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BACKGROUND: The benefit of beta-blockers after myocardial infarction in patients with a preserved left ventricular ejection fraction (LVEF) is unclear.

METHODS: We conducted a meta-analysis at the individual-patient level using data from five open-label trials that randomly assigned patients with recent myocardial infarction, no other indications for beta-blocker therapy, and an LVEF of at least 50% to receive beta-blocker therapy or no beta-blocker therapy. The primary end point was a composite of death from any cause, myocardial infarction, or heart failure. Event rates were analyzed with a one-stage fixed-effects Cox proportional-hazards model.

RESULTS: A total of 17,801 patients were included from the REBOOT (7459 patients), REDUCE-AMI (4967 patients), BETAMI (2441 patients), DANBLOCK (2277 patients), and CAPITAL-RCT (657 patients) trials. Of these 17,801 patients, 8831 (49.6%) were assigned to receive a beta-blocker and 8970 (50.4%) were assigned to receive no beta-blocker. During a median follow-up of 3.6 years (interquartile range, 2.3 to 4.6), a primary-end-point event occurred in 717 patients (8.1%) in the beta-blocker group and 748 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.97; 95% confidence interval [CI], 0.87 to 1.07; P = 0.54). Death from any cause occurred in 335 patients in the beta-blocker group and 326 patients in the no-beta-blocker group (hazard ratio, 1.04; 95% CI, 0.89 to 1.21); myocardial infarction occurred in 360 and 407 patients, respectively (hazard ratio, 0.89; 95% CI, 0.77 to 1.03); and heart failure occurred in 75 and 87 patients (hazard ratio, 0.87; 95% CI, 0.64 to 1.19).

CONCLUSIONS: In this meta-analysis including individual-patient data from five randomized trials, beta-blocker therapy did not reduce the incidence of death from any cause, myocardial infarction, or heart failure in patients with an LVEF of at least 50% after myocardial infarction without other indications for beta-blockers. (Funded by Centro Nacional de Investigaciones Cardiovasculares Carlos III and others; PROSPERO database number, CRD420251119176.).

INTRODUCTION: Persistently elevated cardiac troponin (cTn) values are observed in many patients with suspected acute coronary syndrome (ACS) in the absence of myocardial infarction and may reflect underlying cardiac disease. Chronic myocardial injury is defined where cTn values are elevated and vary by ≤ 20 % on sequential measurements. We aimed to evaluate whether these criteria are reliable over short intervals applied in accelerated diagnostic pathways.

METHODS: In a secondary analysis of a prospective, multi-centre cohort study of patients with suspected ACS, cTnT was measured at presentation, 1, 2 and 6-36 h, and the final diagnosis adjudicated according to the Fourth Universal Definition of Myocardial Infarction. Two criteria for chronic myocardial injury were compared: a relative change in cTn of ≤ 20 % and an absolute change < 3 ng/L, and the findings externally validated.

RESULTS: At presentation cTnT was elevated in 242 of 1,000 (25 %) patients (73 years, 42 % female), of whom 94/242 (39 %), 13/242 (5 %) and 137/242 (56 %) had myocardial infarction, acute or chronic myocardial injury, respectively. A relative change of ≤ 20 % misclassified 58 % (59/101) and 49 % (48/98) of patients with a final diagnosis of acute myocardial injury or infarction at 1 and 2 h, respectively, whereas an absolute change of < 3 ng/L misclassified 22 % (22/101) and 15 % (15/98). In the validation cohort (n = 621), the relative and absolute change criteria at one hour misclassified 43 % (13/30) and 17 % (5/30) of those with myocardial infarction.

CONCLUSIONS: Chronic myocardial injury cannot reliably be differentiated from acute myocardial injury or infarction by recommended criteria over short remeasurement intervals in the Emergency Department. Longer intervals between sampling and absolute rather than relative criteria may reduce the risk of misclassification.

This study examined whether Growth Differentiation Factor-15 (GDF-15) and echocardiographic measures of systolic left ventricular function improve intermediate- and long-term mortality risk prediction beyond the guideline-endorsed GRACE 2.0 score after Acute Coronary Syndrome (ACS). 751 ACS patients were included. GDF-15, left ventricular ejection fraction (LVEF), and global longitudinal strain (GLS) were added stepwise to GRACE 2.0 in Cox regression models. Discriminative performance was assessed using the C-index for all-cause mortality at 3 years and long-term up to a median follow-up of 6.4 years. Mean age was 64.4 years, and 77% were men. There were 40 deaths at 3 years and 104 deaths by end-of-study. GDF-15 outperformed GRACE 2.0 for 3-year mortality prediction (time-dependent AUC 0.82 [95% CI 0.75-0.89] vs. 0.76 [95% CI 0.67-0.84]; P = 0.001). Adding GDF-15 to GRACE 2.0 improved long-term prognostic accuracy, increasing the C-index from 0.74 (95% CI 0.69-0.79) to 0.76 (95% CI 0.70-0.81). LVEF and GLS improved the C-index in the order of 0.01 when added to GRACE 2.0. GDF-15 meaningfully improved discrimination of all-cause death, both at intermediate- and long-term follow-up, when added on top of GRACE 2.0 whereas LVEF and GLS both provided minor improvements.

Background: Impairment of left-ventricular ejection fraction (LVEF) is a major determinant of poor outcome after myocardial infarction (MI). Data on predisposing factors is however, scarce.

Methods: Registry-based cohort study (SWEDEHEART) investigating 46,621 ST-elevation MI (STEMI) patients and 73,708 non-STEMI patients without a history of heart failure, admitted between 2010 and 2022. Associations of cardiovascular risk factors, comorbidities and angiographic features with LVEF <40 % were studied using multivariable logistic regressions.

Results: LVEF <0.40 was noted in 23,165 (47.6 %) STEMI patients and in 20,978 (28.5 %) non-STEMI patients. In minimally adjusted models, anterior MI localization emerged as the strongest predictor of LVEF <0.40 in STEMI (OR 4.32 [95 % CI 4.07-4.59]) while three-vessel disease/left main stenosis was one of the strongest predictors in non-STEMI (OR 1.78 [95 % CI 1.67-1.90]). Following full adjustment including angiographic data, smoking, diabetes, underweight, kidney disease and estimates of preexisting atherosclerotic disease (previous MI, previous stroke, peripheral artery disease) were independently associated with LVEF <0.40 in both MI types. Hypertension and overweight exhibited inverse associations with LVEF <0.40.

Conclusions: Our results emphasize the need of early and complete revascularization in STEMI and non-STEMI, respectively, and of further investigation to inform customized cardioprotective pharmacotherapies in patients with concomitant risk factors and comorbidities, given their risk of developing impaired LVEF.

Background Secondary preventive medications following myocardial infarction (MI) reduce the risk of new cardiovascular events. Discontinuation and suboptimal adherence are common and affect prognosis. However, there is limited knowledge regarding adherence in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). We therefore aim to evaluate the adherence to guideline recommended medications in patients with MINOCA and myocardial infarction with obstructive coronary arteries (MI-CAD). Methods This was a Swedish nationwide observational study of MI patients recorded in the SWEDEHEART registry between 2006 & horbar;2017. A total of 9,138 MINOCA and 107,240 MI-CAD patients were followed for a mean 5.9 years. Initiation of therapy, implementation determined using medication possession ratio, and persistence rates during different time periods were calculated. Results Patients with MINOCA were less frequently prescribed secondary preventive medications than MI-CAD. The percentage of patients taking medication as prescribed were lower in MINOCA than in MI-CAD at all time points; during months 6-12 after discharge: aspirin 94.8% vs 97.2% (p < 0.001), statins 90.3% vs 94.7% (p < 0.001), and ACEI/ARBs 97.7% vs 98.5% (p = 0.002) and at 12 months: aspirin 84.4% vs 93.7% (p < 0.001), statins 83.8% vs 94.8% (p < 0.001), ACEI/ARBs 85.0% vs 92.2% (p < 0.001) and beta blockers 80.4% vs 89.6% (p < 0.001). Conclusion The rates of initiation, implementation, and persistence of secondary preventive medications were high in both MINOCA and MI-CAD patients during the first 5 years after MI. The lower rates in patients with MINOCA may be partially due to uncertainties regarding the diagnosis of MINOCA, differences in patient characteristics, and psychosocial factors. Suboptimal medical adherence in patients with MINOCA may adversely affect prognosis as previously demonstrated in MI-CAD patients.

BACKGROUND: Symptom burden and disease effects following myocardial infarction with nonobstructive coronary arteries (MINOCA) are not well studied. We aimed to evaluate the prevalence of angina pectoris, sick leave, and quality-of-life levels 1 year after the index event, using patients with myocardial infarction due to obstructive coronary artery disease (MI-CAD) as controls.

METHODS AND RESULTS: Patients with first-time myocardial infarction, assessed by coronary angiography and registered in the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry 2005 to 2022 were eligible and included if attending the 1-year follow-up. Patients with previous coronary intervention, heart failure, arrhythmia at admission, and not fully revascularized MI-CAD were excluded. Outcomes were prospectively collected during standard care. A total of 46 428 patients (mean age, 62years; 71% men; MINOCA, n=5281/MI-CAD, n=41 157) were assessed after 1 year. Angina prevalence was 11.6% in MINOCA and 8.8% in fully revascularized MI-CAD (crude risk ratio, 1.32 [95% CI, 1.21-1.47]; odds ratio, 1.18 [95% CI, 1.07-1.30], adjusted for potential confounders). Patients with MINOCA had a higher degree of sick leave than patients with MI-CAD both at index care and at 1 year (8.0% versus 5.6% and 13.4% versus 10.9%, respectively; both P<0.001). Quality-of-life measures were lower in MINOCA. These associations were unaffected when adjusting for angina status but were attenuated when adjusting for potential confounders.

CONCLUSIONS: Patients with MINOCA have significant distress, with higher levels of angina pectoris and sick leave and worse quality of life at 1 year compared with fully revascularized MI-CAD counterparts.

Background Emerging evidence suggests that the ratio between cardiac troponin (cTn) I and T may provide information on the risk of adverse outcomes in individuals with cardiovascular disease. Whether the cTn I/T ratio provides prognostic insights in the general population is unknown. Methods The cTn I/T ratio was calculated in 8855 participants (43% female, median age 56 years) from the Generation Scotland Study where both cTnI and cTnT concentrations were above the limit of blank. Multivariable cause-specific Cox proportional hazard models were used to estimate the associations between cTn I/T ratio and the primary outcome of cardiovascular or non-cardiovascular death. Results The median cTn I/T ratio was 0.5 (25th-75th percentile, 0.3-0.8) and median follow-up was 11.4 (10.8-12.7) years. Individuals in the highest ratio tertile (>= 0.64) were more likely to be male, have a higher body mass index and systolic blood pressure, and a history of cardiovascular disease. Those in the lowest ratio tertile (<0.38) were more likely to be smokers or have diabetes. After adjustment for cardiovascular risk factors, the cTn I/T ratio was positively associated with cardiovascular death (per doubling increase, adjusted hazard ratio [HR] 1.16 [95% CI, 1.05-1.28]), while an inverse association was observed for non-cardiovascular death (HR 0.89 [95% CI, 0.81-0.99]). Conclusions The cTn I/T ratio is positively associated with cardiovascular death in the general population, while inversely associated with non-cardiovascular death. Future research is needed to unravel underlying mechanisms and determine whether the cTn I/T ratio provides valuable information regarding risk of cardiovascular and non-cardiovascular mortality to guide further management.

BACKGROUND: The diagnostic performance of high-sensitivity cardiac troponin T/I (hs-cTnT/I) and the efficacy of the European Society of Cardiology (ESC) 0/1-h hs-cTnT/I algorithms for the early diagnosis of non-ST-elevation myocardial infarction are lower in cancer patients.

OBJECTIVES: The authors aimed to derive new cutoffs for ESC 0/1-h hs-cTnT/I algorithms optimized for use in patients with active or past cancer.

METHODS: Patients presenting with suspected non-ST-elevation myocardial infarction to the emergency department enrolled in an international multicenter study were analyzed. Final diagnoses were centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of myocardial infarction. External validation was performed in 2 independent cohorts.

RESULTS: Among 541 eligible cancer patients, cancer-optimized ESC 0/1-h hs-cTnT cutoffs, <8 ng/L at presentation (if chest pain onset >3 hours) or <14 ng/L if 0/1 h-delta is <3 ng/L for rule-out and ≥54 ng/L or 0/1-h delta ≥4 ng/L for rule-in, increased the efficacy vs the current cutoffs from 58.6% (95% CI: 54.4-62.7) to 68.0% (95% CI: 64.0-71.8; P < 0.001). Sensitivity and specificity remained high and comparable. Similarly, among 516 eligible patients, cancer-optimized ESC 0/1-h hs-cTnI-Architect cutoffs, <7 ng/L at presentation (if chest pain onset >3 hours) or <10 ng/L if 0/1-h delta is <3 ng/L for rule-out and ≥61 ng/L or 0/1-h delta ≥5 ng/L for rule-in, increased the efficacy vs the current cutoffs from 59.3% (95% CI: 55.0-63.5) to 78.9% (95% CI: 75.2-82.2; P < 0.001). Sensitivity and specificity again remained high and comparable. Findings were confirmed in internal and external validation cohorts (n = 130 and n = 195 patients, respectively).

CONCLUSIONS: Cancer-optimized ESC 0/1-h hs-cTnT/I algorithm cutoffs increased efficacy maintaining high safety.