Association Between Tp-e/QT Ratio and Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Background:

Both the Tpeak‐Tend interval (Tp‐e) and the Tp‐e/QT ratio have been linked to increased risk for arrhythmia. Patient Tp‐e/QT ratios were investigated prior to primary percutaneous coronary intervention (pPCI) in patients with ST‐segment elevation myocardial infarction (STEMI).

Hypothesis:

Tp‐e/QT ratio maybe asscioated with the prognosis in patients with ST‐segment elevation.

Methods:

A total of 338 patients (N = 338) with STEMI treated by pPCI were included. The Tp‐e and Tp‐e/QT ratio were determined using electrocardiograms in the subjects exhibiting ST‐segment elevation.

Results:

The Tp‐e/QT ratio was correlated with both short‐ and long‐term outcomes. Analysis of the receiver operating characteristic curve demonstrated that the optimal cutoff value for outcome prediction was a Tp‐e/QT ratio of 0.29. Of the 388 patients enrolled, 115 (34.0%) exhibited a Tp‐e/QT ratio ≥0.29. Patients with a Tp‐e/QT ratio ≥0.29 showed elevated rates of both in‐hospital death (21.9% vs 2.3%; P < 0.001) and main adverse cardiac events (MACE) (48.1% vs 15.3%; P < 0.005). After discharge, Tp‐e/QT ratios ≥0.29 remained an independent predictor of all‐cause death (35.5% vs 5.2%, P < 0.001) and cardiac death (32.3% vs 2.6%, P < 0.001).

Conclusions:

The Tp‐e/QT ratio may serve as a prognostic predictor of adverse outcomes after successful pPCI treatment in STEMI patients. Clin. Cardiol. 2012 doi: 10.1002/clc.22022 This work was supported by grants from the Henan Provincial People's Hospital. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Job strain predicts recurrent events after a first acute myocardial infarction: the Stockholm Heart Epidemiology Program

Abstract. László KD, Ahnve S, Hallqvist J, Ahlbom A, Janszky I. (Karolinska Institute, Stockholm, Sweden; Semmelweis University, Budapest, Hungary; Uppsala University, Uppsala, Sweden; and Karolinska Institute, Stockholm, Sweden). Job strain predicts recurrent events after a first acute myocardial infarction: the Stockholm Heart Epidemiology Program. J Intern Med 2010; 267 :599–611. Objectives. Studies investigating the prognostic role of job stress in coronary heart disease are sparse and have inconclusive findings. We aimed (i) to investigate whether job strain predicts recurrent events after acute myocardial infarction (AMI) and if so (ii) to determine behavioural and biological factors that contribute to the explanation of this association. Design. Prospective study. Setting. Ten emergency hospitals in the larger Stockholm area, Sweden. Subjects. Non‐fatal AMI cases from the Stockholm Heart Epidemiology Program case–control study who were employed and younger than 65 years at the time of their hospitalization (n = 676). Results. During the 8.5 year follow‐up, 155 patients experienced cardiac death or non‐fatal AMI; totally 96 patients died, 52 of cardiac causes. After adjustment for potential confounders, patients with high job strain had an increased risk for the combination of cardiac death and non‐fatal AMI relative to those with low job strain, the hazard ratio (HR) and the 95% confidence interval (CI) being 1.73 (1.06–2.83). Results were similar for cardiac [HR (95% CI): 2.81 (1.16–6.82)] and total mortality [HR (95% CI): 1.65 (0.91–2.98)]. We found no evidence for mediation from lifestyle, sleep, lipids, glucose, inflammatory and coagulation markers on the association between job strain and the combination of cardiac death and non‐fatal AMI. Conclusions. Job strain was associated with poor long‐term prognosis after a first myocardial infarction. Interventions focusing on reducing stressors at the workplace or on improving coping with work stress in cardiac patients might improve their survival post‐AMI.     

Prognostic Value of Standard Electrocardiographic Parameters for Predicting Major Adverse Cardiac Events after Acute Myocardial Infarction

Background: The prognostic value of electrocardiographic (ECG) variables in predicting major adverse cardiac events (MACEs) after acute myocardial infarction (AMI) in the era of modern therapy is unclear. This study was conducted to evaluate the prognostic significance of ECG parameters in predicting 1‐year MACEs for AMI patients. Methods: Between January 2006 and January 2008, 529 AMI patients were included. ECG variables were analyzed from the ECG taken on discharge day. The 1‐year MACEs were defined as death, nonfatal MI, and revascularization including repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Mean follow‐up duration was 360 ± 119 days. Results: Of these patients, 497 (94%) patients provided complete follow‐up data (355 males; 67 ± 12 years old). The rate of 1‐year MACEs was 16%. In univariate analysis, heart rate, corrected QT interval, left ventricular (LV) hypertrophy, voltage (SV₁+ RV₅), lateral ST‐depression (V_5–6 or I, aVL), pathologic Q wave (V_1–4, V_5–6), ST‐elevation (V_1–4, V_5–6 or I, aVL), and T‐wave inversion (V_1–4, V_5–6, or I, aVL) had a significant association with 1‐year MACEs. In the Cox regression hazard model, lateral ST‐depression (hazard ratio [HR] 2.260, 95% confidence interval [CI] 1.204 to 4.241, P = 0.011) and corrected QT interval (HR 1.007, 95% CI 1.002 to 1.011, P = 0.004) were independent predictors of 1‐year MACEs. After adjustment for all risk variables, lateral ST‐depression (HR 3.781, 95% CI 1.047 to 13.656, P = 0.042) was the only ECG variable that independently predicted 1‐year MACEs. Conclusion: Lateral ST‐depression on discharge day ECG is an independent predictor of 1‐year MACEs after AMI. Ann Noninvasive Electrocardiol 2011;16(1):56–63     

Patient-reported symptoms in acute myocardial infarction: differences related to ST-segment elevation: the MONICA/KORA Myocardial Infarction Registry

Kirchberger I, Meisinger C, Heier M, Kling B, Wende R, Greschik C, von Scheidt W, Kuch B. (Central Hospital of Augsburg, Augsburg; and Institute of Epidemiology, Neuherberg; Germany). Patient‐reported symptoms in acute myocardial infarction: differences related to ST‐segment elevation. J Intern Med 2011; 270 : 58–64. Abstract. Objectives. The early recognition of symptoms of myocardial infarction (MI) is crucial for patients with both ST‐segment elevation (STEMI) and non‐STEMI (NSTEMI). However, to date, only a few studies have examined the differences between patients with STEMI and NSTEMI with regard to the range of presenting MI symptoms. Design. The study population comprised 889 individuals with STEMI and 1268 with NSTEMI, aged 25–74, hospitalized with a first‐time MI between January 2001 and December 2006 recruited from a population‐based MI registry. The occurrence of 13 symptoms was recorded during a standardized patient interview. Results. Patients with STEMI were significantly younger, more likely to be smokers and less likely to have a history of hypertension or sleep disturbances prior to the acute MI (AMI) event than those with NSTEMI. A total of 50% of the patients attributed their experienced symptoms to the heart. Logistic regression modelling revealed that patients with STEMI were significantly more likely than patients with NSTEMI to complain of vomiting [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.76–3.05], dizziness (OR 1.63, 95% CI 1.30–2.03) and diaphoresis (OR 1.49, 95% CI 1.23–1.81). Furthermore, patients with STEMI were less likely to experience dyspnoea (OR 0.81, 95% CI 0.68–0.98) or pain in the throat/jaw (OR 0.80, 95% CI 0.66–0.98). Conclusions. Only half of all patients correctly attributed their symptoms to the heart. Patients with STEMI and NSTEMI showed differences regarding several presenting symptoms. Further research is needed to replicate our results, and public awareness of AMI symptoms needs to be improved.     

The impact of unsuccessful percutaneous coronary intervention on short‐ and long‐term prognosis in STEMI and NSTEMI

Objectives: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non‐ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct‐related artery (IRA). Background: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified. Methods: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow‐up was 37.5 months. Results: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx‐related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only. Conclusions: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx. © 2010 Wiley‐Liss, Inc.     

Clinical outcomes in patients with acute left circumflex/obtuse marginal occlusion presenting with myocardial infarction

Background: Acute occlusion of left circumflex (LCx) or obtuse marginal (OM) arteries can present as ST elevation myocardial infarction (STEMI) or non‐ST elevation myocardial infarction (NSTEMI). NSTEMI patients (pts) with occlusions have worse outcomes than those without occlusions, but no studies specifically examine outcomes in acute myocardial infarction (AMI) pts with LCx/OM occlusion. This study aims to define the incidence of NSTEMI in pts presenting with LCx/OM occlusion and analyzes clinical characteristics and outcomes in those presenting with NSTEMI compared to STEMI. Methods and Materials: A review of our catheterization and STEMI database was performed to identify AMI pts presenting with LCx or OM occlusion from 1/1/2007 to 7/31/2009 at the Medical College of Virginia. Patients were divided into STEMI and NSTEMI groups, and a chart review was performed. Primary end‐points were in‐hospital mortality (HM), cardiogenic shock (CS), and in‐hospital CHF. Secondary end‐points included peak CK‐MB and time to catheterization, as well as combined end‐points of 1‐month mortality, and recurrent AMI and CHF. Results: Fifty‐six pts met inclusion criteria, 54% of whom presented with NSTEMI. STEMI pts were significantly more likely to meet the primary end‐points, as well as the combined secondary end‐points. They had shorter times to catheterization but larger infarct sizes. Patients with left or mixed coronary dominance were more likely to have STEMI. Conclusions: AMI pts with LCx/OM occlusion present with NSTEMI as often as STEMI. Those with NSTEMI have better outcomes, which may be related to right coronary dominance. Summary: Patients with acute LCx or OM occlusion present with NSTEMI as often as STEMI, but those with STEMI have worse outcomes. The difference in presentation may be related to coronary dominance. (J Interven Cardiol 2011;24:27–33)     

Effect of Heart Rate on Ventricular Repolarization in Healthy Individuals Applying Vectorcardiographic T Vector and T Vector Loop Analysis

Background: Ventricular repolarization (VR) is strongly influenced by heart rate (HR) and autonomic nervous activity, both of which also are important for arrhythmogenesis. Their relative influence on VR is difficult to separate, but might be crucial for understanding while some but not other individuals are at risk for life‐threatening arrhythmias at a certain HR. This study was therefore designed to assess the “pure” effect of HR increase by atrial pacing on the ventricular gradient (VG) and other vectorcardiographically (VCG) derived VR parameters during an otherwise unchanged condition. Methods: In 19 patients with structurally normal hearts, a protocol with stepwise increased atrial pacing was performed after successful arrhythmia ablation. Conduction intervals were measured on averaged three‐dimensional (3D) QRST complexes. In addition, various VCG parameters were measured from the QRS and T vectors as well as from the T loop. All measurements were performed after at least 3 minutes of rate adaptation of VR. Results: VR changes at HR from 80 to 120 bpm were assessed. The QRS and QT intervals, VG, QRSarea, Tarea, and Tamplitude were markedly rate dependent. In contrast, the Tp‐e/QT ratio was rate independent as well as the T‐loop morphology parameters Tavplan and Teigenvalue describing the bulginess and circularity of the loop. Conclusions: In healthy individuals, the response to increased HR within the specified range suggests a decreased heterogeneity of depolarization instants, action potential morphology, and consequently of the global VR. Ann Noninvasive Electrocardiol 2011;16(3):287–294     

Effect of sex difference in clinical presentation (stable coronary artery disease vs unstable angina pectoris or non‐ST‐elevation myocardial infarction vs ST‐elevation myocardial infarction) on 2‐year outcomes in patients undergoing percutaneous coronary intervention

Objective

To determine whether there is a difference in 2‐year prognosis among patients across the spectrum of coronary artery disease undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients undergoing PCI at a single center from 1/1‐12/31/2013. Clinical presentations were compared between sexes according to baseline clinical, angiographic, and procedural characteristics and 2‐year (mean 730 ± 30‐day) outcomes.

Results

We grouped 10 724 consecutive patients based on sex and clinical presentation. Among patients with ST‐elevation myocardial infarction (STEMI), rates of all‐cause death (6.7% vs 1.4%) and cardiac death (3.8% vs 1.1%) were significantly higher in women than in men (P < 0.05), but these rates did not differ between men and women with stable coronary artery disease (SCAD) and non‐ST‐elevation acute coronary syndrome ((NSTE‐ACS). Incidence of major bleeding was greater than in men only in those women presenting with ACS. After multivariable adjustment, female sex was not an independent predictor of outcomes in STEMI (hazard ratio [HR] for all‐cause death: 1.33, 95% confidence interval [CI]:0.52‐3.38; P = 0.55; HR for cardiac death: 0.69, 95%CI: 0.23‐2.09, P = 0.51], but was still an independent predictor of bleeding in STEMI (HR: 3.53, 95%CI: 1.26‐9.91, P = 0.017).

Conclusion

Among STEMI patients, women had worse 2‐year mortality after PCI therapy, but female sex was not an independent predictor of mortality after adjustment for baseline characteristics. In STEMI patients, women were at higher bleeding risk than men after PCI, even after multivariable adjustment.     

Current characteristics and management of ST elevation and non-ST elevation myocardial infarction in the Tokyo metropolitan area: from the Tokyo CCU network registered cohort

Limited data exists on ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) managed by a well-organized cardiac care network in a metropolitan area. We analyzed the Tokyo CCU network database in 2009–2010. Of 4329 acute myocardial infarction (AMI) patients including STEMI (n = 3202) and NSTEMI (n = 1127), percutaneous coronary intervention (PCI) was performed in 88.8 % of STEMI and 70.4 % of NSTEMI patients. Mean onset-to-door and door-to-balloon times in STEMI patients were shorter than those in NSTEMI patients (167 vs 233 and 60 vs 145 min, respectively, p < 0.001). Coronary artery bypass graft surgery was performed in 4.2 % of STEMI and 11.4 % of NSTEMI patients. In-hospital mortality was significantly higher in STEMI patients than NSTEMI patients (7.7 vs 5.1 %, p < 0.007). Independent correlates of in-hospital mortality were advanced age, low blood pressure, and high Killip classification, statin-treated dyslipidemia and PCI within 24 h were favorable predictors for STEMI. High Killip classification, high heart rate, and hemodialysis were significant predictors of in-hospital mortality, whereas statin-treated dyslipidemia was the only favorable predictor for NSTEMI. In conclusion, patients with MI received PCI frequently (83.5 %) and promptly (door-to-balloon time; 66 min), and had favorable in-hospital prognosis (in-hospital mortality; 7.0 %). In addition to traditional predictors of in-hospital death, statin-treated dyslipidemia was a favorable predictor of in-hospital mortality for STEMI and NSTEMI patients, whereas hemodialysis was the strongest predictor for NSTEMI patients.     

Sodium Channel Blockers Enhance the Temporal QT Interval Variability in the Right Precordial Leads in Brugada Syndrome

Background: Temporal QT interval variability is associated with sudden cardiac death. The purpose of this study was to evaluate temporal QT interval variability in Brugada syndrome (BS). Methods: We measured QT and RR intervals in precordial leads (V₁–V₆) based on 12‐beat resting ECG recordings from 16 BS patients (B group) with spontaneous ST elevation in right precordial leads (V₁–V₂) and from 10 patients with normal hearts (C group). We measured the response in B group before and after administration of pilsicainide (1 mg/kg). The standard deviation (QT‐SD, RR‐SD) of the time domain and total frequency power (QT‐TP, RR‐TP) were calculated for all precordial leads, and the latter was to analyze the frequency domain. Results: The right precordial leads in BS exhibited an additional and prominent ST elevation (coved‐type) after pilsicainide administration. Both QT‐SD and QT‐TP values were significantly more increased in B, than in C (5.1 ± 1.2 vs 3.6 ± 0.2 and 23.4 ± 2.9 vs 12.3 ± 1.7 msec₂, P < 0.01, respectively) and after pilsicainide administration in B. (5.1 ± 0.4 vs 3.9 ± 0.3, 25.8 ± 3.4 vs 16.3 ± 2.6 msec₂, P < 0.01, respectively) However, QT‐SD and QT‐TP did not significantly change in any of other leads (V₃–V₆) and RR‐SD and RR‐TP were similar for both groups, as well as after intravenous pilsicainide administration in B. Conclusions: The temporal QT interval variability was identified in BS. Moreover, sodium channel blocker induced temporal fluctuation in QT interval and it may possibly provide a substrate for ventricular arrhythmia in BS patients.     

Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion

Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to severe clinical deterioration, with devastating sequalae including fatal arrhythmias, abrupt and severe circulatory failure, and sudden cardiac death. Recent guidelines have promoted treatment with percutaneous coronary intervention (PCI) as a class IIa recommendation alongside coronary artery bypass grafting (CABG), but the data are still unclear regarding optimal revascularization strategy for patients with ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) with ULMCA culprit. PCI has the advantages of offering rapid reperfusion to critically ill patients, often those with prohibitive risk for surgical revascularization, with acceptable short‐ and long‐term outcomes. Recent studies demonstrate that PCI of the ULMCA is a viable alternative to CABG for appropriate patient populations, including those with ULMCA occlusion and those in cardiogenic shock, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and significant comorbidities. A randomized trial comparing PCI with CABG is needed to clarify the ideal revascularization strategy, though the clinical picture of these critically ill patients may preclude such studies. © 2014 Wiley Periodicals, Inc.     

Utility of Lead aVR for Identifying the Culprit Lesion in Acute Myocardial Infarction

Background: Lead aVR is a neglected, however, potentially useful tool in electrocardiography. Our aim was to evaluate its value in clinical practice, by reviewing existing literature regarding its utility for identifying the culprit lesion in acute myocardial infarction (AMI). Methods: Based on a systematic search strategy, 16 studies were assessed with the intent to pool data; diagnostic test rates were calculated as key results. Results: Five studies investigated if ST‐segment elevation (STE) in aVR is valuable for the diagnosis of left main stem stenosis (LMS) in non–ST‐segment AMI (NSTEMI). The studies were too heterogeneous to pool, but the individual studies all showed that STE in aVR has a high negative predictive value (NPV) for LMS. Six studies evaluated if STE in aVR is valuable for distinguishing proximal from distal lesions in the left anterior descending artery (LAD) in anterior ST‐segment elevation AMI (STEMI). Pooled data showed a sensitivity of 47%, a specificity of 96%, a positive predicative value (PPV) of 91% and a NPV of 69%. Five studies examined if ST‐segment depression (STD) in lead aVR is valuable for discerning lesions in the circumflex artery from those in the right coronary artery in inferior STEMI. Pooled data showed a sensitivity of 37%, a specificity of 86%, a PPV of 42%, and an NPV of 83%. Conclusion: The absence of aVR STE appears to exclude LMS as the underlying cause in NSTEMI; in the context of anterior STEMI, its presence indicates a culprit lesion in the proximal segment of LAD.     

Favorable Long‐Term Survival in Patients Undergoing Multivessel‐PCI Compared to Predicted Prognosis of CABG Estimated by EuroSCORE: Procedural and Clinical Determinants of Long‐Term Outcome

Aims/Methods: Treatment of patients with multivessel coronary artery disease (CAD) has been an ongoing focus of recent clinical studies, questioning the ideal treatment. Randomized trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have so far only included a minority of screened patients. Therefore, we analyzed data from 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. Expected in‐hospital mortality for CABG was calculated using the EuroSCORE and compared to the observed mortality rate during in‐hospital as well as long‐term follow‐up. Results: The patients were suffering from 2.5 ± 0.6 diseased vessels, and 2.8 ± 1.0 lesions were stented (32% of patients received at least one drug‐eluting stent [DES]; 20% of lesions were treated with DES). Forty‐seven percent of patients were treated for acute coronary syndrome (ACS) ( N = 176 ST‐elevation myocardial infarction [STEMI]; N = 140 non‐ST‐elevation myocardial infarction [NSTEMI]). The EuroSCORE was significantly higher in ACS patients compared to stable patients (logistic: STEMI 16.3 ± 17.2; NSTEMI 13.6 ± 13.0; stable CAD 3.9 ± 4.2). The observed in‐hospital mortality (STEMI 13.0%; NSTEMI 2.9%; stable CAD 1.7%, P < 0.001) was far lower than the estimated 30‐day mortality. Cox regression analysis identified an elevated logistic EuroSCORE (HR per quartile 2.7, P = 0.003), severely reduced left ventricular ejection fraction (HR 2.7, P < 0.001), elevated C‐reactive protein (HR 1.8, P = 0.012), and chronic renal failure (HR 2.8, P = 0.001) as independent predictors of long‐term mortality. Conclusions: The EuroSCORE, which is routinely used to estimate the perioperative risk of patients undergoing CABG, also predicts short‐ and long‐term prognosis of patients undergoing MV‐PCI. The observed mortality of patients undergoing MV‐PCI seems to be much lower than the estimated mortality of CABG.     

Enhanced Transmural Dispersion of Repolarization in Patients with J Wave Syndromes

J Wave Syndromes . Introduction: Recently, great attention has been paid to the risk stratification of asymptomatic patients with an electrocardiographic early repolarization (ER) pattern. We investigated several repolarization parameters including the Tpeak‐Tend interval and Tpeak‐Tend/QT ratio in healthy individuals and patients with J wave syndrome who were aborted from sudden cardiac death. Methods and Results: Ninety‐two subjects were enrolled: 12 patients with ventricular fibrillation associated with J waves, 40 healthy subjects with an uneventful ER pattern and 40 healthy control subjects (C) without any evident J waves. Using ambulatory electrocardiogram recordings, the average QT interval, corrected QT interval (QTc), Tpeak‐Tend (Tp‐e) interval, which is the interval from the peak to the end of the T wave, and Tp‐e/QT ratio were calculated. Using ANOVA and post hoc analysis, there was no significant difference in the average QT and QTc in all 3 groups (QT; 396 ± 27 vs 405 ± 27 vs 403 ± 27 m, QTc; 420 ± 26 vs 421 ± 21 vs 403 ± 19 milliseconds in the C, ER pattern and J groups, respectively). The Tp‐e interval and Tp‐e/QT ratio were significantly more increased in the J wave group than the ER Pattern group (Tp‐e: 86.7 ± 14 milliseconds vs 68 ± 13.2 milliseconds, P < 0.001, Tp‐e/QT; 0.209 ± 0.04 vs 0.171 ± 0.03, P < 0.001), but they did not significantly differ between the C and ER pattern groups (Tp‐e: 68.6 ± 7.5 vs 68 ± 13.2, P = 0.97, Tp‐e/QT 0.174 ± 0.02 vs 0.171 ± 0.03, P = 0.4). Conclusion: As novel markers of heterogeneity of ventricular repolarization, Tpeak‐Tend interval and Tp‐Te/QT ratio are significantly increased in patients with J wave syndromes compared to age and sex‐matched uneventful ER. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1109‐1114, October 2012)     

Real world comparison of the MGuard Stent versus the bare metal stent for ST Elevation myocardial infarction (The REWARD‐MI study)

Aim: The MGuard Stent (MGS) was designed to prevent distal embolization of thrombus and has been shown to improve microcirculation in ST‐elevation myocardial infarction (STEMI). However, there are no real world data comparing it with the bare metal stent (BMS). The aim of this study is to determine the efficacy and safety of the MGS in STEMI in the real world compared to the BMS. Methods and Results: In total, 262 patients were included from a single centre, of which 35.9% had an MGS implanted. Two groups of 79 patients were established after propensity score matching, and they were similar in terms of baseline and periprocedural variables. The mean follow‐up was 321 ± 12.94 days. There was no difference in mortality (7.6% in both groups), major adverse cardiac events (20.3% vs. 12.7%, P = 0.198), non‐cardiac mortality, or non‐fatal myocardial infarction (6.3% in both groups). Target lesion revascularization (TLR) was significantly higher in the MGS group (11.4% (9) vs. 1.3% (1) P < 0.01; RR 10.02 [1.23–81.16]). Conclusion: Our study is the first to compare the MGS with the BMS in STEMI in the real world, and it also appears to confirm that although the MGS is a safe device in STEMI that is not associated with increased mortality, it is associated with a higher long‐term TLR rate. © 2014 Wiley Periodicals, Inc.     

Clinical outcomes according to symptom presentation in patients with acute myocardial infarction: Results from the FAST‐MI 2010 registry

Background

Atypical clinical presentation in acute myocardial infarction (AMI) patients is not uncommon; most studies suggest that it is associated with unfavorable prognosis.

Hypothesis

Long‐term clinical impact differs according to predominant symptom presentation (typical chest pain, atypical chest pain, syncope, cardiac arrest, or dyspnea) in AMI patients.

Methods

FAST‐MI 2010, a nationwide French registry, included 4169 patients with AMI in 213 centers at the end of 2010 (76% of active centers). Demographics, medical history, hospital management, and outcomes were compared according to predominant symptom presentation.

Results

Typical chest pain with no other symptom was reported in 3020 patients (68% in STEMI patients, 76% in NSTEMI patients). Atypical chest pain, dyspnea, syncope, and cardiac arrest were reported in 11%, 11%, 5%, and 1%, respectively. Patients with atypical clinical presentation had a higher cardiovascular risk profile and received fewer medications and a less invasive strategy. Using Cox multivariate analysis, atypical chest pain was not associated with higher death rate at 3 years (HR: 0.96, 95% CI: 0.69‐1.33, P = 0.78), whereas cardiac arrest (HR: 2.44, 95% CI: 1.00‐5.97, P = 0.05), syncope (HR: 1.70, 95% CI: 1.18‐2.46, P = 0.005), and dyspnea (HR: 1.66, 95% CI: 1.31‐2.10, P < 0.001) were associated with higher long‐term mortality compared with patients with typical isolated chest pain. Similar trends were observed in STEMI and NSTEMI populations.

Conclusions

Atypical clinical presentation is observed in about 20% of AMI patients. Cardiac arrest, dyspnea, and syncope represent independent predictors of long‐term mortality in STEMI and NSTEMI populations.

     

Should we improve the management of NSTEMI? Results from the population-based “acute myocardial infarction in Florence 2” (AMI-Florence 2) registry

ST-segment and non-ST-segment elevation myocardial infarction (STEMI, NSTEMI) have opposite epidemiology, the latter being nowadays more common than the former. Consistently with these epidemiological trends, application of evidence-based clinical practice guidelines on the management of NSTEMI should be promoted. We compared clinical features, hospital management and prognosis of STEMI/NSTEMI in an unselected cohort of 1,496 prospectively enrolled patients (STEMI, 36.9 % and NSTEMI, 63.1 %), admitted in 1 year to one of the six hospitals in Florence health district (Italy). Vital status was assessed after 1 year. NSTEMI patients were older, more often female, and affected by cardiovascular and non-cardiovascular comorbidities. Percutaneous coronary intervention (PCI) was performed more often in STEMI (82 %) than in NSTEMI patients (48 %, p < 0.001). Aspirin, clopidogrel, statins, beta-blockers, and ACE-inhibitors were prescribed more frequently in STEMI. In-hospital mortality was significantly lower in NSTEMI than in STEMI (4.2 vs. 8.9 %, p < 0.001), even after adjusting for confounders in a multivariable logistic model (OR 0.27, 95 % CI 0.16–0.45). One-year mortality was similar in NSTEMI and STEMI patients in an unadjusted comparison (18.0 vs. 16.7 %, p = 0.51), but it was lower in NSTEMI patients in multivariable Cox analysis (HR 0.56, 95 % CI 0.42–0.75). PCI reduced the risk of 1-year mortality similarly in STEMI (HR 0.47, 95 % CI 0.28–0.79) and NSTEMI (HR 0.41, 95 % CI 0.28–0.60). PCI reduces mortality in both STEMI and NSTEMI, but it is underutilised in patients with NSTEMI. To improve overall prognosis of AMI, efforts should be made at improving the care of NSTEMI patients.     

Different Statin Effects of ST-elevation Versus Non-ST-Elevation Acute Myocardial Infarction After Stent Implantation

BackgroundIntensive statin therapy reduces cardiovascular events in acute coronary syndrome. The data concerning the long-term clinical impacts of statin therapy between ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) after drug-eluting stent implantation are limited. We compared the 2-year clinical outcomes between these 2 groups after statin therapy.Materials and MethodsA total of 30,616 Korean patients with acute myocardial infarction (AMI) were enrolled. Among them, 13,686 patients were classified as group A (STEMI statin user), 3,824 patients were as group B (STEMI statin nonuser), 10,398 patients were as group C (NSTEMI statin user), and 2,708 patients were as group D (NSTEMI statin nonuser). The major clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), and any repeat revascularization during a 2-year follow-up period.ResultsAfter adjustment, the cumulative risks of MACE (adjusted hazard ratio [aHR] = 1.112 [1.002-1.235]; P = 0.047), all-cause death (aHR = 1.271 [1.054-1.532]; P = 0.012), and target vessel revascularization (TVR, aHR = 1.262 [1.049-1.518]; P = 0.014) in group C were significantly higher than group A. The cumulative risks of MACE, all-cause death, and cardiac death of the statin nonuser group (groups B and D) were significantly higher compared with statin user group (groups A and C).ConclusionsStatin therapy was more effective in reducing the cumulative risks of MACE, all-cause death, and TVR in the STEMI group than NSTEMI group in Korean patients with AMI after successful drug-eluting stent implantation.     

Validation of the Killip-Kimball Classification and Late Mortality after Acute Myocardial Infarction

Background

The classification or index of heart failure severity in patients with acute myocardial infarction (AMI) was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units (CCU) during the decade of 60.

Objective

To validate the risk stratification of Killip classification in the long-term mortality and compare the prognostic value in patients with non-ST-segment elevation MI (NSTEMI) relative to patients with ST-segment elevation MI (STEMI), in the era of reperfusion and modern antithrombotic therapies.

Methods

We evaluated 1906 patients with documented AMI and admitted to the CCU, from 1995 to 2011, with a mean follow-up of 05 years to assess total mortality. Kaplan-Meier (KM) curves were developed for comparison between survival distributions according to Killip class and NSTEMI versus STEMI. Cox proportional regression models were developed to determine the independent association between Killip class and mortality, with sensitivity analyses based on type of AMI. Results: The proportions of deaths and the KM survival distributions were significantly different across Killip class >1 (p <0.001) and with a similar pattern between patients with NSTEMI and STEMI. Cox models identified the Killip classification as a significant, sustained, consistent predictor and independent of relevant covariables (Wald χ2 16.5 [p = 0.001], NSTEMI) and (Wald χ2 11.9 [p = 0.008], STEMI).

Conclusion

The Killip and Kimball classification performs relevant prognostic role in mortality at mean follow-up of 05 years post-AMI, with a similar pattern between NSTEMI and STEMI patients.     

Comparison of the prognostic value of peak creatine kinase-MB and troponin levels among patients with acute myocardial infarction: a report from the Acute Coronary Treatment and Intervention Outcomes Network Registry-get with the guidelines

Background:

Although peak creatine kinase‐myocardial band (CK‐MB) and troponin levels have been correlated with mortality among patients with acute myocardial infarction (AMI), the independent prognostic implications of these markers have not been compared.

Hypothesis:

We hypothesized that in patients with AMI, peak troponin levels (as compared to peak CK‐MB levels) would have greater prognostic value.

Methods:

We examined AMI patients in the National Cardiovascular Data Registry ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines) with CK‐MB and troponin I levels recorded, excluding patients who were transferred in or out. Peak marker levels, standardized by the local laboratory upper limit of normal and assay standard deviation, were fitted into the previously validated ACTION Registry–GWTG mortality model to compare prognostic value.

Results:

Between January 2007 and March 2009, 16 009 ST‐segment elevation myocardial infarction (STEMI) and 26854 non–ST‐segment elevation myocardial infarction (NSTEMI) patients were identified. Peak marker ratios were directly associated with in‐hospital mortality in both STEMI and NSTEMI patients. Peak CK‐MB had slightly greater discrimination compared with peak troponin I in predicting mortality in both STEMI (model C‐statistic 0.881 vs 0.877, P = 0.011) and NSTEMI (C‐statistic 0.831 vs 0.824, P = 0.001) patients.

Conclusions:

Both peak CK‐MB and peak troponin I levels are independently associated with in‐hospital mortality in this large contemporary database of AMI patients treated in routine practice. Peak marker values slightly improved model performance in prognosticating in‐hospital mortality; the incremental value was higher with CK‐MB than with troponin I. These findings may help to guide future risk stratification algorithms and contribute to more efficient use of serial cardiac marker measurements in clinical practice. Clin. Cardiol. 2011 DOI: 10.1002/clc.21980 This project was supported by grant number U18HS016964 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ. The funding source had no role in the design or implementation of the study, or in the decision to seek publication. The authors have no other funding, financial relationships, or conflicts of interest to disclose.