scholarly journals Type 2 Myocardial Infarction: Evolving Approaches to Diagnosis and Risk-Stratification

2020 ◽  
Author(s):  
Andrew R Chapman ◽  
Yader Sandoval
Keyword(s):  
Myocardial Infarction ◽  
Clinical Practice ◽  
Myocardial Ischemia ◽  
Risk Stratification ◽  
Myocardial Injury ◽  
Oxygen Supply ◽  
Scoring Systems ◽  
Adverse Outcomes ◽  
Myocardial Oxygen Supply

Abstract Background Type 2 myocardial infarction (T2MI) is frequently encountered in clinical practice and associated with adverse outcomes. Content T2MI occurs most frequently due to noncoronary etiologies that alter myocardial oxygen supply and/or demand. The diagnosis of T2MI is often confused with acute nonischemic myocardial injury, in part because of difficulties in delineating the nature of symptoms and misunderstandings about disease categorization. The use of objective features of myocardial ischemia using electrocardiographic (ECG) or imaging abnormalities may facilitate more precise T2MI diagnosis. High-sensitivity cardiac troponin (hs-cTn) assays allow rapid MI diagnosis and risk stratification, yet neither maximum nor delta values facilitate differentiation of T2MI from T1MI. Several investigational biomarkers have been evaluated for T2MI, but none have robust data. There is interest in evaluating risk profiles among patients with T2MI. Clinically, the magnitude of maximum and delta cTn values as well as the presence and magnitude of ischemia on ECG or imaging is used to indicate disease severity. Scoring systems such as GRACE, TIMI, and TARRACO have been evaluated, but all have limited to modest performance, with substantial variation in time intervals used for risk-assessment and endpoints used. Summary The diagnosis of T2MI requires biomarker evidence of acute myocardial injury and clear clinical evidence of acute myocardial ischemia without atherothrombosis. T2MIs are most often caused by noncoronary etiologies that alter myocardial oxygen supply and/or demand. They are increasingly encountered in clinical practice and associated with poor short- and long-term outcomes. Clinicians require novel biomarker or imaging approaches to facilitate diagnosis and risk-stratification.

scholarly journals ST-Elevation Myocardial Infarction and COVID-19 Pneumonia: The Importance of Risk-Stratification of Myocardial Injury in COVID-19 Era

2021 ◽  
pp. 263246362199238
Author(s):  
Julio C. Sauza-Sosa ◽  
Oscar Millan-Iturbe ◽  
Jorge Mendoza-Ramirez ◽  
Carlos N. Velazquez-Gutierrez ◽  
Erika Lizeth De la Cruz Reyna ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Injury Risk ◽  
Myocardial Injury ◽  
Cardiovascular Complications ◽  
Adverse Outcomes ◽  
St Elevation ◽  
Diagnostic Coronary Angiography ◽  
Serial Measurements ◽  
Initial Classification

Background: Myocardial injury is a common manifestation in patients with coronavirus disease (COVID-19), and the correlation with adverse outcomes has been demonstrated; therefore, adequate monitoring of myocardial injury markers is very important. Case Summary: A patient with COVID-19 was hospitalized in our hospital with an initial classification of intermediate risk for myocardial injury, after serial measurements of myocardial injury markers, risk was readjusted to high, as shown later by electrocardiographic abnormalities. The patient underwent emergency diagnostic coronary angiography and successful angioplasty. The patient was discharged to home. Discussion: Myocardial injury risk-stratification is essential in patients with COVID-19, since it is essential in the recognition of patients who are susceptible to cardiovascular complications.

scholarly journals Risk stratification score for acute myocardial infarction and sudden cardiac death in type 2 diabetes mellitus

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
S Lee ◽  
J Zhou ◽  
CL Guo ◽  
WKK Wu ◽  
WT Wong ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Myocardial Infarction ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Cardiac Death ◽  
Adverse Outcomes ◽  
Risk Scores ◽  
Diabetic Patients ◽  
Type 2 Diabetic

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute myocardial infarction (AMI) and sudden cardiac death (SCD) are major cardiovascular adverse outcomes in patients with type 2 diabetic mellitus. Although there are many risk scores on composite outcomes of major cardiovascular adverse outcomes or cardiovascular mortality for diabetic patients, these existing scores did not account for the difference in pathogenesis and prognosis between acute coronary syndrome and lethal ventricular arrhythmias. Furthermore, recent studies reported that HbA1c and lipid levels, which were often accounted for in these risk scores, have J/U-shaped relationships with adverse outcomes. Purpose The present study aims to evaluate the application of incorporating non-linear J/U-shaped relationships between mean HbA1c and cholesterol levels into risk scores for predicting for AMI and non-AMI related SCD respectively, amongst type 2 diabetes mellitus patients. Methods This was a territory-wide cohort study of patients with type 2 diabetes mellitus above the age 40 and free from prior AMI and SCD, with or without prescriptions of anti-diabetic agents between January 1st, 2009 to December 31st, 2009 at government-funded hospitals and clinics in Hong Kong. Risk scores were developed for predicting incident AMI and non-AMI related SCD. The performance of conditional inference survival forest (CISF) model compared to that of random survival forests (RSF) model and multivariate Cox model. Results This study included 261308 patients (age = 66.0 ± 11.8 years old, male = 47.6%, follow-up duration = 3552 ± 1201 days, diabetes duration = 4.77 ± 2.29 years). Mean HbA1c and high-density lipoprotein-cholesterol (HDL-C) were significant predictors of AMI under multivariate Cox regression and were linearly associated with AMI. Mean HbA1c and total cholesterol were significant multivariate predictors with a J-shaped relationship with non-AMI related SCD. The AMI and SCD risk scores had an area-under-the-curve (AUC) of 0.666 (95% confidence interval (CI)= [0.662, 0.669]) and 0.677 (95% CI= [0.673, 0.682]), respectively. CISF significantly improves prediction performance of both outcomes compared to RSF and multivariate Cox models. Conclusions A holistic combination of demographic, clinical, and laboratory indices can be used for the risk stratification of type 2 diabetic patients against AMI and SCD.

scholarly journals The appropriateness of coronary investigation in myocardial injury and type 2 myocardial infarction (ACT-2): A randomized trial design

2019 ◽  
Vol 208 ◽  
pp. 11-20 ◽  
Author(s):  
Kristina Lambrakis ◽  
John K. French ◽  
Ian A. Scott ◽  
Tom Briffa ◽  
David Brieger ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Randomized Trial ◽  
Trial Design ◽  
Myocardial Injury

Abstract 13297: Short-Term Mortality in Patients With Myocardial Injury and Myocardial Infarction Type 1 and Type 2

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Laura Sarkisian ◽  
Lotte Saaby ◽  
Tina S Poulsen ◽  
Oke Gerke ◽  
Axel C Diederichsen ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Troponin I ◽  
Clinical Indication ◽  
Short Term ◽  
Cox Regression Analysis ◽  
Short Term Mortality

Introduction: Troponin elevations occur in a myriad of clinical conditions other than myocardial infarction (MI) and imply a poor prognosis. So far, data comparing the short-term outcome in patients with myocardial injury vs. patients with type 1 or type 2 MI are not available. Methods: Over a 1-year period we prospectively studied hospitalized patients having cardiac troponin I (cTnI) measured on clinical indication. The diagnosis of type 1 and type 2 MI was according to the universal definition involving a rising and/or falling pattern of cTnI values above the decision limit of 30 ng/L. cTnI elevations above this limit in patients without overt myocardial ischemia were defined as myocardial injury. A 1-month follow-up was done with mortality as endpoint. Results: The study covered 1577 consecutive patients with cTnI values >30 ng/L, of whom 360 had a type 1 MI, 119 a type 2 MI and 1089 had myocardial injury. Type 1 MI patients were younger with a median age of 70 (IQR 61-81) yrs, whereas the median ages in type 2 MI and myocardial injury were higher but comparable : 78 (IQR 67-84) vs. 77 (IQR 67-85) yrs. Peak cTnI values, however, were highest in type 1 MI: 3820 (530-19030) ng/L, lower in type 2 MI: 850 (390-3270) ng/L, and smallest in patients with myocardial injury: 90 (50-270) ng/L (p=0.0001). At one-month follow-up 285 patients had died. Mortality in the different subgroups was: 9% (33/360) in type 1 MI, 24% (28/119) in type 2 MI, and 21% (224/1089) in patients with myocardial injury. The results are depicted in the figure (Kaplan-Meier curves, log-rank-test; p-value <0.0001). Multivariate COX regression analysis revealed a Hazard Ratio (95%) of 2.1 (1.2-3.7) for type 2 MI and 1.4 (0.9-2.1) for myocardial injury. Conclusion: The short-term mortality in patients with myocardial injury and type 2 MI is almost identical but higher than in patients with type 1 MI. These prognostic findings imply that the clinical distinction between myocardial injury and type 2 MI may be somewhat artificial.

Abstract 1772: Electrocardiographic Unrecognized Myocardial Infarction Risk Stratification: Quantitated SPECT Infarct Size Predicts Mortality Independent of Clinical and Exercise Test Variables

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Khawaja Ammar ◽  
Todd D Miller ◽  
David O Hodge ◽  
Richard J Rodeheffer ◽  
Raymond J Gibbons
Keyword(s):  
Myocardial Infarction ◽  
Risk Stratification ◽  
Infarct Size ◽  
Mortality Risk ◽  
Exercise Test ◽  
Prognostic Score ◽  
Scoring Systems ◽  
Threshold Method ◽  
Duke Treadmill Score ◽  
Prognostic Scoring Systems

Background : Unrecognized myocardial infarction (UMI), as diagnosed by surveillance electrocardiography (ECG), has the same poor prognosis as recognized (RMI), independent of ejection fraction or ischemia. The value of post UMI risk stratification by infarct size is unknown. Methods : The study group consisted of 5430 patients who underwent 2 day stress (exercise n = 191, pharmacologic n = 155) and rest Tc-99m sestamibi SPECT studies. UMI was diagnosed if ECG showed Q wave MI in the absence of history of MI. SPECT infarct size was quantitated based on a 60% of peak counts threshold method and was expressed as a percentage of the left ventricle (% LV). The association between infarct size and mortality was adjusted for clinical and exercise test prognostic scoring systems. Results : The population consisted of 346 UMI, 628 RMI, and 4456 patients without MI (No MI). Compared to No MI, mortality risk was increased in UMI (RR 1.7, 95% CI 1.6–1.9; p < 0.001) and RMI (RR 1.6, 95% CI 1.4–1.9; p < 0.001) patients. In the UMI group, infarct size was significantly associated with mortality ( p < 0.001), which persisted after adjustment for Mayo prognostic score alone (available in all patients) ( p < 0.001) and for Mayo prognostic score, Framingham risk score, and Duke treadmill score (data available in 137 patients) ( p < 0.001). For every 10% LV increase in infarct size, mortality risk increased 30% (RR = 1.3, 95% CI 1.2–1.5) (see figure ). Conclusions: In patients with UMI, larger quantitated SPECT infarct size predicts increased mortality independent of clinical and exercise test prognostic scoring systems. This finding supports the use of infarct size imaging for risk stratification of UMI patients.

TYPE 2 MYOCARDIAL INFARCTION RISK STRATIFICATION VIA MYOCARDIAL PERFUSION IMAGING

2019 ◽  
Vol 73 (9) ◽  
pp. 1656
Author(s):  
Ramey Marshell ◽  
Chad Colon ◽  
Christopher Roth ◽  
Ayman Farag ◽  
Ami Iskandrian ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Perfusion Imaging ◽  
Myocardial Perfusion ◽  
Risk Stratification ◽  
Perfusion Imaging

scholarly journals P774 Utility of global longitudinal strain to predict post-operative outcomes in non-cardiac surgery

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
C J Park ◽  
L S Tan ◽  
P Huang ◽  
P J Tan ◽  
J H J See
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Surgery ◽  
Risk Stratification ◽  
Longitudinal Strain ◽  
Myocardial Injury ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Operative Outcomes ◽  
Lv Dysfunction

Abstract Background Pre-operative echocardiography is performed in selected groups of patients for cardiac risk stratification prior to surgery. Many parameters, including Left Ventricular Ejection Fraction (LVEF), are assessed during echocardiography. While many studies have cited association between low LVEF and poor operative outcomes such as perioperative myocardial infarction or cardiogenic pulmonary edema, LVEF has limitations such as left ventricular (LV) cavity border tracing, geometric assumptions and inter-observer variability. LVEF may also appear normal in the presence of LV hypertrophy and a small LV cavity size. Studies have described the routine use of global longitudinal strain (GLS) as an alternative measure of ventricular function, with GLS having been reported to be a reliable marker in detecting subclinical LV dysfunction. This adds incremental value in predicting myocardial function and in risk stratification. In fact, some studies have documented GLS being a useful preoperative parameter in predicting postoperative LV dysfunction after cardiac valve surgery. Purpose The aim of this study is to determine the value of GLS in predicting post-operative outcomes in patients undergoing non-cardiac surgeries. Methods This was a retrospective study of all patients who had echocardiography performed for a pre-operative indication from February 2017 to October 2017. These patients were screened for those who had normal LVEF, had undergone subsequent non-cardiac surgery, and had post-operative troponins measured. Medical records were traced for baseline demographics, past medical history and echocardiographic features. GLS evaluation was prospectively performed using TOMTEC-ARENA (TOMTEC Imaging Systems GmbH) by assessors blinded to patient outcomes. Outcomes for major adverse cardiovascular events and mortality up to 1 year post surgery were collected. Post-op myocardial injury was defined as a peak Troponin T value of &gt;30 ng/L or a &gt;20% increment from baseline. Results A total of 42 patients were included. 61.9% (n = 26) were male and mean age was 72.3 years. Only 75.6% of patients were fully independent with activities of daily living and mean creatinine was 153.4μmol/L. Mortality at 1 year was 16.7% (n = 7) and 28.6% (n = 12) were deemed to have post-operative myocardial injury. 1-year mortality was associated with a lower GLS (-23.8% vs -19.2%, p = 0.001). However, GLS was not correlated with post-operative myocardial injury or hospital readmissions. In our study population, only a history of past myocardial infarction predicted post-op myocardial injury (58.3% vs 16.7%, p = 0.019). Conclusion Our study did not demonstrate the utility of GLS in predicting post-operative events, but this is likely because of the small sample size with low event rates. Nevertheless, GLS values did correlate with 1-year mortality and could be a marker of frailty and an increased mortality risk.

Assessment of the CHA2DS2-VASc Score in Predicting Mortality and Adverse Cardiovascular Outcomes of Patients on Hemodialysis

2020 ◽  
Vol 51 (8) ◽  
pp. 635-640
Author(s):  
Miri Schamroth Pravda ◽  
Keren Cohen Hagai ◽  
Guy Topaz ◽  
Nili Schamroth Pravda ◽  
Nadeen Makhoul ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cardiovascular Risk ◽  
Risk Stratification ◽  
High Mortality ◽  
Medical Center ◽  
Composite Endpoint ◽  
Chronic Hemodialysis ◽  
Adverse Outcomes ◽  
First Year ◽  
Increased Risk

Background: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis are at high mortality and cardiovascular risk. This study was aimed to assess whether the CHA2DS2-VASc score may be used for risk stratification of this population. Methods: Included were patients undergoing chronic hemodialysis at Meir Medical Center. The CHA2DS2-VASc score was calculated for each patient at the initiation of hemodialysis. Patients were classified into 3 groups according to the CHA2DS2-VASc score: 0–3 (low), 4–5 (intermediate), and ≥6 (high). The primary endpoint was the composite of all-cause mortality, myocardial infarction, and stroke during the first year of hemodialysis. Results: Of the 457 patients with ESRD, 181 (40%) had low, 193 (42%) intermediate, and 83 (18%) high CHA2DS2-VASc scores. During the first year of hemodialysis, 109 (23.8%) patients died, 17 (3.7%) had a stroke, and 28 (6.1%) had a myocardial infarction. Compared to patients in the low CHA2DS2-VASc score group, those in the intermediate and high score groups had higher risk for the composite endpoint (OR: 2.6, 95% CI: 1.6–4.2, p < 0.01 and OR: 4.2, 95% CI: 2.3–7.5, p < 0.01, respectively). Each 1-point increase in CHA2DS2-VASc score was associated with a 38% increased risk for the composite endpoint, a 19% increased risk for 1-year myocardial infarction, and a 29% increased risk for 1-year stroke. Conclusions: Patients with ESRD are at an extremely high mortality and cardiovascular risk within the first year of hemodialysis. The CHA2DS2-VASc score was strongly associated with adverse outcomes and may be used for risk stratification of these patients.

Understanding cardiac troponin part 1: avoiding troponinitis

2017 ◽  
Vol 35 (2) ◽  
pp. 120-125 ◽  
Author(s):  
Richard Body ◽  
Edward Carlton
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Cardiac Troponin ◽  
Myocardial Injury ◽  
Supply And Demand ◽  
Clinical Context ◽  
Serial Sampling ◽  
Artery Disease

Cardiac troponin (cTn) is a highly specific biomarker of myocardial injury and is central to the diagnosis of acute myocardial infarction (AMI). By itself, however, cTn cannot identify the cause of myocardial injury. ‘Troponinitis’ is the condition that leads clinicians to falsely assign a diagnosis of AMI based only on the fact that a patient has an elevated cTn concentration. There are many causes of myocardial injury other than AMI. Clinicians are required to differentiate myocardial injury caused by AMI from other causes.In part 1 of this series on cTn, we provide a structured overview to help practising clinicians to interpret ‘positive’ cTn results appropriately. There are three core principles. First, when reviewing a cTn result, clinicians must carefully consider the clinical context. Only this can distinguish primary (termed type 1) AMI caused by coronary artery disease from secondary (termed type 2) AMI caused by another condition with an imbalance in the supply and demand of oxygen to the myocardium. Second, clinicians must consider the patient’s baseline condition in order to determine the presence or absence of factors that may predict a chronic cTn elevation. Third, clinicians should routinely use serial sampling to detect a change of cTn that is expected in patients with acute (rather than chronic) myocardial injury. Using these simple principles, clinicians can avoid underdiagnosis and overdiagnosis of AMI.

Causes of Death After Type 2 Myocardial Infarction and Myocardial Injury

2021 ◽  
Vol 78 (4) ◽  
pp. 415-416
Author(s):  
Claire E. Raphael ◽  
Véronique L. Roger ◽  
Yader Sandoval ◽  
Matthew Johnson ◽  
Allan Jaffe ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Causes Of Death
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