Relation between body mass index, waist circumference, and death after acute myocardial infarction.

BACKGROUND: An elevated body mass index (BMI) has been reported to be associated with a lower rate of death after acute myocardial infarction (AMI). However, waist circumference (WC) may be a better marker of cardiovascular risk than BMI. We used data from a contemporary French population-based cohort of patients with AMI to analyze the impact of WC and BMI on death rates. METHODS AND RESULTS: We evaluated 2229 consecutive patients with AMI. Patients were classified according to BMI as normal, overweight, obese, and very obese (BMI <25, 25 to 29.9, 30 to 34.5, and >35 kg/m(2), respectively) and as increased waistline (WC >88/102 cm for women/men) or normal. Half of the patients were overweight (n=1044), and one quarter were obese (n=397) or very obese (n=128). Increased WC was present in half of the patients (n=1110). Increased BMI was associated with a reduced death rate, with a 5% risk reduction for each unit increase in BMI (hazard ratio, 0.95; 95% CI, 0.93 to 0.98; P<0.001). In contrast, WC as a continuous variable had no impact on all-cause death (P=0.20). After adjustment for baseline predictors of death, BMI was not independently predictive of death. The group of patients with high WC but low BMI had increased 1-year death rate. CONCLUSIONS: Neither BMI nor WC independently predicts death after AMI. Much of the inverse relationship between BMI and the rate of death after AMI is due to confounding by characteristics associated with survival. This study emphasizes the need to measure both BMI and WC because patients with a high WC and low BMI are at high risk of death.

Prognostic value of ST-segment resolution after rescue percutaneous coronary intervention. Data from the RICO survey.

OBJECTIVES: The goal of the present study was to test the impact of ST segment resolution (STR) after rescue percutaneous coronary intervention (PCI) on the short-term prognosis. BACKGROUND: The prognostic value of STR after rescue PCI for acute ST elevation myocardial infarction (STEMI) remains undetermined. METHODS: From the French regional database, we analyzed 168 consecutive patients with STEMI and failed lysis, defined by <50 percent STR, who underwent rescue PCI. Patients were classified into two groups according to the degree of STR from the maximal ST-elevation measured on the single worst ECG lead before lysis and after rescue PCI: the without STR group (<50% STR) vs. the with STR group (> or =50%). RESULTS: After rescue PCI, 26 (15%) patients did not have STR and 142 (85%) patients did. No difference was observed between the two groups regarding baseline characteristics, risk factors, and median time delay either from symptom onset to thrombolysis or from failed lysis to rescue PCI. We observed a lower proportion of patients with TIMI 2/3 flow post PCI in the without STR group (respectively 61% vs. 97%, P < 0.001) but an increased use of intra-aortic balloon counterpulsation (34% vs. 8%, P < 0.001) in this group. Thirty-day mortality was markedly higher in the without STR group than in the with STR group (27% vs. 9% respectively, P = 0.025). Moreover, multivariate analysis showed that absence of STR (OR: 5.65; 95% CI: 1.24-25.67), was an independent prognostic factor for mortality. CONCLUSIONS: We showed for the first time that analysis of ST-segment resolution may be a simple reliable tool to identify patients at high risk after rescue PCI, and may provide useful information for the elaboration of therapeutic strategies.

Impact of fasting glycemia on short-term prognosis after acute myocardial infarction.

OBJECTIVE: The prognosis of patients with acute myocardial infarction (MI), according to the new criteria for impaired fasting glucose (IFG) (FG 100-126 mg/dl), has not been evaluated. RESEARCH DESIGN AND METHODS: A total of 2353 patients with acute MI and surviving at d 5 after admission were analyzed for short-term morbidity and mortality. FG was obtained at d 4 and 5. Patients were classified as diabetes mellitus (known diabetes or FG > or = 126 mg/dl), high IFG (110 < or = FG < 126 mg/dl), low IFG (100 < or = FG < 110 mg/dl), and normal fasting glucose (NFG) (FG < 100 mg/dl). RESULTS: Among the 2353 patients, 968 (41%) had diabetes mellitus, 262 (11%) had high IFG, 332 (14%) had low IFG, and 791 (34%) had NFG. Compared with NFG patients, 30-d cardiovascular mortality was increased in high but not low IFG subjects. In-hospital heart failure was increased in high IFG subjects (42 vs. 20% for NFG, P < 0.0001) but not low IFG subjects (21 vs. 20%). High IFG, but not low IFG, was an independent factor associated with 30-d cardiovascular mortality [odds ratio 2.33 (1.55-3.47)] and in-hospital heart failure [odds ratio 1.70 (1.36-2.07)]. The optimal threshold levels of FG on the receiver-operating characteristic curves were 114 and 112 mg/dl to predict mortality and in-hospital heart failure, respectively. CONCLUSION: The present study, based on a nonselected cohort of MI patients, underscores the high prevalence of IFG (25%) and highlights the clinical relevance of 110 mg/dl, but not 100 mg/dl, as a cutoff value to define the risk for worse outcome.

Relation of hyperglycemia to ST-segment resolution after reperfusion for acute myocardial infarction (from Observatoire des Infarctus de Côte-d'Or Survey [RICO]).

Hyperglycemia has been shown to be a powerful predictor of worse outcome after ST-segment-elevation myocardial infarction (STEMI), which could be related to impaired myocardial reperfusion. This study investigated the association between hyperglycemia and ST-segment resolution (STR) after thrombolysis. From the French regional Observatoire des Infarctus de Côte-d'Or survey, admission glucose in 371 patients with STEMIs who were treated by lysis<12 hours was analyzed. The single worst lead electrocardiogram before and 90 minutes after lysis was analyzed, and patients were divided into 3 groups according to the degree of STR: none (<30%), partial (30% to 70%), or complete (>or=70%). Of the 371 patients, 101 (27.2%) had no STR, 124 (33.4%) had partial STR, and 146 (39.4%) had complete STR. STR decreased with increasing glycemia (p=0.029), and patients with hyperglycemia (glycemia>or=11 mmol/L) were more likely to have no STR. Moreover, hyperglycemia was an independent predictor of incomplete STR even after adjustment for potential confounders (odds ratio 2.348, 95% confidence interval 1.212 to 4.547). In conclusion, the present study suggests a strong association between hyperglycemia and electrocardiographic signs of reperfusion in patients with STEMIs after lysis and suggests the usefulness of evaluating early glycemic control in the setting of reperfusion for acute myocardial infarction.

Factors affecting the management of outcome in elderly patients with acute myocardial infarction particularly with regard to reperfusion. Data from the French regional RICO survey.

BACKGROUND: Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis. OBJECTIVES: To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI. METHODS: From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old). RESULTS: Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant. CONCLUSION: Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups.

Prevalence and impact of metabolic syndrome on hospital outcomes in acute myocardial infarction.

BACKGROUND: The impact of metabolic syndrome after acute myocardial infarction (AMI) has not yet been studied. In a population-based sample of patients with AMI, we sought to determine the prevalence of metabolic syndrome in patients with AMI, its impact on hospital outcomes, and to assess the relative influence of each of the components of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III definition of metabolic syndrome on the risk of death and heart failure. METHODS: A total of 633 unselected, consecutive patients hospitalized with AMI were categorized according to the NCEP ATP III metabolic syndrome criteria (presence of >/=3 of the following: hyperglycemia; triglyceride level >/=150 mg/dL [>/=1.7 mmol/L]; high-density lipoprotein cholesterol level <40 mg/dL [<1.04 mmol/L] in men and <50 mg/dL [<1.30 mmol/L] in women; blood pressure >/=130/85 mm Hg; and waist circumference >102 cm in men or 88 cm in women). RESULTS: Among the 633 patients, 290 (46%) fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome were older and more likely to be women. Acute myocardial infarction characteristics and left ventricular ejection fraction rates were similar for both groups. In-hospital case fatality was higher in patients with metabolic syndrome compared with those without, as was the incidence of severe heart failure (Killip class >II). In multivariate analysis, metabolic syndrome was a strong and independent predictor of severe heart failure, but not in-hospital death. Analysis of the predictive value of each of the 5 metabolic syndrome components for severe heart failure showed that hyperglycemia was the major determinant (odds ratio, 3.31; 95% confidence interval, 1.86-5.87). CONCLUSIONS: In an unselected population of patients with AMI, the prevalence of metabolic syndrome was high. Metabolic syndrome appeared associated with worse in-hospital outcome, with a higher risk of development of severe heart failure. Among metabolic syndrome components, hyperglycemia was the main correlate of the risk of development of severe heart failure during AMI.

High plasma N-terminal pro-brain natriuretic peptide level found in diabetic patients after myocardial infarction is associated with an increased risk of in-hospital mortality and cardiogenic shock.

AIMS: No studies have yet been conducted concerning plasma N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) levels after Myocardial Infarction (MI) and their relationship with short-term outcomes in diabetic patients. METHODS AND RESULTS: Five hundred and sixty patients hospitalized for MI from the RICO survey, including 199 diabetic and 361 non-diabetic subjects, were included in the study. Plasma Nt-pro-BNP levels were measured on admission. Median Nt-pro-BNP levels were significantly higher in diabetic patients compared with non-diabetic patients [245 (81-77) vs. 130 (49-199) pmol/L, P<0.0001]. This difference remained highly significant after adjustment for age, female gender, creatinine clearance, left ventricular ejection fraction (LVEF), plasma peak troponin, anterior wall necrosis, and hypertension. In multivariable analysis, Nt-pro-BNP levels were negatively associated with creatinine clearance (P<0.0001) and LVEF (P<0.0001) and positively associated with plasma peak troponin (P<0.0001), age (P=0.0029), diabetes (P=0.0031), and female gender (P=0.0102). Diabetic patients showed a 4.7-fold increase in hospital mortality (15.6 vs. 3.3%, P<0.0001) and a 2.2-fold increase in cardiogenic shock (17.6 vs. 7.7%, P=0.0004). In multivariable analysis, diabetes was an independent factor for mortality [OR: 1.79 (1.45-2.20); P=0.0064] and cardiogenic shock [OR: 1.45 (1.22-1.72); P=0.0364] when the variable Nt-pro-BNP level was not introduced into the model, but was less significantly associated with mortality [OR: 1.73 (1.39-2.16); P=0.0107] and no longer associated with cardiogenic shock when Nt-pro-BNP was in the model. CONCLUSION: After MI, diabetes is independently associated with high plasma Nt-pro-BNP levels. This elevated Nt-pro-BNP is strongly associated with the increased incidence of in-hospital mortality and cardiogenic shock observed in diabetes. Our findings clearly indicate that plasma Nt-pro-BNP provides highly valuable prognostic information on in-hospital outcome after MI, in particular in diabetic patients.

Impaired fasting glucose and cardiogenic shock in patients with acute myocardial infarction.

OBJECTIVES: In-hospital outcome after acute myocardial infarction (MI) has not yet been evaluated with regard to the new category of Impaired Fasting Glucose level (IFG) patients defined by the American Diabetes Association (ADA). METHODS: Nine hundred and ninety-nine patients with acute MI from the RICO survey were included in the study. Fasting blood glucose was measured after admission. Patients were grouped according to ADA definitions: Diabetes Mellitus (DM) (FG >/=7mmol/l or personal history of DM); IFG (FG 6.1 to 7mmol/l); NFG (normal FG <6.1mmol/l). RESULTS: Three hundred and eighty-one patients (38%) had DM, 145 (15%) IFG and 473 (47%) NFG. Mortality in the IFG group was twice that of the NFG group (8% vs 4%, P=0.049). A significant increase in cardiogenic shock (12% vs 6%, P=0.011) and ventricular arrhythmia (15% vs 9%, P=0.035) was observed in the IFG vs NFG group. IFG, after adjustment for confounding factors (age, sex, anterior location, and LVEF), was a strong independent predictive factor for cardiogenic shock (P=0.005). CONCLUSION: MI patients with IFG had an overall worse outcome, characterized by a higher risk of developing cardiogenic shock during their hospital stay.