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

Abstract Background While preinfarction angina pectoris (pre-IA) is recognized as favorable effects on acute myocardial infarction (AMI), the detail has not been fully investigated. The aims of the current study were to clarify patient characteristics, lesion morphologies determined by optical coherence tomography (OCT), and cardiac outcomes related to pre-IA in patients with AMI. Methods Clinical data and outcomes were compared between AMI patients with pre-IA (pre-IA group, n = 507) and without pre-IA (non-pre-IA group, n = 653). Angiography and OCT findings were analyzed in patients with pre-intervention OCT and compared between groups of pre-IA (n = 219) and non-pre-IA (n = 269). Results ST-segment elevation myocardial infarction (61% vs. 75%, p < 0.001) and cardiogenic shock (8% vs. 14%, p = 0.001) were less prevalent in pre-IA group. Peak creatine kinase-MB levels were lower in pre-IA group (median 83 IU/mL vs. 126 IU/mL, p < 0.001). In pre-intervention coronary angiography findings, initial TIMI flow grade 0/1 (43% vs. 56%, p = 0.019) and Rentrop collateral circulation 0/1 (69% vs. 79%, p = 0.018) were less frequently observed in pre-IA than in non-pre-IA patients. In post-thrombectomy OCT images, plaque rupture (39% vs. 56%, p = 0.003) and red thrombi (42% vs. 54%, p = 0.027) were also less frequently observed in pre-IA group. Kaplan–Meier estimate survival curves showed that cardiac death at 12-months was lower in pre-IA group than in non-pre-IA group (6.9% vs. 10.1%, p = 0.036). Conclusions Patients with pre-IA had less severe AMI on admission, smaller infarction size, and more favorable long-term survival, which may be caused by difference of lesion morphology between patients with and without pre-IA. Highlights • Features of AMI with preinfarction angina (pre-IA) have not been fully examined. • Clinical presentation on admission was less severe in patients with pre-IA. • Initial TIMI flow grade and Rentrop collateral grade were more favorable in pre-IA. • Plaque rupture and red thrombi determined by OCT were less prevalent in pre-IA. • Cardiac mortality at 12 months was more favorable in patients with pre-IA. [ABSTRACT FROM AUTHOR]

Introduction: Ischemic heart disease (IHD) is associated with a shockable rhythm in out-of-hospital cardiac arrest (OHCA). However, the impact of IHD severity on first recorded rhythm is unknown. We hypothesized that the strength of the association between IHD and shockable rhythm increases with increasing IHD severity.Methods: OHCA patients were identified in the Danish Cardiac Arrest Registry (2001-2014). Population-based registries were used to identify chronic diseases, drug prescriptions and cardiac procedures such as coronary angiography (CAG), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Severity of IHD was categorized as 1) No diagnosis of IHD, 2) IHD without previous CAG, PCI or CABG, 3) IHD with CAG, 4) IHD with PCI, and 5) IHD with CABG. Adjusted odds ratios (ORs) for a shockable rhythm was computed using multivariable logistic regression.Results: Of 34,749 patients with OHCA, 6325 (18.2%) patients had a diagnosis of IHD. The prevalence of a shockable rhythm was higher for patients with a previous diagnosis of IHD (25.6%) and for those with previous CAG (33.3%), PCI (36.4%) or CABG (34.0%) when compared to patients without IHD (21.2%). IHD was associated with shockable rhythm (OR = 1.69, 95%CI 1.55-1.85) when compared to patients without IHD. The association with shockable rhythm was higher for patients with a history of CAG (OR = 1.92, 95%CI 1.67-2.20) and PCI (OR = 1.93, 95%CI 1.67-2.23), but similar in patients with CABG (OR = 1.69, 95%CI 1.37-2.10).Conclusion: IHD was associated with a shockable rhythm, with a moderate increase in the association in patients with a CAG or PCI procedure. [ABSTRACT FROM AUTHOR]

Background High level of red blood cell distribution width (RDW) has been associated with adverse outcomes in coronary artery disease patients. We aimed to investigate the relationship between RDW and the risk of myocardial injury in chest pain patients. Methods and Results We retrospectively reviewed 2078 chest pain patients with suspected acute myocardial infarction. Myocardial injury was defined as high-sensitivity cardiac troponin T (hs-cTnT) >14 ng/L. RDW was associated with hs-cTnT (r = 0.607) and the risk of myocardial injury stepwise increased across increasing RDW quartiles in all subgroups based on age and sex. The receiver operating characteristic curve analysis was calculated to assess the elevated RDW to predict myocardial injury, with the cutoff value of 13.25%. RDW had a high sensitivity (78.10%), specificity (87.44%), as well as positive predictive value (77.48%). The area under the curve (AUC) for all patients was 0.88 (95%CI 0.87, 0.90) and there is no statistical significant in AUCs for all subgroups. Conclusions Elevated RDW was significantly associated with a higher risk of myocardial injury in chest pain patients with potential acute myocardial infarction. The RDW may be helpful to identify myocardial injury in such patients. [ABSTRACT FROM AUTHOR]

Background A variety of risk models have been developed to predict acute myocardial infarction (AMI) in-hospital mortality risk. As a distinct, higher-risk population, women with AMI have different risk profiles from their men counterparts. Published researches have indicated that the interaction between variables in these models for in-hospital mortality and gender are significant. Due to the interaction and gender differences, the predicting value of these risk models for women could be controversial. Methods Databases from the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) Retrospective AMI Study were utilized for model derivation ( n = 16,100, women were 4896) and databases from the China PEACE Prospective AMI Study for model validation ( n = 6207, women were 2090). A multivariable backward stepwise logistic regression was used to examine correlates of in-hospital mortality, and the variables were subsequently weighted and integrated into a scoring system. Results We constructed a novel risk-predicting tool to estimate the baseline risk of in-hospital mortality among women with AMI. The risk score includes 8 variables [age, systolic blood pressure, heart rate, initial glomerular filtration rate (GFR), serum glucose, Killip class, cardiac arrest, ventricular tachycardia/ventricular fibrillation (VT/VF)]. The prognostic discriminatory capacity of the Women Acute Myocardial Infarction in-Hospital Mortality (WAMI) risk score was excellent (c statistic 0.84, 95% confidence interval [CI]: 0.83 to 0.86, p < 0.001). External validation of the model showed better prognostic capacity (c statistic 0.87, 95% CI: 0.84 to 0.90, p < 0.001) than the GRACE risk score (0.77, 95% CI 0.72–0.82, p < 0.001) and TIMI risk score (0.72, 95% CI 0.68–0.77, p < 0.001). Conclusions The WAMI Score is a simple robust tool for predicting the in-hospital mortality risk of women with AMI. Trial registration “China PEACE-Retrospective AMI Study”, NCT01624883, retrospectively registered: April 2012. Date of enrolment of the first participant to the trial: June 17, 2012. “China PEACE-Prospective AMI Study”, NCT01624909, prospectively registered: December 2012. Date of enrolment of the first participant to the trial: June 17, 2012. [ABSTRACT FROM AUTHOR]

Background: Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown.Objectives: The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol.Methods: On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol.Results: Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090).Conclusions: A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women. [ABSTRACT FROM AUTHOR]

Background To evaluate the association of serum albumin (SA) with long-term all-cause, cardiovascular, and cardiac mortality in patients with first-onset acute myocardial infarction (AMI). Methods The cohort study enrolled 2305 patients with first-onset AMI. The median follow-up was of 1088 days (3 years). Impacts of SA on long-time mortality after AMI were determined using multivariate Cox proportional hazard regression analysis with backward selection. Results The patients were divided into three categories by SA tertiles (≤ 3.62, 3.63–4.08, > 4.08 g/dl). High tertile group was used as reference, the adjusted HRs for all-cause death were 1.21 (P = 0.338) and 1.74 (P = 0.003) for intermediate and low tertile, respectively (p-for-trend = 0.001); The equivalent values for cardiovascular death were 1.13 (P = 0.588) and 1.64 (P = 0.022), respectively (p-for-trend = 0.009); The corresponding values for cardiac death were 1.07 (P = 0.806) and 1.59 (P = 0.048), respectively (p-for-trend = 0.022). Moreover, adjusted HRs per 1-g/dl decrease in SA concentrations were 1.66 (P = 0.001) for all-cause death, 1.47 (P = 0.024) for cardiovascular death, and 1.61 (P = 0.012) for cardiac death. Conclusions Low SA level (≤ 3.62 g/dl) on admission was an independent predictor of long-term all-cause, cardiovascular, and cardiac mortality in patients with first-onset AMI. There was a dose–response relationship between decreased SA concentrations and increased long-term all-cause, cardiovascular, and cardiac mortality. [ABSTRACT FROM AUTHOR]

Introduction Impaired renal function, reflected by estimated glomerular filtration rate (eGFR) or cystatin C, is a strong risk predictor in the presence of acute myocardial infarction (AMI). Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is an early marker of acute kidney injury. uNGAL might also be a good predictor of outcome in patients with cardiovascular disease. Aim of the present study was to evaluate the prognostic value of uNGAL compared to eGFR and cystatin C in patients with suspected AMI. Methods 1818 patients were enrolled with suspected AMI. Follow-up information on the combined endpoint of death or non-fatal myocardial infarction was obtained 6 months after enrolment and was available in 1804 patients. 63 events (3.5%) were registered. Results While cystatin C and eGFR were strong risk predictors for the primary endpoint even adjusted for several variables, uNGAL was not independently associated with outcome: When applied continuously uNGAL was associated with outcome but did not remain a statistically significant predictor after several adjustments (i.e. eGFR). By adding cystatin C or uNGAL to GRACE risk score variables, only cystatin C could improve the predictive value while uNGAL showed no improvement. Conclusion We could show that cystatin C is an independent risk predictor in patients with suspected AMI and cystatin C can add improvement to the commonly used GRACE risk score. In contrast uNGAL is not independently associated with outcome and seems not to add further prognostic information to GRACE risk score. [ABSTRACT FROM AUTHOR]

Background Numerous case-crossover and time series studies of PM 2.5 exposure and cardiovascular health effects have been conducted, fever studies have examined the effects of PM 2.5 on the outcomes of CHD, especially on acute myocardial infarction (AMI). Objective The objective of this research is to investigate the association between PM 2.5 exposure in Tianjin City and the outcome of AMI. Methods We conducted a retrospective analysis of a total of 598 patients with AMI in TEDA International Cardiovascular Hospital, from Oct 28th, 2013–Apr 30th 2014. All patients were divided into five groups according to the National Air Quality Classification Standard. Major adverse cardiovascular events (MACEs) including all-cause death, heart failure, myocardial infarction and target lesion revascularization (TLR) during one year follow-up were defined as endpoint. Furthermore, we divided the patients into two groups according to better and worse air quality, then examined the incidence of MACEs in the two groups. The prognostic was assessed by using multivariate Cox regression analysis. Results With the increase of the concentration of PM 2.5 , the incidence of MACEs were higher in patients after 1 year of AMI (In the five groups, Hazard Ratio [HR] 1.622, 95% CI 1.352–1.947; p = 0.000. In the two groups, HR 3.255, 95% CI 2.008–5.276; p = 0.000). Conclusion PM 2.5 exposure was associated with the outcome of patients with AMI, especially, the poorer air quality it is, the worse prognosis of patients will be. [ABSTRACT FROM AUTHOR]

Aim To evaluate the association of post-acute myocardial infarction (AMI) plasma haptoglobin (Hp) levels with long-term overall survival in AMI patients. Methods and results Patients who were diagnosed of AMI were recruited and their Hp phenotypes and plasma levels were determined. According to previously reported cutoff point for Hp level (288.4 ng/ml), patients were classified as higher Hp group (> 288.4 ng/ml) and lower Hp group (≤ 288.4 ng/ml). The primary outcome was overall survival. This study recruited and followed a total of 117 patients for a median of 11.0 (3.2–17.6) years. Higher Hp group had 46 patients (39.3%) and lower Hp group had 71 patients (60.7%). Twelve patients had Hp 1-1 (10.3%), 50 with Hp 2-1 (42.7%), and 55 with Hp 2-2 (47.0%). The lower Hp group had significantly better overall survival (174.1 [51.6–212.5] vs. 106.5 [22.2–209.1], P = 0.037). There was no significant difference in overall survival between the three phenotype groups ( P = 0.477). Multivariate regression analysis revealed that increased age (adjusted HR = 1.06, 95% CI: 1.03–1.10, P < 0.001) and higher Hp level (adjusted HR = 1.65, 95% = 1.02–2.67, P = 0.040) were significantly associated with poor overall survival. Conclusion Higher post-AMI plasma Hp level was independently associated with poor overall survival in AMI patients. No significant difference in overall survival was noted between three Hp phenotype groups. Acute phase Hp level might reflect the severity of oxidative stress during inflammation process. [ABSTRACT FROM AUTHOR]

Background Few clinical trials have focused on populations with a history of distant myocardial infarction (MI). The PEGASUS trial assessed the impact of dual antiplatelet therapy in such patients, selected by enrichment criteria of high cardiovascular risk. Whether the PEGASUS population reflects the risk of a broader post-MI population is questionable. We analyzed whether 4-year mortality of a routine-practice population would differ according to the inclusion and exclusion criteria used in PEGASUS. Methods FAST-MI is a nationwide French registry recruiting acute MI patients in November 2005; 2490 patients alive and without recurrent MI at one year were classified into three groups: Group 1 (“PEGASUS-like” population; n = 1395; 56%), Group 2 (population having ≥ 1 exclusion criterion for the trial; n = 677; 27%), and group 3 (population meeting neither the PEGASUS inclusion nor exclusion criteria; n = 418, 17%). Results Group 1 patients were older than Group 3 patients, with higher GRACE scores, more comorbidity, and less STEMI, but were younger than the PEGASUS trial population. Enrichment criteria successfully defined a population at higher risk: 4-year survival 83% in Group 1, 97% in Group 2, and 68% in Group 3 (P < 0.001). Among risk-enrichment criteria, age alone was highly discriminant: in PEGASUS-like patients, survival was 78% in those ≥ 65 versus 94% in those < 65 years. Conclusions Enrichment criteria used in PEGAGUS succeed in defining a population at increased risk in patients with prior MI, age being the most discriminant factor. The trial population, however, was notably younger and more masculine than the corresponding real-life population in France. Clinicaltrials.gov number: NCT00673036 . [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (AMI) is an important health problem. Cardiac rehabilitation (CR) programs following AMI have shown to be effective in reducing mortality. We aim to systematically review the existing literature that analyzes the factors that affect participation and adherence to cardiac rehabilitation programs. We reviewed Medline, EMBASE and Cochrane databases from 01/01/2004 to June 2016 using predefined inclusion and exclusion criteria. We classified the results into factors affecting participation and factors influencing adherence to CR programs. We included 29 studies, and there was a general agreement in those factors predicting participation and adherence to CR programs. These factors can be classified into person-related factors and aspects related to CR programs. Older participants, women, patients with comorbidities, unemployed and uncoupled persons, less educated people and those with lower income had a lower participation. A similar pattern was observed for CR adherence. Also, those potential participants who live farther from CR facilities, do not have transportation, or do not drive, attended less to CR programs. These factors were very similar when analyzing adherence to CR programs. These aspects were similar in Europe and the USA. These results clearly show that participation in CR programs follows a determined pattern that is very homogeneous in different settings. Health professionals should also be aware of patients reluctant to participate in CR programs and adapt their messages and redesign CR programs, to promote participation and adherence. [ABSTRACT FROM AUTHOR]

Background Atrial natriuretic peptide (ANP) therapy has been reported to have beneficial effects in patients with acute myocardial infarction (AMI); however, its impact on in-hospital mortality remains unclear. This study aimed to investigate the effects of ANP therapy on in-hospital mortality in AMI patients undergoing percutaneous coronary intervention (PCI). Methods This was a retrospective cohort study using the Diagnosis Procedure Combination inpatient database in Japan. We identified AMI patients who underwent PCI with stent implantation on the day of admission, between 2010 and 2014. We compared 30-day in-hospital mortality between patients who started ANP therapy on the day of admission (ANP group) and those who received no ANP therapy during hospitalization (control group), using propensity score and instrumental variable methods. Results Of 60,592 eligible patients (8189 ANP group, 52,403 control group) from 850 hospitals, 1:1 propensity score matching created 8027 pairs. There was no significant difference in 30-day in-hospital mortality between the ANP and control groups (3.4% vs. 3.8%, respectively; p = 0.162; risk difference, − 0.42%; 95% confidence interval [CI], − 1.00% to 0.15%) in the propensity score-matched cohort. Logistic regression analysis with adjustment for propensity score deciles found no significant association between ANP therapy and 30-day in-hospital mortality (odds ratio, 0.99; 95% CI, 0.82 to 1.19). Instrumental variable analysis also showed no significant association between ANP therapy and 30-day in-hospital mortality (risk difference, − 0.59%; 95% CI, − 1.24% to 0.05%). Conclusions This study found no significant association between ANP therapy and in-hospital mortality in AMI patients undergoing PCI. [ABSTRACT FROM AUTHOR]

Background To investigate the age-dependent impact of the superfast door-to-balloon (D2B) times of ≤ 60 min as recommended by the new ESC Guideline for patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) on mid-term survival rates based on a single center registry dataset. Patients and methods This study enrolled consecutive STEMI patients who underwent PPCI from Jan 1, 2009 through Sep 30, 2013. We compared demographics, clinical characteristics and the D2B-survival relationships between patients aged ≥ 65 and < 65. Results The younger group comprised 242 patients (68%) aged < 65 and the elder group consisted of 115 patients (32%) aged ≥ 65. In patients aged < 65, the mortality rate decreased linearly with D2B time shortening (> 90 min vs. 61–90 min vs. ≤ 60 min = 14.9% vs. 13.3% vs. 1.2%, P = 0.001). Contrarily, shortening of D2B time was not associated with reduced mortality rate in patients aged ≥ 65 (> 90 min vs. 61–90 min vs. ≤ 60 min = 23.5% vs. 19% vs. 18.9%, P = 0.99). In younger patients but not the elderly, a D2B time of < 60 min has sufficient power to predict mortality with a sensitivity of 0.83, specificity of 0.74, and Youden index of 0.57. Conclusions Our results show that the new ESC Guideline recommendation of D2B time ≤ 60 min is associated with better survival rates in younger STEMI patients undergoing PPCI. Our findings stress the importance of guideline adherence to minimize reperfusion delay to improve survival in these patients. [ABSTRACT FROM AUTHOR]

Background Initial left ventricular (LV) systolic function is a main determinant of clinical outcomes in patients with acute myocardial infarction (AMI). This study was performed to investigate whether AMI patients have different prognostic factors according to their baseline LV systolic function. Methods A total of 12,988 patients with AMI from a nationwide database were analyzed. Major adverse cardiovascular events (MACEs) within 12 months of AMI, including death, nonfatal myocardial infarction (MI), and revascularization, were assessed. Results Patients were stratified into two groups according to LV ejection fraction (LVEF): those with LVEF < 40% and those with LVEF ≥ 40%. Patients with LVEF < 40% (n = 1962, 15.1%) were older and had more unfavorable cardiovascular risk factors than those with LVEF ≥ 40% (n = 11,026, 84.9%). The rate of MACE was higher in patients with LVEF < 40% than in those with LVEF ≥ 40% (26.8% vs 11.4%, p < 0.001). Independent predictors of 12-month MACEs in patients with LVEF ≥ 40% were history of MI, high Killip stage, three-vessel disease, and lower renal function, which are already known as risk factors. However, diabetes mellitus (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.17–2.40; p = 0.008), and the use of rennin-angiotensin system (RAS) blockers (HR, 0.63; 95% CI, 0.41–0.95; p = 0.029) were independent factors for 12-month MACE in patients with LVEF < 40%. Conclusions Prognostic factors determining 12-month MACE after AMI are different according to LVEF. Management following AMI should be tailored according to their LV systolic function. [ABSTRACT FROM AUTHOR]

Background Many hospitals experience a reduction in the number of available physicians on days when national scientific meetings are conducted. This study investigates the relationship between in-hospital mortality in acute myocardial infarction (AMI) patients and admission during national cardiology meeting dates. Methods Using an administrative database, we analyzed patients with AMI admitted to acute care hospitals in Japan from 2011 to 2013. There were 3 major national cardiology meetings held each year. A hierarchical logistic regression model was used to compare in-hospital mortality and treatment patterns between patients admitted on meeting dates and those admitted on identical days during the week before and after the meeting dates. Results We identified 6,332 eligible patients, with 1,985 patients admitted during 26 meeting days and 4,347 patients admitted during 52 non-meeting days. No significant differences between meeting and non-meeting dates were observed for in-hospital mortality (7.4% vs. 8.5%, respectively; p = 0.151, unadjusted odds ratio: 0.861, 95% confidence interval: 0.704-1.054) and the proportion of percutaneous coronary intervention (PCI) performed on the day of admission (75.9% vs. 76.2%, respectively; p = 0.824). We also found that some low-staffed hospitals did not treat AMI patients during meeting dates. Conclusion Little or no “national meeting effect” was observed on in-hospital mortality in AMI patients, and PCI rates were similar for both meeting and non-meeting dates. Our findings also indicated that during meeting dates, AMI patients may have been consolidated to high-performance and sufficiently staffed hospitals [ABSTRACT FROM AUTHOR]

Background Consuming desalinated seawater (DSW) as drinking water (DW) may reduce magnesium in water intake causing hypomagnesemia and adverse cardiovascular effects. Methods We evaluated 30-day and 1-year all-cause mortality of acute myocardial infarction (AMI) patients enrolled in the biannual Acute Coronary Syndrome Israeli Survey (ACSIS) during 2002–2013. Patients (n = 4678) were divided into 2 groups: those living in regions supplied by DSW (n = 1600, 34.2%) and non-DSW (n = 3078, 65.8%). Data were compared between an early period [2002–2006 surveys (n = 2531) — before desalination] and a late period [2008–2013 surveys (n = 2147) — during desalination]. Results Thirty-day all-cause-mortality was significantly higher in the late period in patients from the DSW regions compared with those from the non-DSW regions (HR = 2.35 CI 95% 1.33–4.15, P < 0.001) while in the early period there was no significant difference (HR = 1.37 CI 95% 0.9–2, P = 0.14). Likewise, there was a significantly higher 1-year all-cause mortality in the late period in patients from DSW regions compared with those from the non-DSW regions (HR = 1.87 CI 95% 1.32–2.63, P < 0.0001), while in the early period there was no significant difference (HR = 1.17 CI 95% 0.9–1.5, P = 0.22). Admission serum magnesium level (M ± SD) in the DSW regions (n = 130) was 1.94 ± 0.24 mg/dL compared with 2.08 ± 0.27 mg/dL in 81 patients in the non-DSW (P < 0.0001). Conclusions Higher 30-day and 1-year all-cause mortality in AMI patients, found in the DSW regions may be attributed to reduced magnesium intake secondary to DSW consumption. [ABSTRACT FROM AUTHOR]

Aim To study the rate of apoptotic cell death in the process of thrombus evolution after plaque rupture in myocardial infarction. Methods Paraffin embedded thrombosuction aspirates of 63 patients were stained with haematoxylin & eosin (H&E) to assess histologically the age of the thrombi: fresh (intact blood cells; < 1 day old), lytic (necrosis; 1–5 days old) or organized (ingrowth of cells; > 5 days old). Presence of plaque constituents (atheroma including foam cells, cholesterol crystals calcifications and fibrous cap tissue) was also recorded. Immunohistochemical (double) stains with anti-caspase-3-antibody were used to visualize apoptosis and the cells involved. For the latter caspase-3 antibody was combined with cell-specific markers MPO (granulocytes), CD68 (macrophages), CD34 (endothelial cells), SMA-1 (smooth muscle cells) and a Feulgen stain (DNA). Second, the rate of apoptosis was evaluated in relation to the age of the thrombi. Platelet apoptosis was further evaluated with the use of TEM. Results From a total of 63 aspirates, plaque constituents were found in 33 of the aspirates, and in 15 of them lipid rich plaque tissue was the sole component. Age classification of all thrombus containing aspirates (n = 48) resulted in 12 fresh (25%), 18 lytic (37.5%) and 18 organized (37.5%) thrombi. Apoptosis was more extensive in lytic thrombi than in fresh or organized thrombi (P < 0.0001). Plaque-containing aspirates showed more apoptosis than aspirates without plaque (P < 0.05). Immuno staining with caspase-3 antibody in combination with cell-specific markers showed that apoptosis was most extensive in MPO + granulocytes. Caspase-3-positive platelets (CD61 + anucleate particles) were most abundant in lytic thrombi. Apoptosis in platelets was confirmed by ultrastructure. Conclusion This study demonstrated a significant association between thrombus age and occurrence of apoptosis of granulocytes and also platelets, with highest rates in (fragile) lytic thrombi. We propose that apoptotic cell death in athero thrombosis could potentially serve as a biomarker for thrombus instability. [ABSTRACT FROM AUTHOR]

Background Autologous progenitor cell therapy comprising granulocyte-colony stimulating factor (G-CSF) for mobilization of bone-marrow derived progenitor cells (BMPCs) into peripheral blood and inhibition of dipeptidylpeptidase-IV by sitagliptin for enhanced myocardial recruitment of circulating BMPCs has been shown to improve survival after acute myocardial infarction (MI) in preclinical studies. In the SITAGRAMI trial we found that during short-term follow-up G-CSF plus sitagliptin (GS) failed to show a beneficial effect on cardiac function and clinical events in patients with acute MI that underwent successful PCI. The objective of the present analysis was to assess the impact of GS versus placebo treatment on long-term clinical outcomes of the SITAGRAMI trial patient population. Methods In the randomized, prospective, double-blind, placebo-controlled SITAGRAMI trial, 174 patients with acute MI were assigned to GS or placebo in a 1:1 ratio. The primary outcome for the present long-term analysis was the composite of death, MI or stroke on long-term follow-up. Results The median [IQR] follow-up duration was 4.50 [3.56–5.95] years. The primary outcome occurred in 12.8% of patients assigned to placebo and 9.2% assigned to GS (HR 0.69, 95% CI 0.28–1.69; p = 0.42). The incidence of the combined cardiovascular outcome was 47.7% in the placebo- and 41.4% in the GS-group (HR 0.75, 95% CI 0.48–1.18; p = 0.21). Overall, there was no significant difference in MACCE rates between both treatment groups (p = 0.41). Conclusion These long-term follow-up data indicate that GS therapy does not improve clinical outcomes of patients with acute MI. [ABSTRACT FROM AUTHOR]

Background: The modified Sgarbossa criteria have been validated as a rule for diagnosis of acute coronary occlusion (ACO) in left bundle branch block (LBBB). However, no analysis has been done on differences in the QRS complex, T-wave, or ST-segment concordance of < 1 mm in the derivation or validation studies. Furthermore, there was no comparison of patients with acute myocardial infarction (AMI) but without ACO (i.e., non-ST-elevation myocardial infarction [non-STEMI]) to patients with ACO or without AMI (no MI).Objective: We compare findings involving the QRS amplitude, ST-segment morphology, ST-concordance < 1 mm, and T-waves in patients with LBBB with ACO, non-STEMI, and no MI.Methods: Retrospectively, emergency department patients were identified with LBBB and ischemic symptoms but no MI, with angiographically proven ACO, and with non-STEMI.Results: ACO, non-STEMI, and no MI groups consisted of 33, 24, and 105 patients. The sum of the maximum deflection of the QRS amplitude across all leads (ΣQRS) was smaller in patients with ACO than those without ACO (101.5 mm vs. 132.5 mm; p < 0.0001) and a cutoff of ΣQRS < 90 mm was 92% specific. For ACO, non-concave ST-segment morphology was 91% specific, any ST concordance ≥ 1 mm was 95% specific, and any ST concordance ≥ 0.5 mm was 94% sensitive. For non-STEMI, terminal T-wave concordance, analogous to biphasic T-waves, was moderately sensitive at 79%.Conclusions: We found differences in QRS amplitude, ST-segment morphology, and T-waves between patients with LBBB and ACO, non-STEMI, and no MI. However, none of these criteria outperformed the modified Sgarbossa criteria for diagnosis of ACO in LBBB. [ABSTRACT FROM AUTHOR]

Background We compared the prognostic capacity of conventional and novel invasive parameters derived from the slope of the preload recruitable stroke work relationship (PRSW) in STEMI patients and assessed their contribution to the TIMI risk score. Methods Left ventricular end-diastolic pressure (EDP), ejection fraction (EF), pressure adjusted maximum rate of pressure change in the left ventricle (dP/dt/P), aortic systolic pressure to EDP ratio (SBP/EDP) and end-diastolic volume adjusted stroke work (EW), derived from the slope of the PRSW relationship, were obtained during the emergency cardiac catheterization in 523 STEMI patients. The predictive power of the analyzed parameters for 30-day and 1-year mortality was evaluated using C-statistics and reclassification analysis was adopted to assess the improvement in TIMI score. Results The highest area under the curve (AUC) values for 30-day mortality were observed for EW (0.872(95% confidence interval 0.801–0.943)), SBP/EDP (0.843(0.758–0.928)) and EF (0.833(0.735–0.931)); p < 0.001 for all values. For 1-year mortality the best predictive value was found for EW (0.806(0.724–0.887) and EF (0.793(0.703–0.883)); p < 0.001 for both. The addition of EDP, SBP/EDP ratio and EW to TIMI score significantly increased the AUC according to De Long's test. For 30-day mortality, increased discriminative power following addition to the TIMI score was observed for EW and SBP/EDP (Integrated Discrimination Improvement was 0.086(0.033–0.140), p = 0.002 and 0.078(0.028–0.128), p = 0.002, respectively). Conclusions EW and SBP/EDP are prognostic markers with high predictive value for 30-day and 1-year mortality. Both parameters, easily obtained during emergency catheterization, improve the discriminatory capacity of the TIMI score for 30-day mortality. [ABSTRACT FROM AUTHOR]

Background: Pre-clinical trials have demonstrated that, during intravenous microbubble infusion, high mechanical index (HMI) impulses from a diagnostic ultrasound (DUS) transducer might restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI).Objectives: The purpose of this study was to test the safety and efficacy of this adjunctive approach in humans.Methods: From May 2014 through September 2015, patients arriving with their first STEMI were randomized to either DUS intermittent HMI impulses (n = 20) just prior to emergent percutaneous coronary intervention (PCI) and for an additional 30 min post-PCI (HMI + PCI), or low mechanical index (LMI) imaging only (n = 10) for perfusion assessments before and after PCI (LMI + PCI). All studies were conducted during an intravenous perflutren lipid microsphere infusion. A control reference group (n = 70) arrived outside of the time window of ultrasound availability and received emergent PCI alone (PCI only). Initial epicardial recanalization rates prior to emergent PCI and improvements in microvascular flow were compared between ultrasound-treated groups.Results: Median door-to-dilation times were 82 ± 26 min in the LMI + PCI group, 72 ± 15 min in the HMI + PCI group, and 103 ± 42 min in the PCI-only group (p = NS). Angiographic recanalization prior to PCI was seen in 12 of 20 HMI + PCI patients (60%) compared with 10% of LMI + PCI and 23% of PCI-only patients (p = 0.002). There were no differences in microvascular obstructed segments prior to treatment, but there were significantly smaller proportions of obstructed segments in the HMI + PCI group at 1 month (p = 0.001) and significant improvements in left ventricular ejection fraction (p < 0.005).Conclusions: HMI impulses from a diagnostic transducer, combined with a commercial microbubble infusion, can prevent microvascular obstruction and improve functional outcome when added to the contemporary PCI management of acute STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330). [ABSTRACT FROM AUTHOR]

Background: Guideline-based admission therapies for acute myocardial infarction (AMI) significantly improve 30-day survival, but little is known about their association with long-term outcomes.Objectives: This study evaluated the association of 5 AMI admission therapies (aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon [D2B] time ≤90 min, and time to fibrinolysis ≤30 min) with life expectancy and years of life saved after AMI.Methods: We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI, with 17 years of follow-up. Life expectancy and years of life saved after AMI were calculated using Cox proportional hazards regression with extrapolation using exponential models.Results: Survival for recipients and non-recipients of the 5 guideline-based therapies diverged early after admission and continued to diverge during 17-year follow-up. Receipt of aspirin, beta-blockers, and acute reperfusion therapy on admission was associated with longer life expectancy of 0.78 (standard error [SE]: 0.05), 0.55 (SE: 0.06), and 1.03 (SE: 0.12) years, respectively. Patients receiving primary percutaneous coronary intervention (PCI) within 90 min lived 1.08 (SE: 0.49) years longer than patients with D2B times >90 min, and door-to-needle (D2N) times ≤30 min were associated with 0.55 (SE: 0.12) more years of life. A dose-response relationship was observed between longer D2B and D2N times and shorter life expectancy after AMI.Conclusions: Guideline-based therapy for AMI admission is associated with both early and late survival benefits, and results in meaningful gains in life expectancy and large numbers of years of life saved in elderly patients. [ABSTRACT FROM AUTHOR]

Background We sought to compare the prognosis of patients with spontaneous coronary artery dissection (SCAD) and atherosclerosis as the cause of acute myocardial infarction (AMI), especially in young females. Methods and results A total of 20,195 patients with AMI at 20 institutions between 2000 and 2013 were retrospectively studied. Major adverse cardiac event (MACE: cardiac death, AMI or urgent revascularization) was the endpoint. The overall prevalence of SCAD was 0.31% (n = 63; female, 94%). SCAD developed following emotional stress in 29% of patients. Revascularization was performed in 56% (35 of 63 patients), and SCAD recurrence developed in the originally involved vessel in 6 of 35 patients with revascularization, compared to none among 28 patients after conservative therapy (p = 0.002). We compared the clinical characteristics of young female AMI patients aged ≤ 50 years in the SCAD (n = 45) and no-SCAD groups (atherosclerotic AMI, n = 55). During a median follow-up of 50 months, SCAD recurred in 27% of patients, of which 42% was in the first 30 days. Kaplan–Meier analysis showed a significantly higher incidence of MACE in the SCAD group compared to the no-SCAD group (hazard ratio, 6.91; 95% confidence interval, 2.5 to 24.3; p < 0.001), although the rate of successful percutaneous coronary intervention for SCAD was as high as 92%. Conclusions Young female patients with SCAD represent a high-risk subgroup of patients with AMI and require close follow-up. [ABSTRACT FROM AUTHOR]

Objective The novel high-sensitivity cardiac troponin (hs-cTn) 0 h/1 h-algorithm substantially improves the early triage of patient's assigned “rule-out” or “rule-in” of acute myocardial infarction (AMI), while diagnostic uncertainty remains in that 25–30% of patients assigned to “observe”. We aimed to better characterize these patients. Methods In a prospective multicenter diagnostic study, we applied the hs-cTnT 0 h/1 h-algorithm in 2213 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists using all available information. Survival at 720-days was the prognostic endpoint. Findings were validated using a hs-cTnI 0 h/1 h-algorithm. Results Twenty-four percent (n = 523) of patients were assigned to “observe” by the hs-cTnT 0 h/1 h-algorithm. These patients differed significantly in multiple characteristics from “rule-out” and “rule-in” patients: they were older, in 75% male, and very often (57%) had pre-existing coronary artery disease (CAD). Diagnostic uncertainty for the presence of an AMI/UA was high. Only 39% of patients were suitable for coronary computed tomography angiography (CCTA). The most common final adjudicated diagnoses were non-cardiac disease (38%), non-coronary cardiac disease (24%), unstable angina (UA, 21%), and AMI (15%). Absolute hs-cTnT-changes within 3 h had the highest diagnostic accuracy for AMI (AUC 0.86). Cumulative 720-day survival rate was 86%, which was significantly lower as compared to “rule-out” (p < 0.001) and comparable to “rule-in” (p = ns). Findings were similar for the hs-cTnI “observe” zone. Conclusion “Observe” patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3 h, functional stress imaging and coronary angiography are the key diagnostic modalities. [ABSTRACT FROM AUTHOR]

Background: Our previous study showed that patients with acute myocardial infarction (AMI) had lower levels of vaspin than patients without AMI. The aim of this study was to investigate the clinical significance of vaspin in patients with AMI.Methods: A total of 80 patients with AMI were enrolled. Plasma vaspin levels, clinical parameters, lipid profile, C reactive protein (CRP) were measured. All the patients were followed-up for 24±2 months for the occurrence of major adverse major cardiac events (MACEs).Results: During the follow-up, 48 patients experienced a MACE. The plasma vaspin concentrations in the MACEs-positive group were lower than those in the MACEs-negative group (0.156 ± 0.015 vs 0.314 ± 0.229ng/mL, p<0.001). Receiver operating characteristic curves showed that circulating vaspin concentration significantly differentiated patients with MACEs (p<0.001). The optimal cutoff value for predicting MACE was 0.259ng/mL. Then the patients were divided into vaspin>0.259ng/mL group and vaspin<0.259ng/mL group according to the plasma vaspin levels. Forty-five patients (74%) in the vaspin<0.259ng/mL group and three (16%) patients in the vaspin>0.259ng/mL group experienced a MACE. Multivariate survival analyses showed that the vaspin level (hazard ratio, HR 0.423) independently predicted the occurrence of MACEs. Compared with the results of echocardiography at admission, the improvement of LVEF in the vaspin>0.259ng/mL group was significant (54.3±7.6% to 61.2±4.7%, p<0.001), but the change of LVEF in the low vaspin group was not significant (51.3±9.7% to 52.5±10.9%).Conclusions: Vaspin might be a useful predictive biomarker in patients with AMI, and patients with low vaspin levels might have a high risk of a MACE. In addition, vaspin might have protective effects on the improvement of LVEF after AMI. [ABSTRACT FROM AUTHOR]

Objectives: To compare 3T T1 mapping to conventional T2-weighted (T2W) imaging for delineating myocardial oedema one week after ST-elevation myocardial infarction (STEMI), and to explore the confounding effects of microvascular obstruction (MVO) on each technique.Methods: T2W spectral attenuated inversion recovery and native T1 mapping were applied in 10 healthy volunteers and 62 STEMI patients, and late gadolinium enhancement was included for infarct localisation at 1 week and at 6 months post-STEMI. Segmental T1 values and T2W signal intensity ratios were calculated; oedema volumes and salvage indices were determined in patients using image thresholding-a receiver operator characteristic (ROC) derived T1 threshold, and a 2SD T2W threshold; and the results were compared between patients with/without MVO (n=35/27).Results: Native T1 mapping delineated oedema with significantly better discriminatory power than T2W-as indicated by ROC analysis (area-under-the-curve, AUC=0.89 versus 0.83, p=0.009; and sensitivity/specificity=83/83% versus 73/73%). The optimal ROC threshold derived for T1 mapping was 1241ms, which gave significantly larger oedema volumes than 2SD T2W (p=0.006); with this threshold, patients with and without MVO showed similar oedema volumes, but patients with MVO had significantly poorer salvage indices (p<0.05) than those without. Neither method was significantly affected by MVO, the volume of which was seen to increase exponentially with infarct size.Conclusions: Native T1 mapping at 3T can delineate oedema one week post-STEMI, showing larger oedema volumes and better discriminatory power than T2W imaging, and it is suitable for quantitative thresholding. Both techniques are robust against MVO-related magnetic susceptibility. [ABSTRACT FROM AUTHOR]

Introduction Several genes are expressed in aspirated coronary thrombi in acute myocardial infarction (AMI), exhibiting dynamic changes along ischemic time. Whether soluble biomarkers reflect the local gene environment and ischemic time is unclear. We explored whether circulating biomarkers were associated with corresponding coronary thrombi genes and total ischemic time. Material and methods In 33 AMI patients undergoing percutaneous coronary intervention (PCI), blood samples were collected within 6–24 h for markers related to plaque rupture (metalloproteinase 9, tissue inhibitor of metalloproteinases 1), platelet and endothelial cell activation (P-selectin, CD40 ligand, PAR-1), hemostasis (tissue factor, tissue plasminogen activator, plasminogen activator inhibitor 1, free and total tissue factor pathway inhibitor, D-dimer, prothrombin fragment 1 + 2), inflammation (interleukin 8 and 18, fractalkine, monocyte chemoattractant protein 1 (MCP-1), CXCL1, pentraxin 3, myeloperoxidase) and galectin 3, caspase 8 and epidermal growth factor (EGF). Laboratory analyses were performed by Proximity Extension Assay (Proseek Multiplex CVD I 96 × 96 ), ELISAs and RT-PCR. Results Only circulating P-selectin correlated to the corresponding P-selectin gene expression in thrombi (r = 0.530, p = 0.002). Plasma galectin 3, fractalkine, MCP-1 and caspase 8 correlated inversely to ischemic time (r = − 0.38–0.50, all p < 0.05), while plasma MCP-1, galectin 3 and EGF were higher at short (≤ 4 h) vs. long (> 4 h) ischemic time (all p < 0.05). Conclusions The dynamic changes in circulating mediators along ischemic time were not reflected in the profile of locally expressed genes. These observations indicate a locally confined milieu within the site of atherothrombosis, which may be important for selective therapy. [ABSTRACT FROM AUTHOR]

Objectives International guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients. The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI. Design and methods hs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed. Patients with negative tests were designated low-risk. Results 63 (17.1%) of 368 patients had AMI. The median (interquartile range) time from symptom onset to first blood sampling was 4.8 h (2.8–8.6). The sensitivity of the presentation and 4 h hs-cTnI using the overall 99th percentile was 92.1% (95% CI 82.4% to 97.4%) and negative predictive value 95.4% (92.3% to 97.4%) with 78.3% low-risk. Applying the sex-specific 99th percentile did not change the sensitivity. The addition of ECG did not change the sensitivity. Conclusion Hs-cTnI > 99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results. [ABSTRACT FROM AUTHOR]

Background: To investigate the efficacy and safety of low-dose tirofiban in elderly patients undergoing primary percutaneous coronary intervention (PPCI) for acute myocardial infarction (AMI).Methods: One hundred and four patients aged 70 years and above undergoing PPCI for AMI were divided into control (n=52) and study (n=52) groups. All patients received bolus intracoronary injection of tirofiban (10μg/kg), which was followed by intravenous infusion at 0.15μg/kg/min in the control group and at 0.075μg/kg/min in the study group for 24h.Results: There was no statistically significant difference between the study group and the control group in patients with complete ST segment resolution (84.2% vs. 85.7%, P=0.851), peak high-sensitive cardiac troponin T level (5.1±1.9 vs. 5.8±2.6μg/L, P=0.123), scores of thrombus in the infarct-related artery (0.98±0.51 vs. 1.12±0.59, P=0.214), and patients with TIMI grade 3 flow (86.0% vs. 88.2%, P=0.737) after PPCI. There were no statistically significant differences between the two groups in left ventricular ejection fraction (57.1±6.3 vs. 57.7±6.1, P=0.611) and composite major adverse cardiovascular events rate (P =0.778) at 90 days after PCI. The total bleeding rate in the study group was lower than in the control group (P=0.048).Conclusion: In elderly patients with AMI undergoing primary PCI, low and standard dose of tirofiban exerts similar effects on platelet aggregation, coronary flow, infarct size, left ventricular systolic function and short-term clinical outcomes. Low dose regimen is associated with a lower bleeding rate than the standard dose. [ABSTRACT FROM AUTHOR]

Background Although intracoronary abciximab failed to improve prognosis compared with intravenous route in unselected ST-segment elevation myocardial infarction (STEMI) patients, little is known about the role of intracoronary abciximab in diabetic patients. Objectives To evaluate the efficacy of intracoronary abciximab administration in diabetic patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Methods Reperfusional and clinical outcomes of intracoronary abciximab compared with intravenous bolus abciximab according to diabetic status were evaluated in a pooled analysis of five randomized trials including 3158 STEMI patients. The primary clinical endpoint of the study was the composite of death or reinfarction at 30-day follow-up. Results Among 584 diabetic patients (18.5%), the composite of death or reinfarction was significantly reduced with intracoronary abciximab compared to intravenous abciximab (4.7% vs. 8.8%; rate ratio [RR], 0.50; 95% confidence intervals [CI], 0.26–0.99; p = 0.04), driven by numerically lower deaths (3.7% vs. 6.4%; RR, 0.56; 95% CI, 0.26–1.20; p = 0.13). Moreover, a significant reduction in definite or probable stent thrombosis was observed in patients receiving intracoronary abciximab (1% vs. 3.5%; RR, 0.27; 95% CI, 0.07–0.99; p = 0.04). Although formal tests for interaction were not significant, no clinical benefit was apparent in the cohort of STEMI patients without diabetes (n = 2574). Conclusions In diabetic patients with STEMI undergoing primary PCI, intracoronary abciximab may improve clinical outcomes as compared with standard intravenous use. These findings require confirmation in a dedicated randomized trial. [ABSTRACT FROM AUTHOR]

Background Statins are reportedly effective in the primary and secondary prevention of cardiovascular disease, mainly due to their ability to aggressively reduce low-density lipoprotein cholesterol (LDL-C) levels. However, patients sometimes exhibit the so-called “statin escape” phenomenon. The purpose of our study was to investigate the impact of the statin escape phenomenon on long-term clinical outcomes in patients with acute myocardial infarction (AMI). Method This was a subgroup analysis of 1144 patients from the Nagoya Acute Myocardial Infarction Study (NAMIS) treated between January 2004 and December 2012. We analyzed 660 patients who initiated statin treatment after AMI. Statin escape phenomenon was defined as an increase in the LDL-C levels during the 9-month treatment period by >10% of the initial values after 4 weeks of initiating statin treatment. Patients were divided into two groups depending on whether they exhibited the statin escape phenomenon, with 474 patients in the non-escape group and 186 patients in the escape group. Result Compared to the non-escape group, the escape group showed significantly lower LDL-C levels at 4 weeks after treatment initiation (81.3 ± 20.1 mg/dL vs. 101.1 ± 25.4 mg/dL, P < 0.01). By contrast, the escape group showed significantly higher LDL-C levels at 9 months after treatment initiation (105.8 ± 28.3 mg/dL vs. 90.3 ± 22.6 mg/dL, P < 0.01). Major adverse cardiac and cerebrovascular events (MACCE; a composite of all-cause death, MI, and stroke) were more frequent in the escape group than in the non-escape group (10.8% vs. 6.1%, P = 0.03). Multivariate analysis showed that statin escape phenomenon was an independent predictor of MACCE (hazard ratio: 2.02, 95% confidence interval: 1.11–3.66, P = 0.02). Conclusion Statin escape phenomenon may be an independent predictor of long-term clinical outcomes in AMI patients. [ABSTRACT FROM AUTHOR]

Background There are few studies on patients suffering acute myocardial infarction (AMI) when already in hospital for other reasons; therefore, this study aimed to compare patients with in-hospital-onset AMI admitted for either medical or surgical reasons versus patients with outpatient-onset AMI. Methods Patients enrolled in the AMIS Plus registry from 2002 to 2014 were analyzed. The main endpoint was in-hospital mortality. Results Among 35,394 AMI patients, 356 (1%) had inpatient-onset AMI following hospital admission due to other pathologies (surgical 175, non-surgical 181). These patients were older (74 vs. 66 years; P < 0.001), more often female (35% vs. 27%; P < 0.001), had less frequently ST-elevation myocardial infarction (35.5% vs. 55.5%; P < 0.001), but higher risk profiles: hypertension (83% vs. 62%; P < 0.001), diabetes (28% vs. 20%; P = 0.001), known coronary artery disease (54% vs. 35%; P < 0.001), and more comorbidities (Charlson Comorbidity Index above 1 in 51% vs. 22%; P < 0.001) than those with outpatient-onset AMI. Percutaneous coronary intervention was less frequently applied (OR 0.45; 95% CI 0.36–0.57), and they were less likely to be treated with aspirin (OR 0.43; 95% CI 0.37–0.59), P2Y12 blockers (OR 0.42; 0.34–0.52) or statins (OR 0.51; 95% CI 0.41–0.63). Crude mortality was higher (14.3% vs. 5.5%; P < 0.001) and inpatient-onset AMI was an independent predictor of in-hospital mortality (OR 2.35; 95% CI 1.63–3.39; P < 0.001). Conclusions Patients with in-hospital-onset AMI were at greater risk of death than those with outpatient-onset AMI. More work is needed to improve the identification of hospitalized patients at risk of AMI in order to provide the appropriate management. [ABSTRACT FROM AUTHOR]

Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) are occasionally found to have no culprit lesion on coronary angiography and are classified as presenting with false-positive STEMI. The clinical presentation and outcomes of these patients need to be further explored. In this case-controlled study, 259 consecutive patients with true code STEMI were compared to 104 consecutive STEMI patients without culprit lesions on emergent coronary angiography. We compared the clinical presentation, electrocardiographic features, etiology, and outcomes of the two groups. STEMI patients without culprit lesions were less likely to have typical chest pain (46% vs. 79%, P < 0.01). The ST-elevation in the group without culprit lesion was more likely to be concave (56% vs. 31%, P < 0.01), with less reciprocal ST-depression (19% vs. 71%, P < 0.01). The group without culprit lesions had a higher rate of ventilator support requirement (12.4% vs. 5.4%, P = 0.02), and higher rate of 30-day mortality (11.0% vs. 5.9%, P = 0.02). However, after excluding the patients with out-of-hospital cardiac arrests from both groups, the difference was no longer significant (P = 0.40 and 0.34 respectively). The relative poor outcomes of patients with false-positive code STEMI reflect the severity of their underlying medical condition. Careful history and review of ECG may help differentiate this group from true STEMI. [ABSTRACT FROM AUTHOR]

Objectives Changes in clot microstructure are increasingly implicated in the pathology of atherosclerosis although most data are from techniques in the remote laboratory using altered blood. We validate the novel biomarker Gel Point in STEMI patients and assess therapeutic interventions. Gel Point marks the transition of blood from a visco-elastic liquid to visco-elastic solid and is rapidly measured using unadulterated blood. The Gel Point provides measurements of three parameters to reflect clot microstructure (fractal dimension ( d f )), real-time clot formation time ( T GP ) and blood clot strength (elasticity at the Gel Point ( G ′ GP )). Methods We prospectively recruited 38 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (pPCI). Venous blood samples were collected on admission, after pPCI and 24 h after admission for assessment of the new biomarkers, standard coagulation tests and scanning electron microscopy (SEM). Results d f after pPCI was lower than d f on admission (mean 1.631 [SD 0.063] vs 1.751 [0.052], p < 0.000001) whereas d f at 24 h was similar to that on admission. G ′ GP also showed similar trend to d f (p < 0.001). T GP was prolonged at after-PCI measurement compared with admission (median 854 s [IQR 581–1801] vs 217 [179–305], p < 0.00001). Changes in the values of d f and G ′ GP were consistent with changes in the SEM images of the mature clot. Conclusions We characterise Gel Point derived markers of clot microstructure in patients admitted with emergency arterial thrombosis. This point of care test can potentially be used to assess the efficacy of therapeutic interventions by measuring changes in clot microstructure. [ABSTRACT FROM AUTHOR]

Background Pre-clinical studies have shown that hypoxia preconditioning can enhance stem cell therapeutic potential for myocardial repair. We sought to investigate the safety and feasibility of intracoronary administration of hypoxia-preconditioned bone marrow mononuclear cells (HP-BMCs) for acute ST segment elevation myocardial infarction (STEMI). Methods We randomized 22 patients with acute STEMI to receive intracoronary administration of normoxia bone marrow mononuclear cells (N-BMCs) (n = 11) or HP-BMCs (n = 11) following successful reperfusion. Another 14 patients receiving standard therapy were recruited as control (n = 14). Results There were no differences in the occurrence of major adverse cardiovascular events at 30 days and 1 year among three groups. There were significant improvement in the change of left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) in HP-BMC group both at 6 and 12 months compared with N-BMCs or control group ( P < 0.05). No differences were observed in the change of left ventricular ejection fraction (LVEF), or wall motion score index (WMSI) among three groups. Nevertheless, WMSI was improved in HP-BMCs and N-BMC group ( P < 0.05, within group), but not in control. The ratio of myocardial perfusion defect determined by SPECT was significantly decreased in HP-BMCs and N-BMC groups at 6 months compared with baseline ( P < 0.05, within group), but no significant differences were observed among three groups. Conclusions Our results provide the first-in-man evidence that intracoronary administration of HP-BMCs following acute MI appears to be safe and feasible. These results provide the basis for future prospective randomized clinical trials in a larger patient cohort. [ABSTRACT FROM AUTHOR]

Introduction Mean platelet volume (MPV) is related to the reactivity of platelets. Among survivors of acute myocardial infarction (MI), greater MPV is known to be associated with impaired reperfusion and higher mortality. The aims of the study is to investigate the dynamic changes of MPV and the relation between MPV and cardiac function in patients with acute MI and received primary percutaneous coronary intervention (PCI). Materials and Methods This retrospective cohort study included patients presented during January 2008 to March 2011 to Peking University Third Hospital with ST-segment elevation MI. All patients received successful PCI. MPV was measured serially, using a Sysmex XE2100 haematology analyser, from admission to day-7 after MI. Results In 375 patients, MPV was at its highest value (10.2 ± 1.0 fL) and correlated well with platelet distribution width (PDW, r = 0.833, p < 0.0001) at the admission, and then reduced by 16% within the 24 hours, together with marked weakening of its correlation with PDW. Patients with poorer ventricular function, estimated by high Killip Class (≥ 2, n = 96), had higher MPV values at all-time points. By logistic regression model and after adjusting for related confounders, high MPV remained as an independent predictor of Killip Class ≥ 2 (OR 1.873, CI 95% 1.373 - 2.673, p = 0.001). Clopidogrel pre-usage resulted in significant MPV reduction on admission. Conclusions MPV undergoes rapid and dynamic changes during the acute phase of MI, and was higher in patients with high Killip Class, suggesting a predictive value of MPV in ventricular dysfunction and clinical outcome of acute phase of MI. Highlights • Mean platelet volume (MPV) undergoes dynamic changes following acute MI; • Early increment of MPV predicts higher Killip Class scores; • Clopidogrel pre-use is associated with a lower MPV value at hospital admission. [ABSTRACT FROM AUTHOR]

Objectives Patients with acute myocardial infarction (AMI) are frequently complicated with major cardiovascular events (MACEs). Endothelial dysfunction has been found to be involved in pathogenesis of AMI, but its role in development of MACEs after AMI is not clearly investigated. This study aimed to determine whether the plasma markers of endothelial dysfunction could serve as independent predictors for MACEs in patients with AMI. Methods This prospective study was conducted from March 2010 to July 2012 and enrolled consecutive 132 patients with acute ST elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (PCI). Plasma levels of thrombomodulin (TM), von Willebrand factor (vWF), angiopoietin (Ang)-1, Ang-2, Tie-2, and vascular endothelial growth factor (VEGF) were measured on day 1 of AMI. The development of MACEs at 1-year follow-up was recorded. Result Patients with STEMI who developed MACEs had increased heart rate on admission (86 ± 24 vs. 74 ± 20 bpm, p = 0.006), lower left ventricular ejection fraction (LVEF) (49.0 ± 12.4 vs. 57.2 ± 12.4%, p = 0.002), and higher incidence of multivessel disease (66.7% vs. 42.2%, p = 0.018) comparing with those without MACEs. Plasma level of Ang-1 was lower in patients with MACEs than in those without (21,165 ± 16,281 vs. 31,411 ± 21,593 pg/mL, p = 0.018). In multivariate analysis, Ang-1 level < median value (OR 2.977, 95% CI 1.16-7.63, p = 0.023), LVEF (OR 0.958, 95% CI 0.92-0.99, p = 0.022) and multivessel disease (OR 3.013, 95% CI 1.19-7.60, p = 0.019) independently predicted 1-year MACEs. Conclusion Decreased plasma Ang-1 levels on admission, LVEF and multivessel disease independently predicted the development of 1-year MACEs in patients with STEMI. These results suggest that endothelial dysfunction may play an important role in mediating MACEs in patients with STEMI. [ABSTRACT FROM AUTHOR]

Background and aims The use of high sensitivity troponin (hs-Tn) may enable early rule out of acute myocardial infarction (AMI) for patients presenting to the emergency department (ED) with chest pain. This study evaluated two approaches to the early rule out of AMI; a combination of a presentation hs-Tn < 4 ng/L and normal glucose at presentation (dual testing) and a presentation hs-Tn troponin below the limit of detection (LoD). Methods We utilised prospectively collected data on adult patients presenting with suspected ACS in two EDs in Australia and New Zealand. Blood samples were taken on presentation and tested for glucose and high sensitivity troponin I. The primary endpoint was index AMI and the secondary endpoint was 30-day acute coronary syndrome (ACS). Sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic accuracy of the dual testing and LoD approaches. Results Of the 1412 participants, 182 (12.9%) had index AMI. The LoD and the dual testing approach were 100% sensitive for index AMI. The specificity of the dual testing approach (25.2%) was slightly higher than that of the LoD (20.4%). Sensitivity for ACS was similar for the two approaches (96.5% for dual testing and 98.1% for the LoD). Conclusions The dual testing and LoD approach identified all patients with index AMI and could be used to reduce the proportion of patients requiring lengthy assessment and inpatient admission. Further investigation is still required to rule out unstable angina pectoris in patients identified as low risk. [ABSTRACT FROM AUTHOR]

Background: Concerns regarding the use of selected bone marrow stem cells (BMSCs) in the field of cardiac repair after acute ischemic events have been raised. The current meta-analysis aimed to assess the efficacy and safety of selected BMSC transplantation in patients with acute myocardial infarction (AMI) based on published randomized controlled trials (RCTs). Methods: A systematic literature search of PubMed, Ovid LWW, BIOSIS Previews, and the Cochrane library from 1990 to 2014 was conducted. Results from RCTs involving subjects with AMI receiving selected BMSC therapy and followed up for at least 6 months were pooled. Results: Eight trials with a total of 262 participants were included. Data were analyzed using a random effects model. Overall, selected BMSC therapy improved left ventricular ejection fraction (LVEF) by 3.17% (95% confidence interval [CI] 0.57–5.76, P = 0.02), compared with the controls. There were trends toward reduced left ventricular end-systolic volume (LVESV) and fewer major adverse cardiac events (MACEs). Subgroup analysis revealed a significant difference in LVEF in favor of selected BMSC therapy with bone marrow mesenchymal stem cells (BMMSCs) as the cell type. Conclusions: Transplantation of selected BMSCs for patients with AMI is safe and induces a significant increase in LVEF with a limited impact on left ventricular remodeling. [ABSTRACT FROM AUTHOR]

Background Short-term mortality has been studied thoroughly in patients undergoing primary percutaneous coronary intervention (PCI), whereas long-term cause of death in patients with ST-segment elevation myocardial infarction (STEMI) remains unknown. Objectives The goal of this study was to describe the association between time and cause of death in patients with STEMI undergoing primary PCI. Methods A centralized civil registration system, patient files, and public disease and death cause registries with an accurate record linkage were used to trace time and cause of death in 2,804 consecutive patients with STEMI (age 63 ± 13 years, 72% males) treated with primary PCI. Results Patients were followed up for a median of 4.7 years. During a total of 13,447 patient-years, 717 patients died. Main causes of death within the first 30 days were cardiogenic shock and anoxic brain injury after cardiac arrest. Age, culprit vessel size and flow, and the presence of heart failure and diabetes were independent predictors of mortality. After 30 days, the annual cardiac mortality rate was <1.5%. Causes of death beyond 30 days were noncardiac in 65% of cases (mainly malignancies and pulmonary diseases). The 30-day, 1-year, and 5-year all-cause (and cardiac) mortality rates were 7.9% (7.3%), 11.4% (8.4%), and 23.3% (13.8%), respectively. Conclusions Patients who survive the first month after an STEMI treated with primary PCI have an excellent prognosis, with a <1.5% annual risk of successive cardiac death. Noncardiac causes are responsible for the majority of later deaths in these patients. [ABSTRACT FROM AUTHOR]

Coronary artery thrombosis in ST-elevation myocardial infarction (STEMI) is a dynamic process often preceded by episodes of silent plaque rupture and subocclusive thrombosis. Thrombus organization is achieved by ingrowth of endothelial and smooth muscle cells. Clinical significance and impact of thrombus neovascularization on primary percutaneous coronary intervention (pPCI) outcome remain unclear. Therefore we investigated composition and neovascularization of thrombi aspirated during pPCI and their association with clinical and angiographic parameters of STEMI patients. Methods Aspirated thrombi retrieved from 84 STEMI patients were classified as fresh (1day), lytic (1-5days) or organized (5days). Thrombus neovascularization was evaluated immunohistochemically using CD34, CD31 and VEGF antibodies. CD34 and CD31 immunopositive (CD34/CD31+) cells were organized as single, clusters and microvessels. VEGF positivity was graded as low or high, based on thrombus surface immunopositive area. Results CD34/CD31+ cells were present in 67% of all aspirated thrombi. Thrombus CD34/CD31 positivity was associated with previous history of angina pectoris (χ2=6.142, p=0.013) and lower myocardial blush grade (MBG<3, χ2=12.602, p<0.001). Organization of CD34/CD31+ cells showed inverse association with the extent of VEGF positivity (χ2=10.607, p=0.005). Fresh thrombi were associated with shorter ischemic time (U=237.5, p=0.002) and MBG 3 (χ2=6.379, p=0.012). Conclusions Older thrombus age and neovascularization are associated with suboptimal myocardial perfusion in STEMI patients. Thrombus VEGF expression is inversely associated with degree of CD34+ cell organization. Therefore, neovascularization of aspirated thrombi may indicate the duration of thrombosis, coronary microcirculation status and outcome in STEMI patients. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction with ST-segment elevation (STEMI) initiates with intraluminal thrombosis and results in total occlusion of the coronary artery. To date, characterization of the coronary thrombus proteome in STEMI patients has not been yet accomplished. Therefore, we aimed to perform an in-depth proteomic characterization of the human coronary thrombus by means of three different approaches: 2-DE followed by mass spectrometry (MALDI MS/MS), 1-DE combined either with liquid chromatography coupled to mass spectrometry in a MALDI TOF/TOF (LC–MALDI-MS/MS), or in a LTQ-Orbitrap (LC–ESI-MS/MS). This approach allowed us to identify a total of 708 proteins in the thrombus. Expression in coronary thrombi (n = 20) of 14 proteins was verified, and the expression of fibrin and 6 cell markers (platelets, monocytes, neutrophils, eosinophils, T-cells and B-cells) quantified by selected reaction monitoring (SRM). A positive correlation of 5 proteins (fermitin homolog 3, thrombospondin-1, myosin-9, beta parvin and ras-related protein Rap-1b) with CD41 was found, pointing out the potential activation of a focal adhesion pathway within thrombus platelets. DIDO1 protein was found to correlate negatively with thrombus fibrin, and was found up-regulated in the plasma of these STEMI patients, which may constitute a starting point for further analyses in the search for biomarkers of thrombosis. Biological significance The proteomic characterization of the human coronary thrombus may contribute to a better understanding of the mechanisms involved in acute coronary syndrome, and thus pave the road for the identification of new therapeutic targets that may help addressing this and other thrombotic diseases. A novel methodology to characterize thrombus composition and expression of a sub-group of proteins is hereby described, which allowed linking protein expression with cellular and ECM matrix composition of the thrombus. Five proteins (fermitin homolog 3, thrombospondin-1, myosin-9, beta parvin and ras-related protein Rap-1b) co-express within the human coronary thrombus with CD41, pointing out the potential activation of a focal adhesion pathway within thrombus platelets during thrombus formation. Besides, the protein death-inducer obliterator 1, found to be expressed within the human coronary thrombus, has been proved to increase in the plasma of STEMI patients, which constitutes an important starting point for further analyses in the search for biomarkers of thrombosis. [ABSTRACT FROM AUTHOR]

Background While sleep apnea (SA) might be a modifiable cardiovascular risk factor, recent data suggest that SA is severely underdiagnosed in patients after acute myocardial infarction (MI). There is limited evidence about day-night variation of onset of MI on dependence of having SA. We therefore investigated the prevalence of SA and examined the day-night variation of onset of MI in acute MI patients. Methods We prospectively studied 782 consecutive patients admitted to the hospital with the diagnosis of acute MI. All subjects underwent sleep evaluations using a portable device after at least 48 h post-admission. Using the apnea-hypopnea index (AHI), groups were defined as patients without SA (< 5 events/h), mild SA (5-15 events/h), moderate SA (15-30 events/h), and severe SA (≥ 30 events/h). Results Almost all patients (98%) underwent urgent coronary angiography and 91% of patients underwent primary PCI. Using a threshold of AHI ≥5 events/h, SA was present in 65.7% of patients after acute MI. Mild SA was present in 32.6%, moderate in 20.4% and severe in 12.7%. The day-night variation in the onset of MI in all groups of SA patients was similar to that observed in non-SA patients. From 6 AM to 12 PM, the frequency of MI was higher in both SA and non-SA patients, as compared to the interval from 12 AM to 6 AM (all p < 0.05). Conclusion There is a high prevalence of SA in patients presenting with acute MI. Peak time of MI onset in SA patients was between 6 AM and noon, similar to that in the general population. Whether diagnosis and treatment of SA after MI will significantly improve outcomes in these patients remains to be determined. [ABSTRACT FROM AUTHOR]

Objectives This study sought to identify clinical and procedural predictors of elevated radiation dose received by patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) and to determine if elevated radiation dose was predictive of mortality in this population. Background Little data exist regarding the impact of excessive radiation burden on clinical outcomes in patients undergoing PCI. Methods The study population included 1,039 patients who underwent PCI for an AMI between January 1, 2007 and December 31, 2008 at an academic tertiary care teaching hospital. Cumulative skin dose (measured in milligray [mGy]) was selected as a measurement of patient radiation burden. Clinical and procedural variables were analyzed in multiple logistic and linear regression models to determine predictors of higher skin dose, and its impact was evaluated on all-cause intermediate-term mortality at two years. Results Median skin dose was 2120 mGy (IQR 1379–3190 mGy) in the overall population, of which 153 (20.8%) patients received an elevated skin dose (defined as a skin dose > 4,000 mGy). Independent predictors of elevated skin dose included male gender, obesity, multivessel intervention, and presentation with a non-ST-elevation MI (NSTEMI) versus an ST-elevation MI (STEMI). Increased skin dose was not predictive of intermediate-term mortality by multivariate analysis in the overall population or in either subgroup of STEMI and NSTEMI. Conclusions In this contemporary observational study examining patients with AMI undergoing PCI, male gender, obesity, multivessel intervention, and presentation with a NSTEMI were associated with increased radiation exposure. [ABSTRACT FROM AUTHOR]

Intermedin functions systemically as a potent vasodilator and its plasma levels have been shown to be elevated in patients with acute myocardial infarction. This study aimed to evaluate the prognostic value of plasma intermedin level in the patients with ST-segment elevation acute myocardial infarction. Plasma intermedin concentrations of 128 patients and 128 healthy controls were determined using a radioimmunoassay. Patients were followed up for 6 months for major adverse cardiovascular events (MACE) consisting of cardiovascular mortality, reinfarction, hospitalization for decompensated heart failure, and lift-threatening arrhythmia. The association of plasma intermedin levels with MACE was investigated by univariate and multivariate analyses. Plasma intermedin levels were significantly higher in patients than in healthy subjects. Elevated plasma level of intermedin was identified as an independent predictor of MACE. Receiver operating characteristic curve analysis showed that plasma intermedin levels had high predictive value for MACE. Moreover, its predictive value was similar to Global Registry of Acute Coronary Events scores' based on area under curve. Meantime, it obviously improved Global Registry of Acute Coronary Events scores' predictive value in a combined logistic-regression model. In multivariate Cox's proportional hazard analysis, plasma intermedin level emerged as an independent predictor of MACE-free survival. Thus, our results suggest that high plasma intermedin level is associated with poor outcomes of patients and may be a useful prognostic biomarker in ST-segment elevation acute myocardial infarction. [ABSTRACT FROM AUTHOR]