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While my sister sleeps
When her sister, a world-class runner, suffers a massive heart attack that leaves her in a coma from which she may never wake up, a woman and her family struggle to cope with the tragedy as their relationships are put to the ultimate test.
Book
Colchicine in Acute Myocardial Infarction
Inflammation is associated with adverse cardiovascular events. Data from recent trials suggest that colchicine reduces the risk of cardiovascular events.
In this multicenter trial with a 2-by-2 factorial design, we randomly assigned patients who had myocardial infarction to receive either colchicine or placebo and either spironolactone or placebo. The results of the colchicine trial are reported here. The primary efficacy outcome was a composite of death from cardiovascular causes, recurrent myocardial infarction, stroke, or unplanned ischemia-driven coronary revascularization, evaluated in a time-to-event analysis. C-reactive protein was measured at 3 months in a subgroup of patients, and safety was also assessed.
A total of 7062 patients at 104 centers in 14 countries underwent randomization; at the time of analysis, the vital status was unknown for 45 patients (0.6%), and this information was most likely missing at random. A primary-outcome event occurred in 322 of 3528 patients (9.1%) in the colchicine group and 327 of 3534 patients (9.3%) in the placebo group over a median follow-up period of 3 years (hazard ratio, 0.99; 95% confidence interval [CI], 0.85 to 1.16; P = 0.93). The incidence of individual components of the primary outcome appeared to be similar in the two groups. The least-squares mean difference in C-reactive protein levels between the colchicine group and the placebo group at 3 months, adjusted according to the baseline values, was -1.28 mg per liter (95% CI, -1.81 to -0.75). Diarrhea occurred in a higher percentage of patients with colchicine than with placebo (10.2% vs. 6.6%; P<0.001), but the incidence of serious infections did not differ between groups.
Among patients who had myocardial infarction, treatment with colchicine, when started soon after myocardial infarction and continued for a median of 3 years, did not reduce the incidence of the composite primary outcome (death from cardiovascular causes, recurrent myocardial infarction, stroke, or unplanned ischemia-driven coronary revascularization). (Funded by the Canadian Institutes of Health Research and others; CLEAR ClinicalTrials.gov number, NCT03048825.).
Journal Article
Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia
In patients with myocardial infarction and anemia, a liberal transfusion strategy led to fewer deaths and heart attacks than a restricted transfusion strategy, but the difference was of borderline significance.
Journal Article
Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction
In patients with ST-segment elevation myocardial infarction, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death and adverse cardiovascular events at 1 year.
Journal Article
PACAP-38 in Acute ST-Segment Elevation Myocardial Infarction in Humans and Pigs: A Translational Study
Acute myocardial infarction (MI) is one of the most common causes of death worldwide. Pituitary adenylate cyclase activating polypeptide (PACAP) is a cardioprotective neuropeptide expressing its receptors in the cardiovascular system. The aim of our study was to examine tissue PACAP-38 in a translational porcine MI model and plasma PACAP-38 levels in patients with ST-segment elevation myocardial infarction (STEMI). Significantly lower PACAP-38 levels were detected in the non-ischemic region of the left ventricle (LV) in MI heart compared to the ischemic region of MI-LV and also to the Sham-operated LV in porcine MI model. In STEMI patients, plasma PACAP-38 level was significantly higher before percutaneous coronary intervention (PCI) compared to controls, and decreased after PCI. Significant negative correlation was found between plasma PACAP-38 and troponin levels. Furthermore, a significant effect was revealed between plasma PACAP-38, hypertension and HbA1c levels. This was the first study showing significant changes in cardiac tissue PACAP levels in a porcine MI model and plasma PACAP levels in STEMI patients. These results suggest that PACAP, due to its cardioprotective effects, may play a regulatory role in MI and could be a potential biomarker or drug target in MI.
Journal Article
Admission heart rate and in-hospital mortality in acute myocardial infarction: a contemporary analysis of the MIMIC-III cohort
Objective
To quantify the shape and strength of the association between heart rate (HR) recorded during the first 30 min of intensive-care admission and in-hospital death in contemporary acute myocardial infarction (AMI), after adjustment for modern reperfusion, pharmacotherapy, and haemodynamic variables.
Methods
We extracted 1,510 adults with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of AMI (410.xx) from MIMIC-III (2008–2012). HR was defined as the mean of the first three electrocardiographic readings obtained within 30 min of ICU triage, before administration of rate-modifying drugs. We modelled HR both as clinically meaningful categories (< 60, 60–99, ≥ 100 bpm) and as a continuous exposure using restricted cubic splines (RCS). Multivariable logistic regression adjusted for age, sex, Killip class, systolic blood pressure, coronary revascularisation, β-blocker use, atrial fibrillation/flutter, hypertension, diabetes, chronic obstructive pulmonary disease, serum creatinine, haemoglobin, white blood cell count, sodium, potassium, glucose, platelet count and anion gap. Pre-specified subgroup analyses compared ST-elevation MI (STEMI) with non-ST-elevation ACS (NSTE-ACS).
Results
Mean age was 66.7 ± 13.9 years; 33.6% were women; STEMI accounted for 42%. Overall in-hospital mortality was 10.9%. HR ≥ 100 bpm (23% of patients) was associated with higher death risk (adjusted OR 2.45, 95% CI 1.56–3.85) versus 60–99 bpm. Bradycardia < 60 bpm (15%) was also associated with excess risk (adjusted OR 1.58, 95% CI 1.02–2.45), yielding a U-shaped RCS curve (non-linearity
p
= 0.01). The HR–mortality gradient was steeper in STEMI than in NSTE-ACS (interaction
p
= 0.04). Findings were robust after including the 46 patients who died within 24 h of admission.
Conclusion
Admission HR exhibits a U-shaped, independent relation with early mortality in modern AMI care; values outside 60–99 bpm identify high-risk patients despite urgent reperfusion and optimal medical therapy.
Journal Article
Microcirculatory dysfunction in patients with acute anterior myocardial infarction combined with new complete right bundle branch block
Objective
This study sought to investigate clinical characteristics of acute anterior ST-segment elevation myocardial infarction (STEMI) patients complicated by new complete right bundle branch block (CRBBB) and evaluate the occurrence of microcirculatory dysfunction post-percutaneous coronary intervention (PCI).
Methods
Retrospective analysis was conducted on 261 patients with acute anterior STEMI, differentiating 40 with concurrent new CRBBB (CRBBB group) from 221 without (no-CRBBB group). Data on demographics and hospitalization were collected, and clinical features and prognoses were compared. Post-PCI microcirculatory function was further characterized using coronary angiography-derived index of microcirculatory resistance (caIMR), thrombolysis in myocardial infarction (TIMI) grade flow, corrected TIMI flow frame count (CTFC) of the infarct-related artery, and ST segment regression in electrocardiograph (STR).
Results
Age, Killip class, GLUC, TG, HDL, BUN, GFR, AST, ALT, WBC, TNI at admission significantly differed between groups (
P
< 0.05). Incidences of in-hospital major adverse cardiovascular events and LVEF showed significant disparities (
P
< 0.05). The CRBBB group exhibited higher CaIMR, lower TIMI flow, and STR (
P
< 0.05). Multivariate analysis indicated TIMI ≤ grade 2 (OR = 6.833, 95% CI: 1.009 ~ 46.287,
P
= 0.049), STR ≥ 50% (OR = 0.176, 95% CI: 0.051 ~ 0.606,
P
= 0.006), CTFC (OR = 1.079, 95% CI: 1.009 ~ 1.155,
P
= 0.027), and caIMR (OR = 1.120, 95% CI: 1.059 ~ 1.185,
P
< 0.001) were independently linked to new onset of CRBBB. Complicated of new CRBBB was strongly associated with elevated CaIMR in anterior STEMI patients. (OR = 5.065, 95% CI:1.793–14.308,
P
= 0.002).
Conclusion
In patients with acute anterior STEMI, those with new CRBBB are at an increased likelihood of experiencing microcirculatory dysfunction.
Journal Article
Burden of cardiac arrhythmias in patients with acute myocardial infarction and their impact on hospitalization outcomes: insights from China acute myocardial infarction (CAMI) registry
Background
The coexistence of cardiac arrhythmias in patients with acute myocardial infarction (AMI) usually exhibits poor prognosis. However, there are few contemporary data available on the burden of cardiac arrhythmias in AMI patients and their impact on in-hospital outcomes.
Methods
The present study analyzed data from the China Acute Myocardial Infarction (CAMI) registry involving 23,825 consecutive AMI patients admitted to 108 hospitals from January 2013 to February 2018. Cardiac arrhythmias were defined as the presence of bradyarrhythmias, sustained atrial tachyarrhythmias, and sustained ventricular tachyarrhythmias that occurred during hospitalization. In-hospital outcome was defined as a composite of all-cause mortality, cardiogenic shock, re-infarction, stroke, or heart failure.
Results
Cardiac arrhythmia was presented in 1991 (8.35%) AMI patients, including 3.4% ventricular tachyarrhythmias, 2.44% bradyarrhythmias, 1.78% atrial tachyarrhythmias, and 0.73% ≥2 kinds of arrhythmias. Patients with arrhythmias were more common with ST-segment elevation myocardial infarction (83.3% vs. 75.5%,
P
< 0.001), fibrinolysis (12.8% vs. 8.0%,
P
< 0.001), and previous heart failure (3.7% vs. 1.5%,
P
< 0.001). The incidences of in-hospital outcomes were 77.0%, 50.7%, 43.5%, and 41.4%, respectively, in patients with ≥ 2 kinds of arrhythmias, ventricular tachyarrhythmias, bradyarrhythmias, and atrial tachyarrhythmias, and were significantly higher in all patients with arrhythmias than those without arrhythmias (48.9% vs. 12.5%,
P
< 0.001). The presence of any kinds of arrhythmia was independently associated with an increased risk of hospitalization outcome (≥ 2 kinds of arrhythmias, OR 26.83, 95%CI 18.51–38.90; ventricular tachyarrhythmias, OR 8.56, 95%CI 7.34–9.98; bradyarrhythmias, OR 5.82, 95%CI 4.87–6.95; atrial tachyarrhythmias, OR4.15, 95%CI 3.38–5.10), and in-hospital mortality (≥ 2 kinds of arrhythmias, OR 24.44, 95%CI 17.03–35.07; ventricular tachyarrhythmias, OR 13.61, 95%CI 10.87–17.05; bradyarrhythmias, OR 7.85, 95%CI 6.0-10.26; atrial tachyarrhythmias, OR 4.28, 95%CI 2.98–6.16).
Conclusion
Cardiac arrhythmia commonly occurred in patients with AMI might be ventricular tachyarrhythmias, followed by bradyarrhythmias, atrial tachyarrhythmias, and ≥ 2 kinds of arrhythmias. The presence of any arrhythmias could impact poor hospitalization outcomes.
Registration
Clinical Trial Registration: Identifier: NCT01874691.
Journal Article