Impact of Implementation of a Region-Wide Low-Density Lipoprotein Cholesterol Management Clinical Pathway for the Secondary Prevention of Acute Myocardial Infarction.

BACKGROUND: Aggressive lipid-lowering therapy is important for secondary prevention of acute myocardial infarction (AMI). The recommended target for low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL is often not achieved. To address this gap, we implemented a clinical pathway in all hospitals that perform percutaneous coronary interventions (PCI) with primary care physicians in Nagasaki and aimed to validate the effectiveness of this pathway in an acute setting. METHODS AND RESULTS: This retrospective cohort study included medical records extracted from 8 hospitals in Nagasaki, Japan, where PCI was performed for patients with AMI. The index date was defined as the date of hospitalization for AMI between July 1, 2021, and February 28, 2023. The primary outcome was the rate of achieving LDL-C <70 mg/dL at discharge. The median baseline LDL-C level at admission was 121 mg/dL (n=226) in the pre-implementation group and 116 mg/dL (n=163) in the post-implementation group. In the post-implementation group, 131 patients were treated using the clinical pathway. The rate of achieving LDL-C <70 mg/dL at discharge increased significantly from 37.2% before implementation to 54.6% after implementation. Logistic regression analysis revealed a positive correlation between the implementation of the clinical pathway and achieving LDL-C <70 mg/dL. CONCLUSIONS: Implementation of a region-wide clinical pathway for LDL-C management significantly improved the rate of intensive lipid-lowering therapy and the achievement of LDL-C targets.

Impact of Morning Onset on the Incidence of Recurrent Acute Coronary Syndrome and Progression of Coronary Atherosclerosis in Acute Myocardial Infarction.

BACKGROUND: The relationship between time of onset of acute myocardial infarction (MI) and long-term clinical outcome has not been completely understood. We hypothesized that morning onset acute MI may be associated with adverse cardiac events.Methods and Results:This study involved 663 patients who underwent primary percutaneous coronary intervention (PCI). The main outcome measures were cardiac death, recurrent acute coronary syndrome (ACS), and re-hospitalization for heart failure. Major adverse cardiac events (MACE) were defined as a composite of individual adverse outcomes. Morning onset acute MI occurred in 212 patients (32.0%); they had higher rates of recurrent ACS (13% vs. 8%, P=0.03) and MACE (21% vs. 14%, P=0.012) than the patients with other times of onset. The PCI rate for progressive lesions was also higher than for patients with other times of onset (23% vs. 14%, P=0.013). On multivariate Cox regression analysis, morning onset was an independent predictor of recurrent ACS, MACE, and PCI for progressive lesions, with adjusted hazard ratios of 1.34 (95% CI: 1.06-2.92, P=0.030), 1.51 (95% CI: 1.02-2.23, P=0.038), and 1.58 (95% CI: 1.03-2.42, P=0.037), respectively. CONCLUSIONS: Morning onset may be associated with increased risk of recurrent ACS and coronary atherosclerosis progression.

Effects of moderate-to-severe obstructive sleep apnea on the clinical manifestations of plaque vulnerability and the progression of coronary atherosclerosis in patients with acute coronary syndrome.

AIMS: It is unclear whether obstructive sleep apnea (OSA) increases the recurrence of acute coronary syndrome (ACS) in patients with acute myocardial infarction (MI). We hypothesized that moderate-to-severe OSA increased the number of adverse cardiovascular events in patients who underwent primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: This study included 272 patients with acute MI. Polysomnography at first admission determined that 124 patients suffered from moderate-to-severe OSA. The main study outcome measures were cardiac death, recurrence of ACS, and re-admission for heart failure. Major adverse cardiac events (MACEs) were defined as composite end points of individual clinical outcomes. Follow-up coronary angiograms were obtained in 222 patients. PCI-related measures were target vessel revascularization and newly necessitated PCI for progressive lesions. The moderate-to-severe OSA patients had increased ACS recurrence and MACEs compared with patients with mild OSA or without sleep apnea (16% vs. 7%, p = 0.014; 22% vs. 11%, p = 0.014, respectively). PCI for progressive lesions was also higher in the moderate-to-severe OSA patients (28% vs. 15%, p = 0.015). Cox regression analysis showed that moderate-to-severe OSA was an independent predictor of ACS recurrence (hazard ratio = 2.30, p = 0.040). In addition, moderate-to-severe OSA was an independent predictor of PCI for progressive lesions, with a hazard ratio of 2.38 (p = 0.015). CONCLUSIONS: Moderate-to-severe OSA increased the risk of ACS and the incidence of PCI for progressive lesions. Increased plaque vulnerability might be related to these clinical manifestations.

The hemodynamic benefit of biventricular pacing therapy on mitral regurgitation as demonstrated in a patient with ischemic cardiomyopathy and intermittent left bundle branch block.

We report a 75-year-old man with ischemic cardiomyopathy who had mitral regurgitation which was increased markedly by intermittent left bundle branch block (LBBB). He complained of angina-like chest pain that was preceded by episodes of LBBB. During LBBB, a marked elevation of the V wave in the pulmonary capillary wedge pressure was shown, and an increase in mitral and tricuspid regurgitation was observed with color Doppler echocardiography. Biventricular pacing (BVP) therapy was selected so as to protect the patient from episodes of LBBB. After BVP, the patient did not experience chest pain or dyspnea. This case sheds valuable light on the ongoing investigation of the hemodynamic benefit of BVP.

Evaluation of neurohumoral activation (adrenomedullin, BNP, catecholamines, etc.) in patients with acute myocardial infarction.

OBJECTIVE: The object of our study was to identify the most useful predictor of patient prognosis in acute myocardial infarction (AMI), from 7 acute-phase cardiovascular peptides which take part in neurohumoral activation [brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), renin, aldosterone, adrenomedullin, epinephrine and norepinephrine]. METHODS: In 141 consecutive AMI patients, 24 hours from onset, we evaluated plasma concentration levels of the 7 types of cardiovascular peptides and the relationships between the values of these peptides and short-term clinical prognosis, including mortality. RESULTS: Plasma levels of all cardiovascular peptides were significantly higher in patients who suffered mortality than in surviving patients (BNP: 1,267+/-997 pg/ml vs. 293+/-327 pg/ml, p<0.0001; ANP: 164+/-186 pg/ml vs. 64+/-76 pg/ml, p<0.001; adrenomedullin: 13.61+/-3.29 Fmol/l vs. 3.45+/-1.52 Fmol/I, p<0.0001; renin: 8.79+/-7.15 ng/ml/h vs. 4.34+/-5.10 ng/ml/h, p<0.01; aldosterone: 249+/-210 pg/ml vs. 68+/-74 pg/ml, p<0.0001; epinephrine: 3,191+/-8,360 pg/ml vs. 68+/-74 pg/ml, p<0.0001; norepinephrine: 21.8+/-46.2 ng/ml vs. 0.9+/-0.8, ng/ml p<0.0001). Multivariate analysis identified only high levels of adrenomedullin as an independent related factor of cardiogenic shock (risk ratio: 5.84, 95% C.I.: 1.80-18.95, p=0.003), and as an independent predictor of short-term mortality (risk ratio: 16.16, 95% C.I.: 1.38-189.71, p=0.03). CONCLUSIONS: Acute-phase neurohumoral activation, involving renin, aldosterone, epinephrine, norepinephrine, BNP, ANP, and adrenomedullin may be closely related to poor patient outcomes, including mortality. Our results suggest that acute-phase plasma adrenomedullin concentrations may be the most useful predictor of patient prognosis in the setting of AMI, out of the 7 types of cardiovascular peptides involved in neurohumoral activation.

[Predictive factors of deteriorating left ventricular function after direct percutaneous coronary intervention for acute anterior myocardial infarction].

OBJECTIVES: To evaluate useful predictors for the deterioration of left ventricular function after direct percutaneous coronary intervention in patients with acute myocardial infarction. METHODS: This study included 96 consecutive patients with first acute anterior myocardial infarction reperfused successfully by direct percutaneous coronary intervention within 6 hr of the onset, who underwent left ventriculography in the acute (soon after reperfusion therapy) and chronic (20 +/- 8 days after onset) phases. The left ventricular ejection fraction (LVEF), and the difference in LVEF (delta LVEF) between the two stages were calculated. The patients were divided into two groups according to the delta LVEF (low delta LVEF group: delta LVEF < 0%, n = 30; high delta LVEF group: delta LVEF > or = 0%, n = 66). RESULTS: There were significantly more patients with diabetes mellitus (53% vs 18%, p = 0.0009), older age (73 +/- 11 vs 67 +/- 12 years, p = 0.003) and complete occlusion of the culprit artery (13% vs 35%, p = 0.03) in the low delta LVEF group than in the high delta LVEF group. Left ventricular end-diastolic volume index (LVEDVI: 75 +/- 14 vs 62 +/- 15 ml/m2, p = 0.002) in the chronic stage and delta LVEDVI(5 +/- 8 vs -3 +/- 14 ml/m2, p = 0.04) were significantly worse in the low delta LVEF group than in the high delta LVEF group. Multivariate analysis identified diabetes mellitus as the only independent predictor of reduction of LVEF (odds ratio 4.44, 95% confidence interval 1.27-15.52, p = 0.02). CONCLUSIONS: Some patients with acute anterior myocardial infarction treated by direct percutaneous coronary intervention had reduction of the LVEF. There was a close relationship between reduction of the LVEF and left ventricular remodeling. Diabetes mellitus was the most useful predictor of reduction of the LVEF.