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Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex differences in care remains unclear. The purpose of this study was to evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. The implementation of a uniform rule-out threshold (<5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from the emergency department and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients were stratified as low-risk compared with uniform threshold. In 16,792 patients (age 58 ± 17 years; 46% female) care was guided using a uniform threshold. This identified more female than male patients as low risk (73% vs 62%), but a similar proportion of low-risk patients were discharged from the emergency department (81% for both) with fewer than 5 (<0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared with a uniform threshold of <5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% vs 65.9%) and reduce the proportion of male (54.8% vs 47.8%) patients identified as low risk. Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited. [Display omitted] [ABSTRACT FROM AUTHOR]

There are concerns about the potential effect of social distancing used to control COVID-19 on the incidence of cardiovascular diseases (CVD). Retrospective cohort study. We examined the association between lockdown and CVD incidence in a Zero-COVID country, New Caledonia. Inclusion criteria were defined by a positive troponin sample during hospitalization. The study period lasted for 2 months, starting March 20, 2020 (strict lockdown: first month; loose lockdown: second month) compared with the same period of the three previous years to calculate incidence ratio (IR). Demographic characteristics and main CVD diagnoses were collected. The primary endpoint was the change in incidence of hospital admission with CVD during lockdown compared with the historical counterpart. The secondary endpoint included influence of strict lockdown, change in incidence of the primary endpoint by disease, and outcome incidences (intubation or death) analyzed with inverse probability weighting method. A total of 1215 patients were included: 264 in 2020 vs 317 (average of the historical period). CVD hospitalizations were reduced during strict lockdown (IR 0.71 [0.58–0.88]), but not during loose lockdown (IR 0.94 [0.78–1.12]). The incidence of acute coronary syndromes was similar in both periods. The incidence of acute decompensated heart failure was reduced during strict lockdown (IR 0.42 [0.24–0.73]), followed by a rebound (IR 1.42 [1–1.98]). There was no association between lockdown and short-term outcomes. Our study showed that lockdown was associated with a striking reduction in CVD hospitalizations, independently from viral spread, and a rebound of acute decompensated heart failure hospitalizations during looser lockdown. [ABSTRACT FROM AUTHOR]

There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. We created a longitudinal cohort (2006–2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75–2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78–1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23–1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26–2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62–2.61, P < 0.001) were higher in women compared with men. Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients. • Limited data about clinical profile and outcomes of CTO PCI stratified by sex • In current study, women observed adjusted higher odds of procedural complications but similar odds of death & MACCE compared with men • Randomised control trial data are needed to validate these observational study findings. [ABSTRACT FROM AUTHOR]

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]

Background: Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.Objectives: This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.Methods: The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.Results: We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.Conclusions: Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703). [ABSTRACT FROM AUTHOR]

Background: Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery lesions. Diabetic patients are associated with high burden of atherosclerosis and microvascular dysfunction. We studied the clinical outcomes of diabetic patients who underwent FFR-guided deferred revascularisation.Methods: Consecutive patients from a single large volume centre who underwent FFR assessment were included. Clinical endpoints were prospectively collected using the national electronic care records system. The primary endpoint was defined as the four-year risk of the vessel-oriented composite outcome of cardiac death, vessel-related myocardial infarction (VMI), and vessel-related urgent revascularisation (VUR). Absolute FFR values groups (0.81 to 0.85; 0.86 to 0.90; and >0.90) were used to further stratify patient outcomes.Results: FFR-guided deferred revascularisation occurred in 860 patients (63%), of whom 159 were diabetic. The primary endpoint was significantly higher in the diabetic compared to the non-diabetic group [HR 1.76 (95%CI 1.08 to 2.88), P = 0.024]. The difference was driven from cardiac death (6.3% vs. 3.0%, P = 0.044) and VMI (5.0% vs. 1.7%, P = 0.012) but not VUR (8.8% vs. 5.1%, P = 0.07). There was a significant decrease in the incidence of the primary endpoint in the diabetic group according to FFR groups (23.6%, 12.3%, 2.4%, P = 0.001) with comparable clinical outcomes in the non-diabetic group (11.8%, 6.4%, 7.4%, P = 0.085).Conclusions: Our study demonstrated an increased risk of death and target vessel MI in diabetic patients undergoing FFR-guided deferred revascularisation compared to non-diabetic group. Nonetheless, FFR remained a useful tool to identify those at future risk, mainly in diabetic patients. [ABSTRACT FROM AUTHOR]

Background: Systems of care have been established to ensure patients with ST-elevation myocardial infarction (STEMI) get timely access to primary percutaneous coronary intervention (PPCI). In this study, we evaluated whether patients undergoing PPCI both in-hours and out-of-hours experience similar care and clinical outcomes.Methods: Of 9,865 patients who underwent PCI for STEMI from 2005 to 2016 and were enrolled in the multi-centre Melbourne Interventional Group registry, patients who had initially presented to a non-PCI capable hospital, received thrombolysis or presented >12hourspost-symptom onset were excluded. Our final study cohort of 4,590 patients were dichotomised by whether PPCI was performed in-hours or out-of-hours, and compared. The primary outcome was 30-day mortality.Results: The in-hours group included 1,865 patients (40.6%) while 2,725 patients (59.4%) had out-of-hours PPCI. Patients presenting out-of-hours had longer median door-to-balloon time (DTBT; 83 [IQR 61-109] vs. 60 [IQR 41-88] mins, p<0.01) and were more likely to receive a drug-eluting stent (p=0.001). Procedural characteristics were otherwise similar although rates of radial access were low overall (18.4%). No differences in in-hospital, 30-day or 12-month mortality were observed between the groups (p=NS). On Cox proportional hazards modelling, out-of-hours presentation was not an independent predictor of 30-day mortality (HR 0.94, 95% CI 0.71-1.22). A landmark analysis of data from 2012 did not change the primary outcome.Conclusion: Despite a slightly longer DTBT, patients undergoing PPCI out-of-hours experienced similar care and clinical outcomes to the in-hours group. Given the majority of patients with STEMI present out-of-hours, these data have implications for STEMI systems of care. [ABSTRACT FROM AUTHOR]

Background: Few studies describe recent changes in the incidence, treatment and outcome of successfully resuscitated STEMI patients after out-of-hospital cardiac arrest (OHCA) compared with non-OHCA STEMI patients.Objective: To examine temporal trends in the incidence, therapeutic management, most serious complications, mortality rate and outcome of OHCA patients fulfilling criteria of STEMI compared with a reference group of STEMI patients without OHCA.Methods: Analysis of registry data (AMIS Plus Registry) among STEMI patients both with and without OHCA between 1997 and 2017.Results: Among 31,650 patients with STEMI, 6.8% were successfully resuscitated prior to hospital admission. Increasing incidences of hospital-admitted patients following successful out-of-hospital CPR were observed (4.5% in 1999 vs. 8.6% in 2017). OHCA STEMI patients were at higher clinical risk at presentation (36.1% vs. 2.7%; p < 0.001 with cardiogenic shock) despite a shorter time span from the onset of symptoms to hospitalization (195 min vs. 107 min; p < 0.001) and a lower prevalence of cardiovascular risk factors except smoking. More PCIs were performed in STEMI patients with OHCA (78.9% vs. 74.5% for non-OHCA patients; p < 0.001). However, over time PCI became the preferred primary intervention irrespective of the OHCA status of STEMI patients. For STEMI patients without OHCA, there was a significant correlation between PCI and time periods on in-hospital mortality (p < 0.001), which was p = 0.002 when adjusted for age and gender. For STEMI patients with OHCA, the interaction between PCI and time was unadjusted p = 0.395 and p = 0.438 when adjusted for age and gender. [ABSTRACT FROM AUTHOR]

Abstract Aims Recent genome-wide association studies (GWAS) have identified several single nucleotide polymorphisms (SNPs) that were associated with blood lipid levels in Europeans. However, little is known about such association in the Chinese populations. The present study was to determine the association of lipid levels susceptibility loci with the risk of China myocardial infarction (MI) patients. Methods A total of 401 patients with MI and 409 controls were included in the study. Five SNPs (including HNF1A rs1169286 and rs2244608, C12orf43 rs2258287, LIPA rs2246833 and TRPS1 rs2293889) were selected using a tagging single nucleotide polymorphism (tSNP) strategy. The SNP genotyping work was performed using an improved multiplex ligation detection reaction (iMLDR) technique. Results The subjects with rs1169286 CT genotype in MI cases had lower FBG levels than the subjects with rs1169286 CC/TT genotypes (P = 0.002). The subjects with rs2246833 TT genotype in MI patients had higher LDL-C levels than the subjects with rs2246833 CC/CT genotypes (P = 0.006). Several SNPs interacted with sex and age to modify TC, TG, LDL-C, CRE and FBG levels, and the risk of MI (P < 0.01 for all). However, our results disclosed no association between the SNPs and susceptibility to MI (P > 0.05 for all). Conclusions Taken together, this study provides additional evidence that functional genetic variation of the lipid related mutations can mediate atherogenic processes and the risk of MI in humans. Highlights • 810 participants, including 401 MI patients and 409 control subjects from China • Those with rs1169286 CT genotype in MI cases had lower FBG levels than those with rs1169286 CC/TT genotypes (P =0.002). • Those with rs2246833 TT genotype in MI cases had higher LDL-C levels than those with rs2246833 CC/CT genotypes (P =0.006). • Several SNPs (rs1169286, rs2244608, rs2258287 and rs2246833) interacted with age to influence TC, TG and LDL-C levels. • Several SNPs interacted with sex to modulate CRE (rs1169286, rs2244608 and rs2293889) and FBG (rs2293889) levels. • The SNP of rs2258287 interacted with hypertension to influence TG levels. [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]

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

Abstract Background Left Anterior Fascicular Block (LAFB) occurs frequently among the elderly, and have a correlation with coronary artery disease (CAD), yet controversies regarding its clinical significance still remain. Methods We carried on a retrospective study involving 92 LAFB and 478 non-LAFB patients, in which anatomic, clinical and electrocardiographic characteristics were compared. Results LAFB subjects had more pathological CAD (66.3% vs 54.6%, P = 0.039), myocardial infarction (MI) (53.3% vs 37.9%, P = 0.007) and myocarditis (5.4% vs 1.7%, P = 0.043). Among the LAFB group, 58.1% of patients with CAD and 30.2% of patients with MI were clinically misdiagnosed, while 42.9% of patients with MI were clinically missed. Logistic regression showed CAD had no independent relevance with LAFB. LAFB subjects displayed heavier hearts [(451.1 ± 101.3)g vs (407.1 ± 102.3)g, P < 0.001], thicker left ventricular walls [(1.6 ± 0.4)cm vs (1.4 ± 0.3)cm, P = 0.001]. Kaplan-Meier survival analysis indicated significant differences in long-term survival time (χ2 = 12.223, P < 0.001) and cardiac mortality (χ2 = 20.982, P < 0.001) between LAFB and non-LAFB group. Cox multivariate analysis demonstrated LAFB was an independent risk factor of all-cause death (HR = 1.552, 95% CI = 1.208–1.994, P = 0.001) and cardiac death (HR = 2.287, 95% CI = 1.545–3.386, P < 0.001). The major death cause of LAFB was cardiac death (46.7%), including more MI (28.3% vs 13.4%, P = 0.008), myocarditis (4.3% vs 1.0%, P = 0.042) and cardiac rupture (6.7% vs 1.9%, P = 0.022). Conclusions LAFB subjects had more pathological CAD and MI, but LAFB was not an independent relevant factor of CAD. LAFB lowered the accuracy to clinically diagnose CAD. LAFB patients gained heavier hearts, thicker left ventricular walls, and suffered increased risk of death and cardiac death. Highlights • Left anterior fascicular block (LAFB) increased all-cause death and cardiac death. • LAFB was not independently relevant with coronary artery disease (CAD). • LAFB lowered the accuracy to clinically diagnose CAD. • LAFB patients had greater heart mass and more left ventricle hypertrophy. • The CAD, cardiac structure and death cause were determined precisely by autopsy. [ABSTRACT FROM AUTHOR]

Background Elevated triglyceride to high density lipoprotein cholesterol (TG/HDL-C) ratio has been identified as a surrogate marker of insulin resistance and an independent predictor for cardiovascular events in the general population. However, the prognostic value of TG/HDL-C ratio in revascularized ST-elevation myocardial infarction(STEMI) patients remains unclear. We examined the association between TG/HDL-C ratio and clinical outcome of revascularized STEMI patients in the Chinese population. Methods 464 STEMI patients who underwent successful revascularization were enrolled to determine the relationship between TG/HDL-C ratio and major adverse coronary events(MACEs) with a 30-month follow-up. The Kaplan-Meier analysis and Cox regression proportional hazard model were applied to assess the prognostic value of TG/HDL-C ratio. Results TG/HDL-C ratio was found to be significantly associated with age (p = 0.017), history of diabetes(p = 0.017), heart rate(p = 0.011), TG(p < 0.001), HDL-C(p < 0.001) and Gensini score(p = 0.034). The multivariate Cox regression analysis revealed that elevated TG/HDL-C ratio was an independent prognostic factor for MACE in female patients (HR = 2.624,95%CI = 1.211–5.687,p = 0.014) but not in male patients(HR = 0.756, 95%CI = 0.484–1.179,p = NS) after adjustment with other MACE-related prognostic factors. Conclusion The TG/HDL-C ratio may be independently associated with MACEs in female revascularized STEMI patients in the Chinese population. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that some patient groups suffer adverse outcomes if they are acutely admitted to hospital over a weekend. We aimed to investigate this 'weekend effect' at our centre in patients presenting with a hip fracture.Methods: Consecutive patients undergoing acute hip fracture surgery were identified from a prospective database. Patient demographics, co-morbidities, fracture type, admission blood parameters were examined. Outcomes analysed included 30-day, 90-day and 1-year mortality as well as length of stay, re-operations and delay to surgery. The data were analysed with regards to day of admission and day of surgery separately.Results: A total of 1326 patients were included, of which 368 patients were admitted over a weekend and 411 patients had their operation over a weekend. Overall 30-day mortality was 7.6% (101 patients), whilst the 90-day and 1-year mortalities were 15.3% and 26.8% (203 and 356 patients). There were no significant differences in any of the outcomes based on the day of admission or the day of surgery. Multivariate analysis for 30-day mortality demonstrated the following variables to be significant predictors: admission urea levels (hazard ratio (HR) 1.042, p = 0.027), age (HR 1.058, p < 0.001), admission source (HR 1.428, p < 0.001), surgical delay >48 h (HR 1.853, p = 0.004), male gender (HR 1.967, p = 0.003), previous stroke (HR 2.261, p = 0.038), acute chest infection (4.240, p < 0.001) and chronic liver disease (HR 4.581, p = 0.014).Conclusion: This data suggests that there is no significant weekend effect in hip fracture surgery and mortality is affected by patient co-morbidities and delay to surgery. [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: Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease.Objectives: This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI.Methods: Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI.Results: Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74).Conclusions: Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients. [ABSTRACT FROM AUTHOR]

Background: Severe chronic kidney disease (CKD) predicts adverse outcomes in patients undergoing pancreatectomy, but the impact of milder CKD is unknown. Additionally, some authors have suggested that, due to physiologic changes of aging, CKD is over-diagnosed in patients above age 65.Methods: Patients undergoing pancreatectomy for malignancy from 2005 to 2014 were identified from the National Surgical Quality Improvement Program. Primary outcomes were all-cause mortality and major complication, defined as myocardial infarction, cardiac arrest, stroke, venous thromboembolism, respiratory failure, deep surgical site infection, pneumonia, acute kidney injury, coma > 24 h, or re-operation occurring within 30 days of surgery.Results: The mean age of 16,173 participants was 66 (range 18-90). Median preoperative creatinine was 0.80 mg/dL (0.10-11.0), and median preoperative eGFR was 86.36 mL/min/1.73m2 (2.98-182.2). Mortality and major complication occurred in 3 and 23% of patients, respectively. In adjusted analyses, CKD stages 2 (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.10-1.40), 3a (aOR 1.50, 95% CI 1.24-1.82), 3b (aOR 1.56, 95% CI 1.19-2.06), and 4 (aOR 2.17, 95% CI 1.25-3.76) were associated with increased major complication, and CKD stage 4 was associated with increased mortality (aOR 2.68, 95% CI 1.10-6.56). Age did not influence the relationship between CKD and either outcome.Conclusion: CKD of any stage was associated with an increased risk of postoperative major complication, and severe CKD was associated with increased mortality among patients undergoing pancreatectomy for malignancy. These associations were not diminished in elderly patients. Our findings could inform preoperative counseling and decision-making. [ABSTRACT FROM AUTHOR]

Sepsis-induced myocardial dysfunction represents a major cause of death. Alamandine is an important biologically active peptide. The present study evaluated whether alamandine improves cardiac dysfunction, inflammation, and apoptosis, and affects the signaling pathways involved in these events. Experiments were carried out in mice treated with lipopolysaccharide (LPS) or alamandine, and in neonatal rat cardiomyocytes. Alamandine increased the ejection fraction and fractional shortening, both of which were decreased upon LPS infusion in mice. LPS and alamandine reduced blood pressure, and increased the expression of inducible nitric oxide synthase (iNOS) and endothelial NOS (eNOS) in the heart in mice. The LPS-induced decrease in α-myosin heavy chain (MHC) and β-MHC, and increase in S100 calcium binding protein A8 (S100A8) and S100A9, were reversed by alamandine pre-treatment. Alamandine pre-treatment prevented LPS-induced myocardial inflammation, apoptosis and autophagy. LPS increased p-ERK, p-JNK, and p-p38 levels, which were inhibited by alamandine. Dibutyryl cyclic AMP (db-cAMP) increased p-ERK, p-JNK, and p-p38 levels, and reversed the inhibitory effects of alamandine on the LPS-induced increase in p-ERK, p-JNK, and p-p38. Moreover, db-cAMP reduced the expression of α-MHC and β-MHC in cardiomyocytes, and reversed the almandine-induced attenuation of the LPS-induced decrease in α-MHC and β-MHC. These results indicate that alamandine attenuates LPS-induced cardiac dysfunction, resulting in increased cardiac contractility, and reduced inflammation, autophagy, and apoptosis. Furthermore, alamandine attenuates sepsis induced by LPS via inhibiting the mitogen-activated protein kinases (MAPKs) signaling pathways. [ABSTRACT FROM AUTHOR]

Depression and anxiety are common among patients who have a major cardiovascular event. However, despite their frequency, there is a lack of evidence regarding the relationship between depression and/or anxiety and receiving revascularization in ST-elevation myocardial infarction (STEMI) hospitalizations. Using data from the Nationwide Inpatient Sample (NIS) from the years 2004 to 2013, we assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations. Our central finding is that, paradoxically, the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. We further discovered that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. In conclusion, these results are suggestive of the potentially underdiagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole. To our knowledge, this is the first study to document and examine the “depression paradox” among a population of cardiac patients. [ABSTRACT FROM AUTHOR]

Background and aims Antioxidant status has been shown to be associated with cardiovascular events (CVEs). The aim of the study was to develop an assay measuring serum hydrogen peroxide (H 2 O 2 ) break-down activity (HBA) of healthy subjects (HS) and to validate it in a cohort of patients with atrial fibrillation (AF). Methods We developed the HBA assay in 121 HS and validated it in 842 AF patients. The occurrence of CVEs was registered and correlated with HBA in AF during a median follow-up of 30.6 months (3226 patient-years). A combined endpoint of CVEs included fatal/non-fatal ischemic stroke and myocardial infarction, cardiovascular death and transient ischemic attack. Results In HS, median HBA was 61.2% [IQR: 52.9–69.4]. AF patients disclosed lower HBA than 30 HS balanced for age and sex (48.6% [IQR: 24.7–65.1] vs. 59.4% [IQR: 49.2–66.2], p < 0.001). During a mean follow-up of 30.6 months (3226 patient-years), 168 CVEs occurred (5.2%/year). A multivariable Cox's proportional hazards regression analysis showed that age group 3 (71–80 years, HR:5.419, p  = 0.020), age group 4 (>80 years, HR:9.783, p  = 0.002), diabetes (HR:1.464, p  = 0.049), previous cardiac events (HR:1.887, p  = 0.001) and HBA (below median, HR:2.313, p < 0.001) predicted CVEs. Conclusions We developed an easy assay to measure serum HBA, which was associated with CVEs in AF patients. This assay may represent an additional useful tool for cardiovascular risk stratification and should be validated in other high-risk populations. [ABSTRACT FROM AUTHOR]

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

Background Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCAs) is an increasingly recognized entity. No previous study has evaluated predictors for new major adverse cardiacvascular events (MACEs) and death in patients with MINOCA. Methods We conducted an observational study of MINOCA patients recorded between July 2003 and June 2013 and followed until December 2013 for outcome events. Out of 199,163 MI admissions, 9092 consecutive unique patients with MINOCA were identified. The mean age was 65.5 years and 62% were women. MACE was defined as all-cause mortality, rehospitalization for acute MI, ischemic stroke and heart failure. Hazard ratio and 95% confidence interval (HR; 95% CI) was calculated using Cox-regression. Results A total of 2147 patients (24%) experienced a new MACE and 1254 patients (14%) died during the mean follow-up of 4.5 years. Independent predictors for MACE after adjustment, were older age (1.05; 1.04–1.06), diabetes (1.44; 1.21–1.70), hypertension (1.25; 1.09–1.43), current smoking (1.38; 1.15–1.66), previous myocardial infarction (1.38; 1.04–2.82), previous stroke (1.69; 1.35–2.11), peripheral vascular disease (1.55; 1.97–2.23), chronic obstructive pulmonary disease (1.63; 1.32–2.00), reduced left ventricular ejection fraction (2.00; 1.54–2.60), lower level of total cholesterol (0.88; 0.83–0.94) and higher level of creatinine (1.01; 1.00–1.03). Independent predictors for all cause death were age, current smoking, diabetes, cancer, chronic obstructive pulmonary disease, previous stroke, reduced left ventricular fraction, lower level of total cholesterol and higher levels of creatinine and CRP. Conclusions The clinical factors predicting new MACE and death of MINOCA patients seem to be strikingly similar to factors previously shown to predict new cardiovascular events in patients with MI and obstructive coronary artery disease. [ABSTRACT FROM AUTHOR]

We aimed to investigate the association of 12 extensively studied polymorphisms in adiponectin ( ADIPOQ ), adiponectin receptor-1 ( ADIPOR1 ) and adiponectin receptor-2 ( ADIPOR2 ) genes with myocardial infarction in Han Chinese. This is a hospital-based, cross-sectional, case-control study, including 717 myocardial infarction patients and 612 controls. Myocardial infarction was confirmed through electrocardiogram/anatomopathological examinations. All polymorphisms met the Hardy-Weinberg equilibrium ( p  > 0.05). The genotype/allele counts of ADIPOQ gene rs2241766 ( p  = 0.001/0.003) and ADIPOR2 gene rs10773989 ( p  < 0.001/=0.008) differed significantly between patients and controls. Under the recessive model, rs2241766 (odds ratio [OR] = 4.16, 95% confidence interval [CI]: 1.83–9.49, p  = 0.001) and rs10773989 (OR = 8.40, 95% CI: 2.54–27.8, p  < 0.001) were associated with the significantly increased risk of myocardial infarction. Haplotype analysis revealed none or marginal significance, and there was no likelihood of genetic interaction as indicated by multifactor dimensionality reduction (MDR). Logistic regression analysis indicated that age, total cholesterol, hypertension, rs2241766, rs1342387, rs10773989 and rs1044471 were significant contributors, and a nomogram based on these contributors exhibited a good predictive utility (C-index: 0.795, p  < 0.001). Our findings demonstrate that two polymorphisms, rs2241766 in ADIPOQ gene and rs10773989 in ADIPOR2 gene, especially under the recessive model of inheritance, played independent leading roles in susceptibility to myocardial infarction in Han Chinese. [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: 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 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 Recent experimental studies have shown a dynamic time course of myocardial edema with an initial wave of edematous reaction within hours after reperfusion which almost resolved at 24 h. However, this dynamic pattern appears to be absent in clinical cohort studies. Thus far, no studies have combined a quantitative and qualitative assessment of acute myocardial injury in a large clinical cohort to explain these divergent findings. Methods A cohort of 225 patients (59 ± 11 years, 83% men) with successfully reperfused STEMI within 12 h of symptom onset were included. Quantitative measurements of myocardial damage such as T1 mapping and T2 triple short-tau inversion recovery (STIR), contrast-to-noise ratio (CNR) and their impact on area-at-risk (AAR), infarct size (IS), and myocardial salvage index (MSI) were assessed at different time points. One-way analysis of variance (ANOVA) and linear regression analysis was used to compare myocardial damage at the different time points. Results A small fraction of patients underwent CMR within 24 h of reperfusion (17/225, 7.6%). No significant variations in AAR, IS, MSI, T2 STIR CNR, or native T1 maps were observed between the different time points after reperfusion. Time of CMR was not a significant predictor of AAR ( P  = 0.90), IS ( P  = 0.27), MSI ( P  = 0.23) or T2 STIR CNR ( P  = 0.23). Conclusions The majority of CMR exams in STEMI patients are performed outside the dynamic time window of early post-MI edema. The stable pattern of markers of acute myocardial damage at different time points suggests these markers are reliable for the prognostication of patients after STEMI. [ABSTRACT FROM AUTHOR]

Background and aims Risk stratification of patients with recent myocardial infarction (MI) for subsequent cardiovascular (CV) events helps identify patients most likely to benefit from secondary prevention therapies. This study externally validated a new risk score (TRS2˚P) for secondary events derived from the TRA2°P-TIMI 50 trial among post-MI patients from two large health care systems. Methods This retrospective cohort study included 9618 patients treated for acute MI at either the Cleveland Clinic (CC) or Geisinger Health System (GHS) between 2008 and 2013. Patients with a clinic visit within 2–52 weeks of MI were included and followed for CV death, repeat MI, and ischemic stroke through electronic medical records (EMR). The TRS2˚P is based on nine factors determined through EMR documentation. Discrimination and calibration of the TRS2˚P were quantified in both patient populations. Results MI patients at CC and GHS were older, had more comorbidities, received fewer medications, and had higher 3-year event rates compared to subjects in the TRA2°P trial: 31% (CC), 33% (GHS), and 10% (TRA2°P-TIMI 50). The proposed risk score had similar discrimination across the three cohorts with c-statistics of 0.66 (CC), 0.66 (GHS), and 0.67 (TRA2°P-TIMI 50). A strong graded relationship between the risk score and event rates was observed in all cohorts, though 3-year event rates were consistently higher within TRS2°P strata in the CC and GHS cohorts relative to TRA2˚P-TIMI 50. Conclusions The TRS2˚P demonstrated consistent risk discrimination across trial and non-trial patients with recent MI, but event rates were consistently higher in the non-trial cohorts. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of brief hypoxia (<7 min) due to cardiac arrest on the integrity of the brain and performance on memory and executive functions tasks.Methods: Patients after out-of-hospital cardiac arrest (CA) (n = 9), who were deemed neurologically intact on discharge, were compared to matched patients with myocardial infarction (MI) (n = 9). A battery of clinical and experimental memory and executive functions neuropsychological tests were administered and MRI scans for all patients were collected. Measures of subcortical and cortical volumes and cortical thickness were obtained using FreeSurfer. Manual segmentations of the hippocampus were also performed. APACHE-II scores were calculated based on metrics collected at admission to ICCU for all patients.Results: Significant differences between the two groups were observed on several verbal memory tests. Both hippocampi were significantly reduced (p < 0.05) in the CA patients, relative to MI patients. Hippocampal subfields segmentation showed significantly reduced presubiculum volumes bilaterally. CA patients had on average 10% reduction in volumes bilaterally across hippocampal subfields. No cortical thickness differences survived correction. Significant correlations were observed in the CA group only between the hippocampal volumes and performance on verbal memory tasks, including recollection. Hippocampal volumes and several memory measures (but not other cognitive domains) were strongly correlated with APACHE-II scores on admission in the CA group, but not in the MI group CONCLUSIONS: Chronic patients with cardiac arrest who were discharged from hospital in "good neurological condition" showed an average of 10% reduction in hippocampal volume bilaterally and significant verbal memory deficits relative to matched controls with myocardial infarction, suggesting even brief hypoxic periods suffice to lead to specific hippocampal damage. [ABSTRACT FROM AUTHOR]

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/aim Sudden cardiac arrest (SCA) has a substantial mortality rate and the acute coronary syndrome constitutes the major cause. Post-resuscitation electrocardiogram ST-elevation SCA (STE-SCA) is a strong indication for emergency coronary angiography, but the role of early angiography and PCI in patients without ST-elevation (NSTE-SCA) remains to be established. This paper aimed to describe this patient group and evaluate the prognostic effect of early PCI in a large nationwide cohort of NSTE-SCA patients undergoing coronary angiography. Methods Data from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) on 4308 SCA patients in Sweden between 2005 and 2016 were descriptively analyzed and related to mortality within 30-days in both unadjusted and adjusted analyses using Cox proportional hazard models. Results NSTE-SCA patients had more often serious comorbidities than STE-SCA patients. Among NSTE-SCA patients, 36.4% had no significant coronary artery stenosis while severe coronary stenosis (≥90%) was present in 43.9% (1271/2896). In NSTE-SCA patients with significant stenosis (≥90%), PCI was performed in 59.2% (753/1271) with an increased unadjusted 30-day mortality (40.9% vs. 32.7%; p = .011). However, after adjustments for confounders, no difference in mortality was observed (hazard ratio 1.07; 95% CI 0.84–1.36; p = .57). Conclusion In resuscitated SCA patients without ST-elevation who underwent coronary angiography, this large retrospective study found severe coronary artery stenosis in 43.9% but found no clear benefit of early PCI. Prospective randomized controlled trials are needed to accurately define the role of coronary angiography and PCI in post-resuscitation care. [ABSTRACT FROM AUTHOR]

Post-MI depression is a critical clinical problem, the comorbidity of which complicates depression treatment and worsens cardiovascular outcomes. However, which antidepressant is the best to lower the risk of cardiovascular events in persons with depression was still unknown. Recently, it has been proposed that the activation of ALDH2 by Alda-1 can effectively reduce depressive-like behaviors and improve the prognosis of coronary heart disease. In the present study, we investigated the effect of Alda-1 on the expression of VEGF in the hippocampus of a rat model with post-MI depression, as well as the potential treatment mechanism. Alda-1 administration significantly decreased the immobility time and increased the swimming time of the post-MI depression rats in the forced swim test. Moreover, treatment of post-MI depression rats with Alda-1 significantly increased the sucrose preference ratio, as assessed by a sucrose preference test. These behaviors were associated with an increase 5-HT and DA neurotransmitter content, as well as an increase of VEGF levels in the hippocampus of the post-MI depression rats. These results suggest that Alda-1 improves depressive-like behavior in rats after MI by increasing VEGF expression in the hippocampus of rats. [ABSTRACT FROM AUTHOR]

Lymphocytes, macrophages, and immunological mediators are critical in atherogenesis, but Th17 cells are still little studied. We investigated blood lymphocyte profiles, cytometric changes in blood Th17 cells, and production of Th17-associated cytokines by peripheral blood mononuclear cells (PBMCs) stimulated with phytohemagglutinin (PHA) in dyslipidemic patients. Forty-nine Brazilian dyslipidemic patients, including 14 with negative coronary angiograms (CAs) and 35 with positive CAs (atherosclerosis), were classified into groups G1 and G2, respectively, and 27 healthy individuals without dyslipidemia were included in the control group (HI). In all participants, lipid profiles, CVD risk factors, atherogenic risk indexes, cytometry of blood T lymphocytes (CD4 + T, CD8 + T, and Th17 cells), and Th17 cytokine production were determined. Production of interleukin (IL)-17A, IL-17F, IL-21, and IL-22 was measured in culture supernatants of PHA-stimulated PBMCs. Patients with atherosclerosis exhibited low levels of high-density lipoprotein cholesterol and apolipoprotein A and showed increased atherogenic risk indexes and a higher frequency of prior acute myocardial infarction (AMI). CD8 + T-cell counts were lower in patients with previous AMI and higher in dyslipidemic obese individuals. Th17 cell frequency was increased in dyslipidemic women with atherosclerosis. PBMCs from patients with atherosclerosis produced less IL-17A and IL-21, but more IL-22. IL-17F production was unaltered. In summary, cytometric changes in CD8 + T and Th17 lymphocytes and altered production of Th17-associated cytokines were observed in these individuals and were related to endocrine factors, obesity, and AMI. The practical implications of these findings need to be investigated in future studies. [ABSTRACT FROM AUTHOR]

Aims: To determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS).Methods: In this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality.Results: We included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation. After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients.Conclusion: There was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients. [ABSTRACT FROM AUTHOR]

Objective Hyaluronan (HA) is a prominent component of the provisional extracellular matrix (ECM) present in the neointima of atherosclerotic plaques. Here the role of HA synthase 3 (HAS3) in atheroprogression was studied. Approach and results It is demonstrated here that HAS isoenzymes 1, -2 and -3 are expressed in human atherosclerotic plaques of the carotid artery. In Apolipoprotein E ( Apoe )-deficient mice Has3 expression is increased early during lesion formation when macrophages enter atherosclerotic plaques. Importantly, HAS3 expression in vascular smooth muscle cells (VSMC) was found to be regulated by interleukin 1 β (IL-1β) in an NF k B dependent manner and blocking antibodies to IL-1β abrogate Has3 expression in VSMC by activated macrophages. Has3/Apoe double deficient mice developed less atherosclerosis characterized by decreased Th1-cell responses, decreased IL-12 release, and decreased macrophage-driven inflammation. Conclusions Inhibition of HAS3-dependent synthesis of HA dampens systemic Th1 cell polarization and reduces plaque inflammation. These data suggest that HAS3 might be a promising therapeutic target in atherosclerosis. Moreover, because HAS3 is regulated by IL-1β, our results suggest that therapeutic anti-IL-1β antibodies, recently tested in human clinical trials (CANTOS), may exert their beneficial effects on inflammation in post-myocardial infarction patients in part via effects on HAS3. TOC category basic study TOC subcategory arteriosclerosis [ABSTRACT FROM AUTHOR]

Background Identification of patients at risk of poor outcome after acute myocardial infarction (MI) would allow tailoring healthcare to each individual. However, lack of prognostication tools renders this task challenging. Previous investigations suggested that blood transcriptome analysis may inform about prognosis after MI. We aim to independently confirm the value of gene expression profiles in the blood to predict left ventricular (LV) dysfunction after MI. Methods and results Five genes (LMNB1, MMP9, TGFBR1, LTBP4 and TNXB) selected from previous studies were measured in peripheral blood samples obtained at reperfusion in 449 MI patients. 79 patients had LV dysfunction as attested by an ejection fraction (EF) ≤ 40% at 4-month follow-up and 370 patients had a preserved LV function (EF > 40%). LMNB1, MMP9 and TGFBR1 were up-regulated in patients with LV dysfunction and LTBP4 was down-regulated, as compared with patients with preserved LV function. The 5 genes were significant univariate predictors of LV dysfunction. In multivariable analyses adjusted with traditional risk factors and corrected for model overfitting, a panel of 3 genes − TNXB, TGFBR1 and LTBP4 – improved the prediction of a clinical model ( p = 0.00008) and provided a net reclassification index of 0.45 [0.23–0.69], p = 0.0002 and an integrated discrimination improvement of 0.05 [0.02–0.09], p = 0.001. Bootstrap internal validation confirmed the incremental predictive value of the 3-gene panel. Conclusion A 3-gene panel can aid to predict LV dysfunction after MI. Further independent validation is required before considering these findings for molecular diagnostic assay development. [ABSTRACT FROM AUTHOR]

Background The prevalence and associated-risk of asymptomatic multisite artery disease (MSAD) in high risk coronary patients are unknown. Whether systematic identification and aggressive management of asymptomatic MSAD is clinically relevant in high risk coronary patients has not been evaluated. Methods We randomly assigned 521 high risk coronary patients defined by the presence of three-vessel coronary disease ( n = 304) or recent acute coronary syndrome beyond the age of 75 years ( n = 215) to either a strategy of systematic detection of asymptomatic MSAD combined with an aggressive secondary prevention ( n = 263) or to a more conventional strategy based on treatment of coronary artery disease only with standard of care ( n = 258). The primary end point was the time to first occurrence of death, any organ failure or ischemic event leading to re-hospitalization through two years of follow-up. Results The pro-active strategy identified asymptomatic MSAD in 21.7% of patients with few revascularizations (3.6%); the pro-active pharmacological secondary prevention was obtained in > 85% of patients and life-style changes in < 60% of patients. At 2-year follow-up, the primary end point occurred in 44.9% of patients in the pro-active group and 43.0% of patients in the conventional group (HR 1.03; 95% confidence interval [CI], 0.80 to 1.34]. The rate of major bleeding did not differ significantly between groups (4.6% vs 5.0%; HR, 0.97; 95% CI, 0.40 to 1.91). Conclusion In high risk coronary patients, there is no apparent benefit of a systematic detection of asymptomatic extra-coronary atherothrombotic disease and intensified treatment over a 2-year follow-up period. (Funded by the Academic Allies in Cardiovascular Trials Initiatives and Organized Networks and Institut de l'Athérothrombose; AMERICA ClinicalTrials.gov number, NCT00445835 ). [ABSTRACT FROM AUTHOR]

Background: Recent trials demonstrated a benefit of multivessel percutaneous coronary intervention (PCI) for noninfarct-related artery (non-IRA) stenosis over IRA-only PCI in patients with ST-segment elevation myocardial infarction (STEMI) multivessel disease. However, evidence is limited in patients with cardiogenic shock.Objectives: This study investigated the prognostic impact of multivessel PCI in patients with STEMI multivessel disease presenting with cardiogenic shock, using the nationwide, multicenter, prospective KAMIR-NIH (Korea Acute Myocardial Infarction-National Institutes of Health) registry.Methods: Among 13,104 consecutive patients enrolled in the KAMIR-NIH registry, we selected patients with STEMI with multivessel disease presenting with cardiogenic shock and who underwent primary PCI. Primary outcome was 1-year all-cause death, and secondary outcomes included patient-oriented composite outcome (a composite of all-cause death, any myocardial infarction, and any repeat revascularization) and its individual components.Results: A total of 659 patients were treated by multivessel PCI (n = 260) or IRA-only PCI (n = 399) strategy. The risk of all-cause death and non-IRA repeat revascularization was significantly lower in the multivessel PCI group than in the IRA-only PCI group (21.3% vs. 31.7%; hazard ratio: 0.59; 95% confidence interval: 0.43 to 0.82; p = 0.001; and 6.7% vs. 8.2%; hazard ratio: 0.39; 95% confidence interval: 0.17 to 0.90; p = 0.028, respectively). Results were consistent after multivariable regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences. In a multivariable model, multivessel PCI was independently associated with reduced risk of 1-year all-cause death and patient-oriented composite outcome.Conclusions: Of patients with STEMI and multivessel disease with cardiogenic shock, multivessel PCI was associated with a significantly lower risk of all-cause death and non-IRA repeat revascularization. Our data suggest that multivessel PCI for complete revascularization is a reasonable strategy to improve outcomes in patients with STEMI with cardiogenic shock. [ABSTRACT FROM AUTHOR]

Background: Limited data are available on the relative performances between different types of drug-eluting stents (DES) for obstructive left main coronary artery disease (LMCAD).Objectives: This study sought to compare effectiveness and safety profiles of various second-generation DES for LMCAD in real-world clinical practice.Methods: Among 4,470 patients in 3, multicenter, prospective registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents] registry, the IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization] registry, and the PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease] study) treated between July 2007 and July 2015, the authors identified 2,692 patients with significant LMCAD who received second-generation DES; 1,254 with cobalt-chromium everolimus-eluting stents (CoCr-EES), 232 with biodegradable polymer biolimus-eluting stents (BP-BES), 616 with platinum-chromium EES (PtCr-EES), and 590 with Resolute zotarolimus-eluting stent (Re-ZES). The primary outcome was target-vessel failure.Results: The observed 3-year rates of target-vessel failure were not significantly different for the different types of DES (16.7% for the CoCr-EES, 13.2% for the BP-BES, 18.7% for the PtCr-EES, and 14.7% for the Re-ZES; p = 0.15). In multiple treatment propensity score analysis, the adjusted hazard ratios (HRs) for target-vessel failure were similar in between-group comparisons of the different DES, except for the PtCr-EES versus the BP-BES (reference; HR: 1.60; 95% confidence interval: 1.01 to 2.54; p = 0.046). There were no significant differences in risk of composite of all-cause death, any myocardial infarction, or any revascularization and its individual components according to the different types of DES. Although the 3-year incidence of stent thrombosis was considerably low (≤1.0%) for all types of DES, between-group differences were observed, generally favoring the EES platforms.Conclusions: In this pooled analysis of 3 prospective registries involving unrestricted use of various second-generation DES for LMCAD, we found no significant between-group differences in 3-year risk of target-vessel failure, except for a higher risk of primary outcome with PtCr-EES compared to BP-BES. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133). [ABSTRACT FROM AUTHOR]

Background: Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE).Objectives: The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates.Methods: The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs.Results: A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001).Conclusions: Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score. [ABSTRACT FROM AUTHOR]

Objective: To determine, in patients with ST-segment Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI), the prognostic weight of cardiac arrest (CA) according to the type of rhythm (shockable vs. non-shockable).Methods: We prospectively enrolled 3278 consecutive STEMI patients undergoing PPCI. Multivariable Cox regression was used to establish the relation to 1-year cardiac mortality of both type of CA. In patients suffering from CA we identified predictors of both poor neurological outcome (cerebral performance categories 3-5) and cardiac mortality at 1year.Results: The incidence of CA was 7.26% (n=238). Of these, 196 (5.98%) had an initial shockable rhythm and 42 (1.28%) a non shockable rhythm. During 1-year follow up 311(9.48%) patients died from cardiac causes. Shockable rhythm (adjusted-HR=1.61; 95%CI 1.08-2.43, p=0.02) and non-shockable rhythm (adjusted-HR=3.83; 95%CI 2.36-6.22, p<0.001) were independently associated with 1-year cardiac mortality. Among patients with CA those with shockable rhythm had a lower risk of poor neurological outcome at 1year follow up (adjusted OR=0.22: 95%CI; 0.08-0.55, p=0.001). Independent predictors of 1-y cardiac mortality were: non shockable rhythm (adjusted HR=2.6; 95%CI; 1.48-4.5, p=0.001), crew-witnessed CA, diabetes mellitus, left ventricle ejection fraction and creatinine on admission. There was a significant interaction between type of rhythm and crew-witnessed CA (p=0.026).Conclusions: In patients with STEMI undergoing PPCI patients with both shockable and non shockable CA are at increased risk of 1-year cardiac mortality. Among patients with CA those with non shockable rhythm have an higher risk of both poor neurological outcome and cardiac mortality at 1year. [ABSTRACT FROM AUTHOR]

Background: There is little data on the prevalence of coronary heart disease (CHD) in the young. The study aimed to estimate the prevalence of asymptomatic CHD in siblings of young patients with myocardial infarction (MI) using coronary computed tomography angiography (CCTA).Methods: Prospective observational data was collected on siblings of patients aged ≤55 years presenting with acute MI and having coronary stenosis ≥50% on invasive coronary angiography in at least one epicardial coronary artery. Inclusion criteria included ages 30-55 and 30-60 years for males and females respectively. Outcome of interest was obstructive CHD by coronary computer tomography angiography (CCTA), which was defined by either moderate (50-69% stenosis) and/or severe (≥70% stenosis).Results: Fifty participants were studied of whom 20 (40%) were male. Thirty (60%) were current or ex-smokers, 4 (8%) had diabetes, 8 (16%) had hypertension and 26 (52%) had dyslipidaemia. Obstructive CHD by CCTA was detected in 9 (18%, 95% CI 9%-31%) participants and 3 (6%, 95% CI 1%-17%) participants were found to have severe luminal stenosis. The median radiation dose was 3.9 (IQR 0.9) mSv.Conclusions: Approximately a fifth of siblings of young MI patients were found to have asymptomatic but obstructive CHD detected on CCTA of which one third was severe. This is a group in whom screening for CHD warrants further investigation. [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]

Background: Available studies have already identified age, heart rate (HR) and systolic blood pressure (SBP) as strong predictors of early mortality in acute pulmonary embolism (PE).Material and Methods: One-hundred-seventy patients, with acute PE confirmed on computed tomography angiography (CTA) were enrolled. Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) was calculated using the formula [heart rate (HR) x (AGE/102)/ systolic blood pressure (SBP)]. Study outcomes were 30-day mortality and/or clinical deterioration.Results: Receiver operating characteristics (ROC) curve revealed that a TRI ≥45 was highly specific for both outcomes (AUC 0.91, 95% CI 0.83-0.98, p<0.0001) with a positive predictive value (PPV) and negative predictive value (NPV) of 8.3 and 96% for 30-day mortality while PPV and NPV for 30-day mortality and/or clinical deterioration were 21.1 and 98.2%, respectively. Multivariate regression analysis showed that TRI ≥45 was an independent predictor of 30-day mortality (O.R. 22.24, 95% CI 2.54-194.10, p=0.005) independently from positive cTnI and RVD (O.R. 9.57, 95% CI 1.88-48.78, p=0.007; OR 24.99, 95% CI 2.84-219.48, p=0.004). Similarly, 30-day mortality and/or clinical deterioration was predicted by TRI ≥45 (O.R. 11.57, 95% CI 2.36-56.63, p=0.003) and thrombolysis (3.83, 95% CI 1.04-14.09, p=0.043), independently from age, RVD and positive cTnI. Cox regression analysis confirmed the role of TRI as independent predictor for both outcomes. Mantel-Cox analysis showed that after 30-day follow-up there was a statistically significant difference in the distribution of survival between patients with and without TRI ≥45 [log rank (Mantel-Cox) chi-square 17.04, p<0.0001].Conclusions: Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) predicted both 30-days mortality (all-causes) and/or clinical deterioration in patients with acute PE. [ABSTRACT FROM AUTHOR]

Backgroud: We investigated reverse left ventricular remodelling (r-LVR), defined as a reduction of >10% in left ventricular end-systolic volume (LVESV) during follow-up, in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).Methods: STEMI patients (n=1,237) undergoing PPCI with echocardiography at baseline and 6-month follow-up were classified into r-LVR (n=466) and no r-LVR groups (n=771). The primary outcome was composite major adverse cardiac events (MACE; all-cause death, myocardial infarction, any revascularisation).Results: r-LVR occurred in 466 patients (37.7%) and was associated with maximum troponin, door-to-balloon time, direct arrival to PPCI-capable hospital, coronary disease extent, initial left ventricular ejection fraction (LVEF), and LVESV. After propensity score (PS)-matching, initial LVEF and LVESV remained significant. During a median 403-day follow-up, 2-year MACE occurred in 166 patients (13.4%); its frequency was similar between groups (entire cohort: 13.5% vs. 13.4%, p=0.247; PS-matched: 11.8% vs. 11.8%, p=0.987). Kaplan-Meier estimates showed that MACE-free survival was comparable between groups (entire cohort: 86.5% vs. 86.6%, log rank p=0.939; PS-matched: 88.2% vs. 88.2%, log rank p=0.867). In Cox proportional hazard analysis, r-LVR was not associated with MACE (entire cohort: hazard ratio [HR] 1.018, 95% confidential interval [CI] 0.675-1.534, p=0.934; PS-matched: HR 1.001, 95% CI 0.578-1.731, p=0.999).Conclusion: We identified independent predictors of r-LVR and showed that while r-LVR occurred in 38% of our patients, it was not associated with clinical outcomes. [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]

Background A longer QTc interval has been associated with more adverse cardiovascular events and death in the general population. Little evidence is available on these relationships among patients with atrial fibrillation (AF). Methods We performed a prospective observational multicenter cohort study of 1413 patients with AF. A resting 12‑lead electrocardiogram (ECG) was performed at baseline. QT interval was corrected for heart rate using the Bazett formula (QTc). Endpoints for this study included hospitalizations for congestive heart failure (CHF), a combination of cardiovascular death, myocardial infarction, stroke, systemic arterial embolism (MACE) and all-cause mortality. Results Mean age of our population was 68 ± 12 years and 420 (30%) participants were female. Median QTc was 432 ms (interquartile range 409; 457). The mean follow-up time was 3.6 ± 1.5 years. After multivariable adjustment, there was a linear increase in risk with increasing QTc interval for incident CHF (hazard ratio (HR) per 1-SD increase in QTc 1.3 [95% CI 1.1; 1.6], p = 0.008), MACE (HR 1.2 [1.0; 1.4], p = 0.02) and all-cause mortality (HR 1.3 [1.0; 1.6], p = 0.002). Results were consistent whether or not patients were in sinus rhythm on the baseline ECG (HR for CHF 1.7 versus 1.3, p interaction 0.08; HR for MACE 1.3 versus 1.2, p interaction 0.9; HR for all-cause mortality 1.4 versus 1.4, p interaction 0.9). Conclusions In this large well-characterized cohort of AF patients, QTc interval was independently associated with adverse outcomes. These results were independent of the rhythm on the baseline ECG. [ABSTRACT FROM AUTHOR]

Background: Early outcomes of patients in the PRAGUE-18 (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction) study did not find any significant differences between 2 potent P2Y12 inhibitors.Objectives: The 1-year follow-up of the PRAGUE-18 study focused on: 1) a comparison of efficacy and safety between prasugrel and ticagrelor; and 2) the risk of major ischemic events related to an economically motivated post-discharge switch to clopidogrel.Methods: A total of 1,230 patients with acute myocardial infarction (MI) treated with primary percutaneous coronary intervention were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The combined endpoint was cardiovascular death, MI, or stroke at 1 year. Because patients had to cover the costs of study medication after hospital discharge, some patients decided to switch to clopidogrel.Results: The endpoint occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; 95% confidence interval: 0.742 to 1.835; p = 0.503). No significant differences were found in: cardiovascular death (3.3% vs. 3.0%; p = 0.769), MI (3.0% vs. 2.5%; p = 0.611), stroke (1.1% vs. 0.7%; p = 0.423), all-cause death (4.7% vs. 4.2%; p = 0.654), definite stent thrombosis (1.1% vs. 1.5%; p = 0.535), all bleeding (10.9% vs. 11.1%; p = 0.999), and TIMI (Thrombolysis In Myocardial Infarction) major bleeding (0.9% vs. 0.7%; p = 0.754). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n = 216) for prasugrel and 44.4% (n = 265) for ticagrelor (p = 0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major cardiovascular events; however, they also had lower ischemic risk.Conclusions: Prasugrel and ticagrelor are similarly effective during the first year after MI. Economically motivated early post-discharge switches to clopidogrel were not associated with an increased risk of ischemic events. (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction [PRAGUE-18]; NCT02808767). [ABSTRACT FROM AUTHOR]