Clinical significance of diabetes on symptom and patient delay among patients with acute myocardial infarction——an analysis from China Acute Myocardial Infarction(CAMI) registry

Background Diabetes is frequently associated with poor prognosis among acute myocardial infarction(AMI)patients.Patients with these comorbidities often have atypical symptoms and subsequent delay in treatment.Few studies have reported detailed AMI symptoms in patients with diabetes.This study compared AMI symptoms and presentation characteristics between diabetics and non-diabetics.Methods We included patients from the China AMI registry diagnosed with AMI between January 2013 and September 2014.Baseline characteristics,symptomology,and delay in treatment were compared between diabetics and non-diabetics.Multivariable logistic regression analysis was used to explore independent predictors of atypical symptoms.Results A total of 4450(20.2%)patients had diabetes.They were older,more often women,higher in body mass index,and more likely to have non-ST segment elevation myocardial infarction.Fewer diabetic patients presented with persistent precordial chest pain(63.1%vs.68%,P<0.0001),diaphoresis(60.1%vs.65.6%,P<0.0001),fatigue(16.7%vs.18.3%,P=0.0123),and incontinence(0.4%vs.0.7%,P=0.0093).Time to hospital presentation was longer among patients with diabetes than those without.In multivariable analysis,diabetes was identified as an independent predictor of atypical symptoms(OR:1.112,95%CI:1.034?1.196).Conclusions Our study is the first large-scale study providing evidence that diabetics are less likely to present with typical chest pain and more likely to experience treatment delay when suffering from an AMI.Our results may increase clinician awareness of recognizing AMI patients rapidly to reduce diagnosis and treatment delay,particularly in the context of diabetes.

The association between matrix metalloprotease-9 gene polymorphisms and primary angle-closure glaucoma in a Chinese Han population

AIM:To examine the association between the single nucleotide polymorphisms (SNPs)of matrix metalloprotease-9 (MMP-9) gene and primary angleclosure glaucoma(PACG)in a Chinese Han population.METHODS:DNA samples were extracted from peripheral-blood mononuclear cells of 214 PACG patients and 224 healthy controls.Genotyping of rs3918249,rs3918254,rs17577 and rs3787268 in MMP-9was performed using polymerase chain reaction restriction fragment length polymorphism(PCR-RFLP)analysis and the direct sequencing technique.The association between these genetic polymorphisms and risk of PACG was estimated by χ2 test.RESULTS:The distributions of rs3918249,rs3918254,rs17577 and rs3787268 genotypes among cases and healthy controls were compatible with that from HardyWeinberg equilibrium(HWE,P】0.05).The increased frequency of CC and CT genotypes of rs3918254 were observed in PACG patients compared to healthy controls[P=0.006,P corrected(Pcorr)=0.048].The haplotype analysis showed that the CCGG haplotype was nominal associated with PACG(P=0.015),however,the significant was lost when the Bonferroni correction was used(Pcorr=0.105).CONCLUSION:Our results revealed that rs3918254 in MMP-9 may be a susceptible locus to PACG in China,people with the CC and CT genotypes of rs3918254 are more susceptible to PACG.The susceptibility to PACG inChinese Han patients may be not influenced by SNPs rs3918249,rs3787268 and rs17577 in MMP-9.

Differences in symptoms and pre-hospital delay among acute myocardial infarction patients according to ST-segment elevation on electrocardiogram: an analysis of China Acute Myocardial Infarction (CAMI) registry

Background: Approximately 70% patients with acute myocardial infarction (AMI) presented without ST-segment elevation on electrocardiogram. Patients with non-ST segment elevation myocardial infarction (NSTEMI) often presented with atypical symptoms, which may be related to pre-hospital delay and increased risk of mortality. However, up to date few studies reported detailed symptomatology of NSTEMI, particularly among Asian patients. The objective of this study was to describe and compare symptoms and presenting characteristics of NSTEMI vs. STEMI patients. Methods: We enrolled 21,994 patients diagnosed with AMI from China Acute Myocardial Infarction (CAMI) Registry between January 2013 and September 2014. Patients were divided into 2 groups according to ST-segment elevation: ST-segment elevation (STEMI) group and NSTEMI group. We extracted data on patients' characteristics and detailed symptomatology and compared these variables between two groups. Results: Compared with patients with STEMI (N=16,315), those with NSTEMI (N=5679) were older, more often females and more often have comorbidities. Patients with NSTEMI were less likely to present with persistent chest pain (54.3% vs.71.4%), diaphoresis (48.6% vs.70.0%), radiation pain (26.4% vs.33.8%), and more likely to have chest distress (42.4% vs.38.3%) than STEMI patients (all P<0.0001). Patients with NSTEMI were also had longer time to hospital. In multivariable analysis, NSTEMI was independent predictor of presentation without chest pain (odds ratio: 1.974, 95% confidence interval:1.849-2.107). Conclusions: Patients with NSTEMI were more likely to present with chest distress and pre-hospital patient delay compared with patients with STEMI. It is necessary for both clinicians and patients to learn more about atypical symptoms of NSTEMI in order to rapidly recognize myocardial infarction.

Angiographic characteristics and in-hospital mortality among patients with ST-segment elevation myocardial infarction presenting without typical chest pain: an analysis of China Acute Myocardial Infarction registry

Background:Patients with ST-segment elevation myocardial infarction(STEMI)who present without typical chest pain are associated with a poor outcome.However,whether angiographic characteristics are related to a higher risk of mortality in this population is unclear.This study aimed to investigate whether the higher mortality risk in patients with STEMI without chest pain could be explained by their"high-risk"angiographic characteristics.Methods:We used data of 12,145 patients with STEMI who was registered in China Acute Myocardial Infarction registry from January 2013 to September 2014.We compared the infarct-related artery(IRA),thrombolysis in myocardial infarction(TIMI)flow grade in the IRA,and other angiographic characteristics between patients without and those with chest pain.Multivariable logistic regression model was used to identify independent risk factor of in-hospital mortality.Results:The 2922(24.1%)patients with STEMI presented without typical chest pain.These patients had a higher TIMI flow grade(mean TIMI flow grade:1.00 vs.0.94,P=0.02)and a lower rate of IRA disease of the left anterior descending artery(44.6%vs.51.2%,χ^2=35.63,P<0.01)than did those with typical chest pain.Patients without chest pain were older,more likely to have diabetes,longer time to hospital and higher Killip classification,and less likely to receive optimal medication treatment and primary percutaneous coronary intervention and higher In-hospital mortality(3.3%vs.2.2%,χ^2=10.57,P<0.01).After adjusting for multi-variables,presentation without chest pain was still an independent predictor of in-hospital death among patients with STEMI(adjusted odds ratio:1.36,95%confidence interval:1.02–1.83).Conclusions:Presentation without chest pain is common and associated with a higher in-hospital mortality risk in patients with acute myocardial infarction.Our results indicate that their poor prognosis is associated with baseline patient characteristics and delayed treatment,but not angiographic lesion characteristics.Clinical trial registration:NCT01874691,https://clinicaltrials.gov.

Risk Factors of Contrast-induced Acute Kidney Injury in Patients Undergoing Emergency Percutaneous Coronary Intervention

Background： Previous studies of contrast-induced acute kidney injury （CI-AK1） were mostly based on selective percutaneous coronary intervention （PCI） cases, and risk factors of CI-AKI after emergency PCI are unclear. The aim of this study was to explore the risk factors of CI-AKi in a Chinese population undergoing emergency PCI. Methods： A total of 1061 consecutive patients undergoing emergency PCI during January 2013 and June 2015 were enrolled and divided into CI-AK1 and non-CI-AKl group. Univariable and multivariable analyses were used to identity the risk factors of CI-AKI in emergency PCI patients. CI-AKI was defined as an increase in serum creatinine ≥25% or ≥0.5 mg/dl （44.2 μmol/L） above baseline within 3 days alter exposure to contrast medium. Results： The incidence of C1-AKI in patients undergoing emergency PCI was 22.7% （241/1061）. Logistic multivariable analysis showed that body surface area （BSA） （odds ratio [OR] 0.213, 95% confidence interval [CI]： 0.075-0.607, P = 0.004）, history, of myocardial infarction （MI） （OR 1.642, 95% CI. 1.079-2.499, P- 0.021 ）, left ventricular ejection fraction （LVEF） （OR 0.969, 95% CI： 0.944-0.994, P = 0.015）, hemoglobin （Hb） （OR 0.988, 95% CI. 0.976-1.000, P 1.018 1.037, P 〈 0.001 ）, left anterior descending （LAD） stented （OR 1 0.009 0.987, P- 0.049）, and diuretics use （OR 1.850, 95% CI： 1.233-2 0.045）, estimated glomerular filtration rate （OR 1.027, 95% CI： 464, 95% CI： 1.000 2.145, P 0.050）, aspirin （OR 0.097, 95%CI： .777, P - 0.003） were independent predictors of CI-AKI in patients undergoing emergency PCI. Conclusion： History of MI, low BSA, LVEF and Hb level, LAD stented, and diuretics use are associated with increased risk of CI-AK1 in patients undergoing emergency PCI.

Relationship between High Level of Estimated Glomerular Filtration Rate and Contrast-Induced Acute Kidney Injury in Patients who Underwent an Emergency Percutaneous Coronary Intervention

Background： Mounts of studies have shown that low estimated glomerular filtration rate （eGFR） is associated with increased risk of adverse outcomes in patients with coronary artery disease. However, high level of eGFR was less reported. In the study, we aimed to explore the relationship between the baseline eGFR, especially the high level, and contrast-induced acute kidney injury （CI-AKI） in a Chinese population who underwent an emergency percutaneous coronary intervention （PCI）. Methods： Patients who underwent an emergency PCI from 2013 to 2015 were enrolled and divided into five groups as eGFR decreasing. Baseline characteristics were collected and analyzed. The rates of CI-AKI and the composite endpoint （including nonfatal myocardial infarction, revascularization, stroke, and all-cause death） at 6- and 12-month follow-up were compared. Logistic analysis for CI-AKI was performed.Results： A total of 1061 patients were included and the overall CI-AKI rate was 22.7% （241 / 1061）. The separate rates were 77.8% （7/9） in Group 1 （eGFR 〉 120 ml·min^-1 -1.73 m^-2）, 26.0% （118/454） in Group 2 （120 ml·min^-1·min^-11.73 m^-2〉 eGFR≥90 ml·min^-1 1.73^-2）, 18.3% （86/469） in Group 3 （90 ml·min^-1 1.73 m^-2〉 eGFR 〉60 ml·min^-1·min^-11.73 m^-2）, 21.8% （26/119） in Group 4 （60 ml·min^-1·1.73 m^-2〉 eGFR≥30 ml·min^-1·min^-11.73 m^-2）, and 40.0% （4/10） in Group 5 （eGFR 〈30 ml·min^-1·min^-1·min^-11.73 m^-2）, with statistical significance （χ^2 = 25.19, P 〈 0.001）. The rates of CI-AKI in five groups were 77.8%, 26.0%, 18.3%, 21.8%, and 40.0%, respectively, showing a U-typed curve as eGFR decreasing （the higher the level of eGFR, the higher the CI-AKI occurrence in case ofeGFR_〉60 ml·min^-1·1.73 m^-2）. The composite endpoint rates in five groups were 0, 0.9%, 2.1%, 6.7%, and 0 at 6-month follow-up, respectively, and 0, 3.3%, 3.4%, 16.0%, and 30.0% at 12-month follow-up, respectively, both with significant differences （χ^2 = 16.26, P = 0.009 at 6-month follow-up, and χ^2 = 49.05, P 〈 0.001 at 12-month follow-up）. The logistic analysis confirmed that eGFR was one of independent risk factors of CI-AKI in emergency PCI patients. Conclusions： High level ofeGFR might be associated with increased risk of CI-AKI in patients with emergency PCI, implying for future studies and risk stratification in clinical practice.

Impacts of smoking status on the clinical outcomes of coronary non-target lesions in patients with coronary heart disease:a single-center angiographic study

Background:Coronary atherosclerotic plaque could go through rapid progression and induce adverse cardiac events.This study aimed to evaluate the impacts of smoking status on clinical outcomes of coronary non-target lesions.Methods:Consecutive patients with coronary heart disease who underwent two serial coronary angiographies were included.All coronary non-target lesions were recorded at first coronary angiography and analyzed using quantitative coronary angiography at both procedures.Patients were grouped into non-smokers,quitters,and smokers according to their smoking status.Clinical outcomes including rapid lesion progression,lesion re-vascularization,and myocardial infarction were recorded at second coronary angiography.Multivariable Cox regression analysis was used to investigate the association between smoking status and clinical outcomes.Results:A total of 1255 patients and 1670 lesions were included.Smokers were younger and more likely to be male compared with nonsmokers.Increase in percent diameter stenosis was significantly lower(2.7[0.6,7.1]%vs.3.5[0.9,8.9]%)and 3.4[1.1,7.7]%,P=0.020)in quitters than those in smokers and non-smokers.Quitters tended to have a decreased incidence of rapid lesions progression(15.8%[76/482]vs.21.6%[74/342]and 20.6%[89/431],P=0.062),lesion re-vascularization(13.1%[63/482]vs.15.5%[53/432]and 15.5%[67/431],P=0.448),lesion-related myocardial infarction(0.8%[4/482]vs.2.6%[9/342]and 1.4%[6/431],P=0.110)and all-cause myocardial infarction(1.9%[9/482]vs.4.1%[14/342]and 2.3%[10/431],P=0.128)compared with smokers and non-smokers.In multivariable analysis,smoking status was not an independent predictor for rapid lesion progression,lesion re-vascularization,and lesion-related myocardial infarction except that a higher risk of all-cause myocardial infarction was observed in smokers than non-smokers(hazards ratio:3.00,95%confidence interval:1.04-8.62,P=0.042).Conclusion:Smoking cessation mitigates the increase in percent diameter stenosis of coronary non-target lesions,meanwhile,smokers are associated with increased risk for all-cause myocardial infarction compared with non-smokers.