Sex-related differences in ST-segment elevation myocardial infarction: A Portuguese multicenter national registry analysis.

INTRODUCTION AND OBJECTIVES: Sex differences among patients with acute myocardial infarctions remain a matter of debate. Inequalities in presentation, diagnosis, treatment, and prognosis are frequently observed, contributing to a worse prognosis in women. The aim of this study was to investigate sex-related differences in Portuguese ST-segment elevation myocardial infarction (STEMI) patients. METHODS: The authors conducted a retrospective analysis of STEMI patients included in the Portuguese Registry on Acute Coronary Syndromes, between October 2010 and 2022. The two co-primary endpoints were in-hospital and one-year mortality. RESULTS: A total of 14470 STEMI patients were studied. Women were underrepresented with 3721 individuals (25.7%). They were significantly older (70 vs. 62 years, p<0.001), with higher prevalence of cardiovascular risk factors, and underwent less frequently coronary angiography (84.4% vs. 88.5%, p<0.001) and guideline-directed medical therapy (e.g., aspirin 92.5% vs. 95.4%, beta blockers 79.2% vs. 83%, p<0.001). Furthermore, they experienced more complications, such as congestive heart failure (23.4% vs. 14.6%), ischemic stroke (47% vs. 40%), and in-hospital mortality (8.5% vs. 4.1%) (p<0.001 for all comparisons). Similarly, they presented higher one-year mortality (11.5% vs. 6.3%, p<0.001). However, after a multivariate analysis testing significant clinical variables, female sex remained an independent predictor for in-hospital (odds ratio=1.633; 95% CI [1.065-2.504]; p=0.025), but not for one-year mortality. CONCLUSIONS: This analysis reveals sex-related disparities in Portuguese STEMI patients. Despite limitations inherent to registry-based analysis, women were significantly older, with increased cardiovascular risk, less treated, and with higher in-hospital mortality. These disparities should be a concern for clinicians to further improve outcomes and move toward equitable medical care.

Post-infarction ventricular septal defect surgery in Portugal.

INTRODUCTION AND OBJECTIVE: We performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect (VSD) registry to further elucidate controversial areas of this clinical entity's surgical treatment. METHODS: A descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented. RESULTS: Median survival of the cohort (n=76) was 72 months (95% CI 4-144 months). Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction (log-rank p=0.036). Concomitant coronary artery bypass grafting (CABG), different closure techniques, location of the VSD, extracorporeal membrane oxygenation as bridge to closure, or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis. Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age (OR 1.08; 95% CI 1.01-1.15) and concomitant CABG (OR 0.23; 95% CI 0.06-0.90). CONCLUSIONS: Our results are comparable with previous reports regarding mortality, risk factors and concomitant procedures. Timing of surgery remains a controversial issue. Later closure seems to be advantageous, however, there is significant observational bias.

The protective effect of gamma aminobutyric acid B receptor activation on sympathetic nerve remodeling via the regulation of M2 macrophage polarization after myocardial infarction.

INTRODUCTION & OBJECTIVES: Acute myocardial infarction (AMI) in coronary heart disease is a leading cause of sudden death primarily due to malignant ventricular arrhythmias (VAs). Inflammatory cell infiltration and inflammation-induced overactivation of sympathetic nerves are the major cause of VAs in AMI pathophysiological processes. Type 2 macrophages play an anti-inflammatory role in AMI. Targeting macrophages may be a therapeutic strategy to prevent VAs post AMI. We found that gamma aminobutyric acid (GABA) promotes macrophages polarized to M2 and hypothesized that GABA might exert anti-inflammatory effects by promoting type 2 macrophage polarization in AMI. We aim to characterized GABAB receptor distribution, function, and mechanisms in M2 macrophage polarization and explored the functional aspect of GABAB receptor activation in sympathetic remodeling. RESULTS: Gamma aminobutyric acid B receptors were expressed on macrophage surface both in vitro and in vivo. GABAB receptor agonist baclofen, GABA promoted macrophage switch to M2. While GABAB receptor antagonist CGP52432 blocked a baclofen induced switch to M2 polarization. GABA and baclofen increased M2 macrophage percentage and CGP52432 blocked this process in vivo. Also, IL-10 and TGF-ß1 released by M2 were increased in both AMI and baclofen/AMI group; Serum NE levels were decreased by baclofen. All the above effects were reversed by CGP52432 treatment. Baclofen decreased TH and GAP-43 staining while CGP52432 enhanced their expression post AMI indicating GABAB receptor activation inhibited sympathetic nerve sprouting and activity by reducing NE release. CONCLUSIONS: Gamma aminobutyric acid B receptor activation promoted M2 polarization and protested AMI heart by regulating sympathetic nerve remodeling.

Long-term recurrent events in ST-elevation myocardial infarction and multivessel disease. The impact of different revascularization strategies.

INTRODUCTION: The benefit of complete revascularization (CR) on long-term total event reduction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), still remains unclear. We assessed the efficacy of three different revascularization strategies on long-term total recurrent events. METHODS: We retrospectively analyzed 414 consecutive patients admitted with STEMI and MVD who were categorized according to the revascularization strategy used: culprit-vessel-only percutaneous coronary intervention (PCI) (n=163); in-hospital CR (n=136); and delayed CR (n=115). The combined endpoint assessed was all-cause mortality, the total number of myocardial infarctions, ischemia-driven revascularizations or strokes. Negative binomial regression was used to assess the association between the revascularization strategy and total events; risk estimates were expressed as an incidence rates ratio (IRR). RESULTS: At a median follow-up of four years (1.2-6), rates of the combined endpoint per 10 patient-years were 18, 0.8, and 0.6 in culprit-vessel-only PCI, in-hospital CR, and delayed CR strategies, respectively (p<0.001). After multivariable adjustment and when compared with culprit-vessel-only PCI, both in-hospital and delayed CR strategies were significantly associated with a reduction in the combined endpoint (IRR=0.40: 95% confidence interval (CI), 0.25-0.64; p<0.001; and IRR 0.40: 95% CI, 0.24-0.62; p<0.001, respectively). No differences were observed across in-hospital and delayed CR strategies. CONCLUSIONS: Complete revascularization of non-culprit lesions in patients with STEMI and MVD reduces the risk of total recurrent events during long-term follow-up. No differences between in-hospital and delayed CR strategies were found.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction.

INTRODUCTION: Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min. OBJECTIVES: To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI. METHODS: We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017. RESULTS: Median DIDO time was 82 min (interquartile range, 61-132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062-1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011). CONCLUSION: A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes.

INTRODUCTION AND OBJECTIVES: Cardiogenic shock (CS) complicates 5-10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI). METHODS: Between October 2010 and December 2019, 27578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding. RESULTS: Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96-3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62-4.06), reinfarction (OR 0.77, 95% CI 0.15-3.90), or major bleeding (OR 1.68, 95% CI 0.75-3.74). CONCLUSION: The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes.

Rescue percutaneous repair of ischemic acute severe mitral regurgitation.

Acute severe mitral regurgitation (MR) because of secondary left ventricular impaired regional contractility can present with severe acute heart failure, associated with a high risk for rapid decompensation, pulmonary edema and cardiogenic shock. Frequently, in these highly unstable patients, surgical risk can be prohibitive. Evidence for percutaneous repair of acute MR is scarce, but a few case series show that this approach could be safe and effective for bailing out hemodynamically unstable patients. We report a case of an 84-year-old man with acute ischemic severe MR post-acute myocardial infarction (MI), who remained hemodynamically unstable despite coronary revascularization, positive pressure non-invasive ventilation, vasodilator therapy and intra-aortic balloon pump (IABP) support. In heart team discussions, he was considered a high risk surgical candidate. We decided on rescue off-label percutaneous mitral valve repair with a MitraClip device (Abbott Vascular, Santa Clara, California), with good clinical result, allowing weaning from the supports and discharge seven days after the procedure. At one-year follow-up, the patient maintained a MV repair results and had a good functional status. In unstable patients with acute ischemic MR, percutaneous MV repair could be a rescue therapeutic option to consider, allowing hemodynamic compensation with potential persistent MR improvement up to one-year follow-up.

Eficácia de um programa de enfermagem de reabilitação, à distância, para a pessoa pós enfarte agudo do miocárdio centrado na autogestão do exercício físico / Efficacy of a distance rehabilitation nursing program for people after acute myocardial infarction centered on self-management of physical exercise

Enquadramento: O Enfarte Agudo do Miocárdio é uma das, mais importantes, causas de diminuição da capacidade funcional e da qualidade de vida. A Reabilitação Cardíaca, sendo, uma das recomendações terapêuticas, não farmacológicas, e, com a componente central focada no exercício físico, é uma ferramenta essencial, possibilitando a redução das limitações físicas e psicológicas, fomentando a adoção de um estilo de vida saudável. O exercício físico é um componente dos programas de Enfermagem de reabilitação que pode ser implementado de forma preventiva ou reabilitadora por Enfermeiros Especialistas em Reabilitação. Objetivos: Avaliar a eficácia de um programa de enfermagem de reabilitação, à distância, para a pessoa pós enfarte agudo do miocárdio centrado na autogestão do exercício físico; na qualidade de vida; na capacidade funcional e na atividade física da pessoa pós Enfarte Agudo do Miocárdio. Metodologia: Desenvolveu-se um estudo quase experimental com uma amostra com 30 doentes numa unidade coronária intensiva de um hospital central em Portugal, organizados em grupo de controlo e experimental, 22 do sexo masculino e 8 do sexo feminino, com uma média de idades de 58,8 anos, sujeitos a um programa de reabilitação fase I, durante o internamento, aos quais foram aplicados: questionário sociodemográfico; IPAQ; EQ-5D-3L, Índice de Lawton-Brody e Índice de Barthel. Foi, também, entregue um folheto, onde constam os exercícios que fazem parte do treino de exercício físico a realizar no domicílio. Uma semana após a alta, foi realizada a intervenção específica de enfermagem de reabilitação dirigida ao grupo experimental, um follow-up telefónico, onde foram reforçados ensinos sobre o exercício físico. Um mês após alta, a todos os elementos da amostra, foram aplicados, todos os instrumentos do primeiro momento. Resultados: Confirma-se a hipótese 1, de que a intervenção melhora a atividade física. Quanto à hipótese 2, não existe evidência estatística da influência direta da intervenção sobre a qualidade de vida (p> 0,05). Apesar de não se observar a influência direta da intervenção, observa-se a presença de um efeito significativo da intervenção sobre a qualidade de vida através da atividade física, confirmando a hipótese 5 (p <0,05). Conclusão: O programa de intervenção revelou-se efetivo, potenciando a adesão ao exercício físico dos doentes pós enfarte agudo do miocárdio com substancial incremento da sua qualidade de vida. Verificando-se, desta forma, um impacto positivo na vida destes doentes.

Suboptimal control of cardiovascular risk factors in myocardial infarction survivors in a cardiac rehabilitation program.

INTRODUCTION AND OBJECTIVES: As short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program. METHODS: Observational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program). RESULTS: A total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p<0.001]. CONCLUSION: Despite contemporary management strategies, including enrollment in a structured EBCR program, a substantial number of patients presented suboptimal control of CV risk factors. Considering the dyslipidemia, hypertension and diabetes results, less than half of the enrolled individuals achieved the recommended targets. These findings highlight a pivotal unmet need which could be particularly relevant in improving CV outcomes by enhancing secondary prevention profiles.

Cadmium and cardiovascular disease: An overview of pathophysiology, epidemiology, therapy, and predictive value.

Cadmium is a widely distributed toxic heavy metal that has been associated with many diseases including chronic renal dysfunction, osteomalacia, acute heart failure, secondary hypertension, and atherosclerosis. Although several studies have suggested that cadmium may affect multiple systems by inducing lipid per oxidation in cells and disturbing the antioxidant system, the mechanism by which cadmium affects the cardiovascular system remains unclear. Recent studies on heart failure and acute myocardial infarction have shown that cadmium has good predictive ability for mortality in patients with cardiovascular disease. In this study, we briefly review the role of cadmium in cardiovascular disease, which may prompt further studies to investigate the potential association between cadmium and mortality in patients with cardiovascular disease.

Five years of Stent for Life in Portugal.

OBJECTIVE: To analyze changes in performance indicators five years after Portugal joined the Stent for Life (SFL) initiative. METHODS: National surveys were carried out annually over one-month periods designated as study Time Points between 2011 (Time Zero) and 2016 (Time Five). In this study, 1340 consecutive patients with suspected ST-elevation myocardial infarction (STEMI) who underwent coronary angiography, admitted to 18 24/7 primary percutaneous coronary intervention (PCI) centers, were enrolled. RESULTS: There was a significant reduction in the proportion of patients who attended primary healthcare centers (20.3% vs. 4.8%, p<0.001) and non-PCI-capable centers (54.5% vs. 42.5%, p=0.013). The proportions of patients who called 112, the national emergency medical services (EMS) number (35.2% vs. 46.6%, p=0.022) and of those transported via the EMS to a PCI-capable center (13.1% vs. 30.5%, p<0.001) increased. The main improvement observed in timings for revascularization was a trend toward a reduction in patient delay (114 min in 2011 vs. 100 min in 2016, p=0.050). System delay and door-to-balloon time remained constant, at a median of 134 and 57 min in 2016, respectively. CONCLUSION: During the lifetime of the SFL initiative in Portugal, there was a positive change in patient delay indicators, especially the lower proportion of patients who attended non-PCI centers, along with an increase in those who called 112. System delay did not change significantly over this period. These results should be taken into consideration in the current Stent - Save a Life initiative.

Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease - insights from a nationwide registry.

INTRODUCTION AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA. METHODS: The authors analyzed a cohort of patients from a multicenter national registry enrolling patients who suffered their first MI between 2010 and 2017, and underwent coronary angiography revealing absence of stenosis ≥50%. Individual antithrombotic therapy was identified. A logistic regression analysis was applied to search for predictors of DAPT. RESULTS: From a total of 16 237 patients analyzed, 709 (4.4%) were categorized as MINOCA. Mean age was 64±13 years, 46.3% (n=409) were females. 390 (55.0%) of MINOCA patients were discharged on DAPT. Males (OR 1.67, CI 95 [1.05-2.38], p=0.027), active smokers (OR=1.82, CI 95 [1.05-3.16], p=0.033), previous percutaneous intervention (OR 3.18, CI 95 [1.48-6.81], p=0.003), ST elevation MI (OR 2.70, CI 95 [1.59-4.76], p<0.001) and sinus rhythm at admission (OR=3.94, CI 95 [2.07-7.48], p<0.001) were independent predictors of DAPT use. CONCLUSION: In this nationwide registry, DAPT was prescribed at discharge in 55% of MINOCA patients. Beyond sinus rhythm, the variables presented as independent predictors for DAPT use identify subgroups of patients who are classified as more prone to thrombotic events. The issue of how to handle antithrombotic agents in MINOCA patients is a topic open for discussion.

P2Y12 inhibitor loading dose before catheterization in ST-segment elevation myocardial infarction: Is this the best strategy? / Dose de carga do inibidor P2Y12 antes do laboratório de hemodinâmica no enfarte agudo do miocárdio com supradesnivelamento do segmento ST ­ Será mesmo a melhor estratégia?

INTRODUCTION AND OBJECTIVES: In ST-segment elevation myocardial infarction (STEMI) the benefit of dual antiplatelet therapy is unequivocal, but the optimal time to administer the loading dose (LD) of a P2Y12 inhibitor is the subject of debate and disagreement. The main aim of this study was characterize current practice in Portugal and to assess the prognostic impact of P2Y12 inhibitor LD administration strategy, before versus during or after primary percutaneous coronary intervention (PCI). METHODS: This multicenter retrospective study based on the Portuguese National Registry on Acute Coronary Syndromes included patients with STEMI and PCI performed between October 1, 2010 and September 19, 2017. Two groups were established: LD before PCI (LD-PRE) and LD during or after PCI (LD-CATH). RESULTS: A total of 4123 patients were included, 66.3% in the LD-PRE group and 32.4% in the LD-CATH group. Prehospital use of a P2Y12 inhibitor was a predictor of the composite bleeding endpoint (major bleeding, need for transfusion or hemoglobin [Hb] drop >2g/dl), Hb drop >2g/dl and reinfarction. There were no differences between groups in major adverse events (MAE) (in-hospital mortality, reinfarction and stroke) or in-hospital mortality. CONCLUSIONS: Prehospital use of a P2Y12 inhibitor was associated with an increased risk of bleeding, predicting the composite bleeding outcome and Hb drop >2g/dl, with no differences in mortality or MAE, calling into question the benefit of this strategy.

Time to reperfusion in high-risk patients with myocardial infarction undergoing primary percutaneous coronary intervention.

INTRODUCTION: Timely reperfusion with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) improves patient outcomes. In recent years, the Stent for Life (SFL) initiative in Portugal developed an action plan to improve timely access to PPCI. This study aims to evaluate performance indicators in high-risk populations (elderly, female, and diabetic patients). METHODS: Data on 1340 patients with suspected STEMI who were admitted to 18 Portuguese interventional cardiology centers were collected during a one-month period every year from 2011 to 2016. The risk of longer patient and system delay in elderly, female, and diabetic patients was assessed by logistic regression analysis. RESULTS: Patient and system delays were longer in elderly patients (incremental median 32 and 40 min; p=0.001 and p<0.001, respectively). Median system delay was also longer in women (incremental median 25 min; p<0.001). Consequently, times to revascularization were longer in elderly patients (incremental median 92 min; p<0.001) and women (incremental median 67 min; p<0.001). There was no significant difference in reperfusion delay in diabetic patients. After adjustment for gender and diabetes, elderly age was an independent predictor of patient delay longer than the median (OR 1.64; 95% CI 1.22-2.20; p=0.001) and system delay >90 min (OR 2.95; 95% CI 1.84-4.72; p<0.001). CONCLUSION: Elderly patients showed longer patient and system delays, regardless of gender and presence of diabetes. These data suggest that the elderly subgroup should be the target of a new action by the SFL initiative.

Impact on mortality of direct admission versus interhospital transfer in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. / Impacto na mortalidade da admissão direta versus transferência inter­hospitalar nos doentes com enfarte agudo do miocárdio com elevação do segmento ST submetidos a intervenção coronária percutânea primária.

INTRODUCTION: In a primary percutaneous coronary intervention (PCI) program, interhospital transfer of patients with ST-elevation myocardial infarction (STEMI) can increase ischemic time, compared to patients who are admitted directly to a catheterization laboratory. OBJECTIVES: To assess the impact of interhospital transfer in patients with STEMI undergoing primary PCI, in terms of time to reperfusion and one-year mortality. METHODS: This was an observational, retrospective, longitudinal study of patients with STEMI admitted to Hospital de Braga between June 2011 and May 2016, who were treated successfully within 12 hours of symptom onset. A total of 1222 patients were included and divided into two groups according to admission to Hospital de Braga: direct or interhospital transfer. RESULTS: In this study, 37.0% (n=452) of the population were admitted directly to Hospital de Braga and 63.0% (n=770) were transferred from other hospitals. Although timings (in min) until reperfusion were longer in interhospital transfer patients (symptom onset-first medical contact (median 76.5, IQR 40.3-150 vs. 91.0, IQR 50-180, p=0.002), first medical contact-reperfusion (median 87.5, IQR 69.0-114 vs. 145, IQR 115-199, p<0.001) and symptom onset-reperfusion (median 177, IQR 125-265 vs. 265, IQR 188-400, p<0.001)), one-year mortality did not differ significantly between the groups (53 [11.7%] vs. 71 [9.2%], p=0.193). In multivariate analysis, age, symptom onset-reperfusion time and especially Killip class IV at admission (HR 11.2, 95% CI 6.35-19.8, p<0.001) were the main independent predictors of one-year mortality. CONCLUSION: Interhospital transfer of patients with STEMI increased the time before PCI. No differences were detected between groups in one-year mortality. This may be related to the fact that the direct admission group had twice as many patients in Killip class IV as the interhospital transfer group.

KAsH: A new tool to predict in-hospital mortality in patients with myocardial infarction.

INTRODUCTION: Complex risk scores have limited applicability in the assessment of patients with myocardial infarction (MI). In this work, the authors aimed to develop a simple to use clinical score to stratify the in-hospital mortality risk of patients with MI at first medical contact. METHODS: In this single-center prospective registry assessing 1504 consecutively admitted patients with MI, the strongest predictors of in-hospital mortality were selected through multivariate logistic regression. The KAsH score was developed according to the following formula: KAsH=(Killip class×Age×Heart rate)/systolic blood pressure. Its predictive power was compared to previously validated scores using the DeLong test. The score was categorized and further compared to the Killip classification. RESULTS: The KAsH score displayed excellent predictive power for in-hospital mortality, superior to other well-validated risk scores (AUC: KAsH 0.861 vs. GRACE 0.773, p<0.001) and robust in subgroup analysis. KAsH maintained its predictive capacity after adjustment for multiple confounding factors such as diabetes, heart failure, mechanical complications and bleeding (OR 1.004, 95% CI 1.001-1.008, p=0.012) and reclassified 81.5% of patients into a better risk category compared to the Killip classification. KAsH's categorization displayed excellent mortality discrimination (KAsH 1: 1.0%, KAsH 2: 8.1%, KAsH 3: 20.4%, KAsH 4: 55.2%) and better mortality prediction than the Killip classification (AUC: KAsH 0.839 vs. Killip 0.775, p<0.0001). CONCLUSION: KAsH, an easy to use score calculated at first medical contact with patients with MI, displays better predictive power for in-hospital mortality than existing scores.

Left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction and low-risk GRACE score: Prevalence, clinical outcomes and predictors.

INTRODUCTION: A low-risk GRACE score identifies patients with a lower incidence of major cardiac events, however it can erroneously classify patients with severe coronary artery disease as low-risk. We assessed the prevalence, clinical outcomes and predictors of left main and/or three-vessel disease (LM/3VD) in non-ST-elevation acute myocardial infarction (NSTEMI) patients with a GRACE score of ≤108 at admission. METHODS: Using data from the Portuguese Registry on Acute Coronary Syndromes, 1196 patients with NSTEMI and a GRACE score of ≤108 who underwent coronary angiography were studied. Independent predictors of LM/3VD and its impact on in-hospital complications and one-year mortality were retrospectively analyzed. RESULTS: LM/3VD was present in 18.2% of patients. Its prevalence was higher in males and associated with hypertension, diabetes, previous myocardial infarction, heart failure and peripheral arterial disease (PAD). Although there were no differences in in-hospital complications, these patients had higher mortality (0.9 vs. 0.0%) and more major adverse cardiac and cerebrovascular events (MACCE) (4.1 vs. 2.5%, p=0.172), and higher one-year mortality (2.4 vs. 0.5%, p=0.005). Independent predictors of LM/3VD were age (OR 1.03; 95% CI 1.01-1.0, p=0.003), male gender (OR 2.56; 95% CI 1.56-4.17, p<0.001), heart rate (1.02; 95% CI 1.01-1.03, p<0.001), PAD (OR 3.21; 95% CI 1.47-7.00, p<0.001) and heart failure (OR 3.38; 95% CI 1.02-11.15, p=0.046). CONCLUSIONS: LM/3VD was found in one in five patients. These patients had a tendency for higher in-hospital mortality and more MACCE, and higher one-year mortality. Simple clinical variables could help predict this severe coronary anatomy.

Left atrial volume index: Can it provide additional prognostic information in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention?

INTRODUCTION: We sought to assess the prognostic impact of left atrial (LA) size on long-term outcomes of ST-segment elevation myocardial infarction (STEMI). METHODS: We studied 200 consecutive patients admitted to a single center between January 2010 and December 2014 with non-fatal STEMI treated with primary percutaneous coronary intervention (pPCI) who underwent a comprehensive echocardiographic examination at discharge. LA volume was estimated by the area-length method. The left atrium was classified as normal, mildly, moderately or severely enlarged by LA volume index (LAVI). The endpoints were defined as all-cause mortality, a cardiac composite endpoint (all-cause mortality, reinfarction, unplanned revascularization and hospitalization for heart failure) and a cardiovascular composite endpoint (cardiac endpoint plus atrial fibrillation and ischemic stroke) during follow-up. RESULTS: In this STEMI population, 58% had normal LA size, 22.5% had mild LA enlargement, 10% had moderate LA enlargement and 9.5% had severe LA enlargement. During a median follow-up of 28 (IQR 21-38) months, 14 (7.0%) patients died, 53 (26.5%) had the cardiac and 58 (29%) the cardiovascular composite endpoints. There was a stepwise increase in the incidence of all-cause mortality (p=0.020) and both cardiac (p<0.001) and cardiovascular (p<0.001) endpoints with each increment of LAVI class. In multivariate analysis, severe LA enlargement by LAVI was an independent predictor of all-cause mortality (HR: 11.153; 95% CI: 1.924-64.642, p=0.007) and the cardiac (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) and cardiovascular (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) endpoints during follow-up. CONCLUSIONS: This contemporary study confirms the prognostic effect of LA size at discharge, applying the most recent reference values in STEMI patients treated with pPCI.

A literacia da pessoa com enfarte agudo do miocardio / The literacy of the person with acute myocardial infarction

O Enfarte Agudo do Miocárdio, de entre as doenças não transmissíveis, é a que mais influência sofre por parte de comportamentos e hábitos de vida diária. Fazer escolhas, e principalmente escolhas acertadas na área da saúde constitui-se como a pedra basilar no controlo desta patologia. Saber quais as capacidades reais do utente para fazer estas escolhas permite-nos, a nós, enfermeiros, como educadores, esclarecer e dotar os utentes desta capacidade crucial para o seu bem estar e qualidade de vida. Como tal, sentimos necessidade de analisar a literacia da pessoa que sofreu um enfarte agudo do miocárdio no domínio da saúde e que recorre às consultas neste centro hospitalar, qual a sua relação com as variáveis sociodemográficas e com a alteração dos estilo de vida. Trata-se de um estudo de natureza quantitativa, descritiva e correlacional em que foram aplicados questionários a utentes da consulta de Enfarte Agudo do Miocárdio, numa unidade da região centro de Portugal, totalizando 81 utentes. São maioritariamente homens, casados, com uma média de idade de 37 anos, reformados em que o nível de ensino se enquadra no ensino primário. 71% já tomava medicação previamente e como fatores de risco mais conhecidos da doença coronária referiram a obesidade, o colesterol, e o stress. 40,7% sabe que o hábito regular de exercício físico e uma alimentação cuidada contribuem muito para a prevenção desta patologia. Os resultados encontrados permitem afirmar que não há relação estatisticamente significativa entre a literacia e a idade, o sexo, o número de enfartes, o grau de adesão às mudanças nos hábitos de vida e o manuseamento do regime terapêutico e medicamentoso. Mas verificou-se relação estatisticamente significativa entre a literacia e as habilitações literárias, a área de residência, o conhecimento dos fatores de risco, o rendimento líquido mensal e o conhecimento do regime terapêutico e medicamentoso, no entanto, o que mais influencia a literacia é o conhecimento do regime terapêutico e medicamentoso e as habilitações literárias.

Myocardial infarction before and after the age of 45: Possible role of platelet receptor polymorphisms.

INTRODUCTION: We examined the potential role of polymorphisms of the platelet genes GP1BA (rs2243093, rs6065 and VNTR), ITGB3 (rs5918), ITGA2 (rs938043469) and P2RY12 (rs2046934, rs6801273 and rs6798347) as risk factors for myocardial infarction (MI). METHODS: The study population was divided into three groups: controls (n=235), MI at age ≤45 years (MI ≤45, n=44), and MI at age >45 years (MI >45, n=78). The control group was further divided into two subgroups (control ≤45 and >45), and subgroups including only men were also considered for statistical analysis. Polymorphisms were detected by polymerase chain reaction and restriction fragment length polymorphism analysis. RESULTS: Regarding non-genetic risk factors, the control group differed statistically from the MI ≤45 group (p<00.5) in terms of smoking, hypertension, diabetes and obesity, and from the MI >45 group (p<0.05) in terms of hypertension, diabetes, obesity, family history of thrombosis and high cholesterol. For the studied ITGA2 polymorphism, a statistical difference was found when MI >45 was compared with the control group, with a higher risk of MI in the TT genotype (OR 2.852; 95% CI: 1.092-7.451; p=0.032). In the GP1BA rs6065 polymorphism, a statistically significant difference was found between control ≤45 only men and MI ≤45 only men, with a higher risk in the CT genotype (OR 5.568; 95% CI: 1.421-21.822; p=0.016), despite the low numbers included. The other polymorphisms studied did not show any statistically significant correlations. CONCLUSION: There is a statistically significant association between the TT genotype of the ITGA2 rs938043469 polymorphism and increased risk for MI >45.