scholarly journals Myocardial Infarction in the ISCHEMIA Trial: Impact of Different Definitions on Incidence, Prognosis, and Treatment Comparisons

Circulation ◽  
2020 ◽  
Author(s):  
Bernard R. Chaitman ◽  
Karen P. Alexander ◽  
Derek D. Cyr ◽  
Jeffrey S. Berger ◽  
Harmony R. Reynolds ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cardiovascular Death ◽  
Unique Identifier ◽  
Clinical Trial Registration ◽  
Conservative Strategy ◽  
Invasive Strategy ◽  
St Segment ◽  
Grade 3 ◽  
Treatment Comparisons

Background: In ISCHEMIA, an initial invasive strategy did not significantly reduce rates of cardiovascular events or all-cause mortality compared with a conservative strategy in patients with stable ischemic heart disease and moderate/severe myocardial ischemia. The most frequent component of composite cardiovascular endpoints was myocardial infarction. Methods: ISCHEMIA prespecified that the primary and major secondary composite endpoints of the trial be analyzed using two MI definitions. For procedural MI, the primary MI definition used CK-MB as the preferred biomarker whereas the secondary definition used cardiac troponin. Procedural thresholds were >5 times URL for PCI and >10 times for CABG. Procedural MI definitions included (i) a category of elevated biomarker only events with much higher biomarker thresholds (ii) new ST segment depression of ≥ 1mm for the primary and ≥ 0.5 mm for the secondary definition and (iii) new coronary dissections ≥ NHLBI grade 3. We compared MI type, frequency, and prognosis by treatment assignment using both MI definitions. Results: Procedural MI's accounted for 20.1% of all MI events with the primary definition and 40.6% of all MI events with the secondary definition. Four-year MI rates in patients undergoing revascularization were more frequent with the invasive vs conservative strategy using the primary [2.7% vs. 1.1%; adjusted HR 2.98 (95% CI 1.87, 4.73)] and secondary [8.2% vs. 2.0%; adjusted HR 5.04 (95% CI 3.64, 6.97)] MI definitions. Type 1 MI's were less frequent with the invasive vs conservative strategy using the primary [3.40% vs. 6.89%; adjusted HR 0.53 (95% CI 0.41,0.69); p<0.0001], and secondary [3.48% vs 6.89%; adjusted HR 0.53 (95% CI 0.41, 0.69); p<0.0001] definitions. The risk of subsequent cardiovascular death was higher after a type 1 MI compared to no MI using the primary [adjusted HR 3.38 (95% CI 2.03,5.61); p<0.001] or secondary MI definition [adjusted HR 3.52 (2.11, 5.88); p<0.001]. Conclusions: In ISCHEMIA, type 1 MI events using the primary and secondary definitions during 5-year follow-up were more frequent with an initial conservative strategy and associated with subsequent cardiovascular death. Procedural MI rates were greater in the invasive strategy and using the secondary MI definition. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT01471522

scholarly journals Evaluation of a 1-hour troponin algorithm for diagnosing myocardial infarction in high-risk patients admitted to a chest pain unit: the prospective FAST-MI cohort study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e032124 ◽  
Author(s):  
Michael Amann ◽  
Felix Gaiser ◽  
Sandra Iris Schwenk ◽  
Faridun Rahimi ◽  
Roland Schmitz ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cohort Study ◽  
Chest Pain ◽  
Chest Pain Unit ◽  
Invasive Strategy ◽  
St Segment ◽  
Acute Mi ◽  
Early Invasive Strategy ◽  
Rule Out

ObjectiveThis study sought to evaluate the diagnostic performance of the 1-hour troponin algorithm for diagnosis of myocardial infarction (MI) without persistent ST-segment elevations (non-ST-segment MI (NSTEMI)) in a cohort with a high prevalence of MI. This algorithm recommend by current guidelines was previously developed in cohorts with a prevalence of MI of less than 20%.DesignProspective cohort study from November 2015 until December 2016.SettingDedicated chest pain unit of a single referral centre.ParticipantsConsecutive patients with suspected MI were screened. Patients with subacute symptoms lasting more than 24 hours, new ST-segment elevations at presentation, or an already diagnosed or ruled-out acute MI were excluded. All enrolled patients (n=1317) underwent a full clinical assessment and measurements of high-sensitivity troponin, and were scheduled for an early invasive strategy if clinically indicated.Main outcome measuresFinal diagnosis of MI according to the Fourth Universal Definition of MI.ResultsThe prevalence of NSTEMI in the present cohort was 36.9%. The sensitivity for rule-out of MI was 99.8%. The specificity for rule-in of MI was found to be 94.3%. However, in 35.7% of patients neither rule-in nor rule-out was possible. In 51.4% of patients diagnosed with MI, a primary non-coronary reason for MI was found (type 2 MI). Different receiver operating characteristic-curve derived cut-offs for troponin and its dynamics did not provide a sufficient differentiation between type 1 and 2 MI for clinical decision making (negative predictive value for rule-out of type 1 MI <70%).ConclusionsThe 1-hour diagnosis algorithm for patients with suspected NSTEMI can accurately diagnose acute MI in high-risk cohorts. However, discrimination between patients needing an early invasive strategy or not is limited.Trial registration numberDRKS00009713.

scholarly journals International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina: The Multinational Observational CLARIFY Study

Circulation ◽  
2021 ◽  
Author(s):  
Jules Mesnier ◽  
Gregory Ducrocq ◽  
Nicolas Danchin ◽  
Roberto Ferrari ◽  
Ian Ford ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Conservative Management ◽  
Coronary Revascularization ◽  
Stable Coronary Artery Disease ◽  
Multivariable Analysis ◽  
Chronic Stable Angina ◽  
Cardiovascular Death ◽  
Unique Identifier ◽  
Clinical Trial Registration ◽  
Stable Cad

Background: Although angina is common in patients with stable coronary artery disease (CAD), limited data are available on its prevalence, natural evolution, and outcomes in the era of effective cardiovascular drugs and widespread use of coronary revascularization. Methods: Using data from 32 691 patients with stable CAD from the prospective observational CLARIFY registry, anginal status was mapped each year in patients without new coronary revascularization or new myocardial infarction. The use of medical interventions in the year preceding angina resolution was explored. The effect of 1-year changes in angina status on 5-year outcomes was analyzed using multivariable analysis. Results: Among 7212 (22.1%) patients who reported angina at baseline, angina disappeared (without coronary revascularization) in 39.6% at 1 year, with further annual decreases. In patients without angina at baseline, 2.0-4.8% developed angina each year. During 5-year follow-up, angina was controlled in 7773 patients, in whom resolution of angina was obtained with increased use of antianginal treatment in 11.1%, with coronary revascularization in 4.5%, and without any changes in medication or revascularization in 84.4%. Compared to patients without angina at baseline and 1 year, persistence of angina and occurrence of angina at 1 year with conservative management were each independently associated with higher rates of cardiovascular death or myocardial infarction (adjusted hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.12−1.55 for persistence of angina; adjusted HR 1.37, 95% CI 1.11−1.70 for occurrence of angina) at 5 years. Patients whose angina had resolved at 1 year with conservative management were not at higher risk of cardiovascular death or myocardial infarction than those who never experienced angina (adjusted HR 0.97, 95% CI 0.82−1.15). Conclusions: Angina affects almost one-quarter of patients with stable CAD but resolves without events or coronary revascularization in most patients. Resolution of angina within 1 year with conservative management predicted outcomes similar to lack of angina, while persistence or occurrence was associated with worse outcomes. As most patients with angina are likely to experience resolution of symptoms, and as there is no demonstrated outcome benefit to routine revascularization, this study emphasizes the value of conservative management of stable CAD. Clinical Trial Registration: URL: https://www.isrctn.com; Unique identifier: ISRCTN43070564

scholarly journals Complete revascularization reduces cardiovascular death in patients with ST-segment elevation myocardial infarction and multivessel disease: systematic review and meta-analysis of randomized clinical trials

2019 ◽  
Vol 41 (42) ◽  
pp. 4103-4110 ◽  
Author(s):  
Rita Pavasini ◽  
Simone Biscaglia ◽  
Emanuele Barbato ◽  
Matteo Tebaldi ◽  
Dariusz Dudek ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Clinical Trials ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Cardiovascular Death ◽  
Multivessel Disease ◽  
Complete Revascularization ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment

Abstract Aims The aim of this work was to investigate the prognostic impact of revascularization of non-culprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease by performing a meta-analysis of available randomized clinical trials (RCTs). Methods and results Data from six RCTs comparing complete vs. culprit-only revascularization in STEMI patients with multivessel disease were analysed with random effect generic inverse variance method meta-analysis. The endpoints were expressed as hazard ratio (HR) with 95% confidence interval (CI). The primary outcome was cardiovascular death. Main secondary outcomes of interest were all-cause death, myocardial infarction (MI), and repeated coronary revascularization. Overall, 6528 patients were included (3139 complete group, 3389 culprit-only group). After a follow-up ranging between 1 and 3 years (median 2 years), cardiovascular death was significantly reduced in the group receiving complete revascularization (HR 0.62, 95% CI 0.39–0.97, I2 = 29%). The number needed to treat to prevent one cardiovascular death was 70 (95% CI 36–150). The secondary endpoints MI and revascularization were also significantly reduced (HR 0.68, 95% CI 0.55–0.84, I2 = 0% and HR 0.29, 95% CI 0.22–0.38, I2 = 36%, respectively). Needed to treats were 45 (95% CI 37–55) for MI and 8 (95% CI 5–13) for revascularization. All-cause death (HR 0.81, 95% CI 0.56–1.16, I2 = 27%) was not affected by the revascularization strategy. Conclusion In a selected study population of STEMI patients with multivessel disease, a complete revascularization strategy is associated with a reduction in cardiovascular death. This reduction is concomitant with that of MI and the need of repeated revascularization.

scholarly journals Cardiac and Kidney Benefits of Empagliflozin in Heart Failure Across the Spectrum of Kidney Function: Insights from the EMPEROR-Reduced Trial

Circulation ◽  
2020 ◽  
Author(s):  
Faiez Zannad ◽  
João Pedro Ferreira ◽  
Stuart J. Pocock ◽  
Cordula Zeller ◽  
Stefan D. Anker ◽  
...  
Keyword(s):  
Kidney Function ◽  
Primary Outcome ◽  
Cardiovascular Death ◽  
Unique Identifier ◽  
Clinical Trial Registration ◽  
Reduced Ejection Fraction ◽  
Secondary Outcomes ◽  
Kidney Impairment ◽  
Kidney Function Decline

Background: In EMPEROR-Reduced, empagliflozin reduced cardiovascular death or HF hospitalization, total HF hospitalizations, and slowed the progressive decline in kidney function in patients with HF and a reduced ejection fraction (HFrEF), with and without diabetes. We aim to study the effect of empagliflozin on cardiovascular and kidney outcomes across the spectrum of kidney function. Methods: In this pre-specified analysis, patients were categorized by the presence or absence of CKD at baseline (eGFR<60ml/min/1.73m 2 or UACR>300mg/g). The primary and key secondary outcomes were (1) a composite of cardiovascular death or HF hospitalization (primary outcome); (2) total HF hospitalizations, and (3) eGFR slope. The direct impact on kidney events was investigated by a prespecified composite kidney outcome (defined as a sustained profound decline in eGFR, chronic dialysis or transplant). The median follow-up was 16 months. Results: 3730 patients were randomized to empagliflozin or placebo, of whom 1978 (53%) had CKD. Empagliflozin reduced the primary outcome and total HF hospitalizations in patients with and without CKD: primary outcome HR=0.78 (95%CI=0.65-0.93) and HR=0.72 (95%CI=0.58-0.90), respectively; interaction P=0.63. Empagliflozin slowed the slope of eGFR decline by 1.11 (0.23-1.98) ml/min/1.73m 2 /year in patients with CKD and by 2.41 (1.49-3.32) ml/min/1.73m2/year in patients without CKD. The risk of the composite kidney outcome was reduced similarly in patients with and without CKD: HR=0.53 (95%CI=0.31-0.91) and HR=0.46 (95%CI=0.22-0.99), respectively. The effect of empagliflozin on the primary composite outcome and the key secondary outcomes was consistent across a broad range of baseline kidney function, measured by clinically relevant eGFR subgroups or by albuminuria, including patients with eGFR as low as 20 ml/min/1.73m 2 . Empagliflozin was well tolerated in CKD patients. Conclusions: In EMPEROR-reduced, empagliflozin had a beneficial effect on the key efficacy outcomes and slowed the rate of kidney function decline in patients with and without CKD and regardless of the severity of kidney impairment at baseline. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT03057977

IgA-CK-BB complex with CK-MB electrophoretic mobility can lead to erroneous diagnosis of acute myocardial infarction.

1989 ◽  
Vol 35 (9) ◽  
pp. 2003-2008 ◽  
Author(s):  
R Venta ◽  
S A Geijo ◽  
A C Sánchez ◽  
C G Bao ◽  
L A Bartolome ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Electrophoretic Mobility ◽  
Electrophoretic Pattern ◽  
T Wave ◽  
St Segment ◽  
Erroneous Diagnosis ◽  
Total Creatine ◽  
Tentative Diagnosis

Abstract This patient, on admission, presented with a tentative diagnosis of myocardial infarction: the electrocardiogram showed a nonspecific ST-segment and T-wave abnormalities, and total creatine kinase (CK; EC 2.7.3.2) activity was slightly increased (238 U/L). However, a high electrophoretic value for CK-MB (50% of total CK activity) and the electrophoretic pattern of lactate dehydrogenase (EC 1.1.1.27) isoenzymes ruled out myocardial infarction. The isoenzyme migrating as CK-MB was found later to contain no immunologically normal CK-M subunits, and it was bound to IgA. A mixture of the patient's serum and a human serum control containing all CK isoenzymes showed altered electrophoretic mobility only for CK-BB, indicating that the patient's serum contained antibodies to the B unit of CK. Elution from a Sephadex G-200 column showed that the peak at which most of the anodic CK was eluted corresponded to a molecular mass of approximately 200 kDa. Evidently this atypical isoenzyme was an IgA-CK-BB complex. Because this macro CK type 1 can mimic CK-MB, it may therefore be a source of confusion.

scholarly journals Initial Invasive Versus Conservative Management of Stable Ischemic Heart Disease in Patients With a History of Heart Failure or Left Ventricular Dysfunction

Circulation ◽  
2020 ◽  
Vol 142 (18) ◽  
pp. 1725-1735
Author(s):  
Renato D. Lopes ◽  
Karen P. Alexander ◽  
Susanna R. Stevens ◽  
Harmony R. Reynolds ◽  
Gregg W. Stone ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Primary Outcome ◽  
Cardiovascular Death ◽  
Left Ventricular ◽  
Ischemic Heart ◽  
Conservative Strategy ◽  
Stable Ischemic Heart Disease ◽  
History Of

Background: Whether an initial invasive strategy in patients with stable ischemic heart disease and at least moderate ischemia improves outcomes in the setting of a history of heart failure (HF) or left ventricular dysfunction (LVD) when ejection fraction is ≥35% but <45% is unknown. Methods: Among 5179 participants randomized into ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), all of whom had left ventricular ejection fraction (LVEF) ≥35%, we compared cardiovascular outcomes by treatment strategy in participants with a history of HF/LVD at baseline versus those without HF/LVD. Median follow-up was 3.2 years. Results: There were 398 (7.7%) participants with HF/LVD at baseline, of whom 177 had HF/LVEF >45%, 28 HF/LVEF 35% to 45%, and 193 LVEF 35% to 45% but no history of HF. HF/LVD was associated with more comorbidities at baseline, particularly previous myocardial infarction, stroke, and hypertension. Compared with patients without HF/LVD, participants with HF/LVD were more likely to experience a primary outcome composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, HF, or resuscitated cardiac arrest (4-year cumulative incidence rate, 22.7% versus 13.8%; cardiovascular death or myocardial infarction, 19.7% versus 12.3%; and all-cause death or HF, 15.0% versus 6.9%). Participants with HF/LVD randomized to the invasive versus conservative strategy had a lower rate of the primary outcome (17.2% versus 29.3%; difference in 4-year event rate, −12.1% [95% CI, −22.6 to −1.6%]), whereas those without HF/LVD did not (13.0% versus 14.6%; difference in 4-year event rate, −1.6% [95% CI, −3.8% to 0.7%]; P interaction = 0.055). A similar differential effect was seen for the primary outcome, all-cause mortality, and cardiovascular mortality when invasive versus conservative strategy–associated outcomes were analyzed with LVEF as a continuous variable for patients with and without previous HF. Conclusions: ISCHEMIA participants with stable ischemic heart disease and at least moderate ischemia with a history of HF or LVD were at increased risk for the primary outcome. In the small, high-risk subgroup with HF and LVEF 35% to 45%, an initial invasive approach was associated with better event-free survival. This result should be considered hypothesis-generating. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01471522.

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