturally sensitive prevention program is warranted. [ABSTRACT FROM AUTHOR]

Background An oral glucose tolerance test (OGTT) and/or glycosylated haemoglobin A1c (HbA1c) in patients with acute myocardial infarction (AMI) identify patients with increased mortality risk, but no comparison of the long-term prognostic values has yet been investigated. Methods This study was a prospective cohort enrolling patients with AMI between 2002 until 2008 and follow-up until 1st October, 2012. Patients without known diabetes mellitus (DM) underwent an OGTT. Seventy-nine patients with known DM did not have an OGTT performed. Primary endpoint was all-cause mortality. We included 548 patients with AMI, of whom 469 underwent a standardized OGTT and were stratified according to OGTT and HbA1c. Results During 9.8 years of follow-up, 179 (33%) patients died. In patients having increased HbA1c ≥ 6.5%, a significantly increased mortality was observed (Hazard Ratio (HR) 1.60 [1.09–2.34]). However, when adjusting for known DM, no significance was detected. An OGTT did not show a significantly increased mortality, if used separately. A combined estimate showed a significantly increased mortality in patients categorized as newly diagnosed DM by OGTT and HbA1c < 6.5% (HR 1.56 [95% CI 1.07–2.30]) compared to patients categorized as normal/impaired fasting glycaemia/impaired glucose tolerance by OGTT and HbA1c < 6.5%. Approximately 50% of the patients with newly diagnosed DM by OGTT were only detected due to 2-hour post-load glucose values. Conclusion An OGTT is recommended in AMI patients without known DM and HbA1c < 6.5%. Patients categorized as newly diagnosed DM by OGTT although HbA1c < 6.5% share the same high risk of mortality as patients with HbA1c ≥ 6.5%. [ABSTRACT FROM AUTHOR]

Purpose: Previous research has explored the association between social support (SS), cardiovascular disease, and mortality. Perceived SS (PSS) refers to an individual's attitude toward received SS. This study aimed to: (1) assess the association between PSS levels and long-term mortality among first myocardial infarction (MI) survivors, (2) compare the effect of PSS measured shortly after the first MI to PSS measured 10-13 years after MI, and (3) compare the prognostic role of different PSS components: family, friends, and significant others.Methods: Patients were drawn from the longitudinal prospective Israel Study of First Acute Myocardial Infarction (ISFAMI). PSS, sociodemographic and health variables were assessed in two subcohorts during initial hospitalization from 1992 to 1993 (T1, n = 660) and in 2002-2005 (T2, n = 969). Vital status was determined through 2011. Cox regression models assessed mortality risk associated with PSS.Results: By the end of follow-up, 212 (32%) of the T1 and 229 (24%) of T2 subcohorts had died. Higher PSS levels were associated with lower mortality risk at both T1 and T2 (per one standard deviation [1SD] increase hazard ratio [HR] = 0.85, 95% confidence interval [CI] = 0.75-0.96; HR = 0.74, 95% CI = 0.66-0.83, respectively). These associations were attenuated on adjustment for sociodemographic and clinical variables (HR = 0.93, 95% CI = 0.80-1.07; HR = 0.88, 95% CI = 0.77-1.00, respectively). PSS from friends was significantly associated with lower mortality risk at both T1 and T2 and remained significant only at T2 after adjustment (HR = 0.85, 95% CI = 0.73-0.98).Conclusions: Higher PSS levels were significantly associated with reduced mortality risk post-MI. This should encourage clinicians to assess post-MI psychosocial status to identify high-risk patients. [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: Persistent severe left ventricular (LV) systolic dysfunction after myocardial infarction (MI) is associated with increased mortality and is a class I indication for implantation of a cardioverter-defibrillator.Objectives: This study developed models and assessed independent predictors of LV recovery to >35% and ≥50% after 90-day follow-up in patients presenting with acute MI and severe LV dysfunction.Methods: Our multicenter prospective observational study enrolled participants with ejection fraction (EF) of ≤35% at the time of MI (n = 231). Predictors for EF recovery to >35% and ≥50% were identified after multivariate modeling and validated in a separate cohort (n = 236).Results: In the PREDICTS (PREDiction of ICd Treatment Study) study, 43% of patients had persistent EF ≤35%, 31% had an EF of 36% to 49%, and 26% had an EF ≥50%. The model that best predicted recovery of EF to >35% included EF at presentation, length of stay, prior MI, lateral wall motion abnormality at presentation, and peak troponin. The model that best predicted recovery of EF to ≥50% included EF at presentation, peak troponin, prior MI, and presentation with ventricular fibrillation or cardiac arrest. After predictors were transformed into point scores, the lowest point scores predicted a 9% and 4% probability of EF recovery to >35% and ≥50%, respectively, whereas profiles with the highest point scores predicted an 87% and 49% probability of EF recovery to >35% and ≥50%, respectively.Conclusions: In patients with severe systolic dysfunction following acute MI with an EF ≤35%, 57% had EF recovery to >35%. A model using clinical variables present at the time of MI can help predict EF recovery. [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 Diabetes mellitus (DM) is an established adverse prognostic factor in patients sustaining myocardial infarction (MI). However, its impact on long-term survival remains less clear. The aim of this observational study was to quantify lifetime mortality and years of life lost after MI in patients with and without DM. Methods In 1995, 2153 individuals with MI were recruited from 20 adjacent hospitals within Yorkshire, UK. Median survival, all-cause mortality at 20 years and lost years of life when compared to actuarial predictions were compared in patients with and without DM. Landmark analyses were conducted to define the ongoing impact of DM beyond specified time points. Results 13% (279/2153) had known DM. They experienced higher mortality at 30 days (33.1% vs 24.6%; p < 0.0001) and at 20 years (84.9% vs 75.7%; p < 0.0001). Overall, there was a 48% increased risk of death (p < 0.0001), which persisted after adjustment for potential confounders. There was no interaction between DM and prior MI in predicting mortality (p = 0.67). Median survival decreased by 3.3 years (p < 0.0001). The adverse impact of DM persisted in sequential landmark analyses at 1, 5 and 10 years. Presence of DM conferred 2 extra years of life lost when compared with actuarial predictions (8 vs 6 years; p < 0.0001). Conclusions DM remains an independent adverse prognostic factor in the long-term after MI. Persistently diverging survival curves support enduring efforts to reduce mortality late after MI. [ABSTRACT FROM AUTHOR]

The long-term prognosis of patients with ST-elevation myocardial infarction (STEMI) aged 45 years or younger and differences according to gender have not been well characterized. Methods We included 16,685 consecutive STEMI patients from 2003 to 2012 (67,992 patient-years follow-up) from the Eastern Danish Heart Registry and the Swedish Coronary Angiography and Angioplasty Registry who were treated with primary percutaneous coronary intervention (PCI). Results We identified 1026 (6.2%) patients up to 45 years of age (mean age: 40.7 vs. 66.3 years, P < 0.001). Patients in the young group were predominantly men (79.7% vs. 71.9%) and smokers (71.2% vs. 44.2%, P < 0.001) but with a lower prevalence of hypertension (17.3% vs. 39.3%), hyperlipidemia (18.0% vs. 23.8%), diabetes (9.0% vs. 12.4%) and previous myocardial infarction (6.9% vs. 12.2%, all P < 0.001) compared with older patients. Young patients had a 0.8% annual mortality. During the follow-up period 6.3% of young patients died vs. 28.5% of older patients ( P < 0.001). Both 30-day-mortality (adjusted hazard ratio [HR] = 0.26, 95% confidence interval [CI]: 0.12–0.54, P < 0.001) and mortality after 30 days and onwards (HR = 0.25, CI: 0.17–0.37, P < 0.001) were significantly lower in the young group. There was no difference in short-term (HR = 0.78, CI: 0.32–1.90, P = 0.59) or long-term (HR = 0.62, CI: 0.33–1.91, P = 0.59) mortality between women and men in the young group (HR = 0.79, CI: 0.21–1.80, P = 0.39). Conclusions STEMI patients, aged 45 years or younger, have an excellent prognosis after treatment with primary PCI. Long-term annual survival is more than 99% in these patients. Young women with STEMI do not have a worse long-term prognosis than young men with STEMI. [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]