S. Hoo

Triggering of acute coronary occlusion by episodes of anger

Aims: The aim of this study was to report the association between episodes of anger and acute myocardial infarction (MI) in patients with angiographically confirmed coronary occlusion. Methods and results: 313 participants with acute coronary occlusion (Thrombolysis In Myocardial Infarction 0 or 1 at emergency angiography) reported frequency of anger episodes in the 48 h prior to MI. In primary analysis, anger exposures within 2 h and 2–4 h prior to symptom onset were compared with subjects’ own usual yearly exposure to anger using case-crossover methodology. Anger level ≥5 (on an anger scale of 1–7) was reported by seven (2.2%) participants within 2 h of MI. Compared with usual frequency, the relative risk of onset of MI symptoms occurring within 2 h of anger level ≥5 (defined as very angry) was 8.5 (95% confidence interval 4.1–17.6). Anger level <5 was not associated with onset of MI symptoms. Compared with 24–26 h pre MI, anxiety scores >75th percentile on State–Trait Personality Inventory were associated with a relative risk of 2.0 (95% confidence interval 1.1–3.8) and in those above the 90th percentile, the relative risk of MI symptom onset was 9.5 (95% confidence interval 2.2–40.8). Conclusion: Findings confirm that episodes of intense anger, defined as being ‘very angry, body tense, clenching fists or teeth’ (within 2 h) are associated with increased relative risk for acute coronary occlusion. Additionally, increased anxiety was associated with coronary occlusion. Further study, including the role of potential modifiers, may provide insight into prevention of MI during acute emotional episodes.

Triggering of Acute Myocardial Infarction by Respiratory Infection

Respiratory infection has been associated with an increased short‐term risk of myocardial infarction (MI). However, previous studies have predominantly been conducted without angiographic confirmation of MI. The possibility can therefore not be excluded that raised troponin levels or electrocardiogram abnormalities that may be seen with respiratory infections are due to non‐ischaemic causes.

Increasing proportion of ST elevation myocardial infarction patients with coronary atherosclerosis poorly explained by standard modifiable risk factors

Aims Identification and management of the Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) has substantially improved cardiovascular disease outcomes. However, cardiovascular disease remains the leading cause of death worldwide. Suspecting an evolving pattern of risk factor profiles in the ST elevation myocardial infarction (STEMI) population with the improvements in primary care, we hypothesized that the proportion of ‘SMuRFless’ STEMI patients may have increased. Methods/results We performed a single centre retrospective study of consecutive STEMI patients presenting from January 2006 to December 2014. Over the study period 132/695 (25%) STEMI patients had 0 SMuRFs, a proportion that did not significantly change with age, gender or family history. The proportion of STEMI patients who were SMuRFless in 2006 was 11%, which increased to 27% by 2014 (odds ratio 1.12 per year, 95% confidence interval: 1.04–1.22). The proportion of patients with hypercholesterolaemia decreased (odds ratio 0.92, 95% confidence interval 0.86–0.98), as did the proportion of current smokers (odds ratio 0.93, 95% confidence interval 0.86–0.99), with no significant change in the proportion of patients with diabetes and hypertension. SMuRF status was not associated with extent of coronary disease; in-hospital outcomes, or discharge prescribing patterns. Conclusion The proportion of STEMI patients with STEMI poorly explained by SMuRFs is high, and is significantly increasing. This highlights the need for bold approaches to discover new mechanisms and markers for early identification of these patients, as well as to understand the outcomes and develop new targeted therapies.

Predictors of cardiac rehabilitation attendance following primary percutaneous coronary intervention for ST-elevation myocardial infarction in Australia

Cardiac rehabilitation is an important component of recovery and secondary prevention following urgent primary percutaneous coronary intervention. However, attendance and factors that predict participation by patients admitted with ST-elevation myocardial infarction remain unclear. This Australian study was conducted using a descriptive, comparative design. Consecutive patients (n = 246) at two hospitals were interviewed by telephone at four weeks and six months. Open-ended questions were used to assess cardiac rehabilitation attendance, sociodemographics, modifiable risk factors, clinical outcomes, and post-discharge health support. Post-discharge home visits at four weeks (odds ratio: 2.64, 95% confidence interval: 1.48-4.71) and at six months were associated with better cardiac rehabilitation attendance; more males participated at four weeks and at six months. The results suggest the need to integrate post-discharge health support with cardiac rehabilitation to facilitate recovery after primary percutaneous coronary intervention, particularly for females with ST-elevation myocardial infarction.

Left bundle branch block without concordant ST changes is rarely associated with acute coronary occlusion

BACKGROUND The Sgarbossa score has been used to identify acute myocardial infarction on ECG in the presence of LBBB but has relied on elevated CK-MB for validation rather than angiographic evidence of vessel occlusion. METHODS We determined (a) the presence or absence of Sgarbossa criteria with concordant (S-con) or discordant (S-dis) ST changes, (b) the presence of acute coronary occlusion or likely recent occlusion on angiography and (c) the biochemical evidence of myocardial infarction (Troponin T >0.10 μg/L, Troponin I >1.0 μg/L) in patients field-triaged with suspected AMI and LBBB. RESULTS Between April 2004 and March 2009, 102 patients had field ECGs transmitted by paramedics for triage--8 with S-con, 26 with S-dis and 68 with LBBB alone. Acute coronary occlusion was present in 8/8 with S-con but none of the S-dis or LBBB alone patients, and in all 8 S-con patients reperfusion resulted in resolution of S-con changes. Likely culprit lesions with TIMI 3 flow were found in 3 S-dis patients but stenting did not result in resolution of S-dis. LBBB did not resolve in any patient. Troponin was elevated in 26 patients--11 with occlusion or likely culprit lesions, 15 with non-ischaemic causes. CONCLUSIONS In the absence of S-con, LBBB is not associated with acute coronary occlusion and should not be used as criteria for reperfusion therapy in myocardial infarction.

Routine aspiration thrombectomy improves the diagnosis and management of embolic myocardial infarction

Assess the effect of aspiration thrombectomy on diagnosis and management of embolic acute myocardial infarction.

Myocardial injury following Primary Percutaneous Coronary Intervention (PCI) is comparable in patients with multi-vessel disease compared to single vessel disease

Background: “Ischaemic Preconditioning” is a well-documented mechanism, which protects viable myocardium that is repeatedly exposed to ischaemic episodes. Patients with multi-vessel disease (MVD) should have been exposed to a higher level of ischaemic burden than similar patients with single vessel disease (SVD). If these patients subsequently present with acute myocardial infarction (AMI), our hypothesis suggests that there should be a reduction in their amount of myocardial injury compared to patients with SVD. Methods: We examined all patients who presented to our institutionwith suspectedAMI to identify (a) presence of MVD or SVD (b) myocardial injury (CK). Results: Between May 2005 and February 2009, 1297 patients underwent coronary angiography for suspected AMI. Complete data was missing in 108 patients. 264 Patients were found to have normal or minor disease in their coronary arteries andwere excluded from this study. Of the remaining925patients, PrimaryPCIwasperformed <6h from symptom onset in 564 patients, 283(SVD) and 281(MVD). The mean CK values for each group were 2020U/L (SVD) and 1915U/L (MVD). Conclusions: Myocardial injury following primary PCI for AMI is similar in patients irrespective of number of concomitant vessels diseased. Based on this result, there is no evidence to support our hypothesis, however a larger study may be needed to fully address this question.