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Searcy R, Patel R, Drossopoulos P, Arora S, Stouffer GA. Rural-urban disparity in survival and use of PCI in patients who develop STEMI while hospitalized for a non-cardiac condition. Curr Probl Cardiol 2025; 50:102979. [PMID: 39800089 DOI: 10.1016/j.cpcardiol.2025.102979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 01/06/2025] [Indexed: 01/15/2025]
Abstract
BACKGROUND The development of ST-segment elevation myocardial infarction (STEMI) in patients hospitalized for non-cardiac indications carries a high mortality rate. OBJECTIVES Determine the impact of rural vs. urban hospital location and hospital percutaneous coronary intervention (PCI) volumes on clinical outcomes. METHODS The New York Statewide Planning and Research Cooperative System database was queried for STEMI claims from 2011 to 2018. The 2010 Rural-Urban Commuting Area classification scheme was used to stratify hospitals as urban or rural. RESULTS 64960 STEMI patients were identified from 231 hospitals with 2880 (4.4%) being classified as inpatient STEMI (IPS). IPS patients were older (73.5 ± 13.3 years vs 64.6 ± 14.2 years; p < .0001) and more frequently female (49.3% vs 33.1%; p < .0001), had more comorbidities, were less likely to receive PCI (13.1% vs 69.4%; p < .0001), and had higher 1-year mortality (59.6% vs 16.4%; p < .0001) than outpatient STEMI (OPS). IPS that occurred in rural hospitals were less often treated with PCI (3.8% vs 13.8%; p < 0.01) and had higher one-year mortality (68.6% vs 58.9%; p < 0.01) than those occurring in urban hospitals. Similar results were observed when hospitals were divided into rural vs suburban vs urban based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Patients with IPS admitted to low-volume PCI centers were significantly less likely to receive PCI and had higher one-year mortality, after adjustment for demographics and comorbidities, compared to those admitted to high-volume PCI centers. CONCLUSIONS IPS treated at rural hospitals and/or low-volume PCI centers were less likely to be treated with PCI and had higher one-year mortality rates. UNSTRUCTURED ABSTRACT The development of ST-Segment Elevation Myocardial Infarction (STEMI) in patients hospitalized for non-cardiac indications carries a high mortality rate. Using a large retrospective cohort study, we investigated the impact of hospital location and PCI volume on outcomes in inpatient STEMI (IPS). Patients with IPS were generally older, more frequently female, and had more comorbidities than those with outpatient STEMI. After adjustment for demographics and comorbidities, those with IPS admitted to rural and/or low-volume PCI centers were less likely to receive PCI and experienced higher one-year mortality rates.
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Affiliation(s)
- Ryan Searcy
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Rajiv Patel
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Drossopoulos
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Sameer Arora
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA.
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Roguin AL, Birati EY, Kobo OM. The Effect of Iodinated Contrast Media Sensitivity on the Prognosis of Patients with STEMI. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:973. [PMID: 38929590 PMCID: PMC11205422 DOI: 10.3390/medicina60060973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Iodinated Contrast Media (ICM) is used daily in many imaging departments worldwide. The main risk associated with ICM is hypersensitivity. When a severe hypersensitivity reaction is not properly managed and treated swiftly, it may be fatal. Currently, there is no data to demonstrate how ICM sensitivity affects the prognosis of cardiac patients, especially those diagnosed with ST elevation myocardial infarction (STEMI), in whom urgent coronary angiography is indicated. This study aimed to identify and characterize this relationship. Materials and Methods: We included patients hospitalized with STEMI between 2016 and 2019 from the National Inpatient Sample. The population was compared based on ICM sensitivity status, sensitive vs. non-sensitive. The primary endpoint was in-hospital mortality, with additional endpoints: length of stay and in-hospital complications. Results: The study included 664,620 STEMI patients, of whom 4905 (0.7%) were diagnosed with ICM sensitivity. ICM-sensitive patients were older, more often white, females, and had more comorbidities and cardiovascular risk factors. Both groups show similarities in management but are slightly less probable to undergo PCI or CABG. Multivariable logistic regression models found that the ICM-sensitive population had similar odds of in-hospital mortality (OR: 1.02, 95% CI: 0.89-1.16) and MACCE (OR: 1.05, 95% CI: 0.95-1.16), and less major bleeding (OR: 0.73, 95% CI: 0.60-0.87). Conclusions: Our study found that ICM sensitivity status was not a significant factor for worse prognosis in patients hospitalized with STEMI.
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Affiliation(s)
- Alon L. Roguin
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel; (A.L.R.); (E.Y.B.)
| | - Edo Y. Birati
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel; (A.L.R.); (E.Y.B.)
- The Kittner-Davidai Division of Cardiovascular Medicine and Surgery, Tzafon Medical Center, Ramat Gan 5290002, Israel
| | - Ofer M. Kobo
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, Hadera 38100, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel
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Ratwatte S, Ng ACC, Hyun K, Philip R, Boroumand F, Weber C, Kritharides L, Brieger D. Pre-hospital and in-hospital ST-elevation myocardial infarction from 2008 to 2020 in Australia. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 19:200214. [PMID: 37771608 PMCID: PMC10522901 DOI: 10.1016/j.ijcrp.2023.200214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Austin Chin Chwan Ng
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Karice Hyun
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Robin Philip
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Farzaneh Boroumand
- School of Mathematical and Physical Sciences, Macquarie University, NSW, Australia
| | - Courtney Weber
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
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Sethi R, Mohan L, Vishwakarma P, Singh A, Sharma S, Bhandari M, Shukla A, Sharma A, Chaudhary G, Pradhan A, Chandra S, Narain VS, Dwivedi SK. Feasibility and efficacy of delayed pharmacoinvasive therapy for ST-elevation myocardial infarction. World J Cardiol 2023; 15:23-32. [PMID: 36714366 PMCID: PMC9850672 DOI: 10.4330/wjc.v15.i1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) refers to a clinical syndrome that features symptoms of myocardial ischemia with consequent ST-elevation on electrocardiography and an associated rise in cardiac biomarkers. Rapid restoration of brisk flow in the coronary vasculature is critical in reducing mortality and morbidity. In patients with STEMI who could not receive primary percutaneous coronary intervention (PCI) on time, pharmacoinvasive strategy (thrombolysis followed by timely PCI within 3-24 h of its initiation) is an effective option. AIM To analyze the role of delayed pharmacoinvasive strategy in the window period of 24-72 h after thrombolysis. METHODS This was a physician-initiated, single-center prospective registry between January 2017 and July 2017 which enrolled 337 acute STEMI patients with partially occluded coronary arteries. Patients received routine pharmacoinvasive therapy (PCI within 3-24 h of thrombolysis) in one group and delayed pharmacoinvasive therapy (PCI within 24-72 h of thrombolysis) in another group. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) within 30 d of the procedure. The secondary endpoints included major bleeding as defined by Bleeding Academic Research Consortium classification, angina, and dyspnea within 30 d. RESULTS The mean age in the two groups was comparable (55.1 ± 10.1 years vs 54.2 ± 10.5 years, P = 0.426). Diabetes was present among 20.2% and 22.1% of patients in the routine and delayed groups, respectively. Smoking rate was 54.6% and 55.8% in the routine and delayed groups, respectively. Thrombolysis was initiated within 6 h of onset of symptoms in both groups (P = 0.125). The mean time from thrombolysis to PCI in the routine and delayed groups was 16.9 ± 5.3 h and 44.1 ± 14.7 h, respectively. No significant difference was found for the occurrence of measured clinical outcomes in the two groups within 30 d (8.7% vs 12.9%, P = 0.152). Univariate analysis of demographic characteristics and risk factors for patients who reported MACCE in the two groups did not demonstrate any significant correlation. Secondary endpoints such as angina, dyspnea, and major bleeding were non-significantly different between the two groups. CONCLUSION Delayed PCI pharmacoinvasive strategy in a critical diseased but not completely occluded artery beyond 24 h in patients who have been timely thrombolyzed seems a reasonable strategy.
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Affiliation(s)
- Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Lalit Mohan
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Pravesh Vishwakarma
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Abhishek Singh
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Swati Sharma
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Ayush Shukla
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Akhil Sharma
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Gaurav Chaudhary
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Sharad Chandra
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Varun Shankar Narain
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Sudhanshu Kumar Dwivedi
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
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Frydman S, Freund O, Banai A, Zornitzki L, Banai S, Shacham Y. Relation of Gender to the Occurrence of AKI in STEMI Patients. J Clin Med 2022; 11:6565. [PMID: 36362793 PMCID: PMC9655780 DOI: 10.3390/jcm11216565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Patients undergoing percutaneous coronary interventions (PCIs) are prone to a wide range of complications; one complication that is constantly correlated with a worse prognosis is acute kidney injury (AKI). Gender as an independent risk factor for said complications has raised some interest; however, studies have shown conflicting results so far. We aimed to investigate the possible relation of gender to the occurrence of AKI in STEMI patients undergoing PCI. This retrospective observational study cohort included 2967 consecutive patients admitted with STEMI between the years 2008 and 2019. Their renal outcomes were assessed according to KDIGO criteria (AKI serum creatinine ≥ 0.3 mg/dL from baseline within 48 h from admission), and in-hospital complications and mortality were reviewed. Our main results show that female patients were older (69 vs. 60, p < 0.001) and had higher rates of diabetes (29.2% vs. 23%, p < 0.001), hypertension (62.9% vs. 41.3%, p < 0.001), and chronic kidney disease (26.7% vs. 19.3%, p < 0.001). Females also had a higher rate of AKI (12.7% vs. 7.8%, p < 0.001), and among patients with AKI, severe AKI was also more prevalent in females (26.1% vs. 14.5%, p = 0.03). However, in multivariate analyses, after adjusting for the baseline characteristics above, the female gender was a non-significant predictor for AKI (adjusted OR 1.01, 95% CI 0.73−1.4, p = 0.94) or severe AKI (adjusted OR 1.65, 95% CI 0.80−1.65, p = 0.18). In conclusion, while females had higher rates of AKI and severe AKI, gender was not independently associated with AKI after adjusting for other confounding variables. Other comorbidities that are more prevalent in females can account for the difference in AKI between genders.
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Affiliation(s)
- Shir Frydman
- Correspondence: ; Tel.: +972-3-6973395; Fax: +972-3-6962334
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Stehli J, Dinh D, Dagan M, Dick R, Oxley S, Brennan A, Lefkovits J, Duffy SJ, Zaman S. Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction. Clin Cardiol 2022; 45:427-434. [PMID: 35253228 PMCID: PMC9019891 DOI: 10.1002/clc.23797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients. METHODS Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models. RESULTS A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13). CONCLUSIONS In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.
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Affiliation(s)
- Julia Stehli
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Epworth HealthCareRichmondVictoriaAustralia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Misha Dagan
- Department of General MedicineThe Alfred HospitalMelbourneVictoriaAustralia
| | - Ron Dick
- Epworth HealthCareRichmondVictoriaAustralia
| | | | - Angela Brennan
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Jeffrey Lefkovits
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Stephen J. Duffy
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Sarah Zaman
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
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Stehli J, Dagan M, Dinh DT, Lefkovits J, Dick R, Oxley S, Brennan AL, Duffy SJ, Zaman S. Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis. BMJ Open 2022; 12:e052000. [PMID: 35256441 PMCID: PMC8905957 DOI: 10.1136/bmjopen-2021-052000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI. DESIGN, SETTING AND PARTICIPANTS Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018). PRIMARY AND SECONDARY OUTCOMES Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding. RESULTS Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001). CONCLUSIONS Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.
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Affiliation(s)
- Julia Stehli
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Misha Dagan
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ron Dick
- Epworth HealthCare, Richmond, Victoria, Australia
| | | | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Stephen J Duffy
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sarah Zaman
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIctoria, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
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Caughey MC, Arora S, Qamar A, Chunawala Z, Gupta MD, Gupta P, Vaduganathan M, Pandey A, Dai X, Smith SC, Matsushita K. Trends, Management, and Outcomes of Acute Myocardial Infarction Hospitalizations With In-Hospital-Onset Versus Out-of-Hospital Onset: The ARIC Study. J Am Heart Assoc 2021; 10:e018414. [PMID: 33399008 PMCID: PMC7955301 DOI: 10.1161/jaha.120.018414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
Background Acute myocardial infarction (AMI) with in-hospital onset (AMI-IHO) has poor prognosis but is clinically underappreciated. Whether its occurrence has changed over time is uncertain. Methods and Results Since 1987, the ARIC (Atherosclerosis Risk in Communities) study has conducted adjudicated surveillance of AMI hospitalizations in 4 US communities. Our analysis was limited to patients aged 35 to 74 years with symptomatic AMI. Patients with symptoms initiating after hospital arrival were considered AMI-IHO. A total of 26 678 weighted hospitalizations (14 276 unweighted hospitalizations) for symptomatic AMI were identified from 1995 to 2014, with 1137 (4%) classified as in-hospital onset. The population incidence rate of AMI-IHO increased in the 4 ARIC communities from 1995 through 2004 to 2005 through 2014 (12.7-16.9 events per 100 000 people; P for 20-year trend <0.0001), as did the proportion of AMI hospitalizations with in-hospital onset (3.7%-6.1%; P for 20-year trend =0.03). The 10-year proportions were stable for patients aged 35 to 64 years (3.0%-3.4%; P for 20-year trend =0.3) but increased for patients aged ≥65 years (4.6%-7.8%; P for 20-year trend =0.008; P for interaction by age group =0.04). AMI-IHO had a more severe clinical course with lower use of AMI therapies or invasive strategies and higher in-hospital (7% versus 3%), 28-day (19% versus 5%), and 1-year (29% versus 12%) mortality (P<0.0001 for all). Conclusions In this population-based community surveillance, AMI-IHO increased from 2005 to 2014, particularly among older patients. Quality initiatives to improve recognition and management of AMI-IHO should be especially focused on hospitalized patients aged >65.
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Affiliation(s)
- Melissa C. Caughey
- Joint Department of Biomedical EngineeringUniversity of North Carolina and North Carolina State UniversityNC
| | - Sameer Arora
- Division of CardiologyUniversity of North Carolina School of MedicineNC
| | - Arman Qamar
- Section of Interventional Cardiology & Vascular MedicineNorthShore University Health System, University of Chicago Pritzker School of MedicineEvanstonIL
| | | | - Mohit D. Gupta
- Department of CardiologyGobind Ballabh Pant Institute of Postgraduate Medical EducationNew DelhiIndia
| | - Puneet Gupta
- Department of CardiologyJanakpuri Super Specialty HospitalNew DelhiIndia
| | | | - Ambarish Pandey
- Division of CardiologyUniversity of Texas SouthwesternDallasTX
| | - Xuming Dai
- Division of CardiologyLang Research CenterNew York Presbyterian Queens HospitalFlushingNY
| | - Sidney C. Smith
- Division of CardiologyUniversity of North Carolina School of MedicineNC
| | - Kunihiro Matsushita
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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9
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Shahandeh N, Dai X, Jaski B, Dave R, Jacobs A, Denktas A, Levine G, Markovic D, Smith SC, Press MC. Mortality differences among patients with in-hospital ST-elevation myocardial infarction. Clin Cardiol 2020; 43:1555-1561. [PMID: 33159461 PMCID: PMC7724232 DOI: 10.1002/clc.23480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In-hospital ST-elevation myocardial infarction (STEMI) is associated with a higher mortality rate than out-of-hospital STEMI. Quality measures and universal protocols for treatment of in-hospital STEMI do not exist, likely contributing to delays in recognition and treatment. HYPOTHESIS To analyze differences in mortality among three subsets of patients who develop in-hospital STEMI. METHODS This was a multicenter, retrospective observational study of patients who developed in-hospital STEMI at six United States medical centers between 2008 and 2017. Patients were stratified into three groups: (1) cardiac, (2) periprocedure, or (3) noncardiac/nonpostprocedure. Outcomes examined include time from electrocardiogram (ECG) acquisition to cardiac catheterization lab arrival (ECG-to-CCL) and survival to discharge. RESULTS We identified 184 patients with in-hospital STEMI (mean age 68.7 years, 58.7% male). Group 1 (cardiac) patients had a shorter average ECG-to-CCL time (69 minutes) than group 2 (periprocedure, 215 minutes) and group 3 (noncardiac/nonpostprocedure, 199 minutes). Compared to group 1, survival to discharge was lower for group 2 (OR 0.33, P = .102) and group 3 (OR 0.20, P = .016). After adjusting for prespecified covariates, the relationship between group and survival showed a similar trend but did not reach statistical significance. CONCLUSIONS Patients who develop in-hospital STEMI in the context of a preceding procedure or noncardiac illness appear to have longer reperfusion times and higher in-hospital mortality than patients admitted with cardiac diagnoses. Larger studies are warranted to further investigate these observations. Health systems should place an increased emphasis on developing quality metrics and implementing quality improvement initiatives to improve outcomes for in-hospital STEMI.
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Affiliation(s)
| | - Xuming Dai
- University of North CarolinaChapel HillNorth CarolinaUSA
| | - Brian Jaski
- Sharp Memorial Hospital San DiegoSan DiegoCaliforniaUSA
| | - Ravi Dave
- University of California Los AngelesLos AngelesCaliforniaUSA
| | - Alice Jacobs
- Boston University Medical CenterBostonMassachusettsUSA
| | - Ali Denktas
- The Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Baylor College of MedicineHoustonTexasUSA
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Bisogni V, Cerasari A, Pucci G, Vaudo G. Matrix Metalloproteinases and Hypertension-Mediated Organ Damage: Current Insights. Integr Blood Press Control 2020; 13:157-169. [PMID: 33173330 PMCID: PMC7646380 DOI: 10.2147/ibpc.s223341] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/12/2020] [Indexed: 12/16/2022] Open
Abstract
Matrix metalloproteinases (MMPs) are important extracellular enzymes involved in many physiological and pathological processes. Changes in the activity and concentration of specific MMPs, as well as the unbalance with their inhibitors (tissue inhibitors of metalloproteinases – TIMPs), have been described as a part of the pathogenic cascade promoted by arterial hypertension. MMPs are able to degrade various protein substrates in the extracellular matrix, to influence endothelial cells function, vascular smooth muscle cells migration, proliferation and contraction, and to stimulate cardiomyocytes changes. All these processes can be activated by chronically elevated blood pressure values. Animal and human studies demonstrated the key function of MMPs in the pathogenesis of hypertension-mediated vascular, cardiac, and renal damage, besides age and blood pressure values. Thus, the role of MMPs as biomarkers of hypertension-mediated organ damage and potential pharmacological treatment targets to prevent further cardiovascular and renal complications in hypertensive population is increasingly supported. In this review, we aimed to describe the main scientific evidence about the behavior of MMPs in the development of vascular, cardiac, and renal damage in hypertensive patients.
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Affiliation(s)
- Valeria Bisogni
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy
| | - Alberto Cerasari
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy.,Department of Medicine, University of Perugia, Perugia, Italy
| | - Giacomo Pucci
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy.,Department of Medicine, University of Perugia, Perugia, Italy
| | - Gaetano Vaudo
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy.,Department of Medicine, University of Perugia, Perugia, Italy
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11
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Levine GN, Dai X, Henry TD, Calfon Press M, Denktas AE, Garberich RF, Jacobs AK, Jaski BE, Kaul P, Kontos MC, Stouffer GA, Smith SC. In-Hospital ST-Segment Elevation Myocardial Infarction: Improving Diagnosis, Triage, and Treatment. JAMA Cardiol 2019; 3:527-531. [PMID: 29466558 DOI: 10.1001/jamacardio.2017.5356] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI. Observations Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care. Conclusions and Relevance Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.
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Affiliation(s)
| | - Xuming Dai
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | | | - Marcella Calfon Press
- Cardiology Division, Department of Medicine, Ronald Reagan Medical Center, University of California, Los Angeles in Westwood
| | | | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Brian E Jaski
- San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California
| | | | | | - George A Stouffer
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | - Sidney C Smith
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
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12
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Abstract
Matrix metalloproteinases (MMPs) and their endogenous inhibitors have been studied in the myocardium for the past 2 decades. An incomplete knowledge base and experimental design issues with inhibitors have hampered attempts at translation, but clinical interest remains high because of strong associations between MMPs and outcomes after myocardial infarction (MI) as well as mechanistic studies showing MMP involvement at multiple stages of the MI wound-healing process. This Review focuses on how our understanding of MMPs has evolved from a one-dimensional early focus on measuring MMP activity, monitoring MMP:inhibitor ratios, and evaluating one MMP-substrate pair to the current use of systems biology approaches to integrate the whole MMP repertoire of roles in the left ventricular response to MI. MMP9 is used as an example MMP to explain these concepts and to provide a template for examining MMPs as mechanistic mediators of cardiac remodelling.
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Affiliation(s)
- Merry L Lindsey
- Mississippi Center for Heart Research, Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA. .,Research Service,, G.V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, MS, USA.
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13
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Lykov YV, Dyatlov NV, Morozova TE, Dvoretsky LI. [In-hospital Myocardial Infarction: Scale of the Problem]. KARDIOLOGIIA 2019; 59:52-60. [PMID: 31322090 DOI: 10.18087/cardio.2019.7.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
All cases of acute myocardial infarction (AMI) can be divided into outpatient-onset AMI and in-hospital-onset AMI depending on the place and circumstances of their development. In this review we consider the problem of in-hospital AMI. Special attention is paid to specific features of its clinical manifestations and the scale of the clinical problem. Possible causes of difficulties in the diagnosis and treatment of this condition are presented in comparison with those in patients with outpatient-onset AMI.
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Affiliation(s)
- Yu V Lykov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N V Dyatlov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T E Morozova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - L I Dvoretsky
- Sechenov First Moscow State Medical University (Sechenov University)
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14
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Yan F, Liu H, Jiang W. Prevalence and associated factors of mortality after percutaneous coronary intervention for adult patients with ST elevation myocardial infarction: A systematic review and meta-analysis protocol. Medicine (Baltimore) 2019; 98:e16226. [PMID: 31261578 PMCID: PMC6617472 DOI: 10.1097/md.0000000000016226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The percutaneous coronary intervention (PCI) has been one of the fastest growing therapeutic interventions for patients with ST elevation myocardial infarction (STEMI). However, the mortality of patients with STEMI after PCI is uncertain currently. There is a paucity of systematic review on the associated factors of mortality among patients with STEMI after PCI. Therefore, this meta-analysis was designed to synthesize available evidence on the prevalence and associated factors of mortality after PCI for adult patients with STEMI. METHODS Both case-control and cohort studies reporting on mortality after PCI for patients with STEMI, published in Chinese and English will be eligible for inclusion. Studies from 12 databases covering the period from 2008 to present will be considered for systematic searches. Two reviewers will independently screen and select studies, extract data, and assess methodologic quality. When available, meta-analysis will be performed. Pooled proportions of mortality, and proportions in the exposed and unexposed groups, and population attributable fraction of each factor will be calculated by a suitable transformation of proportions. If necessary, meta-regression models, subgroup analysis, sensitivity analysis, funnel plot, and Egger test will be performed. Narrative synthesis will be done where meta-analysis cannot be performed. Reporting of this protocol will comply with the preferred reporting items for systematic review and meta-analyses (PRISMA-P) guidelines. RESULTS This systematic review will be developed according to the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. CONCLUSION This study will provide a comprehensive review on the available evidence regarding the prevalence and associated factors of mortality for patients with STEMI following PCI. This review will be constrained by the divergence of definition and assessment of specific factors between studies. However, the development of a qualitative description of definition and assessment tools will also provide an overview of the current practice. Formal ethical approval is not required since the secondary data will be collected for systematic review. The findings will be disseminated in a relevant peer-reviewed journal and academic presentations. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017070969.
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Affiliation(s)
- Fanghong Yan
- Xi’an Jiaotong University Health Science Center, Shaanxi Province
- Lanzhou University, School of Nursing, Gansu Province, China
| | - Huan Liu
- Xi’an Jiaotong University Health Science Center, Shaanxi Province
| | - Wenhui Jiang
- Xi’an Jiaotong University Health Science Center, Shaanxi Province
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15
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Tahir K, Pauley E, Dai X, Smith SC, Sweeney C, Stouffer GA. Mechanisms of ST Elevation Myocardial Infarction in Patients Hospitalized for Noncardiac Conditions. Am J Cardiol 2019; 123:1393-1398. [PMID: 30773247 DOI: 10.1016/j.amjcard.2019.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
ST elevation myocardial infarction (STEMI) occurring in patients hospitalized for a noncardiac condition is associated with a high mortality rate and thus we sought to determine the mechanisms underlying STEMI in this patient population. This is a single center retrospective study of 70 patients who had STEMI while hospitalized on a noncardiac service and underwent coronary angiography. Thrombotic in-hospital STEMI was defined by angiographic or intravascular imaging evidence of intracoronary thrombus, plaque rupture, or stent thrombosis. Thirty-six (51%) inpatient STEMIs developed in the operating room or various postoperative stages and 6 (9%) after endoscopy or a percutaneous procedure. Thrombotic etiologies were found in 39 (56%) patients. Nonthrombotic etiologies included vasospasm, supply-demand mismatch, and takotsubo cardiomyopathy. Patients in the thrombotic group were more likely to have antiplatelet medications discontinued on admission, had higher peak troponin levels and were more likely to undergo percutaneous coronary intervention than patients in the nonthrombotic group. Exposure to vasopressors, time from ECG to angiography, post-STEMI ejection fraction, length of stay, and in-hospital mortality were similar in both groups. There was no difference in the use of percutaneous coronary intervention in patients but longer ECG to coronary angiography times and fivefold higher in-hospital mortality in thrombotic inpatient STEMI compared with 643 patients who presented with an out-of-hospital STEMI during the same time period. In conclusion, thrombotic and nonthrombotic mechanisms cause STEMI in hospitalized patients and are associated with a high mortality.
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Affiliation(s)
- Khola Tahir
- Division of Cardiology University of North Carolina, Chapel Hill, North Carolina
| | - Eric Pauley
- Division of Cardiology University of North Carolina, Chapel Hill, North Carolina
| | - Xuming Dai
- Division of Cardiology, New York-Presbyterian Medical Group-Queens, New York, New York
| | - Sidney C Smith
- Division of Cardiology University of North Carolina, Chapel Hill, North Carolina
| | - Craig Sweeney
- Division of Cardiology University of North Carolina, Chapel Hill, North Carolina
| | - George A Stouffer
- Division of Cardiology University of North Carolina, Chapel Hill, North Carolina; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina.
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16
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Sustained nicorandil administration reduces the infarct size in ST-segment elevation myocardial infarction patients with primary percutaneous coronary intervention. Anatol J Cardiol 2019; 21:163-171. [PMID: 30821716 PMCID: PMC6457402 DOI: 10.14744/anatoljcardiol.2018.57383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: Currently, there is still no effective strategy to diminish the infarct size (IS) in patients with ST-segment elevation myocardial infarction (STEMI). According to a previous animal study, nicorandil treatment is a promising pharmaceutical treatment to limit the infarct area. In this study, we aim to investigate the effects of continual nicorandil administration on the IS and the clinical outcomes in patients with STEMI who underwent primary percutaneous coronary intervention (pPCI). Methods: One hundred seventeen patients with STEMI and undergoing pPCI were randomly divided into the sustained nicorandil group (5 mg, three times daily) or the control group (only single nicorandil before PCI). The primary endpoint was the IS, evaluated by single-photon emission computed tomography (SPECT) 3 months after pPCI. Results: Eighty-five patients completed the IS assessment via SPECT, and 99 participants were available for follow-up after 6 months. Finally, there was a statistical difference in the IS between the nicorandil and control groups {13% [interquartile range (IQR), 8–17] versus 16% [IQR, 12–20.3], p=0.027}. Additionally, we observed that maintained nicorandil administration significantly improved the left ventricular ejection fraction at 3 months and enhanced the activity tolerance (physical limitation and angina stability) at 6 months after PCI. Conclusion: Sustained nicorandil treatment reduced the IS and improved the clinical outcomes compared to the single nicorandil administration for patients with STEMI undergoing the pPCI procedure. Continuous cardioprotective therapy may be more beneficial for patients with STEMI.
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17
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Patel N, Baker SM, Paterick TE, Tajik AJ. The de Winter Variation: Anterior ST-Elevation Myocardial Infarction. Am J Med 2017; 130:288-289. [PMID: 27913100 DOI: 10.1016/j.amjmed.2016.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Nachiket Patel
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville.
| | | | - Timothy E Paterick
- Methodist Cardiovascular Consultants, Methodist Health System, Dallas, Tex
| | - A Jamil Tajik
- Cardiac Specialty Centers, Aurora Health Care, Milwaukee, Wisc
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18
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Dai X, Garberich RF, Jaski BE, Smith SC, Henry TD. In-Hospital ST Elevation Myocardial Infarction: Clinical Characteristics, Management Challenges, and Outcome. Interv Cardiol Clin 2016; 5:471-480. [PMID: 28581996 DOI: 10.1016/j.iccl.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Timely reperfusion therapy reduces complications and improves survival in ST elevation myocardial infarction (STEMI). An effective chain of survival has been established for STEMIs occur in the community (outpatient STEMI). Recent studies have identified a subgroup of patients who develop STEMI while hospitalized for primary conditions, often not directly related to coronary artery disease (in-hospital STEMI or inpatient STEMI). This article summarizes current understanding of patient demographics, clinical characteristics, care delivery system and outcomes of in-hospital STEMI, comparing with outpatient STEMI. We also identified opportunities for quality improvement and proposed strategies and future directions to improve care for these patients.
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Affiliation(s)
- Xuming Dai
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA.
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA
| | - Brian E Jaski
- San Diego Cardiac Center, Sharp Healthcare, 3131 Berger Avenue, San Diego, CA 92123, USA
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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