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Aims Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) are a heterogenous group and previous studies indicate a decreased Health-related quality-of-life (HRQoL) compared with patients with myocardial infarction with obstructive coronary artery disease and healthy individuals. However, longitudinal data are scarce. Therefore, the aim was to explore HRQoL among patients with MINOCA during a one-year period after the acute event in comparison with a group of healthy individuals and to describe HRQoL in patients with Takotsubo Syndrome (TTS). Methods and results Patients with MINOCA were recruited from five hospitals in the Stockholm region (SMINC-2 study, clinical trials: NCT2318498). Patients responded to the HRQoL questionnaire RAND-36 between days 2–4, after 6 and 12 months respectively. A sample of population-based individuals was used as a comparison group. A total of 142 MINOCA patients, (70% women) mean age of 56 years, responded. A population-based sample of 317 volunteers (66% women) mean age of 57 years. Patients with MINOCA scored lower than the comparison group in the domains role functioning physical, social functioning, and role functioning emotional (P = 0.01–0.02) at 12 months. In these domains of HRQoL there was no improvement in MINOCA patients during 12 months follow-up. In the domains of energy/fatigue vitality and emotional well-being the scores improved and were similar to the comparison group at 12 months. Patients with TTS scored generally lower on RAND-36 than MINOCA patients without TTS. Conclusion Physical, social, and emotional functioning did not improve during the first year after MINOCA, indicating a need for increased follow-up including psychological support.

BackgroundIn patients with myocardial infarction with nonobstructive coronary arteries (MINOCA), cardiovascular magnetic resonance imaging (CMR) can often establish a causal diagnosis. It is unknown if CMR is warranted in patients with normal echocardiographic findings, or if measurement of high-sensitive troponin T (hs-TnT) and NT-pro-BNP can be of value in selecting patients for further imaging.ObjectivesTo assess the diagnostic accuracy of echocardiography and hs-TnT and NT-pro-BNP for identifying patients receiving any diagnosis using CMR.MethodsWe included patients (n = 123) from the SMINC2 study who underwent same day CMR and echocardiography, at a median of 3 days after hospital admission for MINOCA. Normal echocardiography was defined as left ventricular ejection fraction ≥ 55%, absolute global longitudinal strain ≥ 17%, E/e′ ≤ 14, and no regional wall motion abnormalities. Logistic regression models were fitted to assess the probability of CMR diagnosis at increasing levels of hs-TnT and NT-pro-BNP.ResultsOf patients with a normal echocardiographic examination, 23/33 (70%) received a diagnosis using CMR. Pathological echocardiography identified patients with a diagnosis using CMR with a sensitivity of 77%, specificity 38%, positive predictive value 82%, and negative predictive value 30%, respectively. There was no level of hs-TnT or NT-pro-BNP below which a CMR diagnosis could be reliably excluded.ConclusionsThe majority of patients with MINOCA and a normal echocardiogram will receive a diagnosis by CMR. A CMR diagnosis was common even among patients with low levels of biomarkers. CMR should be recommended regardless of echocardiographic findings and hs-TnT or NT-pro-BNP levels in patients with MINOCA.

AimsDiastolic dysfunction after myocardial infarction (MI) is a marker of poor prognosis. The relationship between myocardial infarction size (IS), myocardial edema, and diastolic dysfunction is poorly understood, both in the acute phase, and in the development of diastolic dysfunction in the follow-up setting. Using a mechanistic approach could potentially add insights.Methods and resultsPatients underwent cardiovascular magnetic resonance (CMR) imaging and echocardiography including mechanistic analysis using the parameterized diastolic filling method within 4-7 days (acute) and 6 months after a first acute anterior MI (n=74). Linear regression modeling of echocardiographic diastolic parameters using CMR IS with and without inclusion of the myocardium at risk (MAR) and model comparisons with likelihood ratio tests were performed. Diastolic parameters at 6 months follow-up were modelled using final IS. For most parameters there was no association with acute IS, except for deceleration time (R2=0.24, p2=0.13, p=0.01) and the mechanistic stiffness parameter (R2=0.21, p2 increase: 0.08, p=0.02). At 6 months follow-up, final IS was only associated with viscoelastic energy loss (R2=0.22, p=0.001).ConclusionIn acute MI, both IS and MAR are related to diastolic function but only to a limited extent. At 6 months after infarction, increasing IS is related to less viscoelastic energy loss, albeit also to a limited extent. The relationship between IS and diastolic dysfunction seems to be mediated by mechanisms beyond simply the spatial extent of ischemia or infarction.

Background Takotsubo syndrome (TS) is a life-threatening acute heart failure syndrome without any evidence-based treatment options. No treatment for TS has been examined in a randomized trial.Study design and objectives BROKEN-SWEDEHEART is a multicenter, randomized, open-label, registry-based 2 x 2 factorial clinical trial in patients with TS designed to test whether treatment with adenosine and dipyridamole accelerates cardiac recovery and improves clinical outcomes compared to standard care (study 1); and apixaban reduces the risk of thromboembolic events compared to no treatment with antithrombotic drugs (study 2). The trial will enroll 1,000 patients. Study 1 (adenosine hypothesis) will evaluate 2 coprimary end points: (1) wall motion score index at 48 to 96 hours (evaluated in the first 200 patients); and (2) the composite of death, cardiac arrest, need for mechanical assist device or heart failure hospitalization within 30 days or left ventricular ejection fraction Funding Agencies|Swedish Research Council [2019-00475]; Swedish Heart and Lung Foundation [20200826]; ALF Goteborg [ALFGBG-920961]

Background: Bivalirudin was not superior to unfractionated heparin in patients with myocardial infarction (MI) treated with percutaneous coronary intervention and no planned use of GPI (glycoprotein IIb/IIIa inhibitors) in contemporary clinical practice of radial access and potent P2Y 12 -inhibitors in the VALIDATE-SWEDEHEART randomized clinical trial (Bivalirudin Versus Heparin in STEMI and NSTEMI Patients on Modern Antiplatelet Therapy–Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry). Methods: In this prespecified separately powered subgroup analysis, we included patients with ST-segment–elevation MI undergoing primary percutaneous coronary intervention with the primary composite end point of all-cause death, MI, or major bleeding event within 180 days. Results: Among the 6006 patients enrolled in the trial, 3005 patients with ST-segment–elevation MI were randomized to receive bivalirudin or heparin. The mean age was 66.8 years. According to protocol recommendations, 87% were treated with potent oral P2Y 12 -inhibitors before start of angiography and radial access was used in 90%. GPI was used in 51 (3.4%) and 74 (4.9%) of patients randomized to receive bivalirudin and heparin, respectively. The primary end point occurred in 12.5% (187 of 1501) and 13.0% (196 of 1504; hazard ratio [HR], 0.95 [95% CI, 0.78–1.17], P =0.64) with consistent results in all major subgroups. All-cause death occurred in 3.9% versus 3.9% (HR, 1.00 [0.70–1.45], P =0.98), MI in 1.7% versus 2.2% (HR, 0.76 [0.45–1.28], P =0.30), major bleeding in 8.3% versus 8.0% (HR, 1.04 [0.81–1.33], P =0.78), and definite stent thrombosis in 0.5% versus 1.3% (HR, 0.42 [0.18–0.96], P =0.04). Conclusions: In patients with ST-segment–elevation MI undergoing primary percutaneous coronary intervention with radial access and receiving current recommended treatments with potent P2Y 12 -inhibitors rate of the composite of all-cause death, MI, or major bleeding was not lower in those randomized to receive bivalirudin as compared with heparin. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02311231.

Background Recent studies demonstrate that prothrombotic antiphospholipid antibodies (aPL) are overrepresented in patients with myocardial infarction (MI) due to coronary artery disease (MICAD). However, it is not known whether aPL differ between the two subsets of MI: MICAD and MI with nonobstructive coronary arteries (MINOCA). Objectives To determine whether aPL are associated with MINOCA or MICAD, or with hypercoagulability as assessed by activated protein C-protein C inhibitor (APC-PCI) complex. Methods Well-characterized patients with MINOCA (n = 98), age- and gender-matched patients with MICAD (n = 99), and healthy controls (n = 100) were included in a cross-sectional case-control study. Autoantibodies (IgA/G/M) targeting cardiolipin and β2 glycoprotein-I and specific nuclear antigens were analyzed by multiplexed bead technology. The concentration of APC-PCI was determined as a measure of hypercoagulability by an immunofluorometric sandwich assay. Results Both prevalence and titers of aPL of the IgG isotype (anti-cardiolipin and/or anti-β2 glycoprotein-I) were higher in patients with MINOCA and MICAD than in controls. aPL IgG positivity was twice as frequent among patients with MICAD than MINOCA (11% vs. 6%, nonsignificant). We observed no group differences regarding aPL IgA/M or antibodies targeting specific nuclear antigens. Levels of APC-PCI were elevated in aPL IgG-positive compared to aPL IgG-negative MICAD patients. Conclusions aPL IgG, but not IgA/M, are enriched particularly in patients with MICAD but also in patients with MINOCA, as compared to controls. Interestingly, signs of hypercoagulability-measured by increased levels of the APC-PCI complex-were present in aPL IgG-positive MICAD patients, indicating an association with functional disturbances of the coagulation system.

Background: The optimal anti-coagulation strategy for patients with non-ST-elevation myocardial infarction treated with percutaneous coronary intervention is unclear in contemporary clinical practice of radial access and potent P2Y12-inhibitors. The aim of this study was to investigate whether bivalirudin was superior to heparin monotherapy in patients with non-ST-elevation myocardial infarction without routine glycoprotein IIb/IIIa inhibitor use. Methods: In a large pre-specified subgroup of the multicentre, prospective, randomised, registry-based, open-label clinical VALIDATE-SWEDEHEART trial we randomised patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention, treated with ticagrelor or prasugrel, to bivalirudin or heparin monotherapy with no planned use of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention. The primary endpoint was the rate of a composite of all-cause death, myocardial infarction or major bleeding within 180 days. Results: A total of 3001 patients with non-ST-elevation myocardial infarction, were enrolled. The primary endpoint occurred in 12.1% (182 of 1503) and 12.5% (187 of 1498) of patients in the bivalirudin and heparin groups, respectively (hazard ratio of bivalirudin compared to heparin treatment 0.96, 95% confidence interval 0.78–1.18, p=0.69). The results were consistent in all major subgroups. All-cause death occurred in 2.0% versus 1.7% (hazard ratio 1.15, 0.68–1.94, p=0.61), myocardial infarction in 2.3% versus 2.5% (hazard ratio 0.91, 0.58–1.45, p=0.70), major bleeding in 8.9% versus 9.1% (hazard ratio 0.97, 0.77–1.24, p=0.82) and definite stent thrombosis in 0.3% versus 0.2% (hazard ratio 1.33, 0.30–5.93, p=0.82). Conclusion: Bivalirudin as compared to heparin during percutaneous coronary intervention for non-ST-elevation myocardial infarction did not reduce the composite of all-cause death, myocardial infarction or major bleeding in non-ST-elevation myocardial infarction patients receiving current recommended treatments with modern P2Y12-inhibitors and predominantly radial access.

Aims It is well‐accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma‐free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC‐2) study where TS constituted more than one third of the patients. Methods and results The patients included in the SMINC‐2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma‐free catecholamine metabolites; metanephrine, normetanephrine, and methoxy‐tyramine were measured on day 2–4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC‐2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy‐tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC‐2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma‐triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC‐2 study. Conclusion There was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma‐induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood‐borne catecholamines do not play a direct role in the pathogenesis of TS.

Aim To evaluate utilization and outcomes of rotational atherectomy (RA) using data from the Swedish Coronary and Angioplasty Registry (SCAAR) Methods We included 1476 patients with 2218 lesions who underwent RA from 2005 to 2016. To study temporal changes, the study period was divided into three equal time-periods, period A, B and C. Results Although the number of RA procedures increased 3-fold from 2005 to 2016, the rate of RA (of all PCI procedures) remained low (0.5% vs 1.2% in 2005 vs 2016). RA patients consisted a high-risk group, with advanced age and clustering of comorbidities. Over time, included patients were older and had a higher risk profile. Trans-radial access, drug eluting stent (DES) use and use of intravascular imaging significantly increased from period A to C whereas positioning of a temporary pacemaker or intra-aortic balloon pump declined. Unfractionated heparin became the main anticoagulant (52 vs 87%) and use of glycoprotein IIb/IIIa inhibitors declined (31 vs 12%, in period A vs C). Following RA, 11% of lesions were treated without stent (15 vs 15 vs 8%, in period A, B and C) (Rota-only). In lesions treated with a stent, a bare metal stent (BMS) was implanted in 39% vs 12% vs 2% and a new generation DES (N-DES) in 5 vs 75 vs 97% (period A vs B vs C) of lesions. The 3-year cumulative rate of restenosis was 6.7% (122 events), (11.1 vs 7.1 vs 4.1% in period A vs B vs C). As compared to DES, rota-only (adjusted HR 2.71; 95% CI 1.69- 4.36) and BMS (adjusted HR 3.63; 95% CI 2.27- 5.81) were associated with significantly higher risk for restenosis. First generation DES were associated with numerically higher but not significantly different risk for restenosis as compared to N-DES (adjusted HR 1.31; 95% CI 0.74- 2.31). The 3 year cumulative rate of major adverse cardiac events (MACE), including death, myocardial infarction (MI) or any restenosis was 30.6% (34.2 vs 31.4 vs 28.2%, in period A vs B vs C) and the corresponding numbers for all-cause mortality were 18.1% (18.9 vs 18.4 vs 17.0%). After adjustment for baseline characteristics and angiographic findings, RA in period A was associated with higher risk for MACE as compared to period C (adjusted HR 1.40; 95% CI 1.09- 1.79), due to higher risk for MI and restenosis. The difference disappeared when procedural characteristics, including DES use, were added to the model. The rate of major in-hospital complications was 7.0%, including in-hospital death 1.3%, periprocedural MI 2.8%, perforation 1.1%, cardiac tamponade 0.7%, stroke 0.2% and major bleedings 2.1%. We found no significant differences over time. Conclusion During the studied period, RA remained a rare procedure, utilised in a highly selected population. Over time a declining rate of restenosis and MI after RA was observed, a finding that appeared to be mainly driven by an increased use of DES. The rate of major in-hospital complication remained low. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Boston Scientific International

Background To investigate the optimal periprocedural antithrombotic strategy in patients on oral anticoagulants (OAC) who undergoing unplanned percutaneous coronary intervention (PCI). Methods Using data from the SWEDEHEART registry, we identified all patients on OAC who underwent an unplanned PCI, from 2005 to 2017. We compared uninterrupted OAC (U-OAC) vs interrupted OAC (I-OAC) therapy, defined as any discontinuation of OAC at least 24 hours prior to PCI. Outcomes were major adverse cardiac and cerebrovascular events (MACCE), including death, MI or stroke and net adverse cardiac and cerebrovascular events (NACCE), including MACCE or major bleeds, up to 120 days after the index procedure. Results We included 6485 patients, 3163 in U-OAC and 3322 in I-OAC group. The U-OAC strategy increased over time, by 13% per year. Almost 80% of patients in both groups had an acute coronary syndrome. We found no major differences in terms of medical history, clinical characteristics and the CRUSADE bleeding score on admission. The proportion of patients on warfarin was higher in the I-OAC group (85 vs 81%). Patients in the I-OAC were more likely to receive low-molecular weight heparin (29 vs 12%) and glycoprotein IIb/IIIa inhibitors (6 vs 3%) during the index hospitalisation. In the I-OAC group, dual antiplatelet therapy without OAC was more often prescribed (22 vs 8%) and OAC plus single antiplatelet therapy was less often prescribed (8 vs 22%) at discharge. At 120 days, the cumulative rate of MACCE was 8.2 vs 8.2% and the rate of NACCE was 12.6 vs 12.9% in I-OAC vs U-OAC, respectively. We found no significant difference in the risk for MACCE and NACCE between the two groups (table). The risk for major or minor in-hospital bleeds was similar. I-OAC was associated with significantly longer time-delay to PCI and length of hospitalisation (table). Conclusion Uninterrupted OAC was safe and was associated with significantly shorter length of hospitalisation. Our data support U-OAC as the preferable strategy in patients on OAC undergoing PCI. Funding Acknowledgement Type of funding source: None

Objectives This study sought to compare interrupted and uninterrupted oral anticoagulant therapy (I-OAC vs. U-OAC) in patients on OAC undergoing percutaneous coronary intervention. Background There is a paucity of data regarding the optimal peri-procedural management of OAC-treated patients. Methods In the SWEDEHEART registry, all patients on OAC who were admitted acutely and underwent percutaneous coronary intervention or coronary angiography with a diagnostic procedure, from 2005 to 2017, were included. Outcomes were major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction, or stroke) and bleeds at 120 days. Propensity score was used to adjust for the nonrandomized treatment selection. Results The study included 6,485 patients: 3,322 in the I-OAC group and 3,163 in the U-OAC group. The cumulative incidence of MACCE was 8.2% (269 events) versus 8.2% (254 events) in the I-OAC and the U-OAC groups, respectively. The adjusted risk for MACCE did not differ between the groups (I-OAC vs. U-OAC hazard ratio: 0.89; 95% confidence interval: 0.71 to 1.12). Similarly, no difference was found in the risk for MACCE or bleeds (12.6% vs. 12.9%, adjusted hazard ratio: 0.87; 95% confidence interval: 0.70 to 1.07). The risk for major or minor in-hospital bleeds did not differ between the groups. However, U-OAC was associated with a significantly shorter duration of hospitalization: 4 (3 to 7) days versus 5 (3 to 8) days; p Conclusions I-OAC and U-OAC were associated with equivalent risk for MACCE and bleeding complications. An U-OAC strategy was associated with shorter length of hospitalization. These data support U-OAC as the preferable strategy in patients on OAC undergoing coronary intervention.

The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging.The etiology of MINOCA is heterogeneous, including coronary, cardiac, and noncardiac causes. Patients with MINOCA, therefore, represent a diagnostic challenge where CMR is increasingly used.The SMINC-2 study was a prospective study of 148 patients with MINOCA imaged with 1.5-T CMR with TCMR was performed at a median of 3 (SMINC-2) versus 12 (SMINC-1) days after hospital admission. In total, 77% of patients received a diagnosis with CMR imaging in the SMINC-2 study compared to 47% in the SMINC-1 study (p 0.001). Compared to SMINC-1, CMR in SMINC-2 detected higher proportions of myocarditis (17% vs. 7%; p = 0.01) and takotsubo syndrome (35% vs. 19%; p = 0.002) but similar proportions of myocardial infarction (22% vs. 19%; p = 0.56) and other cardiomyopathies (3% vs. 2%; p = 0.46).The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2]; NCT02318498).

Background Myocardial infarction with non-obstructive coronary arteries is a working diagnosis for several heart disorders. Previous studies on anxiety and depression in patients with myocardial infarction with non-obstructive coronary arteries are lacking. Our aim was to investigate the prevalence of anxiety and depression among patients with myocardial infarction with non-obstructive coronary arteries. Methods We included 99 patients with myocardial infarction with non-obstructive coronary arteries together with age- and sex-matched control groups who completed the Beck Depression Inventory and the Hospital Anxiety and Depression Scale (HADS) 3 months after the acute event. Results Using the Beck Depression Inventory, we found that the prevalence of depression in patients with myocardial infarction with non-obstructive coronary arteries (35%) was higher than in healthy controls (9%; P = .006) and similar to that of patients with coronary heart disease (30%; P = .954). Using the HADS anxiety subscale, we found that the prevalence of anxiety in patients with myocardial infarction with non-obstructive coronary arteries (27%) was higher than in healthy controls (9%; P = .002) and similar to that of patients with coronary heart disease (21%; P = .409). Using the HADS depression subscale, we found that the prevalence of depression in patients with myocardial infarction with non-obstructive coronary arteries (17%) was higher than in healthy controls (4%; P = .003) and similar to that of patients with coronary heart disease (13%; P = .466). Patients with myocardial infarction with non-obstructive coronary arteries and takotsubo syndrome scored higher on the HADS anxiety subscale than those without (P = .028). Conclusions This is the first study on the mental health of patients with myocardial infarction with non-obstructive coronary arteries to show that prevalence rates of anxiety and depression are similar to those in patients with coronary heart disease.

Background Previous studies indicate that remote ischemic conditioning performed before percutaneous coronary intervention (PCI) reduces infarct size in patients with ST-elevation myocardial infarction (STEMI). It remains unclear whether remote conditioning affords protection when performed in adjunct to primary PCI. We aimed to study whether remote ischemic per-postconditioning (RIperpostC) initiated after admission to the catheterization laboratory attenuates myocardial infarct size in patients with anterior STEMI. Methods In this prospective multicenter trial 93 patients with anterior STEMI were randomized to RIperpostC or sham procedure as adjunct to primary PCI. RIperpostC was started on arrival in the catheterization laboratory by 5-minute cycles of inflation and deflation of a blood pressure cuff around the left thigh and continued throughout the PCI procedure. Infarct size and myocardium at risk were determined by cardiac magnetic resonance at day 4 to 7. The primary outcome was myocardial salvage index. Results There was no significant difference in myocardial salvage index between the RIperpostC and control group (median 48.5% and interquartile range 30.9%-60.8% vs 49.2% [42.1%-58.8%]). Neither did absolute infarct size in relation to left ventricular myocardial volume differ significantly (RIperpostC 20.6% [14.1%-31.7%] vs control 17.9% [13.4%-25.0%]). The RIperpostC group had larger myocardial area at risk than the control group (43.1% (35.4%-49.7%) vs 37.0% (30.8%-44.1%) of the left ventricle, P =.03). Peak value and area under the curve for troponin T did not differ significantly between the study groups. Conclusions RIperpostC initiated after admission to the catheterization laboratory in patients with anterior STEMI did not confer protection against reperfusion injury.

BACKGROUND Conflicting evidence exists concerning the cardioprotective efficacy of remote ischemic conditioning as an adjunct to primary percutaneous intervention (PCI) in ST-elevation myocardial infarction (STEMI) and data on long-term outcomes are scarce. We evaluated final infarct size by cardiac magnetic resonance (CMR) performed 6 months after anterior STEMI treated with remote ischemic conditioning and clinical outcomes up to 3 years after the event. METHODS One hundred and fifteen patients with anterior STEMI were randomized to remote ischemic per-postconditioning (RIperpostC) or sham procedure as adjunct to primary PCI. The primary outcome was myocardial salvage index (MSI) on CMR 6 months after the event. Secondary outcomes were absolute infarct size, left ventricular function, cardiac mortality, major adverse cardiac and cerebrovascular events (MACCE-composite of all-cause mortality, myocardial infarction, readmission for heart failure, ischemic stroke, and target lesion revascularization) and all the individual components of MACCE. RESULTS There was no difference in MSI or left ventricular function between the RIperpostC and the control group after 6 months. Nor did clinical outcomes at 6 months or 3 years differ between the groups. CONCLUSIONS RIperpostC as an adjunct to PCI in anterior STEMI did not result in better MSI or left ventricular function 6 months after the event. Furthermore, clinical outcomes at 6 months and 3 years were not altered.

Around 5%-10% of patients with myocardial infarction (MI) present with nonobstructive coronary arteries (MINOCA). We aimed to assess pathophysiological mechanisms in MINOCA by extensively evaluating cardiovascular biomarkers in the stable phase after an event, comparing MINOCA patients with cardiovascular healthy controls and MI patients with obstructive coronary artery disease (MI-CAD).Ninety-one biomarkers were measured with a proximity extension assay 3 months after MI in 97 MINOCA patients, 97 age- and sex-matched MI-CAD patients, and 98 controls. Lasso analyses (penalized logistic regression models) and adjusted multiple linear regression models were used for statistical analyses.In the Lasso analysis (MINOCA vs MI-CAD), 8 biomarkers provided discriminatory value: P-selectin glycoprotein ligand 1, C-X-C motif chemokine 1, TNF-related activation-induced cytokine, and pappalysin-1 (PAPPA) with increasing probabilities of MINOCA, and tissue-type plasminogen activator, B-type natriuretic peptide, myeloperoxidase, and interleukin-1 receptor antagonist protein with increasing probabilities of MI-CAD. Comparing MINOCA vs controls, 7 biomarkers provided discriminatory value: N-terminal pro-B-type natriuretic peptide, renin, NF-κ-B essential modulator, PAPPA, interleukin-6, and soluble urokinase plasminogen activator surface receptor with increasing probabilities of MINOCA, and agouti-related protein with increasing probabilities of controls. Adjusted multiple linear regression analyses showed that group affiliation was associated with the concentrations of 7 of the 8 biomarkers in the comparison MINOCA vs MI-CAD and 5 of the 7 biomarkers in MINOCA vs controls.Three months after the MI, the biomarker concentrations indicated greater inflammatory activity in MINOCA patients than in both MI-CAD patients and healthy controls, and a varying degree of myocardial dysfunction among the 3 cohorts.

Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine‐Treated Patients With ST‐Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST‐segment–elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on‐treatment platelet reactivity and plasma concentrations of ticagrelor and AR ‐C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31–50) versus 45.5 (37–60) minutes ( P =0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on‐treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P =0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self‐estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02942550.

Background Spontaneous coronary artery dissection (SCAD) is an under-recognized acute cardiac disease entity. It is often missed, or misdiagnosed as coronary spasm, coronary atherosclerotic lesion, or thrombotic coronary occlusion. During the last years, SCAD also has been reported to be ‘misdiagnosed as takotsubo syndrome (TS)’ in patients with features consistent with both conditions. Spontaneous coronary artery dissection may present as an acute coronary syndrome and sometimes as sudden cardiac death. Case summary We report on the case of a 67-year-old woman who presented with features of ST-elevation myocardial infarction treated with fibrinolysis. The patient showed to have obtuse-marginal SCAD, which was misdiagnosed as fibrinolysis caused lysis of a coronary thrombus. The patient had moreover all other features of TS. Discussion This case report teaches important information about SCAD. The association between SCAD and TS are discussed.

Aims: Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients. Methods: This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days. Results: There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women. Conclusion: In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.

The purpose of this study was to describe type A behavior pattern and trait anger in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and compare them with patients with coronary heart disease and healthy controls. Type A behavior pattern and anger have been linked to coronary heart disease in previous studies. This is the first study to assess type A behavior pattern and trait anger in MINOCA patients.One hundred MINOCA patients, consecutively recruited during 2007-2011 at 5 coronary care units in Stockholm, were matched for sex and age to 100 coronary heart disease patients and 100 healthy controls. All participants completed the Bortner Rating Scale to quantify type A behavior pattern and the Spielberger Trait Anger Scale to quantify anger 3 months after the acute event.MINOCA patients' Bortner Rating Scale score was 70.9 ± 10.8 (mean ± SD) and Spielberger Trait Anger Scale score was 14 (12-17) (median; interquartile range). Coronary heart disease patients' Bortner Rating Scale score was 70.5 ± 10.2 and Spielberger Trait Anger Scale score was 14 (12-17). Healthy controls' Bortner Rating Scale score was 71.9 ± 9.1 and Spielberger Trait Anger Scale score was 13 (11-16).We found no significant differences in Bortner Rating Scale score and Spielberger Trait Anger Scale score among MINOCA, coronary heart disease patients, and healthy controls, regardless of whether total scores, subscales, or cutoffs were used to classify type A behavior pattern and trait anger. However, we cannot exclude the existence of an occasional episode of anger or mental stress in relation to the coronary event. This is the first study to assess type A behavior pattern and trait anger in patients with MINOCA, and future studies need to confirm the current findings before any firm conclusions can be made.

Background Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is common with a prevalence of 6% of all patients fulfilling the diagnosis of myocardial infarction. MINOCA should be considered a working diagnosis. Cardiac Magnetic Resonance (CMR) imaging has recently been suggested to be of great value to determine the cause behind MINOCA. The objectives of this paper are to describe the rationale behind the second Stockholm Myocardial Infarction with Normal Coronaries (SMINC-2) study and to discuss the protocol for investigation of MINOCA patients in the light of the recently published position paper from the European Society of Cardiology. Methods The SMINC-2 study is an open non-randomised study using historical controls for comparison. The primary aim is to prove that MINOCA patients investigated with the latest CMR imaging technique can achieve a diagnosis in 70% of all cases entirely by imaging. By including 150 patients we will have >80% chance to prove that the diagnostic accuracy can be improved by 20 absolute % with a p-value of less than 0.05 when compared with CMR imaging in the SMINC-1 study. Furthermore, in addition to invasive coronary angiography, coronary arteries are evaluated by computed tomography angiography to investigate coronary causes and questionnaires are used to describe Quality-of-Life (QoL). By January 1st 2017, 75 patients have been included. Discussion Whether CMR imaging can provide a diagnosis to an adequate proportion of MINOCA patients is unknown. Well-defined inclusion and exclusion criteria will be used to compare a MINOCA cohort from the population with an appropriate control group. Positive results are likely to influence future guidelines of the management of MINOCA. Furthermore, the study will give mechanistic insights into MINOCA in particular in patients with “true” myocardial infarction and describe QoL in this vulnerable group of patients. Trial registration Clinical Trials NCT02318498 .

BACKGROUND The comparative efficacy of various anticoagulation strategies has not been clearly established in patients with acute myocardial infarction who are undergoing percutaneous coronary intervention (PCI) according to current practice, which includes the use of radial-artery access for PCI and administration of potent P2Y 12 inhibitors without the planned use of glycoprotein IIb/IIIa inhibitors. METHODS In this multicenter, randomized, registry-based, open-label clinical trial, we enrolled patients with either ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) who were undergoing PCI and receiving treatment with a potent P2Y(12) inhibitor (ticagrelor, prasugrel, or cangrelor) without the planned use of glycoprotein IIb/IIIa inhibitors. The patients were randomly assigned to receive bivalirudin or heparin during PCI, which was performed predominantly with the use of radial-artery access. The primary end point was a composite of death from any cause, myocardial infarction, or major bleeding during 180 days of follow-up. RESULTS A total of 6006 patients (3005 with STEMI and 3001 with NSTEMI) were enrolled in the trial. At 180 days, a primary end-point event had occurred in 12.3% of the patients (369 of 3004) in the bivalirudin group and in 12.8% (383 of 3002) in the heparin group (hazard ratio, 0.96; 95% confidence interval [CI], 0.83 to 1.10; P = 0.54). The results were consistent between patients with STEMI and those with NSTEMI and across other major subgroups. Myocardial infarction occurred in 2.0% of the patients in the bivalirudin group and in 2.4% in the heparin group (hazard ratio, 0.84; 95% CI, 0.60 to 1.19; P = 0.33), major bleeding in 8.6% and 8.6%, respectively (hazard ratio, 1.00; 95% CI, 0.84 to 1.19; P = 0.98), definite stent thrombosis in 0.4% and 0.7%, respectively (hazard ratio, 0.54; 95% CI, 0.27 to 1.10; P = 0.09), and death in 2.9% and 2.8%, respectively (hazard ratio, 1.05; 95% CI, 0.78 to 1.41; P = 0.76). CONCLUSIONS Among patients undergoing PCI for myocardial infarction, the rate of the composite of death from any cause, myocardial infarction, or major bleeding was not lower among those who received bivalirudin than among those who received heparin monotherapy. (Funded by the Swedish Heart-Lung Foundation and others; Funding Agencies|Swedish Heart-Lung Foundation; Swedish Research Council; AstraZeneca; Medicines Company; Swedish Foundation for Strategic Research (as part of the TOTAL-AMI project)

Background The combination of deformation analysis with conventional wall motion scoring (WMS) has been shown to increase the diagnostic sensitivity of dobutamine stress echocardiography (DSE). The feasibility and diagnostic power of WMS is largely improved by contrast agents; however, they are not used in combination with deformation analysis, as contrast agents are generally considered to render strain measurement unfeasible. Aims To assess the feasibility of tissue velocity (TVI)- and 2D speckle tracking (ST)-based strain analysis during contrast-enhanced DSE; and to show whether there is an incremental value in combining deformation analysis with contrast-enhanced WMS. Methods DS echocardiograms containing native, tissue Doppler, and contrast-enhanced loops of 60 patients were analysed retrospectively. The feasibility of WMS, TVI-, and ST-strain measurement was determined in 40 patients according to pre-defined criteria. The diagnostic ability of a combined protocol integrating data from contrast-WMS and TVI-strain measurement was then compared with contrast-WMS alone in all 60 patients, using coronary angiograms as a gold standard. Results Both TVI- and ST-based strain analysis were feasible during contrast-DSE (feasibility at peak stress: 87 and 75%). At the patient level, the diagnostic accuracy of the combined method did not prove superior to contrast-WMS (82 vs. 78%); a trend towards improved sensitivity and specificity for detecting coronary artery disease in the right coronary artery circulation (sensitivity: 85 vs. 77%, P = NS; specificity: 96 vs. 94%) was, however, observed. Conclusion Both TVI- and ST-based myocardial deformation analysis are feasible during contrast-enhanced DSE, however, our results fail to demonstrate a clear diagnostic benefit of additional strain analysis over expert WMS alone.

According to Swedish National Board of Health and Welfare statistics, a dramatic decrease in both the incidence of and mortality from acute myo-cardial infarction has been seen in the past two deca...

Tissue Doppler imaging (TDI) is a promising echocardiographic modality allowing quantification of myocardial performance. However, the prognostic potential of TDI in patients with acute myocardial infarction (AMI) is not yet investigated. We sought to explore the ability of TDI in identifying patients at risk for new cardiovascular events after AMI.One hundred and nineteen patients with AMI were recruited prospectively (mean age 61 years; range 32-81 years of age). Patients with diabetes mellitus (DM) were excluded. Echocardiography was performed 3-12 months after AMI. Two-dimensional (2-D) and TDI variables were recorded. The patients were followed during a mean period of 4·6 years (range 1-8 years). The primary end-point was defined as any of the following: death from any cause, non-fatal reinfarction or stroke, unstable angina pectoris, congestive heart failure requiring hospitalization and coronary revascularization procedure.Thirty patients had some form of cardiovascular events during follow-up. Seven patients had cardiovascular death, 13 patients had reinfarction and four patients had a stroke. New angina or unstable angina was recorded in 21 patients. Of these patients, 13 underwent percutaneous coronary angioplasty (PCI) or coronary artery bypass grafting (CABG). The early diastolic myocardial velocity (E(m)) emerged as the only echocardiographic variable that offered a clear differentiation between patients that presented with new cardiovascular (CV) events as compared to the corresponding group without any CV events at follow-up (P0·05). In multivariate statistical analysis and after adjustment for age, sex, total cholesterol, body mass index (BMI) and other baseline characteristics, Em remained as independent predictors of CV events (HR, 1·18, 95% CI, 1·02-1·36; P0·05). However, none of the investigated variables evolved as an independent predictor of cardiovascular morbidity and mortality.E(m) appears to be a sensitive echocardiographic index in identifying non-diabetic patients with AMI at risk of new cardiovascular events.

Summary This study aimed to evaluate the effect of standard medical treatment on the progression of atherosclerosis after a myocardial infarction, in an ordinary clinical setting, by measuring the right and left common carotid intima-media thickness (IMT). The first investigation took place 3–12 months after the index event; the second took place 3·3–8·2 years after the first. In both investigations, the right and left carotid arteries of 102 patients were examined with an ultrasound duplex scanner. Common carotid IMT and calculated cross-sectional intima-media area (cIMa) were measured on both sides. More than 90% of the patients were treated with aspirin, beta-blockers and statins. In the first investigation, IMT and cIMa were significantly greater on the left side compared to the right (IMT: 0·83 ± 0·22 and 0·74 ± 0·18 mm, P

5-Fluorouracil (5-FU) and its oral pro-drug capecitabine are widely used in oncology for the treatment of various solid tumours, including colorectal cancers. Cardiotoxicity to these drugs is not an uncommon adverse effect and has been reported in 1%-18% of patients. Capecitabine has been reported to trigger mid-apical Takotsubo syndrome (TS). We describe here the case of a 55-year-old man who presented with cardiogenic shock and ECG signs of ST-elevation myocardial infarction. The symptoms began 28 h after the commencement of capecitabine adjuvant therapy, following a radical right-sided hemicolectomy for low-differentiated adenocarcinoma of the caecum. Echocardiography showed severe global left ventricular dysfunction. Cardiac magnetic resonance imaging showed no signs of late gadolinium enhancement. These clinical, cardiac image study findings and the course of the disease with full recovery within one week were consistent with global TS triggered by the adjuvant therapy capecitabine and presenting with a life-threatening cardiogenic shock. Moreover, we have demonstrated the speedy dynamic of the left ventricular wall motion abnormality with global TS at presentation and basal (inverted) TS findings 4 days later on.

PURPOSE Coronary computed tomography angiography (CTA) and several circulating biomarkers have prognostic value regarding cardiovascular disease (CVD) events, but their association is incompletely studied. We aimed to investigate whether markers of lipid metabolism, inflammation and kidney function could predict non-obstructive coronary artery disease (CAD) determined by coronary CTA, in a low-to-intermediate-risk group. METHODS Coronary CTA and laboratory testing were performed for 115 subjects (45-70 years), with low prevalence of CVD risk factors, predominantly low-to-intermediate Framingham risk and normal or mildly reduced kidney function. RESULTS Forty-nine (43%) had no CAD at coronary CTA, and 66 (57%) had CAD in ≥1 segment (stenosis

The incidence of cardiovascular events remains high in patients with myocardial infarction (MI) despite advances in current therapies. New and better methods for identifying patients at high risk of recurrent cardiovascular events are needed. This study aimed to analyze the clinical predictors of cardiovascular events in patients with MI.The prospective cohort study consisted of 123 men and women aged between 31 and 80 years who had suffered a previous myocardial infarction (MI) 3-12 months before the examinations. The exclusion criteria were known diabetes mellitus and chronic inflammatory disease. Patients were followed up over 6.03 ± 1.36 years for CV death, recurrent MI, stroke and unstable angina pectoris. Plasma levels of high-sensitivity C-reactive protein (hs-CRP), total cholesterol and triglycerides were measured at the baseline. Echocardiography was performed.hs-CRP was significantly higher (P0.05) and left ventricular ejection fraction (LVEF) was borderline significantly lower (P = 0.057) in patients with CV events compared with those without CV events. In multivariate statistical analysis and after adjustment for age, sex, total cholesterol, smoking, and other baseline characteristics, hs-CRP3 mg/l, (RR: 6.23, 95%CI: 1.47-26.39; P0.01) and LVEF (RR: 0.94, 95%CI: 0.88-1.00; P0.05) remain as independent predictors of CV events.In this study population with previous MI an elevated hs-CRP3 mg/l and left ventricular dysfunction were significant predictors of CV death, recurrent MI, stroke and unstable angina pectoris, independent of baseline characteristics and medical treatment. Data from the study suggest that hs-CRP levels ≥ 3 mg/l and baseline ejections fraction can be used to stratify individuals at high risk of adverse CV events from patients with stable and asymptomatic coronary artery disease (CAD).

Collste O, Sorensson P, Frick M, Agewall S, Daniel M, Henareh L, Ekenback C, Eurenius L, Guiron C, Jernberg T, Hofman-Bang C, Malmqvist K, Nagy E, Arheden H, Tornvall P (Sodersjukhuset, Stockholm; Karolinska Hospital, Karolinska Institutet, Stockholm, Sweden; University of Oslo, Oslo, Norway; Sankt Goran Hospital Capio, Karolinska Institutet, Stockholm; Huddinge, Stockholm; Danderyd Hospital, Karolinska Institutet, Stockholm; and Skane University Hospital, Lund University, Lund, Sweden). Myocardial infarction with normal coronary arteries is common and associated with normal findings on cardiovascular magnetic resonance imaging: results from the Stockholm Myocardial Infarction with Normal Coronaries study. J Intern Med 2013; 273: 189-196. Objectives Myocardial infarction with angiographically normal coronary arteries (MINCA) is an important subtype of myocardial infarction; however, the prevalence, underlying pathophysiology, prognosis and optimal management of this condition are still largely unknown. Cardiovascular magnetic resonance (CMR) imaging has the potential to clarify the underlying pathology in patients with MINCA. The objective of this study was to investigate the diagnostic value of CMR imaging in this group of patients. Design The prospective, multicentre, observational Stockholm Myocardial Infarction with Normal Coronaries (SMINC) study. Setting Coronary care units in the Stockholm metropolitan area. Subjects Patients between 35 and 70 years of age with MINCA were consecutively included in the screening phase of the SMINC study. All patients had a typical clinical presentation, fulfilling the universal definition of myocardial infarction and had normal coronary angiography finding. Patients with known structural or coronary heart disease or other known causes of elevated troponin levels were excluded. Results In total, 176 patients with MINCA were screened from 2007 to 2011. Of these, 152 underwent CMR imaging. The investigation was performed a median of 12 (interquartile range 628) days after hospital admission; 67% of the findings were normal, whereas 19% of patients had signs of myocardial necrosis and 7% had signs of myocarditis. The remaining patients (7%) had either unrecognized hypertrophic cardiomyopathy or could not be classified. Conclusion In this consecutive series of patients with MINCA, CMR imaging may help to differentiate between those with myocarditis, myocardial necrosis and normal myocardium. The incidence of MINCA was higher than previously reported. After excluding cases of myocarditis, MINCA consists of a large group of patients with normal CMR imaging results and a smaller group with myocardial necrosis. The aetiologies of these different imaging findings need to be explored.

Increased carotid intima-media thickness (IMT) has been associated with increased risk of myocardial infarction (MI) and stroke. A measure of echogenicity, the grey scale median (GSM), has been shown to be inversely correlated with cardiovascular risk factors and to be predictive of mortality in a community-based cohort. We assessed the factors associated with carotid IM-GSM in younger, non-diabetic patients with a recent MI.A total of 122 patients (women, 25%) aged 31-80 years (61) were recruited 2-3 days after an acute MI. Ultrasound examinations of the carotid arteries were performed 1-12 months after the MI. IMT was 0·78 (SD 0·17) mm on the right side and 0·81 (0·20) mm on the left side (P = 0·05). GSM was 88·60 (range 46-132, SD 18·32) on the right side and 82·10 (40-126, 17·89) on the left side (P = 0·002). Triglycerides (TG) correlated with GSM on both sides (right, r = -0·27, P = 0·003; left, r = -0·18, P = 0·05). On the right side, GSM was 92·15 and 82·26 (P = 0·05) in patients with TGand ≥1·7, and on the left side, it was 84·04 and 74·55 (P = 0·02) in patients with TGand ≥2·3. On multivariate analysis, TG were significantly associated with GSM, both on the right side (P = 0·01) and on the left side (P = 0·009).We found a negative association between TG and carotid IM-GSM on both sides in patients with a recent MI. Our results also suggest that atherosclerosis progression may be faster on the left side in patients with coronary heart disease.

The interest and awareness of myocardial infarction with normal coronary arteries (MINCA) have increased recently due to the frequent use of coronary angiography, the description of Takotsubo stress cardiomyopathy, and new sensitive troponin analyses. The prevalence of MINCA in all patients with myocardial infarction (MI) was registered during a 3-month period in the Stockholm metropolitan area in Sweden. The results showed that MINCA is more common than previously thought (7%) and affecting one third of every woman with MI. Patients with myocarditis were younger and more often presented with signs of inflammation such as elevated C-reactive protein and fever. Myocarditis constitutes an important differential diagnosis for coronary artery disease. There is a need for larger studies of MINCA, including investigation with cardiac magnetic resonance imaging, to establish prevalence and pathological process in this important subgroup of MI.

Atherosclerosis is an inflammatory disease of multifactorial origin, in which immune cells together with metabolic risk factors may initiate, propagate, and activate lesions in the arterial tree. We investigated the role of auto-antibodies against endothelial cells in patients with previous myocardial infarction.One hundred and four patients were studied four to five years after acute myocardial infarction (aged 36-84 years) and 83 sex-matched healthy controls (aged 32-70 years). Anti-endothelial cells IgM and IgG auto-antibodies (AECA) were quantified in plasma using flow cytometry.IgM and IgG AECA were significantly higher (23.08 ± 0.81 and 10.63 ± 0.31 channel shifts, respectively; p0.001) in patients as compared to controls (13.40 ± 0.95 and 3.53 ± 0.54 channel shifts, respectively). Further, patients who got an invasive treatment had significantly higher levels of AECA as compared to patients with only medical treatment. Plasma concentration of IgG was positively (p0.05) correlated to the levels of high-sensitivity C-reactive protein (hsCRP).We report for the first time evidence that AECA are related to signs of inflammation and are increased in patients with atherosclerosis and previous myocardial infarction and with further increase with severity of disease.

Aims: To investigate the association between intima-media thickness of brachial and common carotid arteries and factors of the coagulation- and fibrinolysis-system with left ventricular diastolic dysfunction in patients with a previous myocardial infarction. Patients and methods: One hundred and twenty three patients, men (76%) and women (24%) aged between 32and 81 years with a history of previous acute myocardial infarction were included. B-mode ultrasound of common carotid and brachial arteries and echocardiography with tissue Doppler imaging (TDI) were evaluated. Factors of the coagulation- and fibrinolysis-system were also measured. Results: In patients with previous myocardial infarction, late diastolic filling time was significantly and positively associated with log Prothrombin fragment 1 + 2 (P < 0.001) and with calculated intima-media area (cIMa) of the both common carotid and brachial arteries (P < 0.05). Mitral early-to-late flow velocity ratio (E/A) was significantly and negatively associated with log Prothrombin fragment 1 + 2 (P < 0.001), total cholesterol and cIMa of the both common carotid and brachial arteries (P < 0.05). Moreover both late diastolic filling time and mitral E/A correlated significantly with age and systolic blood pressure. In stepwise multiple regression analysis, log Prothrombin fragment 1 + 2 remained the only variable with independent significant correlation to late diastolic filling time and mitral E/A. Conclusions: In a population sample of patients with myocardial infarction, late diastolic filling time and mitral E/A were associated with cIMa of common carotid and brachial arteries, systolic blood pressure, and prothrombin fragment 1 + 2, suggesting a relationship between diastolic dysfunction, thrombin generation and atherosclerosis. (Echocardiography 2010;27:651-658).

BACKGROUND AND OBJECTIVE Diabetes mellitus and impaired glucose tolerance have not only been associated with increased morbidity and mortality, but also with poor quality of life. The purpose of this study was to determine whether there is a relationship between poor quality of life and insulin resistance in patients with myocardial infarction without known diabetes mellitus. METHODS AND RESULTS One hundred and nineteen patients, men and women aged between 31 and 80 years with a hospital-diagnosed myocardial infarction occurring 3 months before inclusion, were studied. Minor symptoms evaluation profile was used to estimate the quality of life at entry. Low quality of life (contentment and vitality) was significantly negatively (P

To investigate the association between glucose abnormalities and left ventricular (LV) function assessed by tissue Doppler imaging (TDI) in patients with previous history of myocardial infarction and without known diabetes mellitus.In a cross-sectional study, 123 patients, aged 31-80 years, with a history of previous myocardial infarction and without known diabetes mellitus were examined with TDI echocardiography. A standard oral glucose test (OGTT) with 75 g of glucose was performed.Two-hour plasma glucose were significantly and negatively associated with TDI parameters such as LV ejection time; early diastolic filling velocity (E'-v); ratio of the early to late diastolic filling velocity (E'/A') and positively associated with regional myocardial performance index (MPI) (P0.05). Left ventricular ejection time and MPI were significantly higher; E'/A' and E'-v were significantly lower in patients with disturbed glucose metabolism compared with patients with normal glucose tolerance (P0.01). These differences remain significant also when the patients with DM were excluded.The present study demonstrates that disturbed glucose metabolism is associated with more pronounced LV dysfunction using TDI in patients with myocardial infarction. These abnormalities in LV function were more common not only in subjects with diabetes, but also in patients with prediabetic condition, impaired glucose intolerance.

Mechanisms of acute myocardial infarction and nonobstructed coronary arteries (MINOCA) are incompletely understood. Myocardial bridging (MB) is usually considered a benign congenital variant, but serious complications have been reported. MB has also been proposed as a cause of takotsubo syndrome (TS). We aimed to examine whether MB was more frequent in patients with MINOCA or TS than in age- and gender-matched controls and to compare the MB detection rates of coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA). Patients with MINOCA (n = 57) and age- and gender-matched controls (n = 58), aged 45 to 70 were enrolled. Myocarditis was excluded by cardiovascular magnetic resonance imaging. Patients with TS (n = 15) were considered as a subgroup and therefore not excluded. Patients with MINOCA underwent ICA and all study participants underwent coronary CTA. All examinations were reviewed with focus on MB. Among 57 MINOCA patients, 15 MINOCA patients with TS and 58 controls, MB was demonstrated in 28 patients (49%), 8 patients (53%), and 26 patients (45%), respectively. There were no statistically significant differences regarding the prevalence of MB or the type, location, length, or thickness of MB. There was a statistically significant difference (p

Microalbuminuria (MA) is a cardiovascular risk factor. The aim of this study was to examine the relationship between MA and the intima-media complex of the carotid and brachial artery, endothelial function, glucose metabolism, haemostatic variables and cardiac hypertrophy in patients with coronary heart disease. A total of 123 patients, aged 31-80 years, with a history of previous myocardial infarction and without known diabetes mellitus were examined with B-mode ultrasound of common carotid and brachial arteries, flow-mediated dilatation of the brachial artery and echocardiography. A standard oral glucose tolerance test with 75 g of glucose was performed. MA was defined as excretion of 20-200 microg albumin/min. MA was present in 11% of patients. Patients with MA had significantly higher level of 2-h plasma glucose, a lower displacement of the atrioventricular plane, a thicker septum wall and a higher prevalence of impaired glucose tolerance test compared with patients with normoalbuminuria (P0.05). Urinary albumin excretion (UAE) was significantly and positively associated with calculated intima-media area (cIMa) in both brachial and common carotid arteries as well as with age and interventricular septum thickness. In conclusion, UAE was significantly and positively associated with cIMa in both the common carotid and the brachial arteries as well as with left ventricular septum thickness and glucose intolerance in patients with a history of previous myocardial infarction without known diabetes mellitus.

The aims of this study were to determine whether non-invasive measurement of endothelial function in conduit arteries reflects that of subcutaneous resistance arteries measured in vitro and to examine whether there is an endothelial dysfunction also in resistance arteries in patients with a previous myocardial infarction. The brachial artery diameter responses to a hyperemic flow stimulus and an in vitro method, pressure myography, to directly evaluate flow-mediated responses in arteries obtained from biopsies of subcutaneous fat were measured in 25 patients with a previous myocardial infarction and in 8 aged matched healthy subjects. Flow-mediated dilatation of the brachial artery was more pronounced in the healthy group compared with the group with coronary disease, 5.1 +/- 2.5% and 2.6 +/- 2.1%, respectively (p < 0.05). The flow-mediated dilatation in subcutaneous arteries from CHD patients was significantly reduced compared to control subjects (e.g. percent change from initial preconstriction at maximum flow rate of 204 microl/min: 42 +/- 7% CHD (n = 25) versus 84 +/- 24% control (n = 8), ANOVA, p = 0.03). There was a significant correlation between flow-mediated dilatation of the brachial artery and maximum flow-mediated dilatation at microvascular level, (p < 0.01). In conclusion this study demonstrates endothelial dysfunction in both conduit and resistance circulation in patients after myocardial infarction compared to an aged-matched healthy control group. Furthermore, a significant and independent relationship between endothelial function by means of flow-mediated dilatation in large conduit arteries and resistance arteries was observed.