Complete blood count is the most widely available laboratory datum in the early in-hospital period after ST-elevation myocardial infarction (STEMI). We assessed the clinical utility of the combined ...use of hemoglobin (Hb) level and neutrophil-to-lymphocyte ratio (N/L) for early risk stratification in patients with STEMI. We analyzed 801 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) within 12 hours of onset of symptoms. Patients with cardiogenic shock or underlying malignancy were excluded, and 739 patients (63 ± 13 years, 74% men) were included in the final analysis. Patients were categorized into 3 groups using the median value of N/L (3.86) and the presence of anemia (Hb <13 mg/dl in men and <12 mg/dl in women); group I had low N/L and no anemia (n = 272), group II had low N/L and anemia, or high N/L and no anemia (n = 331), and group III had high N/L and anemia (n = 136). There were significant differences on clinical outcomes during 6-month follow-up among the 3 groups. Prognostic discriminatory capacity of combined use of Hb level and N/L was also significant in high-risk subgroups such as patients with advanced age, diabetes mellitus, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on Thrombolysis In Myocardial Infarction risk score. In a Cox proportional hazards model, after adjusting for multiple covariates, group III had higher mortality at 6 months (hazard ratio 5.6, 95% confidence interval 1.1 to 27.9, p = 0.036) compared to group I. In conclusion, combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with STEMI undergoing primary PCI.
Objectives We investigated whether statin therapy could be beneficial in patients with acute myocardial infarction (AMI) who have baseline low-density lipoprotein cholesterol (LDL-C) levels below 70 ...mg/dl. Background Intensive lipid-lowering therapy with a target LDL-C value <70 mg/dl is recommended in patients with very high cardiovascular risk. However, whether to use statin therapy in patients with baseline LDL-C levels below 70 mg/dl is controversial. Methods We analyzed 1,054 patients with AMI who had baseline LDL-C levels below 70 mg/dl and survived at discharge from the Korean Acute MI Registry between November 2005 and December 2007. They were divided into 2 groups according to the prescribing of statins at discharge (statin group n = 607; nonstatin group n = 447). The primary endpoint was the composite of 1-year major adverse cardiac events, including death, recurrent MI, target vessel revascularization, and coronary artery bypass grafting. Results Statin therapy significantly reduced the risk of the composite primary endpoint (adjusted hazard ratio HR: 0.56; 95% confidence interval CI: 0.34 to 0.89; p = 0.015). Statin therapy reduced the risk of cardiac death (HR: 0.47; 95% CI: 0.23 to 0.93; p = 0.031) and coronary revascularization (HR: 0.45, 95% CI: 0.24 to 0.85; p = 0.013). However, there were no differences in the risk of the composite of all-cause death, recurrent MI, and repeated percutaneous coronary intervention rate. Conclusions Statin therapy in patients with AMI with LDL-C levels below 70 mg/dl was associated with improved clinical outcome.
Abstract Background The long-term prognosis of patients with variant angina presenting with aborted sudden cardiac death (ASCD) is unknown. Objectives The purpose of this study was to evaluate the ...long-term mortality and ventricular tachyarrhythmic events of variant angina with and without ASCD. Methods Between March 1996 and September 2014, 188 patients with variant angina with ASCD and 1,844 patients with variant angina without ASCD were retrospectively enrolled from 13 heart centers in South Korea. The primary endpoint was cardiac death. Results Predictors of ASCD manifestation included age (odd ratio OR: 0.980 by 1 year increase; 95% confidence interval CI: 0.96 to 1.00; p = 0.013), hypertension (OR: 0.51; 95% CI: 0.37 to 0.70; p < 0.001), hyperlipidemia (OR: 0.38; 95% CI: 0.25 to 0.58; p < 0.001), family history of sudden cardiac death (OR: 3.67; 95% CI: 1.27 to 10.6; p = 0.016), multivessel spasm (OR: 2.06; 95% CI: 1.33 to 3.19; p = 0.001), and left anterior descending artery spasm (OR: 1.40; 95% CI: 1.02 to 1.92; p = 0.04). Over a median follow-up of 7.5 years, the incidence of cardiac death was significantly higher in ASCD patients (24.1 per 1,000 patient-years vs. 2.7 per 1,000 patient-years; adjusted hazard ratio HR: 7.26; 95% CI: 4.21 to 12.5; p < 0.001). Death from any cause also occurred more frequently in ASCD patients (27.5 per 1,000 patient-years vs. 9.6 per 1,000 patient-years; adjusted HR: 3.00; 95% CI: 1.92 to 4.67; p < 0.001). The incidence rate of recurrent ventricular tachyarrhythmia in ASCD patients was 32.4 per 1,000 patient-years, and the composite of cardiac death and ventricular tachyarrhythmia was 44.9 per 1,000 patient-years. A total of 24 ASCD patients received implantable cardioverter-defibrillators (ICDs). There was a nonsignificant trend of a lower rate of cardiac death in patients with ICDs than those without ICDs (p = 0.15). Conclusions The prognosis of patients with variant angina with ASCD was worse than other patients with variant angina. In addition, our findings supported ICDs in these high-risk patients as a secondary prevention because current multiple vasodilator therapy appeared to be less optimal.
Many patients discontinue statin after acute myocardial infarction (AMI) despite its necessity. However, limited data are available describing the clinical impact of statin withdrawal after AMI. This ...study enrolled 3,807 patients in the Korean multicenter registry who survived for 1 year after AMI. All patients were prescribed statin at discharge and were divided into 2 groups on the basis of statin withdrawal history; 603 patients had a history of statin discontinuation and 3,204 patients continued statin therapy. The primary outcome was mortality from any cause. We also analyzed the incidence of cardiac death, nonfatal myocardial infarction, any revascularization, and stroke. The duration of follow-up was 4 years after AMI. Statin withdrawal was associated with higher mortality than continued statin treatment (hazard ratio 3.45, 95% confidence interval 2.81 to 4.24, p <0.001), primarily as the result of increased cardiac mortality (hazard ratio 4.65, 95% confidence interval 3.14 to 6.87, p <0.001). However, the incidences of nonfatal myocardial infarction, any revascularization, and stroke were not different between the groups. Analysis by propensity score matching did not affect the results. In conclusion, many patients experienced statin withdrawal after AMI, which significantly increased long-term mortality in the present study. Careful education and monitoring are needed to reduce adverse cardiac outcomes in patients after AMI.
There are few data available on the prognosis of painless ST-segment elevation myocardial infarction (STEMI). The aim of this study was to determine the incidence, clinical characteristics, and ...outcomes of painless STEMI. We analyzed the Korea Acute Myocardial Infarction Registry (KAMIR) study, which enrolled 7,288 patients with STEMI (61.8 ± 12.8 years old, 74% men; painless STEMI group, n = 763; painful STEMI group, n = 6,525). End points were in-hospital mortality and 1-year major adverse cardiac events (MACEs). Patients with painless STEMI were older and more likely to be women, nonsmokers, diabetic, and normolipidemic and to have a higher Killip class. The painless group had more in-hospital deaths (5.9% vs 3.6%, p = 0.026) and 1-year MACEs (26% vs 19%, p = 0.002). In Cox proportional hazards analysis, hypotension (hazard ratio HR 4.40, 95% confidence interval CI 1.41 to 13.78, p = 0.011), low left ventricular ejection fraction (HR 3.12, 95% CI 1.21 to 8.07, p = 0.019), and a high Killip class (HR 3.48, 95% CI 1.19 to 10.22, p = 0.023) were independent predictors of 1-year MACEs in patients with painless STEMI. In conclusion, painless STEMI was associated with more adverse outcomes than painful STEMI and late detection may have contributed significantly to total ischemic burden. These results warrant more investigations for methodologic development in the diagnosis of silent ischemia and painless STEMI.
Assessment of risk at time of discharge could be a useful tool for guiding postdischarge management. The aim of this study was to develop a novel and simple assessment tool for better hospital ...discharge risk stratification. The study included 3,997 hospital-discharged patients with acute myocardial infarction who were enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry-1 (KAMIR-1) from November 2005 through December 2006. The new risk score system was tested in 1,461 hospital-discharged patients who were admitted from January 2007 through January 2008 (KAMIR-2). The new risk score system was compared to the Global Registry of Acute Coronary Events (GRACE) postdischarge risk model during a 12-month clinical follow-up. During 1-year follow-up, all-cause death occurred in 228 patients (5.7%) and 81 patients (5.5%) in the development and validation cohorts, respectively. The new risk score (KAMIR score) was constructed using 6 independent variables related to the primary end point using a multivariable Cox regression analysis: age, Killip class, serum creatinine, no in-hospital percutaneous coronary intervention, left ventricular ejection fraction, and admission glucose based on multivariate-adjusted risk relation. The KAMIR score demonstrated significant differences in its predictive accuracy for 1-year mortality compared to the GRACE score for the developmental and validation cohorts. In conclusion, the KAMIR score for patients with acute myocardial infarction is a simpler and better risk scoring system than the GRACE hospital discharge risk model in prediction of 1-year mortality.
Abstract Background Coronary artery spasm is associated with vascular smooth muscle hyper-reactivity. Statins suppress coronary spasm by inhibiting the vascular smooth muscle contraction. However, it ...is unclear whether statin therapy benefits patients with coronary spasm-induced acute myocardial infarction (AMI). Methods and results We analyzed 501 (median age 57 years; male/female, 346/155) patients with coronary spasm-induced AMI with nonobstructive coronary arteries (stenosis severity <50%) from the Korea AMI Registry between November 2005 and October 2013. They were divided into two groups according to statin prescription at discharge (statin group n = 292; nonstatin group n = 209). The primary endpoint was the composite of 12-month major adverse cardiac events, including all causes of death, non-fatal myocardial infarction, and target vessel revascularization. The primary endpoint occurred in 17 patients during 12 months of follow-up. Statin therapy significantly reduced the risk of the composite primary endpoint adjusted hazard ratio (HR): 0.30; 95% confidence interval (CI): 0.09–0.97; p = 0.045. Statin therapy reduced the risk of myocardial infarction (HR: 0.19; 95% CI: 0.04–0.93; p = 0.040). However, we found no significant difference in the risk of the composite of all-cause death. Conclusion Statin therapy in patients with coronary spasm-induced AMI with nonobstructive coronary arteries was associated with improved clinical outcome, which was predominantly accounted for by reducing the incidence of myocardial infarction.
Only a few studies have focused on the clinical characteristics and outcomes of non-ST-segment myocardial infarction (NSTEMI) during off-hours. The purpose of this study was to compare the impact of ...patients' arrival time on the care of NSTEMI and whether this pattern might affect hospital mortality. This study analyzed 4,736 NSTEMI patients included in the Korea Acute Myocardial Infarction Registry from November 2005 to January 2008. Patients' arrival time was classified into regular hours (weekdays, 9:00 a.m. to 6:00 p.m. ) and off-hours (weekdays 18:01 p.m. to 8:59 a.m. , weekends, and holidays). A subtotal of 2,225 (46.9%) patients was admitted during off hours, compared with 2,511 (53.1%) patients with regular-hour admission. A higher proportion of patients admitted during off-hours had a higher Killip class, had more frequent cardiopulmonary resuscitation, were less likely to receive percutaneous coronary intervention (PCI) (67.7% vs 72.7%, p <0.001), and had longer door-to-balloon times (28 hours, interquartile range: 11 to 63 vs 23 hours, interquartile range 4 to 67, p <0.001). Although unadjusted hospital mortality was associated with admission during off-hours (4.5% vs 3.3%, p = 0.023), after adjusting for all patients covariates, the difference in mortality was attenuated and was no longer statistically significant (odds ratio 0.94, 95% confidence interval 0.59 to 1.48, p = 0.793). In conclusion, despite receiving fewer PCIs and having substantially longer waiting times to PCI, patients admitted during off-hours may not be at risk for increased in-hospital mortality. If patients are treated within an appropriate reperfusion strategy according to their clinical risk, arrival time may not influence on mortality.
Plaque Characteristics in Culprit Lesions and Inflammatory Status in Diabetic Acute Coronary Syndrome Patients Young Joon Hong, Myung Ho Jeong, Yun Ha Choi, Jum Suk Ko, Min Goo Lee, Won Yu Kang, Shin ...Eun Lee, Soo Hyun Kim, Keun Ho Park, Doo Sun Sim, Nam Sik Yoon, Hyun Ju Yoon, Kye Hun Kim, Hyung Wook Park, Ju Han Kim, Youngkeun Ahn, Jeong Gwan Cho, Jong Chun Park, Jung Chaee Kang To determine the characteristics of culprit lesions in diabetic patients with acute coronary syndrome (ACS), intravascular ultrasound and virtual histology-intravascular ultrasound were performed in a large series of patients with ACS. Diabetic patients had greater hs-CRP, multivessel disease, and plaque burden. In the acute myocardial infarction patients, diabetics had more multiple plaque ruptures and thrombus. Diabetic patients also had greater necrotic core volumes and greater incidence of thin-cap fibroatheromas. Therefore, the diabetic patients with ACS have more characteristics of plaque vulnerability and elevated inflammatory state compared with nondiabetic patients with ACS.
Summary The effect of body mass index (BMI) on outcomes after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is not well known. ...In patients registered in the Korean Acute Myocardial Infarction Registry (KAMIR) between November 2005 and November 2007, 3824 STEMI patients who arrived at hospital within 12 h after onset of chest pain and underwent primary PCI were analyzed, and divided into four groups according to their BMI: underweight (BMI < 18.5 kg/m2 , n = 129); normal weight (18.5 ≤ BMI < 23.0 kg/m2 , n = 1253); overweight (23.0 ≤ BMI < 27.5 kg/m2 , n = 1959); and obese (BMI ≥ 27.5 kg/m2 , n = 483). In-hospital mortality, revascularization in 1 year, mortality in 1 year, and overall mortality were compared between groups. Overweight and obese group were significantly younger, had normal left ventricular ejection fraction, and were more likely to be men with a higher incidence of hypertension, diabetes, and hyperlipidemia. There were no significant differences in symptom-to-door time and door-to-balloon time between groups. Obese patients had significantly lower in-hospital and overall mortalities. Major adverse cardiac events showed a bimodal pattern. Obese STEMI patients treated with primary PCI were associated with lower mortality, which may be explained by better use of medical treatment, hemodynamic stability, and younger age.
PDF
