The MI SYNTAX score for risk stratification in patients undergoing primary percutaneous coronary intervention for treatment of acute myocardial infarction: A substudy of the COMFORTABLE AMI trial

Background

To investigate the performance of the MI Sxscore in a multicentre randomised trial of patients undergoing primary percutaneous coronary intervention (PPCI).

Methods and results

The MI Sxscore was prospectively determined among 1132 STEMI patients enrolled into the COMFORTABLE AMI trial, which randomised patients to treatment with bare-metal (BMS) or biolimus-eluting (BES) stents. Patient- (death, myocardial infarction, any revascularisation) and device-oriented (cardiac death, target-vessel MI, target lesion revascularisation) major adverse cardiac events (MACEs) were compared across MI Sxscore tertiles and according to stent type.The median MI SXscore was 14 (IQR: 9–21). Patients were divided into tertiles of Sxscore_low (≤ 10), Sxscore_intermediate (11–18) and Sxscore_high (≥ 19). At 1 year, patient-oriented MACE occurred in 15% of the Sxscore_high, 9% of the Sxscore_intermediate and 5% of the Sxscore_low tertiles (p < 0.001), whereas device-oriented MACE occurred in 8% of the Sxscore_high, 6% of the Sxscore_intermediate and 4% of the Sxscore_low tertiles (p = 0.03). Addition of the MI Sxscore to the TIMI risk score improved prediction of patient- (c-statistic value increase from 0.63 to 0.69) and device-oriented MACEs (c-statistic value increase from 0.65 to 0.70). Differences in the risk for device-oriented MACE between BMS and BES were evident among Sxscore_high (13% vs. 4% HR 0.33 (0.15–0.74), p = 0.007 rather than those in Sxscore_low: 4% vs. 3% HR 0.68 (0.24–1.97), p = 0.48) tertiles.

Conclusions

The MI Sxscore allows risk stratification of patient- and device-oriented MACEs among patients undergoing PPCI. The addition of the MI Sxscore to the TIMI risk score is of incremental prognostic value among patients undergoing PPCI for treatment of STEMI.     

Job insecurity and prognosis after myocardial infarction: The SHEEP Study

Background

The prognostic role of job insecurity in coronary heart disease is unknown. We aimed to analyze whether job insecurity predicts mortality and recurrent events after a first acute myocardial infarction (AMI).

Methods

We studied non-fatal AMI cases involved in the Stockholm Heart Epidemiology Program who were in paid employment and younger than 65 years (n = 676). Shortly after their AMI, patients completed a questionnaire about job insecurity, demographic, work-related, clinical and lifestyle factors and participated in a clinical examination three months after discharge from the hospital. They were followed for 8.5 years for mortality and cardiovascular events.

Results

After adjusting for previous morbidity, demographic and work-related factors, job insecurity was associated with an increased risk of the combined endpoint of cardiac death and non-fatal AMI, of total mortality and of heart failure; the hazard ratios (HR) and the 95% confidence intervals (CI) were 1.50 (1.02-2.22), 1.69 (1.04-2.75) and 1.62 (1.07-2.44), respectively. Similar associations, but with less statistical power were observed between job insecurity and cardiac death (HR (95% CI): 1.57 (0.80-3.09)) and stroke (HR (95% CI): 1.46 (0.71-3.02)), respectively. Adjustment for potential mediators, i.e. sleep problems, health behaviour, hypertension, blood lipids, glucose, inflammatory and coagulation factors did not alter considerably the relationship between job insecurity and the combination of cardiac mortality and non-fatal AMI.

Conclusions

Our results suggest that job insecurity is an adverse prognostic factor in patients with a first AMI. Future studies are needed to confirm this finding and to determine the mechanisms underlying the observed relationship.     

Comparison of new point-of-care troponin assay with high sensitivity troponin in diagnosing myocardial infarction

Objectives

The aim of this study is to compare a new improved point of care cardiac troponin assay (new POC-cTnI) with 1. its predecessor (old POC-cTnI) and 2. a high sensitivity assay (hs-cTnI) for the diagnosis of acute myocardial infarction (AMI) and for major adverse cardiac events (MACE) by 30 days.

Methods

This is a single centre observational study, set in Christchurch Hospital, New Zealand. Patients presenting to the emergency department with non-traumatic chest pain underwent blood sampling at 0 h and 2 h post presentation for analysis with the 3 cTnI assays for the outcome of AMI and for analysis using an accelerated diagnostic protocol (ADP-normal 2 h troponins, normal electrocardiograms and Thrombolysis In Myocardial Infarction (TIMI) score of 0 or ≤ 1) for 30 day MACE.

Results

Of 962 patients, 220 (22.9%) had AMI. Old POC-cTnI was least sensitive at 70.0% (65.4–73.9%) by 2 h (p < 0.001). New POC-cTnI, sensitivity 93.6% (89.9–96.2%) had similar sensitivity to hs-cTnI, sensitivity 95.0% (91.5–97.3%) (p = 0.508). There were 231 (24.0%) patients with 30 day MACE. When used as part of the ADP, all assays had 100% (98.0–100%) sensitivity using TIMI = 0. Sensitivities of new POC-cTnI ADP, 98.3% (95.4–99.4%), old POC-cTnI, 96.5% (93.2–98.4%) and hs-cTnI, 98.7% (96.0–99.7%) were similar (p = 0.063–0.375) using TIMI ≤ 1.

Conclusions

A new POC-cTnI has improved sensitivity for AMI and MACE compared with its predecessor and comparable sensitivity to a high sensitivity assay. Now that sensitivities of the POC assay are improved, the new assay may be a useful alternative to central laboratory assays when rapid turn-around times are not possible.     

Low socioeconomic status increases short-term mortality of acute myocardial infarction despite universal health coverage

Background

This nationwide population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for acute myocardial infarction (AMI) in Taiwan.

Methods

A population-based follow-up study included 23,568 patients diagnosed with AMI from 2004 to 2008. Each patient was monitored for 2 years, or until their death, whichever came first. The individual income-related insurance payment amount was used as a proxy measure of patient's individual SES. Neighborhood SES was defined by household income, and neighborhoods were grouped as advantaged or disadvantaged. The Cox proportional hazards model was used to compare the mortality rates between the different SES groups after adjusting for possible confounding risk factors.

Results

After adjusting for potential confounding factors, AMI patients with low individual SES had an increased risk of death than those with high individual SES who resided in advantaged neighborhoods. In contrast, the cumulative readmission rate from major adverse cardiovascular events did not differ significantly between the different individual and neighborhood SES groups. AMI patients with low individual SES had a lower rate of diagnostic angiography and subsequent percutaneous coronary intervention (P < 0.001). The presence of congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, septicemia, and shock revealed an incremental increase with worse SES (P < 0.001).

Conclusions

The findings indicate that AMI patients with low individual SES have the greatest risk of short-term mortality despite being under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.     

Prognostic value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: A prospective,multicenter study

Objective

The pre-procedural neutrophil to lymphocyte ratio (N/L) is associated with adverse outcomes among patients with coronary artery disease but its prognostic value in ST-segment elevation myocardial infarction (STEMI) has not been fully investigated. This study evaluated the relations between pre-procedural N/L ratio and the in-hospital and long-term outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 682 STEMI patients presented within the first 6 h of symptom onset were enrolled and stratified according to tertiles of N/L ratio based on the blood samples obtained in the emergency room upon admission.

Results

The mean follow-up period was 43.3 months (1–131 months). In-hospital in-stent thrombosis, non-fatal myocardial infarction, and cardiovascular mortality increased as the N/L tertile ratio increased (p < 0.001, p < 0.001, p = 0.003, respectively). Long-term in-stent thrombosis, non-fatal myocardial infarction and cardiovascular mortality also increased as the N/L ratio increased (p < 0.001, p < 0.001, p = 0.002, respectively). On multivariate analysis, N/L ratio remained an independent predictor for both in-hospital (OR 1.189, 95% CI 1.000–1.339; p < 0.001) and long-term major (OR 1.228, 95% CI 1.136–1.328; p < 0.001) adverse cardiac events.

Conclusion

The N/L ratio was an independent predictor of both in-hospital and long-term adverse outcomes among STEMI patients undergoing primary PCI. Our findings suggest that this inexpensive, universally available hematological marker may be incorporated into the current established risk assessment model for STEMI.     

Population trends and inequalities in incidence and short-term outcome of acute myocardial infarction between 1998 and 2007

Objective

We studied time trends in acute myocardial infarction (AMI) incidence, including out-of-hospital mortality proportions and hospitalized case-fatality rates. In addition, we compared AMI trends by age, gender and socioeconomic status.

Methods

We linked the national Dutch hospital discharge register with the cause of death register to identify first AMI in patients ≥ 35 years between 1998 and 2007. Events were categorized in three groups: 178,322 hospitalized non-fatal, 43,210 hospitalized fatal within 28 days, and 75,520 out-of-hospital fatal AMI events. Time trends were analyzed using Joinpoint and Poisson regression.

Results

Since 1998, age-standardized AMI incidence rates decreased from 620 to 380 per 100,000 in 2007 in men and from 323 to 210 per 100,000 in 2007 in women. Out-of-hospital mortality decreased from 24.3% of AMI in 1998 to 20.6% in 2007 in men and from 33.0% to 28.9% in women. Hospitalized case-fatality declined from 2003 onwards. The annual percentage change in incidence was larger in men than women (− 4.9% vs. − 4.2%, P < 0.001). Furthermore, the decline in AMI incidence was smaller in young (35–54 years: − 3.8%) and very old (≥ 85 years: − 2.6%) men and women compared to middle-aged individuals (55–84 years: − 5.3%, P < 0.001). Smaller declines in AMI rates were observed in deprived socioeconomic quintiles Q5 and Q4 relative to the most affluent quintile Q1 (P = 0.002 and P = 0.015).

Conclusions

Substantial improvements were observed in incidence, out-of-hospital mortality and short-term case-fatality after AMI in the Netherlands. Young and female groups tend to fall behind, and socioeconomic inequalities in AMI incidence persisted and have not narrowed.     

Weather,pollution, and acute myocardial infarction in Hong Kong and Taiwan

Background

Several previous studies examined the association between acute myocardial infarction (AMI) incidence and temperature and/or air pollution. Results of these studies have been inconsistent and few studies have been done in cities with sub-tropical or tropical climates.

Methods

Daily data on AMI hospitalizations, mean temperature and humidity, and pollutants, were collected for 2000–2009 for three warm-climate Asian cities. Poisson Generalized Additive Models were used to regress daily AMI counts on temperature, humidity, and pollutants while controlling for day of the week, long-term trends and seasonal effects. Smoothing splines allowing non-linear associations were used for temperature and humidity while pollutants were modeled as linear terms.

Results

A 1 °C drop below a threshold temperature of 24 °C was significantly (p < .0001) associated with AMI hospitalization increases of 3.7% (average lag 0–13 temperature) in Hong Kong, 2.6% (average lag 0–15) in Taipei, and 4.0% (average lag 0–11) in Kaohsiung. No significant heat effects were observed. Among pollutants same day nitrogen dioxide (NO₂) levels were the strongest predictors in all three cities, with a 10 mg/m³ increase in NO₂ being associated with a 1.1% rise in AMI hospitalization in Hong Kong, and a 10 ppb rise being associated with 4.4% and 2.6% rises in Taipei and Kaohsiung, respectively.

Conclusions

Cool temperatures and higher NO₂ levels substantially raised AMI risk in these warm-climate cities and the effect sizes we observed were stronger than those found in previous studies. More attention should be paid to the health dangers of cold weather in warm-climate cities.     

Prognostic significance of elevated lipoprotein(a) in coronary artery revascularization patients

Background

Although lipoprotein(a) [Lp(a)] has been considered a cardiovascular risk factor for many years, there is a paucity of data in regard to the potential risk of elevated Lp(a) in symptomatic patients with CAD. Therefore, we sought to evaluate whether elevated Lp(a) is associated with worse outcome in symptomatic patients with coronary artery disease (CAD), and to clarify the prognostic value of Lp(a) in the era of coronary artery revascularization.

Methods

6252 consecutive subjects (59.2% male, mean age 61.2 ± 11.2 years) suspected of having CAD underwent coronary angiography. Laboratory values for lipid parameters including Lp(a) were obtained on the day of coronary angiography. Baseline risk factors, coronary angiographic findings, length of follow-up, and major adverse cardiovascular events (MACE), including cardiac death and non-fatal myocardial infarction were recorded.

Results

Over a mean follow-up period of 3.1 ± 2.2 years, there were 100 MACE (56 cardiac deaths and 44 non-fatal myocardial infarctions), with an event rate of 1.6%. In multivariate Cox regression analysis, elevated Lp(a) was a significant predictor of MACE [hazard ratio 1.773 (95% confidence interval 1.194–2.634, p = 0.005)], and the addition of this factor to the model significantly increased the global х² value over traditional risk factors and CAD (from 79.1 to 88.7, p = 0.003).

Conclusions

Elevated Lp(a) is an independent prognostic risk factor for cardiovascular events, and moreover, has incremental prognostic value in symptomatic patients with coronary artery revascularization.     

Feasibility of free-breathing late gadolinium-enhanced cardiovascular MRI for assessment of myocardial infarction: Navigator-gated versus single-shot imaging

Objectives

The aim of this study was to evaluate the feasibility of two free-breathing late gadolinium-enhanced cardiovascular magnetic resonance (LGE-CMR) techniques (two-dimensional segmented navigator-gated [NAV-LGE] and single-shot [SS-LGE]) by comparing with breath-hold LGE-CMR (BH-LGE) as reference.

Methods

A total of 200 consecutive patients underwent the three LGE-CMR imaging techniques. BH patterns were assessed with dynamic navigator MR imaging. Image quality was graded on a 5-point scale (4 = optimal; 0 = not assessable). In patients with sufficient BH capability (diaphragmatic movement with a deviation of < 3 mm), hyperenhancement was scored with a 5-point scale, and global infarct size (%left ventricle) was quantified.

Results

Compared to free-breathing LGE-CMR, BH-LGE had higher image quality grade in patients with sufficient BH capability (P < 0.01 [vs. NAV-LGE]; P < 0.001 [vs. SS-LGE]) but poorer image quality in patients with insufficient BH capability (P < 0.001 [vs. NAV-LGE]; P < 0.01 [vs. SS-LGE]). NAV-LGE had higher sensitivity for infarct detection than SS-LGE (97.1% vs. 88.4%, P < 0.05), but specificity was not significantly different (97.3% vs. 94.7%, P = 0.37). By Bland–Altman analysis, the average differences in global infarct size were 0.4% and 1.2%, and the limits of agreement were ± 4.0% and ± 5.9% for NAV- and SS-LGE, respectively.

Conclusions

Although both NAV- and SS-LGE improve the image quality in patients with insufficient BH capability, NAV-LGE is superior to SS-LGE in infarct detection and infarct size measurement. NAV-LGE can be a possible first-line technique for patients with inability to perform sufficient BH.     

Effects of ganglionated plexi ablation on ventricular electrophysiological properties in normal hearts and after acute myocardial ischemia

Background

Ganglionated plexi (GP) ablation has been shown to play an important role in atrial fibrillation (AF) initiation and maintenance. Also, GP ablation increases chances for prevention of AF recurrence. This study investigated the effects of GP ablation on ventricular electrophysiological properties in normal dog hearts and after acute myocardial ischemia (AMI).

Methods

Fifty anesthetized dogs were assigned into normal heart group (n = 16) and AMI heart group (n = 34). Ventricular dynamic restitution, effective refractory period (ERP), electrical alternans and ventricular fibrillation threshold (VFT) were measured before and after GP ablation in the normal heart group. In the AMI heart group, the incidence of ventricular arrhythmias and VFT were determined.

Results

In the normal heart group, GP ablation significantly prolonged ERP, facilitated electrical alternans but did not increase ERP dispersion, the slope of restitution curves and its spatial dispersion. Also, GP ablation did not cause significant change of VFT. In the AMI heart group, the incidence of ventricular arrhythmias after GP ablation was significantly higher than that in the control group or the GP plus stellate ganglion (SG) ablation group (P < 0.05). Spontaneous VF occurred in 8/12, 1/10 and 2/12 dogs in the GP ablation group, the GP plus SG ablation group and the control group, respectively (P < 0.05). VFT in the GP ablation group showed a decreased trend though a significant difference was not achieved compared with the control or the GP plus SG ablation group.

Conclusions

GP ablation increases the risk of ventricular arrhythmias in the AMI heart compared to the normal heart.     

Left circumflex artery-related myocardial infarction: Does ST elevation matter? Results from the Euro Heart Survey PCI registry

Background/objectives

Little is known about angiographic and clinical differences in patients presenting with left circumflex artery (LCX)-related ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI). We sought to determine the clinical significance of ST elevations in patients with LCX-related myocardial infarction.

Methods and results

Between 2005 and 2008 10,503 consecutive patients with acute STEMI and NSTEMI undergoing percutaneous coronary intervention (PCI) were prospectively enrolled into the Euro Heart Survey PCI-Registry. For the present analysis patients with LCX-related STEMI (n = 1100, 54.7%) were compared to those with LCX-related NSTEMI (n = 910, 45.3%). NSTEMI-patients were older, more often female and had a higher incidence of prior cardiac events. Patients with STEMI more frequently presented with shock (8.0 versus 3.9%, P < 0.001) or had been resuscitated (8.5 versus 2.7%, P < 0.0001). TIMI 0–1 before PCI was much more often found among those with STEMI (58.2 versus 25.1%, P < 0.0001). In the univariate analysis there were no significant differences in hospital mortality (STEMI: 4.8%, NSTEMI: 3.5%, P = 0.17), however after adjustment for age, female gender, diabetes and chronic renal failure hospital mortality was significantly higher in STEMI patients (odds ratio 1.71, 95%-CI 1.08–2.72, P < 0.05).

Conclusions

Over 50% of the patients with LCX-related myocardial infarction treated with PCI had ST elevations in the initial electrocardiogram. STEMIs were more often associated with total vessel occlusions or haemodynamic instability. In-hospital mortality was significantly higher in patients with LCX-related STEMI.     

Impact of increased transmitral gradients after undersized annuloplasty for chronic ischemic mitral regurgitation

Introduction

It is unknown whether drug-eluting stents (DES), in comparison with bare-metal stents (BMS), improve clinical outcomes of ST-elevation myocardial infarction (STEMI) patients with renal insufficiency. We aimed to compare the clinical outcomes of BMS versus DES, as well as sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES), in STEMI patients with renal insufficiency.

Methods

From the Korea Acute Myocardial Infarction Registry, 874 STEMI patients with renal insufficiency (glomerular filtration rate < 60 ml/min) comprising 116 patients with BMS and 758 patients with DES (430 SES and 328 PES) implantation were selected. Major adverse cardiac events (MACE) within 1 year, defined as composite of all-cause mortality, nonfatal myocardial infarction and target lesion revascularization were compared. In addition to multivariate adjusted analysis, propensity analysis for stent choice was performed.

Results

With a median follow-up of 342 days, 116 MACE occurred. MACE was more frequent in the BMS group than in the DES group before (HR [95% CI] = 2.3 [1.3-3.8]) and after propensity score matching (HR [95% CI] = 2.0 [1.0-3.8]). The difference of MACE was mainly driven by a higher rate of target lesion revascularization rate in the BMS group. In comparison between SES and PES, there was no significant difference between the 2 groups in propensity score-matched populations (HR [95% CI] = 0.7 [0.4-1.1]).

Conclusions

In STEMI patients with renal insufficiency, DES implantation exhibits a favorable 1 year clinical outcomes than BMS implantation, however, no difference was found between SES and PES.     

Uric acid suppresses 1 alpha hydroxylase in vitro and in vivo

Objective

Patients with gout have lower calcitriol levels that improve when uric acid is lowered. The mechanism of these observations is unknown. We hypothesized that uric acid inhibits 1-αhydroxylase.

Materials and methods

In vivo, Sprague Dawley rats were randomized to control (n = 5), allantoxanamide (n = 8), febuxostat (n = 5), or allantoxanamide + febuxostat (n = 7). Vitamin D, PTH, and 1-αhydroxylase protein were evaluated. In order to directly evaluate the effect of uric acid on 1-αhydroxylase, we conducted a series of dose response and time course experiments in vitro. Nuclear factor κ-B (NFκB) was inhibited pharmacologically. Finally, to evaluate the potential implications of these findings in humans, the association between uric acid and PTH in humans was evaluated in a cross-sectional analysis of data from the NHANES (2003–2006); n = 9773.

Results

1,25(OH)₂D and 1-αhydroxylase protein were reduced in hyperuricemic rats and improved with febuxostat treatment. Uric acid suppressed 1-αhydroxylase protein and mRNA expression in proximal tubular cells. This was prevented by NFκB inhibition. In humans, for every 1 mg/dL increase in uric acid, the adjusted odds ratio for an elevated PTH (> 65 pg/mL) was 1.21 (95% C.I. 1.14, 1.28; P < 0.0001), 1.15 (95% C.I. 1.08, 1.22; P < 0.0001), and 1.16 (95% C.I. 1.03, 1.31; P = 0.02) for all subjects, subjects with estimated GFR ≥ 60, and subjects with estimated GFR < 60 mL/min/1.73 m² respectively.

Conclusion

Hyperuricemia suppresses 1-αhydroxylase leading to lower 1,25(OH)₂D and higher PTH in rats. Our results suggest this is mediated by NFκB. The association between uric acid and PTH in NHANES suggests potential implications for human disease.     

A critical challenge: Dosage-related efficacy and acute complication intracoronary injection of autologous bone marrow mesenchymal stem cells in acute myocardial infarction

Background

Previous studies showed improvement in heart function by injecting bone marrow mesenchymal stem cells (BMSCs) after AMI. Emerging evidence suggested that both the number and function of BMSCs decline with ageing. We designed a randomized, controlled trial to further investigate the safety and efficacy of this treatment.

Methods

Patients with ST-elevation AMI undergoing successful reperfusion treatment within 12 hours were randomly assigned to receive an intracoronary infusion of BMSCs (n = 21) or standard medical treatment (n = 22) (the numbers of patients were limited because of the complication of coronary artery obstruction).

Results

There is a closely positive correlation of the number and function of BMSCs vs. the cardiac function reflected by LVEF at baseline (r = 0.679, P = 0.001) and at 12-month follow-up (r = 0.477, P = 0.039). Six months after cell administration, myocardial viability within the infarct area by 18-FDG SPECT was improved in both groups compared with baseline, but no significant difference in the BMSCs compared with control groups (4.0 ± 0.4% 95%CI 3.1–4.9 vs. 3.2 ± 0.5% 95%CI 2.1–4.3, P = 0.237). 99mTc-sestamibi SPECT demonstrated that myocardial perfusion within the infarct area in the BMSCs did not differ from the control group (4.4 ± 0.5% 95%CI 3.2–5.5 vs. 3.9 ± 0.6% 95%CI 2.6–5.2, P = 0.594). Similarly, LVEF after 12 and 24 months follow-up did not show any difference between the two groups. In the BMSCs group, one patient suffered a serious complication of coronary artery occlusion during the BMSCs injection procedure.

Conclusions

The clinical benefits of intracoronary injection of autologous BMSCs in acute STEMI patients need further investigation and reevaluation.     

Five-year outcomes of surgical or percutaneous myocardial revascularization in diabetic patients

Background

The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to prefer surgical or percutaneous revascularization.

Methods

Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction [AMI], stroke, and repeat revascularization [TVR]) were assessed with Kaplan–Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization.

Results

PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4–2.2 p < 0.0001), AMI (HR: 3.3, 95% CI 2.4–4.6 p < 0.0001) and TVR (HR: 4.5, 95% CI 3.4–6.1 p < 0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5–1.2 p = 0.26).The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only.

Conclusions

Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.     

Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction: a 6-year experience

Berglin Blohm M, Hartford M, Karlsson T, Herlitz J (Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden). Factors associated with pre-hospital and in-hospital delay time in acute myocardial infarction: a 6-year experience. J Intern Med 1998; 243 : 243–50.

Objectives

To explore factors associated with delay time prior to hospital admission and in hospital amongst acute myocardial infarction (AMI) patients with particular emphasis on the delay time to the administration of thrombolytic therapy.

Methods

During a 6-year period we prospectively computerized pre-hospital and in-hospital time intervals for AMI patients admitted to the coronary care unit (CCU) direct from the emergency department (ED) or via paramedics, at Sahlgrenska Hospital, Göteborg, Sweden.

Results

Pre-hospital delay: independent predictors of a prolonged delay were increased age (P<> = 0.0007), female sex (P<> = 0.02) and a history of hypertension (P<> = 0.03). For AMI patients who received thrombolytic treatment and the only independent predictor of a prolonged delay was increased age (P<> = 0.005). In-hospital delay: for all AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), increased age (P= 0.03) and a history of angina (P= 0.002), hypertension (P= 0.01) and diabetes (P= 0.01). For thrombolytic treated AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), female sex (P= 0.02) and a history of diabetes (P= 0.02).

Conclusion

Risk factors for both pre-hospital and hospital delay time could in AMI be defined although slightly different. Two factors appeared for both, i.e. increasing age and a history of hypertension.

     

Comparison between a second and a third generation parathyroid hormone assay in hemodialysis patients

Objective

Third generation parathyroid hormone (PTH) assays are new generation assays that do not recognize the PTH_7–84 fragment whereas second generation assays detect both PTH_1–84 and PTH_7–84 fragments. Despite the excellent correlation between both assays in chronic renal failure (CRF) subjects, the mean PTH levels are typically 50% lower with the third compared to the second generation assays. The assessment of third generation PTH assays has not been extensively studied in hemodialysis subjects. The purpose of our study was to compare a third generation PTH assay to a second generation one in a population of hemodialysis subjects.

Materials and methods

92 haemodialysis subjects (36 women and 56 men) with a mean age of 67±12.9 years were included in this study. Anthropometric and clinical parameters (Body Mass Index (BMI) and blood pressure) were measured. Second and third generation PTH assays (Cis biomedical and Diasorin respectively) were performed in each subject. In addition, the following biochemical tests were measured: 25-hydroxyvitamin D (25-(OH)D), 1,25-hydroxyvitamin D (1,25-(OH)₂D), crosslaps and alkaline phosphatase.

Results

The mean second and third generation PTHs are respectively 211±205 pg/ml and 151±164 pg/ml. The mean third generation PTH values are 28.4% lower compared to the second generation ones. Both methods are strongly correlated (r = 0.923, p < 0.001). This correlation persisted without any significant difference after controlling for gender, age, BMI and Blood Pressure. However, the difference between both methods increases when baseline PTH increases. Each of the second and third generation method is significantly correlated with hemodialysis duration (p < 0.01), crosslaps (p < 0.001), alkaline phosphatase (p < 0.05), but not with age, BMI, Blood Pressure, 25-(OH)D or 1,25-(OH) ₂D levels.

Conclusion

Our results show that both second and third generation PTH methods are strongly correlated in hemodialysis patients mainly when PTH values are low. However, the difference between both methods increases when PTH values are high. More research is needed to establish which method is the gold standard when PTH values are high.     

Prognostic implications of quantitative evaluation of baseline Q-wave width in ST-segment elevation myocardial infarction

Objectives

To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI).

Background

Baseline Q-waves are useful in predicting clinical outcomes after MI.

Methods

3589 STEMI patients were assessed from a multi-centre study.

Results

1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p < 0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥ 40 ms for inferior and ≥ 20 ms for lateral/apical MI in all patients (n = 3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54–3.85), p < 0.001) and the composite (HR: 2.32, 95% CI (1.70–3.16), p < 0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p < 0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02–0.29), p = 0.027).

Conclusions

The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥ 40 ms in inferior and ≥ 20 ms for lateral/apical MI enhances prognostic insight beyond current criteria.     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

Mid-regional pro-adrenomedullin in the early evaluation of acute chest pain patients

Background

The purpose of this study was to investigate the utility of mid-regional pro-adrenomedullin (MR-proADM) in the early diagnosis and risk stratification of patients with acute chest pain in comparison with established and novel biomarkers and risk scores.

Methods

In this prospective, observational, international, multi-center trial (APACE), MR-proADM was determined in 1179 unselected patients with acute chest pain. Patients were followed for 24 months.

Results

MR-proADM concentrations at presentation were higher in patients with AMI (median: 0.78 nmol/l, IQR 0.60–1.13) than in patients with other diagnoses (0.64 nmol/l, IQR 0.49–0.86 nmol/l; p < 0.001). The diagnostic accuracy of MR-proADM for AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0.66. Adding MR-proADM to hs-cTnT could not improve its diagnostic accuracy for AMI (p = 0.431). Seventy-six percent of all deaths occurred in the fourth quartile of MR-proADM (> 0.90 nmol/l). Adding MR-proADM to the TIMI-score (AUC 0.87) predicted 1-year mortality more accurately than the TIMI-score alone (AUC 0.82; p < 0.001). Net reclassification improvement (TIMI vs. additionally MR-proADM) amounted to 0.137 (p = 0.012). MR-proADM had higher prognostic accuracy as compared to hs-cTnT in patients with AMI (p = 0.015) and in those without AMI (p = 0.003). MR-proADM at presentation was tantamount to GRACE score and BNP as to its prognostic accuracy for mortality. The AUC for the prediction of cardiovascular events amounted to 0.63.

Conclusions

While MR-proADM does not have clinical utility in the early diagnosis of AMI or predicting cardiovascular events in patients with acute chest pain, it may provide prognostic value for all-cause mortality.