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Circadian patterns in ST-segment elevation myocardial infarction (STEMI) patients have been previously reported, but little is known about the impact of time dependence of symptom onset on long-term prognosis. Our study population consisted of 11,731 STEMI patients treated by primary percutaneous coronary intervention (PPCI), enrolled in the Singapore Myocardial Infarction Registry (SMIR). Analysis of STEMI incidence trends over the 24-hour period showed the highest rate of symptom onset in the morning, with the peak incidence at 09:00 am . Patients with symptom onset in between 00:00 am -5:59 am showed the highest prevalence of diabetes (P = .010) and anterior STEMI (P pm -11:59 pm and 00:00 am -05:59 am having an estimated 30% to 50% higher risk of rehospitalization for HF at 1 year. Moreover, symptom onset remained a predictor of worse prognosis only in the subgroup of patients with symptoms lasting longer than 120 minutes. The results of this study demonstrate for the first time that rehospitalization for HF in STEMI patients treated with PPCI has a dependence on the time of onset of symptoms, with prolonged ischemia time playing a pivotal role. This may be an additional risk factor to identify those who warrant closer monitoring and more rigorous optimization of their treatment at follow-up, to improve their outcomes.

It is unclear whether universal access to primary percutaneous coronary intervention (pPCI) may reduce sex differences in 1-year rehospitalization for heart failure (HF) and myocardial infarction (MI) after ST-elevation myocardial infarction (STEMI). We studied 7,597 consecutive STEMI patients (13.8% women, n = 1,045) who underwent pPCI from January 2007 to December 2013. Cox regression models adjusted for competing risk from death were used to assess sex differences in rehospitalization for HF and MI within 1 year from discharge. Compared with men, women were older (median age 67.6 vs 56.0 years, p0.001) with higher prevalence of co-morbidities and multivessel disease. Women had longer median door-to-balloon time (76 vs 66 minutes, p0.001) and were less likely to receive drug-eluting stents (19.5% vs 24.1%, p = 0.001). Of the medications prescribed at discharge, fewer women received aspirin (95.8% vs 97.6%, p = 0.002) and P2Y

Appropriate use criteria (AUC) for single-photon emission computed tomography myocardial perfusion images (SPECT-MPIs) were developed to address the growth of cardiac imaging studies. Long-term prognostic value of AUC in SPECT-MPI has not been tested in existing cohorts. We sought to determine the long-term prognostic value of MPI classified as appropriate. AUC was evaluated in a prospectively designed cohort of patients who underwent clinically indicated MPI. MPI studies were classified based on 2009 AUC for SPECT-MPI. Data regarding downstream coronary angiography (cath), revascularization and all-cause mortality, cardiac death, and nonfatal myocardial infarction (MI) were collected from national registries. Among n = 1,129 MPI scans that received an appropriate grading, 148 all-cause deaths, 109 MIs, 58 cardiac deaths, 152 caths, 113 revascularization procedures occurred over a mean follow-up period of 5.4 ± 1.2 years (0.9% cardiac death rate per year, 1.8% MI rate per year). Most of the scans were low-risk normal MPI scans (summed stress score ≤3; 74.1%). An abnormal scan was associated with higher rates of MI (19.5% vs 6.2%, hazard ratio 1.72, p = 0.017) and cardiac death (13.4% vs 2.3%, hazard ratio 2.12, p = 0.016). In conclusion, MPI scans classified as appropriate have long-term prognostic value, despite a high proportion of low-risk scans. This provides support for clinicians to consider the use of appropriate grading in addition to MPI scan results in patient management.

Statins reduce risk of major adverse cardiovascular events (MACE) in women and men; whether the same holds true for PCSK9 inhibition is uncertain. The ODYSSEY OUTCOMES trial compared alirocumab with placebo, added to high-intensity or maximum-tolerated statin treatment, in 4,762 women and 14,162 men

There is emerging interest in the assessment of coronary vascular flow by SPECT myocardial perfusion imaging (MPI). Coronary flow may be influenced by underlying alterations in diastolic function. To advance understanding of coronary vascular flow measures obtained by SPECT, we investigated the

Background Acute myocardial infarction (AMI) is a leading cause of mortality in Asia. However, quantitative risk scores to predict mortality after AMI were developed without the participation of Asian countries. Methods We evaluated the performance of the Global Registry of Acute Coronary Events (GRACE) in-hospital mortality risk score, directly and after recalibration, in a large Singaporean cohort representing 3 major Asian ethnicities. Results The GRACE cohort included 11,389 patients, predominantly of European descent, hospitalized for AMI or unstable angina from 2002 to 2003. The Singapore cohort included 10,100 Chinese, 3,005 Malay, and 2,046 Indian patients hospitalized for AMI from 2002 to 2005.Using the original GRACE score, predicted in-hospital mortality was 2.4% (Chinese), 2.0% (Malay), and 1.6% (Indian). However, observed in-hospital mortality was much greater at 9.8% (Chinese), 7.6% (Malay), and 6.4% (Indian). The c statistic for Chinese, Malays, and Indians was 0.86, 0.86, and 0.84, respectively, and the Hosmer-Lemeshow statistic was 250, 56, and 41, respectively. Recalibration of the GRACE score, using the mean-centered constants derived from the Singapore cohort, did not change the c statistic but substantially improved the Hosmer-Lemeshow statistic to 90, 24, and 18, respectively. The recalibrated GRACE score predicted in-hospital mortality as follows: 7.7% (Chinese), 6.0% (Malay), and 5.2% (Indian). Conclusion In this large cohort of 3 major Asian ethnicities, the original GRACE score, derived from populations outside Asia, underestimated in-hospital mortality after AMI. Recalibration improved risk estimation substantially and may help adapt externally developed risk scores for local practice.

Although chest pain is one of the leading presenting complaints in the Emergency Department (ED), only 12-15% account for Acute Coronary Syndrome (ACS). Hence early triage and exclusion of ACS is crucial to improve ED throughput and workflow. We aim to determine and compare the accuracy of the

Coronary Artery Calcium (CAC) is highly associated with the presence of coronary atherosclerotic plaque that has prognostic value towards cardiovascular events. It has shown that CAC varies among different ethnic groups in the same age and gender. Studies looking at the spectrum of CAC in the multi

There are few data comparing heart failure (HF) outcomes in STEMI and non-STEMI. State legislature mandates that all patients hospitalized for acute MI enter the Singapore MI Registry. All EKGs are centrally adjudicated. Mortality and rehospitalization due to HF are ascertained through linkage with

Incidental solitary pulmonary nodules (SPN) found on coronary computed tomography angiography (CCTA) are largely benign requiring no further evaluation, which would otherwise cause unnecessary healthcare cost and patient anxiety. The Fleischner guidelines 2017 for management of incidental SPN

The Duke Clinical Score (DCS) was developed to estimate the pre-test probability of obstructive coronary artery disease in symptomatic patients. However, it has not been validated in a South East Asian population and its use is limited to health care workers with the ability to interpret ECGs. We

Coronary Artery Calcium (CAC) scoring may have potential as a gatekeeper to further testing with Coronary Computed Tomography Angiography (CCTA) or other tests in patients presenting with chest pain and suspected Coronary Artery Disease (CAD). Apart from a substudy of the CONFIRM Registry, other

Objectives. This study compares technetium-99m sestamibi (sestamibi) electrocardiographic (ECG) gated single-photon emission computed tomography (gated SPECT) and echocardiography for the evaluation of myocardial function and assesses the feasibility of single-injection, single-acquisition stress perfusion/rest function technetium-99m sestamibi-gated SPECT as an alternative to conventional stress/rest imaging for assessment of myocardial perfusion and viability. Background. Simultaneous assessment of stress perfusion and rest function is possible with gated SPECT acquisition of stress-injected technetium-99m sestamibi. Methods. Rest thallium-201 SPECT followed by stress sestamibigated SPECT (acquired 0.5 to 1 h after sestamibi injection) was performed in 58 patients. Echocardiography was performed immediately after or before gated SPECT in 43 of the patients. All studies were analyzed by semiquantitative visual scoring. Sestamibi-gated SPECT studies were read for stress perfusion and rest wall motion and thickening. Reversibility on sestamibi-gated SPECT was defined as the presence of a definite stress defect with normal or mildly impaired wall motion or thickening on gated SPECT. Results. There was high segmental score agreement between gated SPECT and echocardiography for wall motion (91%, kappa = 0.68, p Conclusions. Gated SPECT of stress-injected sestamibi correlates well with echocardiographic assessment of regional function and thus adds information to perfusion SPECT. In patients without previous myocardial infarction, a single-injection stress perfusion/rest function approach using sestamibi-gated SPECT can substitute for conventional stress/rest myocardial perfusion imaging, adding a rest perfusion study only if there are nonreversible defects or consideration of attenuation artifacts. In patients with previous myocardial infarction, the gated SPECT approach does not replace the need for a rest perfusion study.

The Coronary Artery Calcium score (CACS) is a well-established independent predictor of coronary atherosclerosis, ischemic heart disease and cardiac events but requires exposure to radiation. Carotid Intima Media Thickness (CIMT), measured by ultrasound, is a less well-established marker but does