Atherosclerotic risk genotypes and recurrent coronary events after myocardial infarction

The association of a group of prespecified atherosclerotic risk genotypes with recurrent coronary events (coronary-related death, nonfatal myocardial infarction, or unstable angina) was investigated in a cohort of 1,008 patients after infarction during an average follow-up of 28 months. We used a carrier-ship approach with time-dependent survivorship analysis to evaluate the average risk of each carried genotype. Contrary to expectation, the hazard ratio for recurrent coronary events per carried versus noncarried genotype was 0.89 (95% confidence interval 0.80 to 0.99, p = 0.03) after adjustment for relevant genetic, clinical, and environmental covariates. This hazard ratio, derived from the 7 prespecified genotypes, indicated an average 11% reduction in the risk of recurrent coronary events per carried versus noncarried genotype. At 1 year after hospital discharge, the cumulative probability of recurrent coronary events was 26% in those who carried < or =1, 20% for those with 2 to 4, and 13% for those with > or =5 of these genotypes (p = 0.02). This unexpected risk reversal is a likely consequence of changes in the mix of risk factors in pre- and postinfarction populations. In conclusion, this under appreciated, population-based, risk-reversal phenomenon may explain the inconsistent associations of genetic risk factors with outcome events in previous reports involving coronary populations with different risk attributes.     

Myocardial infarction after influenza vaccination

Influenza is a common disease in the population. Influenza vaccination is performed routinely and is usually well tolerated. Minor local or systemic side effects like fever and myalgia are described. Rarely there are more severe adverse events. Systemic vasculitis has been reported in some cases. In this case we report on a female patient with secondary vasculitis and myocardial infarction after influenza vaccination. The patient received cortisol and recovered. The literature about influenza vaccination, its side effects and recommendations about vaccination in patients with coronary artery disease is reviewed.     

Essential thrombocythemia and recurrent myocardial infarction

We report the case of recurrent myocardial infarction with essential thrombocythemia (ET) in a 61-year-old female patient. Only one report of recurrence of myocardial infarction has been previously described. Coronary angiography 10 days after the infarction was normal. Thrombocythemia had been controlled with hydroxyurea.     

Association of renal transplantation with reduced risk of myocardial infarction and ischemic stroke in ANCA-associated vasculitis: An observational cohort study

ObjectiveMyocardial infarction and ischemic stroke are leading causes of cardiovascular (CV) morbidity and mortality in ANCA-associated vasculitis (AAV), especially for the 20% with end-stage renal disease (ESRD). We assessed the impact of renal transplantation on the risk of myocardial infarction and stroke among patients with ESRD due to AAV.MethodsWe identified patients from the United States Renal Data System with ESRD due to AAV between 2000 and 2016. We examined the association between renal transplantation and the risk of non-fatal and fatal myocardial infarction or ischemic stroke among waitlisted patients using Medicare claims and death data through 2017. We used time-varying Cox proportional hazards models with age as the time scale to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for myocardial infarction and ischemic stroke events among patients who received a renal transplant compared to those who remained on the waitlist.ResultsOf 1029 waitlisted patients, 593 (58%) were transplanted over a mean of 5.7 years. There were 17 events (4.6/1,000 person-years) in the transplanted group and 40 events (13.7/1,000 person-years) in the group that remained waitlisted. A renal transplant was associated with a 78% lower risk of myocardial infarction or ischemic stroke (HR=0.22, 95% CI 0.11 to 0.47). These findings persisted across sex and age groups and when censoring patients after living donor transplantation.ConclusionsAmong AAV patients with ESRD, renal transplantation can substantially reduce the risk of myocardial infarction and ischemic stroke. Improving access to transplantation for this population may further improve outcomes.     

Association of elevated homocysteine levels with a higher risk of recurrent coronary events and mortality in patients with acute myocardial infarction

BACKGROUND: Despite the prothrombotic and proinflammatory effects associated with elevated homocysteine levels, only limited data exist regarding the effect of homocysteine levels on outcome of patients with acute myocardial infarction. METHODS: Homocysteine levels were determined within 24 hours of presentation in 157 consecutive patients with acute myocardial infarction. Patients were allocated to 2 groups: those with homocysteine levels of 2.7 mg/L (20 micro mol/L) or more (n = 22 [14%]) and those with homocysteine levels of less than 2.7 mg/L (n = 135 [86%]). RESULTS: Female and diabetic patients had significantly lower homocysteine levels than males (P<.01) and nondiabetic patients (P =.005), respectively, with no significant correlation with age (r = 0.07, P =.42) or other risk factors. Patients with homocysteine levels greater than or equal to 2.7 mg/L and less than 2.7 mg/L did not differ significantly regarding extent of coronary artery disease as reflected by prevalence of multivessel disease (54% vs 61%; P =.87), and their in-hospital course. However, in a mean +/-SD follow-up of 30 +/- 10 months, patients with homocysteine levels greater than or equal to 2.7 mg/L had a higher incidence of recurrent coronary events (36% vs 17%; P =.04) and death (18% vs 5%; P<.05). Homocysteine levels greater than or equal to 2.7 mg/L remain a significant determinant of recurrent coronary event and/or death after controlling for potential cofounders by multivariate analysis (odds ratio, 3.8; 95% confidence interval, 1.3-11.0). CONCLUSIONS: In patients with acute myocardial infarction, elevated homocysteine levels are associated with a higher risk of recurrent coronary events and death, independent of other risk factors and the extent of coronary artery disease.     

Association of anxiety with reduced baroreflex cardiac control in patients after acute myocardial infarction

Background Although depression has been associated with increased mortality in patients after acute myocardial infarction (AMI), little is known about the effects of depression on autonomic nervous system control of heart rate. This study evaluated whether depression is associated with impaired baroreflex sensitivity (BRS) in patients with AMI. Methods Two hundred four hospitalized patients with AMI were evaluated 6 ± 3 (mean ± SD) days after AMI. BRS was assessed using cross-spectral analysis to measure baroreceptor-mediated R-R interval oscillations. Depression was determined using the Diagnostic Interview Schedule, and severity of depressive symptoms was measured with the Beck Depression Inventory. In order to adjust for possible differences in anxiety, we also measured state anxiety using the Spielberger State Anxiety Inventory. Results Depression was not significantly related to BRS. However, anxiety was significantly related to low BRS in multivariate analysis, after the potentially confounding variables of age, blood pressure, and respiratory frequency were controlled for. Comparison of groups with high and low anxiety (on the basis of a median split of state anxiety scores) showed that BRS was reduced by approximately 20% in the patients with the higher anxiety scores (4.7 ± 3.2 ms/mm Hg vs 5.7 ± 3.3 ms/mm Hg, P < .05), after adjustment for differences in age, blood pressure, and respiratory frequency. Conclusions High levels of anxiety, but not depression, are associated with reduced vagal control in patients after AMI. (Am Heart J 2002;143:460-6.)     

Association of the alpha-adducin polymorphism with blood pressure and risk of myocardial infarction

Genetic variation in adducin, a protein associated with the inner leaflet of the plasma membrane, may be in part responsible for salt-sensitive hypertension. In the Netherlands, 560 men who survived a myocardial infarction and 646 men who had undergone an orthopaedic intervention participated in a case-control study. In men in this study, the alpha-adducin polymorphism was not associated with the risk of myocardial infarction either among those with or among those without a clinical history of hypertension. In a cross-sectional analysis of blood pressure data from the controls, the alpha-adducin polymorphism was associated neither with self-reported hypertension (OR = 0.78, 95% CI = 0.51-1.19) nor with mean levels of systolic or diastolic blood pressure. Additional studies in other populations are needed to assess the contribution of alpha-adducin to high blood pressure and cardiovascular risk.     

Body mass index and the risk of recurrent coronary events following acute myocardial infarction

Although excess adiposity appears to increase the risk of coronary heart disease in the general population, its importance in patients with established coronary disease is less defined. We evaluated a population-based inception cohort of survivors to hospital discharge following first acute myocardial infarction (AMI) (n = 2,541) to assess the association between body mass index (BMI) and the risk of recurrent coronary events and to explore the mechanisms for this relation. Using Cox proportional-hazards regression, we assessed the risk of recurrent coronary events associated with levels of adiposity as defined by BMI and then investigated potential mechanisms through which adiposity conferred risk by examining how adjustment for diabetes mellitus, systemic hypertension, and dyslipidemia affected the association. Forty-one percent of the cohort were overweight (BMI 25 to 29.9), and 27.8% were obese (BMI > or =30). After adjustment for other risk factors, the risk of recurrent coronary events (n = 418) increased as BMI increased, especially among those who were obese. Using a BMI of 16 to 24.9 as the reference group, for mildly overweight patients (BMI 25 to 27.4), the relative risk (RR) was 0.93 (95% confidence interval [CI] 0.70 to 1.24); it was 1.16 for more severe overweight patients (BMI 27.5 to 29.9; 95% CI 0.87 to 1.55). For patients with class I obesity (BMI 30 to 34.9), the RR was 1.49 (95% CI 1.12 to 1.98), and for class II to III obesity (BMI > or =35), the RR was 1.80 (95% CI 1.30 to 2.48). We estimated that clinical measurements of diabetes, hypertension, and dyslipidemia explained approximately 43% of this risk. Thus, excess adiposity as measured by BMI was associated with an increased risk of recurrent coronary events following AMI, particularly among those who were obese.     

Clinical features of early recurrent myocardial infarction

Recurrence of myocardial infarction, especially when occurring early after the prior one, carries a significant morbidity and mortality rate. The aim of this study was to investigate the characteristics of patients who experienced recurrence under secondary prevention therapy. Case record review identified myocardial infarction patients who had a history of previous myocardial infarction within 5 years. Hospital chart records, initial laboratory data, medications, and type of infarction were reviewed. Patients were divided into two groups according to the interval of recurrence: an early group (recurrence within 1 year), and a late group (recurrence after more than 1 year). A total of 89 patients were included in the analysis; 40 patients in the early group, and 49 patients in the late group. Mean age in the early group and late groups was 67.3 ± 11.9 and 59.4 ± 8.9, respectively (P = 0.001). Mean body mass index in the early and late groups was 22.1 ± 3.6 and 25.0 ± 3.3, respectively (P < 0.001). There were fewer current smokers in the early group (7.5% vs 44.9%, P < 0.001) and more stent thrombosis (17.5% vs 2%, P = 0.02), as compared with the late group. The in-hospital mortality rate tended to be higher in the early group (7.5% vs 0%, P = 0.09). Multiple logistic regression revealed that smoking status (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02?0.49, P = 0.005), HDL cholesterol level (5 mg/dl increase: OR 1.34, 95% CI 1.04?1.74, P = 0.03), and stent thrombosis (OR 35.59, 95% CI 2.13?595.49, P = 0.01) had significant associations with early recurrence. Early recurrence of myocardial infarction was associated with stent thrombosis, a higher HDL cholesterol level, and a lower frequency of smoking. Early recurrence had a trend toward higher mortality than late recurrence.     

再发急性心肌梗死患者的临床特征

目的 :探讨再发急性心肌梗死 (AMI)患者的临床特征。方法 :将再发 AMI患者 36例与同期患有AMI,出院后无再梗死的 6 9例患者对比 ,分析其临床特征。结果 :与 AMI者比较 ,发生再梗死时 ,症状多不典型(2 7.8% ,6 9.4% ,P <0 .0 1) ;多支病变者显著高于无再梗死者 (72 .2 % ,47.8% ,P <0 .0 1) ;冠状动脉病变积分亦显著高于无再梗死者 (12 .75± 5 .6 1,8.96± 3.48,P <0 .0 1) ;再梗死者的血总胆固醇水平显著高于无再梗死者(5 .6 9± 1.34 ,3.95± 1.73,P <0 .0 5 ) ;血糖水平亦高于后者 (9.2 1± 1.39,7.0 3± 1.97,P <0 .0 5 )。结论 :再梗死患者多具有严重的冠状动脉多支病变 ,再梗死时临床症状多不典型 ,其血总胆固醇和血糖水平增高为主要的危险因素     

Association of TNF-alpha serum levels and TNFA promoter polymorphisms with risk of myocardial infarction

Elevated levels of tumor necrosis factor-alpha (TNF-alpha), and presence of polymorphisms of the TNFA gene have been implicated in cardiovascular disease pathogenesis. We explored the relationship between polymorphisms in the TNFA gene (-1031C/T, -863C/A -857T/C, -308G/A, -238G/A), protein levels of TNF-alpha and their association to myocardial infarction (MI) using a sample of 1213 post-MI patients and 1561 healthy controls. MI risk was higher among men with elevated TNF-alpha levels, with the highest compared to the lowest TNF-alpha quartile giving a 70% risk increase (OR [95% CI]: 1.7 [1.1; 2.6]). Obese subjects who also had elevated TNF-alpha levels were at even higher risk for MI (OR [95% CI]: 3.4 [2.1; 5.6]). Higher TNF-alpha levels were seen among smokers (but not among non-smokers) carrying the -857T allele. Furthermore, a rare haplotype occurred more frequently among the cases than the controls. Elevated TNF-alpha levels are associated with increased MI risk. Obese subjects with elevated TNF-a levels, and carriers of polymorphisms in or near TNFA are particularly susceptible to the hazards of smoking, results which may have implications for cardiovascular preventive measures.     

Association of hypo-responsive toll-like receptor 4 variants with risk of myocardial infarction.

AIM: Toll-like receptor 4 (TLR4) is a receptor for bacterial lipopolysaccharide (LPS) and heat shock protein essential for innate immunity. Recent studies imply that TLR4 polymorphisms might affect atherogenesis. In this study we investigated the impact of LPS-hypo-responsive TLR4 variants on the risk of myocardial infarction (MI). METHODS AND RESULTS: Using TaqMan PCR technology, we determined the prevalence of the Asp299Gly and Thr399Ile polymorphisms in the TLR4 gene, and their association with MI in a study of 1213 survivors of a first MI and 1561 controls from the Stockholm region. The frequency was 0.096 for carriers of both 299Gly and 399Ile, and 0.006 for carriers of 399Ile alone. Carriers of both 299Gly and 399Ile were more frequent among the male cases than the male controls (10.7% vs 7.9%, p = 0.004). Compared with wild-type carriers, men with the 299Gly and the 399Ile TLR4 genotype had an increased risk of MI (OR [95% CI]: 1.4 [1.0;1.9]) whereas no association was observed for women. Furthermore a synergistic interaction was found between the TLR4 polymorphism and smoking in men. CONCLUSION: The association found between TLR4 genotype and risk of MI suggests that TLR4 genetic variants could potentially affect the susceptibility to MI and that TLR4-mediated innate immunity is implicated in the pathogenesis of MI.