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Background Diabetes mellitus (DM) is associated with an increased mortality risk in patients hospitalized with acute myocardial infarction (AMI); however, no studies have investigated the impact of the duration of DM on in-hospital mortality. In this study, we evaluated in-hospital mortality in AMI patients according to DM status and its duration. Methods Using health administrative databases of Lombardy, DM patients≥50 years hospitalized with AMI from 2010 to 2019 were included in the analysis and were stratified according to the duration of DM: <5, 5–10, and > 10 years. The primary endpoint was mortality during AMI hospitalization and the secondary endpoint was 1-year mortality in comparison with No-DM patients. Logistic and Cox regressions analyses were used to estimate odds ratios (ORs, CI 95%) and hazard ratios (HRs, CI 95%) for the outcomes, according to DM status and duration and AMI type (STEMI and NSTEMI). Results Our study cohort comprised 29,566 and 109,247 DM and No-DM patients, respectively. Adjusted ORs and HRs showed a significantly higher risk of in-hospital mortality (OR 1.50, 95% CI 1.43–1.58) and 1-year mortality (HR 1.51, 95% CI 1.46–1.55) in DM patients in comparison with those without. These risks increased progressively with the duration of DM, with the highest risk observed in patients with DM duration ≥ 10 years (OR 1.59, 95% CI 1.50–1.69 for in-hospital mortality and HR 1.59, 95% CI 1.53–1.64 for 1-year mortality). These findings were similar in STEMI and in NSTEMI patients. Conclusions Our study demonstrates that the duration of DM parallels mortality risk in patients hospitalized with AMI, highlighting that DM duration should be considered as an important early prognostic risk factor in patients with AMI.

Background and aimsCurrent ESC guidelines on the management of patients after acute myocardial infarction only include the evaluation of left ventricular (LV) function by assessment of the ejection fraction in addition to clinical risk scores to estimate the patient’s prognosis. We aimed to determine, whether comprehensive evaluation of cardiac function using LV and right ventricular (RV) global longitudinal strain (GLS) and left atrial (LA) reservoir strain improves the prediction of survival in patients with acute myocardial infarction.MethodsIn patients with non-ST segment elevation or ST segment elevation myocardial infarction receiving echocardiography within 1 year after revascularisation, LV-GLS, RV-GLS and LA reservoir strain were quantified. In multivariable Cox regression analysis, HRs and 95% CIs were calculated per 1 SD increase in strain measure, adjusting for age, sex, systolic blood pressure, low-density lipoprotein cholesterol, smoking, diabetes and family history of premature coronary artery disease.ResultsDuring a median follow-up of 1.5 (0.5–4.2) years, 157 (11.1%) out of 1409 patients (64.4±13.5 years, 24.7% female) died. LV-GLS (1.68 (1.37–2.06), p<0.001), RV-GLS (1.39 (1.16–1.67), p<0.001) and LA reservoir strain (0.57 (0.47–0.69), p<0.001) were associated with mortality. Adding LV ejection fraction, tricuspid annular plane systolic excursion (TAPSE) or LA volume index to these models did not alter the association of strain measures of the LV (1.41 (1.06–1.89), p=0.02), RV (1.48 (1.03–2.13), p=0.04) or LA (0.61 (0.49–0.76), p<0.001). In receiver operating characteristics, combining the three strain measures improved the prediction of mortality above risk factors (AUC: 0.67 (0.63–0.71) to 0.75 (0.70–0.80)), while further addition of LV ejection fraction, TAPSE and LA volume index did not (0.75 (0.70–0.81)).ConclusionThe comprehensive evaluation of contractility of various cardiac chambers via transthoracic echocardiography using myocardial strain analysis, when routinely performed after acute myocardial infarction, may help to detect patients at increased mortality risk.

ObjectiveThe study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI).BackgroundIntensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients.MethodsConsecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan–Meier analyses, multivariable Cox proportional regression analyses and propensity score matching.Results273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199–2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153–2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020–2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528).ConclusionAMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Guideline adherence and variation in acute coronary syndrome (ACS) outcomes by race in the modern era of drug-eluting stents (DES) are not well understood. Previous studies also fail to capture rapidly growing minority populations, such as Asians. A retrospective analysis of 689,238 hospitalizations for ACS across all insurance types from 2008 to 2011 from the Healthcare Cost and Utilization Project database was performed to determine whether quality of ACS care and mortality differ by race (white, black, Asian, Hispanic, or Native American), with adjustment for patient clinical and demographic characteristics and clustering by hospital. We found that black patients had the lowest in-hospital mortality rates (5% vs 6% to 7% for other races, p <0.0001, odds ratio [OR] 1.02, 95% confidence interval [CI] 0.97 to 1.07), despite low rates of timely angiography in ST-elevation myocardial infarction and non–ST-elevation myocardial infarction, and lower use of DES (30% vs 38% to 40% for other races, p <0.0001). In contrast, Asian patients had the highest in-hospital mortality rates (7% vs 5% to 7% for other races, p <0.0001, odds ratio 1.13, 95% CI 1.08 to 1.20, relative to white patients), despite higher rates of timely angiography in ST-elevation myocardial infarction and non–ST-elevation myocardial infarction, and the highest use of DES (74% vs 63% to 68% for other races, p <0.0001). Asian patients had the worst in-hospital mortality outcomes after ACS, despite high use of early invasive treatments. Black patients had better in-hospital outcomes despite receiving less guideline-driven care.

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.

Klotho is a transmembrane and secretory protein and acts as a co-receptor for fibroblast growth factor 23 (FGF23). This study aimed to analyse the concentration of Klotho and FGF23 proteins in patients with myocardial infarction (MI). The study group comprised 129 patients diagnosed with acute coronary syndrome (ACS), who were referred for further invasive diagnostics (MI group). Blood samples were collected at 4 time points: at admission, and 6h, 24h, and between 24-48h post-admission. The criteria for the control subjects (n = 30) were no declaration of MI and ACS (non-MI group). Klotho and FGF23 concentrations in plasma were tested by ELISA at each time point. The concentration of soluble Klotho in the MI group was increased at admission, 6h and 24 h post-admission, and then normalized at 24-48h. Klotho concentration was also significantly increased in patients with ST-segment elevation MI (STEMI) only at admission, in comparison to non-ST-segment elevation MI (NSTEMI). The concentration of FGF23 in the MI group was higher at admission, 6h and 24h post-admission, and continued to increase after 24-48 h. There was an increase in FGF23 concentration in the STEMI group at 24-48h post-admission, in comparison to NSTEMI. The concentrations of Klotho and FGF23 in plasma were higher in patients with MI and changed over time. Thus, Klotho and FGF23 may be recognized as new factors in the diagnosis and/or monitoring of ACS, as well as novel therapeutic targets.

Background It was found that delayed activation wave often appeared in terminal QRS wave in non‐ST‐elevated myocardial infarction (NSTEMI) with culprit vessel in left circumflex artery (LCX), yet little is known about the similarities among non‐“N”‐wave non‐ST‐elevated myocardial infarction (N‐NSTEMI) and ST‐elevated myocardial infarction (STEMI). Hypothesis In AMI patients with the culprit vessel in LCX, “N” wave NSTEMI has a risk equivalent to STEMI. Methods All 874 patients admitted to Shenjing Hospital of China Medical University between January 1, 2013 and December 30, 2017 were included and whose coronary angiography (CAG) indicated the culprit vessel in LCX. Patients were divided into three groups: ST‐elevated myocardial infarction group (STEMI group, n = 322), “N” wave non‐ST‐elevated myocardial infarction group (N‐NSTEMI group, n = 232) and non‐“N”‐wave NSTEMI group (non N‐NSTEMI group, n = 320). The basic data and the incidence of MACE during hospitalization and 12 months were analyzed. Results In STEMI and N‐NSTEMI groups, AST, CK, CK‐MB, TnI, and stenosis severity were significantly higher than non N‐NSTEMI (P < .05). The lesions in the N‐NSTEMI and STEMI groups were more often located proximal LCX before giving rise to OM1 of LCX (P < .05), however, the non N‐NSTEMI group was often located distal LCX after giving rise to OM1 and the OM1 (P < .05). The incidence rates of all MACEs, all‐cause death, ST, TVR, and rUAP were similar in N‐NSTEMI and STEMI groups, which were greater than non N‐NSTEMI (P < .05). Both N‐NSTEMI and STEMI are independent risk factors for MACE (P < .05). Conclusion The basic data and the incidence of major adverse cardiac event were similar in N‐NSTEMI and STEMI patients, N‐NSTEMI has a risk equivalent to acute STEMI.

Background COVID-19 affects healthcare resource allocation, which could lead to treatment delay and poor outcomes in patients with acute myocardial infarction (AMI). We assessed the impact of the COVID-19 pandemic on AMI outcomes. Methods We compared outcomes of patients admitted for acute ST-elevation MI (STEMI) and non-STEMI (NSTEMI) during a non-COVID-19 pandemic period (January–February 2019; Group 1, n = 254) and a COVID-19 pandemic period (January–February 2020; Group 2, n = 124). Results For STEMI patients, the median of first medical contact (FMC) time, door-to-balloon time, and total myocardial ischemia time were significantly longer in Group 2 patients (all p  < 0.05). Primary percutaneous intervention was performed significantly more often in Group 1 patients than in Group 2 patients, whereas thrombolytic therapy was used significantly more often in Group 2 patients than in Group 1 patients (all p  < 0.05). However, the rates of and all-cause 30-day mortality and major adverse cardiac event (MACE) were not significantly different in the two periods (all p  > 0.05). For NSTEMI patients, Group 2 patients had a higher rate of conservative therapy, a lower rate of reperfusion therapy, and longer FMC times (all p  < 0.05). All-cause 30-day mortality and MACE were only higher in NSTEMI patients during the COVID-19 pandemic period ( p  < 0.001). Conclusions COVID-19 pandemic causes treatment delay in AMI patients and potentially leads to poor clinical outcome in NSTEMI patients. Thrombolytic therapy should be initiated without delay for STEMI when coronary intervention is not readily available; for NSTEMI patients, outcomes of invasive reperfusion were better than medical treatment.

Myocardial infarction (MI), including ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI), is still a leading cause of death worldwide. Metabolomics technology was used to explore differential metabolites (DMs) as potential biomarkers for early diagnosis of STEMI and NSTEMI. In the study, 2531 metabolites, including 1925 DMs, were discovered. In the selected 27 DMs, 14 were successfully verified in a new cohort, and the AUC values were all above 0.8. There were 10 in STEMI group, namely L-aspartic acid, L-acetylcarnitine, acetylglycine, decanoylcarnitine, hydroxyphenyllactic acid, ferulic acid, itaconic acid, lauroylcarnitine, myristoylcarnitine, and cis-4-hydroxy-D-proline, and 5 in NSTEMI group, namely L-aspartic acid, arachidonic acid, palmitoleic acid, D-aspartic acid, and palmitelaidic acid. These 14 DMs may be developed as biomarkers for the early diagnosis of MI with high sensitivity and specificity. These findings have particularly important clinical significance for NSTEMI patients because these patients have no typical ECG changes.

In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple criteria have been proposed to predict the culprit artery based on the 12-lead electrocardiogram (ECG). We assessed the utilities of 11 traditional and 2 new criteria to devise a new ECG algorithm to localize the culprit artery in acute inferior STEMI. We analyzed electrocardiographic and angiographic findings of 194 consecutive patients with acute inferior STEMI to devise a new ECG algorithm, further validated in another cohort of 80 patients with acute inferior STEMI. In derivation cohort, the 2 new criteria including (1) ST-segment depression in lead I equal to half of that in lead aVL and (2) equal ST-segment elevation in leads II, III, and aVF did not prove useful. The most powerful electrocardiographic criteria were (1) the ratio of ST elevation in lead III to that in lead II, (2) the ratio of ST depression in lead I to that in lead aVL, and (3) ST changes in lead I; these formed a 3-step algorithm. Application of this algorithm suggested the location of the culprit artery in 192 of 194 patients (nearly 99%) in the derivation cohort. In validation cohort, the algorithm possessed a sensitivity and specificity of 100% and 89%, respectively, for predicting the right coronary artery and 89% and 100%, respectively, for predicting the left circumflex artery. A new 3-step algorithm based on 12-lead ECG is proposed to localize the culprit artery at the bedside of acute inferior STEMI patients before primary percutaneous coronary intervention, allowing immediate decisions about therapy.