bluuebunny/crossref_metadata_2025 huggingface dataset:
Mendelian randomization identifies sex differences in pain manifestation of coronary artery disease
Authors: Methorst R , Jongbloed M R M , Noordam R , Deruiter M C
Published: November 2023

Background and aim

Clinical manifestation of atherogenic cardiovascular disease differs between men and women. Men often present with classical symptoms i.e., chest pain radiating to left arm and jaw. Women may show a wide range of symptoms considered atypical, including but not limited to back pain and nausea. Anatomical pathways feeding cardiac pain have not been properly characterized with respect to sex-related differences in human at population level.

Methods

We performed sex-stratified GWAS analysis on CAD as well as chest, neck and shoulder, back and facial pain using the UK Biobank cohort (men N = 203,823; women N = 239,631). To unravel given differences in pain manifestation of atherogenic cardiovascular disease in men and women, we performed Mendelian Randomization to approximate the causal associations between coronary artery disease (CAD) and a variety of pain locations.

Results

We identified 32 and 19 independent instrumental variables (R2< 0.001, p-value 5x10-6) associated with CAD for men and women, respectively. MR analysis revealed potential causality between CAD and self-reported chest pain for men (OR: 1.33, CI: 1.25 – 1.41) and women (OR: 1.44, CI: 1.20 – 1.73) as well as a link between CAD and clinical chest pain for both sexes (men OR: 1.22, CI: 1.17 — 1.26; women OR: 1.31, CI: 1.18 — 1.46). MR displayed a relationship between CAD and back pain in women (OR: 1.35, CI: 1.03 — 1.66) but not in men (OR: 0.99, CI: 0.90 — 1.11, p-value difference: 0.036). Manifestation of neck and shoulder pain revealed a suggestive difference in causality between men and women (p-value difference: 0.051).

Discussion

Our study provided evidence supporting a causal association between CAD with manifestation of chest pain in both men and women. Additionally, no stronger effect in men was found contrary to clinical observations suggesting pain perception of the chest at population level could be similar between the sexes. Manifestation of back pain with CAD, however, showed a more causal effect in women compared to men. Here we show that pain perception of the heart is not limited to the chest in women at population level. Future research is required to identify what drives these differences at multiple levels.
Incidence of flow-limiting coronary artery stenoses in patients with diabetes - a coronary angiography natural history study
Authors: Rosen H C , Mohammad M A , Erlinge D
Published: November 2023

Background

Diabetes is an established risk factor for the development of coronary atherosclerosis. We sought to assess the association between diabetes and the incidence of coronary artery atherosclerosis progression on coronary angiography.

Methods

Using the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we included all coronary artery segments with mild to no atherosclerosis defined as <50% luminal obstruction in patients undergoing a first-time coronary angiography in Sweden between 1989 and 2017. Patients with two or more vessel disease were excluded as were patients with a previous history of coronary artery disease. In patients with one vessel disease, the diseased vessel including all its branches were excluded. Patients were followed for 15 years until a clinically indicated re-angiography was done, death occurred or end of follow-up (April 2018). The primary outcome was plaque progression to flow-limiting coronary artery stenosis defined as ≥50% luminal obstruction on repeat angiography assessed using epidemiological tables, Kaplan Meier event rates, and Cox proportional hazard models. The importance of selected risk factors (smoking, hypertension, hyperlipidemia, and established coronary artery disease) was assessed.

Results

A total of 2 661 245 coronary segments in 248 736 patients were included in the study. Diabetes was present in 30 533 patients and 320 815 coronary artery segments. Kaplan-Meier event rates and incidence rates (IR) per 1000 segment-years were higher in patients with diabetes (5.5%, IR 2.78 [95% CI 2.70–2.85] vs. 3.0%, 1.44 [1.42–1.46]) resulting in an almost two-folded hazard ratio (HR) of plaque progression (HR 1.93 [95% CI 1.87– 2.00]). The anatomical distribution of plaque progression was similar between the two cohorts on all levels of analysis (coronary artery level, main artery and branches level, and coronary segment level artery). Diabetic patients with established coronary artery disease had a significantly higher risk of future events compared to those without clinically significant coronary artery disease.

Conclusions

Diabetes was associated with an almost twofold higher incidence rate of plaque progression but did not appear to alter the anatomical location of plaque development compared to the absence of diabetes. Once coronary artery disease is established, the rate of atherosclerotic events accelerates. Therefore, adopting aggressive primary prevention strategies is crucial to reduce the risk of adverse outcomes in diabetic patients.Event rates and anatomical distributionProgression of stenoses by risk factor
Sex aspects of guideline-directed therapy in young ST- elevation myocardial infarction patients
Authors: Fischer A J , Feld J , Makowski L , Engelbertz C , Lange S A , Kuehnemund L , Guenster C , Droege P , Ruhnke T , Freisinger E , Gerss J , Reinecke H , Koeppe J
Published: November 2023

Background

Young women are at specific risk for a poor outcome after ST- elevation myocardial infarction (STEMI). We aimed to investigate sex- and age-specific differences in adherence to a guideline-directed drug therapy for secondary prophylaxis and to assess its effect on overall survival.

Methods

Administrative health insurance data (≈26 million members) was screened for patients 18- < 60 years with STEMI from 01/2008 to 12/2018. Patient demographics, details on in-hospital treatment, long-term adherence to guideline-directed drug therapy and the effect on mortality was assessed.

Results

59,401 patients <60 years (19.3 % women, median age 53 (IQR 48 - 56) were treated in-hospital with STEMI. Overall, adherence to a guideline-directed heart failure therapy decreased over time. 180 days post STEMI, 80.3 % of women and 82.9 % of men <60 were on complete secondary prophylaxis with ACE/AT1 blockers, beta blockers, statins and a platelet activation inhibitor. Five years after the event, however, only 36.6 % of women and 40.9 % of men were under complete therapy. Similarly with a lower drug adherence, women showed a poorer outcome after STEMI with a 90-day mortality of 7.9 % compared to 6.4 % in men as well as a poorer overall survival (p<0.001).

After adjustment for patients’ risk factors, there was a clear association between guideline directed therapy and overall survival. The positive association increased with the number of drugs taken. Moreover, sex-specific differences were specifically evident, if all four drugs were prescribed. The effect on overall survival of one heart failure drug was marginal and not sex-specific with a HR of 0.88 (95% CI 0.76-1.02) in women versus HR 0.91 (95% CI 0.84 - 0.99) in men (pint =0.707). Under complete guideline directed therapy, however, HR for overall survival was 0.22 (95% CI 0.19-0.26) in women versus HR 0.31 (95% CI 0.28 - 0.33) in men (pint <0.001).

Conclusion

Long-term adherence to an optimal guideline-directed drug therapy after STEMI is generally low with specifically women <60 years lacking a consistent therapy. The lack of consistent therapy is one aspect explaining the poor outcome after STEMI in younger women. Our data show, that women specifically benefit from a consistent secondary prophylaxis. As the underutilization of heart failure drugs is contributory to the unfavorable outcome in young female and male patients, systematic approaches and education of healthcare providers are needed to ensure the long-term use of heart failure drugs specifically in this patient cohort at risk.Kaplan-Meier estimatesCox regression analysis
GLP-2 predicts cardiovascular outcomes in patients with myocardial infarction and increases atherosclerosis in mice
Authors: Kahles F , Sausen M , Quintana L , Rueckbeil M , Idel P , Mertens R , Just S , Arrivas M C , Moellmann J , Biener M , Giannitsis E , Katus H A , Drucker D J , Marx N , Lehrke M
Published: November 2023

Background

GLP-1 and GLP-2 (glucagon-like peptide-1/2) are incretin hormones that are co-secreted from intestinal L-cells in response to food intake and inflammatory stimuli. While GLP-1 is known to induce postprandial insulin secretion and to improve cardiovascular outcomes in patients with diabetes, GLP-2 enhances intestinal nutrient absorption. GLP-2 agonists are clinically used for the treatment of patients with short bowel syndrome. The relevance of GLP-2 beyond the gut is not well understood. The aim of this study was to investigate the role of GLP-2 for cardiovascular disease (CVD).

Methods

Total GLP-2 levels were assessed at time of admission in 918 patients with myocardial infarction presenting with acute chest pain, among them 597 patients with NSTEMI and 321 with STEMI. The primary composite outcome of the study was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke (3-P-MACE) with a median follow-up of 311 days. To induce atherosclerosis, Glp2r−/− or WT mice were injected with PCSK9 virus and fed a diet high in cholesterol (HCD) for 12 weeks.

Results

Kaplan-Meier survival plots (separated by the median of GLP-2 with a cut-off value of 4.4 pM) and univariable cox regression analyses found GLP-2 values to be associated with adverse outcome (3-P-MACE and all-cause mortality; logarithmized GLP-2 values HR: 2.87; p<.0001). Further adjustment for age, sex, smoking, hypertension, hypercholesterinemia, previous CVD and diabetes mellitus did not affect this association (logarithmized GLP-2 values HR: 2.66; p=0.0055). Receiver operating characteristic curve (ROC) analyses illustrated that GLP-2 is a strong indicator for early events (area under the curve of the combined endpoint at 7 days: 0.74; 14 days: 0.76; 30 days: 0.76; 6 months: 0.72), which proved to be superior to Troponin T and hs-CRP. To asses the functional role of GLP-2 in CVD in an experimental approach we injected Glp2r−/− or WT mice PCSK9 virus (to induce functional Ldlr-deficiency and hypercholesterolemia) and fed these mice a HCD. After 12 weeks Glp2r−/− mice compared to WT littermates presented with a significant reduction in plaque volume and lesion size. While body weight and circulating leukocyte numbers (FACS analysis) were unaffected, Glp2r−/− mice had lower cholesterol levels.

Conclusion

Circulating GLP-2 levels are associated with cardiovascular events in patients with acute myocardial infarction while inactivation of the GLP-2 system reduces atherosclerosis in mice. Future studies are needed to investigate whether the GLP-2 receptor might provide a novel therapeutic target for cardiovascular disease.
Patients cancelled after initial activation for suspected STEMI via the ODiSEA APP, what happens to them?
Authors: Martin Dominguez C , Palacios J C , Agudelo V , Rodriguez A , Aguilo O , Perez V , Diaz G , Gaitan E , Martinez J M , Vicente M , Brugada R , Aboal J
Published: November 2023

Introduction

The use of technological innovation in STEMI care networks has been shown to be effective in sharing diagnostic ECG tracing and clinical information with the cardiology department, reducing the number of inappropriate cases transferred to the cathlab. These inappropriate cases have been shown to be more likely to die than those undergoing urgent coronary angiography, but data on incidence, cause of cancellation and prognosis are limited1.

Objective

Our aim was to investigate the characteristics and prognosis of patients in whom transfer to the cathlab was cancelled, compared with those who underwent emergent coronary angiography (EC).

Material and Methods

Prospective study analysing all STEMI alert activations during the year 2022. Information on ECG pattern and clinical history was transmitted using an APP (ODiSEA2,3). Based on the ECG pattern and clinical history, cancellations were made. Patient characteristics, myocardial infarction, ECG activation pattern, angiography results and in-hospital mortality were studied.

Results

A total of 406 infarction codes were activated through the ODISEA APP, of which 284 (70%) underwent EC and 122 (30%) were cancelled. The cancelled patients had a higher comorbidity than the transferred patients. The reasons for cancellation based on ECG patterns are shown in Figure 1. The most common were ST depression (23%), concave ST elevation (18.8%) and intraventricular conduction disturbances (22.9%).

In addition, coronary angiography was performed in 33% of the cancelled patients compared to 99% of the transferred patients (p<0.001). The number of patients with coronary arteries without lesions was significantly higher in the cancelled group (31.7% vs. 9.6% p<0.001). In the EC group, 90.5% of patients presented with a final diagnosis of ACS, whereas in the cancelled group this was 32.8% (final diagnosis of STEMI 2.5% in the cancelled group vs. 83.5% in the CE group, p<0.001). Discharge from the emergency department was 46% in the cancellation group versus 2.7% in the transfer group (p<0.001). Finally, the in-hospital mortality rate was significantly higher in the cancelled group: 14 patients (11.4%) vs. 12 patients (4.2%) in the transferred group (p<0.001).

Discussion

Compared to patients who are transferred to a centre with cathlab, the subgroup of patients initially activated as STEMI alerts and eventually cancelled have a high comorbidity, a low probability of a final diagnosis of ACS and a high in-hospital.Table 1.Patients characteristicsFigure 1.ECG pattern
Deep learning-based quantitative image analysis for detecting coronary artery stenosis, calcification, and vulnerable plaque in coronary computed tomography angiography
Authors: Kim D
Published: November 2023

Purpose

To develop a quantitative image analysis for detecting coronary artery stenosis, calcification, and vulnerable plaque in reconstructed coronary computed tomography angiography.

Materials and Methods

2,978 reconstructed coronary artery CT angiography (CCTA) of our hospital in South Korea from 2014 to 2022 were enrolled. For each CCTA scan, a total of 13 images were reconstructed for each coronary artery (CA) by CT Cardiac Package, TeraRecon Inc. A total of 769 CT images were independently selected as the test data set in the last period, while the remaining were utilized in a 4:1 ratio as train and validation datasets. The locations of stenosis and vulnerable plaques were strongly labeled by an expert radiologist with more than 10 years of experience to train a 2D segmentation model (SM). First of all, the correlation between a quantitative stenosis index (QSI) and conventionally measured quantitative angiographic analysis (QCA) was evaluated. We developed an SM for CA and stenosis using 2D nnU-Net. Using SM, the position and length of stenosis per image were evaluated, and a CA diameter profile was analyzed through Full Width at Half Maximum analysis. The QSI is acquired through the calculation of the CA diameter profile. Secondly, images with marked calcifications and calcification scores (CS) were evaluated by an expert cardiologist with more than 15 years of experience. The CS was calculated by measuring the number of voxels over 1100 Hounsfield units in the CA using the previously developed vascular SM. The result of CS was evaluated by visual scoring of the expert cardiologist with a 10-scale. Lastly, the presence or absence of vulnerable plaques per CA was evaluated. In addition, another SM for normal CA and vulnerable plaques were trained. For the evaluation method, sensitivity and specificity were calculated for each CA.

Results

The correlation between QSI and QCA was 0.715. Visual scoring on the result of CS was 7.150 ±2.354 to 10. The sensitivity and specificity of the vulnerable plaque for evaluating vascular unit classification were 0.929 and 0.910, respectively. Conclusions We developed an automated quantitative image analysis for evaluating QSI, detecting calcification, and vulnerable plaque in CCTA, which could be used in the actual screening setting.
The specificity of cardiac troponin elevations for myocardial infarction declines with age
Authors: Hasselbalch R , Sindet-Pedersen C , Pries-Heje M , Strandkjaer N , Kristensen J H , Porsborg Andersen M , Torp-Pedersen C , Bundgaard H , Iversen K
Published: November 2023

Background

Cardiac troponin T (cTnT) and I (cTnI) are the gold standard biomarkers of myocardial infarction (MI). Studies have shown that the concentration of cTn increases with age among healthy individuals, but the clinical impact of this is unclear. Further, there seem to be a difference in the increases in cTnI and in cTnT - the latter being more sensitive to increasing age.

Purpose

To investigate the impact of age on the diagnostic ability of cTnT and cTnI for myocardial infarction.

Methods

This nationwide cohort study includes patients admitted with cTn measurements from 2009-2022 using one of five cTn assays: Roche high-sensitivity cTnT (hs-cTnT), Abbott Alinity high sensitivity cTnI (hs-cTnI), Siemens Vista Hs-cTnI, Siemens Atellica hs-cTnI and Beckman-Coulter hs-cTnI. We selected the peak concentration of cTn on admission and grouped patients into those who had cTnI and those who had cTnT measured which were divided into age groups of <40 years, 40-50 years, 50-60 years, 60-70 years, 70-80 years, 80-90 years and >90 years. The primary outcome was a diagnosis of MI during admission. Receiver operating characteristics (ROC) were used for the concentration of cTn normalized to the assays 99th percentile, and we explored the specificity of elevations of each assay above the 99th percentile.

Results

A total of 350,428 patients were included in this study with a median age of 67 years (IQR 52-77); 188,382 (54%) were males and 48,262 (14%) had a history of ischemic heart disease prior to the admission. When grouping for type of cTn used, more patients were treated when hs-cTnT (240,660, 69%) was used compared with hs-cTnI (109,768, 31%). The patient treated using hs-cTnT were slightly older than patients treated with hs-cTnI, 67 years (IQR 53-77) vs 65 years (53-77) p<0.001.

During the admission 29,023 patients (8.3%) had a MI. Figure 1 panel A shows the ROC curve of hs-cTnT and hs-cTnI for each age group. Both biomarkers showed a decline in the area under the curve (AUC) with increasing age. Figure 1 panel B shows the AUC for each age group. Hs-cTnI had a higher AUC for all age groups and seemed to decrease less with age. Figure 2 shows the specificity for the 99th percentile of each assay for the age groups. There were substantial differences in the specificity at the 99th percentile between cTn assays, with the cTnT assay being the least specific for all age groups, while the two Siemens assays had the highest specificity. An elevation above the 99th percentile of the cTnT assay had a specificity of 3% in the group of patients >90 years old.

Conclusion

The specificity of elevation of cTn for MI declined with increasing age for all assays. This decline seemed to be largest for the cTnT assay were an elevation above the 99th percentile among patients >90 years old had a specificity of 3% for MI.Figure 1Figure 2
Biomarkers for identification of high-risk coronary plaques in patients with suspected coronary artery disease
Authors: Pedersen G P , Dahl J D , Rasmussen L D R , Blavnsfeldt A B , Boettcher S B , Boettcher M B , Nyegaard M N , Nissen L N , Winther S W
Published: November 2023

Background

Patients with atherosclerotic plaques containing high-risk features have an increased likelihood of events and a worse prognosis. Whether elevated levels of biomarkers of ischemia e.g. TnI and inflammation e.g. high sensitive C-reactive protein (hsCRP) are associated with the presence of high-risk coronary atherosclerotic plaques (HRP) evaluated on coronary computed tomography angiography (CCTA) is not well described.

Objectives

To assess the association between 1) TnI and 2) hsCRP and quantified coronary plaque burden, luminal diameter stenosis and HRP in symptomatic patients with low/intermediate pre-test probability of obstructive coronary artery disease (CAD) referred to CCTA evaluation.

Methods

On enrolled patients (n=1,615), CCTA were analysed using a semiautomatic software for coronary artery plaque characterization. Patients with high (>6 ng/L) and low (<3 ng/L) TnI as well as high (>2 mg/L) and low (<1 mg/L) hsCRP were identified. Associations of high levels of TnI and hsCRP compared to low levels were investigated for the following: high plaque burden (defined as having total plaque volume above the 75th percentile on CCTA), presence of significant stenosis (defined as ≥50% luminal diameter stenosis on CCTA), and presence of HRP (defined as having a plaque with at least two risk features on CCTA).

Results

TnI and hsCRP were both positively correlated with total plaque burden (TnI rs=0.14, p<0.001; hsCRP rs=0.08, p<0.001). In multivariate logistic regression analyses, high TnI was when compared to low TnI associated with presence of stenosis (OR 1.43, 95% confidence interval (CI) 1.03-1.99, p=0.034), the presence of HRP (OR 1.79, 95% CI: 1.17– 2.74, p=0.008) and further the subtypes of HRP including low attenuation plaque (OR 1.93, 95% CI: 1.24–3.00, p=0.003) and positive remodelling (OR 1.51, 95% CI: 1.07–2.13, p=0.018). For high hsCRP levels, only the presence of stenosis and the HRP-subtype napkin ring sign correlated significantly.

Conclusion

In patients with suspected CAD TnI and hsCRP are associated with the presence of HRP features. These findings suggest that inflammatory and particularly ischemic biomarkers might improve early risk stratification and potentially also affect patient management.
ESC 0/1h-algorithm using the updated, biotin-resistant high-sensitivity cardiac troponin T assay
Authors: Twerenbold R , Boeddinghaus J , Nestelberger T , Puelacher C , Rubini Giemenez M , Guo L , Lopez Ayala P , Miro O , Martin-Sanchez F J , Morawiec B , Keller D , Mueller C
Published: November 2023

Background

For rapid and safe triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI), the European Society of Cardiology (ESC) recommends the use of a 0/1h-algorithm based on high-sensitivity cardiac troponin (hs-cTn) T or I. Recently, multiple widely used immuno-assays including hs-cTnT have been reported to interfere with high biotin concentrations, potentially leading to false-negative results. To address this major concern, an updated, biotin-resistant hs-cTnT assays has been developed by the manufacturer to replace its previous version.

Purpose

We aimed to assess and compare the clinical performance of the updated, biotin-resistant hs-cTnT Elecsys assay when using the original ESC hs-cTnT 0/1h-algorithm.

Methods

In a prospective international diagnostic study enrolling patients presenting with suspected NSTEMI to the emergency department (ED), hs-cTnT was serially measured at ED presentation and after one hour with the original, biotin-sensitive (hs-cTnT-original) and the updated, biotin-resistant hs-cTnT (hs-cTnT-updated) assay.

Patients presenting with STEMI were excluded. The final diagnosis was centrally adjudicated by two independent cardiologists using all available data including coronary angiography, echocardiography, follow-up data, and serial measurements of hs-cTn. We assessed the overall efficacy, rule-out safety and rule-in accuracy of the ESC hs-cTnT 0/1h-algorithm when using hs-cTnT-updated and compared it with the use of hs-cTnT-original.

Results

NSTEMI was the final diagnosis in 162 of 865 (19%) patients. The ESC 0/1h-algorithm using hs-cTnT-updated triaged 58% of patients towards "rule-out", 21% towards "rule-in", and 21% towards "observe" compared to 56%, 21% and 23% using hs-cTnT-original, respectively (Figure 1, p=ns). Only 6 patients were reclassified using hs-cTnT-updated. Safety of rule-out was very high using hs-cTnT-updated with a negative predictive value for NSTEMI of 100% (95% confidence interval (CI), 99.2-100%) and a sensitivity of 100% (95%CI, 97.7-100%) and was highly comparable to hs-cTnT-original (NPV 100% [95%CI 99.2-100], sensitivity 100% [95%CI, 97.7-100%], all p-values for comparison not significant). Of note, no NSTEMI-patient was missed by the ESC 0/1h-algorithm neither using hs-cTnT-updated nor original. Similarly, accuracy of rule-in was very high (positive predictive value 73.7% [95%CI, 66.8-79.6%], specificity 93.3% [95%CI, 91.2-94.9%]) and highly comparable to hs-cTnT-original (PPV 73.9% [95%CI 67.1-79.7%], specificity 93.2% [95%CI, 91.1-94.8%], all p-values for comparison not significant).

Conclusions

The safety and efficacy of the ESC 0/1h-algorithm using the novel updated, biotin-resistant hs-cTnT-assay is excellent and similar to the use of the original assay without the need to adjust the cutoffs to the new assay.Figure 1
A novel deep learning model for a coronary computed tomography angiography diagnosis of plaque erosion
Authors: Yuki H , Park S , Suzuki K , Kinoshita D , Niida T , Mcnulty I , Alexander B , Lee H , Nakamura S , Kakuta T , Ye J , Jang I K
Published: November 2023

Background

Plaque erosion is the underlying pathology in up to 50% of patients with non-ST-segment elevation acute coronary syndromes (ACS). Previous studies suggest that patients with erosion might be treated conservatively without stenting. Currently, a diagnosis of plaque erosion requires invasive intracoronary imaging.

Purpose

We sought to develop a deep learning (DL) model that enables an accurate diagnosis of plaque erosion using coronary computed tomography angiography (CTA).

Methods

A total of 532 coronary CTA scans (143 coronary CTA scans with plaque rupture, 113 with plaque erosion, and 276 with reference segment) from 395 patients were included to develop a model: 426 coronary CTA scans from 316 patients for training and internal validation, and 106 separate scans from 79 patients for test set validation. Among ACS patients, the diagnosis of plaque rupture or erosion identified by OCT was used as the ground truth, and the corresponding site on the CTA image matched with OCT image was determined to be the culprit lesion. A novel DL, Momentum Distillation Composite Transformer Attention (MD-CTA) model, was developed that can effectively process the whole CTA scans to diagnose plaque erosion.

Results

The novel DL model showed diagnostic performance in the five-fold cross-validation with an area under the receiver-operating characteristic curve (AUC) of 0.901 (0.873-0.930), a sensitivity of 81.2 (72.8-88.0), and a specificity of 86.6 (82.4-90.2), all of which were significantly higher than those of convolutional neural network (CNN) model with an AUC of 0.621 (0.567-0.675), the sensitivity of 59.8 (50.1-69.0), and specificity of 60.2 (54.5-65.7) in training validation. Similarly, in the test set validation, the AUC, sensitivity, and specificity of the MD-CTA model were 0.899 (0.841-0.957), 87.1 (70.2-96.4), and 85.3 (75.3-92.4), respectively, higher than those of 0.724 (0.622-0.826), 71.0 (52.0-85.8), and 68.0 (56.2-78.3) of the CNN model. At the slice level, the MD-CTA model was also superior in the five-fold cross-validation and the test set validation compared to the CCN model. This model significantly outperformed experienced cardiologists, especially for sensitivity.

Conclusions

The newly developed DL model enables an accurate CTA diagnosis of plaque erosion, which might enable the cardiologist to provide tailored therapy without invasive procedures. This algorithm might lead to a major shift in managing millions of patients with plaque erosion each year.Table 1Figure 1
The effect of PCI and post procedural TIMI flow on patients with late arrival STEMI
Authors: Tarabih M , Ovdat T , Karkabi B , Eitan A , Maguli B , Mahamid M , Shiran A
Published: November 2023

Introduction

Patients with ST-elevation myocardial infarction (STEMI) and late arrival (>12h) may have worse outcome following percutaneous coronary intervention (PCI). A worse TIMI flow after PCI is associated with poor outcome. Our aim was to compare the TIMI flow after PCI and to find its effect on outcomes in patients with late-arrival STEMI Compared with that of patients presenting early (<12h).

Methods

Data source was available for patients enrolled in the biennial acute coronary syndrome Israeli Surveys (ACSIS) during 2000-2021. TIMI flow data was reviewed in patients with late arrival STEMI (12-48h and >48h) who underwent PCI. We analyzed its effect on clinical outcomes in patients with late-arrival STEMI compared with that of patients presenting early (<12h).

Results

Available data regarding the time from symptom onset to hospital arrival was available in 6,466 patients with STEMI. Data regarding TIMI flow following primary PCI was available in 2,437/6466 (38%) patients. Pre procedural TIMI-0 flow in the infarct related artery (IRA) was present in 59% of patients, irrespective of time of presentation (Figure). The rate of TIMI-3 flow following PCI was similar in all groups, 89% in patients arriving 12-48h, 96% in those arriving >48h after symptoms onset and 92% in patients presenting within 12h (p=0.632). Most importantly, PCI significantly reduced the rate of 30 days MACE only in those arriving less than 12 H from symptoms onset (Table).

Conclusions

In patients participating in the Israeli ACSIS registry, TIMI-3 flow after primary PCI was achievable in most STEMI patients, but PCI improved the outcome only in those arriving less than 12hour.
Quantitative flow ratio for non culprit lesions in ST elevation myocardial infarction and multi vessel disease - a direct comparison with fractional flow reserve
Authors: Memisevic N , Haertel F , Lauer B , Moebius-Winkler S , Schulze P C
Published: November 2023

Objectives

In acute myocardial infarction and multivessel disease (MVD), current guidelines recommend treatment of the culprit lesion followed by staged full revascularization of functionally relevant stenoses. We sought to analyze the hemodynamic relevance of intermediate stenoses using quantitative flow ratio (QFR, an angiography-derived fractional flow reserve [FFR]) in a population presenting with ST elevation myocardial infarction (STEMI) and MVD on index procedure.

Methods

We retrospectively analyzed 36 coronary lesions in 34 Patients presenting with STEMI and MVD from January 2017 to September 2022. 31 (86%) patients were male, mean age 63 ± 7, mean ejection fraction (EF %) 50 ± 8, arterial hypertension 30 (88%), diabetes 13 (38%). The non culprit lesion location was left anterior descending (LAD) in 24 (67%), circumflex artery (RCX) in 8 (22%) and right coronary artery (RCA) in 4 (11%). All patients received an invasive assessment of non culprit lesions using FFR within 3 months after STEMI. A QFR assessment of non culprit lesions in an acute invasive coronary angiography has been compared with FFR results in a staged procedure.

Results

QFR showed an excellent accuracy in ruling out functionally relevant stenosis with no false negative results (sensitivity 100% compared to FFR). Three coronary lesions (8,3%) were graded false positive (functionally relevant). Due to poor image acquisition, we were unable to perform QFR analysis in ten coronary lesions (28%). Overall specificity (56,5%) was lower than reported in previous trials. After excluding the lesions that could not be analyzed due to poor acquisition we achieved specificity of 81,2% (Fig. 1).

Concusion: QFR showed an excellent correlation with FFR (Fig. 1). Performing QFR in STEMI Patients with MVD could reduce the need of repeated invasive coronary angiographies and optimize the clinical therapy management in this high-risk population. Further studies on diagnostic performance and outcomes are needed.Fig. 1: Correlation plot
Incidence and pattern of repeat coronary revascularizations in patients with acute coronary syndromes treated with ticagrelor or prasugrel
Authors: Aytekin A , Scalamogna M , Coughlan J J , Lahu S , Ndrepepa G , Menichelli M , Mayer K , Joner M , Xhepa E , Kufner S , Laugwitz K L , Neumann F J , Schunkert H , Kastrati A , Cassese S
Published: November 2023

Background

The ISAR-REACT 5 randomized trial compared the efficacy and safety of ticagrelor and prasugrel in patients with acute coronary syndromes (ACS) managed invasively. Data are missing with regard to the effect of these antiplatelet agents on the repeat revascularization procedures.

Purpose

We sought to investigate the impact of ticagrelor and prasugrel on the incidence and pattern of repeat coronary revascularizations in patients with ACS undergoing percutaneous coronary intervention (PCI).

Methods

This post-hoc analysis of the ISAR-REACT 5 trial included all ACS patients who underwent PCI. Patients were divided into two groups as per assigned antiplatelet treatment. The primary outcome for this analysis was the incidence of repeat coronary revascularization (percutaneous or surgical) up to 12-month follow-up. Secondary outcomes were target vessel revascularization (TVR) and non-target vessel revascularization (NTVR). We also studied whether repeat revascularization procedures were urgent in nature.

Results

Among 3,377 ACS patients, 1,676 were assigned to ticagrelor and 1,701 to prasugrel group before receiving PCI. Compared with prasugrel, the incidence of repeat coronary revascularization at 12 months was significantly higher in patients treated with ticagrelor (hazard ratio [HR]=1.14; 95% confidence interval [CI] 1.01-1.29), mostly attributable to significantly more NTVR (HR=1.15 [1.01-1.32]) in this latter group. There were numerically more urgent repeat revascularizations in patients receiving ticagrelor compared with prasugrel (HR=1.32 [1.00-1.75]), mostly due to urgent NTVR (HR=1.62 [1.09-2.41]). The risk of TVR was not significantly different between treatment groups (HR=1.04 [0.76-1.44]).

Conclusions

In patients with ACS treated with PCI, ticagrelor is associated with significantly more repeat coronary revascularizations compared to prasugrel after 12 months, predominantly in remote coronary vessels.
Comparison of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in myocardial infarction patients with type 2 diabetes
Authors: Tjerkaski J , Ueda P , Alfredsson J , Erlinge D , Lindahl B , Mohammad M A , Omerovic E , Reitan C , Svensson P , Jernberg T
Published: November 2023

Background

Both sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) have been shown to reduce the risk of adverse cardiovascular outcomes in type 2 diabetes mellitus (T2DM) patients with established atherosclerotic cardiovascular disease.

Purpose

The aim of this study was to assess the comparative effectiveness of SGLT2i and GLP1-RA in myocardial infarction (MI) patients with T2DM.

Methods

This observational cohort study included MI patients with T2DM who were treated with SGLT2i or GLP1-RA within 180 days of hospital discharge between 2013 and 2021. Data was acquired from the SWEDEHEART registry, a nationwide quality register. The co-primary endpoints of this study were a composite of MI, ischemic stroke and all-cause mortality (MACE) and a composite of heart failure hospitalisation (HHF) and all-cause mortality. Inverse probability of treatment weighting was used to adjust for differences in baseline covariates between the treatment groups.

Results

This study consisted of 617 patients who were treated with SGLT2i and 543 patients who were treated with GLP1-RA. We observed no statistically significant differences between SGLT2i and GLP1-RA concerning the risk of MACE (adjusted incidence rate 76 vs. 68 events per 1000 person-years; HR 1.09 [95% CI 0.85 - 1.40]) and the risk of HHF or all-cause mortality (adjusted incidence rate 52 vs. 50 events per 1000 person-years; HR 1.04 [95% CI 0.80 - 1.36]). Similarly, we did not observe any statistically significant differences between the treatment groups concerning the secondary outcomes of MI (adjusted incidence rate 63 vs. 53 events per 1000 person-years; HR 1.08 [95% CI 0.83 - 1.40]), stroke (adjusted incidence rate 7 vs. 6 events per 1000 person-years; HR 1.22 [95% CI 0.57 - 2.87]), HHF (adjusted incidence rate 45 vs. 38 events per 1000 person-years; HR 1.06 [95% CI 0.80 - 1.41]) and all-cause mortality (adjusted incidence rate 11 vs. 15 events per 1000 person-years; HR 1.06 [95% CI 0.63 - 1.82]).

Conclusions

There were no statistically significant differences between SGLT2i and GLP1-RA concerning the risk of recurrent ischemic events, HHF and all-cause mortality in this cohort of MI patients with T2DM.Cumulative incidence of events
Comparison of ticagrelor and prasugrel just before PCI in NSTE acute coronary syndromes, LIKE-ACCOAST analysis
Authors: Motovska Z , Jarkovsky J , Kovarik A , Mrozek J , Hlinomaz O , Precek J , Hromadka M , Zohor A , Kala P , Tomasov P , Cervinka P , Matejka J , Benesova K , Drabkova S
Published: November 2023

Background

Recommendations for the preference of prasugrel over ticagrelor just before PCI in NSTE ACS are based on limited and controversial evidence. Furthermore, prasugrel can’t be used in patients after a stroke/TIA, and the risk of bleeding in older and low-weight patients annuls its benefit.

Purpose

We aimed to add to the current evidence comparing the benefit of prasugrel and ticagrelor just before PCI (without pretreatment) in NSTE ACS patients.

Methods

The prasugrel population comprised the ACCOAST study non-pretreatment arm undergoing PCI (N 1372) (ref 1). The ticagrelor study population was selected from the long-term all-comers National Registry of Cardiovascular Surgery and Interventions: Module of Cardiovascular interventions of Institute of Health Information and Statistics of the Czech Republic (N 15126)who were 1) undergoing PCI for NSTE ACS, 2) received ticagrelor loading dose 180 mg just before the procedure, 3) fulfilled the inclusion and exclusion criteria of the ACCOAST trial (N 1370).

The endpoint (identically to the ACCOAST primary EP) was a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout seven days after PCI.

The data were matched to the structure of published ACCOAST no pre-treatment group using R with maic package, which provides a generalized workflow for the generation of subject weights to be used in Matching-Adjusted Indirect Comparison (MAIC) (Ref 3,4). In MAIC, unbiased comparison between outcomes of two trials is facilitated by weighting the subject-level outcomes of one trial with weights derived such that the weighted aggregate measures of the prognostic or effect modifying variables are equal to those of the sample in the comparator trial.

Results

The study population characteristics are presented in Table. We did not find any difference in the efficacy endpoint at seven and 30 days after PCI between the groups treated with prasugrel and ticagrelor (Figure).

Conclusion

Prasugrel and ticagrelor given just before PCI for NSTE ACS are equally effective in reducing ischemic risk.Table.Efficacy endpoint occurence.
Temporal trends and predictors of emergency department visits and hospital readmissions in angina and no obstructive coronary artery disease (ANOCA): a population-based study of 85,573 adults
Authors: Patel S , Fung M , Butalia S , Anderson T J
Published: November 2023

Background

Chest pain in patients with angina and no obstructive coronary artery disease (ANOCA) is a diagnostic and treatment challenge, resulting in a significant burden on healthcare resources. With increasing recognition of ANOCA, it is uncertain if the healthcare resource utilization of patients with ANOCA has changed over time. We aimed to determine whether emergency department (ED) visits and hospital readmissions in patients with ANOCA has changed over time and their predictors.

Methods

A retrospective population-based cohort of patients who had their first cardiac angiography for a chest pain syndrome in Alberta between 2002 and 2020 were extracted from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. A temporal trend analysis was performed to investigate the proportion of ED visits and hospital readmissions in ANOCA and obstructive coronary artery disease (CAD). The predictors of ED visits and readmissions were also analyzed.

Results

In our analysis, 85,573 patients were included (26% ANOCA, 31% female, mean age 62.1 ± 12.0 years, 65% ED visit≥1, 30% readmission). The percentage of patients with ANOCA and obstructive CAD having an ED visit ranged between 26.3% to 30.7% and 47.7% to 53.1%, respectively. The percentage of patients with ANOCA and obstructive CAD having readmission declined slightly over time, from 6.5% to 3.8% in ANOCA and 24.8% to 15.3% in obstructive CAD. Obstructive CAD was found to be the most significant predictor of both ED visits (OR=1.933, 95% CI=1.837–2.034), and readmissions (HR=2.638, 95% CI=2.518–2.764), with congestive heart failure (OR=1.302, 95% CI=1.125–1.507) , peripheral artery disease (OR=1.291, 95% CI=1.116–1.494), cerebrovascular disease (OR=1.382, 95% CI=1.224–1.559), myocardial infarction (vs stable angina (SA): OR=1.233, 95% CI=1.172–1.297), and unstable angina (vs SA: OR=1.564, 95% CI=1.466-1.668–0.89) also contributing to ED visits, and diabetes (HR=1.276, 95% CI=1.229–1.323) and stable angina (vs MI: HR=0.746, 95% CI=0.719–0.774; vs UA: HR=0.895, 95% CI=0.857–0.934) contributing to readmissions.

Conclusions

Emergency department visits for patients with ANOCA have remained stable over time, with a slight decline in hospital readmissions. Patients with ANOCA had fewer ED visits and readmissions than obstructive CAD patients, and no sex differences were observed in the utilization of healthcare resources. This study suggests that education and follow-up interventions are still needed for patients with ANOCA.Comparison of baseline characteristicsED visits & Readmission Temporal Trends
The prevalence of young ST-elevation myocardial infarction, the risk factors, and the pattern of coronary artery involvement in the Serdang PPCI Registry over 7 years
Authors: Mat Lawi F , Abd Malek A M , Sk Abdul Kader M A LI , Abdullah Ramaiah A S R I R , Selvaraj K A M A R A , Abd Ghapar A B D K
Published: November 2023

Background

Acute coronary syndrome has remained Malaysia's leading cause of death for the past 15 years, with a more than 50% increase in the last ten years. There is limited published literature focusing on this population. Hence, we aim to assess the clinical risk factors, angiographic profile, and outcome of young patients (aged ≤ 40 years) with acute STEMI from the Serdang Primary PCI STEMI Network over a period of 7 years.

Methods

We evaluated all patients ≤40 years of age admitted with acute ST-segment elevation acute myocardial infarction (STEMI) who were studied between May 2015 and December 2022 at Serdang Heart Center Hospital. Risk factors were determined by review of electronic medical records. The primary outcomes of interest were all-cause mortality.

Results

Out of 1374 patients, 184 were very young STEMI patients, accounting for 13.4% of all patients in our study, with the majority being male (92.9%). The average age was 34.61±4.71. The mean pain score was 5.7±2.4. Anterior wall MI was present in 90 patients (48.9%), inferior wall MI in 84 patients (45.7%), lateral wall MI in 9 patients (4.9%), and left main stem MI in 1 patient (0.5%). The prevalence of diabetes mellitus was 27.7%, with a mean HbA1c of 6.9±2.4. With a mean TC of 5.68±1.61 mmol/L and a mean LDL of 3.70±1.48 mmol/L, the prevalence of dyslipidaemia was 49.5%. The mean creatinine was 83.04±21.04. The majority presented a Killip I score, which accounted for 91.3%. The radial vascular access was 84.8%. Single-vessel disease was the most common finding, at 77.7%. At 1 month, 98.4% of patients survived.

Conclusion

STEMI in people under the age of 40 is almost entirely seen in men. Around 15% of patients have no significant stenosis of the coronary arteries. Anterior-wall MI is more common, and more than three-quarters of patients have single-vessel disease. The 1-month survival rate is high.
Clinical and long-term prognostic trends in ST-segment elevation myocardial infarction: a multicentre national registry analysis
Authors: Miguel Goncalves C , Cabral M , Carvalho M , Vazao A , Martins A , Fernandes S , Pernencar S , Saraiva F , Morais J
Published: November 2023

Background

Although significant advances in patient care, ST-segment elevation myocardial infarction (STEMI) remains a major health problem.

Purpose

To describe clinical and prognostic characteristics of Portuguese STEMI patients.

Material and methods

Retrospective multicentre analysis of STEMI patients included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and October 2022. Baseline characteristics, clinical findings, treatment and mortality were analyzed. Multivariate analysis was performed to assess predictors of mortality.

Results

The authors studied 14470 patients with a mean age of 64 ± 14 years, of which 74% were male. A high frequency cardiovascular risk factors was observed, namely high blood pressure (63%), dyslipidemia (54%), smoking (35%) and diabetes (25%). Previous myocardial infarction was present in 11%. The most common symptom was chest pain (94%), Killip class 1 the most frequent presentation and left ventricular ejection fraction was preserved in 52%. Around 88% of patients were submitted to coronary angiography and coronary angioplasty was successful in roughly 98%. Multivessel disease was found in 44% although left anterior descending artery was the most frequent culprit artery - in about 44% of cases. Regarding in-hospital complications: shock (36%), congestive heart failure (17%) and death (5%) were reported. Thirty-day and one-year mortality occurred in 6% and 8%, respectively.

After multivariate analysis, older age (HR=4.06; CI 95% [2.556-6.448]; p<0.001), left ventricular ejection fraction under 30% (HR=2.038; CI 95% [1.284-3.234]; p=0.003) and Killip class above 1 (HR=1.578; CI 95% [1.104-2.256]; p=0.012) remained as independent risk factors for one-year mortality.

Conclusions

Cardiovascular risk factors were highly prevalent in our population. Although multivessel disease was common, the most frequent culprit artery was the left anterior descending artery with successful treatment. Several clinical characteristics, namely age, left ventricular ejection fraction and Killip class, were independent risk factors for one-year mortality.