Aims The current definition of post ST-segment elevation myocardial infarction (STEMI) left ventricular (LV) remodelling is purely structural (LV dilatation) and does not consider LV function ... Show moreAims The current definition of post ST-segment elevation myocardial infarction (STEMI) left ventricular (LV) remodelling is purely structural (LV dilatation) and does not consider LV function (ejection fraction, EF), even though it is known to be a predictor of long-term post-STEMI outcome. This study aimed to reclassify LV remodelling after STEMI by integrating LV dilatation and function (LVEF) and to investigate the prognostic implications.Methods and results Data from an ongoing registry of STEMI patients who were treated with primary percutaneous coronary intervention (PCI) were retrospectively evaluated. Four distinct remodelling subgroups were identified: (i) no LV dilatation, no LVEF impairment,(ii) no LV dilatation but LVEF impairment, (iii) LV dilatation but no LVEF impairment, and (iv) LV dilatation and LVEF impairment. The impact of functional LV remodelling on outcomes was analysed. A total of 2346 patients were studied (mean age 60 +/- 11 years, 76% men). During a median follow-up of 76 (interquartile range 52 to 107) months, 282 (12%) died, while the composite of death and heart failure hospitalization occurred in 305 (13%) patients. Those with LV remodelling and LVEF impairment had a significantly lower survival rate (P < 0.001) and event-free survival rate (P < 0.001) compared with other functional LV remodelling groups.Conclusions Employing a functional LV post-infarct remodelling classification has the potential to improve risk stratification beyond structural LV remodelling alone. Identification of patients with the worst prognosis by using a functional LV remodelling approach may allow institution of early preventative therapies. Show less
Introduction It is unknown how long-term prognosis after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis is impacted by cancer-related factors as diagnosis,... Show moreIntroduction It is unknown how long-term prognosis after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis is impacted by cancer-related factors as diagnosis, stage, and treatment. We aimed to assess long-term survival trends after STEMI in this population to evaluate both cardiovascular and cancer-related drivers of prognosis over a follow-up period of 5 years. Methods In this retrospective single-center cohort study, patients with a prior cancer diagnosis admitted with STEMI between 2004 and 2014 and treated with primary percutaneous coronary intervention (PCI) were recruited from the STEMI clinical registry of our institution. Results In the 211 included patients, the cumulative incidence of all-cause death after 5 years of follow-up was 38.1% (N = 60). The cause of death was predominantly malignancy-related (N = 29, 48.3% of deaths) and nine patients (15.0%) died of a cardiovascular cause. After correcting for age and sex, a recent cancer diagnosis (< 1 year relative to > 10 years, HRadj 2.98 [95% CI: 1.39-6.41], p = 0.005) and distant metastasis at presentation (HRadj 4.02 [1.70-9.53], p = 0.002) were significant predictors of long-term mortality. While maximum levels of cardiac troponin-T and creatinine kinase showed significant association with mortality (resp. HRadj 1.34 [1.08-1.66], p = 0.008; HRadj 1.36 [1.05-1.76], p = 0.019), other known determinants of prognosis after STEMI, e.g., hypertension and renal insufficiency, were not significantly associated with survival. Conclusions Patients with a prior cancer diagnosis admitted with STEMI have a poor survival rate. However, when the STEMI is optimally treated with primary PCI and medication, cardiac mortality is low, and prognosis is mainly determined by factors related to cancer stage. Show less
Objective To assess whether the COVID-19 lockdown in 2020 had negative indirect health effects, as people seem to have been reluctant to seek medical care. Methods All emergency medical services ... Show moreObjective To assess whether the COVID-19 lockdown in 2020 had negative indirect health effects, as people seem to have been reluctant to seek medical care. Methods All emergency medical services (EMS) transports for chest pain or out-of-hospital cardiac arrest (OHCA) in the Dutch region Hollands-Midden (population served > 800,000) were evaluated during the initial 6 weeks of the COVID-19 lockdown and during the same time period in 2019. The primary endpoint was the number of evaluated chest pain patients in both cohorts. In addition, the number of EMS evaluations of ST-elevation myocardial infarction (STEMI) and OHCA were assessed. Results During the COVID-19 lockdown period, the EMS evaluated 927 chest pain patients (49% male, age 62 +/- 17 years) compared with 1041 patients (51% male, 63 +/- 17 years) in the same period in 2019, which corresponded with a significant relative risk (RR) reduction of 0.88 (95% confidence interval (CI) 0.81-0.96). Similarly, there was a significant reduction in the number of STEMI patients (RR 0.52, 95% CI 0.32-0.85), the incidence of OHCA remained unchanged (RR 1.23, 95% CI 0.83-1.83). Conclusion During the first COVID-19 lockdown, there was a significant reduction in the number of patients with chest pain or STEMI evaluated by the EMS, while the incidence of OHCA remained similar. Although the reason for the decrease in chest pain and STEMI consultations is not entirely clear, more attention should be paid to the importance of contacting the EMS in case of suspected cardiac symptoms in possible future lockdowns. Show less
Background Early prehospital recognition of critical conditions such as ST-segment-elevation myocardial infarction (STEMI) has prognostic relevance. Current international electrocardiographic STEMI... Show moreBackground Early prehospital recognition of critical conditions such as ST-segment-elevation myocardial infarction (STEMI) has prognostic relevance. Current international electrocardiographic STEMI thresholds are predominantly based on individuals of Western European descent. However, because of ethnic electrocardiographic variability both in health and disease, there is a need to reevaluate diagnostic ST-segment elevation thresholds for different populations. We hypothesized that fulfillment of ST-segment elevation thresholds of STEMI criteria (STE-ECGs) in apparently healthy individuals is ethnicity dependent.Methods and Results HELIUS (Healthy Life in an Urban Setting) is a multiethnic cohort study including 10 783 apparently healthy subjects of 6 different ethnicities (African Surinamese, Dutch, Ghanaian, Moroccan, South Asian Surinamese, and Turkish). Prevalence of STE-ECGs across ethnicities, sexes, and age groups was assessed with respect to the 2 international STEMI thresholds: sex and age specific versus sex specific. Mean prevalence of STE-ECGs was 2.8% to 3.4% (age/sex-specific and sex-specific thresholds, respectively), although with large ethnicity-dependent variability. Prevalences in Western European Dutch were 2.3% to 3.0%, but excessively higher in young (<40 years) Ghanaian males (21.7%-27.5%) and lowest in older (40 years) Turkish females (0.0%). Ethnicity (sub-Saharan African origin) and other variables (eg, younger age, male sex, high QRS voltages, or anterolateral early repolarization pattern) were positively associated with STE-ECG occurrence, resulting in subgroups with >45% STE-ECGs.Conclusions The accuracy of diagnostic tests partly relies on background prevalence in healthy individuals. In apparently healthy subjects, there is a highly variable ethnicity-dependent prevalence of ECGs with ST-segment elevations exceeding STEMI thresholds. This has potential consequences for STEMI evaluations in individuals who are not of Western European descent, putatively resulting in adverse outcomes with both over- and underdiagnosis of STEMI. Show less
After a reperfused myocardial infarction (MI), dynamic tissue changes occur (edema, inflammation, microvascular obstruction, hemorrhage, cardiomyocyte necrosis, and ultimately replacement by... Show moreAfter a reperfused myocardial infarction (MI), dynamic tissue changes occur (edema, inflammation, microvascular obstruction, hemorrhage, cardiomyocyte necrosis, and ultimately replacement by fibrosis). The extension and magnitude of these changes contribute to long-term prognosis after MI. Cardiac magnetic resonance (CMR) is the gold-standard technique for noninvasive myocardial tissue characterization. CMR is also the preferred methodology for the identification of potential benefits associated with new cardioprotective strategies both in experimental and clinical trials. However, there is a wide heterogeneity in CMR methodologies used in experimental and clinical trials, including time of post-MI scan, acquisition protocols, and, more importantly, selection of endpoints. There is a need for standardization of these methodologies to improve the translation into a real clinical benefit. The main objective of this scientific expert panel consensus document is to provide recommendations for CMR endpoint selection in experimental and clinical trials based on pathophysiology and its association with hard outcomes. (C) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. Show less
Bodde, M.C.; Hermans, M.P.J.; Laarse, A. van der; Mertens, B.; Romijn, F.P.H.T.M.; Schalij, M.J.; ... ; Jukema, J.W. 2019
IntroductionThe current way to assess the risk of cardiovascular disease (CVD) is to measure conventional lipid and lipoprotein cholesterol fractions. Despite the success of statin treatment,... Show moreIntroductionThe current way to assess the risk of cardiovascular disease (CVD) is to measure conventional lipid and lipoprotein cholesterol fractions. Despite the success of statin treatment, residual cardiovascular risk remains high. Therefore, the value of extensive serum apolipoprotein (apo) profiling to assess the risk of ST-segment elevation myocardial infarction (STEMI) and of major adverse cardiac events (MACE) in patients with STEMI was investigated in a case-control design.Methods and resultsSerum apo levels were measured using liquid chromatography and mass spectrometry in 299 healthy individuals and 220 patients with STEMI. First, the association of apo profiles in baseline samples with risk of STEMI was examined, and second, the association of apo profiles at baseline with risk of recurrent MACE in patients with STEMI in a longitudinal study design was studied. High baseline (>1.25g/L) apoA1 levels were associated with a decreased risk of STEMI [odds ratio (OR) 0.17; 95% CI 0.11-0.26], whereas high apoB (>1.00g/L) levels (OR 2.17; 95% CI 1.40-3.36) and apoB/apoA1 ratio (OR per 1 SD (OR/SD): 2.16; 95% CI 1.76-2.65) were associated with an increased risk. Very-low-density-lipoprotein (VLDL)-associated apos gave conflicting results. Neither conventional lipid levels nor apo levels were associated with MACE in the STEMI group.ConclusionIn conclusion, apoA1, apoB, and apoB/apoA1 were strongly associated with risk of STEMI. No clear relation between VLDL-associated apos and the risk of STEMI was found. Neither baseline serum apos nor lipids predicted MACE in statin-treated patients during long-term follow-up after a first STEMI. Show less
Aim of this thesis was to evaluate contemporary care and prognosis for patients with acute coronary syndrome and identify pitfalls in its treatment. Complications after coronary stent implantation... Show moreAim of this thesis was to evaluate contemporary care and prognosis for patients with acute coronary syndrome and identify pitfalls in its treatment. Complications after coronary stent implantation were explored and demonstrated that in sirolimus-eluting stents, the benefit of reduced repeat revascularization during one year after primary PCI was not sustained during long-term follow-up. Additionally, an increased risk of very late stent thrombosis was suggested. Late stent malapposition, more commonly observed after this stent type and suspected to be involved in the multifactorial etiology of stent thrombosis, is shown to persist in the greater portion of STEMI patients during long-term follow-up, depending on the degree of vessel wall remodelling and change in plaque burden. Women were identified as a sub-population with poorer prognosis early after STEMI. Identification of high-risk patients, and estimation of infarct size and prognosis, which a single measurement of troponin already may indicate, facilitates individualized treatment and likely results in better outcomes. Although numerous novel treatment modalities emerged in recent years, certain pitfalls become increasingly important. Major bleeding is one of them, responsible for an excess mortality amongst STEMI patients after primary PCI, and should be incorporated in risk stratification models for the choice of treatment strategy. Show less
Luca, G. de; Dirksen, M.T.; Spaulding, C.; Kelbaek, H.; Schalij, M.; Thuesen, L.; ... ; Stone, G.W. 2014
