Performance of the thrombolysis in myocardial infarction risk index in the National Registry of Myocardial Infarction-3 and -4: a simple index that predicts mortality in ST-segment elevation myocardial infarction

OBJECTIVES: We sought to evaluate a simple risk index based on age and vital signs in a community sample of patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: A simple risk index based on age and vital signs (heart rate x [age/10](2)/systolic blood pressure) developed from patients with STEMI accurately predicts mortality in clinical trials of fibrinolysis. The application of such a tool in an unselected population is necessary to evaluate its utility in clinical practice. METHODS: To evaluate the Thrombolysis In Myocardial Infarction (TIMI) risk index for routine practice, we tested it in the National Registry of Myocardial Infarction (NRMI)-3 and -4. The risk index was evaluated as a continuous variable in patients with STEMI from NRMI and in subgroups based on age and reperfusion status. RESULTS: A total of 153,486 patients with STEMI were eligible. As anticipated, STEMI patients in NRMI had a higher risk index profile, as compared with those in the clinical trial (median 26.9 vs. 20, p < 0.0001). Classification of NRMI patients with STEMI into risk groups revealed a significant graded relationship with mortality (0.9% to53.2%, p(trend) < 0.0001, c statistic 0.79). The discriminatory capacity of the risk index was particularly strong in the 81,679 patients receiving reperfusion therapy (0.6% to60%, p(trend) < 0.0001, c statistic 0.81). For the 71,807 patients not receiving reperfusion therapy, a strong graded relationship remained (1.9% to 52.2%, p(trend) < 0.0001, c statistic 0.71). Among the elderly, although the distribution of scores was shifted toward higher risk, the performance remained (0% to 53.1%, p(trend)< 0.0001, c statistic 0.71). CONCLUSIONS: A simple risk index from baseline clinical variables routinely obtained at the first patient encounter predicted mortality in a large unselected heterogeneous group of patients with STEMI.     

Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients

BACKGROUND: The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients. METHODS: The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model's discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status. RESULTS: The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated. CONCLUSIONS: The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.     

中国急性心肌梗死患者住院期间死亡的危险因素分析

目的:探讨当代中国急性心肌梗死(AMI)患者住院期间死亡的危险因素。方法:纳入2013年01月至2014年09月中国急性心肌梗死(CAMI)注册登记研究的AMI患者23417例[其中5795例非ST段抬高型心肌梗死(NSTEMI)患者和17622例ST段抬高型心肌梗死(STEMI)患者]。1504例患者在住院期间死亡,为死亡组,余住院期间生存的21913例患者为生存组。收集患者基线资料、实验室检查、治疗方法、院内结局等临床资料,以住院期间死亡为主要终点构建多因素Logistic回归模型,探讨AMI患者住院期间死亡的独立危险因素。结果:6.42%(1504/23417)的AMI患者在住院期间死亡。与生存组比较,死亡组患者年龄更大,女性患者更多,体重指数更低,合并糖尿病、高血压的比例更高,Killip心功能分级更高,并发症更多,并且更易出现心脏骤停(P均<0.05)。多因素Logistic回归分析结果提示,年龄、性别、体重指数、收缩压、心率、血肌酐水平、白细胞计数、血清钾浓度、血清钠浓度、STEMI、前壁心肌梗死、心脏骤停、Killip心功能分级、高血压、高脂血症及吸烟史是预测患者住院期间死亡的独立危险因素。结论:本研究发现16个当代中国AMI患者住院期间死亡的独立危险因素,有助于临床医师早期识别高危患者并选择最佳诊疗策略。     

Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLAC trial)

We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.     

Comparison of angiographic and other findings and mortality in non-ST-segment elevation versus ST-segment elevation myocardial infarction in patients undergoing early invasive intervention

We sought to compare the angiographic findings and mortality in patients with non-ST-segment elevation (NSTEMI) versus ST-segment elevation myocardial infarction (STEMI) undergoing early invasive intervention. Of 11,872 patients enrolled in the Korean Acute Myocardial Infarction Registry from November 2005 to January 2008, we studied patients with NSTEMI undergoing early invasive intervention (n = 1,486) and those with STEMI undergoing primary percutaneous coronary intervention (n = 4,392). Multivessel coronary disease, baseline Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and the left circumflex artery as a culprit lesion occurred more frequently in patients with NSTEMI than in those with STEMI. Those with NSTEMI had a significantly lower mortality rate than those with STEMI during a median follow-up of about 12 months (3.8% vs 6.7%, p <0.001). In the patients with NSTEMI, the independent predictors of mortality included postprocedural TIMI flow grade 0 to 2 (hazard ratio [HR] 3.07, 95% confidence interval [CI] 1.01 to 9.29, p = 0.047) and multivessel coronary disease (HR 3.83, 95% CI 1.36 to 10.81, p = 0.010) but not baseline TIMI flow or infarct location. However, baseline TIMI flow grade 0 to 2 (HR 1.56, 95% CI 1.03 to 2.36, p = 0.035), anterior infarction (HR 1.69, 95% CI 1.28 to 2.23, p <0.001), multivessel coronary disease (HR 1.45, 95% CI 1.10 to 1.91, p = 0.008), and postprocedural TIMI flow grade 0 to 2 (HR 2.00, 95% CI 1.42 to 2.82, p <0.001) were all independent predictors of mortality in the patients with STEMI. In conclusion, the angiographic findings in patients from NSTEMI differ from those in patients with STEMI. Postprocedural TIMI flow and multivessel coronary disease were independent predictors of mortality in patients with NSTEMI undergoing early invasive intervention.     

非ST段抬高急性心肌梗死患者的临床特点及不良事件发生率分析

目的探讨非ST段抬高急性心肌梗死的临床特点及住院不良事件发生率。方法回顾性分析我院急性心肌梗死患者105例,分为ST段抬高组（n=68）和非ST段抬高组（n=37）,分析比较两组患者的冠状动脉造影特点及住院不良事件发生率。结果冠状动脉造影示病变血管数差异无显著性意义（P〉0．05）;非ST段抬高组以老年人多见（71％）,其中〉60岁的女性患者占41％,相关血管不完全闭塞比例较高、累及非主支血管较多,且梗死相关血管周围多有侧支循环形成。非ST段抬高组总住院不良事件（包括心力衰竭、再次心肌梗死、再次冠脉介入治疗和脑卒中等）的发生率明显较低,差异有显著性意义（P〈0．01）,但住院病死率和消化道出血发生率差异无显著性意义（P〉0．05）。结论非ST段抬高者以老年、女性患者居多,临床表现和冠状动脉造影的结果不典型,但有较好的近期预后。     

Effect of Ischemia Duration and Door-to-Balloon Time on Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction: An Analysis From HORIZONS-AMI Trial (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction)

ObjectivesThis study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial.BackgroundDespite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation.MethodsWe examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI.ResultsIn 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality.ConclusionsThe present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.     

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.     

Relationship between baseline white blood cell count and degree of coronary artery disease and mortality in patients with acute coronary syndromes: a TACTICS-TIMI 18 (Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy- Thrombolysis in Myocardial Infarction 18 trial)substudy

OBJECTIVES: This study was designed to determine the relationship between baseline white blood cell (WBC) count and angiographic and clinical outcomes in patients with unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI) and to see if WBC count was a significant predictor of outcomes independent of other biomarkers. BACKGROUND: Inflammation has been shown to play a role in atherosclerosis and acute coronary syndromes. METHODS: We evaluated the relationship between baseline WBC count, other baseline variables and biomarkers, angiographic findings, and clinical outcomes in 2,208 patients in the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction 18 (TACTICS-TIMI 18) trial. RESULTS: Higher baseline WBC counts were associated with lower Thrombolysis In Myocardial Infarction (TIMI) flow grades (p = 0.0045) and TIMI myocardial perfusion grades (p = 0.03) as well as a greater extent of coronary artery disease (CAD) (p < 0.0001). A higher baseline WBC count was predictive of higher six-month mortality, ranging from 1.5% to 3.6% to 5.1% for patients with low, intermediate, and high WBC counts, respectively (p = 0.0017). In a multivariable proportional hazards model, patients with a low C-reactive protein (CRP) but an elevated WBC remained at significantly higher risk of death at six months (hazard ratio [HR] 4.3, p = 0.049), and patients with a high CRP were at even higher risk (HR 8.6, p = 0.004). conclusions: In patients with UA/NSTEMI, elevations in a simple, widely available blood test, the WBC count, were associated with impaired epicardial and myocardial perfusion, more extensive CAD, and higher six-month mortality. After adjustment for traditional risk factors and other biomarkers, assessment of two inflammatory markers, WBC count and CRP, can be used to stratify patients across an eightfold gradation of six-month mortality risk.     

Suboptimal medical care of patients with STElevation Myocardial Infarction and Renal Insufficiency: results from the Korea acute Myocardial Infarction Registry

ABSTRACT: BACKGROUND: The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) are poor in patients with renal insufficiency. This study investigated changes in the likelihood that patients received optimal medical care throughout the entire process of myocardial infarction management, on the basis of their glomerular filtration rate (GFR). METHODS: This study analyzed 7,679 patients (age, 63 +/- 13 years; men 73.6 %) who had STEMI and were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to August 2008. The study subjects were divided into 5 groups corresponding to strata used to define chronic kidney disease stages. RESULTS: Patients with lower GFR were less likely to present with typical chest pain. The average symptom-to-door time, door-to-balloon time, and symptom-to-balloon time were longer with lower GFR than higher GFR. Primary reperfusion therapy was performed less frequently and the results of reperfusion therapy were poorer in patients with renal insufficiency; these patients were less likely to receive adjunctive medical treatment, such as treatment with aspirin, clopidogrel, beta-blocker, angiotensin-converting enzyme (ACE) inhibitor/angiotensinreceptor blocker (ARB), or statin, during hospitalization and at discharge. Patients who received less intense medical therapy had worse clinical outcomes than those who received more intense medical therapy. CONCLUSIONS: Patients with STEMI and renal insufficiency had less chance of receiving optimal medical care throughout the entire process of MI management, which may contribute to worse outcomes in these patients.     

急性非ST段抬高心肌梗死与ST段抬高心肌梗死冠状动脉病变特点的比较

目的 比较非ST段抬高心肌梗死（NSTEMI）与ST段抬高心肌梗死（STEMI）的冠状动脉病变特点。方法：NSTEMI与STEMI病人入院后10d内行冠状动脉造影术，分析病变类型、范围、狭窄程度及侧支循环。结果：NSTEMI组的多支病变、〉90％的严重狭窄及侧支循环比率高于STEMI组，而完全闭塞率低于STEMI组（P〈0．05）。结论 NSTEMI的多支病率高于STEMI，前者的远期预后有可能较后者差。     

急性心肌梗死患者急性期高血糖与心血管不良事件的相关性研究

目的 探讨不同类型心肌梗死患者急性期高血糖与其心血管不良事件及病情严重程度的关系。方法 将183例急性心肌梗死（AMI）患者分为ST段抬高型84例(STEMI)及非ST段抬高型99例（NSTEMI）,根据入院即刻血糖(ABG)、入院后首次（次日）空腹血糖(FBG)、是否合并有糖尿病为切点,回顾性分析各组患者住院期间急性期高血糖与主要心血管不良事件（心力衰竭、恶性心律失常、死亡）以及心梗后心功能状态的相关指标（Killip分级、LVEF、BNP）和心梗后心肌缺血、病变严重程度及范围的相关指标（冠脉病变支数、Gensini积分）的关系。结果 ABG、FBG 水平与 Killip分级、BNP、冠脉病变支数、Gensini积分等指标均呈正相关,与LVEF值均呈负相关,且相关程度STEMI均较NSTEMI更明显。结论 急性期高血糖水平在STEMI患者中对心血管不良事件发生率的预测较 NSTEMI患者更好,心梗后心功能状态、冠脉病变程度相关性更高,有助于住院期间不良心血管事件及心梗后心功能的判断,可作为STEMI患者危险分层及评估心梗后高危人群的一个简易临床指标。     

Combined Thrombolysis with Abciximab Favourably Influences Platelet-Leukocyte Interactions and Platelet Activation in Acute Myocardial Infarction

Background: The standard of care for ST-segment elevation myocardial infarction (STEMI) is prompt coronary reperfusion with thrombolysis or percutaneous coronary intervention. Women have higher mortality rates than men following STEMI and fewer women are considered eligible for reperfusion therapy. We analyzed the impact of gender, and other factors, on the outcome and treatment of STEMI in the TETAMI trial and registry.Methods: This exploratory analysis included 2741 patients from Treatment with Enoxaparin and Tirofiban in Acute Myocardial Infarction (TETAMI) presenting with STEMI within 24 hours of symptom onset. The primary composite end point was the combined incidence of all-cause death, recurrent myocardial infarction, and recurrent angina, at 30 days. Three multivariate analyses were performed to determine predictors of not receiving reperfusion therapy, the composite end point, or death.Results:The triple end point occurred in 17.8% of women versus 13.3% of men. Reperfusion therapy was utilized in 38.2% of women versus 47.3% in men. However, age > 75 years, delayed presentation, high systolic blood pressure (> 100) and region (South Africa), were significant, independent predictors of not receiving reperfusion therapy. Significant predictors of the triple end point included not receiving reperfusion therapy, age > 60 years, and higher Killip class. Predictors of death included age > 60 years, low systolic blood pressure, higher Killip class, high heart rate, delayed presentation, and region (South Africa and South America).Conclusion: Female gender was not an independent predictor of outcome or underutilization of reperfusion therapy. Factors more common in female STEMI patients (advanced age and delayed presentation) were associated with not receiving reperfusion therapy and adverse outcome. Increased awareness is needed to reduce delayed presentation after symptom onset, especially among women.Abbreviated abstract. In this analysis of 2741 ST-segment elevation myocardial infarction patients in the TETAMI trial and registry, a trend was observed for women being less likely to receive reperfusion therapy and more likely to have an adverse outcome than men. This was related to factors more common in female patients (advanced age and delayed presentation), and showed that an increased awareness is needed to reduce delayed presentation after symptom onset, especially among women.Supported by a grant from sanofi-aventis, Bridgewater, NJ, USA.     

Early prognostic usefulness of C-reactive protein added to the Thrombolysis In Myocardial Infarction risk score in acute coronary syndromes

The aim of the present study was to evaluate whether an elevated plasma C-reactive protein (CRP) level provides any additional prognostic information to the validated Thrombolysis In Myocardial Infarction (TIMI) risk score in patients with acute coronary syndromes. For this purpose, 1,846 consecutive patients with either acute ST-segment elevation myocardial infarction (STEMI; 861 patients) or non-ST-segment elevation acute coronary syndrome (NSTEACS; 985 patients) were included. The incidence of 30-day death and 14-day composite of death, myocardial infarction (or repeat myocardial infarction) and recurrent ischemia was the prespecified primary end point in the STEMI and NSTEACS cohorts, respectively. The incidence of the primary end point was 9.8% and 23.6% in the STEMI and NSTEACS cohorts, respectively. A significantly increased risk of the primary end point was present with an increase in the STEMI and NSTEACS TIMI risk score (p(trend) < 0.001 for the 2 groups). A plasma CRP value of > or = 5 and > or = 3 mg/L (defined by receiver-operating characteristic analysis) was associated with a significantly increased risk of the primary end point in the STEMI and NSTEACS cohorts, respectively (p < 0.001 for the 2 cohorts), and it was true throughout the subgroups of STEMI and NSTEACS TIMI risk scores. In conclusion, an elevated plasma CRP level appears to be a marker that adds prognostic information to the validated STEMI and NSTEACS TIMI risk score. The plasma CRP and TIMI risk score may be used together for enhanced risk stratification in the setting of acute coronary syndromes.     

B-type natriuretic peptide at presentation and prognosis in patients with ST-segment elevation myocardial infarction: an ENTIRE-TIMI-23 substudy

OBJECTIVES: We sought to evaluate B-type natriuretic peptide (BNP), alone and in comparison to cardiac troponin I (cTnI) and high-sensitivity C-reactive protein (hs-CRP), for risk assessment at initial presentation with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Elevated levels of BNP drawn two to four days after acute myocardial infarction are associated with higher mortality. Sparse data are available on its use at first presentation with STEMI. METHODS: We obtained samples from 438 patients presenting within 6 h of STEMI enrolled in the Enoxaparin Tenecteplase-Tissue-Type Plasminogen Activator With or Without Glycoprotein IIb/IIIa Inhibitor as Reperfusion Strategy in ST-Segment Elevation Myocardial Infarction (ENTIRE)-Thrombolysis In Myocardial Infarction (TIMI)-23 trial. Outcomes were assessed through 30 days. RESULTS: Median BNP was higher in patients who died (89 pg/ml, 25th to 75th percentile: 40 to 192), compared with survivors (15 pg/ml, 25th to 75th percentile: 8.8 to 32, p < 0.0001). Patients with BNP >80 pg/ml were at significantly higher risk of death (17.4% vs. 1.8%, p < 0.0001). Cardiac troponin established a gradient of mortality between the highest and lowest quartile (7.9% vs. 0%, p = 0.007). C-reactive protein was not associated with outcome. After adjustment for cTnI, hs-CRP, and major clinical predictors, including age, heart failure, anterior myocardial infarction location, heart rate, and blood pressure, a BNP level >80 pg/ml was associated with a seven-fold higher mortality risk (odds ratio 7.2, 95% confidence interval 2.1 to 24.5, p = 0.001). Patients with BNP >80 pg/ml were also more likely to have impaired coronary flow (p = 0.049) and incomplete resolution of ST-segment elevation (p = 0.05). CONCLUSIONS: Increased concentrations of BNP at initial presentation of patients with STEMI are associated with impaired reperfusion after fibrinolysis and higher short-term risk of mortality. These data support the value of combining markers of hemodynamic stress with traditional approaches to risk assessment in acute myocardial infarction.     

青年初发急性心肌梗死患者心肌梗死类型及危险因素变化趋势分析

目的:分析青年(18~44岁)初发急性心肌梗死(AMI)患者心肌梗死类型及危险因素变化趋势。方法:收集2007年1月至2017年12月我院18~44岁初次诊断为AMI的住院患者。通过电子病历系统提取患者年龄、性别、出院诊断等一般临床资料,高血压病史、糖尿病病史、高胆固醇血症、肥胖、吸烟和饮酒6项心血管疾病可改变危险因素相关信息以及冠状动脉造影结果。结果:共纳入青年初发AMI患者2866例,男性2739例(95.6%),年龄(38.9±4.7)岁。心血管疾病可改变的危险因素前三位分别是吸烟[2084例(72.7%)]、高血压[1170例(40.8%)]和肥胖[1084例(37.8%)]。心肌梗死类型以ST段抬高型心肌梗死(STEMI)为主(77.3%)。非ST段抬高型心肌梗死(NSTEMI)构成比呈现上升趋势,由2007年的9.2%上升到2017年的36.9%,上升了27.7%(P_趋势<0.001)。NSTEMI患者中高血压、糖尿病、高胆固醇血症和肥胖者比例显著高于STEMI患者,单支冠状动脉病变者比例低于STEMI患者(P均<0.05);随着代谢危险因素(高血压、糖尿病、高胆固醇血症和肥胖)数目增多,临床表现为NSTEMI的几率增加(OR=1.39,95%CI:1.20~1.60,P<0.001);与单支冠状动脉病变患者相比,多支冠状动脉病变患者(OR=1.27,95%CI:1.05~1.54,P<0.05)以及冠状动脉正常或无明显狭窄患者(OR=2.15,95%CI:1.59~2.90,P<0.001)临床表现为NSTEMI的几率增加。2007~2017年,多个(2个以上)代谢危险因素者比例显著上升(P_趋势=0.01),单支冠状动脉病变者比例显著下降(P_趋势=0.001)。结论:青年初发AMI患者以男性占绝对优势,心肌梗死类型仍以STEMI为主,但NSTEMI构成比呈上升趋势,多个代谢危险因素及冠状动脉病变特点变化与NSTEMI构成比趋势变化有关。     

Randomized Trial of Interleukin-6 Receptor Inhibition in Patients With Acute ST-Segment Elevation Myocardial Infarction

BackgroundPrompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.ObjectivesThis study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.MethodsThe ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.ResultsWe randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.ConclusionsTocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703)     

Fate of patients with prehospital resuscitation for ST-elevation myocardial infarction and a high rate of early reperfusion therapy (results from the PREMIR [Prehospital Myocardial Infarction Registry])

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.     

Thrombus aspiration before primary angioplasty improves myocardial reperfusion in acute myocardial infarction: the DEAR-MI (Dethrombosis to Enhance Acute Reperfusion in Myocardial Infarction) study.

OBJECTIVES: This study sought to test the hypothesis that thrombus removal, with a new manual thrombus-aspirating device, before primary percutaneous coronary intervention (PPCI) may improve myocardial reperfusion compared with standard PPCI in patients with ST-segment elevation acute myocardial infarction (STEMI). BACKGROUND: In STEMI patients, PPCI may cause thrombus dislodgment and impaired microcirculatory reperfusion. Controversial results have been reported with different systems of distal protection or thrombus removal. METHODS: One-hundred forty-eight consecutive STEMI patients, admitted within 12 h of symptom onset and scheduled for PPCI, were randomly assigned to PPCI (group 1) or manual thrombus aspiration before standard PPCI (group 2). Patients with cardiogenic shock, previous infarction, or thrombolytic therapy were excluded. Primary end points were complete (>70%) ST-segment resolution (STR) and myocardial blush grade (MBG) 3. RESULTS: Baseline clinical and angiographic characteristics were similar in the 2 groups. Comparing groups 1 and 2: complete STR 50% versus 68% (p < 0.05); MBG-3 44% versus 88% (p < 0.0001); coronary Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 78% versus 89% (p = NS); corrected TIMI frame count 21.5 +/- 12 versus 17.3 +/- 6 (p < 0.01); no reflow 15% versus 3% (p < 0.05); angiographic embolization 19% versus 5% (p < 0.05); direct stenting 24% versus 70% (p < 0.0001); and peak creatine kinase-mass band fraction 910 +/- 128 mug/l versus 790 +/- 132 mug/l (p < 0001). In-hospital clinical events were similar in the 2 groups. After adjusting for confounding factors, multivariate analysis showed thrombus aspiration to be an independent predictor of complete STR and MBG-3. CONCLUSIONS: Manual thrombus aspiration before PPCI leads to better myocardial reperfusion and is associated with lower creatine kinase mass band fraction release, lower risk of distal embolization, and no reflow compared with standard PPCI. (Thrombus Aspiration Before Standard Primary Angioplasty Improves Myocardial Reperfusion in Acute Myocardial Infarction; http://clinicaltrials.gov/ct/show/NCT00257153).     

Is coding for myocardial infarction more accurate now that coding descriptions have been clarified to distinguish ST-elevation myocardial infarction from non-ST elevation myocardial infarction?

Outcomes are typically graded on the basis of diagnoses coded according to the International Classification of Diseases, Ninth Revision (ICD-9). To facilitate performance measurement, the ICD-9 codes for acute myocardial infarction changed in October 2005 to completely separate non-ST elevation myocardial infarction (NSTEMI; code 410.71) and ST elevation myocardial infarction (STEMI; all other codes 410.x), yet it is unclear whether these changes have been implemented by coders. Patients in the National Registry of Myocardial Infarction (NRMI), version 5, were categorized in 2 ways: by electrocardiographic (ECG) findings and ICD-9 codes. Agreement between ECG findings and ICD-9 codes for type of myocardial infarction (STEMI or NSTEMI) was assessed before and after ICD-9 revision. Mortality rates were measured in a subgroup of patients discharged without transfer after the coding change. There were 102,679 hospitalizations before October 2005 and 63,012 hospitalizations after the coding change, among which the mean age was 66.7 years. Previously, 81% of NSTEMIs (by ECG diagnosis) were coded ICD-9 410.71; after the reclassification of code 410.71 to reflect NSTEMI, 82% of NSTEMIs were coded 410.71 (p <0.001). Overall, the correlation of ECG diagnosis with ICD-9 code improved only slightly after the coding change. In conclusion, despite more distinctly separated definitions of STEMI and NSTEMI in the new ICD-9 coding system as of October 2005, there appears to be little change in coding, which may reflect a lack of awareness of this substantial change in classification.