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Myocardial Infarction and Myocardial Injury in Acute Cardiac Care

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (30 September 2020) | Viewed by 39245

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Prof. Dr. Johannes Neumann

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1. Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
2. School of Public Health and Preventive Medicine, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
Interests: cardiac biomarkers; troponin; acute myocardial infarction; risk prediction

Special Issue Information

Dear Colleagues,

It is my great pleasure and honor to announce this Special Issue on “Myocardial Infarction and Myocardial Injury in Acute Cardiac Care”. In recent decades, diagnosis, treatment, and outcome of patients with an acute myocardial infarction have changed tremendously. It is just less than 20 years ago that new treatments, such as drug-eluting stents or P2Y₁₂-inhibitors became available and showed substantial benefit to patients. Twenty years ago, diagnosis of myocardial infarction was only possible based on clinical symptoms, ECG, and insensitive biomarkers. Today, high-sensitivity cardiac troponin assays are well established and have enabled the use of fast and accurate diagnostic strategies. Finally, awareness and prevention of important cardiovascular risk factors have improved substantially. All these changes have resulted in a noticeable drop of cardiovascular mortality after an acute event.

However, there are still numerous challenging and interesting topics in the field of myocardial infarction. The use of high-sensitivity cardiac troponin assays has enabled the detection of even mild biomarker elevations. Based on this advantage, the concept of myocardial injury, defined as elevated biomarkers in the absence of acute myocardial ischemia, has been introduced. Myocardial injury is strongly associated with poor outcome, but specific pathways for diagnostic workup or treatment are lacking. In addition to cardiac troponin, there are other novel and emerging biomarkers, which are discussed for diagnostic or prognostic application. Finally, the use of machine-learning approaches for decision processes in acute cardiac care, but also for risk evaluation, is of increasing interest and has the potential to change our current practice.

With this Special Issue, we aim to provide a glimpse on these topics and are very much looking forward to receiving your original research or review articles.

Prof. Dr. Johannes Neumann
Guest Editor

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Keywords

Prevention
Myocardial infarction
Diagnosis
Treatment
Risk prediction
Biomarkers
Acute coronary syndrome
Myocardial injury

Published Papers (10 papers)

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Research

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12 pages, 3128 KiB

Open AccessArticle

Prognostic Value of Elevated Copeptin and High-Sensitivity Cardiac Troponin T in Patients with and without Acute Coronary Syndrome: The ConTrACS Study

by Hanna Waldsperger, Moritz Biener, Kiril M. Stoyanov, Mehrshad Vafaie, Hugo A. Katus, Evangelos Giannitsis and Matthias Mueller-Hennessen

J. Clin. Med. 2020, 9(11), 3627; https://doi.org/10.3390/jcm9113627 - 11 Nov 2020

Cited by 9 | Viewed by 2176

Abstract

Aims: We aimed to assess the prognostic role of copeptin in patients presenting to the emergency department with acute symptoms and increased high-sensitivity cardiac troponin T. Methods: A total of 3890 patients presenting with acute symptoms to the emergency department of Heidelberg University Hospital were assessed for increased hs-cTnT (>14 ng/L) from three cohorts: the Heidelberg Acute Coronary Syndrome (ACS) Registry (n = 2477), the BIOPS Registry (n = 320), and the ACS OMICS Registry (n = 1093). In a pooled analysis, 1956 patients remained, comprising of 1600 patients with ACS and 356 patients with non-ACS. Results: Median follow-up was 1468 days in the ACS cohort and 709 days in the non-ACS cohort. Elevated copeptin levels (>10 pmol/L) were found in 1174 patients (60.0%) in the entire cohort (58.1% in ACS and 68.5% in non-ACS, respectively) and mortality rates were significantly higher than in patients with normal copeptin levels (29.0% vs. 10.7%, p < 0.001). In a multivariate Cox regression, elevated copeptin was independently associated with all-cause death in the ACS (HR = 1.7, 1.3–2.3, p = 0.002) and non-ACS cohort (HR = 2.7, 1.4–5.0, p = 0.0018). Conclusion: Copeptin may aid in identifying patients at risk for adverse outcomes in patients with increased levels of hs-cTnT in ACS patients and in non-ACS conditions. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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10 pages, 912 KiB

Open AccessArticle

Managed Care after Acute Myocardial Infarction (MC-AMI) Reduces Total Mortality in 12-Month Follow-Up—Results from a Poland’s National Health Fund Program of Comprehensive Post-MI Care—A Population-Wide Analysis

by Krystian Wita, Andrzej Kułach, Jacek Sikora, Joanna Fluder, Ewa Nowalany-Kozielska, Krzysztof Milewski, Piotr Pączek, Henryk Sobocik, Jacek Olender, Lucjan Szela, Zbigniew Kalarus, Pawel Buszman, Piotr Jankowski and Mariusz Gąsior

J. Clin. Med. 2020, 9(10), 3178; https://doi.org/10.3390/jcm9103178 - 30 Sep 2020

Cited by 13 | Viewed by 6291

Abstract

Introduction: Advances in the acute treatment of myocardial infarction (AMI) substantially reduced in-hospital mortality, but the post-discharge prognosis is still unacceptable. The Managed Care in Acute Myocardial Infarction (MC-AMI) is a program of Poland’s National Health Fund that aims at comprehensive post-AMI care to improve long-term prognosis. The aim of the study was to assess the effect of MC-AMI on all-cause mortality in one-year follow-up. Methods: MC-AMI includes acute MI treatment, complex revascularization, cardiac rehabilitation (CR), scheduled one-year outpatient follow-up, and prevention of sudden cardiac death. In this retrospective observational study performed in a province of Silesia, Poland, we analyzed 3893 MC-AMI participants, and compared them to 6946 patients in the control group. After propensity score matching, we compared two groups of 3551 subjects each. To assess the effect of MC-AMI and other variables on mortality, we preformed a Cox regression. Results: MC-AMI was related with mortality reduction by 38% in a 12-month observation period and the effect persisted even after. Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with 1-year mortality (HR 0.52, 95%CI 0.42–0.65, p < 0.001). Besides that, older age (HR 1.47/10 y), ST-elevation AMI (HR 1.41), heart failure (HR 2.08), diabetes (HR 1.52), and dialysis (HR 2.38) were significantly associated with the primary endpoint. Among MC-AMI components, cardiac rehabilitation (HR 0.34) and strict outpatient care (HR 0.42) are the crucial factors affecting mortality reduction. Conclusions: Participation in MC-AMI reduced 1-year mortality by 38% and the effect persisted after the program had been completed. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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9 pages, 871 KiB

Open AccessArticle

Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

by Peter A. Kavsak, Joshua O. Cerasuolo, Shawn E. Mondoux, Jonathan Sherbino, Jinhui Ma, Brock K. Hoard, Richard Perez, Hsien Seow, Dennis T. Ko and Andrew Worster

J. Clin. Med. 2020, 9(9), 2948; https://doi.org/10.3390/jcm9092948 - 12 Sep 2020

Cited by 6 | Viewed by 2819

Abstract

For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012–February 2013 and April 2013–September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46–60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32–0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64–82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98–3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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12 pages, 532 KiB

Open AccessArticle

Predictive Value of Serial ECGs in Patients with Suspected Myocardial Infarction

by Jonas Lehmacher, Johannes Tobias Neumann, Nils Arne Sörensen, Alina Goßling, Paul Michael Haller, Tau Sarra Hartikainen, Peter Clemmensen, Tanja Zeller, Stefan Blankenberg and Dirk Westermann

J. Clin. Med. 2020, 9(7), 2303; https://doi.org/10.3390/jcm9072303 - 20 Jul 2020

Cited by 11 | Viewed by 4012

Abstract

The electrocardiogram (ECG) is an important diagnostic tool for patients with suspected acute myocardial infarction (AMI). Current guidelines recommend serial ECGs in case of persisting symptoms. We aimed to analyze the predictive value of ischemic ECG-signs in patients with suspected AMI. Patients presenting to the emergency department with suspected AMI were included. All patients with ST-elevation AMI were excluded from analyses. Patients received 12-lead-ECG and high-sensitive Troponin T (hs-TnT)-measurement at admission and after 3 h. Four groups were defined: no ischemic signs in either ECG; new ischemic signs in the second ECG; resolved ischemic signs in the second ECG; and persistent ischemic signs in both ECGs. Patients were followed for 2 years to assess the composite endpoint of all-cause-mortality, AMI, and coronary revascularization. Using a 30-day landmark analysis, a Cox regression with ischemic signs as the variable of interest, adjusted by cardiovascular risk factors, was calculated. Of 1675 patients, 1321 showed no ischemic signs, in 25 new-, in 92 resolved- and in 237 patients, persistent ischemic signs were documented. Patients with persistent ischemic signs had significantly worse outcomes, compared to those without. Compared to no ischemic signs, adjusted hazard ratios for the combined endpoint were 0.81 (95% CI 0.20, 3.31; p-value = 0.77) for new-, 0.59 (95% CI 0.26, 1.34; p-value = 0.21) for resolved-, and 1.47 (95% CI 1.102, 2.13; p-value = 0.041) for persistent ischemic signs. In patients with suspected AMI, persistent ischemic ECG-signs are predictive of a higher rate of all-cause-mortality, AMI, and revascularization. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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15 pages, 962 KiB

Open AccessArticle

Sex-Specific Outcomes in Patients with Acute Coronary Syndrome

by Johannes T. Neumann, Alina Goßling, Nils A. Sörensen, Stefan Blankenberg, Christina Magnussen and Dirk Westermann

J. Clin. Med. 2020, 9(7), 2124; https://doi.org/10.3390/jcm9072124 - 6 Jul 2020

Cited by 13 | Viewed by 2713

Abstract

Sex differences in patients with acute coronary syndrome (ACS) are a matter of debate. We investigated sex-specific differences in the incidence, outcomes, and related interventions in patients diagnosed with ACS in Germany over the past decade. All ACS cases from 2005 to 2015 were collected. Procedures and inhospital mortality were assessed by sex. Age-adjusted incidence rates were calculated. In total, 1,366,045 females and 2,431,501 males presenting with ACS were recorded. Females were older than males (73.1 vs. 66.4 years of age), had a longer mean hospital stay (7.7 vs. 6.9 days), and less frequently underwent coronary angiographies (55% vs. 66%) and coronary interventions (35% vs. 47%). The age-adjusted incidence rate of ACS was lower in females than in males, and decreased in both sexes from 2005 to 2015. The age-adjusted inhospital mortality rate was substantially higher in females than in males, but decreased in both sexes over time (in females, from 87 to 71 cases per 1000 person years; in males, from 57 to 51 cases per 1000 person years). In conclusion, we reported sex differences in the incidence, treatment, and outcomes of ACS patients in Germany within the past decade. Women had a substantially higher mortality rate and lower rate of coronary interventions. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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12 pages, 911 KiB

Open AccessArticle

Widespread Introduction of a High-Sensitivity Troponin Assay: Assessing the Impact on Patients and Health Services

by Jaimi H. Greenslade, William Parsonage, Laura Foran, Louise McCormack, Sarah Ashover, Tanya Milburn, Sara Berndt, Martin Than, David Brain and Louise Cullen

J. Clin. Med. 2020, 9(6), 1883; https://doi.org/10.3390/jcm9061883 - 16 Jun 2020

Cited by 10 | Viewed by 2804

Abstract

Adoption of High-sensitivity troponin (hs-cTn) assays by hospitals worldwide is increasing. We sought to determine the effects of a simultaneous state-wide hs-cTn assay introduction on the implementing health service. A quasi-experimental pre–post design was used. Participants included all adult patients presenting to 21 Australian hospitals who had troponin testing commenced within the Emergency Department (ED). Data were collected for 124,357 episodes of care between 30 April 2018 and 23 April 2019; six months pre- and six months post-implementation of the assay. The primary outcome was hospital length of stay (LOS). Secondary outcomes included ED LOS, 90-day cardiovascular mortality, elevated troponin, diagnosis of acute myocardial infarction (AMI), admission to a cardiology ward, invasive cardiac procedures, and total hospital costs. Following hs-cTn implementation, there was a 1.9-h (95% CI: −2.9 to −1.0 h) reduction in overall LOS. This equated to a cost saving of over 9 million Australian dollars per year. There was no increase in diagnosis of AMI, invasive cardiac procedures or ward admissions. The use of hs-cTn assays facilitates important benefits for health services by enabling more rapid evaluation protocols within the ED. This benefit may be considerable given the large cohort of emergency patients with possible ACS. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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15 pages, 2615 KiB

Open AccessArticle

Adjunctive Cilostazol to Dual Antiplatelet Therapy to Enhance Mobilization of Endothelial Progenitor Cell in Patients with Acute Myocardial Infarction: A Randomized, Placebo-Controlled EPISODE Trial

by Yongwhi Park, Jin Hyun Kim, Tae Ho Kim, Jin-Sin Koh, Seok-Jae Hwang, Jin-Yong Hwang and Young-Hoon Jeong

J. Clin. Med. 2020, 9(6), 1678; https://doi.org/10.3390/jcm9061678 - 1 Jun 2020

Cited by 2 | Viewed by 3259

Abstract

Background: Endothelial progenitor cells (EPCs) have the potential to protect against atherothrombotic event occurrences. There are no data to evaluate the impact of cilostazol on EPC levels in high-risk patients. Methods: We conducted a randomized, double-blind, placebo-controlled trial to assess the effect of adjunctive cilostazol on EPC mobilization and platelet reactivity in patients with acute myocardial infarction (AMI). Before discharge, patients undergoing percutaneous coronary intervention (PCI) were randomly assigned to receive cilostazol SR capsule (200-mg) a day (n = 30) or placebo (n = 30) on top of dual antiplatelet therapy (DAPT) with clopidogrel and aspirin. Before randomization (baseline) and at 30-day follow-up, circulating EPC levels were analyzed using flow cytometry and hemostatic measurements were evaluated by VerifyNow and thromboelastography assays. The primary endpoint was the relative change in EPC levels between baseline and 30-day. Results: At baseline, there were similar levels of EPC counts between treatments, whereas patients with cilostazol showed higher levels of EPC counts compared with placebo after 30 days. Cilostazol versus placebo treatment displayed significantly higher changes in EPC levels between baseline and follow-up (ΔCD133⁺/KDR⁺: difference 216%, 95% confidence interval (CI) 44~388%, p = 0.015; ΔCD34⁺/KDR⁺: difference 183%, 95% CI 25~342%, p = 0.024). At 30-day follow-up, platelet reactivity was lower in the cilostazol group compared with the placebo group (130 ± 45 versus 169 ± 62 P2Y12 Reaction Unit, p = 0.009). However, there were no significant correlations between the changes of EPC levels and platelet reactivity. Conclusion: Adjunctive cilostazol on top of clopidogrel and aspirin versus DAPT alone is associated with increased EPC mobilization and decreased platelet reactivity in AMI patients, suggesting its pleiotropic effects against atherothrombotic events (NCT04407312). Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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10 pages, 971 KiB

Open AccessArticle

Post-Infectious Myocardial Infarction: Does Percutaneous Coronary Intervention Improve Outcomes? A Propensity Score-Matched Analysis

by Alain Putot, Frédéric Chagué, Patrick Manckoundia, Philippe Brunel, Jean-Claude Beer, Yves Cottin and Marianne Zeller

J. Clin. Med. 2020, 9(6), 1608; https://doi.org/10.3390/jcm9061608 - 26 May 2020

Cited by 7 | Viewed by 1931

Abstract

Acute infection is a frequent trigger of myocardial infarction (MI). However, whether percutaneous coronary intervention (PCI) improves post-infectious MI prognosis is a major but unsolved issue. In this prospective multicenter study from coronary care units, we performed propensity score-matched analysis to compare outcomes in patients with and without PCI for post-infectious MI with angiography-proven significant coronary stenosis (>50%). Among 4573 consecutive MI patients, 476 patients (10%) had a concurrent diagnosis of acute infection at admission, of whom 375 underwent coronary angiography and 321 patients had significant stenosis. Among the 321 patients, 195 underwent PCI. Before the matching procedure, patients without PCI had a similar age and sex ratio but a higher rate of risk factors (hypertension, diabetes, chronic renal failure, and prior coronary artery disease), pneumonia, and SYNTAX score than patients without PCI. After propensity score matching, neither in-hospital mortality (13% with PCI vs. 8% without PCI; p = 0.4) nor one-year mortality (24% with PCI vs. 19% without PCI, p = 0.5) significantly differed between the two groups. In this first prospective cohort of post-infectious MI in coronary care units, PCI might not improve short- and long-term prognosis in patients with angiography-proven significant coronary stenosis. If confirmed, these results do not argue for systematic invasive procedures after post-infectious MI. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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Review

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17 pages, 2274 KiB

Open AccessReview

Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury

by Caelan Taggart, Ryan Wereski, Nicholas L. Mills and Andrew R. Chapman

J. Clin. Med. 2021, 10(11), 2331; https://doi.org/10.3390/jcm10112331 - 26 May 2021

Cited by 10 | Viewed by 10342

Abstract

The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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Other

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9 pages, 624 KiB

Open AccessBrief Report

Intracranial Hemorrhage Complicating Acute Myocardial Infarction: An 18-Year National Study of Temporal Trends, Predictors, and Outcomes

by Sri Harsha Patlolla, Pranathi R. Sundaragiri, Wisit Cheungpasitporn, Rajkumar Doshi, Gregory W. Barsness, Alejandro A. Rabinstein, Allan S. Jaffe and Saraschandra Vallabhajosyula

J. Clin. Med. 2020, 9(9), 2717; https://doi.org/10.3390/jcm9092717 - 22 Aug 2020

Cited by 7 | Viewed by 1880

Abstract

Background: There is a paucity of contemporary data on the burden of intracranial hemorrhage (ICH) complicating acute myocardial infarction (AMI). This study sought to evaluate the temporal trends, predictors, and outcomes of ICH in AMI. Methods: The National Inpatient Sample (2000–2017) was used to identify adult (>18 years) AMI admissions with ICH. In-hospital mortality, hospitalization costs, length of stay, and measure of functional ability were the outcomes of interest. The discharge destination along with use of tracheostomy and percutaneous endoscopic gastrostomy were used to estimate functional burden. Results: Of a total 11,622,528 AMI admissions, 23,422 (0.2%) had concomitant ICH. Compared to those without, the ICH cohort was on average older, female, of non-White race, had greater comorbidities, and had higher rates of arrhythmias (all p < 0.001). Female sex, non-White race, ST-segment elevation AMI presentation, use of fibrinolytics, mechanical circulatory support, and invasive mechanical ventilation were identified as individual predictors of ICH. The AMI admissions with ICH received less frequent coronary angiography (46.9% vs. 63.8%), percutaneous coronary intervention (22.7% vs. 41.8%), and coronary artery bypass grafting (5.4% vs. 9.2%), as compared to those without (p < 0.001). ICH was associated with a significantly higher in-hospital mortality (41.4% vs. 6.1%; adjusted OR 5.65 (95% CI 5.47–5.84); p < 0.001), longer hospital length of stay, higher hospitalization costs, and greater use of percutaneous endoscopic gastrostomy (all p < 0.001). Among ICH survivors (N = 13, 689), 81.3% had a poor functional outcome at discharge. Conclusions: ICH causes a substantial burden in AMI due to associated higher in-hospital mortality and poor functional outcomes. Full article

(This article belongs to the Special Issue Myocardial Infarction and Myocardial Injury in Acute Cardiac Care)

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