Novel Insights Into the Effects of Interleukin 6 Antagonism in Non-ST-Segment-Elevation Myocardial Infarction Employing the SOMAscan Proteomics Platform

Background: Interleukin 6 concentration is associated with myocardial injury, heart failure, and mortality after myocardial infarction. In the Norwegian tocilizumab non-ST-segment-elevation myocardial infarction trial, the first randomized trial of interleukin 6 blockade in myocardial infarction, concentration of both C-reactive protein and troponin T were reduced in the active treatment arm. In this follow-up study, an aptamer-based proteomic approach was employed to discover additional plasma proteins modulated by tocilizumab treatment to gain novel insights into the effects of this therapeutic approach. Methods and Results: Plasma from percutaneous coronary intervention-treated patients, 24 in the active intervention and 24 in the placebo-control arm, drawn 48 hours postrandomization were randomly selected for analysis with the SOMAscan assay. Employing slow off-rate aptamers, the relative abundance of 1074 circulating proteins was measured. Proteins identified as being significantly different between groups were subsequently measured by enzyme immunoassay in the whole trial cohort (117 patients) at all time points (days 1-3 [7 time points] and 3 and 6 months). Five proteins identified by the SOMAscan assay, and subsequently confirmed by enzyme immunoassay, were significantly altered by tocilizumab administration. The acute-phase proteins lipopolysaccharide-binding protein, hepcidin, and insulin-like growth factor-binding protein 4 were all reduced during the hospitalization phase, as was the monocyte chemoattractant C-C motif chemokine ligand 23. Proteinase 3, released primarily from neutrophils, was significantly elevated. Conclusions: Employing the SOMAscan aptamer-based proteomics platform, 5 proteins were newly identified that are modulated by interleukin 6 antagonism and may mediate the therapeutic effects of tocilizumab in non-ST-segment-elevation myocardial infarction

Genetic epidemiology of amyotrophic lateral sclerosis in Norway - a 2-year population based study

Background: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that affects motor neurons. In Europe, disease-causing genetic variants have been identified in 40-70% of familial ALS patients and approximately in 5% of sporadic ALS patients. In Norway, the contribution of genetic variants to ALS has not yet been studied. In light of the potential development of personalized medicine, knowledge of genetic causes of ALS in a population is becoming increasingly important. The present study provides clinical and genetic data on familial and sporadic ALS patients in a Norwegian population-based cohort. Methods: Blood samples and clinical information from ALS patients were obtained at all 17 neurological departments throughout Norway during a 2-year period. Genetic analysis of the samples involved expansion analysis of C9orf72 and exome sequencing targeting 30 known ALS-linked genes. The variants were classified using genotype-phenotype correlations and bioinformatics tools. Results: A total of 279 ALS patients were included in the study. Of these, 11.5% had one or several family members affected with ALS, whereas 88.5% had no known family history of ALS. A genetic cause of ALS was identified in 31 individuals (11.1%), among which 18 (58.1%) were familial and 13 (41.9%) were sporadic. The most common genetic cause was the C9orf72 expansion (6.8%), which was identified in 8 familial and 11 sporadic ALS patients. Pathogenic or likely pathogenic variants of SOD1 and TBK1 were identified in 10 familial and 2 sporadic cases. C9orf72 expansions dominated in patients from the Northern and Central regions, whereas SOD1 variants dominated in patients from the South-Eastern region. Conclusion: In the present study, we identified several pathogenic gene variants in both familial and sporadic ALS patients. Restricting genetic analysis to only familial cases would miss more than 40 percent of those with a disease-causing genetic variant, indicating the need for genetic analysis in sporadic cases as well.publishedVersio

Proteogenomic integration reveals CXCL10 as a potentially downstream causal mediator for IL-6 signaling on atherosclerosis

BACKGROUND: Genetic and experimental studies support a causal involvement of interleukin-6 (IL-6) signaling in atheroprogression. While trials targeting IL-6 signaling are underway, any benefits must be balanced against an impaired host immune response. Dissecting the mechanisms that mediate the effects of IL-6 signaling on atherosclerosis could offer insights about novel drug targets with more specific effects. METHODS: Leveraging data from 522,681 individuals, we constructed a genetic instrument of 26 variants in the gene encoding the IL-6 receptor (IL-6R) that proxied for pharmacological IL-6R inhibition. Using Mendelian randomization (MR), we assessed its effects on 3,281 plasma proteins quantified with an aptamer-based assay in the INTERVAL cohort (n=3,301). Using mediation MR, we explored proteomic mediators of the effects of genetically proxied IL-6 signaling on coronary artery disease (CAD), large artery atherosclerotic stroke (LAAS), and peripheral artery disease (PAD). For significant mediators, we tested associations of their circulating levels with incident cardiovascular events in a population-based study (n=1,704) and explored the histological, transcriptomic, and cellular phenotypes correlated with their expression levels in samples from human atherosclerotic lesions. RESULTS: We found significant effects of genetically proxied IL-6 signaling on 70 circulating proteins involved in cytokine production/regulation and immune cell recruitment/differentiation, which correlated with the proteomic effects of pharmacological IL-6R inhibition in a clinical trial. Among the 70 significant proteins, genetically proxied circulating levels of CXCL10 were associated with risk of CAD, LAAS, and PAD with up to 67% of the effects of genetically downregulated IL-6 signaling on these endpoints mediated by decreases in CXCL10. Higher midlife circulating CXCL10 levels were associated with a larger number of cardiovascular events over 20 years, whereas higher CXCL10 expression in human atherosclerotic lesions correlated with a larger lipid core and a transcriptomic profile reflecting immune cell infiltration, adaptive immune system activation, and cytokine signaling. CONCLUSIONS: Integrating multiomics data, we found a proteomic signature of IL-6 signaling activation and mediators of its effects on cardiovascular disease. Our analyses suggest the interferon-γ-inducible chemokine CXCL10 to be a potentially causal mediator for atherosclerosis in three vascular compartments and as such could serve as a promising drug target for atheroprotection

IL-6 Receptor Inhibition by Tocilizumab Attenuated Expression of C5a Receptor 1 and 2 in Non-ST-Elevation Myocardial Infarction

Background: Elevated interleukin-6 (IL-6) and complement activation are associated with detrimental effects of inflammation in coronary artery disease (CAD). The complement anaphylatoxins C5a and C3a interact with their receptors; the highly inflammatory C5aR1, and the C5aR2 and C3aR. We evaluated the effect of the IL-6 receptor (IL-6R)-antagonist tocilizumab on the expression of the anaphylatoxin receptors in whole blood from non-ST-elevation myocardial infarction (NSTEMI) patients. Separately, anaphylatoxin receptor expression in peripheral blood mononuclear cells (PBMC) from patients with different entities of CAD was investigated.Materials and Methods: NSTEMI patients were randomized to one dose of tocilizumab (n = 28) or placebo (n = 32) and observed for 6 months. Whole blood samples drawn at inclusion, at day 2, 3 and after 6 months were used for mRNA isolation. Plasma was prepared for analysis of complement activation measured as sC5b-9 by ELISA. Furthermore, patients with different CAD entities comprising stable angina pectoris (SAP, n = 22), non-ST-elevation acute coronary syndrome (NSTE-ACS, n = 21) and ST-elevation myocardial infarction (STEMI, n = 20) were included. PBMC was isolated from blood samples obtained at admission to hospital and mRNA isolated. Anaphylatoxin-receptor-expression was analyzed with qPCR using mRNA from whole blood and PBMC, respectively.Results: Our main findings were (i) Tocilizumab decreased C5aR1 and C5aR2 mRNA expression significantly (p < 0.001) and substantially (>50%) at day 2 and 3, whereas C3aR expression was unaffected. (ii) Tocilizumab did not affect complement activation. (iii) In analyzes of different CAD entities, C5aR1 expression was significantly increased in all CAD subgroups compared to controls with the highest level in the STEMI patients (p < 0.001). For C5aR2 and C3aR the expression compared to controls were more moderate with increased expression of C5aR2 in the STEMI group (p < 0.05) and C3aR in the NSTE-ACS group (p < 0.05).Conclusion: Expression of C5aR1 and C5aR2 in whole blood was significantly attenuated by IL-6R-inhibition in NSTEMI patients. These receptors were significantly upregulated in PBMC CAD patients with particularly high levels of C5aR1 in STEMI patients

Interleukin-6 receptor inhibition in non-ST-elevation myocardial infarction - Results from a randomized clinical trial

Norsk sammenfatning: Inhibering av interleukin-6 ved hjerteinfarkt uten ST-segment elevasjon i EKG. Resultater fra en randomisert klinisk studie. Dette arbeidet inneholder resultater fra en klinisk, randomisert, dobbel-blindet, placebokontrollert studie, som ble designet for å belyse effekten av å hemme aktiviteten til det proinflammatoriske cytokinet interleukin-6 (IL-6) ved akutt hjerteinfarkt uten ST-segment elevasjon i EKG (NSTEMI). På tross av dagens behandling som inkluderer blodplatehemmende og plakkstabiliserende medisinsk behandling, samt revaskularisering med perkutan koronar intervensjon (PCI) eller koronar bypass kirurgi, så er fortsatt akutt hjerteinfarkt en diagnose som er belastet med høy morbiditet og mortalitet. Økt betennelsesaktivitet i forbindelse med hjerteinfarktet, og særlig økte sirkulerende nivåer av IL-6, er en robust markør for dårligere prognose hos disse pasientene. I denne studien ble aktiviteten til IL-6 hemmet ved intravenøs administrering av én enkelt dose av IL-6 reseptor antagonisten tocilizumab i akuttforløpet av NSTEMI, umiddelbart i forkant av prognostisk utredning med koronar angiografi. I denne studien ble enten tocilizumab eller placebo gitt i tillegg til standard behandling av hjerteinfarkt i henhold til gjeldende norske og europeiske retningslinjer. Effekten av behandlingen ble vurdert med repeterte blodprøver under innleggelsen og ved langtidskontroller etter 3 og 6 måneder. Det ble også utført ultralyd av hjertet under innleggelsen og etter 6 måneder. Dette var en to-senter studie som representerer et samarbeid mellom NTNU, Universitetet i Oslo, St. Olavs hospital og Oslo universitetssykehus Rikshospitalet. 117 pasienter med NSTEMI ble inkludert i studien. Pasientene ble fortløpende inkludert ved Klinikk for hjertemedisin, St. Olavs hospital, og ved Kardiologisk avdeling, Oslo universitetssykehus Rikshospitalet, i perioden august 2011 til og med november 2013. Hver pasient ble fulgt i 6 måneder, og siste kontroll ble gjennomført i april 2014. Artikkel 1: Inflammasjon reflektert ved stigning av C-reaktivt protein (CRP) i blod ved hjerteinfarkt, er positivt korrelert med infarktstørrelse og assosiert med utvikling av hjertesvikt og dårligere prognose. Ved betennelse er det i hovedsak IL-6 som stimulerer leveren til å produsere CRP, og i likhet med CRP er også IL-6 assosiert med infarktstørrelse og dårligere prognose ved akutt hjerteinfarkt. I denne studien så vi derfor på effekten av tocilizumab på CRP-nivåer, og sekundært om medikamentet kunne påvirke hjerteskade bedømt ved nivåer av den spesifikke hjerteskademarkøren troponin T i blod. Pasienter som fikk tocilizumab fikk betennelsesaktiviteten signifikant redusert med 50 % bedømt ved repeterte målinger av CRP under innleggelsen. Videre reduserte også tocilizumab troponin T verdiene, justert for nivåer målt før medikamentet ble gitt (baseline). Effekten på troponin T ble kun sett hos pasienter som ble behandlet med PCI, det vil si ballongutblokking av trange kransårer inn til hjertemuskelen med samtidig levering av stent. Denne artikkelen viser at tocilizumab reduserer betennelse ved hjerteinfarkt, og at medikamentet kan redusere hjerteskaden som kan oppstå som konsekvens av PCI-behandling. Funnene åpner for at medikamentet kan være prognostisk gunstig for pasienter med hjerteinfarkt. Artikkel 2: I denne studien evaluerte vi hvorvidt tocilizumab påvirket koronar- og systemisk endotelfunksjon. Pasienter med akutt hjerteinfarkt karakteriseres både av økt betennelse og dårligere endotelfunksjon. Betennelse er delvis årsaken til redusert endotelfunksjon i denne settingen, og både betennelse og redusert endotelfunksjon er assosiert med dårligere prognose. Den totale karfunksjonen er i hovedsak betinget av funksjonen til glatt muskulatur i karveggen, samt funksjonen til endotelcellene som dekker innsiden av blodårene. I denne artikkelen undersøkte vi karfunksjonen i koronarkarene ved å måle koronar blodstrømsreserve (CFR) med ultralyd under stimulering med medikamentet adenosin. CFR ble undersøkt én gang under innleggelsen etter at medikamentet var gitt, og etter 6 måneder. Videre målte vi markører for endotelfunksjon i blod (VCAM-1, ICAM-1 og vWF). Vi fant ingen effekt av tocilizumab på CFR under innleggelsen eller etter 6 måneder. VCAM-1 var signifikant høyere i tocilizumab-gruppen, men i motsetning til pasienter som fikk placebo, fant vi ingen invers korrelasjon mellom VCAM-1 verdier og koronar karfunksjon bedømt ved CFR hos disse pasientene. Denne artikkelen viser at tocilizumab ikke påvirker koronar karfunksjon i akuttforløpet, samt at tocilizumab øker nivået av VCAM-1, men uten at dette er et uttrykk for forverret koronar karfunksjon. Tocilizumab ser dermed ikke ut til å ha akutte effekter på kar og endotelfunksjon som eventuell forklaring på de gunstige funnene på troponin T observert i artikkel 1. Artikkel 3: I denne studien så vi på effekten av IL-6 hemming på cytokinnettverket ved NSTEMI. Betennelsesresponsen utløst av hjerteinfarkt inkluderer oppregulering av en rekke cytokiner som potensielt kan ha både beskyttende og skadelige effekter i forhold til infarktskade og reparasjonsprosessen av hjertet i etterkant. Vi analyserte plasmaverdiene av 27 forskjellige cytokiner på samtlige tidspunkt. Vi fant at tocilizumab førte til en betydelig stigning av kjemokinene interferon gamma-induserbart protein (IP-10) og makrofag inflammatorisk protein-1β (MIP-1β) som vedvarte under innleggelsen. I tocilizumabgruppen var MIP-1β inverst korrelert til nøytrofile granulocytter og troponin T. Nært samtlige cytokiner analysert i denne studien var oppregulert under innleggelsen sammenliknet med senkontroller, men kun IP-10 og MIP-1β ble påvirket av behandlingen. Denne studien viser at tocilizumab har en begrenset og selektiv effekt på det aktiverte cytokinnettverket ved NSTEMI, med oppregulering av IP-10 og MIP-1β i akuttfasen. Betydningen av disse funnene er usikker, men antyder at MIP-1β kan ha en gunstig effekt i forhold til infarktstørrelse. Tocilizumabs begrensede effekt på andre cytokiner ved hjerteinfarkt, kan også indikere at de mulig positive effektene av IL-6 hemming ved hjerteinfarkt er direkte forårsaket av inhibering av IL-6, og ikke via sekundære effekter på andre cytokiner

Miljøregnskap ved bruk av massivtre sammenlignet med stål

I dagens samfunn med store globale miljøutfordringer kreves det drastiske tiltak for å redusere klimafarlige utslipp. Bygg- og anleggsbransjen er en stor produsent av miljøfiendtlige gasser og har derfor mye å hente på endring og optimalisering av produksjon og drift. Samfunnet har stadig større fokus på klima og det er viktig for en entreprenør å kunne tilby grønne løsninger for å møte kundens krav. Å levere gode miljømessige produkter og tjenester er derfor ikke bare etisk korrekt, men kan også gi et konkurransefortrinn for bedriftene som klarer å redusere sitt klimaavtrykk. Denne oppgaven tar for seg klimagassutslippene ved produksjon og transport av alle materialer til oppføring av en verkstedhall for studieretningen Teknikk og industriell produksjon ved Skjetlein Videregående skole. Klimagassregnskapet føres og sammenlignes deretter med et referansebygg med bæring i stål og vegg og tak av sandwichelementer. Consto AS har som hovedentreprenør på prosjektet besluttet å oppføre bygget i massivtre med søyler og takstoler i limtre. Denne oppgaven er gjennomført for å kunne se på eventuelle miljømessige fordeler og ulemper med denne løsningen. Regnskapet som er gjennomført begrenses til produksjon og transport av de materialer og mengder som er prosjektert for bygget. Med denne begrensing vil ikke elementer som blant annet energibehov ved drift og levetid på bygg spille noen rolle for resultatet. Produkt som solcellepanelet vises i regnskapet som en stor utslippskilde, men dets positive bidrag under driftsfasen vil ikke gjenspeiles. Et slikt regnskap vil derfor ikke vise helhetsbilde, men gi et inntrykk av hvilke typer produkter som er de mest miljøvennlige å produsere og transportere for denne type bygg. I all hovedsak sammenlignes bygningsformen i massivtre/limtre med et referansebygg, prosjektert i stål. Gjennom samarbeid med Consto og tilgang til deres dokumenter, tegninger og BIM-modeller er det hentet ut materialer og mengder for prosjektet. For å hente enkeltprodukters data benyttes en Environmental Product Declaration (EPD). Disse miljødokumentene er hentet ifra EPD-Norge sine hjemmesider eller direkte fra produsent. Om produkter har manglende dokumentasjon er det blitt gjort løsninger og beregninger for å minimere feilmarginen. Med dette som grunnlag ble det utviklet helhetlige regnestykker for byggets utslipp gitt i kg CO2-ekvivalenter. Det ble utført både et biogent og et ikke-biogent regnskap for verkstedhallen. Det totale regnskapet viser at med en biogen regnemetode blir totalt utslipp 100 tonn CO2-ekvivalenter, mens det ikke-biogene regnskapet resulterte i 250 tonn CO2-ekvivalenter. Det ikke-biogene regnskapet utjevner trevirkets karbondioksidopptak og utslipp ved avfallshåndtering, dette resulterer i at klimagassutslippet for trevirke blir «tilnærmet null». Dette er en typisk regnemetode for klimagassutslipp og mest aktuelt å sammenligne med referansebygget. Bruken av massivtre for verkstedhallen på Skjetlein resulterer i en utslippsbesparelse på ca 28% kontra å bygge i stål og sandwichelementer. Valg av massivtre utgjør dermed en tydelig forbedring

Serum PCSK9 is modified by interleukin-6 receptor antagonism in patients with hypercholesterolaemia following non-ST-elevation myocardial infarction

Objective: It is unclear if activation of inflammatory pathways regulates proprotein convertase subtilisin-kexin type 9 (PCSK9) levels. Approach: We evaluated (1) the temporal course of serum PCSK9 during hospitalisation following acute coronary syndrome and associations with markers of inflammation (leucocyte counts, interleukin (IL)-6, C-reactive protein) and lipid levels and (2) the effect of inhibition of IL-6 signalling with the IL-6 receptor antibody tocilizumab on PCSK9 levels in a randomised, double-blind, placebo-controlled trial release in patients with non-ST-elevation myocardial infarction. Results: Serum PCSK9 increased during the acute phase and this response was modestly associated with neutrophil counts (r=0.24, p=0.009) and presence of hypercholesterolaemia (r=0.019, p=0.045), but was not modified by tocilizumab. However, a modifying effect of tocilizumab on PCSK9 levels was observed in patients with hypercholesterolaemia (p=0.024, repeated measures analysis of variance) and this effect was strongly correlated with the decrease in neutrophils (r=0.66, p=0.004). Conclusions: Our study suggests that patients with a more atherogenic profile may benefit from anti-IL-6 therapy with regard to PCSK9. Trial registration number: NCT01491074

Tocilizumab increases citrullinated histone 3 in non-ST segment elevation myocardial infarction

Objective Beyond reducing inflammation and troponin T (TnT) release, the interleukin-6 receptor antagonist tocilizumab reduces neutrophil counts in patients with non-ST segment elevation myocardial infarction (NSTEMI). It is unclear if this is related to formation of neutrophil extracellular traps (NETs), carrying inflammatory and thrombotic properties.Methods In a placebo-controlled trial, 117 patients with NSTEMI were randomised to a single dose of tocilizumab (n=58) or placebo (n=59) before coronary angiography. The NETs related markers double-stranded DNA (dsDNA), myloperoxidase–DNA (MPO–DNA) and citrullinated histone 3 (H3Cit) were measured at five consecutive time points during hospitalisation (days 1–3).Results Our major findings were: (1) H3Cit levels were significantly higher in the tocilizumab compared with the placebo group at all time points (all p<0.05), and H3Cit area under the curve (AUC) was 2.3 fold higher in the tocilizumab compared with placebo group (p<0.0001). (2) MPO–DNA and dsDNA did not differ between the groups. (3) In both treatment arms, dsDNA AUC was associated with TnT AUC. (4) Neutrophil count AUC correlated inversely to H3Cit AUC (p=0.015) in the total population.Conclusions In patients with NSTEMI, treatment with tocilizumab is associated with increased circulating H3Cit levels, suggesting that tocilizumab enhances NETosis. Further studies should clarify whether NETosis is a relevant side effect of tocilizumab. Regardless of tocilizumab, dsDNA associated with TnT release, indicating a link between extracellular nuclear material and myocardial injury

Novel Insights Into the Effects of Interleukin 6 Antagonism in Non-ST-Segment-Elevation Myocardial Infarction Employing the SOMAscan Proteomics Platform

Background Interleukin 6 concentration is associated with myocardial injury, heart failure, and mortality after myocardial infarction. In the Norwegian tocilizumab non-ST-segment-elevation myocardial infarction trial, the first randomized trial of interleukin 6 blockade in myocardial infarction, concentration of both C-reactive protein and troponin T were reduced in the active treatment arm. In this follow-up study, an aptamer-based proteomic approach was employed to discover additional plasma proteins modulated by tocilizumab treatment to gain novel insights into the effects of this therapeutic approach. Methods and Results Plasma from percutaneous coronary intervention-treated patients, 24 in the active intervention and 24 in the placebo-control arm, drawn 48 hours postrandomization were randomly selected for analysis with the SOMAscan assay. Employing slow off-rate aptamers, the relative abundance of 1074 circulating proteins was measured. Proteins identified as being significantly different between groups were subsequently measured by enzyme immunoassay in the whole trial cohort (117 patients) at all time points (days 1-3 [7 time points] and 3 and 6 months). Five proteins identified by the SOMAscan assay, and subsequently confirmed by enzyme immunoassay, were significantly altered by tocilizumab administration. The acute-phase proteins lipopolysaccharide-binding protein, hepcidin, and insulin-like growth factor-binding protein 4 were all reduced during the hospitalization phase, as was the monocyte chemoattractant C-C motif chemokine ligand 23. Proteinase 3, released primarily from neutrophils, was significantly elevated. Conclusions Employing the SOMAscan aptamer-based proteomics platform, 5 proteins were newly identified that are modulated by interleukin 6 antagonism and may mediate the therapeutic effects of tocilizumab in non-ST-segment-elevation myocardial infarction

Effect of a single dose of the interleukin-6 receptor antagonist tocilizumab on inflammation and troponin T release in patients with non-ST-elevation myocardial infarction: a double-blind, randomized, placebo-controlled phase 2 trial

Aims Interleukin-6 (IL-6) contributes to atherosclerotic plaque destabilization and is involved in myocardial injury during ischaemia–reperfusion. Interleukin-6 is therefore a potential therapeutic target in myocardial infarction (MI). We hypothesized that the IL-6 receptor antagonist tocilizumab would attenuate inflammation, and secondarily reduce troponin T (TnT) release in non-ST-elevation MI (NSTEMI). Methods and results In a two-centre, double-blind, placebo-controlled trial, 117 patients with NSTEMI were randomized at a median of 2 days after symptom onset to receive placebo (n = 59) or tocilizumab (n = 58), administered as a single dose prior to coronary angiography. High sensitivity (hs) C-reactive protein and hsTnT were measured at seven consecutive timepoints between Days 1 and 3. The area under the curve (AUC) for high-sensitivity C-reactive protein was the primary endpoint. The median AUC for high-sensitivity C-reactive protein during hospitalization was 2.1 times higher in the placebo than in the tocilizumab group (4.2 vs. 2.0 mg/L/h, P < 0.001). Also, the median AUC for hsTnT during hospitalization was 1.5 times higher in the placebo group compared with the tocilizumab group (234 vs. 159 ng/L/h, P = 0.007). The differences between the two treatment groups were observed mainly in (i) patients included ≤2 days from symptom onset and (ii) patients treated with percutaneous coronary intervention (PCI). No safety issues in the tocilizumab group were detected during 6 months of follow-up. Conclusion Tocilizumab attenuated the inflammatory response and primarily PCI-related TnT release in NSTEMI patients