Cigarette smoking as a risk factor for ST-elevation of myocardial infarction in young women

Background St-elevation myocardial infarction (STEMI) is the most serious form of clinical presentation of coronary heart disease. Women with STEMI have worse prognosis compared with men. The overall reduction in both incidence of STEMI and active smokers makes it unclear what role smoking continues to play as a risk factor for STEMI in the two sexes. Purpose To use the relation between current cigarette smoking and myocardial infarction to quantify the relative risk (RR) ratio of STEMI in women and men. Methods Data were derived from 11,925 consecutive patients admitted to 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT0128776) from January 2010 to July 2018 with a first acute myocardial infarction. Outcome measures included rates of STEMI at clinical presentation as marker of larger infarctions. Estimates were obtained using logistic-regression and propensity score matching models for current versus never or former smokers. The RR was estimated using men as a reference value. Results Smokers experienced myocardial infarction (either STEMI or non-STEMI) much earlier than did non-smokers both in women (59.0±10.2 versus 68.7±11.30 years) and men (55.8±10.3 versus 63.3±11.7 years). Current tobacco smoking was more prevalent in men (50.35% vs 31.75%) and in younger patients (57.71 vs 28.81%). Among younger patients, smoking remained prevalent in men (60.11% vs 49.85%). Smoking was significantly related to STEMI (OR 1.45; 95% CI: 1.32–1.59) compared with non-STEMI. This association was noted in women (OR 1.61; 95% CI: 1.34–1.93) and men (OR 1.39; 95% CI: 1.24–1.56) and was stronger for younger (<65 years) compared with older ages (ORs 1.49; 95% CI: 1.33–1.67 vs 1.34; 95% CI: 1.13–1.59). The risk of STEMI in young women was higher than in young men (ORs 1.63; 95% CI 1.30–2.06 vs 1.45; 95% CI 1.26–1.66,). Propensity score matching analysis confirmed data. Rates of STEMI in young women and young men were 75.8% versus 64.5%, with a significant RR ratio (OR 1.15; CI 1.07–1.23) across outcomes. Conclusions Although current smoking still is an important risk factor for STEMI at all ages and sexes, it is especially relevant in younger women. Mechanisms underlying the sex difference are not related to differences in smoking behaviour. This finding is a critical reminder that physicians and society should address in rigorous tobacco-control programs in the general population with a distinctive emphasis on women, particularly in those countries where smoking among young women is increasing in prevalence

Percutaneous coronary intervention in the age of frailty

Background Although guidelines from the European Society of Cardiology and American Heart Association/American College of Cardiology recommend early percutaneous coronary intervention (PCI) in all patients with non-ST-elevation myocardial infarction/ unstable angina (NSTE-ACS), in day-to-day practice persists uncertainty as to whether to follow guidelines in patients aged 75 years or older. Indeed, recommendations are based on large randomized trials where patients aged 75 years or older are under-represented. Purpose We aimed to investigate whether patients aged 75 years or older would benefit from an early invasive strategy versus a conservative strategy. We also analyzed the factors associated with the choice of an early PCI in this population. Methods The research was conducted on the population of the International Survey of Acute Coronary Syndromes (ISACS-TC) registry. The study population consisted of 6826 eligible patients with NSTE-ACS. Of these patients, 1496 were 75 years old or older and were included in the analysis. The primary outcome measure was 30-day mortality. Key secondary outcomes were bleeding complications during the index hospitalization. Multivariate logistic regression analyses were conducted to establish outcomes and factors associated with outcomes. We evaluated specific ranges of ages: 75–79 years, 80–84 years, and 85 years or over. Further, data were sorted by sex and diabetes mellitus status. Results The mean age of our study population was 80.0 (interquartile range: 77–82) years old. Elderly patients treated with early PCI and medical therapy were significantly younger than those treated with only medical therapy were (78.9 vs 80.5, p<0.001), with each one-year increase in age corresponding to a 7% reduction in likelihood of receiving invasive treatment (OR 0.93, 95% CI 0.91–0.96). Crude 30-day mortality was significantly lower in the overall invasively managed population (5.4% vs 13.1%, p<0.001). After multivariable logistic adjustment for demographic and clinical features, early PCI was associated with lower mortality (OR 0.47, 95% CI 0.30–0.76). No significant differences in outcomes were observed between sexes (interaction, p=0.54) or by the presence of diabetes mellitus (interaction, p=0.61). In addition, no differences were seen among age groups (75–79 vs 80–84, interaction p=0.47; group 80–84 vs ≥85, interaction p=0.69). In early PCI, the group between 75–79 years had 5 (1.6%) major and 5 (1.6%) minor bleeding complications whereas the older groups had 1 (1.1%) and 1 (2.7%) major and 3 (3.2%) and 2 (5.4%) minor bleeding complications for patients aged 80–84 and ≥85, respectively. Conclusions In the real-life clinical setting, early PCI is a safe and efficacious treatment option in very elderly patients presenting with NSTE-ACS. Revascularization is better than medical therapy whatever the age is

Risk factors, revascularization therapies and cardiovascular mortality in countries with middle and low public health expenditure

Background: Studies from countries with high public health expenditure (PHE) have reported a decline of the rates of mortality from cardiovascular disease (CVD).Given that most mortality from CVD occurs in countries with low and middle PHE, there is a need for broader information on the relationship between variability in disease burden and outcomes in such countries. Purpose: The aim of this study was to evaluate the relation among risk factors, revascularization therapies and short-term mortality from acute coronary syndromes (ACS) in patient admitted to hospitals in middle versus low PHE countries. Methods: Data were derived from 18,704 patients admitted to 41 hospitals referring data to the ISACS-TC registry (NCT0128776). Patients were divided in two groups:low and middle PHE. Bosnia and Herzegovina,Croatia,Hungary,Italy,and Serbia have high PHE values, whereas Macedonia, Romania, Lithuania, Russian Federation, Kosovo,Moldova, and Montenegro, have low values. Main outcome measure was 30-day mortality. We used logistic-regression models to assess the effect of variables on the associations of interest. Results: There were 18,704 patients admitted to hospital for an ACS. Of these patients, 45% were in the low PHE group and 55% in the middle PHE group. Patients in middle PHE group were older (64% vs 61%), had higher prevalence of traditional risk factors, namely hypertension (75% vs 66%), hypercholesterolemia (55% vs 31%), diabetes (28.58% vs 23.10%), and positive family history of coronary artery disease (45.66% vs 17.56) as compared with patients in the low PHE group.Furthermore, patients in the middle PHE group had more frequently history of prior ischemic heart disease and higher rate of ST segment elevation myocardial infarction (STEMI) as clinical presentation (63.91 vs 61.98). The crude 30-day mortality rate was 6.97% in the middle PHE and 5,82% in the low PHE group. After multivariable adjustment for comorbidities and treatment covariates, patients in the middle PHE group had a better outcome compared with those in the low PHE group (OR 0.64; 95% CI 0.45\u20130.93).As most patients presented to hospital with STEMI we performed separate analyses for such patients and stratified outcomes in function of time to hospital presentation from initial symptom onset. The odds of mortality were still lower in patients in the middle PHE group (OR 0.41; 95% CI 0.22\u20130.76) if they presented within 6 hours from symptom onset.In contrast there were no difference in outcomes between middle and low PHE groups (OR 0.69; 95% CI 0.34\u20131.44) in patients with delayed presentation.This held true even in patients undergoing primary percutaneous intervention (OR 1.02; 95% CI 0.43\u20132.39). Conclusions: There are significant costs and infrastructure limitations that prohibit most countries with low PHE from having timely admission to hospital of patients with suspected ACS. Currently, many of the Eastern European countries are facing an enormous burden of mortality from CVD

Machine learning in critical care: the role of diabetes and age in acute coronary syndromes

Background Patients with diabetes and non-ST elevation acute coronary syndrome (NSTE-ACS) have an increased risk of mortality and adverse outcomes following percutaneous coronary intervention (PCI). Purpose We aimed to investigate the impact of early, within 24 hours PCI compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with NSTE-ACS and diabetes. Methods We identified 1,250 patients with diabetes and NSTE-ACS from a registry-based population between October 2010 and April 2016. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction <40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse-probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization. Results Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 years; 59%, men), 470 (37.6%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6.3% vs. 2.5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age 6565 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0.35; 95% CI: 0.14 to 0.92 and 0.43; 95% CI: 0.21 to 0.86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint. Conclusions Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers