Gender differences in management of myocardial infarction in elderly patients

Background There are conflicting data about the proportion and prognosis of patients (pts) with acute myocardial infarction (AMI) with nonobstructive coronary arteries (MINOCA). Purpose To define the incidence and prognosis of MINOCA pts in different types of AMI. Methods The Hungarian Myocardial Infarction Registry (HUMIR) is a nationwide, mandatory database in which the clinical and demographic informations of patients with AMI are recorded. Between January 1, 2014 and June 30, 2018, a total of 45,223 AMI (ST-elevation myocardial infarction (STEMI) n=22,469) pts were registered. After excluding pts with previous AMI, PCI, CABG, and congestive heart failure, 2003 MINOCA pts were found (MINOCA group), while 43,220 AMI pts had obstructive coronary artery disease (MI-CAD group). Results The proportion of pts with MINOCA disease was 4.4% among the total pts with AMI. The prevalence was higher in the non ST-elevation myocardial infarction (NSTEMI) group (n=1546, 6.8%) than in the STEMI (n=457, 2.0%) group. The pts with MINOCA disease were slightly younger compared to the pts with MI-CAD (mean age 64.0±14.4 vs. 65.5±12.2 years respectively). The proportion of women was higher in the MINOCA group than in the MI-CAD group (55.7% vs. 36.5%). At discharge, pts with MINOCA disease were less likely to be prescribed certain drugs compared to the pts with MI-CAD. These include aspirin (85.4% vs. 95.6%), RAAS blockers (83.8% vs. 90.4%), statins (86.2% vs. 94.7%), β-blockers (86.8% vs. 89.8%) for the MINOCA and MI-CAD groups respetively. At the 1-year follow-up, the incidence of new AMI events was 1.6% in the MINOCA group compared with 5.0% in the MI-CAD group (HR=2.79). All-cause mortality was higher among the pts with MI-CAD compared to the pts with MINOCA disease. In the MINOCA group, among the pts with NSTEMI, men and women had similar outcomes at 30 days, but men had somewhat higher mortality at one and two years. In contrast, in the STEMI group, women had higher mortality compared to men at all time points during the study (Table 1). Mortality among MINOCA and MI-CAD pts Mortality MINOCA (n=2003) MI-CAD (n=43,220) MINOCA – STEMI MINOCA – NSTEMI Men (n=218) Women (n=239) Men (n=669) Womenr (n=877) 30-day 5.9% [4.9–7.0] 8.4% [8.1–8.7] 8.7% [4.9–12.4] 13.4% [9–17.6] 4.3% [2.8–5.9] 4.4% [3.1–5.8] 1-year 12.5% [11.0–14.0] 15.6% [15.3–16.0] 12.1% [7.6–16.4] 20.3% [15–25.2] 12.2% [9.6–14.7] 10.8% [8.7–12.8] 2-year 16.7% [14.9–18.5] 19.9% [19.5–20.3] 18.2% [12.4–23.6] 23.6% [17.8–29] 16.9% [13.8–20] 14.3% [11.7–16.7] 95% confidence interval in brackets. Conclusion The population-level incidence of MINOCA disease was 4.4% in AMI; the incidence was higher in the NSTEMI group compared to the STEMI group (6.8% vs. 2.0%). Despite the benign anatomy, the long-term prognosis is poor, especially in women after STEMI: 1 out of 4 pts died at the two-year follow up. Acknowledgement/Funding None

Aim. To assess comorbidities in elderly patients with acute coronary syndrome (ACS) and to analyze patient subgroups with different treatment strategies in the Regional Vascular Center (RVC).Material and methods. The prospective study included 205 patients with confirmed ACS 75 years and older, the mean age was 81±4.9 years, and 68% were women. ST segment elevation myocardial infarction (STEMI) was diagnosed in 46 (22.4 %) patients, non-ST segment elevation myocardial infarction (NSTEMI) was diagnosed in 159 (77,6 %) patients. The Charlson Comorbidity Index (CCI) was calculated in every patient. Early outcomes were defined as those assessed during hospital stay. Late outcomes were assessed at 6 months after the discharge using phone calls and/or clinic visits. All patients provided written informed consent.Results. Percutaneous coronary intervention (PCI) was performed in 42% of patients. In patients with STEMI and NSTEMI PCI was performed in 73% and 32%, respectively. Mean CCI score was 7.9 points: 7.6 points in men and 8.04 in women. Patients with STEMI had higher CCI score than NSTEMI patients (p<0.01): 8.1 points and 7.1 points, respectively. Patients who underwent PCI had lower CCI score (7.2 points) than patients in non-PCI group (8.2 points; p<0.05). Patients with STEMI in PCI and non-PCI groups had significant difference in CCI score (p<0.05): 7.4 and 8.4 points, respectively. Mean CCI score in patients who died in hospital was 8.5 while discharged patients had 7.6 points (p<0.01). In 6 months 13 patients (6.3%) died, their mean age was 84.9 years, mean CCI was 9 points, PCI was performed in 3 (23%) patients.Conclusions. Elderly patients with ACS had high comorbidity level assessed by CCI score. Higher CCI score was associated with PCI non-performance in elderly patients. Elderly patients with STEMI had higher CCI score than patients with NSTEMI which was significantly associated with PCI non-performance. Patients who died in hospital or in 6 months after the ACS onset had higher CCI score than other elderly patients with ACS.

Introduction: Several inflammatory markers are associated with coronary artery disease severity and worse cardiovascular outcomes. The haemoglobin, albumin, lymphocyte, and platelet (HALP) score is an indicator of inflammation and nutritional status. We aimed to evaluate the practicity of HALP score in non-ST elevation myocardial infarction (NSTEMI) patients. Materials and Methods: This study was designed as a retrospective cohort study. Patients over the age of 18 who have been diagnosed with acute coronary syndrome were retrospectively searched from hospital records. The study groups were formed according to the results of the coronary angiography. Demographic data such as age, gender, total blood count, albümin levels, troponin levels and HALP scores of the patients were analyzed and comparisons between the groups were made decisively. Results: 201 patients were enrolled in the study and the data was obtained from hospital records retrospectively. 79 patients were excluded from the study due to ST segment elevation myocardial infarction (STEMI). The study population was collected under two groups; the NSTEMI group (n=66) and normal coronary arteries (NCA) group (n=56). The mean age of NSTEMI group was 62.3 ± 11.8 and 71.2% (n=47) was male. The mean age of NCA group was 51.8 ± 9.2 and 30.3% (n=17) was male. There were statistically significant difference between NSTEMI and NCA groups in term of age and gender (p<0.05). The HALP score was statistically higher in NSTEMI group compared to NCA group (p<0.001). Age and HALP score have explanatory powers on NSTEMI patients (p=0.001 and p=0.022, in order of). Conclusion: HALP score may be used as an easily applicable and inexpensive method in clinical practice that can contribute to the early diagnosis of NSTEMI patients.

Increased estimated body iron stores have been recently suggested to be associated with increased risk of acute myocardial infarction (AMI); however the question of whether serum ferritin level as an indicator for estimating body iron is an independent risk factor for cardiac events is still questioned. In the present study, we assessed whether serum ferritin was associated with the incidence of AMI. The study population consisted of 100 consecutive male patients with first AMI (50 suffered STEMI and 50 with NSTEMI diagnosis) admitted within 12 hours of the onset of chest pain to coronary care units (CCU) at Ekbatan hospital in the city of Hamadan, Iran. A control group (n = 50) was also randomly selected among men without any evidences of AMI from same hospital. Serum ferritin was measured using an ELISA assay by a special kit at the first and fifth days after admission. The first and fifth day serum ferritin concentrations averaged 56.75 and 112.5 µg/dl in STEMI (ST Elevation Myocardial Infarction) group, 36.5 and 87.25 µg/dl in NSTEMI (Non ST Elevation Myocardial Infarction)group and 22.5 and 42.0 µg/dl in control group that was significantly higher in former group. In this regard, the medium level of ferritin in STEMI, NSTEMI, and control groups were 159, 146, and 32.5 µg/dl, respectively that was significantly higher in those who suffered STEMI than in other study subgroups (p < 0.001). Multivariable logistic regression model showed that the elevated level of serum ferritin could predict occurrence of STEMI adjusted for initial ferritin concentration, patients' age and coronary disease risk factors (OR = 5.1, P = 0.017). Elevated serum ferritin can be a potent factor for predicting AMI especially STEMI.

AimsLipoprotein(a) [Lp(a)] levels are generally constant throughout an individual’s lifetime, and current guidelines recommend that a single measurement is sufficient to assess the risk of coronary artery disease (CAD). However, it is unclear whether a single measurement of Lp(a) in individuals with acute myocardial infarction (MI) is indicative of the Lp(a) level six months following the event.Methods and resultsLp(a) levels were obtained from individuals with non–ST-elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI) (n = 99) within 24 h of hospital admission and after six months, who were enrolled in two randomized trials of evolocumab and placebo, and in individuals with NSTEMI or STEMI (n = 9) who enrolled in a small observation arm of the two protocols and did not receive study drug, but whose levels were obtained at the same time points. Median Lp(a) levels increased from 53.5 nmol/L (19, 165) during hospital admission to 58.0 nmol/L (14.8, 176.8) six months after the acute infarction (P = 0.02). Subgroup analysis demonstrated no difference in the baseline, six-month, or change between the baseline and six-month Lp(a) values between the STEMI and NSTEMI groups and between the group which received evolocumab and the group that did not.ConclusionThis study demonstrated that Lp(a) levels in individuals with acute MI are significantly higher six months after the initial event. Therefore, a single measurement of Lp(a) in the peri-infarction setting is not sufficient to predict the Lp(a)-associated CAD risk in the post-infarction period.RegistrationEvolocumab in Acute Coronary Syndrome Trial [EVACS I] NCT03515304, Evolocumab in Patients with Acute Myocardial Infarction [EVACS II], NCT04082442

Background According to statistics of Organisation for Economic Cooperation and Development (OECD) Latvia has one of the highest 30-day mortality for acute myocardial infarction (AMI). The output data used in the calculation of this indicator was analysed at a hospital level to explain the causes of it. Methods Linked to Causes of death registry administrative reimbursement system data from 2014 to 2017 were analysed. Defined exclusion criteria were applied and 11675 emergency AMI admissions were indexed. As evaluation of the inter-hospital differences in non-ST elevation myocardial infarction (NSTEMI) revealed significant inconsistency in statistical classification of non-ST elevation acute cardiac events, the 30-day mortality and the factors influencing it, was exclusively analysed for 9168 ST elevation myocardial infarction (STEMI) cases. The outcomes of different reperfusion scenarios were analysed for five groups of hospitals of size, location, the availability of percutaneous coronary interventions (PCI) and cardiac surgery - local hospitals without PCI, n=10 (non-PCI local), regional hospitals without PCI, n=5 (non-PCI regional), regional hospitals with part-time PCI, n=2 (PCI regional), university hospital with PCI, n=1 (PCI general univ.), university cardiology tertiary hospital with PCI, n=1 (PCI tertiary univ.). The multivariable logistic regression was employed to adjust the results for potential explanatory variables as patient age, gender, comorbidities (measured as Charlson index (Ch. index)), the distance between their residence and hospitals. Results 30-day mortality for all indexed AMI admissions (17,4%) was in line with the value of the indicator in OECD reports. However only 21,5% of all cases have been coded as NSTEMI (12,2% mortality). The mortality of the patients with STEMI have reached 18,8% composed by mortality in range from 13,7% for patients directly admitted to hospitals having both PCI and cardiac surgery units to 23,7% for patients initially admitted to local hospitals. Significant variations in mortality between reperfusion scenarios as well as the variations in the frequency of application reperfusion methods between hospital groups were observed. Some variation in mortality between hospital groups persisted also after adjustment to the reperfusion therapy scenario and other potential confounders. Distribution of STEMI patients Conclusion The improvement of statistical classification practice for NSTEMI is needed to measure the actual AMI mortality in Latvia. Although the 30-day mortality for AMI may be lower than internationally reported because of under-accounting of prognostically more favourable NSTEMI cases, it is still very high. Among patients with STEMI, there are wide inter-hospital variations in care and mortality. There is a substantial room for improvements in all types of hospitals to increase reperfusion rates and to reduce delays in initiation of it Acknowledgement/Funding University of Latvia/Centre for Disease Prevention and Control joint grant for project “Transparency for health care quality and efficiency”

Young Adults Undergoing Percutaneous Coronary Intervention for Myocardial Infarction in the United States, 2011 to 2023.

61-Year-Old Man With Nausea and Vomiting

Background Improvements in percutaneous coronary intervention have reduced complications in the treatment of left main coronary artery disease. The objective of this study was to characterize percutaneous coronary intervention procedures in left main coronary artery, and evaluate patients’ outcomes. Methods A retrospective study performed from January 2015 to December 2018, in patients submitted to percutaneous coronary intervention in left main coronary artery for stable coronary artery disease or myocardial infarction, with second-generation drug-eluting stents. Results A total of 82 patients were submitted to percutaneous coronary intervention in left main coronary artery. Among them, 26.8% had stable coronary artery disease, 50% had non-ST segment elevation myocardial infarction, and 23.2% had ST segment elevation myocardial infarction. Cardiogenic shock was present in 20.7% of them. Most patients were male, elderly, with cardiovascular risk factors, namely diabetes, hypertension and hyperlipemia. Among patients with stable coronary artery disease, patients had low to intermediate SYNTAX score. During hospitalization, patients did not develop any complications. During follow-up, cardiovascular death was of 4.5% (n=1). Regarding non-ST segment elevation myocardial infarction, during hospitalization, there were no registries of events. During follow-up, 9.1% of patients had cardiovascular-related hospitalizations. A patient died (3%) during the re-hospitalization from severe heart failure. Concerning ST segment elevation myocardial infarction patients, there was one case of acute stent thrombosis during hospitalization resulting in death. One patient was readmitted for percutaneous coronary intervention in left main coronary artery due to restenosis. Regarding the patients admitted in cardiogenic shock, in-hospital mortality was 58.8%. During follow-up, two patients experienced restenosis and were hospitalized (one underwent coronary artery bypass grafting, and the other, percutaneous coronary intervention). Conclusion This is a real-world study in which we described our experience with percutaneous coronary intervention in left main coronary artery. In general, percutaneous coronary intervention in left main coronary artery in stable left main coronary artery disease, or in unstable disease with no cardiogenic shock, was a safe procedure. Further studies with extended follow-up are needed.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines. The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective . Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data …

BackgroundIn patients presenting with non-ST elevation myocardial infarction, we investigated the relationship of left atrial deformational parameters evaluated by 2-dimensional speckle tracking imaging (2D-STI) with conventional echocardiographic diastolic dysfunction parameters and brain natriuretic peptide level.Material/MethodsWe enrolled 74 non-ST segment elevation myocardial infarction patients who were treated with percutaneous coronary intervention and 58 healthy control subjects. Non-ST segment elevation myocardial infarction patients had echocardiographic examination 48 h after the percutaneous coronary intervention procedure and venous blood samples were drawn simultaneously. In addition to conventional echocardiographic parameters, left atrial strain curves were obtained for each patient. Average peak left atrial strain values during left ventricular systole were measured.ResultsBNP values were higher in non-ST segment elevation myocardial infarction patients compared to controls. Mean left atrium peak systolic global longitudinal strain in Group 2 (the control group) was higher than in the non-ST segment elevation myocardial infarction group. Left atrium peak systolic global longitudinal strain was significantly correlated with left ventricular ejection fraction. There was a significant inverse correlation between left atrium peak systolic global longitudinal strain and brain natriuretic peptide level, left atrium volume maximum, and left atrium volume minimum.ConclusionsOur study shows that Left atrium peak systolic global longitudinal strain values decreased consistently with deteriorating systolic and diastolic function in non-ST segment elevation myocardial infarction patients treated with percutaneous coronary intervention. Left atrium peak systolic global longitudinal strain measurements may be helpful as a complimentary method to evaluate diastolic function in this patient population.

Prevalence of acute coronary syndrome in young individuals is increasing progressively. Previous studies have focused on the analysis of risk factors and to some extent coronary angiographic profile in young vs. old patients with acute coronary syndrome, but no study compared the angiographic profile in young patients based on the type of acute coronary syndrome. So, this study was conducted to determine the differences in demographic and coronary angiographic profile of young patients with ST-elevated myocardial infarction (STEMI) vs. those with non-ST-elevated myocardial infarction (NSTEMI) or unstable angina (UA). We retrospectively analyzed young patients (age <40 years) with acute coronary syndrome who underwent coronary angiography at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India between April 2010 and March 2011. Coronary risk factor profile and angiographic features were compared between STEMI and NSTEMI/UA patients. Of 8,268 patients who underwent coronary angiography during the study period, 820 (~10%) were ≤40 year age. Of them, 611 exhibited STEMI and 209 exhibited NSTEMI/UA. Angiographic analysis revealed that single-vessel disease was significantly more common in the STEMI group (56.6% vs. 36.6% respectively; P<0.001) whereas triple-vessel disease was significantly more common in the NSTEMI/UA group (3.6% vs. 10.5% respectively; P<0.001). Conversely, left anterior descending coronary artery was more commonly involved in the STEMI group (55.3% vs. 40.2% respectively; P<0.001), whereas left circumflex coronary artery was more commonly involved in the NSTEMI/UA group (11.8 vs. 23.4% respectively; P<0.001). Of note, smoking/tobacco consumption was the most significant coronary risk factor with prevalence as high as 65% in both groups. In the present study, significant differences were observed in coronary risk factor profile and angiographic features between young patients with STEMI and NSTEMI/UA. Larger studies will be required to establish specific associations between presentation of acute coronary syndromes and angiographic profiles in young patients.

Background: Our study aims to compare in-hospital management and outcomes in patients with cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI) versus non-ST-segment elevation myocardial infarction (NSTEMI). Methods: We conducted a retrospective cohort study using the National Inpatient Sample database between 2016-2019, including patients with STEMI/NSTEMI complicated by cardiogenic shock. An inverse probability treatment weighting analysis was performed to compare in-hospital management and outcomes between patients with STEMI and NSTEMI. Adjusted relative risks (aRR) with their 95% confidence intervals (CIs) were estimated. Results: A total of 150,395 patients with cardiogenic shock due to acute myocardial infarction were included, of whom 52.8% had STEMI. The median age was 68 years (60-77) and 35% were female. Percutaneous coronary intervention, intra-aortic balloon counterpulsation, percutaneous ventricular assist device, extracorporeal membrane oxygenation, and mechanical ventilation use were significantly higher in the STEMI group compared to NSTEMI. Coronary artery bypass grafting, renal replacement therapy, length of hospital stay, and total costs were lower in the STEMI group. Pulmonary arterial catheterization and cardiac transplantation were similar between both groups. Inverse probability treatment weighting analysis showed that in-hospital mortality was significantly higher in the STEMI group compared to NSTEMI (34.2% vs. 28.8%, aRR 1.19, 95% CI 1.14-1.23) and also major bleeding. Conclusion: In conclusion, patients with cardiogenic shock due to STEMI had worse prognosis, higher use of percutaneous coronary intervention/mechanical circulatory support, and major bleeding than the NSTEMI group. In contrast, patients with NSTEMI had greater use of coronary artery bypass grafting and hospital resources.