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Background: The European Society of Cardiology (ESC) guideline on non-ST-elevation acute coronary syndrome (N-STE ACS) proposed a new ACS rule-out protocol.Objectives: To evaluate this new tool, which uses diagnostic levels of high-sensitivity troponin T (hs-TnT; > 14 ng/L) in a slightly modified version and compare this to a recently proposed approach using undetectable levels of hs-TnT to rule out patients.Methods: There were 534 consecutive patients with suspected ACS included. Protocol 1: symptom duration, hs-TnT at 0 and 6-9 h, Global Registry of Acute Coronary Events (GRACE) score, and symptom status at 6-9 h. Protocol 2: a single blood sample of hs-TnT. The primary endpoint was a discharge diagnosis of ACS by blinded adjudication. Secondary endpoints were ACS re-admission < 30 days and 1-year mortality.Results: Protocol 1 classified 434/534 (81%) patients, with 27.9% being ruled out. All myocardial infarctions were correctly ruled in, but 15 cases of unstable angina were missed, resulting in a sensitivity and negative predictive value of 87.3% (79.6-92.5%) and 87.6% (80.4-92.9%), respectively. Protocol 2 ruled out 17.5% of the population, yielding a sensitivity and negative predictive value of 94.1% (88.2-97.6%) and 90.8% (81.9-96.2%), respectively. Both protocols correctly ruled in 2/3 patients with ACS re-admission < 30 days and 55/56 1-year fatalities.Conclusion: The present study confirms the diagnostic value of a modified version of the ESC rule-out protocol (Protocol 1) in N-STE ACS patients, but also suggests that a simpler protocol using undetectable levels of hs-TnT (Protocol 2) could provide a similar or even superior sensitivity. [ABSTRACT FROM AUTHOR]

Objective: Obstructive sleep apnea (OSA) increases the risk of cardiovascular disease (CVD) in both morbidity and mortality. We used the risk chart of Systemic Coronary Risk Evaluation (SCORE) from European Society of Cardiology (ESC) to determine the 10-year risk of cardiovascular death, and adherence to cardiovascular risk factor management in Danish patients investigated for obstructive sleep apnea., Research Design and Methods: In a prospective cohort study, 303 patients with mild, moderate and severe OSA were investigated for cardiovascular risk factors before initiating CPAP therapy. Primary outcome was estimates of 10-year risk of cardiovascular death assessed from the ESC risk chart SCORE based on sex, age, smoking status, systolic blood pressure and s-total cholesterol. Furthermore we analyzed treatment indication with statins in patients with mild (apnea-hypopnea index, AHI <15), moderate (AHI 15-29.9) and severe OSA (AHI ≥30)., Results: Patients with mild OSA predominately had low or moderate 10-year risk of CVD (low risk 55.4%, moderate risk 30.8%) while patients with moderate and severe OSA were more likely to have high or very high risk of 10-year CVD (p = 0.001). The large majority of included OSA patients had dyslipidemia, 235 (77.6%) and of those, only 27.4% were treated with cholesterol lowering drugs while additional 27.7% were eligible for oral statin supplement as risk-estimated by the ESC SCORE. In multiple regression analysis among statin naive patients, AHI was positively associated with statin eligibility when adjusted for age and sex., Conclusion: Patients with moderate and severe OSA had an elevated 10-year risk of fatal CVD and were undertreated with CVD risk lowering agents such as statins., Competing Interests: Declaration of competing interest Author AH, MMS, PT, TB and PH declared no conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

Guidelines recommend the use of transthoracic echocardiography (TTE) and clinical scores to risk stratify patients after ST-elevation myocardial infarction (STEMI). High sensitivity troponin T (hs-cTnT) is predictive of outcome after STEMI but the predictive value of hs-cTnT relative to other risk assessment tools has not been established. We aimed to compare the predictive value of hs-cTnT to other risk assessment tools in patients with STEMI. A subset of 578 patients with STEMI were included in this post-hoc study from the Third DANish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction trial. Patients underwent cardiac magnetic resonance imaging (CMR) during index hospitalization as well as TTE at 1 year after their STEMI. The predictive value of hs-cTnT was compared with CKMB, infarct size (IS)/left ventricular ejection fraction (LVEF) assessed with CMR, LVEF assessed at discharge with TTE and the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk-scores. The primary outcome was LV systolic dysfunction defined as LVEF ≤40% after 1 year on TTE. The area under the receiver operating characteristic curve analyses showed no significant difference between hs-cTnT and early CMR-assessed IS or LVEF in predicting subsequent LVEF ≤40%. Area under the curve for hs-cTnT was 0.82, 0.85 for IS (p = 0.22), and 0.87 for LVEF (p = 0.23). For predischarge TTE-assessed LVEF, the value was 0.85 (p = 0.45), 0.63 for creatine kinase-MB (p <0.001), 0.61 for the GRACE score (p <0.001), and 0.70 for the TIMI score (p = 0.02). A peak hs-cTnT value <3,500 ng/L ruled out LVEF ≤40% with probability of 98%. In conclusion, in patients presenting with STEMI undergoing PCI, hs-cTnT level strongly predicted long-term LV dysfunction and could be used as a clinical risk stratification tool to identify patients at high risk of progressing to LV dysfunction due to its general availability and high-predictive accuracy., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: This study investigated the incidence and long-term prognostic importance of multiple myocardial scars in cardiac magnetic resonance (CMR) in a large contemporary cohort of patients with ST-segment elevation myocardial infarction (STEMI)., Background: Patients presenting with STEMI may have multiple infarctions/scars caused by multiple culprit lesions, previous myocardial infarction (MI) or procedure-related MI due to nonculprit interventions. However, the incidence, long-term prognosis, and distribution of causes of multiple myocardial scars remain unknown., Methods: CMR was performed in 704 patients with STEMI 1 day after primary percutaneous coronary intervention (PCI) and again 3 months later. Myocardial scars were assessed by late gadolinium enhancement (LGE). T2-weighted technique was used to differentiate acute from chronic infarctions. The presence of multiple scars was defined as scars located in different coronary territories. The combined endpoints of all-cause mortality and hospitalization for heart failure were assessed at 39 months (interquartile range [IQR]: 31 to 48 months)., Results: At 3 months, 59 patients (8.4%) had multiple scars. Of these, multiple culprits in STEMI were detected in 7 patients (1%), and development of a second nonculprit scar at follow-up occurred in 10 patients (1.4%). The most frequent cause of multiple scars was a chronic scar in the nonculprit myocardium. The presence of multiple scars was independently associated with an increased risk of all-cause mortality and hospitalization for heart failure (hazard ratio: 2.7; 95% confidence interval: 1.1 to 6.8; p = 0.037)., Conclusions: Multiple scars were present in 8.4% of patients with STEMI and were independently associated with an increased risk of long-term morbidity and mortality. The presence of multiple myocardial scars on CMR may serve as a useful tool in risk stratification of patients following STEMI. (DANish Study of Optimal Acute Treatment of Patients With ST-elevation Myocardial Infarction [DANAMI-3]; NCT01435408) (Primary PCI in Patients With ST-elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization [PRIMULTI]; NCT01960933)., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to evaluate the effect of fractional flow reserve (FFR)-guided revascularization compared with culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) on infarct size, left ventricular (LV), function, LV remodeling, and the presence of nonculprit infarctions., Background: Patients with STEMI with multivessel disease might have improved clinical outcomes after complete revascularization compared with PCI of the infarct-related artery only, but the impact on infarct size, LV function, and remodeling as well as the risk for periprocedural infarction are unknown., Methods: In this substudy of the DANAMI-3 (Third Danish Trial in Acute Myocardial Infarction)-PRIMULTI (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization) randomized trial, patients with STEMI with multivessel disease were randomized to receive either complete FFR-guided revascularization or PCI of the culprit vessel only. The patients underwent cardiac magnetic resonance imaging during index admission and at 3-month follow-up., Results: A total of 280 patients (136 patients with infarct-related and 144 with complete FFR-guided revascularization) were included. There were no differences in final infarct size (median 12% [interquartile range: 5% to 19%] vs. 11% [interquartile range: 4% to 18%]; p = 0.62), myocardial salvage index (median 0.71 [interquartile range: 0.54 to 0.89] vs. 0.66 [interquartile range: 0.55 to 0.87]; p = 0.49), LV ejection fraction (mean 58 ± 9% vs. 59 ± 9%; p = 0.39), and LV end-systolic volume remodeling (mean 7 ± 22 ml vs. 7 ± 19 ml; p = 0.63). New nonculprit infarction occurring after the nonculprit intervention was numerically more frequent among patients treated with complete revascularization (6 [4.5%] vs. 1 [0.8%]; p = 0.12)., Conclusions: Complete FFR-guided revascularization in patients with STEMI and multivessel disease did not affect final infarct size, LV function, or remodeling compared with culprit-only PCI., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Midregional proadrenomedullin (MR-proADM) has demonstrated prognostic potential after myocardial infarction (MI). Yet, the prognostic value of MR-proADM at admission has not been examined in patients with ST-segment-elevation MI (STEMI)., Methods and Results: The aim of this substudy, DANAMI-3 (The Danish Study of Optimal Acute Treatment of Patients with ST-segment-elevation myocardial infarction), was to examine the associations of admission concentrations of MR-proADM with short- and long-term mortality and hospital admission for heart failure in patients with ST-segment-elevation myocardial infarction. Outcomes were assessed using Cox proportional hazard models and area under the curve using receiver operating characteristics. In total, 1122 patients were included. The median concentration of MR-proADM was 0.64 nmol/L (25th-75th percentiles, 0.53-0.79). Within 30 days 23 patients (2.0%) died and during a 3-year follow-up 80 (7.1%) died and 38 (3.4%) were admitted for heart failure. A doubling of MR-proADM was, in adjusted models, associated with an increased risk of 30-day mortality (hazard ratio, 2.67; 95% confidence interval, 1.01-7.11; P =0.049), long-term mortality (hazard ratio, 3.23; 95% confidence interval, 1.97-5.29; P <0.0001), and heart failure (hazard ratio, 2.71; 95% confidence interval, 1.32-5.58; P =0.007). For 30-day and 3-year mortality, the area under the curve for MR-proADM was 0.77 and 0.78, respectively. For 3-year mortality, area under the curve (0.84) of the adjusted model marginally changed (0.85; P =0.02) after addition of MR-proADM., Conclusions: Elevation of admission MR-proADM was associated with long-term mortality and heart failure, whereas the association with short-term mortality was borderline significant. MR-proADM may be a marker of prognosis after ST-segment-elevation myocardial infarction but does not seem to add substantial prognostic information to established clinical models., Clinical Trial Registration: URL: http:/www.ClinicalTrials.gov/. Unique identifiers: NCT01435408 and NCT01960933., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Since 2005, ST-elevation myocardial infarction (STEMI) patients from the island of Bornholm in the Baltic Sea have been transferred for primary percutaneous coronary intervention (pPCI) by an airborne service. We describe the result of pPCI as part of the Danish national reperfusion strategy offered to a remote island population., Methods: In this observational study, patients from Bornholm (n=101) were compared with patients from the mainland (Zealand) (n=2495), who were grouped according to time intervals (<120, 121-180, >180 min). The primary endpoint was all-cause 30-day mortality. Individual-level data from the Central Population Registry provided outcome that was linked to our inhospital PCI database., Results: Treatment delay was longer in patients from Bornholm (349 min (IQR 267-446)) vs Zealand (211 (IQR 150-315)) (p<0.001). In patients from Zealand, 30-day mortality did not increase with time intervals (p=0.176), whereas, long-term mortality did (∼3 years) (p=0.007). Thirty-day mortality was similar for Bornholm and the overall Zealand group (5.9% vs 6.2% p=0.955). Early presenters (<180 min) from Zealand (37%) had similar 30-day (5.3% vs 5.9% p=0.789), but numerically reduced long-term mortality compared with Bornholm (12.8% vs 15.8% p=0.387). Age, female gender, diabetes, Killipclass >2 and preprocedural thrombolysis in myocardial infarction (TIMI) flow 0/1 independently predicted 30-day mortality, however, treatment delay did not. Postprocedural TIMI flow 3 predicted improved survival., Conclusions: In this small population of STEMI patients from a remote island, airborne transfer appears feasible and safe, and their 30-day mortality after pPCI comparable with that of the mainland population despite inherent reperfusion delay exceeding guidelines., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is essential. Although primary percutaneous coronary intervention (pPCI) is the preferred revascularization technique, it often involves longer primary transportation or secondary inter-hospital transfers and thus longer system related delays. The current ESC Guidelines state that PCI should be performed within 120 minutes from first medical contact, and door-to-balloon time should be <60 minutes in order to reduce long term mortality. STEMI networks should be established with regionalization of pPCI treatment to address the challenges regarding pre-hospital treatment, triage and transport of STEMI patients and collaborations between hospitals and Emergency Medical Services (EMS). We report on a regional decade long experience from one of Europe's largest STEMI networks located in Eastern Denmark, which serves a catchment area of 2.5 million inhabitants by processing ~4000 prehospital ECGs annually transmitted from 4 EMS systems to a single pPCI center treating 1100 patients per year. This organization has led to a significant improvement of the standard of therapy for acute myocardial infarction (MI) patients leading to historically low 30-day mortality for STEMI patients (<6%). About 70-80% of all STEMI patients are being triaged from the field and rerouted to the regional pPCI center. Significant delays are still found among patients who present to local hospitals and for those who are first admitted to a local emergency room and thus subject to inter-hospital transfer. In the directly transferred group, approximately 80% of patients can be treated within the current guideline time window of 120 minutes when triaged within a 185 km (~115 miles) radius. Since 2010, a Helicopter Emergency Medical Service has been implemented for air rescue. Air transfer was associated with a 20-30 minute decrease from first medical contact to pPCI, at distances down to 90 km from the pPCI center and with a trend toward better survival among air transported patients. The pPCI center also serves a small island in the Baltic Sea, where STEMI patients are rescued via air force helicopters. Based on data from more than 100 patients transferred over the past decade, we have found a similar in-hospital and long term mortality rate compared to the main island inhabitants. In conclusion, with the optimal collaboration within a STEMI network including local hospitals, university clinics, EMS and military helicopters using the same telemedicine system and field triage of STEMI patients, most patients can be treated within the time limits suggested by the current guidelines. These organizational changes are likely to contribute to the improved mortality rate for STEMI patients., (© 2013.)

To investigate whether pregnancy-associated plasma protein-A (PAPP-A) is a prognostic marker in patients admitted with high-risk acute coronary syndrome. In patients admitted with high-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and ST-segment elevation myocardial infarction (STEMI), risk stratification is primarily determined by the markers of myocardial necrosis and known demographic risk profiles. However, it has recently been proposed that the presence and extent of vulnerable plaques might influence the prognosis significantly. A marker for the vulnerable plaque could identify patients at high risk who would potentially benefit from intensive treatment and surveillance. Two populations of consecutive patients admitted with high-risk NSTE-ACS (n = 123) and STEMI (n = 314) were evaluated with serial measurements of PAPP-A. The incidence of mortality and nonfatal myocardial infarction was prospectively registered for 2.66 to 3.47 years. In the patients with high-risk NSTE-ACS, PAPP-A was related to the risk of nonfatal myocardial infarction (p = 0.02) and death (p = 0.03). This result was consistent on multivariate analysis of the combination of mortality or nonfatal myocardial infarction (odds ratio 2.65, 95% confidence interval 1.40 to 5.03) but not for mortality alone (p = NS). In patients with STEMI, PAPP-A was related to the risk of death (p = 0.01) but not the composite outcome of myocardial infarction and death. This was also true after adjustment for other univariate predictors of death (odds ratio 2.19, 95% confidence interval 1.16 to 4.16). In conclusion, PAPP-A seems to be valuable in predicting the outcomes of patients admitted with high-risk NSTE-ACS or STEMI.