ACE angiotensin converting enzyme BAL bronchoalveolar lavage CRT cardiac resynchronization therapy CT computed tomography 18 F-FDG fluorine-18 fluorodeoxyglucose 67 Ga gallium-67 HRCT high resolution computed tomography ICD implantable cardioverter defibrillator MRI magnetic resonance imaging PET positron emission tomography sIL-2R soluble interleukin 2 recepter SPECT single photon emission computed tomography JCS GUIDELINES

Atrial fibrillation (AF) is associated with a high risk of thromboembolic events, and its prevalence is projected to increase because of population aging. 17 Indeed, the thromboembolic complications of AF are an important cause of morbidity and mortality. The CHADS 2 and CHA 2 DS 2 -VASc scores are useful for thromboembolic risk stratification. 18,19 Background-Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of acute myocardial infarction. Its prevalence, clinical features, and prognosis remain insufficiently characterized. Methods and Results-We screened 1776 consecutive patients who presented with de novo acute myocardial infarction between 2001 and 2013. CE was diagnosed based on criteria encompassing histological, angiographic, and other diagnostic imaging findings. The prevalence, clinical characteristics, treatment strategies, in-hospital outcomes, and long-term risk of CE recurrence or major adverse cardiac and cerebrovascular events (cardiac death, fatal arrhythmia, or recurrent thromboembolism) were evaluated. The prevalence of CE was 2.9% (n=52), including 8 (15%) patients with multivessel CE. Atrial fibrillation was the most common cause (n=38, 73%). Only 39% of patients with CE were treated with vitamin K antagonists, and the median international normalized ratio was 1.42 (range, 0.95-1.80). Eighteen of the 30 CE patients with nonvalvular atrial fibrillation had a CHADS 2 score of 0 or 1. When those patients were reevaluated using CHA 2 DS 2 -VASc, 61% were reassigned to a higher risk category. During a median follow-up of 49 months, CE and thromboembolism recurred in 5 atrial fibrillation patients. The 5-year rate of major adverse cardiac and cerebrovascular events was 27.1%. In the propensity score-matched cohorts (n=45 each), Kaplan-Meier analysis showed a significantly higher incidence of cardiac death in the CE group than in the non-CE group (hazard ratio, 9.29; 95% confidence interval, 1.13-76.5; P<0.001). Correspondence to Teruo Noguchi, MD, PhD, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, 565-8565, Japan. E-mail tnoguchi@hsp. The present study was designed to evaluate the prevalence, clinical characteristics, and initial management of CE, and early and late outcomes, as well, in a large consecutive series of patients. We also propose new diagnostic criteria for CE based on histological, angiographic, and other diagnostic imaging findings. Conclusions-Atrial Methods Study Population and PCI ProcedureWe retrospectively analyzed a total of 2135 consecutive patients with AMI from January 2001 to December 2013 in the National Cerebral and Cardiovascular Center AMI database. We excluded 359 patients with a history of previous myocardial infarction (n=241), PCI (n=90), coronary artery bypass grafting (n=18), or both PCI and coronary artery bypass grafting (n=10), resulting in a total of 1776 patients with de novo AMI that were ultimately analyzed in this study (Figure 1). All study patients under...

BackgroundThere is little known about whether the clinical and pathological characteristics and incidence of cardiac rupture (CR) in patients with acute myocardial infarction (AMI) have changed over the years.Methods and ResultsThe incidence and clinical characteristics of CR were investigated in patients with AMI, who were divided into 3 cohorts: 1977–1989, 1990–2000, and 2001–2011. Of a total of 5699 patients, 144 were diagnosed with CR and 45 survived. Over the years, the incidence of CR decreased (1977–1989, 3.3%; 1990–2000, 2.8%; 2001–2011, 1.7%; P=0.002) in association with the widespread adoption of reperfusion therapy. The mortality rate of CR decreased (1977–1989, 90%; 1990–2000, 56%; 2001–2011, 50%; P=0.002) in association with an increase in the rate of emergent surgery. In multivariable analysis, first myocardial infarction, anterior infarct, female sex, hypertension, and age >70 years were significant risk factors for CR, whereas impact of hypertension on CR was weaker from 2001 to 2011. Primary percutaneous coronary intervention (PPCI) was a significant protective factor against CR. In 64 autopsy cases with CR, myocardial hemorrhage occurred more frequently in those who underwent PPCI or fibrinolysis than those who did not receive reperfusion therapy (no reperfusion therapy, 18.0%; fibrinolysis, 71.4%; PPCI, 83.3%; P=0.001).ConclusionsWith the development of medical treatment, the incidence and mortality rate of CR have decreased. However, first myocardial infarction, anterior infarct, female sex, and old age remain important risk factors for CR. Adjunctive cardioprotection against reperfusion‐induced myocardial hemorrhage is emerging in the current PPCI era.

The presence of CAE predicted future cardiac events in patients with acute MI. Our findings suggest that acute MI patients with CAE are a high-risk subset who might benefit from a pharmacological approach to controlling the coagulation cascade.

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