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Aims: To compare survival outcomes of Impella support and medical treatment in patients with post-cardiac arrest cardiogenic shock related to acute myocardial infarction (AMI).Methods: Retrospective single center study of patients resuscitated from out of hospital cardiac arrest (OHCA) due to AMI with post-cardiac arrest cardiogenic shock between September 2014 and September 2016. Patients were either assisted with Impella or received medical treatment only. Survival outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between both groups.Results: A total of 90 consecutive patients with post-cardiac arrest shock due to AMI were included; 27 patients in the Impella group and 63 patients in the medical treatment group. Patients with Impella support had a longer duration of low-flow time (29.54 ± 10.21 versus 17.57 ± 8.3 min, p < 0.001), higher lactate levels on admission (4.75 [IQR 3.8-11] versus 3.6 [IQR 2.6-3.9] mmol/L, p = 0.03) and lower baseline systolic LVEF (25% [IQR 25-35] versus 45% [IQR 35-51.25], p < 0.001) as compared to patients without circulatory support. After propensity score matching, patients with Impella support had a significantly higher survival to hospital discharge (65% versus 20%, p = 0.01) and 6-months survival (60% versus 20%, p = 0.02).Conclusion: The results from our study suggest that Impella support is associated with significantly better survival to hospital discharge and at 6 months compared to medical treatment in OHCA patients admitted with post-cardiac arrest cardiogenic shock and AMI. [ABSTRACT FROM AUTHOR]

Background Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation. Methods Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000–2010. Results Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p < 0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value = 0.40). There was a significant decline in the referral trend over the study decade (6.7% – 1.7%; p < 0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006–2010) vs. early (years: 2000–2005) period (85.7% vs. 90%; log-rank p-value = 0.15), whereas, among patients who didn’t undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001). Conclusions Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group. [ABSTRACT FROM AUTHOR]

Objectives: This study analyzed the outcomes of patients who presented with non-ST-elevation myocardial infarction (NSTEMI) and subsequently underwent orbital atherectomy for severe coronary artery calcification (CAC).Background: Patients who present with NSTEMI have increased risk for death and recurrent MI after percutaneous coronary intervention (PCI). Patients with severe CAC have worse outcomes after PCI.Orbital atherectomy modifies calcified plaque, facilitating stent delivery and optimizing stent expansion. There are no data on these patients who present with NSTEMI who undergo orbital atherectomy.Methods: Of the 454 consecutive real-world patients who underwent orbital atherectomy in our retrospective multicenter registry, 51 patients (11.2%) presented with NSTEMI. The primary safety endpoint was the rate of major adverse cardiac and cerebrovascular events (MACCE) at 30days.Results: Patients with NSTEMI had a higher prevalence of chronic kidney disease, lower mean ejection fraction, and required more vessels to be treated. The primary endpoint was similar in patients who presented with and without NSTEMI (2.0% vs. 2.2%, p=0.9), as were the 30-day rates of death (2.0% vs. 1.2%, p=0.67), MI (0% vs. 1.2%, p=0.42), target vessel revascularization (0% vs. 0%, p>0.91), and stroke (0% vs. 0.2%, p=0.72). The rates of angiographic complications and stent thrombosis rate were low in both groups.Conclusions: Despite having worse baseline characteristics, patients who presented with NSTEMI and subsequently underwent orbital atherectomy had similar clinical outcomes compared with patients without NSTEMI. [ABSTRACT FROM AUTHOR]

Background and Aim: It was hypothesized that the pattern of coronary occlusion (thrombus composition) might contribute to the onset of ventricular arrhythmia and sudden cardiac death (SCD) in myocardial infarction (MI).Methods: The TIDE (Thrombus and Inflammation in sudden DEath) study included patients with angiographically-proven acute coronary occlusion as the cause of a ST elevation MI (STEMI) complicated by Sudden Cardiac Death (SCD group) or not (STEMI group). Thrombi were obtained by thrombo-aspiration before primary percutaneous coronary stenting and analyzed with a quantitative method using scanning electron microscopy. We compared the composition of the thrombi responsible for the coronary occlusion between the two groups and evaluated factors influencing its composition.Results: We included 121 patients and found that thrombus composition was not different between the SCD group (n=23) and the STEMI group (n=98) regarding content of fibrin fibers (60.3±18.4% vs. 62.4±18.4% respectively, p=0.68), platelets (16.3±19.2% vs. 15.616.7±%, p=0.76), erythrocytes (14.6±12.5% vs. 13±12.1%, p=0.73) and leukocytes (0.6±0.9% vs. 0.8±1.5%, p=0.93). Thrombus composition did not differ between patients receiving upstream-use of glycoprotein IIb/IIIa platelet receptor inhibitors (GPI) and patients free of GPI. The only factor found to influence thrombus composition was the ischemic time from symptom onset to primary PCI, with a decreased content in fibrin fibers (57.8±18.5% vs. 71.9±10.1%, p=0.0008) and a higher platelet content (19.2±19.1% vs. 7.9±5.7% p=0.014) in early presenters (<3h of ischemic time) vs. late presenters (>6h of ischemic time).Conclusion: Composition of intracoronary thrombi in STEMI patients does not differ between those presenting with and without SCD. Time from symptom onset to coronary reperfusion seems to be the strongest factor influencing thrombus composition in MI. [ABSTRACT FROM AUTHOR]

Background It is unclear whether simvastatin–ezetimibe could be an alternative therapy to high-intensity statin therapy in high-risk patients. The aim of this study was to compare the clinical outcomes of simvastatin–ezetimibe and high-intensity statin therapy in patients with acute myocardial infarction (AMI), and especially in those with high-risk factor. Methods A total of 3520 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were classified into simvastatin–ezetimibe group (n = 1249) and high-intensity statin group (n = 2271). Multivariate analysis and propensity-score matching analysis were performed. The primary endpoint was major adverse cardiac events (MACE) at 12-months follow-up. Results In overall AMI patients, MACE occurred in 116 patients (9.3%) in simvastatin–ezetimibe group and 116 patients (5.1%) in high-intensity statin group. The difference in MACE between groups was driven by repeat revascularization (5.9% vs. 2.2%). After propensity matching analysis, simvastatin–ezetimibe was associated with a higher incidence of MACE than high-intensity statin therapy (adjusted hazard ratio: 3.090, 95% confidence interval: 1.715 to 5.566, p < 0.001). However, in patients with high-risk factors, such as diabetes, old age, or heart failure, simvastatin-ezetimibe had similar incidence of MACE compared with high-intensity statin therapy in further adjusted analysis. Conclusions In overall AMI patients, high-intensity statin therapy had better clinical outcomes than simvastatin–ezetimibe. However, in patients with high-risk factor, simvastatin–ezetimibe had comparable clinical outcomes to high-intensity statin therapy. Therefore, simvastatin–ezetimibe could be used as an alternative to high-intensity statin therapy in such patients. [ABSTRACT FROM AUTHOR]

Objective: During an acute myocardial infarction, patients often use denial as a coping mechanism which may provide positive mood regulating effects but may also prolong prehospital delay time (PHD). However, empirical evidences are still sparse.Methods: This cross-sectional study included 533 ST-elevated myocardial infarction (STEMI) patients from the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. The outcome was assessed using the Cardiac Denial of Impact Scale (CDIS) with the median split as cutoff point. A total of 206 (41.8%) STEMI patients were thus classified as deniers.Results: Deniers were less likely to suffer from major depression (p=0.04), anxiety (p=0.01) and suboptimal well-being (p=0.01) compared to non-deniers during the last six months prior to STEMI. During STEMI, they were less likely to perceive severe pain strength (p=0.04) and racing heart (p=0.02). Male deniers were also less likely to perceive shortness of breath (p=0.03) and vomiting (p=0.01). Denial was not associated with overall delay time. However, in the time window of 3 to 24h, denial accounted for roughly 40min extra delay (356 vs. 316.5min p=0.02 n=196).Conclusions: Denial not only contributes to less suffering from acute heart related symptoms and negative affectivity but also leads to a clinically significant delay in the prevalent group. [ABSTRACT FROM AUTHOR]

Background Limited data are available on the efficacy of statin therapy for secondary prevention in patients with vasospastic angina (VSA). We investigated the association of statin therapy with long-term clinical outcomes in VSA patients without significant coronary artery disease. Methods From January 2003 to June 2014, we enrolled a total of 804 patients with VSA proven by an ergonovine provocation test without significant (≥ 70% diameter stenosis) coronary artery disease. We classified patients into a statin group (n = 330) and a no-statin group (n = 474) according to the use of statin. Primary outcome were major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, myocardial infarction, and any revascularization. Results Median follow-up duration was 4.5 years (interquartile range: 2.0 to 7.3 years). MACE occurred in 14 patients (4.2%) in the statin group, and 21 patients (4.4%) in the no-statin group. There were no differences between the two groups (p = 0.97). After 1:1 propensity-score matching (281 pairs), MACE (statin versus [vs.] no-statin; 3.2% vs. 4.3%, hazard ratio [HR]; 0.80, 95% confidence interval [CI]; 0.34–1.89, p = 0.60) and readmission due to chest pain (17.1% vs. 17.4%, HR; 1.08, 95% CI; 0.72–1.06, p = 0.72) were not statistically different between the two groups. Conclusion Our results suggest that statin therapy could not improve long-term clinical outcomes in VSA patients without significant coronary artery disease. [ABSTRACT FROM AUTHOR]

Inflammation plays an important role on every stage of atherosclerosis. Myeloperoxidase (MPO), a leukocyte-derived enzyme that participates in the innate immunity, probably is involved in many stages of atherothrombosis. According to the recent studies, MPO is related with unfavorable outcome in patients with chest pain and acute coronary syndromes. Its role in prediction of outcomes after ST-segment elevation myocardial infarction (STEMI) remains unclear. The aim of the study was to assess if elevated MPO level is a predictor of long-term adverse cardiac events in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Material and methods We evaluated data of 127 patients with STEMI. Plasma levels of MPO collected on admission and the 3rd–4th day of hospitalization were measured by ELISA method. C-reactive protein (CRP) and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) were also determined. All patients were followed-up prospectively for the occurrence of major adverse cardiovascular events (MACE) defined as unscheduled coronary revascularization procedure, stroke, reinfarction or all-cause death. Results After 14 months of follow-up 20% of patients developed MACE. Elevated MPO levels collected on the 3rd–4th day of STEMI were the predictor of death, reinfarction, the need for coronary revascularization and all adverse events taken together. In multivariate analysis, MPO and CRP levels assessed on the 3rd–4th day of hospitalization revealed to be significant predictors of MACE. MPO demonstrated to be significantly better predictor of MACE than NT-proBNP level. Conclusions Myeloperoxidase is a prognostic marker in patients with STEMI treated with pPCI. [ABSTRACT FROM AUTHOR]

Background Prognostic value of the infarct- and non-infarct like patterns and cardiac magnetic resonance (CMR) parameters on long-term outcome of patients after acute myocarditis is not well known. Methods Between 2006 and 2015, 112 consecutive patients with CMR-based diagnosis of acute myocarditis were identified in our institution. Of them, 88 were available for clinical follow-up and represented our studied population. Patients were divided into infarct-like group (n = 48) (association of acute chest pain, elevated Troponin levels and ST-elevation) and non-infarct-like group (n = 40) with any other presentation. The composite primary endpoint of major cardiovascular events (MACE) included: all-cause mortality, cardiac mortality, recurrence of myocarditis, heart failure, and sustained ventricular tachycardia. Results During follow-up, 21 patients (24%) experienced MACE and infarct-like patients were significantly more at risk for MACE than non-infarct-like patients (HR 2.4, 95% CI [1.01–5.80] p = 0.04). Infarct-like patients exhibited in particular a higher risk of sustained ventricular tachycardia and recurrence of myocarditis (p = 0.03). They had lower CMR-derived left (p = 0.03) and right (p = 0.001) ventricular ejection fractions, and exhibited larger areas of late gadolinium enhancement (LGE) (p = 0.001). In multivariate analysis, both initial NYHA functional class > II and LGE mass were independent predictors for long-term MACE occurrence (HR 5.8 and 1.07 per gram respectively, p = 0.007). Moreover, a threshold of LGE mass > 17 g provided a high discrimination for MACE occurrence (AUC of 0.81). Conclusions The infarct-like pattern of acute myocarditis is associated with MACE occurrence. Initial NYHA functional class > II and LGE are independent predictive factors of MACE during long-term follow-up after acute myocarditis. [ABSTRACT FROM AUTHOR]

When a patient arrives at the Emergency Room with acute myocardial infarction (AMI), the provider on duty must quickly decide how aggressively the patient should be treated. Using Florida data on all such patients from 1992 to 2014, we decompose practice style into two components: The provider's probability of conducting invasive procedures on the average patient (which we characterize as aggressiveness), and the responsiveness of the choice of procedure to the patient's characteristics. We show that within hospitals and years, patients with more aggressive providers have consistently higher costs and better outcomes. Since all patients benefit from higher utilization of invasive procedures, targeting procedure use to the most appropriate patients benefits these patients at the expense of the less appropriate patients. We also find that the most aggressive and responsive physicians are young, male, and trained in top 20 schools. [ABSTRACT FROM AUTHOR]

Background: Mineralocorticoid receptor antagonists (MRA) improve outcome in the setting of post-myocardial infarction (MI) heart failure (HF).Objectives: The study sought to assess the benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction.Methods: We randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone. The primary outcome of the study was the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, indication for implantable defibrillator, or new or worsening HF at 6-month follow-up. Key secondary/safety outcomes included death and other individual components of the primary outcome and rates of hyperkalemia at 6 months.Results: The primary outcome occurred in 95 (11.8%) and 98 (12.2%) patients in the treatment and control groups, respectively (hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.73 to 1.28). Death occurred in 11 (1.4%) and 17 (2.1%) patients in the treatment and control groups, respectively (HR: 0.65; 95% CI: 0.30 to 1.38). In a non-pre-specified exploratory analysis, the odds of death were reduced in the treatment group (3 [0.5%] vs. 15 [2.4%]; HR: 0.20; 95% CI: 0.06 to 0.70) in the subgroup of ST-segment elevation MI (n = 1,229), but not in non-ST-segment elevation MI (p for interaction = 0.01). Hyperkalemia >5.5 mmol/l(-1) occurred in 3% and 0.2% of patients in the treatment and standard therapy groups, respectively (p < 0.0001).Conclusions: The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI. (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up; NCT01059136). [ABSTRACT FROM AUTHOR]

Background The prognostic role of left ventricular remodeling and renal function in elderly hypertensive patients has been so far scarcely investigated. Aims We assessed the impact of left ventricular geometry and renal function on 24 h-Holter electrocardiogram (ECG) recordings and outcome in elderly hypertensive patients. Methods We enrolled 251 asymptomatic hypertensive elderly patients (> 65 year-old). Left ventricular remodeling was evaluated by 2-D echocardiogram. Lown's class, mean QTc and standard deviation of all normal R–R intervals (SDNN) were assessed by 24-h Holter-ECG recordings. Data on all-cause and cardiovascular mortality were collected for 2 years. Results Mean age was 76.2 ± 11.4 years. High Lown's classes were more frequently observed in the presence of left ventricular hypertrophy (LVH) (57.3% vs. 23.7%; p < 0.001). Mean QTc was 444.8 ± 34.8 ms and resulted directly correlated with indexed left ventricular mass (r = 0.228; p = 0.001). Patients with Chronic Kidney Disease (CKD) showed lower SDNN as compared with those with preserved renal function (92.02 ± 36.11 ms vs. 103.84 ± 33.96 ms, respectively; p = 0.017). At 2 years, all-cause and cardiovascular mortality rates were 38.0% and 21.1%, respectively. Diabetes mellitus (HR: 2.40; 95% C.I.1.16 to 4.99; p = 0.019), CKD (HR: 2.22; 95% C.I.1.10 to 4.52; p = 0.028), prolonged QTc (HR: 2.18; 95% C.I.1.07 to 4.41; p = 0.030) and SDNN < 96 ms (HR: 1.98; 95% C.I.1.03 to 4.13; p = 0.048) were independent predictors of cardiovascular death at 2 year follow-up. Conclusions CKD and left ventricular remodeling predicted altered ventricular batmotropism. Diabetes, CKD, heart rate variability and QTc are important predictors of cardiovascular death in elderly hypertensive patients. [ABSTRACT FROM AUTHOR]

Background Patients with renal dysfunction (RD) who present with acute myocardial infarction (AMI) are at a high risk for subsequent cardiovascular morbidity and mortality. We sought to evaluate changes in the short and long term mortality of AMI patients with RD compared to patients with normal renal function over the last decade. Methods This study based on 4 bi-annually surveys was performed from 2002 to 2010 and included 9468 AMI patients, that were followed for 1 year, of whom 2770 (29%) had reduced estimated GFR ([eGFR] < 60 ml/min/m 2 ). Among patients with reduced eGFR: 1251 patients (45%) were included in the 2002–2005 surveys (early period) and 1519 (55%) in the 2006–2010 surveys (late period). Results Patients with RD were more likely to have advanced cardiovascular disease, multiple comorbidities and higher in-hospital, 30-day, and 1-year mortality rates (8.1%,12.3% and 23% vs. 0.7%, 1.7% and 4%, respectively; all p < 0.001). Patients with RD enrolled during the late survey periods were more likely to undergo primary PCI and be discharged with current evidence based medical treatment. 1-year mortality rates were significantly lower among patients with RD who were enrolled during the late vs. early survey periods: 22% vs. 25% respectively; (Log-rank P-value < 0.001). Consistently, multivariate analysis showed that patients with RD who were enrolled during the late survey periods displayed a lower adjusted risk for 1-year mortality (HR 0.83; CI[0.70–0.94] P = 0.01). Conclusions Prognosis of patients with RD admitted with AMI has significantly improved over the last decade, possibly due to an improvement of pharmacological and non-pharmacological management. [ABSTRACT FROM AUTHOR]

Background Women with AMI may have worse outcomes than men. However, it is unclear if this is related to differences in treatment, treatment effect or gender specific factors. We sought to determine whether primary percutaneous intervention (PCI) has a differential impact on infarct size, myocardial perfusion and ST segment resolution in men and women with acute myocardial infarction (AMI). Methods A total of 501 AMI patients were prospectively enrolled in the EMERALD study and underwent PCI with or without distal protection. Post hoc gender subset analysis was performed. Results 501 patients (108 women, 393 men) with ST-segment elevation AMI presenting within 6 h underwent primary (or rescue) PCI with stenting and a distal protection device. Women were older, had more hypertension, less prior AMI, smaller BSA, and smaller vessel size, but had similar rates of diabetes (30% versus 20.2%, p = 0.87), LAD infarct, and time-to-reperfusion compared to men. Women more frequently had complete ST-resolution (> 70%) at 30 days (72.8% versus 59.8%, p = 0.02), and smaller infarct size compared to males (12.2 ± 19.6% versus 18.4 ± 18.5%, p = 0.006). At 6 months, TLR (6.9% versus 5.2%) and MACE (11.4% versus 10.3%) were similar for women and men. Conclusions Despite worse comorbidities, women with AMI treated with primary PCI with stenting showed similar early and midterm outcomes compared to men. [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 The relationship between culprit vessel, infarct size, and outcomes in non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear. In some reports, the left circumflex artery (LCX) was more often the culprit at angiography than the right coronary artery (RCA) or left anterior descending artery (LAD), and infarcts were larger with LCX culprits. Methods We determined culprit vessel frequency and initial patency (TIMI flow grade), median fold elevation of peak troponin above the upper limit of normal, and outcomes (30-day death or myocardial infarction [MI] and 1-year mortality) by culprit vessel in high-risk NSTE ACS patients in the EARLY ACS trial. Results Of 9406 patients, 2066 (22.0%) had angiographic core laboratory data. We evaluated 1774 patients for whom the culprit artery was not the left main, a bypass graft, or branch vessel. The culprit was the LCX in 560 (31.6%), LAD in 653 (36.8%), and RCA in 561 (31.6%) patients. There were fewer women (24.1%) and more prior MI (25.5%) among patients with a culprit LCX compared with those with a culprit LAD or RCA. Patients with LCX (21.2%) and RCA (27.5%) culprits more often had an occluded artery (TIMI 0/1) than did those with LAD (11.3%). Peak troponin elevation was significantly higher for LCX than RCA or LAD culprits. LCX culprit vessels were not associated with worse 30-day or 1-year outcomes in adjusted models. Conclusions Among patients with NSTE ACS, the frequencies of LCX, LAD, and RCA culprits were similar. Although LCX lesions were associated with higher peak troponin levels, there was no difference in short- or intermediate-term outcomes by culprit artery. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to perform a preliminary evaluation of the potential association between platelet distribution width (PDW) and frequency of major adverse cardiovascular events (MACEs) development in an observational study of acute coronary syndrome (ACS) patients.Methods: A total of 679 consecutive patients with ACS (498 (73.3%) males; mean age was 63.31±11.2 years; study population composed of 320 patients with acute myocardial infarction and 359 patients with unstable angina pectoris) subjected to primary percutaneous coronary intervention with transradial approach (TRA) were retrospectively enrolled to the study. Tertiles were formed based on PDW levels. The associations between PDW and in-hospital and long-term MACEs were analysed.Results: The frequencies of in-hospital instent thrombosis (P=0.05), long-term instent restenosis (P=0.005) and long-term total MACEs (P=0.008) were higher in tertiles having a high PDW value. In multivariate analyses, PDW was an independent predictor of in-hospital and long-term MACEs (odds ratio 1.081, 95% confidence interval 1.003-1.165; p=0.042). The projected Kaplan-Meier incidence of a MACEs in the PDW tertiles groups were 12.8%, 12.1%, and 21.6% at 40 months (respectively, p=0.003).Conclusions: The pre-procedural PDW may be an independent predictor of both in-hospital and long-term adverse outcomes in patients with ACS. [ABSTRACT FROM AUTHOR]

Background Adequate antiplatelet therapy in patients with myocardial infarction with ST-elevation (STEMI) is vital in order to avoid ischemic complications. However, especially with the novel potent oral drugs, bleeding is a major concern. We aimed to investigate whether STEMI patients switched to novel ADP receptor inhibitors due to high platelet reactivity (HPR) on clopidogrel have similar outcomes compared to patients with adequate response to clopidogrel. Methods A prospective cohort of 175 STEMI patients (mean age 62.3 years) undergoing primary PCI were included in the PASTOR study. Patients were loaded with 600 mg clopidogrel before the index PCI procedure. Bedside VerifyNow P2Y12 platelet function testing was performed the following morning. Results 46 patients (26.3%) were found to have HPR on clopidogrel (PRU > 235) and were switched to novel ADP receptor antagonists. The remaining 129 patients were treated with clopidogrel. The mean duration of dual antiplatelet therapy (DAPT) was 6.7 months. Duration of entire follow-up of patients was approximately 2 years. Major adverse cardiac events (MACE) while patients were on DAPT occurred in 7.0% in the clopidogrel group compared to 8.7% in the novel ADP receptor antagonist group (p = 0.70). No differences were observed between groups off-DAPT either. Conclusions Following primary PCI for STEMI, patients with adequate response to clopidogrel show similar outcomes compared to patients switched to novel ADP receptor antagonists due to HPR on clopidogrel. Platelet reactivity testing can be used to guide the choice of antiplatelet therapy in patients with STEMI treated by primary PCI. [ABSTRACT FROM AUTHOR]

Background Adenosine administered as an adjunct to reperfusion can reduce coronary no-reflow and limit myocardial infarct (MI) size in ST-segment elevation myocardial infarction (STEMI) patients. Whether adjunctive adenosine therapy can improve clinical outcomes in reperfused STEMI patients is not clear and is investigated in this meta-analysis of 13 randomized controlled trials (RCTs). Methods We performed an up-to-date search for all RCTs investigating adenosine as an adjunct to reperfusion in STEMI patients. We calculated pooled relative risks using a fixed-effect meta-analysis assessing the impact of adjunctive adenosine therapy on major clinical endpoint including all-cause mortality, non-fatal myocardial infarction, and heart failure. Surrogate markers of reperfusion were also analyzed. Results 13 RCTs (4273 STEMI patients) were identified and divided into 2 subgroups: intracoronary adenosine versus control (8 RCTs) and intravenous adenosine versus control (5 RCTs). In patients administered intracoronary adenosine, the incidence of heart failure was significantly lower (risk ratio [RR] 0.44 [95% CI 0.25–0.78], P = 0.005) and the incidence of coronary no-reflow was reduced (RR for TIMI flow<3 postreperfusion 0.68 [95% CI 0.47–0.99], P = 0.04). There was no difference in heart failure incidence in the intravenous adenosine group but most RCTs in this subgroup were from the thrombolysis era. There was no difference in non-fatal MI or all-cause mortality in both subgroups. Conclusion We find evidence of improved clinical outcome in terms of less heart failure in STEMI patients administered intracoronary adenosine as an adjunct to reperfusion. This finding will need to be confirmed in a large adequately powered prospective RCT. [ABSTRACT FROM AUTHOR]

Aims Initial thrombolysis in myocardial infarction (TIMI) flow and mortality are related in ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty (PPCI). It is unclear whether early adjunctive treatment with unfractionated heparin (UFH) is beneficial for coronary patency. We investigated the effect of UFH administered before transfer versus in the catheterization laboratory (CathLab) on initial patency of the infarct related artery (IRA) in transferred STEMI patients treated with PPCI. Methods and results Consecutive STEMI patients (n = 1326, February 2007–December 2013) were allocated in two groups relative to UFH administration: pre-transfer group — administration by ambulance crew or physician-in-charge at the non-PPCI centre, 758 patients (57%); post-transfer group — administration in the CathLab, 568 patients (43%). The time range between symptom onset (SO) and UFH administration (SO–UFH) was assessed and the 1-year mortality prediction was analysed by logistic regression. Initial IRA TIMI 2-3 flow was 30.3% in pre-transfer group vs. 21.2% in post-transfer group (p < 0.001). A time-dependent association was found between SO–UFH and initial TIMI 2-3 in pre- vs. post-transfer groups [< 120 min: 33.2% vs. 18%, p < 0.001; 120–240 min: 29.2% vs. 22.8%, p = 0.18; > 240 min: 25% vs. 28%, p = 0.57]. No differences in major bleeding were found between groups. UFH administration before transfer remained an independent predictor for initial TIMI 2-3 flow (OR 1.60 CI 95% 1.22–2.11, p = 0.01) and for 1-year mortality (OR 0.51 CI 95% 0.29–0.91, p = 0.02). Conclusions Early UFH administration in STEMI patients transferred for PPCI results in higher IRA initial patency in a time-dependent manner and improves clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective Chronic dysglycemia was recently identified as a predictor for adverse outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention. Data for non-diabetic patients who underwent thrombolysis is scarce. In this context, we aimed to study the effect of HbA1c on cardiovascular outcome after STEMI. Methods A prospective cohort of 326 non-diabetic STEMI individuals was used for the analyses. We measured plasma glucose, hemoglobin A 1c [HbA 1c ], lipid profile, C-reactive protein (CRP), and nitrate/nitrite (NOx) upon admission and five days after STEMI (D5). Flow-mediated dilation (FMD) was performed 30 days after STEMI. During clinical follow-up, we assessed patients for incident diabetes (progression to HbA1c ≥ 6.5%) and major adverse cardiac events (MACE), defined as a composite of fatal and non-fatal MI, sudden cardiac death, and angina requiring hospitalization. Results Using ROC-curve analysis, a 5.8% HbA1c best predicted MACE with a sensitivity of 75% and specificity of 53% (AUC 0.673, p = 0.001). Patients were categorized as high HbA1c if ≥ 5.8% and low HbA1c if <5.8%. Compared with patients with low HbA1c, those with high HbA1c presented with 20% higher CRP-D5 (p = 0.009) and 19% higher ΔCRP (p = 0.01), a 32% decrease in ΔNOx (p < 0.001), and 33% lower FMD (p < 0.001). After a median follow-up of 1.9 (1.1–2.8) years, patients with high HbA 1c had more incident diabetes (HR 2.3 95% CI 1.01–5.2; p = 0.048) and MACE (HR 3.32 95% CI 1.09–10.03; p = 0.03). Conclusion Non-diabetic STEMI patients with high HbA 1c present with decreased endothelial function and increased inflammatory response and long-term risk of MACE. [ABSTRACT FROM AUTHOR]

Background: Direct coronary stenting is a validated therapeutic option for coronary lesions. We studied the feasibility of direct deployment with a bioresorbable vascular scaffold (BVS) in acute coronary syndrome (ACS).Methods: Demographic, procedural, and survival data were obtained for patients who had direct scaffold deployment with BVS from 1 May 2013 to 1 April 2014.Results: We performed a retrospective review of nine patients which included eight patients having ST-elevation myocardial infarction. There were no cases of worsening coronary flow, scaffold thrombosis, target lesion revascularization or death up to 30 days post intervention.Conclusion: Direct BVS deployment in ACS appears safe and feasible. [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 Antithrombotic therapy for acute myocardial infarction (MI) with atrial fibrillation (AF) among higher risk older patients treated with percutaneous coronary intervention (PCI) remains unclear. Objectives This study sought to determine appropriate antithrombotic therapy for acute MI patients with AF treated with PCI. Methods We examined 4,959 patients ≥65 years of age with acute MI and AF who underwent coronary stenting (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). The primary effectiveness outcome was 2-year major adverse cardiac events (MACE) comprising death, readmission for MI, or stroke; the primary safety outcome was bleeding readmission. Outcomes with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus warfarin) were compared using Cox proportional hazard modeling with inverse probability-weighted propensity adjustment. Results Among 4,959 patients, 27.6% (n = 1,370) were discharged on triple therapy. Relative to DAPT, patients on triple therapy had a similar risk of MACE (adjusted hazard ratio [HR]: 0.99 [95% confidence interval (CI): 0.86 to 1.16]) but significantly greater risk of bleeding requiring hospitalization (adjusted HR: 1.61 [95% CI: 1.31 to 1.97]) and greater risk of intracranial hemorrhage (adjusted HR: 2.04 [95% CI: 1.25 to 3.34]). Of 1,591 Medicare Part D patients, 90-day post-discharge warfarin persistence among patients discharged on warfarin was 93.2% (n = 412). Results of 90-day landmark analyses comparing triple therapy versus DAPT in patients persistently on warfarin versus those not discharged on warfarin who had not filled a warfarin prescription were similar to our primary findings. Conclusions Approximately 1 in 4 older AF patients undergoing PCI for MI were discharged on triple therapy. Those receiving triple therapy versus DAPT had higher rates of major bleeding without a measurable difference in composite MI, death, or stroke. [ABSTRACT FROM AUTHOR]

Introduction There are conflicting data on patient characteristics and outcomes of myocardial infarction (MI) patients presenting with and without the symptom of chest pain. Objectives Compare the characteristics and survival of patients stratified by the symptom chest pain. Methods This retrospective cohort study identified patients with an emergency department discharge diagnosis of MI, who arrived by ambulance at a teaching hospital in Perth, Western Australia, between January 2008 to October 2009. The cohort was linked to hospital data and the state-based death register; clinical data were extracted by medical record review. Patient characteristics were compared using logistic regression models and survival analysis using Kaplan-Meier curves and Cox regression models. Results Of 382 patients, 26% presented without chest pain. The odds of presenting without chest pain were increased if aged 80+ (OR 7.54; 95%CI 2.81-20.3) and aged 70-79 years (OR 4.33; 95% CI 1.50-12.5), and female (OR 1.67; 95%CI 0.99-2.82). The adjusted hazard (median follow-up time 2.2 years) of presenting without chest pain was not significantly associated with survival (HR 1.03; 95%CI 0.71-1.48). Conclusion Characteristics differed between patients with and without chest pain. However, the symptom of chest pain was not associated with survival. [ABSTRACT FROM AUTHOR]

Aims This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT). Methods A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed. Results 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients’ baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001). Conclusion PMI as defined by the current Universal Definition using hsTnT is an independent predictor of adverse clinical outcome at 12 months in patients undergoing PCI. Accordingly, PMI remains a clinically relevant factor in current practice and should be considered a key outcome measure in clinical trials and a potential target for therapy. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Mild therapeutic hypothermia (TH) is standard of care after cardiac arrest of any cause. However, its impact on on-treatment platelet reactivity and clinical outcome in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock and undergoing PCI with P2Y12 receptor inhibitor treatment is less clear. METHODS AND RESULTS: For the ISAR-SHOCK registry, 145 patients with AMI, cardiogenic shock and primary PCI in two centers (Deutsches Herzzentrum München and Klinikum rechts der Isar, Technical University Munich) between January 2009-May 2012 were analysed. Of these, 64 (44%) patients received TH treatment. The median [IQR] ADP-induced platelet aggregation following thienopyridine loading dose administration (clopidogrel in 95 and prasugrel in 50 patients) did not differ between the two groups (419 [283-684] for TH vs. 355 [207-710] AU x min for non-TH patients, P=0.22). After 30days follow-up, no significant differences were observed between both groups for mortality (42 vs. 44 %, HR: 0.93, 95% CI [0.56-1.53], p=0.77), MI (6 vs. 6%, HR: 0.99 95% CI [0.27-3.7], p=0.99) and TIMI minor bleedings (17 vs. 17%, HR 0.99 95% CI [0.45-2.18], p=0.98). TIMI major bleedings were numerically higher in the TH vs. non-TH cohort (25 % vs. 12 %, HR: 2.1 95% CI [0.95-4.63], p=0.07). Three definite stent thrombosis (ST) were observed in this registry and all STs occurred in the TH group of patients (p=0.09). CONCLUSION: Results of this registry suggest that TH does not negatively impact on platelet reactivity in shock patients receiving either clopidogrel or prasugrel. The numerically higher rate of major bleedings and the clustering of STs in the TH cohort warrant further investigation. [ABSTRACT FROM AUTHOR]

Background/Purpose Stent thrombosis is an infrequent yet one of the most feared complications after stent implantation. Stent thrombosis most commonly manifests as ST-segment elevation myocardial infarction, thus the data regarding non-ST-segment elevation myocardial infarction (NSTEMI) resulting from stent thrombosis are still sparse. The aim of the study is to evaluate the prevalence and outcomes of NSTEMI resulting from stent thrombosis. Methods/Materials We performed a retrospective analysis of 378 consecutive NSTEMI patients who underwent coronary angiography. Patients were divided into those with and without stent thrombosis. The primary outcome was in-hospital mortality. Secondary outcome was the incidence of large myocardial infarction defined as a peak troponin I value greater than 90th percentile of the entire study population (26.5 μg/L). Results Among 378 patients with NSTEMI, 12 (3.2%) patients had angiographically confirmed definite stent thrombosis. With respect to the timing of stent thrombosis, 2 patients had early, 3 had late and 7 had very-late stent thrombosis. Patients with stent thrombosis had a higher incidence of large myocardial infarction (33% vs. 9%, p = 0.02) and a higher albeit statistically insignificant peak troponin value (interquartile, 4.62 [0.19–64.0] μg/L vs. 1.21 [0.14–7.12] μg/L, p = 0.25) compared to those without stent thrombosis. There was no significant difference in in-hospital mortality between the two groups (8% vs. 2%, p = 0.2). Conclusions Stent thrombosis accounted for 3.2% cases of NSTEMI in our cohort of patients and patients with NSTEMI resulting from stent thrombosis had a higher incidence of large myocardial infarction. [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]

The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). Multivariable logistic regression models evaluated the impact of stable angina on outcomes. Of 1,568 patients (median age 70 years; 35% women) with previous MI who underwent major noncardiac surgery, 5.5% had postoperative MI and/or cardiac arrest. Patients with history of preoperative angina had significantly greater incidence of primary outcome compared to those without anginal symptoms (8.4% vs 5%, p = 0.035). In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication. [ABSTRACT FROM AUTHOR]

Background There has been a decline in hospital length of stay (LOS) after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). Objectives The objective of this study was to examine whether shorter LOS is safe for older patients undergoing PPCI for STEMI. Methods The study analyzed patients’ characteristics and 30-day outcomes by LOS (short, ≤3 days; medium, 4 to 5 days; long >5 days; where LOS was the discharge date minus the admission date plus 1) among 33,920 patients with STEMI in the linked CathPCI Registry-Centers for Medicare & Medicaid Services dataset who were ≥65 years of age and treated with PPCI from 2004 to 2009. Results Percents of patients in each category were as follows: 26.9%, 46.3%, and 26.8% for short, medium, and long LOS, respectively. Patients with a long LOS were generally older, female, and had more comorbidities, including cardiogenic shock and multivessel disease. Patients with a short LOS generally had higher ejection fraction and single-vessel disease. There was no significant difference in 30-day all-cause mortality (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.74 to 1.34) or major adverse cardiac events (MACE) (death, readmission for myocardial infarction, unplanned revascularization: HR: 1.03; 95% CI: 0.86 to 1.25) for medium versus short LOS. There was a significant increase in adjusted mortality (HR: 2.30; 95% CI: 1.72 to 3.07) and MACE (HR: 1.75; 95% CI: 1.44 to 2.12) for long versus short LOS. Patients with a very short LOS (1 to 2 days) had significantly increased 30-day mortality and MACE compared with a 3- to 4-day LOS. Conclusions Patients discharged as early as 48 h after PPCI have outcomes similar to patients who stay in the hospital for 4 to 5 days. Early, but not very early (<48 h), discharge may be safe among selected older patients with STEMI. [ABSTRACT FROM AUTHOR]

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

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

Background The elderly (? 75 years) constitute a high-risk subset of patients who continue to have a poorer prognosis than non-elderly (< 75 years). Whether the effects of everolimus-eluting stent (EES) in ST-segment elevation myocardial infarction (STEMI) are independent of age has not been reported. We investigated the outcomes following primary PCI (PPCI) with bare-metal stent (BMS) or EES in elderly vs. non-elderly STEMI patients. Methods The EXAMINATION trial randomized 1498 STEMI patients to BMS or EES. The primary patient-oriented endpoint (POCE) was the combined of all-cause death, any-recurrent myocardial infarction (MI) and any-revascularization at 1-year. The secondary endpoint included the device-oriented combined (DOCE) of cardiac death, target-vessel MI and target-lesion revascularization. These endpoints and their components were compared between elderly and non-elderly. Results Among patients enrolled in the trial, 245 (16.3%) were elderly, allocated to BMS (n = 132) or EES (n = 113), while the remaining 1253 (83.7%) were non-elderly, allocated to BMS (n = 615) or EES (n = 638). At 1-year, both the POCE and DOCE were observed more frequently in elderly vs. non-elderly group (24.5% vs. 10.5%, p < 0.001 and 15.9% vs. 5.1%, p < 0.001). Whereas in non-elderly, both POCE and DOCE were lower in EES vs. BMS (12.4% vs. 8.8%, p = 0.03 and 6.7% vs. 3.6%, p = 0.01), no differences were found in elderly, with a tendency for interaction between age and stent type for POCE (p = 0.05). On multivariate analysis age ? 75 years was an independent predictor of POCE (HR 2.19 [95%CI 1.59-3.01], p < 0.0001) and DOCE (HR 2.42 [95%CI 1.60-3.7], p < 0.001) at 1-year. Conclusions In STEMI patients undergoing PPCI, advanced age (? 75 years) is associated with worse outcomes. The beneficial effects of EES over BMS tended to be age-dependent. [ABSTRACT FROM AUTHOR]

Background Few recent studies have compared the outcomes of coronary artery bypass graft (CABG) surgery with percutaneous coronary interventions (PCIs) in patients with isolated (single vessel) proximal left anterior descending (PLAD) coronary artery disease in the era of drug-eluting stents (DES). Objectives The goal of this study was to compare outcomes in patients with PLAD who underwent CABG and PCI with DES. Methods New York’s Percutaneous Coronary Interventions Reporting System was used to identify and track all patients who underwent CABG surgery and received DES for isolated PLAD disease between January 1, 2008 and December 31, 2010, and who were followed-up through December 31, 2011. A total of 5,340 of 6,064 (88%) patients received DES. Patients were matched to vital statistics data to obtain mortality after discharge and matched to New York’s administrative data to obtain readmissions for myocardial infarction (MI) and stroke. To minimize selection bias, patients were propensity matched into 715 CABG and/or DES pairs, and 3 outcome measures were compared across the pairs. Results Kaplan-Meier estimates for CABG and DES did not significantly differ for mortality or mortality, MI, and/or stroke, but repeat revascularization rates were lower for CABG (7.09% vs. 12.98%; p = 0.0007). After further adjustment with Cox proportional hazards models, there were still no significant differences in 3-year mortality rates (CABG and/or DES adjusted hazard ratio (AHR): 1.14; 95% confidence interval [CI]: 0.70 to 1.85) or mortality, MI, and/or stroke rates (AHR: 1.15; 95% CI: 0.76 to 1.73), and the repeat revascularization rate remained significantly lower for CABG patients (AHR: 0.54; 95% CI: 0.36 to 0.81). Conclusions Despite the higher rating in current guidelines of CABG (Class IIa vs. Class IIb) for patients with isolated PLAD disease, there were no differences in mortality or mortality, MI, and/or stroke, although CABG patients had significantly lower repeat revascularization rates. [ABSTRACT FROM AUTHOR]

Background: Data from multiple studies have shown the relationship between myocardial infarction (MI) and depressive disorders; however, most of these studies have focused only on one direction in evaluating the effect of depressive disorders on MI outcomes. This study analyzed data compiled from a large-scale dataset, the National Health Insurance Research Database, to determine whether a bidirectional relationship exists between MI and depressive disorders. Methods: A total of 3482 patients diagnosed with MI between 2002 and 2004 were included in analyzing the effects of MI on depressive disorders. A total of 26,418 patients diagnosed with depressive disorders between 2002 and 2004 were included in studying the effect of depressive disorders on MI. The comparison groups of both analyses were 4-fold larger than the case group. The Cox proportional hazard regression model was used to analyze the results. Results: The risk of MI patients developing depressive disorders was significantly higher (P < .001) than that of the comparison group, even after the data were adjusted for the variables of age, gender, income, region, and the Charlson Comorbidity Index. Conversely, the risk of patients with depressive disorders developing MI was not significantly higher than that of the comparison group after we controlled for covariates. Conclusion: The patients with MI exhibited a significantly higher risk of developing depressive disorders compared with the patients without MI. The results suggest that health providers should carefully manage the treatment offered for mental conditions and sensitively detect the psychological reactions of patients with MI. [ABSTRACT FROM AUTHOR]

Ischaemia−reperfusion (IR) injury is an important cause of myocardial damage during percutaneous coronary intervention (PCI). There are few therapies in widespread clinical use which impact on IR injury and it remains an important and underutilized target for treatment in acute myocardial infarction. This review will examine the translational scientific evidence for ischaemic conditioning and pharmacological agents including conditioning mimetics such as cyclosporine, anti-inflammatory agents, and those which modify myocardial glucose metabolism. We will address the reasons why many trials have failed to demonstrate clinical benefit and emphasize the need to deliver the right therapy to the right patient, at the right time to achieve successful translation of cardioprotection from bench-to-bedside. We critique trial design and offer advice for future translational trials in the field to ensure that effective treatments can be demonstrated clinically to improve patient outcomes during PCI. [ABSTRACT FROM AUTHOR]

Contrast-induced acute kidney injury (CI-AKI) is a serious complication that is difficult to predict in patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). The aim of this study was to investigate predictors and clinical out-comes of CI-AKI in patients with CKD after PCI. A total of 297 patients with CKD who underwent PCI from September 2006 to December 2011 were enrolled. CI-AKI was defined as serum creatinine level either ≥25% or ≥0.5 mg/dl from baseline within 72 hours after PCI. The primary outcome was all-cause death. The median follow-up duration was 26 months (interquartile range 12 to 40), and CI-AKI occurred in 55 patients (19%). In multivariate logistic regression analyses, the development of CI-AKI was associated with female gender, left ventricular systolic dysfunction, acute myocardial infarction, PCI for left main disease, serum hemoglobin level, and a contrast volume to creatinine clearance ratio >6.0. The development of CI-AKI was significantly associated with increased in-hospital mortality (18.2% vs 3.7%, p = 0.001). Cox proportional-hazard analysis showed that the incidence of all-cause death was significantly higher in patients who developed CI-AKI than in those without CI-AKI (41.8% vs 16.1%, adjusted hazard ratio 3.0, 95% confi-dence interval 1.6 to 5.6, p <0.001). In conclusion, female gender, left ventricular systolic dysfunction, acute myocardial infarction, PCI for left main disease, serum hemoglobin level, and contrast volume to creatinine clearance ratio >6.0 are independent predictors of CI-AKI. The development of CI-AKI is significantly associated with increased in-hospital and long-term adverse clinical outcomes in patients with CKD undergoing PCI. [ABSTRACT FROM AUTHOR]

This study was undertaken to assess the impact of acute hyperglycemia (acute-HG) and chronic hyperglycemia (chronic-HG) on short-term outcomes in patients with acute myocardial infarction (AMI). This study consisted of 696 patients with AMI. Acute-HG was defined as admission plasma glucose ≥200 mg/dl and chronic-HG as hemoglobin A1c ≥6.5%. Acute-HG was associated with higher peak serum creatine kinase (4,094 ± 4,594 vs 2,526 ± 2,227 IU/L, p <0.001) and in-hospital mortality (9.8% vs 1.6%, p <0.001). On the contrary, there was no significant difference in peak creatine kinase (2,803 ± 2,661 vs 2,940 ± 3,181 IU/L, p = 0.59) and mortality (3.3 vs 3.7%, p = 0.79) between patients with chronic-HG and those without. Multivariate analysis showed that admission plasma glucose was an independent predictor of in-hospital mortality (odds ratio 1.15, 95% con-fidence interval 1.05 to 1.27, p <0.001), but hemoglobin A1c was not. When only patients with acute-HG were analyzed, chronic-HG was associated with a significantly smaller infarct size (3,221 ± 3,001 vs 5,904 ± 6,473 IU/L, p <0.001) and lower in-hospital mortality (5.5 vs 18.9%, p = 0.01). In conclusion, these results suggested that acute-HG, but not chronic-HG, was associated with adverse short-term outcomes after AMI. Paradoxically, in patients with acute-HG, chronic-HG might abate the adverse effects of acute-HG. [ABSTRACT FROM AUTHOR]

Background Reconfiguration of the Irish Health Service has diverted of large numbers of acutely ill medical patients to a reduced number of hospitals and may have caused in delays in treatment. Although prompt care improves outcomes for patients with acute myocardial infarction, stroke, infection and shock, there is surprisingly little evidence for its value in other conditions. Methods The time of admission and time patients waited to be seen and clerked by a doctor was reviewed on all medical patients admitted to Nenagh Hospital prior to service reconfiguration (i.e. from 17 February 2000 to 6 March 2004). Results Over the study period of 1442, days 9435 patients were admitted (i.e. 6.5 patients per day or 0.3 per hour) and waited 37.6 SD 53.1 min after admission before they were seen by a doctor. The peak time of admission is in the late afternoon and early evening and there was a liner correlation between the delay before seeing a doctor and the time of admission. The 1095 patients who waited 80 min or more to be seen and clerked by a doctor (median delay 120 min) were more likely to die (odds ratio 1.36 95% CI 1.03–1.81, p < 0.03). Conclusion Waiting to be seen by a doctor may increase the risk of death to some patients. For these patients it is probably safer to be seen quickly by any doctor, rather than travel many miles and wait several hours to see a better one. [ABSTRACT FROM AUTHOR]

Background Immature platelets are less responsive to the effects of antiplatelet drugs and contain messenger ribonucleic acid that is translationally active. They can be measured easily using an automated hematoanalyzer and reported as part of the complete blood count. Objectives The purpose of this study was to determine the prognostic significance of elevated immature platelet count (IPC) in patients with coronary artery disease (CAD). Methods In this prospective cohort study in patients with CAD, patients underwent IPC measurement and were then followed up for the composite endpoint of major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, myocardial infarction, unplanned revascularization, or hospitalization for angina. For the purposes of analysis, patients were stratified into tertiles of IPC. Results Eighty-nine patients were followed up for a median of 31 months. Stratification to the high IPC tertile was associated with higher rates of MACE compared with the intermediate and low tertiles (60% vs. 24% vs. 16%, respectively; p < 0.001). Time-dependent receiver-operating characteristic analysis revealed that an IPC level ≥7,632 platelets/μl was 70.7% sensitive and 82.1% specific for MACE. After adjustment for age, admission diagnosis, index revascularization, heart failure, smoking, hematocrit, and baseline platelet count, patients with an IPC level ≥7,632 platelets/μl were more likely to experience a MACE (hazard ratio: 4.65; 95% confidence interval: 1.78 to 12.16; p < 0.002). Conclusions IPC is a novel biomarker for MACE risk stratification in patients with CAD. Future studies should focus on the utilization of this marker for individualized antiplatelet therapy. [ABSTRACT FROM AUTHOR]

Background Improved early outcome in non-ST elevation myocardial infarction (NSTEMI) patients has been mainly attributed to a broader use of invasive strategies. Little is known about the impact of other changes in early management. Methods We aimed to assess 15-year trends in one-year mortality and their determinants in NSTEMI patients. We used data from 4 one-month French registries, conducted 5 years apart from 1995 to 2010 including 3903 NSTEMI patients admitted to intensive care units. Results From 1995 to 2010, no major change was observed in patient characteristics, while therapeutic management evolved considerably. Early use of antiplatelet agents, β-blockers, ACE-inhibitors and statins increased over time (P < 0.001); use of newer anticoagulants (low-molecular-weight heparin, bivalirudin or fondaparinux) increased from 40.8% in 2000 to 78.9% in 2010 (P < 0.001); percutaneous coronary intervention (PCI) ≤ 3 days of admission rose from 7.6% to 48.1% (P < 0.001). One-year death decreased from 20% to 9.8% (HR adjusted for baseline parameters, 2010 vs. 1995 = 0.47, 95% CI: 0.35-0.62). Early PCI (HR = 0.67; 95% CI: 0.49-0.90), use of newer anticoagulants (HR = 0.62; 95% CI: 0.48-0.78) and early use of evidence based medical therapy (HR = 0.54; 95% CI: 0.40-0.72) were predictors of improved one year-survival. Conclusions One-year mortality of NSTEMI patients decreased by 50% in the past 15 years. Our data support current guidelines recommending early invasive strategies and use of newer anticoagulants for NSTEMI, and also show a strong positive association between early use of appropriate medical therapies and one-year survival, suggesting that these medications should be used from the start. [ABSTRACT FROM AUTHOR]

Background Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) improved outcomes compared with an angiography-guided strategy in patients with multivessel coronary artery disease (CAD). However, the effect of age on FFR has not been well-studied. We aimed to evaluate the impact of age on the favorable results of routine FFR-guided PCI for multivessel CAD. Methods We compared 1 year outcomes between FFR-guided PCI and angiography-guided PCI in the 512 patients enrolled in the FAME study < 65 years old compared to the 493 patients ≥ 65 years old. We also evaluated the effect of age on the FFR result of varying degrees of visually estimated coronary stenosis. Results The 1-year rate of death, myocardial infarction or repeat revascularization in the angiography-guided group tended to be higher than in the FFR-guided group for both those patients < 65 (17.2% vs. 12.0%, P = 0.098) and those ≥ 65 years old (19.7% vs. 14.3%, P = 0.111) with no significant interaction based on age (P = 0.920). Older patients had higher FFR in vessels with 50% to 70% stenosis (0.83 ± 0.11 vs. 0.80 ± 0.13, P = 0.028) and in vessels with 71% to 90% stenosis (0.69 ± 0.15 vs. 0.65 ± 0.16, P = 0.002). The proportion of functionally significant lesions (FFR ≤ 0.80) in vessels with 71% to 90% stenosis was significantly lower in elderly compared to younger patients (75.3% vs. 84.1%, P = 0.013). Conclusions FFR-guided PCI is beneficial regardless of age, however, older patients have fewer functionally significant lesions, despite a similar angiographic appearance. [ABSTRACT FROM AUTHOR]

High RDW values are associated with adverse prognosis in many clinical conditions including short and medium term outcome of patients with ST Elevation Myocardial Infarction (STEMI). The aim of the present study was to evaluate the association between RDW and long term mortality in STEMI patients undergoing primary angioplasty (PPCI). Material and methods A cohort of 535 STEMI patients undergoing PPCI were divided into two groups (RDW 14%, RDW↜14%) using CHAID and CART methods. The association between RDW and 5-year all-cause mortality was assessed using Cox's proportional hazards analysis. Results A total of 37 patients died during follow up of 5years (mean: 1059, median: 1013, range 2-2130 days). RDW 14% was associated with increased risk of all-cause mortality (HR=5, CI 95% 2.7- 9.9, p<0.001). In multivariate analysis, RDW>14 remained significantly associated with increased risk for all-cause mortality (HR=3.8, CI 95% 1.8- 7.99, p<0.001). Patients with RDW above 14% did not have lower ejection fraction, higher CPK or more conventional risk factors. Conclusion RDW value above 14 is independently associated with increased long term all-cause mortality in patients with STEMI undergoing PPCI. [ABSTRACT FROM AUTHOR]

As an inducible isoform of heme oxygenase (HO), HO-1 was suggested to have an anti-oxidative stress, anti-inflammatory, anti-apoptotic and anti-proliferative effect. It was regarded as an important cytoprotective enzyme. We undertook this study to investigate whether HO-1 gene rs2071746 polymorphism was associated with clinical outcomes in atherosclerosis ischemic stroke patients. Between December 2009 and October 2012, consecutive atherosclerosis ischemic stroke patients were enrolled. The primary endpoint was the composite of vascular death, nonfatal ischemic stroke and myocardial infarct. A total of 961 patients were enrolled. After an average follow-up of 15.13 (SD = 7.42) months, 89 patients (9.26%) had the primary endpoint. The cumulative incidence of the primary endpoint was significantly lower in A carriers (AT + AA) than TT genotype (7.9% vs. 12.2%, HR = 0.648, 95% CI: 0.425-0.988, P = 0.044). After adjustment for age, sex and other cardiovascular risk factors, we found that A carrier was an independent protective factor for atherosclerosis ischemic stroke (HR = 0.646, 95% CI: 0.420-0.994, P = 0.047). Age (HR = 1.023, P = 0.028) and low level of HDL (HR = 1.772, P = 0.012) were independent risk factors for the primary endpoint. In conclusion, HO-1 gene rs2071746 A allele carrier might be a protective factor for patients with atherosclerotic stroke. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) frequently coexists in the setting of myocardial infarction (MI), being associated with increased mortality. Nonetheless, temporal trends in the occurrence of AF complicating MI and in the prognosis of these patients are not well described. We examined temporal trends in prevalence of AF in the setting of MI and the effect of AF on prognosis in the community. We studied a population-based sample of 20,049 validated first-incident nonfatal hospitalized MIs among 35- to 74-year old residents of 4 communities in the Atherosclerosis Risk in Communities (ARIC) Study from 1987 through 2009. Prevalence of AF in the setting of MI increased from 11% to 15% during the 23-year study period. The multivariable adjusted odds ratio for prevalent AF, per 5-year increment, was 1.11 (95% confidence interval 1.04 to 1.19). Overall, in patients with MI, AF was associated with increased 1-year case fatality (odds ratio 1.47, 95% confidence interval 1.07 to 2.01) compared with those without AF. However, there was no evidence that the impact of AF on MI survival changed over time or differed over time by sex, race, or MI classification (all p values >0.10). In conclusion, co-occurrence of AF in MI slightly increased between 1987 and 2009. The adverse impact of AF on survival in the setting of MI was consistent throughout. In the setting of MI, co-occurrence of AF should be viewed as a critical clinical event, and treatment needs unique to this population should be explored further. [ABSTRACT FROM AUTHOR]

Background Myocardial bridging (MB) is mostly confined to the left anterior descending coronary artery (LAD) and has been reported to be correlated with increased atherosclerotic plaques in the segment proximal to the bridging. This study aimed to assess the impact of MB on the clinical outcomes of patients with DES implantation in the LAD. Methods A total of 551 consecutive patients with DES implantation on LAD from January 2008 to December 2009 were included. Patients were divided into an MB group (n=94, 17.1%) and a non-MB group (n=457, 82.9%) based on angiographic findings. They were followed up for three years to evaluate major adverse cardiac events (MACE), which were defined as all-cause death, myocardial infarction (MI), target lesion revascularisation (TLR) or ischaemic driven target vessel revascularisation (Id-TVR). Results During three years of follow-up, the rate of MACE was significantly higher in the MB group than in the non-MB group (18.1% vs. 9.8%, p=0.024), especially rates of TLR (8.5% vs. 2.4%; p=0.003) and Id-TVR (13.8% vs. 4.2%; p<0.001). However, no difference was observed for MI (3.2 vs. 2.6%; p=0.692) and all-cause death rates (3.2 vs. 4.6%; p=0.575). Multivariate regression analysis showed that the presence of MB was an independent predictor for MACE (Hazard ratio 2.897, 95% CI 1.536 - 5.464, p=0.001). Conclusion MB appears to be associated with adverse effects in patients with DES implantation in the LAD. [ABSTRACT FROM AUTHOR]

Objective Anti-anxiety medication in patients with anxiety may lessen the stress and thereby lower their risk for myocardial infarction (MI). The aim of current study is to examine an association between the use of anti-anxiety medication and long-term mortality risk in patients following MI. Methods A universal national health insurance (NHI) program has been implemented in Taiwan since 1995. We used system sampling database from 1997 to 2008 with a total of 1,000,000 subjects. We included subjects with first episode of MI and were above 30 years old. Sudden death, cardiovascular mortality, and heart failure hospitalization were assessed in all included subjects. Anti-anxiety as well as other medications and risk factors were obtained. Cox regression analysis was used to evaluate the adjusted hazard ratio (HR) for all patients and subgroups. Results The adjusted HRs of sudden death were significantly associated with increased benzodiazepam (BZD) dosage (HRs = 0.639, 1.003, 1.957 from Q2 to Q4 vs. Q1, p = .019 for trend) during approximately 4.8 years. For cardiac mortality and heart failure hospitalization, there was a J-curve dose-response relationship. The HRs for cardiac mortality were 0.255 (p < .001) and 0.385 (p < .001) for Q2 and Q3 vs. Q1, respectively. For patients receiving higher doses of daily BZDs (>5 mg), protective effects for cardiac mortality and heart failure hospitalization decreased and a J-curve dose-response relationship was seen. Conclusion Anti-anxiety medications are independent associated with a decreased risk of cardiac mortality and heart failure hospitalization in patients after a new MI. [ABSTRACT FROM AUTHOR]

Background The effectiveness of beta-blockers for preventing cardiac events has been questioned for patients who have coronary heart disease (CHD) without a prior myocardial infarction (MI). Objectives The purpose of this study was to assess the association of beta-blockers with outcomes among patients with new-onset CHD. Methods We studied consecutive patients discharged after the first CHD event (acute coronary syndrome or coronary revascularization) between 2000 and 2008 in an integrated healthcare delivery system who did not use beta-blockers in the year before entry. We used time-varying Cox regression models to determine the hazard ratio (HR) associated with beta-blocker treatment and used treatment-by-covariate interaction tests (pint) to determine whether the association differed for patients with or without a recent MI. Results A total of 26,793 patients were included, 19,843 of whom initiated beta-blocker treatment within 7 days of discharge from their initial CHD event. Over an average of 3.7 years of follow-up, 6,968 patients had an MI or died. Use of beta-blockers was associated with an adjusted HR for mortality of 0.90 (95% confidence limits [CL]: 0.84 to 0.96), and an adjusted HR for death or MI of 0.92 (CL: 0.87 to 0.97). The association between beta-blockers and outcomes differed significantly between patients with and without a recent MI (HR for death: 0.85 vs. 1.02, pint = 0.007; and HR for death or MI: 0.87 vs. 1.03, pint = 0.005). Conclusions Use of beta-blockers among patients with new-onset CHD was associated with a lower risk of cardiac events only among patients with a recent MI. [ABSTRACT FROM AUTHOR]

We evaluated the relation between reperfusion indexes and right ventricular (RV) dysfunction in patients with inferior ST-segment elevation myocardial infarction (STEMI). We included patients with inferior STEMI undergoing percutaneous coronary intervention and right coronary artery as infarct-related artery. Myocardial reperfusion was evaluated by Thrombolysis In Myocardial Infarction (TIMI) flow, TIMI frame count, myocardial blush grade, and STsegment resolution. RV dysfunction was defined as tricuspid annular plane systolic excursion ≤16 mm in M-mode imaging. RV dysfunction was present in 58 of 141 patients (41.1%) and was more frequent in patients achieving suboptimal postprocedural TIMI flow grade (66.7% vs 36.7%, grades 0 to 2 vs 3, p = 0.01), TIMI frame count (63.2% vs 37.7%, 40 vs <40 frames, p = 0.04), and myocardial blush grade (33.3% vs 56.2%, grade 0 or 1 vs 2 or 3, p = 0.001). RV dysfunction rates did not differ according to ST-segment resolution. Patients with RV dysfunction had increased rates of cardiac death (13.2% vs 2.6%, p = 0.03), reinfarction (24.5% vs 10.3%, p = 0.03), and stent thrombosis (22.6% vs 6.4%, p = 0.01) at 2-year follow-up. Postprocedural TIMI flow grade 3 (odds ratio 0.25, 95% confidence interval 0.09 to 0.68, p = 0.007) was the only reperfusion correlate of RV dysfunction at multivariate analysis. In an independent cohort of 84 patients with STEMI, postprocedural TIMI flow grade 3 had a limited sensitivity (52%), with a high specificity (74.5%) and negative predictive value (71%) for excluding RV dysfunction. In conclusion, in patients with inferior STEMI undergoing coronary revascularization, RV dysfunction is associated with a worse long-term prognosis. Postprocedural TIMI flow grade may be a useful tool to predict RV dysfunction. [ABSTRACT FROM AUTHOR]