Whole-exome sequencing in individuals with multiple cardiovascular risk factors and normal coronary arteries.

OBJECTIVES: Most studies on the genes involved in coronary artery disease (CAD) targeted individuals with angiographically or clinically proven CAD. Focusing on high-risk individuals with normal coronary arteries (NCA) may offer novel insights into the pathogenesis of CAD. We aimed to identify genes putatively protective for development of CAD. METHODS: Pooled whole-exome sequencing (WES) was performed on 17 patients with multiple cardiovascular risk factors and NCA and on 17 controls with multivessel CAD. Rare NCA-unique sequence variants were subsequently individually validated using the Fluidigm platform in 100 additional CAD controls and 100 general population controls. RESULTS: In total, 555 100 variants were detected in at least one WES pool in the study group and in none of the control WES pools. For second phase validation, we focused on rare, nonsynonymous variants, resulting in a total of 144 variants in 40 genes, of which 96 were selected for subsequent genotyping. Validation phase genotyping resulted in 19 variants in 16 genes that were found in the NCA group and in none of the CAD controls. The SPTBN5, NID2, and ADAMTSL4 genes harbored sequence variants in more than one CAD-protected patient and none of the 117 CAD controls. CONCLUSION: Applying WES technology and focusing on individuals seemingly protected from developing CAD successfully identified 19 variants that may offer protection from CAD by undetermined mechanisms. Studying the genetics of high-risk individuals apparently protected from CAD may provide novel insights into the pathogenesis of CAD.

Acute Stress Disorder Symptoms Predict All-Cause Mortality Among Myocardial Infarction Patients: a 15-Year Longitudinal Study.

BACKGROUND: Studies have recognized myocardial infarction (MI) as a risk for acute stress disorder (ASD), manifested in dissociative, intrusive, avoidant, and hyperarousal symptoms during hospitalization. PURPOSE: This study examined the prognostic role of ASD symptoms in predicting all-cause mortality in MI patients over a period of 15 years. METHODS: One hundred and ninety-three MI patients filled out questionnaires assessing ASD symptoms during hospitalization. Risk factors and cardiac prognostic measures were collected from patients' hospital records. All-cause mortality was longitudinally assessed, with an endpoint of 15 years after the MI. RESULTS: Of the participants, 21.8 % died during the follow-up period. The decedents had reported higher levels of ASD symptoms during hospitalization than had the survivors, but this effect became nonsignificant when adjusting for age, sex, education, left ventricular ejection fraction, and depression. A series of analyses conducted on each of the ASD symptom clusters separately indicated that-after adjusting for age, sex, education, left ventricular ejection fraction, and depression-dissociative symptoms significantly predicted all-cause mortality, indicating that the higher the level of in-hospital dissociative symptoms, the shorter the MI patients' survival time. CONCLUSION: These findings suggest that in-hospital dissociative symptoms should be considered in the risk stratification of MI patients.

Expediting Time from Symptoms to Medical Contact Utilizing a Telemedicine Call Center.

BACKGROUND: No definitive solution has been forthcoming for the often dangerously long interval between symptom onset and seeking medical care in the prehospital setting. We examined the implementation of telemedicine technology and characterization of its utilizers for its efficacy in reducing this possibly life-threatening time lag. MATERIALS AND METHODS: A retrospective observational study was performed on the working database of an operational telemedicine facility that included all subscribers. Time-to-contact measurements throughout 2012 were retrieved from its medical files, and data on age, gender, medical history, and main complaint were analyzed. RESULTS: Throughout 2012, 22,274 of a total of 46,556 calls (47.8%) were made ≤60 min from symptom onset. It is important that 26.9% of all calls (12,522/46,556) were made in <15 min. Significantly more males (10,794/22,229 [49%]) contacted in ≤60 min compared with females (11,480/24,327 [47%], p<0.03). Subjects <60 years of age (2,889/5,717 [51%]) called earlier than those >60 years (19,386/40,839 [47%], p<0.001). Patients with prior resuscitation and/or myocardial infarction contacted significantly more rapidly than those with other cardiac diseases. Over one-half of patients with cardiac complaints contacted the call center ≤60 min from symptom onset, as did those who suffered physical trauma, but not patients with gastrointestinal symptoms or pain elsewhere. CONCLUSIONS: A telemedicine system with rapid accessibility to a professional call center and prompt triage thereafter could be an additional promising strategy for shortening the interval between symptom onset and call for medical assistance. Implementation of a widespread telemedicine infrastructure may bridge the unmet gap between occurrence of symptoms to initiation of medical treatment.

Admission Glucose Levels and the Risk of Acute Kidney Injury in Nondiabetic ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Hyperglycemia upon admission is associated with an increased risk for acute kidney injury (AKI) in ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). However, the relation of this association to the absence of diabetes mellitus (DM) is less studied. We evaluated the effect of acute hyperglycemia levels on the risk of AKI among STEMI patients without DM who were all treated with primary PCI. METHODS: We retrospectively studied 1,065 nondiabetic STEMI patients undergoing primary PCI. Patients were stratified according to admission glucose levels into normal (<140 mg/dl), mild (140-200 mg/dl), and severe (>200 mg/dl) hyperglycemia groups. Medical records were reviewed for the occurrence of AKI. RESULTS: The mean age was 61 ± 13 years and 81% were males. Hyperglycemia upon hospital admission was present in 402 of 1,065 patients (38%). Patients with severe admission hyperglycemia had a significantly higher rate of AKI compared to patients with no or mild hyperglycemia (20 vs. 7 and 8%, respectively; p = 0.001) and had a significantly greater serum creatinine change throughout hospitalization (0.17 vs. 0.09 and 0.07 mg/dl, respectively; p = 0.04). In multivariate logistic regression, severe hyperglycemia emerged as an independent predictor of AKI (OR = 2.46, 95% CI 1.16-5.28; p = 0.018). CONCLUSION: Severe admission hyperglycemia is an independent risk factor for the development of AKI among nondiabetic STEMI patients undergoing primary PCI.

High Degree Atrioventricular Block Complicating Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: Incidence, Predictors and Outcomes.

BACKGROUND: In the era of primary percutaneous coronary intervention (PPCI), information on the incidence and prognostic significance of high degree atrioventricular block (AVB) in ST elevation myocardial infarction (STEMI) patients is limited. OBJECTIVES: To assess the incidence, time of onset, predictors and prognostic significance of high degree AVB in a large cohort of consecutive STEMI patients undergoing PPCI. METHODS: We retrospectively studied 1244 consecutive STEMI patients undergoing PPCI. Patient records were reviewed for the presence of high degree AVB, its time of occurrence and relation to in-hospital complications, as well as long-term mortality over a 5 year period. RESULTS: High degree AVB was present in 33 patients (3.0%), in 25 (76%) of whom the conduction disorder occurred prior to PPCI. Twelve patients (36%) required temporary pacing, all prior to or during coronary intervention, and all AVB resolved spontaneously before hospital discharge. AVB was associated with a significantly higher 30 day (15% vs. 2.0%, P = 0.001) and long-term mortality rate (30% vs. 6.0%, P < 0.001). Time of AVB had no effect on mortality. In a multivariate regression model, AVB emerged as an independent predictor for long-term mortality (hazard ratio 2.8, 95% confidence interval 1.20-6.44, P = 0.001). CONCLUSIONS: High degree AVB remains a significant prognostic marker in STEMI patients in the PPCI era, albeit transient.

Acute Cardio-Renal Syndrome as a Cause for Renal Deterioration Among Myocardial Infarction Patients Treated With Primary Percutaneous Intervention.

BACKGROUND: Early hemodynamic impairment frequently complicates myocardial injury, however, limited data are present regarding its direct association with acute kidney injury (AKI) after ST segment elevation myocardial infarction (STEMI) in patients who undergo primary percutaneous coronary intervention (PCI). We evaluated the effect of acute hemodynamic derangement on the risk of AKI among STEMI patients who undergo primary PCI. METHODS: We performed a retrospective analysis of 1656 consecutive patients admitted with the diagnosis of STEMI between January 2008 and December 2014, and treated with primary PCI. Medical records were reviewed for the presence of various clinical parameters of hemodynamic derangement and for the occurrence of AKI. RESULTS: Mean age was 61 ± 13 and 1329 (80%) were men. AKI occurred in 168 patients (10%). Patients with AKI were older, of female sex, with more comorbidities, had longer time to reperfusion, and were more likely to have hemodynamic impairment including critical state, congestive heart failure, life-threatening arrhythmias, and worse left ventricular function (P < 0.001 for all). In a multivariate logistic regression model critical state (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.39-7.8; P = 0.006), reduced left ventricular ejection fraction (OR, 0.95; 95% CI, 0.92-0.99; P = 0.03), congestive heart failure (OR, 2.34; 95% CI, 1.02-5.39; P = 0.04), and a trend for time to coronary reperfusion (OR, 1.01; 95% CI, 1.00-1.01; P = 0.07) emerged as independent predictors of AKI. CONCLUSIONS: Among STEMI patients who underwent primary PCI AKI should not be assumed to be solely contrast-induced nephropathy and acute hemodynamic abnormalities should be considered.

Gender-related mortality and in-hospital complications following ST-segment elevation myocardial infarction: data from a primary percutaneous coronary intervention cohort.

BACKGROUND: The increased mortality related to female gender in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) has been reported from various patient cohorts and treatment strategies with controversial results. In the present work, we evaluated the impact of female gender on mortality and in-hospital complications among a specific subset of consecutive STEMI patients managed solely by PPCI. HYPOTHESIS: Female gender is not an independent predicor for mortality among STEMI patients. METHODS: We performed a retrospective, single-center observational study that included 1346 consecutive STEMI patients undergoing PPCI, of which 1075 (80%) were male. Patient's records were evaluated for 30-day mortality, in-hospital complications, and long-term mortality over a mean period of 2.7 ± 1.6 years. RESULTS: Compared with males, females were older (69 ± 13 vs 60 ± 13 years, P < 0.001), had a significantly higher rate of baseline risk factors, and had prolonged symptom duration (460 ± 815 minutes vs 367 ± 596 minutes, P = 0.03). Females suffered from more in-hospital complications and had higher 30-day mortality (5% vs 2%, P = 0.008) as well as higher overall mortality (12.5% vs 6%, P < 0.001). In spite of the significant mortality risk in unadjusted models, a multivariate adjusted Cox regression model did not demonstrate that female gender was an independent predictor for mortality among STEMI patients. CONCLUSIONS: Among patients with STEMI treated by PPCI, female gender is associated with a higher 30-day mortality and complications rates compared to males. Following multivariate analysis, female gender was not a significant predictor of long-term death following STEMI.

Relation of in-hospital serum creatinine change patterns and outcomes among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

BACKGROUND: The worsening of serum creatinine (sCr) level is a frequent finding among ST-segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short-term and long-term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels. HYPOTHESIS: Reversible renal impairment prior to PCI is not associated with adverse outcomes. METHODS: We retrospectively studied 1260 STEMI patients undergoing primary PCI. The incidence of in-hospital complications and long-term mortality was compared between patients having stable, worsened (>0.3 mg/dL increase), or improved (>0.3 mg/dL decrease) sCr levels throughout hospitalization. RESULTS: Overall, 127 patients (10%) had worsening in sCr levels, whereas 44 (3.5%) had an improvement of sCr compared with admission levels. Patients with worsening sCR had more complications during hospitalization, higher 30-day (13% vs 1%; P < 0.001) and up to 5-year all-cause mortality (28% vs 5%; P < 0.001) compared with those with stable sCR. No significant difference was found regarding complications and mortality between patients having an improvement in sCr and stable sCr. Compared with patients with stable sCr, the adjusted hazard ratio for all-cause mortality in patients with worsened sCr was 6.68 (95% confidence interval: 2.1-21.6, P = 0.002). CONCLUSIONS: In STEMI patients undergoing primary PCI, renal impairment prior to PCI is a frequent finding. In contrast to post-PCI sCr worsening, this entity is not associated with adverse short-term and long-term outcomes.

Temporal trends in management and outcome of diabetic and non-diabetic patients with acute coronary syndrome (ACS): residual risk of long-term mortality persists: Insights from the ACS Israeli Survey (ACSIS) 2000-2010.

BACKGROUND/OBJECTIVES: In the past diabetes was strongly associated with elevated mortality rate after acute coronary syndrome (ACS). Over the past decade a treatment of the ACS has evolved rapidly with major advances in the management techniques. The aim of the present study was to compare temporal trends of the outcomes of diabetic vs. non-diabetic patients using nationwide data. METHODS: We evaluated time-dependent changes in the clinical characteristics, management strategies, and outcomes of diabetic and non-diabetic patients enrolled in the biannual ACS Israeli Surveys (ACSIS) between 2000 and 2010. We divided the survey into early (2000-2005) vs. late (2006-2010) periods. RESULTS: There were 3964 diabetic and 7322 non-diabetic patients, a total of 11,472 ACS patients. Although diabetic patients were significantly younger, they displayed more advanced coronary artery disease and considerably higher rates of all-cause mortality at 30 days and 1-year. Both diabetic and non-diabetic patients who were enrolled in the late survey period received more evidence-based therapies (primary PCI, guideline-based medications) and experienced a better 1-year survival probability (respectively 88% vs. 84% and 93% vs. 90%; all p-values<0.01). Multivariate analysis demonstrated that diabetes and early survey period were each independently associated with a significantly increased mortality risk (respectively 39% and 25%, p<0.001 for both). CONCLUSION: Our data suggest that despite the overall improvement in the management and outcomes of the ACS, diabetic patients are still at increased residual risk of long-term mortality that needs to be further addressed.

Association of left ventricular function and acute kidney injury among ST-elevation myocardial infarction patients treated by primary percutaneous intervention.

Acute kidney injury (AKI) is a common complication among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and it is associated with poor long-term clinical outcomes. No studies have yet evaluated the association between cardiac function and the risk of AKI in this patient population. We conducted a retrospective study of consecutive 386 patients with STEMI who underwent primary PCI and had a full echocardiography study performed within 72 hours of hospital admission from June 2011 to December 2013. AKI was defined as an increase of ≥0.3 mg/dl in serum creatinine within 48 hours after admission. Thirty-four patients (9.7%) developed AKI. Echocardiography demonstrated that patients with AKI had significantly lower systolic ejection fraction (EF; 48% ± 8% vs 41% ± 10%, p <0.001), lower septal (p = 0.001) and lateral (p = 0.01) e' velocities, higher average E/e' ratio (p = 0.006), elevated systolic pulmonary artery pressure (p <0.001), and higher right atrial pressure (p = 0.001). In multivariate regression analysis, left ventricular EF emerged as an independent predictor of AKI (odds ratio 1.1, 95% confidence interval 0.86 to 0.96; p = 0.001) for every 1% reduction in EF. In conclusion, among patients with STEMI undergoing primary PCI, left ventricular EF is a strong and independent predictor of AKI.

Association of admission hemoglobin levels and acute kidney injury among myocardial infarction patients treated with primary percutaneous intervention.

BACKGROUND: Anemia on admission is associated with an increased risk for contrast-induced nephropathy, however, its association with acute kidney injury (AKI) after ST segment elevation myocardial infarction (STEMI) in patients undergoing primary percutaneous coronary intervention (PPCI) has not been studied. Our aim was to evaluate whether admission hemoglobin levels might increase the risk of AKI among STEMI patients who undergo PPCI. METHODS: We performed a retrospective analysis of 1248 consecutive patients admitted with the diagnosis of STEMI between January 2008 and January 2014, and treated with PPCI. Patient medical records were reviewed for admission hemoglobin levels and for the occurrence of AKI. RESULTS: The mean age of patients was 61 ± 13 years and 1009 (81%) were male. AKI occurred in 115 patients (9.2%). Patients with AKI were more likely to be older, female, with more comorbidities, had longer symptom duration, and more likely to be in a critical state. Patients with AKI had significantly lower admission hemoglobin levels (13.6 ± 1.7 g/dL vs 14.4 ± 1.5 g/dL; P < 0.001) and were more likely to be anemic (27% vs 12%; P < 0.001). In a multivariate logistic regression model, a lower admission hemoglobin level (odds ratio, 0.86; 95% confidence interval, 0.74-0.98; P = 0.04) and the presence of anemia on admission (odds ratio, 1.76; 95% confidence interval, 1.02-3.02; P = 0.04) emerged as independent predictors of AKI. CONCLUSIONS: Among STEMI patients who underwent PPCI, a lower admission level of hemoglobin and anemia (hemoglobin < 12 in women or < 13 in men) were independent predictors of AKI. Precautions to prevent AKI should be particularly considered in anemic patients.

High sensitive C-reactive protein and the risk of acute kidney injury among ST elevation myocardial infarction patients undergoing primary percutaneous intervention.

BACKGROUND: Elevated periprocedural high sensitive C-reactive protein (hs-CRP) was shown to be associated with an increased risk for acute kidney injury (AKI) in non-myocardial infarction (MI) patients undergoing percutaneous coronary intervention (PCI), however, no information to date is present regarding its predicting role for AKI in MI patients. We evaluated whether admission serum hs-CRP levels may predict risk of AKI among ST elevation MI (STEMI) patients undergoing primary PCI. METHODS: Five hundred and sixty-two patients that were admitted with STEMI and treated with primary PCI were included in the study. Serum hs-CRP levels were determined from blood samples taken prior to PCI. Patients' medical records were reviewed for occurrence of AKI, in-hospital complications and 30 days mortality. RESULTS: Mean age was 62 ± 16 and 455 (80 %) were males. Patients were divided into two groups, according to their admission hs-CRP values: group 1: hs-CRP ≤9 mg/l (n = 394) and group 2: hs-CRP >9 mg/l (n = 168). Patients with hs-CRP >9 mg/l had significantly higher rate of AKI following PCI (17 vs. 6 %; p < 0.001), more in-hospital complications and higher30 -day mortality rate (11 vs. 1 %; p = 0.02). In a multivariable logistic regression model admission hs-CRP level >9 mg/l was an independent predictor for AKI (OR 2.7, 95 % CI: 1.39-5.29; p = 0.001) and a strong trend for 30 day mortality (OR 4.27, 95 % CI: 0.875-21.10; p = 0.07). CONCLUSION: Admission serum hs-CRP level >9 mg/l is an independent predictor for AKI following primary PCI in STEMI patients.

Incidence and mortality of acute kidney injury in acute myocardial infarction patients: a comparison between AKIN and RIFLE criteria.

PURPOSE: Acute kidney injury (AKI) is associated with adverse outcomes after acute ST elevation myocardial infarction (STEMI). The recently proposed AKI network (AKIN) suggested modifications to the consensus classification system for AKI known as the risk, injury, failure, loss, end-stage (RIFLE) criteria. The aim of the current study was to compare the incidence and mortality (early and late) of AKI diagnosed by RIFLE and AKIN criteria in the STEMI patients undergoing primary percutaneous intervention (PCI). METHODS: We retrospectively studied 1,033 consecutive STEMI patients undergoing primary PCI. Recruited patients were admitted between January 2008 and November 2012 to the cardiac intensive care unit with the diagnosis of acute STEMI. We compared the utilization of RIFLE and AKIN criteria for the diagnosis, classification, and prediction of mortality. RESULTS: The AKIN criteria allowed the identification of more patients as having AKI (9.6 vs. 3.9 %, p < 0.001) and classified more patients with stage 1 (risk in RIFLE) (7.6 vs. 1.9 %, p < 0.001) compared with the RIFLE criteria. Mortality was higher in AKI population defined by either RIFLE (46.3 vs. 6.8 %, OR 11.9, 95 % CI 6.15-23.1; p < 0.001) or AKIN (29 vs. 6.1 %; OR 6.3, 95 % CI 3.8-10.4; p < 0.001) criteria. In a multivariable logistic regression model, AKI defined with both RIFLE and AKIN was an independent predictor of both 30-day and up to 5-year all-cause mortality. However, there was no significant statistical difference in the risk provided by these two scoring systems. CONCLUSIONS: AKIN criteria are more sensitive in defining AKI compared with the RIFLE criteria in STEMI. However, no difference exists in the mortality risk provided by these two scoring systems.

Relation of time to coronary reperfusion and the development of acute kidney injury after ST-segment elevation myocardial infarction.

Time to coronary reperfusion and acute kidney injury (AKI) are powerful prognostic markers in patients with ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI); however, no information to date is present regarding the association between time to reperfusion and AKI. We evaluated whether time to reperfusion predicts the risk of developing AKI in patients with STEMI who underwent primary PCI. Medical records of 417 patients admitted to our department from January 2008 to July 2013, for STEMI, and treated with primary PCI were reviewed. Patients were stratified by time to coronary reperfusion tertiles, and their records were assessed for the occurrence of AKI after PCI. Mean age was 61 ± 13 years, and 346 patients (83%) were men. The cut-off points for the time to reperfusion tertiles were <120, 120 to 300, and >300 minutes. Patients having longer time to reperfusion had significantly more AKI complicating the course of STEMI (3% vs 11% vs 13%, p = 0.007) and had significantly higher serum creatinine change throughout hospitalization (0.13 vs 0.18 vs 0.21 mg/dl, p = 0.003). In a multivariable regression model, time to coronary reperfusion emerged as an independent predictor of AKI and to the maximal change in serum creatinine. In conclusion, longer time to coronary reperfusion is an independent risk factor for the development of AKI in patients with STEMI who underwent primary PCI.

Temporal trends in all-cause mortality of smokers versus non-smokers hospitalized with ST-segment elevation myocardial infarction.

BACKGROUND/OBJECTIVES: Over the past decade, the development of novel management strategies has resulted in improved outcomes among patients hospitalized with ST-segment myocardial infarction (STEMI). The aim of the present study was to compare temporal trends in the mortality of smokers versus non-smokers admitted with STEMI in a real world setting between 2000 and 2010. METHODS: We evaluated time-dependent changes in the clinical characteristics, management strategies, and one year all-cause mortality of STEMI patients who were enrolled in the biannual Acute Coronary Syndrome Israeli Survey (ACSIS) between 2000 and 2010, categorized as smokers (n=2399) and non-smokers (n=3069). We divided the survey periods into early (2000-2004) and late (2006-2010). The primary endpoint of the study was the occurrence of one-year all-cause mortality. RESULTS: A total of 4564 STEMI patients were enrolled in the study. Compared with non-smokers, smokers were significantly younger and displayed a significantly lower rate of all-cause mortality at 30 days and 1-year. Both smokers and non-smokers who were enrolled in the late survey period received more evidence-based therapies (primary PCI and guideline-based medications) (p<0.001 for all). There was a significant reduction in the risk of 1-year all-cause mortality only among non-smokers (HR=0.664 CI 95% 0.52-0.85, p=0.0009), whereas smokers who were enrolled in more recent survey periods did not display a significant risk reduction (HR=1.08 CI 95% 0.77-1.51, p=0.67). CONCLUSION: Survival following STEMI among smokers has not improved over the past decade despite corresponding changes in management strategies. Future trials should focus on reducing the risk in smokers.

Is telemedicine an answer to reducing 30-day readmission rates post-acute myocardial infarction?

BACKGROUND: Patients hospitalized for an acute myocardial infarction (AMI) are at risk for early readmission. Readmission rates in the community reportedly reach approximately 20%, and 30-day readmission rates have become a quality-of-care marker. Telemedicine is one strategy for improving clinical outcomes by offering real-time biometrics tracking and rapid intervention. We retrospectively assessed the 30-day readmission rate of post-AMI members of a telemedicine system. MATERIALS AND METHODS: All "SHL"-Telemedicine subscribers who sustained an AMI and those who became subscribers within 10 days from discharge post-AMI between 2009 and 2012 were assessed. Their files were reviewed for demographics, coronary risk factors, reasons for readmission, and discharge diagnoses. RESULTS: In total, 897 suitable patients (mean age, 62±14 years; 81% males) were included. They had made 3,318 calls to the monitor center for consultation. A mobile intensive care unit was dispatched for 158 patients, 64 were transported to the hospital, and 52 (5.8%) were readmitted (10 patients were readmitted twice). Thirty-five readmissions were for noncardiac reasons. Twelve patients had acute coronary syndrome (11 were revascularized). Readmission rates were higher in patients with repeat AMIs (11.9% versus 5.3% among those with no AMI history) and in females (9.6% versus 4.9% among males). Unlike published figures for the general population, there were no significant differences between readmitted and non-readmitted patients regarding diabetes, hypertension, or congestive heart failure. CONCLUSIONS: Telemedicine technology shows considerable promise for reducing 30-day readmission rates of post-AMI patients.

Comparison of left ventricular function following first ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention in men versus women.

Previous data reported worse outcomes in female patients after acute ST elevation myocardial infarction (STEMI), related at least in part to less aggressive and nonparallel treatment. We investigated the presence of gender differences in left ventricular (LV) systolic and diastolic function in patients presenting with first STEMI, treated with primary percutaneous coronary intervention (PCI). Study population included 187 consecutive patients (81% men) presenting with STEMI and treated by primary PCI and guideline-based medications. Their mean age was 58 ± 10 years. All patients underwent a comprehensive echocardiographic evaluation within 3 days of admission. Female patients were older (62 ± 11 vs 59 ± 10 years, p = 0.006), with more co-morbidities and longer symptom duration (490 ± 436 vs 365 ± 437 minutes, p = 0.013). Echocardiography demonstrated that female patients had significantly lower LV systolic function (47 ± 8% vs 45 ± 8%, p = 0.03), lower septal and lateral e' velocities, higher average E/e' ratio (all p <0.001), elevated systolic pulmonary artery pressure (p = 0.03), and worse diastolic dysfunction (p = 0.007). No significant changes were present in left atrial volumes. In a logistic multivariate analysis model, female gender emerged as an independent predictor of septal e' <8 cm/s (odds ratio 10.11, 95% confidence interval 1.23 to 82.32, p = 0.002) and E/average e' ratio >15 (odds ratio 6.47, 95% confidence interval 1.63 to 25.61, p = 0.008). In conclusion, female patients undergoing primary PCI for first STEMI demonstrated worse systolic and diastolic LV function, despite receiving similar treatment as male patients.

Renal impairment according to acute kidney injury network criteria among ST elevation myocardial infarction patients undergoing primary percutaneous intervention: a retrospective observational study.

OBJECTIVE: Conflicting data exists regarding the frequency and significance of acute kidney injury (AKI) in ST segment elevation MI (STEMI) patients. The acute kidney injury network (AKIN) classification has been shown to predict mortality in various critically ill patients; however, limited information is available regarding its use and its clinical relevance among STEMI patients. STUDY DESIGN AND METHODS: We retrospectively studied 1,033 STEMI patients undergoing primary percutaneous intervention (PCI). AKI was identified on the basis of the changes in serum creatinine during hospitalization according to the AKIN criteria. Patients were assessed for in-hospital adverse outcomes as well as all-cause mortality up to 5 years. RESULTS: Overall, 100 patients (9.6 %) developed AKI: 79 patients (79 %) had stage 1, 14 patients (14 %) developed stage 2, and 7 patients (7 %) developed stage 3 AKI. Patients with AKI had more complications during hospitalization, with higher 30 days (11 vs 1 %; p < 0.001) and 5-year all-cause mortality (29 vs 6 %; p < 0.001) compared to those without AKI. The adjusted risk of death increased proportionally to AKI severity. Compared to patients with no AKI, the adjusted hazard ratio for all-cause mortality was 6.68 (95 % confidence interval: 2.1-21.6, p = 0.002) in patients with AKI. Age, hypertension, chronic kidney injury and low left ventricular ejection fraction were independent predictors of developing AKI. CONCLUSION: In STEMI patients undergoing primary PCI, AKI assessed by AKIN criteria is a frequent complication, associated with an increased risk of both short- and long-term mortality.

Lower admission hemoglobin levels are associated with longer symptom duration in acute ST-elevation myocardial infarction.

BACKGROUND: An acute-phase response in patients with acute myocardial infarction could contribute to the development of anemia. HYPOTHESIS: An association may exist between symptom duration, hemoglobin (Hb) concentration and serum C-reactive protein (CRP) values in patients presenting to an emergency department (ED) with acute ST-segment elevation myocardial infarction (STEMI). METHODS: A retrospective analysis was conducted on consecutive male STEMI patients who were admitted to our medical center's ED from January 2008 to November 2012 and had presented within the first 12 hours after the onset of chest pain. Hemoglobin concentration and serum CRP levels were determined from blood samples taken prior to any drug or fluid administration. Analyses of variance were used to determine interactions between selected time-to-presentation cutoffs and admission Hb and CRP concentrations. Patients with other reasons known to cause elevation of inflammatory markers, anemia, or bleeding diathesis were excluded. RESULTS: The study population comprised 718 patients whose mean age was 61 ± 12 years (range, 27-96 years). Blood was drawn for Hb and CRP measurements directly upon admission. Patients who presented to the ED within 3 hours of symptom onset had higher Hb concentrations (P = 0.048) and lower serum CRP levels (P < 0.001) compared with those who presented after a longer interval from symptom onset. CONCLUSIONS: Longer symptom duration is associated with a lower admission Hb level and an early rise in the CRP level of male patients with acute STEMI.