Fractional flow reserve in patients with type 1 or type 2 non-ST elevation acute myocardial infarction.

AIMS: We assessed a combined strategy of fractional flow reserve (FFR) plus angiography in stratifying cardiovascular risk in patients with type 1 myocardial infarction (T1MI) or type 2 (T2MI) non-ST elevation acute myocardial infarction (NSTEMI). METHODS: A cohort of 150 NSTEMI patients were prospectively studied. Clinical and angiographic features guided the identification of T1MI vs T2MI and the treatment of culprit lesions. Subsequently, T1MI patients underwent FFR evaluation of nonculprit stenoses. In T2MI patients all angiographically significant stenoses were evaluated by FFR. FFR < 0.80 was an indication for revascularization. Based on FFR results, two groups were compared: patients with all lesions ≥0.80 ('defer' group, n = 87) and those with at least one lesion <0.80 ('perform' group, n = 63). The primary end point was the composite of all-cause death, nonfatal MI and unplanned coronary revascularization. RESULTS: Median clinical follow-up was of 35 months (interquartile range 14-44). Primary end-point rates in the 'defer' and 'perform' groups were 14.5% and 30.0% at 12 months and 28% and 46% at 36 months, respectively (log-rank test: at 1 year, P = 0.007; at the end of follow-up P = 0.014). On multivariable analysis, chronic kidney disease (HR 3.50, 95% CI: 1.89-6.46, P = 0.0001) and FFR group ('perform' vs 'defer': HR 1.75 95% CI: 1.01-3.04, P = 0.046) were independent predictors of adverse events. CONCLUSIONS: In NSTEMI patients, our results indicated that FFR combined with angiography allowed the treatment of nonfunctional significant lesions to be safely deferred and patient cardiovascular risk to be identified.

Development and validation of a model for predicting 18-month mortality in type 2 myocardial infarction.

BACKGROUND: Despite the poor prognosis in patients with type 2 myocardial infarction (MI), no prospective data on risk stratification exists. The aim of this study was to develop and validate a model for prediction of 18-month mortality of among patients with type 2 MI (T2MI) and compare its performance with GRACE and TARRACO scores. METHODS: The prospective observational study included 712 consecutive patients diagnosed with MI undergoing coronary angiography <24 h between January 2017 and December 2018. Diagnosis of T2MI was adjusted according to Third universal definition. A prognostic model was developed by using Bayesian approach and logistic regression analysis with identifying predictors for mortality. The model was validated by bootstrap validation. Comparison performance between scores using Delong test. RESULTS: T2MI was identified in 174 (24.4%) patients. The median age of patients was 69 years, 52% were female. The mortality rate was 20.1% at 18 months. Prior MI, presence of ST elevation, hemoglobin level at admission, Charlson comorbidity index and were independently associated with 18-month mortality. The model to predict 18-month mortality showed excellent discrimination (optimism corrected c-statistic = 0.822) and calibration (corrected slope = 0.893). GRACE and TARRACO scores had moderate discrimination [c-statistic = 0.748 (95% CI 0.652-0.843) and 0.741, 95% CI 0.669-0.805), respectively] and inferior compared with model (p = 0.043 and 0.037, respectively). CONCLUSIONS: The risk of mortality among T2MI patients could be accurately predicted by using common clinical characteristics and laboratory tests. Further studies are required with external validation of nomogram prior to clinical implementation.

The relationship between galectin-3 and SYNTAX Score I in patients with non-ST-segment elevation myocardial infarction.

OBJECTIVE: The expression of galectin-3 has been found to be increased in human atherosclerotic lesions, suggesting a role in atherogenesis. However, there is a lack of data regarding an association between galectin-3 and the extent, severity, and complexity of coronary artery disease (CAD). The aim of this study was to investigate the relationship between galectin-3 and SYNTAX Score I in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: This study included a total of 95 consecutive patients who were diagnosed with NSTEMI and underwent coronary angiography. The baseline galectin-3 level of each patient was measured. The SYNTAX Score I of each patient was calculated using the online calculator (www.syntaxscore.com). The study population was divided into 2 groups: SYNTAX Score I ≤22 group (n=55) and SYNTAX Score I >22 group (n=40). RESULTS: The galectin-3 level was significantly higher in the SYNTAX Score I >22 group than in the SYNTAX Score I ≤22 group (22.1±8.3 ng/mL vs. 13.5±7.7 ng/mL; p<0.001). Forward stepwise logistic regression analysis demonstrated that galectin-3 (odds ratio [OR]: 1.195, 95% confidence interval [CI]: 1.097-1.302; p<0.001), left ventricular ejection fraction (OR: 0.941, 95% CI: 0.888-0.997; p=0.040), and platelet count (OR: 1.013, 95% CI: 1.003-1.024; p=0.014) were independently associated with intermediate and high SYNTAX scores. ROC analysis provided a cut-off value of 14.0 ng/mL for galectin-3 to predict an intermediate or high SYNTAX Score I with 75.0% sensitivity and 51.0% specificity (p<0.001). CONCLUSION: In patients with NSTEMI, galectin-3 was associated with the extent, severity, and complexity of CAD as assessed by the SYNTAX Score I.

[A rare cause of type 2 non-ST-elevation myocardial infarction: Cardiac compression and left ventricular obstruction by a giant hiatal hernia]. / Une cause rare d'infarctus du myocarde sans sus-décalage du segment ST de type 2 : compression cardiaque et obstruction intraventriculaire gauche par une volumineuse hernie hiatale.

We report the case of a 89 year-old woman admitted to the emergency department for epigastric pain, nausea, vomiting. Because of a circulatory failure with electrocardiographic ST changes and a slight elevation of ultra-sensible troponin, a coronary angiography was performed and found normal coronary arteries. Thoraco-abdominal CT scan revealed a large hiatal hernia causing a cardiac compression, and a left intraventricular obstruction showed by Doppler echocardiography. All signs resolved after fasting and gastric drainage.

Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types.

Advances in cardiovascular (CV) imaging, redefined electrocardiogram criteria, and high-sensitivity CV biomarker assays have enabled more differentiated etiological classification of myocardial infarction (MI). Type 1 MI has a different underlying pathophysiology than type 2 through type 5 MI; type 1 MI is characterized primarily by intracoronary atherothrombosis and the other types by a variety of mechanisms, which can occur with or without an atherosclerotic component. In type 2 MI, there is evidence of myocardial oxygen supply-demand imbalance unrelated to acute coronary atherothrombosis. Types 1 and 2 MI are spontaneous events, while type 4 and type 5 are procedure-related; type 3 MI is identified only after death. Most type 1 and type 2 MI present as non-ST-elevation MI (NSTEMI), although both types can also present as ST-elevation MI. Because of their different underlying etiologies, type 1 and type 2 NSTEMI have different presentation and prognosis and should be managed differently. In this article, we discuss the epidemiology, prognosis, and management of NSTEMI occurring in the setting of underlying type 1 or type 2 pathophysiology. Most NSTEMI (65%-90%) are type 1 MI. Patients with type 2 MI have multiple comorbidities and causes of in-hospital mortality among these patients are not always CV-related. It is important to distinguish between type 1 and type 2 NSTEMI early in the clinical course to allow for the use of the most appropriate treatments that will provide the greatest benefit for these patients.

Epidemiology and mortality in an Italian region after the adoption of the universal definition of myocardial infarction.

AIMS: The aim of the study is to validate at the biochemical level (presence of myocardial damage) the discharge diagnosis code ICD-9-CM 410.x1, and to compare the acute myocardial infarction (AMI) epidemiology based on pure administrative data with the epidemiology based on troponin and clinical data. METHODS: The health-related administrative databases of the Italian Region Friuli Venezia Giulia were used as the source of information. All the databases are anonymous and can be linked with each other at the individual patient level through a univocal stochastic key. Two methods were used to assess incidence in 2017: the first used the main hospital discharge diagnosis, validated by biochemical myocardial necrosis; the second identified from the cohort of all patients with any myocardial injury those with ischemic origin. RESULTS: The positive-predictive value of the clinical diagnosis of AMI (410.x1), validated at the biochemical level, was 96.2%.About 40% of patients with a not trivial biochemical myocardial injury and an ischemic heart disease diagnosis (e.g. 411) were discharged without either ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) diagnosis, leading to a sensitivity of clinical discharge diagnosis of 47.6%.Thirty-day and 90-day mortality at multivariate analysis resulted respectively, 1.8 and 4.0% in NSTEMI, 6.6 and 9.8% in STEMI, 8.8 and 12.2% in patients with biochemical AMI and discharge diagnosis other than 410.x1. CONCLUSION: Pure administrative data (clinical discharge diagnosis) are today insufficient to catch the whole hospital epidemiology of myocardial infarction missing an important proportion of AMI with an adverse prognosis comparable with STEMI.

Implications of Misclassification of Type 2 Myocardial Infarction on Clinical Outcomes.

BACKGROUND: Patients with type 2 myocardial infarction (MI) are often classified under the diagnosis of non-ST-segment-elevation MI (NSTEMI) despite the significant differences in clinical characteristics, management, and outcomes between type 2 MI and type 1 NSTEMI. This may have significant implications that can lead to inaccurate assessment of quality measures by MI quality review programs. METHODS: A single-center retrospective study of 1224 patients discharged with the diagnosis of type 1 NSTEMI between January 2015 and September 2017. Based on the third universal definition of MI, we stratified patients into type 2 MI or type 1 NSTEMI. Patient's characteristics, comorbidities, medications prescribed during hospitalization and at discharge, readmissions within 30 days after discharge, and diagnostic and therapeutic interventions data was collected. The primary goal of this study was to identify how often type 2 MI patients were misclassified as type 1 NSTEMI, we also assessed the differences in treatment and outcomes between type 2 MI and type 1 NSTEMI. RESULTS: 1224 patients assigned the ICD-9 and ICD-10 codes of type 1 NSTEMI at discharge were evaluated for study inclusion. After application of the inclusion criteria, 945 patients were included in the final analysis. Of these 945 patients, 281 (29.7%) patients were classified as type 2 MI and 664 (70.3%) patients were classified as type 1 NSTEMI. Patients with type 2 MI were older, more likely to have systolic heart failure, had lower peak troponin levels, were less likely to receive aspirin, P2Y12 inhibitors and statin at discharge, and had longer length of stay. Compared with type 1 NSTEMI patients, those with type 2 MI had higher all cause 30-day mortality (13.5% versus 2.9%, P < 0.0001) (RR: 4.65; 95% CI, 2.85-9.65). After adjusting for patient demographics, comorbidities, and medications, patients with type 2 MI were still more likely to die within 30 days after discharge (RR: 2.89; 95% CI, 1.58-7.46). In addition, patients with type 2 MI were more likely to be readmitted within 30 days after discharge than patients with type 1 NSTEMI (17.7% versus 13.9%, P < 0.01) (RR: 1.27; 95% CI, 1.08-2.5). CONCLUSIONS: Close to one third of patients given the diagnosis of type 1 NSTEMI at discharge at our institution were type 2 MI patients. Patients with type 2 MI are managed differently from type 1 NSTEMI patients and have higher 30-day mortality and readmission rate. Misclassification of type 2 MI as type 1 NSTEMI can have a significant impact on hospitals MI clinical performance and quality measures.

Impact of Type 2 Myocardial Infarction (MI) on Hospital-Level MI Outcomes: Implications for Quality and Public Reporting.

BACKGROUND: The International Classification of Diseases (ICD) coding system does not recognize type 2 myocardial infarction (MI) as a separate entity; therefore, patients with type 2 MI continue to be categorized under the general umbrella of non-ST-segment-elevation myocardial infarction (NSTEMI). We aim to evaluate the impact of type 2 MI on hospital-level NSTEMI metrics and discuss the implications for quality and public reporting. METHODS AND RESULTS: We conducted a single-center retrospective analysis of 1318 patients discharged with a diagnosis of NSTEMI between July 2013 and October 2014. The Third Universal Definition was used to define type 1 and type 2 MI. Weighted Kaplan-Meier curves were used to analyze risk of mortality and readmission. Overall, 1039 patients met NSTEMI criteria per the Third Universal Definition; of those, 264 (25.4%) had type 2 MI. Patients with type 2 MI were older, were more likely to have chronic kidney disease, and had lower peak troponin levels. Compared with type 1 MI patients, those with type 2 MI had higher inpatient mortality (17.4% versus 4.7%, P<0.0001) and were more likely to die from noncardiovascular causes (71.7% versus 25.0%, P<0.0001). Despite weighting for patient characteristics and discharge medications, patients with type 2 MI had higher mortality at both 30 days (risk ratio: 3.63; 95% confidence interval, 1.67-7.88) and 1 year (risk ratio: 1.98; 95% confidence interval, 1.44-2.73) after discharge. Type 2 MI was also associated with a lower 30-day cardiovascular-related readmission (risk ratio: 0.49; 95% confidence interval, 0.12-2.06). CONCLUSIONS: NSTEMI metrics are significantly affected by type 2 MI patients. Type 2 MI patients have distinct etiologies, are managed differently, and have higher mortality compared with patients with type 1 MI. Moving forward, it may be appropriate to exclude type 2 MI data from NSTEMI quality metrics.