SummaryBackgroundRemote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.MethodsWe did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed.FindingsBetween Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91–1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.InterpretationRemote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI.FundingBritish Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.

Unrecognised MI is common among patients with schizophrenia and may contribute to the increased mortality found in this patient group.

During the period from 1978 to 2012, there was a significant decline in MI incidence among most age groups for both genders; however, an incidence increase was observed in men under 50 and women under 60 years, and ≥90 years for both genders. One-year case-fatality decreased constantly during the study period.

BackgroundPatients with non-ST-segment elevation myocardial infarction (NSTEMI) without obstructive coronary artery disease (CAD) are often managed differently than those with obstructive CAD, therefore we aimed in this study to examine the long-term prognosis of patients with NSTEMI according to the degree of CAD on coronary angiography (CAG).MethodsWe examined 8.889 consecutive patients admitted for first time NSTEMI during 2000–2011, to whom CAG was performed. Patients were classified by CAG into: 0-vessel disease (0VD), diffuse atherosclerosis (DA) (0% < stenosis <50%), 1-vessel disease (1VD), 2VD, and 3VD with stenosis ≥50%. Follow-up period: 13 years (median 4.5).ResultsOne-year mortality for NSTEMI patients with 0VD was 3.7%, DA 5.7%, 1VD 2.5%, 2VD 4.8%, and 3VD 11.5%. Non-diabetic 0VD patients had higher risk of mortality than 1VD patients (HR:1.59; 95% CI:1.21–2.02; P < 0.001), while those with diabetes mellitus (DM) had not significantly different risk. In addition 0VD group had higher risk of heart failure (HF) (HR 1.61; 95% CI: 1.39–1.88; P < 0.001), and lower risk of recurrent MI (HR:0.55; 95% CI:0.39–0.77; P < 0.001) compared with 1VD. For patients with DA; mortality and HF risks were higher than 1VD and not different than 2VD, while recurrent MI risk was not different than 1VD and lower than 2VD.Finally, the DA group had higher risk of mortality if they had DM, higher risk of recurrent MI, and not different risk of HF and stroke compared with the 0VD group patients.ConclusionPatients with NSTEMI and non-obstructive CAD (both normal coronaries and diffuse atherosclerosis) have a comparable prognosis to patients with one- or two-vessel disease. Patients with diffuse atherosclerosis have worse prognosis than those with angiographically normal coronary arteries.Electronic supplementary materialThe online version of this article (10.1186/s12872-017-0710-3) contains supplementary material, which is available to authorized users.

Introduction Myocardial Infarction (MI) with Non-Obstructive Coronary Arteries (MINOCA) is now a recognised MI subtype. A 2013 systematic review of MINOCA literature indicated that MINOCA prognosis is favourable compared to those with MI and obstructive coronary artery disease (MICAD), but healthy controls were not included. With the growth of recent literature and evaluation of MINOCA prognosis, we performed an in-depth analysis of MINOCA prognosis, in relation to 1-year all-cause mortality and 1-year re-infarction compared with MICAD patients and a healthy cohort. Methods An unrestricted literature search was conducted on the terms “MI”, “non-obstructive”, “angiography” and “prognosis” using PubMed and Embase. Publications with non-consecutive recruitment, less than 100 MINOCA patients or selection bias (i.e. restricted age group) were excluded. MINOCA & MICAD were defined as the presence of an MI (as per the universal criteria) in the absence & presence of CAD (i.e. epicardial vessel with a stenosis ≥50% on angiography), respectively. The healthy cohort was defined as those with no history of cardiovascular diseases. Unpublished data were accumulated via the MINOCA Global Collaboration. Data from the included studies were pooled and analysed using DerSimonian-Laird random-effects meta-analysis. Heterogeneity was assessed using Cochran's Q and I2 statistics. Odds ratios (ORs), mean differences and 95% confidence intervals (CI) were calculated for proportion and continuous data respectively. Results The search identified 2889 unique publications, of which 27 included prognosis data. Of the 563660 consecutive MI patients, the overall pooled prevalence of MINOCA wasat 8.7% (95% CI: 7.5%-9.9%). The 1-year mortality and 1-year re-infarction data by diagnosis are presented in the table. Prognosis comparison by diagnosis MINOCA (n=41658) MINOCA vs MICAD MINOCA vs Healthy % (95% CI) MINOCA (n=16642) MICAD (n=174461) Mean difference or OR 95% CI MINOCA (n=8465) Healthy (n=33074) Mean difference or OR 95% CI Years or % (95% CI) Years or % (95% CI) Years or % (95% CI) Years or % (95% CI) Age 61 (60–62) 61 (59–63) 64 (63–66) 3.2 (2.2–4.2) 62 (57–66) 60 (58–63) 1.6 (−5–8.6) Female 51 (48–53) 51 (48–55) 28 (26–30) 2.8 (2.5–3.1) 56 (48–64) 38 (24–52) 2.2 (1.3–3.7) 1 year mortality 3.4 (2.9–4) 3.4 (2.9–3.9) 5.5 (4.7–6.2) 0.6 (0.5–0.7) 2.6 (1.2–4) 0.7 (0.5–1) 3.7 (1.7–8.2) 1 year Re-MI 2.7 (2.1–3.3) 2.8 (1.8–3.7) 5.7 (3.9–7.5) 0.5 (0.4–0.7) 3.5 (0–7) 0.3 (0–0.6) 14.1 (9.5–21.2) Conclusions This pooled analysis shows that MINOCA accounts for almost one in ten MI presentations. The risks of re-infarction and death among MINOCA patients are much higher than in healthy controls, but lower than for MICAD patients. Efforts are needed to improve understanding of the optimal management and secondary prevention strategies in this unique and heterogeneous population.