Elevated Glucose on Admission Was an Independent Risk Factor for 30-Day Major Adverse Cardiovascular Events in Patients with STEMI but Not NSTEMI.

Background: The purpose of this study was to evaluate the impact of glucose levels on admission, on the risk of 30-day major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction (AMI), and to assess the difference in outcome between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients. Methods: This study was a post hoc analysis of the Acute Coronary Syndrome Quality Improvement in Kerala Study, and 13,398 participants were included in the final analysis. Logistic regression models were used to assess the association between glucose levels on admission and the risk of 30-day MACEs, adjusting for potential confounders. Results: Participants were divided according to the glucose quintiles. There was a positive linear association between glucose levels at admission and the risk of 30-day MACEs in AMI patients [adjusted OR (95% CI): 1.05 (1.03, 1.07), p < 0.001]. Compared to participants with an admission glucose between 5.4 and 6.3 mmol/L, participants with the highest quintile of glucose level ( ≥ 10.7 mmol/L) were associated with increased risk of 30-day MACEs in the fully adjusted logistic regression model [adjusted OR (95% CI): 1.82 (1.33, 2.50), p < 0.001]. This trend was more significant in patients with STEMI (p for interaction = 0.036). Conclusions: In patients with AMI, elevated glucose on admission was associated with an increased risk of 30-day MACEs, but only in patients with STEMI.

Dissecting the role of cannabinoids in vascular health and disease.

Cannabis, often recognized as the most widely used illegal psychoactive substance globally, has seen a shift in its legal status in several countries and regions for both recreational and medicinal uses. This change has brought to light new evidence linking cannabis consumption to various vascular conditions. Specifically, there is an association between cannabis use and atherosclerosis, along with conditions such as arteritis, reversible vasospasm, and incidents of aortic aneurysm or dissection. Recent research has started to reveal the mechanisms connecting cannabinoid compounds to atherosclerosis development. It is well known that the primary biological roles of cannabinoids operate through the activation of cannabinoid receptor types 1 and 2. Manipulation of the endocannabinoid system, either genetically or pharmacologically, is emerging as a promising approach to address metabolic dysfunctions related to obesity. Additionally, numerous studies have demonstrated the vasorelaxant properties and potential atheroprotective benefits of cannabinoids. In preclinical trials, cannabidiol is being explored as a treatment option for monocrotaline-induced pulmonary arterial hypertension. Although existing literature suggests a direct role of cannabinoids in the pathogenesis of atherosclerosis, the correlation between cannabinoids and other vascular diseases was only reported in some case series or observational studies, and its role and precise mechanisms remain unclear. Therefore, it is necessary to summarize and update previously published studies. This review article aims to summarize the latest clinical and experimental research findings on the relationship between cannabis use and vascular diseases. It also seeks to shed light on the potential mechanisms underlying these associations, offering a comprehensive view of current knowledge in this evolving field of study.

Glycemic control, HbA1c variability, and major cardiovascular adverse outcomes in type 2 diabetes patients with elevated cardiovascular risk: insights from the ACCORD study.

BACKGROUND: Although recent guidelines advocate for HbA1c target individualization, a comprehensive criterion for patient categorization remains absent. This study aimed to categorize HbA1c variability levels and explore the relationship between glycemic control, cardiovascular outcomes, and mortality across different degrees of variability. METHODS: Action to Control Cardiovascular Risk in Diabetes study data were used. HbA1c variability was measured using the HbA1c variability score (HVS) and standard deviation (SD). K-means and K-medians clustering were used to combine the HVS and SD. RESULTS: K-means clustering was the most stable algorithm with the lowest clustering similarities. In the low variability group, intensive glucose-lowering treatment significantly reduced the risk of adverse cardiovascular outcomes (HR: 0·78 [95% CI: 0·63, 0·97]) without increasing mortality risk (HR: 1·07 [0.81, 1·42]); the risk of adverse cardiovascular events (HR: 1·33 [1·14, 1·56]) and all-cause mortality (HR: 1·23 [1·01,1·51]) increased with increasing mean HbA1c. In the high variability group, treatment increased the risk of cardiovascular events (HR: 2.00 [1·54, 2·60]) and mortality (HR: 2·20 [1·66, 2·92]); a higher mean HbA1c (7·86%, [7·66%, 8·06%]) had the lowest mortality risk, when the mean HbA1c was < 7·86%, a higher mean HbA1c was associated with a lower mortality risk (HR: 0·63 [0·42, 0·95]). In the medium variability group, a mean HbA1c around 7·5% was associated with the lowest risk. CONCLUSIONS: HbA1c variability can guide glycemic control targets for patients with type 2 diabetes. For patients with low variability, the lower the HbA1c, the lower the risk. For those with medium variability, controlling HbA1c at 7·5% provides the maximum benefit. For patients with high variability, a mean HbA1c of around 7·8% presents the lowest risk of all-cause mortality, a lower HbA1c did not provide cardiovascular benefits but instead increased the mortality risk. Further studies, especially those with patients that reflect the general population with type 2 diabetes undergoing the latest therapeutic approaches, are essential to validate the conclusions of this study.

Association Between the Frailty and Cognitive Impairment Among Patients With Hypertension-A Post Hoc Analysis of the SPRINT Trial.

Background Frailty and cognitive impairment are common in the elderly, with various shared risk factors like hypertension. Frailty is a marker for future cognitive function. Moreover, whether intensive blood pressure interacted with frailty and cognitive impairment is unknown. Methods and Results We performed a post hoc analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial). The relationship between frailty and a composite of probable dementia (PD) and mild cognitive impairment (MCI) was analyzed. Also, we evaluated the interaction of intensive blood pressure lowering in the relationship between frailty and cognitive impairment. A total of 8537 patients were included in our study, and 35.1% were women. The mean age of these participants was 67.9±9.3 years. According to the baseline frailty index, 1670, 4637, and 2230 patients were in fit, less fit, and frail statuses, respectively. During a mean follow-up of 4.61 years, 871 cases of PD or MCI occurred. Compared with those in fit status, those with less fit (hazard ratio [HR], 2.14 [95% CI, 1.65-2.77]) and frailty (HR, 4.28 [95% CI, 3.26-5.61]) status had a higher incidence of a composite of PD and MCI. Blood pressure control strategy interacted with the correlation between frailty and cognitive impairment. Intensive blood pressure control (HR, 2.4 [95% CI, 2.0-2.8]) accelerated the relationship between frailty and incidence of PD and MCI compared with the standard treatment group (HR, 1.8 [95% CI, 1.5-2.1]; P for interaction=0.009). Conclusions This study found that the baseline frailty status was a possible marker for the incidence of a composite of PD and MCI. Intensive blood pressure control may strengthen this correlation. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT01206062.

Relationship between orthostatic blood pressure changes and intensive blood pressure management in patients with hypertension.

INTRODUCTION: The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that closely controlling blood pressure (BP) could decrease cardiovascular outcome risk without increasing the orthostatic hypotension rate. We aimed to evaluate the association between baseline orthostatic BP change and major adverse cardiovascular event (MACE) occurrence. METHODS: We conducted a post hoc analysis using SPRINT data including 9329 patients with hypertension. The SPRINT trial was a two-arm, multicentre, randomised clinical trial designed to test whether an intensive treatment aimed at reducing systolic BP (SBP) to <120 mm Hg would reduce cardiovascular disease risk. Orthostatic BP change was defined as baseline standing systolic BP (SBP)-baseline mean seated SBP, or diastolic BP (DBP)-baseline mean seated DBP. RESULTS: We found a U-shaped relationship between orthostatic BP changes and MACE occurrence. All lowest risk points were around 0 mm Hg. On the left side of the inflection point, MACE risk decreased with orthostatic BP change decrease (HR=0.99, 95% CI (0.98 to 1.00), p=0.04, SBP change) (HR=0.97, 95% CI (0.95 to 0.99), p<0.01, DBP change); on the right side, MACE risk increased with orthostatic BP change increase (HR=1.02, 95% CI (1.01 to 1.06), p<0.01, SBP change) (HR=1.01, 95% CI (1.00 to 1.03), p=0.16, DBP change). There was no significant interaction effect between orthostatic SBP (p for interaction=0.37) or DBP changes (p for interaction=0.33) and intensive BP management. CONCLUSIONS: Orthostatic DBP increase and SBP decrease were associated with an increased MACE risk. The benefits of intensive BP management were also consistent across different orthostatic BP change ranges.

Effect of body size and intensive blood pressure management on cardiovascular and serious adverse events.

BACKGROUND: Previous studies have shown that obese hypertensive patients have a lower risk of cardiovascular events than normal-weight patients, and that the performed hypertension treatment affects cardiovascular outcomes depending on the patient's body size. This study aimed to investigate the relationship between the BMI and cardiovascular outcomes and safety endpoints in hypertensive patients with intensive or standard blood pressure (BP) management. METHODS: We used data from the Systolic Blood Pressure Intervention Trial (SPRINT). Cox proportional hazards models were used to analyze the data. The primary endpoint was cardiovascular disease (CVD) death, and the safety endpoint was serious adverse events. RESULTS: In total, 9284 patients were included in our analysis. Thirty-seven patients in the intensive arm and 65 patients in the standard arm had CVD death. After multivariable adjustment, the BMI was not associated with the incidence of CVD death in the standard arm [hazard ratio 0.96, 95% confidence interval (CI) 0.91-1.02]. In the intensive arm, the incidence of CVD death decreased (hazard ratio 0.86, 95% CI 0.78-0.96) first and, then, increased (hazard ratio 1.15, 95% CI 1.07-1.25) with an increase in the BMI (inflection point, 32.33 kg/m2). CONCLUSION: Intensive BP management in overweight, class I, and class II obese patients significantly reduced the cardiovascular outcomes without increasing the safety risks. Nevertheless, further clinical evidence is needed to verify the effectiveness of intensive BP management in patients with normal weight and class III obesity.

Gut bacterial metabolite Urolithin A inhibits myocardial fibrosis through activation of Nrf2 pathway in vitro and in vivo.

BACKGROUND: Myocardial fibrosis after myocardial infarction (MI) is one of the leading causes of cardiovascular diseases. Cardiac fibroblasts (CFs) are activated and promoted by MI to undergo myofibroblast transformation (CMT). Urolithin A (UA) is an active and effective gut metabolite derived from polyphenolics of berries and pomegranate fruits, which has been reported to have anti-inflammatory and anti-oxidant functions. However, whether UA affects the CMT process during myocardial fibrosis remains unclear. METHODS: TGF-ß1-treated primary rat cardiac fibroblasts were used for in vitro study. Cell proliferation ability was evaluated by MTT assay. Cell migration and invasion abilities were tested by wound healing and Transwell assays. The expression of CMT process-related markers were measured by qRT-PCR and western blot. The rat MI model was established by left anterior descending coronary artery (LAD) ligation and evaluated by H&E and Masson staining. RESULTS: Our data demonstrated that UA treatment could inhibit the CMT process in TGF-ß1-induced CFs, including cell proliferation, migration and invasion abilities. Knocking down of Nrf2, which was activated by UA treatment, could mitigate the effects of UA treatment on CMT process. Moreover, in vivo administration of UA in rat MI model successfully up-regulated Nrf2 expression and improved the myocardial damage and fibrosis. CONCLUSIONS: The study discovered the function and mechanism of UA on myocardial fibrosis and demonstrated the protective effects of UA administration through activation of Nrf2 pathway.

Traditional Cardiovascular Risk Factors and Coronary Collateral Circulation: A Meta-Analysis.

Objective: Patients with well-developed coronary collateral circulation (CC) usually have low mortality, improved cardiac function, and reduced infarct size. Currently, there is conflicting evidence on the association between traditional cardiovascular risk factors (diabetes, hypertension, and smoking habit) and CC. Design: We performed a meta-analysis of case-control studies to better understand such associations. Data Sources: We searched the MEDINE, EMBASE, and Science Citation Index databases to identify relevant studies. Eligibility Criteria for Selecting Studies: Case control studies reporting data on risk factors (smoking habit, hypertension, and diabetes mellites) in comparing cases between poor CC and well-developed CC groups. Well-developed CC was the primary outcome of this meta-analysis Data Extraction and Synthesis: Relevant data were extracted by two independent investigators. We derived pooled odds ratios (ORs) with random effects models. We performed quality assessments, publication bias, and sensitivity analysis to ensure the reliability of our results. Results: In total, 18 studies that had 4,746 enrolled patients were analyzed. Our results showed that hypertension and smoking habit did not (OR = 0.94, 95% CI: 0.75-1.17, p = 0.564 and OR = 1.00, 95% CI: 0.84-1.18, p = 0.970, respectively), and diabetes did (OR = 0.50, 95% CI: 0.38-0.67, p = 0.00001) affect the development of CC. Conclusion: Unlike hypertension and smoking habit, diabetes was associated with poor CC formation. Trial Registration Number: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=87821, identifier: CRD42018087821.

The association of interferon-alpha with development of collateral circulation after artery occlusion.

BACKGROUND: Previous studies have demonstrated that interferon (IFN) signaling is enhanced in patients with poor collateral circulation (CC). However, the role and mechanisms of IFN-alpha in the development of CC remain unknown. METHODS: We studied the serum levels of IFN-alpha and coronary CC in a case-control study using logistics regression, including 114 coronary chronic total occlusion (CTO) patients with good coronary CC and 94 CTO patients with poor coronary CC. Restricted cubic splines was used to flexibly model the association of the levels of IFN-alpha with the incidence of good CC perfusion restoration after systemic treatment with IFN-alpha was assessed in a mice hind-limb ischemia model. RESULTS: Compared with the first IFN-alpha tertile, the risk of poor CC was higher in the third IFN-alpha tertile (OR: 4.79, 95% CI: 2.22-10.4, p < .001). A cubic spline-smoothing curve showed that the risk of poor CC increased with increasing levels of serum IFN-alpha. IFN-alpha inhibited the development of CC in a hindlimb ischemia model. Arterioles of CC in the IFN-alpha group were smaller in diameter than in the control group. CONCLUSION: Patients with CTO and with poor CC have higher serum levels of IFN-alpha than CTO patients with good CC. IFN-alpha might impair the development of CC after artery occlusion.

Hb Levels and Sex Differences in Relation to Short-Term Outcomes in Patients With Acute Myocardial Infarction.

Background: Women had worse outcomes after acute myocardial infarction (AMI), and physiologically, women had lower hemoglobin values. We examined whether there were sex-related differences in the relationship between hemoglobin levels and adverse outcomes in patients with acute myocardial infarction. Method: We conducted a post-hoc analysis of data from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS-QUIK) Study. We explored the relationship between baseline hemoglobin level and 30-days adverse outcomes by logistic regression model, generalized additive model (GAM) and two-piecewise linear regression model. We used multiple imputation, based on five replications and a chained equation approach method in the R multiple imputation procedure, to account for missing data. The primary outcome were 30-day major adverse cardiovascular events (MACEs) defined as death, reinfarction, stroke, and major bleeding. The secondary outcomes were 30-day major bleeding, 30-day stroke and 30-day cardiovascular death (CVD death). Results: Twenty thousand, five hundred fifty-nine patients with AMI were included in our analysis. Baseline hemoglobin level was associated with major bleeding [OR: 0.74, 95%CI (0.60, 0.92) P < 0.01], CVD death [OR: 0.94, 95%CI (0.90, 0.99) P < 0.01], and MACEs [OR: 0.95, 95%CI (0.92, 0.99) P < 0.01]. There was no significant relationship between baseline hemoglobin level and stroke incidence in both men [OR: 1.02, 95%CI (0.90, 1.14) P = 0.77] and women [OR: 1.15, 95%CI (0.96, 1.37) P = 0.18]. Baseline hemoglobin level was associated with major bleeding [OR: 0.71, 95%CI (0.58, 0.85) P < 0.01] in male patients, however we did not find the same relationship in female patients [OR: 0.89, 95%CI (0.56, 1.41) P = 0.61]. GAM and two-piecewise linear regression model showed the relationships of hemoglobin level with major bleeding, CVD death, and MACEs were non-linear (non-linear P < 0.05), and the threshold value were 13, 14.8, and 14.3 g/dL for MACEs and CVD death, respectively. Conclusion: Baseline hemoglobin level was one of the independent predictors of prognosis in South Asia patients with acute myocardial infarction. Moreover, its impact on prognosis was largely different depending on the patients' sex.

High-density lipoprotein cholesterol levels are associated with major adverse cardiovascular events in male but not female patients with hypertension.

BACKGROUND: The relationship between high-density lipoprotein cholesterol (HDL-C) levels and major adverse cardiovascular events (MACEs) in hypertensive patients of different sexes is unclear. HYPOTHESIS: Sex differences in the relationship between HDL-C levels and the risk of MACEs among hypertensive patients. METHODS: We performed a post-hoc analysis of data obtained from the Systolic Blood Pressure Intervention Trial (SPRINT) and explored sex-based differences in the relationship between HDL-C levels and MACEs among hypertensive patients using Cox proportional hazards regression. RESULTS: A total of 9323 hypertensive patients (6016 [64.53%] men and 3307 [35.47%] women) were assessed using SPRINT data. MACEs occurred in 395 (6.57%) men and 166 (5.02%) women after a mean follow-up of 3.26 years. When HDL-C levels were used as a continuous covariate, each 10 mg/dl increase in HDL-C levels decreased the risk of MACEs in men (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.70-0.88; p < .0001). However, HDL-C levels were not associated with MACEs in female hypertensive patients (HR, 1.02; 95% CI, 0.89-1.16; p = .7869). Compared with those in the first quartile, MACEs in the fourth quartile had the lowest risk among male patients (HR, 0.58; 95% CI, 0.41-0.82; p = .0023). Female patients in the fourth quartile of HDL-C levels had an HR of 1.09 for MACEs (95% CI, 0.62-1.93; p = .7678). HDL-C levels were not associated with the risk of MACEs among females. CONCLUSION: Among elderly hypertensive patients, higher HDL-C levels were associated with a lower MACE incidence in men but not in women. Unique identifier: NCT01206062.

Short-term and long-term outcomes of revascularization interventions for patients with severely reduced left ventricular ejection fraction: a meta-analysis.

AIMS: This meta-analysis aimed to determine whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) should be preferred in patients with severely reduced left ventricular (LV) ejection fraction. METHODS AND RESULTS: We searched the PubMed, EMBASE, and Cochrane Library databases from the conception of the databases till 1 May 2020 for studies on patients with severely reduced LV ejection fraction undergoing CABG and PCI. The primary clinical endpoints were 30 day and long-term mortalities. The secondary endpoints were 30 day and long-term incidences of myocardial infarction (MI) and stroke, long-term cardiovascular mortality, and repeat revascularization. Eighteen studies involving 11 686 patients were analysed. Compared with PCI, CABG had lower long-term mortality [hazard ratio (HR): 0.70, 95% confidence interval (CI): 0.61-0.80, P < 0.01], cardiovascular mortality (HR: 0.60, 95% CI: 0.43-0.85, P < 0.01), MI (HR: 0.51, 95% CI: 0.36-0.72, P < 0.01), and repeat revascularization (HR: 0.32, 95% CI: 0.23-0.47, P < 0.01) risk. Significant differences were not observed for long-term stroke (HR: 1.18, 95% CI: 0.74-1.87, P = 0.49), 30 day mortality (HR: 1.18, 95% CI: 0.89-1.56, P = 0.25), and MI (HR: 0.42, 95% CI: 0.16-1.11, P = 0.08) risk. CABG was associated with a higher risk of stroke within 30 days (HR: 2.88, 95% CI: 1.07-7.77, P = 0.04). In a subgroup analysis of propensity score-matched studies, CABG was associated with a higher long-term risk of stroke (HR: 1.61, 95% CI: 1.20-2.16, P < 0.01). CONCLUSIONS: Among patients with severely reduced LV ejection fraction, CABG resulted in a lower mortality rate and an increased risk of stroke.

Intraventricular muscle bundle as a novel cause of left ventricular aneurysm.

BACKGROUND: There are a variety of causes of left ventricular aneurysm, but it is rarely due to a disturbance in intraventricular hemodynamics. To the best of our knowledge, there have been no reports of ventricular aneurysm at the left ventricular apex caused by an abnormal left ventricular muscle bundle. CASE PRESENTATION: We report two cases of patients with congenital abnormal left ventricular muscle bundles which caused disturbances in intraventricular hemodynamics. This process eventually led to a left ventricular aneurysm at the apex of the heart. In both cases, transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) indicated ventricular aneurysm formation at the apex of the left ventricle. There were also abnormal muscular bundles connecting the ventricular septum and the posterior wall of the left ventricle. The only differences between these two cases were the comorbidities and severity of symptoms. CONCLUSION: Ventricular aneurysm at the apex of the left ventricle is common. However, it is rare for a ventricular aneurysm to form due to intraventricular hemodynamic disturbances caused by an abnormal muscle bundle as opposed to that due to original ventricular wall damage, which is more common. There is currently a lack of relevant studies on the treatment and prognosis of such patients. Whether surgical resection of a ventricular aneurysm leads to a better prognosis remains uncertain.

Post-Procedural Anticoagulation After Primary Percutaneous Coronary Intervention for Anterior Acute Myocardial Infarction With Severe Left Ventricular Dysfunction.

BACKGROUND: Patients with anterior acute myocardial infarction (AMI) and left ventricular (LV) dysfunction have an increased risk of LV thrombus (LVT). In the thrombolytic era, short-term anticoagulation using low-molecular-weight heparin during hospitalization proved to significantly reduce LVT formation, but, the effect of this prophylactic approach remains unclear in the current era. Therefore, we conducted a study to evaluate the effects of post-procedural anticoagulation (PPAC) using enoxaparin in addition to dual antiplatelet therapy (DAPT) after primary percutaneous coronary intervention (PCI) in such patients.Methods and Results:A total of 426 anterior AMI patients with LV ejection fraction ≤40% were retrospectively enrolled and classified into 2 groups based on whether they received PPAC (enoxaparin SC for at least 7 days). All patients received primary PCI and DAPT. The primary endpoint was definite LVT at 30 days diagnosed by echocardiography. The secondary endpoints were 30-day mortality, embolic events, and major bleeding events. PPAC was independently associated with a lower incidence of LVT (odds ratio 0.139, 95% confidence interval 0.032-0.606, P=0.009). The 30-day mortality, embolic events, and major bleeding events were not statistically different between groups. CONCLUSIONS: Short-term PPAC using enoxaparin after primary PCI may be an effective and safe way to prevent LVT in patients with anterior AMI and LV dysfunction.

Association between admission systolic blood pressure and major adverse cardiovascular events in patients with acute myocardial infarction.

BACKGROUND: Several studies have previously demonstrated that higher systolic blood pressure level means lower risk of adverse cardiovascular outcomes. However, there is a lack of further investigation into the nonlinear relationship between admission systolic blood pressure (SBP) and adverse outcomes of acute myocardial infarction (AMI) patients. OBJECTIVES: The aim of this study was to investigate the specific relationship between admission SBP and incidence of major adverse cardiovascular events (MACE) in 30 days for AMI patients. METHODS AND RESULTS: Using data from the ACS-QUIK trial, we analyzed 21,364 patients from Kerala, India. In univariate linear-regression model, the OR was 0.90 per 10mmHg, the confidence interval (CI) was 95% (0.87-0.92) and P < 0.0001. The generalized additive model (GAM) showed a nearly U-shaped curve between admission SBP and MACE. Using a two-piecewise linear regression model, we calculated an inflection point of 159 mmHg. We found that the higher admission SBP is associated with lower incidence of MACE of AMI patients. In addition, subgroups with different LVEF have distinct effects on blood pressure-related outcomes. Lower SBP has a greater risk when LVEF < 40%. CONCLUSION: The present study revealed the U-shaped relationship between admission SBP and the risk of adverse cardiovascular outcome. The admission SBP could be a marker to provide clinical assessment and treatment. TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02256657.

Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction.

BACKGROUND: Admission electrocardiographic (ECG) findings of non-ST-segment elevation myocardial infarction (NSTEMI) include transient ST-segment elevation (TSTE), ST-segment depression (STD), T-wave inversion (TWI), and no ischemic changes (NIC). HYPOTHESIS: This study aimed to assess the prognostic value of qualitative ECG findings at presentation and to clarify the influence of invasive treatment on the prognostic value of admission ECG findings. METHODS: We analyzed the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) study post hoc. NSTEMI patients were included and classified into four groups per ECG findings. Study endpoints were in-hospital and 30-day mortality rates and major adverse events (MAE). We performed multivariate logistic regression, adjusting for covariates in the Global Registry of Acute Coronary Events risk model, with subset analyses of patients treated with or without invasive management. RESULTS: STD patients had significantly higher in-hospital and 30-day mortality rates/MAE than TWI patients, which had lower in-hospital mortality rate/MAE than the NIC group. TSTE patients had intermediate outcomes. In multivariate logistic regression using the TWI group as the reference, STD and NIC remained independently associated with worse outcomes. Subset analysis showed prognostic value of admission ECG in non-invasively managed but not in invasively managed patients. CONCLUSIONS: STD was associated with adverse outcomes, TWI with benign prognoses. NIC should not be taken to indicate low risk. Qualitative analysis of admission ECG is suitable for rapid risk stratification of NSTMI patients at presentation. However, it may not be predictive of short-term outcomes of NSTEMI patients after invasive management.

The Brain-Heart Connection in Takotsubo Syndrome: The Central Nervous System, Sympathetic Nervous System, and Catecholamine Overload.

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is a type of acute heart failure syndrome triggered by intense psychological or physiological stress. TTS typically manifests as acute chest pain, dyspnea or syncope that mimics an acute myocardial infarction but does not involve coronary artery obstruction. The current understanding of the pathogenesis of TTS suggests that sympathetic nervous system (SNS) activation plays a central role. Specifically, stress can activate the SNS and lead to the over-release of catecholamine, which have toxic effects on myocardial tissue when present at excessive levels. However, the brain changes associated with TTS and the connection between the brain and the heart in patients with this disease remain unclear. In recent years, several published reports have revealed the role of this brain-heart connection in the pathogenesis of TTS. This review summarizes recent studies regarding SNS activation, catecholamine overload, and the brain-heart connection in patients with TTS from both pathophysiological and mechanistic aspects.

Waist circumference is associated with major adverse cardiovascular events in male but not female patients with type-2 diabetes mellitus.

BACKGROUND: Although studies have shown that waist circumference (WC) is positively associated with an increased risk of cardiovascular diseases among the normal population, few studies have investigated WC in patients with type-2 diabetes mellitus (T2DM). METHODS: This was a post hoc analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. The Cox proportional hazards models was used to investigate the relationship between WC and major adverse cardiovascular events (MACEs) in T2DM patients with cardiovascular disease (CVD) or high risk factors of CVD. RESULTS: A total of 10,251 T2DM patients (6299 men [61.4%], 3952 women [38.6%]) were included in our analysis. The mean age was 64.0 ± 7.53 years. After a mean follow-up at 9.2 ± 2.4 years later, 1804 patients (event rate of 23 per 1000 person-years) had developed MACEs. MACEs rates in men and women were 18.0 and 26.0 events per 1000 person-years, respectively. After multivariable adjustment, each increase in WC of 1 SD increased the risk of MACEs (HR: 1.10, 95% CI 1.04-1.17; P < 0.01) in men, with a non-significant increase in MACEs (HR: 1.04, 95% CI 0.95-1.13; P = 0.40) in women. Compared with those in the first quartile of WC, male patients in the fourth quartile of WC had a hazard ratio (HR) of 1.24 (95% CI 1.05-1.46) for MACEs; female patients in the fourth quartile of WC had an HR of 1.22 (95% CI 0.96-1.56) for MACEs. CONCLUSIONS: Higher WC is associated with increased risks of MACEs in male but not female T2DM patients. Trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000620).

The prognostic effect of left ventricular thrombus formation after acute myocardial infarction in the contemporary era of primary percutaneous coronary intervention: A meta-analysis.

BACKGROUNDS: The prognosis and management of left ventricular thrombus (LVT) following acute myocardial infarction (AMI) have not been well evaluated since the advent of primary percutaneous coronary intervention (PCI). We therefore conducted a meta-analysis to assess the prognostic effect of LVT after AMI in primary PCI era and investigate the impact of triple therapy on outcomes. METHODS: We searched MEDLINE, EMBASE and the Cochrane Library for studies conducted in primary PCI era up to 29 March 2019, compering the incidence of embolic events and mortality after AMI between LVT patients and Non-LVT patients. Random-effect models were used. Subgroup analysis was done by comparing triple therapy treated LVT group with Non-LVT group. RESULT: A total of 12 studies were included. LVT was associated with increased risk of embolic events and long-term mortality (RR 3.97, 95%CI 2.68-5.89, P < 0.0001; RR 2.34, 95%CI 1.38-3.96, P = 0.002). Subgroup analysis was also done by comparing triple therapy treated LVT group with Non-LVT group. Despite a downward tendency was observed, the embolic risk of triple therapy subgroup was higher than non-LVT group (RR 2.79, 95%CI 1.32-5.91, P = 0.007). Triple therapy subgroup had a similar mortality rate compared with non-LVT group (RR 0.93, 95%CI 0.34-2.52, P = 0.88). CONCLUSION: In primary PCI era, LVT formation after AMI indicated a fourfold increased embolic risk and twofold long-term mortality rate. Triple therapy may be a safe way to improve the outcomes, but still need to be confirmed by future trials.