During acute myocardial infarction (MI), the incidence of atrial fibrillation (AF) is 6% to 22%, and its occurrence in this setting is associated with increased short- and long-term morbidity and ...mortality.
The purpose of this case control study was evaluate the characteristics associated with the development of new-onset AF.
Of 2,460 consecutive patients with acute MI, 149 (6%) were identified as having AF within 7 days of MI. After excluding patients with prior AF, previously documented heart failure, reduced left ventricular (LV) ejection fraction, valvular heart disease, LV hypertrophy, AF after coronary artery bypass grafting, or pericarditis; we identified 42 AF patients in whom coronary anatomy was assessed by invasive angiography and cardiac structure and function was evaluated using transthoracic echocardiography. Another 42 patients from the same cohort with MI but no AF matched for age, gender, and LV ejection fraction were studied as controls.
AF patients were more likely to present with an inferior MI (P = .002) but less likely to present with ST-segment elevation MI (P = .02). Univariate associations with AF included indexed left atrial volume (P <.001), LV filling pressure (E/e'; P = .001), right atrial branch disease (P <.001), left atrial branch disease (P = .009), sinoatrial branch disease (P <.001), left main stem disease (P = .02), and time from onset of symptoms to coronary intervention (P = .002). In multivariable analysis, right and left coronary artery atrial branch disease (P = .02) were predictors of AF post-MI.
Coronary artery disease affecting the atrial branches is an independent predictor for the development of AF after MI.
Atrial fibrillation (AF) has been established as an independent predictor of long-term mortality after acute myocardial infarction. However, this is less well defined across the whole spectrum of ...acute coronary syndromes (ACSs). The Acute Coronary Syndrome Prospective Audit is a prospective multicenter registry with 12-month outcome data for 3,393 patients (755 with ST-segment elevation myocardial infarction, 1942 with high-risk non–ST-segment elevation ACS NSTE-ACS, and 696 with intermediate-risk NSTE-ACS). A total of 149 patients (4.4%) had new-onset AF and 387 (11.4%) had previous AF. New-onset AF was more, and previous AF was less frequent in those with ST-segment elevation myocardial infarction than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS (p <0.001). Compared to patients without arrhythmia, patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation (p <0.004). Patients with new-onset AF more often had left main coronary artery disease, resulting in a greater rate of surgical revascularization (p <0.001). Only new-onset AF resulted in adverse in-hospital outcomes (p <0.001). Only patients with previous AF had greater long-term mortality (hazard ratio 1.42, p <0.05). New-onset AF was only associated with a worse long-term composite outcome (hazard ratio 1.66, p = 0.004). However, the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS (odds ratio 3.9, p = 0.02) than for those with high-risk NSTE-ACS (odds ratio 2.0, p = 0.01) or ST-segment elevation myocardial infarction (odds ratio 1.4, p = 0.4). In conclusion, new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up. The prognostic burden of new-onset AF differed with the type of ACS presentation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Assessing risk and weighing the potential benefits from evidence-based therapies are essential in the clinical decision making process of optimizing care and outcomes for patients ...presenting with acute coronary syndromes (ACS). Such practices are advocated in international clinical guidelines of ACS care. While the GRACE risk score (GRS) is a guideline advocated, well-validated risk stratification tool, its utility in improving care and outcomes remains unproven, and its application has been limited in routine clinical practice. Objective This study will assess the effectiveness using the GRS tool and treatment recommendations during patient assessment on improving the application of guideline-recommended therapies in ACS care. Design This study employs a PROBE (prospective cluster hospital-level randomized open-label, blinded endpoint) design to evaluate objective measures of hospital performance, with clinical events adjudicated by a blinded event committee. This randomized study is nested within the established CONCORDANCE registry of ACS patients, with existing methods for data collection and monitoring of care and clinical outcomes. The hospital-level intervention is the integration of the GRS into routine ACS patient assessment process. The study will assess the use of early invasive management, prescription of guideline recommended pharmacology and referral to cardiac rehabilitation by hospital discharge; with the key composite clinical endpoint of cardiovascular death, new or recurrent myocardial infarction, in-hospital heart failure or cardiovascular readmission at 12 months. Health economic impacts of risk stratification implementation will also be evaluated. The study will recruit 3000 patients from 30 hospitals. Summary The AGRIS trial will establish the effect of routine objective risk stratification using the GRACE risk score on ACS care and clinical outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Acute kidney injury (AKI) after cardiopulmonary bypass (CPB) is associated with a requirement for dialysis, a longer stay in the intensive care unit, a longer hospital length of stay, and ...mortality. An oxygenator arterial outlet temperature greater than 37°C has been reported to be associated with AKI; however, the influence of other rewarming temperatures is unclear. Using multicenter registry data, this study aimed to evaluate the role of CPB rewarming temperatures on AKI. Methods Data from 8,407 adult patients undergoing coronary artery bypass grafting (CABG) or valve repair or replacement, or a combination, were collected using the Perfusion Downunder Collaborative Database. Primary variables of interest were rewarming temperatures, defined as cumulative time the oxygenator arterial outlet temperature was greater than 36°C, greater than 36.5°C, or greater than 37°C. Propensity scores were calculated to determine the predicted probability of hyperthermic perfusion (rewarming temperature >37°C). The influence of temperature on AKI was determined using separate multivariate models adjusting for propensity score in the entire cohort (n = 6,904) and in propensity-matched patients (n = 2,044). Results Overall, 11.8% of patients acquired AKI. The duration of rewarming temperature greater than 36°C or 36.5°C was not associated with AKI. The duration of rewarming temperature greater than 37°C (hyperthermic perfusion) was independently associated with RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) risk classification or greater (odds ratio OR, 1.42; 95% confidence interval CI, 1.09–1.77; p = 0.012) and injury classification or greater AKI (OR, 1.52; 95% CI, 1.09–1.97; p = 0.016) in the entire cohort, and injury classification or greater AKI (OR, 1.51; 95% CI, 1.15–1.90; p = 0.006) in propensity-matched patients. Conclusions The duration of hyperthermic perfusion—rewarming temperature greater than 37°C—was an independent predictor of AKI. Avoidance of hyperthermic perfusion may be more beneficial in reducing AKI than avoidance of rewarming.
Background There is a clinical need for an intravenous P2Y12 inhibitor in patients with acute coronary syndromes (ACS) for patients who are unable to take oral medications or might benefit from a ...rapidly reversible compound. As the time from admission to percutaneous coronary intervention (PCI) shortens, establishing the benefit of novel therapies impacting ischemic events is increasingly challenging. Cangrelor, an intravenous potent rapidly acting P2Y12 inhibitor, bolus 30 μg/Kg plus infusion of 4 μg/Kg/min, was compared to a 600-mg loading dose of clopidogrel either before or early after PCI in patients with ACS undergoing PCI in The CHAMPION (Cangrelor versus standard tHerapy to Achieve optimal Management of Platelet InhibitiON) PLATFORM and PCI studies. Methods As both CHAMPION studies used similar inclusion/exclusion criteria and death, myocardial infarction, or ischemia-driven revascularization (including stent thrombosis) at 48 hours as their primary end points, the studies were pooled. The clinical events committee adjudicated myocardial infarction. The universal definition was used to define myocardial infarction. Results A total of 13 049 patients were included. Cangrelor had no effect on the primary end point with the original MI definition ( P = .646). With the use of the universal definition, the primary end point was decreased with cangrelor (odds ratio 0.82, 95% confidence interval 0.68-0.99, P = .037). Stent thrombosis was reduced from 0.4% to 0.2% (odds ratio 0.44, 95% confidence interval 0.22-0.87, P = .018). Thrombolysis in Myocardial Infarction major bleeding and transfusions were not increased with cangrelor. Conclusion With the use of the universal definition of myocardial infarction, cangrelor was associated with a significant reduction in early ischemic events when compared with clopidogrel in patients with non–ST-elevation ACS undergoing PCI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Although proof-of-concept for mobile health (mHealth) life-style programs targeting physical inactivity and overweight/obesity has been established in randomized trials, the ...feasibility and effect of a globally distributed, large-scale, mass-participation mHealth implementation has not been investigated. Objectives The purpose of this study was to determine the effect of Stepathlon, an international, low-cost, mass-participation mHealth intervention, on physical activity, sitting, and weight. Methods We prospectively collected cohort data from participants completing Stepathlon, an annual 100-day global event in 2012, 2013, and 2014. Participants were organized in worksite-based teams, issued pedometers, and encouraged to increase daily steps and physical activity as part of the team-based race. The program was conducted via an interactive multiplatform application available on mobile devices and the Internet. Analysis was performed according to a pre-specified plan. Results A total of 69,219 subjects participated (481 employers, 1,481 cities, 64 countries, all populated continents, age 36 ± 9 years, 23.9% female, 8.0% high-income countries, and 92.0% lower-middle income countries). After Stepathlon completion, participants recorded improved step count (+3,519 steps/day; 95% confidence interval CI: 3,484 to 3,553 steps/day; p < 0.0001), exercise days (+0.89 days; 95% CI: 0.87 to 0.92 days; p < 0.0001), sitting duration (−0.74 h; 95% CI: −0.78 to −0.71 h; p < 0.0001) and weight (−1.45 kg; 95% CI: −1.53 to −1.38 kg; p < 0.0001). Improvements occurred in women and men, in all geographic regions, and in both high and lower-middle income countries, and the results were reproduced in 2012, 2013, and 2014 cohorts. Predictors of weight loss included step increase, sitting duration decrease, and increase in exercise days (all p < 0.0001). Conclusions Distributed mHealth implementation of a low-cost life-style intervention is associated with short-term, reproducible, large-scale improvements in physical activity, sitting, and weight. (Effect of the Stepathlon Pedometer Program on Physical Activity, Weight and Well-Being; ACTRN12615001310550 )
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
In Unstable Angina or Non–ST-Segment Acute Coronary Syndrome, Should Patients With Multivessel Coronary Artery Disease Undergo Multivessel or Culprit-Only Stenting? Mehdi H. Shishehbor, Michael S. ...Lauer, Inder M. Singh, Derek P. Chew, Juhana Karha, Sorin J. Brener, David J. Moliterno, Stephen G. Ellis, Eric J. Topol, Deepak L. Bhatt We examined the safety and efficacy of nonculprit multivessel compared with culprit-only stenting in patients who had multivessel disease that presented with non–ST-segment elevation myocardial infarction (NSTEMI). From January 1995 to June 2005, 479 patients underwent multivessel and 761 patients underwent culprit-only stenting and met our study criteria. Multivessel intervention was associated with lower death, myocardial infarction, or revascularization after both adjusting for baseline and angiographic characteristics (hazard ratio 0.80; 95% confidence interval, 0.64 to 0.99; p = 0.04) and propensity matched analysis (hazard ratio 0.67; 95% confidence interval 0.51 to 0.88; p = 0.004). In patients with multivessel coronary artery disease presenting with NSTEMI, multivessel intervention was significantly associated with a lower incidence of the composite end point compared with culprit-only stenting.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background There is uncertainty about the benefit of a higher loading dose (LD) of clopidogrel in patients with non–ST elevation acute coronary syndrome (NSTEACS) undergoing early percutaneous ...coronary intervention (PCI). Methods We compared the effects of a 600- versus a 300-mg LD of clopidogrel on inhibition of platelet aggregation, myonecrosis, and clinical outcomes in patients with NSTEACS undergoing an early invasive management strategy. Patients with NSTEACS (n = 256, mean age 63 years, 81.6% elevated troponin) without thienopyridine for at least 7 days were randomized to receive 600- or 300-mg LD of clopidogrel. Percutaneous coronary intervention was performed in 140 patients, with glycoprotein IIb/IIIa inhibitor use in 68.6%. Adenosine diphosphate (ADP)–induced platelet aggregation was measured by optical platelet aggregometry immediately before coronary angiography. Results Post-PCI myonecrosis was defined as a next-day troponin I greater than 5 times the upper limit of reference range and greater than baseline levels. Clopidogrel 600-mg LD compared with 300-mg LD was associated with significantly reduced ADP-induced platelet aggregation (49.7% vs 55.7% with ADP 20 μmol/L) but did not reduce post-PCI myonecrosis or adverse clinical outcomes to 6 months. There was no association between preprocedural platelet aggregation and outcome. Conclusions These data confirm a modest incremental antiplatelet effect of a 600-mg clopidogrel LD compared with 300-mg LD but provide no support for a clinical benefit in patients with NSTEACS managed with an early invasive strategy including a high rate (69%) of glycoprotein IIb/IIIa inhibitor use during PCI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Despite advances in primary percutaneous coronary intervention (pPCI) and regional systems of care, the development of cardiogenic shock is associated with poor clinical outcomes in ...patients with ST-segment elevation myocardial infarction (STEMI). We sought to better characterize the baseline characteristics and clinical outcomes of patients who underwent crossover to intraaortic balloon counterpulsation (IABC) in the CRISP AMI trial. Methods Patients with anterior STEMI were randomized to IABC before pPCI or pPCI alone. Infarct size and 6-month clinical outcomes were evaluated in patients both in the pPCI-alone group who did undergo crossover to IABC and those who did not undergo crossover to IABC. Results Among 176 patients randomized to pPCI alone, 161 patients did not later receive IABC during the index hospitalization, and 15 patients (8.5%) underwent crossover and did receive unplanned IABC. Hypotension and/or cardiogenic shock precipitated crossover to IABC in 12 patients (80%). Patients who underwent crossover to IABC demonstrated lower systolic and diastolic blood pressures on admission. At 6 months, rates of death (26.7% vs 3.1%, P = .003), readmission for severe hypotension (53.3% vs 3.7%, P < .001), resuscitated cardiac arrest, and ventricular arrhythmia were higher in the group that did crossover to IABC. Crossover to IABC was not associated with increased infarct size. Conclusions The most significant predictor of crossover to IABC in the setting of anterior STEMI was relative hypotension at the time of hospital admission, and crossover to IABC in CRISP AMI was associated with significantly worse clinical outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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