bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of diabetes status and chronic kidney disease on myocardial infarction mortality among elderly patients - a retrospective analysis of data from an ongoing nationwide registry
Authors: Loiveke P , Fischer K , Ainla T , Marandi T , Blondla M , Saar A , Eha J
Published: November 2023

Background

Prevalence of diabetes (DM) is rapidly increasing. With high rate of concomitant chronic kidney disease (CKD) in the elderly population the risk of cardiovascular (CV) complications is very high.

Purpose

Aim of our study was to evaluate the effect of DM status and CKD on mortality among elderly patients after acute myocardial infarction (AMI).

Methods

EMIR is an ongoing nationwide registry recording data from all patients in Estonia diagnosed with AMI (ICD-10 I21-I22). The study included all patients aged > 65 years who were hospitalized with the first AMI from 2012 to 2019. Data on glycated haemoglobin (HbA1c) in the time frame of 30 days prior to 7 days after admission, estimated glomerular filtration (eGFR) and creatinine levels within 24 hours of admission were obtained from the hospitals’ databases. Mortality data was acquired by linking the database to the Estonian population register. Follow up period lasted until the end of 2021. Prediabetes was defined as HbA1c ≥ 5,7 – 6,4 %, new DM as HbA1c ≥ 6,5 % without previous DM diagnosis. Information about previous DM diagnosis was acquired from EMIR. Statistical analysis was done using Cox proportional hazards regression model adjusted for age, sex, DM status and renal function.

Results

A total of 8902 patients (50.5 % women) were identified. Among female patients there was a larger proportion of diabetics and patients with lower eGFR (Table 1). We found that 30 day, 1-year and long – term (median 5.5 years) mortality was higher for both newly diagnosed (30 days: HR 1.6 (95 % CI 1.14 – 2.23); 1–year: HR 1.57 (95 % CI 1.25 – 1.99); long–term: HR 1.53 (95 % CI 1.29 – 1.81)) and known DM (30 days: HR 1.39 (95 % CI 1.19 – 1.61); 1–year: HR 1.28 (95 % CI 1.15 – 1.42); long–term: HR 1.47 (95 % CI 1.37 – 1.58)) patients. Prediabetes did not increase post MI mortality. In all follow up periods mortality increased progressively in accordance with declining renal function from eGFR below 59 ml/min/1.73m2 (Figure 1).

Conclusions

Our study suggests that newly diagnosed and known DM status and CKD have a considerable effect on elderly patients’ mortality after AMI, both in short and long term. Timely diagnosis and treatment of DM and CKD and meticulous secondary prevention can add to lowering mortality after AMI. However, our data also indicates that a more lenient medical management of prediabetes and mild CKD would be adequate for the elderly AMI patients in the current polypharmacotherapy era.Table 1.Figure 1.
Differences in left anterior descending coronary artery disease in participants without standard modifiable cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA)
Authors: Gray M P , Vernon S T , Budoff M J , Figtree G A
Published: November 2023

Background/Introduction

The development of coronary artery disease (CAD) and myocardial infarction (MI) in the absence of standard modifiable cardiovascular risk factors (SMuRFs) has been highlighted as an unmet clinical need, accounting for between 10-27% of ST elevation MI and associated with higher 30-day mortality. One potential contributor to the early mortality is the higher observed rates of LAD territory culprit lesions in SMuRFless patients compared to those with at least one SMuRF.

Purpose

To characterise the differential proportion of LAD disease in an asymptomatic population with no prior cardiovascular disease (CVD) history, comparing individuals with CAD despite no SMuRFs to those with at least one SMuRF in the Multi-Ethnic Study of Atherosclerosis (MESA).

Methods

A MESA sub-cohort with a baseline coronary artery calcium score (CACS) >0 Agatston units (AU) was prepared. SMuRF status was assigned by self-report, treatment, or biomarkers for hypertension, hypercholesterolaemia, diabetes, and smoking. Proportion of disease in the left main, LAD, circumflex, and right coronary arteries were calculated by the vessel CACS divided by the total CACS. Standard descriptive statistics were used to characterise baseline differences. Group comparisons were completed with Wilcoxon rank sum for continuous measures and Chi-square for categorical.

Results

A CAC positive cohort of 3,417 participants was prepared from participants with SMuRF and CT imaging data, 14.3% of whom were considered SMuRFless. Total CACS was lower in SMuRFless participants compared to those with ≥1 SMuRF (58 AU vs. 102 AU, p<0.0001). However, proportion of calcium burden in the LAD was significantly higher in SMuRFless participants with CAD (74.2% vs. 56.8%, p<0.0001). When considering clinically significant CACS strata, proportion of LAD calcium burden was not significantly different between SMuRFless vs. ≥1 SMuRF participants with a total CACS of 1-99 AU (93.7% vs. 80.0%). However, statistically significant differences in LAD calcium proportion were observed between SMuRFless vs. ≥1 SMuRF participants with a total CACS 100-400 AU (69.5% vs. 57.8%) and CACS>400AU (45.2% vs. 40.5%). This difference remained significant during multivariate modelling, including consideration of absolute CACS.

Conclusion

Of patients with evidence of CAD (CACS>0) in the MESA cohort, SMuRFless status was associated with a higher proportion of LAD disease compared to participants with ≥1 SMuRF. This adds to previous observations in STEMI cohorts suggesting a heightened susceptibility to atherosclerosis development in the LAD territory against a lower traditional risk burden, and highlights the need for consideration of distinct biology and clinical significance in future studies.Fig. 1Fig. 2
Progression of atherosclerosis in smokers: a longitudinal nation-wide serial angiography study
Authors: Dahlgren A , Mohammad M A M , Erlinge D E
Published: November 2023

Introduction

Smoking is a modifiable risk factor for coronary artery disease (CAD). Cross-sectional studies have shown that prevalence of CAD is higher among smokers as is incidence of myocardial infarction. However, few studies have assessed how smoking affects the incidence of coronary artery plaque progression.

Purpose

To investigate how CAD progress in smokers.

Method

All coronary artery segments with <50% luminal stenosis in patients having a first-time coronary angiogram between 1989-2017 were identified from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and followed until a clinically indicated angiography within 15 years was performed or death or end of follow-up occurred. The patients were divided into cohorts based on smoking status and studied with regard to plaque progression defined as the occurrence of ≥50 luminal stenosis on subsequent coronary angiogram.

Results

A total of 2,272,518 coronary artery segments in 215,364 patients were included of whom 48.1% were never smokers (NS), 33.4% were previous smokers and 18.5% were active smokers (S). The plaque progression incidence rate (IR) was 2.1 (2.04-2.16) per 1000 segment years (SY) for S, 1.77 (1.73-1.81) per 1000 SY for PS, and 1.33 (1.30-1.36) per 1000 SY for NS. The largest increase in plaque progression IR per 1000 SY in relation to smoking status was the middle right coronary artery (RCA) segment (NS: 1.36 (1.27-1.45), PS: (2.23 (2.08-2.39), S: 3.25 (3.01-3.51)). Kaplan-Meier curves depict increased progression in the RCA among smokers (supplementary picture 1).

Discussion: In this nationwide longitudinal coronary angiography study, plaque progression occurred more frequently in smokers and in whom the right coronary artery was more commonly affected by coronary atherosclerosis.Plaque progression in RCA vs LAD
Left atrial strain measured by three-dimensional echocardiography predicts atrial fibrillation in the general population
Authors: Yafasov M , Javier Olsen F , Grundtvig Skaarup K , Hoejbjerg Lassen M , Dyrby Johansen N , Boje Jensen G , Schnohr P , Moegelvang R , Biering Soerensen T
Published: November 2023

Background

Left atrial (LA) strain is prognostic of adverse cardiovascular events. LA strain by three-dimensional echocardiography (3DE) has been proposed as a more accurate measure of LA function and provide incremental prognostic benefits than traditional two-dimensional approaches. Our aim was to evaluate the prognostic value of LA strain by 3DE in predicting incident atrial fibrillation (AF) in the general population.

Methods

The study included 4,466 participants from a prospective longitudinal cohort study in the general population, among these 2,082 participants underwent 3DE of the LA. After excluding participants with poor image quality (n=70), low volume rate (n=8) and AF at baseline (n=51) 1,956 participants were included in the final study. The endpoint was incident AF.

Results

Mean age was 54±17 years, 44% were male. During a median follow-up time of 4.8 years (interquartile range 4.3-5.5 years) 59 participants (3.0%) developed AF. At baseline, mean left atrial reservoir strain (LASr) was 29.3±6.7%, mean left atrial conduit strain (LAScd) was 16.5±6.7%, and mean left atrial contractile strain (LASct) was 12.8±4.8. The incidence of AF increased significantly with decreasing LA strain measures (p<0.001) (figure 1). In univariable analysis, all three parameters were associated with incident AF (p value for all <0.01). After multivariable adjustment for CHARGE-AF risk score (age, height, weight, systolic blood pressure, diastolic blood pressure, smoking, antihypertensive medication, diabetes, congestive heart failure and myocardial infarction), only LASr and LASct were associated with incident AF (LASr: HR 1.11 (1.07-1.17), p<0.001, per 1% decrease; LASct: HR 1.16 (1.09-1.24), p<0.001, per 1% decrease), whereas LAScd was not (HR 1.04 (0.98-1.10), p=0.17, per 1% decrease).

Conclusion

LA reservoir and contraction strain by 3DE are independently associated incident AF in the general population.
Prevalence of clonal hematopoiesis driver mutations in patients undergoing coronary angiography and its association with coronary artery disease severity
Authors: Ehlert C A , Dederichs T S , Wolf D , Von Zur Muehlen C , Westermann D , Hilgendorf I
Published: November 2023

Background

Clonal hematopoiesis of indeterminate potential (CHIP) is an acquired, genetic cardiovascular (CV) risk factor affecting about 10% of the general population at the age of 70 years. Experimental studies suggest a causal link between CHIP and inflammation-driven atherosclerosis. We hypothesized that CHIP is more frequent in patients undergoing coronary angiography and associates with coronary artery disease (CAD) severity.

Methods

Patients at the age of 40 or older, presenting indications for a left heart coronary angiography examination at the Freiburg Heart Center, Germany, were eligible for screening. Study participants presenting abnormal hematological readouts, C-reactive protein >10 mg/L, glomerular filtration rate <30 mL/min/m2, undergoing antibiotics treatments, having history of malignancy or chronic inflammatory diseases were excluded. Genomic DNA (gDNA) extracted from citrated arterial blood, sampled during angiography, was subjected to CHIP-driver gene mutation screening (TruSight Myeloid Sequencing Panel, Illumina). Targeted genomic sequencing. CAD severity was determined in coronary angiograms using Gensini score by investigators blinded to DNA sequencing results.

Results

We enrolled 178 out of 815 patients that were screened for our observational study, which did not feature exclusion criteria such as hematologic abnormalities or relevant comorbidities (see methods). Median age was 69 years. With a cutoff of 2% variant allele frequency (VAF), nearly 30% of the included patients carried CHIP driver mutations – a prevalence at least three times higher compared to the general public. Most CHIP carriers harbored only one mutation, nearly 80% of mutations were located in the epigenetic regulator genes, DNMT3A and TET2. Among the included patients, the clinical characteristics were generally comparable between the CHIP-carriers and the non-carriers in terms of gender, body mass index, differential blood count, C-reactive protein, lipid profiles, and CV comorbidities. As expected, CHIP-carriers were significantly older. Approximately 80% of patients in our cohort were diagnosed with CAD, the severity of which was quantified by Gensini score, accounting for both the degree and location of coronary artery plaque stenosis. Overall, CHIP-carriers presented with higher scores. in the middle-aged population (40-69 years old) harboring DNMT3A or TET2 mutations, Gensini scores were twice as high compared to non-carriers.

Conclusion

Our findings support a role of CHIP as a novel acquired cardiovascular risk factor independent of other modifiable risk factors, in particular in the middle-aged population that is more affected by genetic traits. CHIP carrier status is disproportionally high among patients in the catherization laboratory and may represent a population to consider additional anti-inflammatory therapy.
Clinical characteristics of first myocardial infarction in women by history of adverse pregnancy outcomes
Authors: Pehrson M , Pihlsgard M , Timpka S
Published: November 2023

Background

Adverse pregnancy complications are known risk factors for future coronary artery disease in women and small studies suggest that a history of hypertensive disorders of pregnancy are associated with ST-elevation myocardial infarction (STEMI) at the time of myocardial infarction. (1) Recent evidence from a population-based study also suggests that middle aged women with a history of either hypertensive disorders of pregnancy or a small for gestational age infant have a different segmental-level pattern of coronary artery atherosclerosis as detected by coronary computed tomography angiography. (2)

Purpose

To study clinical characteristics of first-time myocardial infarction by adverse pregnancy outcome history (preterm delivery, hypertensive disorders of pregnancy [including preeclampsia and gestational hypertension], and small for gestational age infant).

Methods

In 8,320 women age ≤65 years with first myocardial infarction in Sweden 2007-2022, we used logistic regression to estimate the association between adverse pregnancy outcome history and presenting with STEMI (vs. non ST-elevation myocardial infarction [NSTEMI]), in-hospital revascularization, and peak troponin >75th percentile, respectively. In addition to age-adjusted results, we also considered predictors of coronary artery disease (body mass index, diabetes, hypertension, smoking status and dyslipidemia).

Results

In total, 1301 (15.6 %) women with a first myocardial infarction had a history of preterm delivery, 887 (10.7 %) women had a history of small for gestational age infant, 1078 (13.0 %) women had a history of hypertensive disorders of pregnancy, and 3,128 (37.6%) women presented with STEMI. The odds of presenting with STEMI were higher in women with a history of delivering a small for gestational age infant (age-adjusted odds ratio 1.40, 95% CI 1.22-1.61), as well as the odds of in-hospital revascularization (odds ratio 1.30, 95% CI 1.12-1.50), and peak troponin >75th percentile (odds ratio 1.23, 95% CI 1.05-1.43). Accounting for predictors of coronary artery disease did not change these estimates substantially. No consistent associations were observed between preterm delivery or hypertensive disorders of pregnancy and outcomes.

Conclusion(s)

Among women presenting with a first myocardial infarction, a history of small for gestational age infant was associated with clinical characteristics indicating larger myocardial injury. The extent to which this is relevant for the prevention and treatment of coronary artery disease in women warrants further studies.
Long-term clinical outcomes of hemodialysis patients with acute coronary syndrome undergoing primary percutaneous coronary intervention
Authors: Matsuura H , Itonaga J , Hara A , Kisanuki H , Sada M , Okabe K , Okahara A , Kawai S , Tokutome M , Matsukawa R , Mukai Y
Published: November 2023

Background

Number of hemodialysis (HD) patients, especially those with diabetic nephropathy (DN) has increased all over the world. It is well known that the leading cause of death in HD patients is cardiovascular event, however, little is known regarding the long-term clinical outcomes of hemodialysis (HD) patients with acute coronary syndrome (ACS) undergoing primary percutaneous coronary intervention (pPCI) in the current real-world setting.

Purpose

We aimed to characterize and clarify the long-term clinical outcome of HD patients with ACS undergoing pPCI. Method: Consecutive 531 patients (70.3±13.0 yrs, male 75.5%, 51 HD patients, 9.6% ) with ACS undergoing pPCI in our hospital from 2015 to 2019 were enrolled. The primary endpoint of the present study was the composite outcomes; all-cause death, any unplanned PCI after ACS, heart failure (HF) admission, major bleeding, non-fatal myocardial infarction (MI), non-fatal stroke, and stent thrombosis. Event rate in the studied subjects was stratified with the log-rank test.

Result

Incidence of the primary endpoint during the median follow-up period of 1515 days in HD patients was significantly higher than non-HD patients (94.1% in HD vs. 61.6% in non-HD; p<0.01, Figure 1). In HD patients, all-cause death, any unplanned PCI, HF hospitalization, and non-fatal MI were significantly more prevalent (52.9% in HD vs. 24.4% in non-HD; p<0.01, 52.9% in HD vs. 16.9% in non-HD; p<0.01, 19.6% in HD vs. 6.5% in non-HD; p<0.01, and 7.8% in HD and 2.1% in non-HD; p=0.04, respectively, Table 1). Incidence of major bleeding, non-fatal stroke and ST were comparable between the two groups (11.8% in HD vs. 7.3% in non-HD; p=0.27, 3.9% in HD vs. 2.7% in non-HD; P=0.64, and 0% in HD vs. 0.4% in non-HD, P=1.0, respectively). In the HD patients, incidence of primary endpoint in DN was similar compared with non-HD patients (93.9% in DN vs. 94.4% in non-DN; p=0.4). Incidence of primary endpoint in patients with HD duration longer than or equal to 6 years was also comparable to those in patients with HD duration less than 6 years (92.6% vs. 95.8%, p=0.09), however, 180-day primary endpoint in the former group was significantly higher than the latter group (66.7% vs 29.2%, P<0.01) due to all-cause death and major bleeding.

Conclusion

HD patients with ACS undergoing pPCI have extremely worse clinical outcomes with more all-cause death, any unplanned PCI, HF admission, and non-fatal MI even in the current pPCI era. In the long-term, diabetic nephropathy and longer HD years had no significant impact on the clinical outcomes, however those with longer HD years have an extremely poor prognosis in a short-term.
Illicit drug use in very young patients with acute myocardial infarction: temporal trends from a nationwide hospital medical information database
Authors: Cottin Y , Bentounes S , Genet T , Vigny P , Zeller M , Fauchier L
Published: November 2023

Introduction

Illicit drug use, including cannabis, opioid and cocaine, which has been associated with increased risk of acute myocardial infarction (MI), has dramatically increase in young European people over the last decade.

Aim

From a French administrative database, we aimed to examine the rate and temporal trend in illicit drugs use in younger patients hospitalized for an acute MI between 2010 and 2022.

Methods

From a nationwide medical information system, all adult patients hospitalized for acute MI in the 1546 French healthcare facilities from the 1st January 2010 to 31st December 2022 were included in the analyse. Rate of Illicit drug use was compared in very young patients (18 to 25 y) vs older (>25y) patients.

Results

Over the 12y study period, 1,011,706 patients were analyzed. The percentage of very young patients remains stable from 2010 to 2022 (0.12% to 0.13%). When compared with older (≥25y), illicit drug use was much more frequent in very young patients, and showed a huge increase, by ≈50%, in drug use over the period (9.7% to 14.9%) (Figure). The rate of drug also increased in older (0.3% to 1.1%). Meanwhile, the prevalence of smoking remains stable in very young (33.1% to 32.2%). Early CV mortality was low in very young, especially in recent years (3.7% to 0.8%).

Conclusion

This large nationwide observational study reports an alarming increase rate of illicit drug among patients with acute MI over the last years. Very young adults (<25y) are particularly at risk, suggesting the need for systematical screening and urinary toxic identification.Trends in illicit drug use
Routine functional testing in high-risk patients after imaging- or physiology-guided percutaneous coronary intervention
Authors: Choi Y , Kim H , Lee J , Kang D , Ahn J , Park D , Park S
Published: November 2023

Background

Imaging-guided or physiology-guided percutaneous coronary intervention (PCI) improved clinical outcomes in complex coronary artery disease. However, it is not known to what extent routine functional testing after imaging or physiology-guided PCI affect clinical outcomes among high-risk patients.

Objectives

To assess clinical impact of routine functional test or standard care alone after intravascular ultrasound (IVUS) or fractional flow reserve(FFR) guided PCI.

Methods

Of the 1706 randomized patients with high-risk anatomical or clinical features enrolled in the POST-PCI (Pragmatic Trial Comparing Symptom-Oriented versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial, 1269 patients underwent IVUS-guided PCI and 609 patients underwent FFR-guided PCI. The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years.

Results

The rate of the 2-year primary outcomes was similar between strategies of routine functional-testing or standard-care in IVUS use group (5.3% vs. 6.6%, respectively; HR, 0.79; 95% CI, 0.50–1.24; P=0.30) and in IVUS non-use group (5.7% vs. 3.8%, respectively; HR,1.52; 95% CI, 0.63–3.68; P=0.21); there was no significant interaction between IVUS use and follow up strategies (p for interaction=0.21). The rate of the 2-year outcomes was not significantly different with functional-testing or standard-care in FFR use group (2.6% vs. 3.9%, respectively; HR, 0.65; 95% CI, 0.26–1.58, P=0.34) and in FFR non-use group (7.0% vs. 7.1%, respectively; HR, 0.99; 95% CI, 0.63–1.55, P=0.97) without significant interaction (p for interaction=0.59).

Conclusions

In patients with high-risk PCI, IVUS and FFR use did not affect clinical outcome of routine surveillance stress testing and standard-care alone during follow-up.TableFigure
The impact of microcirculation improvements of coronary artery flow on macrocirculation after coronary intervention
Authors: Wang M T W , Huang W C H
Published: November 2023

Background

The impact of microcirculation changes of coronary artery after percutaneous coronary intervention (PCI) and its association with macrocirculation remained obscured.

Purpose

This study aimed to investigate the impact of microcirculation changes of coronary artery flow on macrocirculation after coronary intervention.

Methods

This prospective study enrolled patients who underwent PCI. Electrical cardiometry was used for hemodynamics measurement before and after PCI. Deidentified data of patients in this study cohort were analyzed. Moreover, peri-procedural deidentified N-terminal-pro-B type natriuretic peptide level (NT-proBNP) values were analyzed.

Results

There was a total of 40 patients. The mean age was 62.1± 12.1 years, and there was male dominant (82.5%). The index of contractility (ICON) and stroke volume index worsened after PCI but improved on the next day after the procedural day. In addition, systemic vascular resistance index decreased and the improvement of ICON on the next day had remarkable contribution on the overall contractility rather than transient diminution after intervention. Hierarchical Clustering indicated that PCI had benefits for young patients, heart failure population, and patients with moderate to severe Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score. In addition, NT-proBNP values were analyzed, which reported a decreasing trend of level after intervention.

Conclusions

This study supported that PCI improved coronary flow and myocardial contractility over time after conquering the microvascular impedance. Moreover, microcirculation of coronary flow had impact on macrocirculation improvement, and it was feasible to measure the change by using electrical cardiometry.Figure 1Figure 2
Coronary artery calcium assessment on routine non-gated chest CT as a gatekeeper for additional imaging in patients with stable chest pain
Authors: Groen R A , Van Dijkman P R M , Jukema J W , Bax J J , Lamb H J , De Graaf M A
Published: November 2023

Aims

In Coronary Artery Disease (CAD), currently applied risk assessment methods often overestimate patients’ risk of obstructive CAD. To enhance and patient-tailor risk estimation, assessment of Coronary Artery Calcium (CAC) can be applied. In ∼10% of patients presenting with stable chest pain a non-gated chest computed tomography (CT) has been previously performed, suitable for CAC assessment. This study is the first to investigate the clinical value of CAC assessment on non-gated chest CT for risk assessment of obstructive CAD.

Purpose

This study aims to point out the clinical utility of visual CAC assessment for enhancing risk assessment and avoid unnecessary additional imaging in patients presenting with stable chest pain.

Methods

For this study, all patients referred for coronary CT angiography (CCTA), in whom a prior non-gated chest CT was performed, were included. To assess the extent of patients’ CAC, an ordinal score was applied. CAD was assessed on CCTA and obstructive CAD was defined as stenosis of ≥70%. Patients were stratified in to groups according to CAC severity, pre-test probability and number of risk factors. Percentages of patients with obstructive CAD were compared between the groups.

Results

A total of 181 patients of 30-88 years old were included. The percentage of obstructive CAD was significantly different between de CAC groups (p<0.01). The absence of CAC ruled out obstructive CAD with 100% certainty, irrespective of sex, pre-test probability, type of complaint and number of risk factors. Additionally, a mild CAC score ruled out obstructive CAD in patients with low – intermediate PTP or non-anginal complaints, with 100% certainty.

Conclusion

CAC assessment on non-gated chest CT can safely rule out obstructive CAD in patients presenting with stable chest pain and can therefore function as a radiation-free and cost-free gatekeeper for additional imaging.CCTA results for CAC severityDecisiontree patients with chest pain
Pre-test probability for coronary artery disease in patients with chest pain based on machine learning techniques
Authors: Rha S W , Choi B G , Choi S Y , Byun J K , Cha J , Hyun S , Park S , Kim J B , Choi C U
Published: November 2023

Background

A correct and prompt diagnosis of coronary artery disease (CAD) is a crucial component of disease management to reduce the risk of death and improve the quality of life in patients with CAD. Currently, the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC) guidelines recommend selecting an appropriate pre-diagnosis test for an individual patient according to the CAD probability. The purpose of this study was to develop a practical pre-test probability (PTP) for obstructive CAD in patients with chest pain using machine learning (ML); also, the performance of ML-PTP for CAD is compared to the final result of coronary angiography (CAG).

Methods

We used a database from a single-center, prospective, all-comer registry designed to reflect real-world practice since 2004. All subjects underwent invasive CAG at our hospital in South Korea. We used logistic regression algorithms, random forest (RF), supporting vector machine, and K-nearest neighbor classification for the ML models. The dataset was divided into two consecutive sets according to the registration period to validate the ML models. ML training for PTP and internal validation used the first dataset registered between 2004 and 2012 (8,631 patients). The second dataset registered between 2013 and 2014 (1,546 patients) was used for external validation. The primary endpoint was obstructive CAD. Obstructive CAD was defined as having a stenosis diameter of greater than 70% on the quantitative CAG of the main epicardial coronary artery.

Results

We derived an ML-based model consisting of three different models according to the subject used to obtain the information, such as the patient himself (dataset 1), the community's first medical center (dataset 2), and doctors (dataset 3). The performance range of the ML-PTP models as the non-invasive test had C-statistics of 0.795 to 0.984 compared to the result of invasive testing via CAG in patients with chest pain. The training ML-PTP models were adjusted to have 99% sensitivity for CAD so as not to miss actual CAD patients. In the testing dataset, the best accuracy of the ML-PTP model was 45.7% using dataset 1, 47.2% using dataset 2, and 92.8% using dataset 3 and the RF algorithm. The CAD prediction sensitivity was 99.0%, 99.0%, and 98.0%, respectively.

Conclusion

We successfully developed a high-performance model of ML-PTP for CAD which is expected to reduce the need for non-invasive tests in chest pain. However, since this PTP model is derived from data of a single medical center, multicenter verification is required to use it as a PTP recommended by the major American societies and the ESC.
Performance of ensemble of UNets for epicardial adipose tissue quantification: a multi-center APOLLO study
Authors: Cheng N , Tan E W P , Leng S , Baskaran L , Teo L , Yew M S , Singh M , Go M C R , Huang W M , Raffiee N A S , Chan M Y Y , Ngiam K Y , Tan S Y , Lee H K , Zhong L
Published: November 2023

Background

Epicardial adipose tissue (EAT) surrounding the heart and coronary arteries, has been proposed to be a potential therapeutic target for the prevention of cardiac remodeling and arrhythmias in cardiovascular disease. Specifically, EAT volume is positively correlated with these cardiovascular events and therapeutic options are being developed with the aim to reduce EAT volume. EAT volume can be measured from non-contrast CT scans, but requires manual segmentation of the pericardium to isolate the EAT, which is prone to inter-observer variability.

Purpose

We aimed to develop a new AI EAT toolkit for automated quantification of EAT volume from multi-center non-contrast CT data and assess its performance against clinical annotations from four trained human experts.

Methods

This is a multicenter study which performs CT scans in 5000 Asian Admixture patients (APOLLO study). In the current stage of this study, NCCT data analysis was conducted in 1003 patients (mean age of 58±11 years; 33% females, with ethnicity breakdown of 72% Chinese, 20% Indian/Malay, 8% Others). Of these patients, 52% had hypertension, 19% had diabetes, 69% had hyperlipidemia, and 31% had obesity. AI EAT tool was developed via a novel deep learning framework using an ensemble of UNets (See Figure 1 and 2). The performance of AI EAT tool was evaluated with respect to expert clinical segmentations of four independent raters for a test dataset of 50 patient scans using dice similarity coefficient (DSC), Pearson correlation, and Bland-Altman analysis.

Results

The AI EAT quantification process took less than 20 seconds per subject, compared with 20-30 minutes for expert readers. Compared to clinical ground truth, our AI EAT achieved a DSC of 96.0 ± 1.0% and 89.1 ± 3.0% for pericardium and EAT segmentations, respectively. There was strong agreement between the AI EAT and clinical ground truth in deriving the EAT volume (r=0.99, p<0.001) and minimal error of 5.3±2.6%. The Bland-Altman analysis revealed the mean bias between the predicted EAT volume and the ground truth volumes to be 0.95 cm³ with the limits of agreement as [-12.86 cm³, 14.77 cm³].

Conclusion

Ensemble of UNets based AI EAT tool is a novel method with high performance for the quantification of epicardial adipose tissue volume, as a potential diagnostic and prognostic tool for cardiac remodeling and arrhythmias.Figure 1.Ensemble of UNets framework.Figure 2.UNet Architecture used.
The incremental value of coronary artery calcium in predicting obstructive coronary artery disease in a symptomatic mixed Asian cohort: external validation of RF-CL and CACS-CL
Authors: Yan L , Ho W W , Tan A C S , Zhong Y , Lau M C J , Tan S Y , Winther S , Baskaran L
Published: November 2023

Background

Estimating the pre-test probability (PTP) of coronary artery disease (CAD) is an essential step in the evaluation of patients with stable chest pain. Risk factor-weighted clinical likelihood (RF-CL) and coronary artery calcium score-weighted clinical likelihood (CACS-CL) are two simple models recently proposed to estimate the probability of obstructive CAD. However, these tools were predominantly developed and validated on Western populations. There is limited evidence of their predictive value in Asian populations.

Purpose

We sought to evaluate the performance of RF-CL and CACS-CL in a symptomatic mixed Asian cohort.

Methods

The study cohort included symptomatic patients referred for coronary computed tomography angiography (CTA) at a tertiary cardiac centre in Singapore. Patients with known CAD were excluded. Obstructive CAD was defined as ≥ 50% stenosis on coronary CTA. RF-CL was calculated with age, sex, symptom characteristics, and the number of risk factors. CACS-CL was calculated from RF-CL by further incorporating the CACS. Discriminative performance was evaluated with the area under the receiver-operating characteristic curves (AUC). Categorical net reclassification index (NRI) was calculated to assess the reclassification improvement of CACS-CL as compared with RF-CL.

Results

A total of 1293 patients were analysed (mean age 55.8±11.3 years, 45.6% female). The majority of the patients were of Asian descent (73.9% Chinese, 10.6% Indian, 6.4% Malay). The overall prevalence of obstructive CAD was 26.1% (n=338). The RF-CL achieved an AUC of 0.72 (95% CI, 0.69-0.75). The incorporation of CACS in CACS-CL further improved the AUC to 0.89 (95% CI, 0.87-0.91; p<0.001) (Figure 1). Compared to RF-CL, CACS-CL demonstrated an improved reclassification, resulting in a categorical NRI of 0.28 (95% CI, 0.23-0.33) at a 5% cutoff. Among 955 patients without obstructive CAD, the CACS-CL model reclassified a significant proportion (21.4%, n=204) into the low-risk group, in which further testing is not recommended. (Table 1)

Conclusions

In a symptomatic mixed Asian cohort, the RF-CL model had good discriminative performance in predicting obstructive CAD. Incorporating CACS in the CACS-CL model improved both discrimination and reclassification substantially. These results indicate that the RF-CL and CACS-CL perform similarly in different ethnicities and support their use in optimising the diagnostic workflow in Asian patients with stable chest pain.
Meta-analysis of cardiac imaging modalities for the diagnosis of left ventricular thrombus following acute myocardial infarction
Authors: Leow A S T , Low C J , Teo Y N , Teo Y H , Syn N L , Goh F Q , Ho J S Y , Tan B Y Q , Yeo L L L , Li T Y W , Wong R C C , Chai P , Yeo T C , Chan M Y Y , Sia C H
Published: November 2023

Background

The formation of left ventricular thrombus (LVT) in post-acute myocardial infarction (AMI) patient carries significant risk of systemic embolism. Hence, there is a need to adopt strategies aimed at accurate and early diagnosis of LVT in order to mitigate the risk of embolic events with anti-thrombotic therapy. We aimed to conduct a systematic review and meta-analysis to appraise the current literature on the various diagnostic modalities used in post-AMI LVT detection.

Methods

We conducted a comprehensive search in Medline, EMBASE, and Scopus using an appropriate keyword/MeSH term search strategy up to 31 December 2021. All studies reporting a comparison between at least two imaging modalities in the diagnosis of LVT in post-AMI patients were included.

Results

A total of 2039 patient from 11 studies published between 2006 and 2021 were studied. Across all study populations, a majority of patients were male (82.3%) and the overall incidence of LVT was 15.2%. Using delayed-enhancement cardiac magnetic resonance imaging (DE-CMR) as the gold standard reference, transthoracic echocardiogram (TTE) with ultrasound enhancing agent (UEA) had the highest sensitivity (0.886, 95% CI 0.667-0.967) and specificity (0.980, 95% CI 0.900-0.996), while cine-CMR had the best diagnostic performance in terms of positive likelihood ratio (LR+ 437, 95% CI 37.2-1890), negative likelihood ratio (LR- 0.246, 95% CI 0.118-0.423) and diagnostic odds ratio (DOR 2050, 95% CI 134-9590). The summary receiver operating characteristic curves (SROCs) of the three studied imaging modalities were plotted and the AUC values were 0.920, 0.974 and 0.989 for TTE without and with UEA, and cine-CMR.

Conclusions

The diagnostic modalities used for LVT detection examined in this study had good specificity but poor sensitivity when compared to DE-CMR. Post-AMI patients at higher risk of LVT formation may benefit from further imaging studies with DE-CMR if initial TTE were negative.
Cost-effectiveness of sequential CAC-first imaging approach for detection of coronary artery disease in comparison to SPECT-first imaging
Authors: Kamerman M A N D Y , Van Dijk J , Mouden M
Published: November 2023

Background

Prior guidelines recommended a functional first-line test as in patients with suspected CAD. More recently the high NPV of a coronary artery calcium score (CACS) of zero has put focus on CACS-first strategy in selected patients. However, it is unknown if a CACS-first strategy followed by additional Coronary CT angiography (CCTA) or PET MPI if CACS > 0 is a cost-effective alternative.

Purpose

Our aim was to retrospectively compare the costs-effectiveness of sequential CACS-first imaging to SPECT-first imaging.

Methods

2152 patients with CACS-first strategy were retrospectively 1:1 propensity matched with a cohort of SPECT-first strategy resulting in a total of 4304 patients. Referral to invasive coronary angiography (ICA), percentage of patients with diagnosed obstructive CAD, revascularization or all-cause death during 1 year follow-up were compared between both groups. In addition, the non-invasive and invasive diagnostic costs within the first year to detect obstructive CAD were also compared.

Results

30.0% (N=646) in the CACS-first group had CAC zero and 51.% (N=1086) had normal stress-SPECY only.

Downstream referral to ICA <90 days was lower in the CAC group ( 8.4% vs 11.5%, p=0.001), while obstructive CAD on ICA within 90 days was comparable (60.2% vs 62.5%, p=0.705) between the CACS-first and SPECT-first. Number of revascularizations (6.3% vs 7.9%, p=0.044) was lower in the CACS-first group, while death (0.5% vs 0.3%, p=0.331) was comparable between the CACS-first and SPECT-first group within the first year, respectively. The average costs spent on both non-invasive (€407 vs. €674, p<0.001) and invasive diagnostic imaging (€587 vs. €888, p<0.001) was lower when offering CACS-first instead of a MPI SPECT first protocol, respectively.

Conclusion

Sequential CAC-first protocol is a more cost-effective than a SPECT-first protocol in patients suspected of having CAD and reduces the referral for ICA while more patients underwent revascularization in the SPECT-first group without impact on prognosis. We therefore recommend the use of a CAC-first CT protocol in these patients.
Inter-corelab agreement of angiography-derived wall shear stress distribution
Authors: Kageyama S , Tufaro V , Torii R , Karamasis G , Rakhit R D , Poon E K W , Aben J P , Baumbach A , Serruys P W , Onuma Y , Bourantas C V
Published: November 2023

Aims

Wall shear stress (WSS) estimated in models reconstructed from intravascular imaging and 3D-quantitative coronary angiography (QCA) data provides important prognostic information and enables the identification of high-risk lesions. However, these analyses are time-consuming and require expertise limiting WSS applications and adoption in clinical practice. Recently, a novel software has been developed for real-time computation of WSS and multidirectional WSS distribution. The aim of this study is to examine its inter-corelab reproducibility.

Methods and results

Sixty lesions (20 in coronary bifurcations) with a borderline negative fractional flow reserve were selected and processed using the CAAS Workstation WSS prototype (version 6.0 PIE MEDICAL) to estimate WSS and multi-directional WSS. Analysis was performed by two Core laboratories; the estimations of the two corelabs for the WSS in 3 mm segments across each reconstructed vessel were extracted and compared. To examine the concordance between inter-observer analysis of clinically relevant values, the scatterplot was divided into 4 quadrants with AS 61.3% and maximum WSS 8.24 Pa based on the previous publications and Cohen’s Kappa value was presented using these cut-off values. In total 700 segments (256 located in bifurcated vessels) were included in the present analysis. Average analysis time on the software was 219±45s in straight model and 291±61s in bifurcation model. A high intraclass correlation was noted for all the WSS metrics for the estimations of the two core labs irrespective of the presence (range: 0.90 – 0.92) or absence (range: 0.89 - 0.90) of a coronary bifurcation, while the ICC was good-moderate for the multidirectional WSS (range: 0.72-0.86). In addition, the bias between the WSS estimations was low and the limits of agreement were narrow in Bland-Altman analyses (Figure 1). When using the cut-off value of maximum WSS and % AS, a substantial agreement was noted between the two estimations of the two core labs; κ=0.77 for identifying maximum WSS >8.24Pa and κ=0.71 for identifying AS >61.3% (Figure 2).

Conclusion

The CAAS workstation enables reproducible 3D-QCA reconstruction and computation of WSS metrics. Further research is needed to explore its efficacy in predicting cardiovascular events.Figure 1Figure 2
Ventricular arrhythmia without acute coronary syndrome as an indication for invasive coronary angiography
Authors: Kriechbaum S D , Thomassek S , Treiber J , Wolter J S , Hamm C W , Liebetrau C , Fischer-Rasokat U
Published: November 2023

Background

In the clinical setting of acute coronary syndrome, ventricular arrhythmia is a validated indication for urgent invasive coronary angiography (ICA). However, the indication for ICA in patients with ventricular arrhythmia but no acute coronary syndrome is less clear. This study aimed to determine the incidence of occlusive coronary artery disease (CAD) in such patients and to evaluate the association of arrhythmia subtypes and ICA findings with survival.

Methods

This study included 309 patients who underwent ICA due to documented ventricular arrhythmia but no acute coronary syndrome between January 2004 and October 2017. Subtypes of arrhythmia and findings from ICA were correlated to outcome.

Results

Overall, 309 patients [240 male (78%) 69 female (22%), mean age 68 ± 11 y] with the evidence of ventricular arrhythmia were included. The documented ventricular arrhythmia were sustained ventricular tachycardia [VT; N= 140 (45.3%)], non-sustained ventricular tachycardia [nsVT; N= 97 (31.4%)], ventricular extrasystoles [VES; N= 72 (23.3%)]. A history of CAD was documented in 164 (53%) patients.

The ICA detected a new CAD [N= 38 (12%)] or significant progression of known CAD [N= 72 (23%)] in 110 (36%) patients. Out of these patients 91 (83%) were treated with percutaneous coronary intervention (PCI), four (4%) were treated with coronary artery bypass grafting (CABG). The other 199 (64%) patients showed no progression of a known CAD [N= 92 (30%)] or no CAD [N= 107 (34%)] without significant progression.

During a median follow-up time of 42 months (IQR 18-60), 44 (14.2%) patients died. The subtype of ventricular arrhythmia was associated to prognosis (figure 1). In all subgroups (VT, nsVT, VES), the survival analysis revealed no difference between patients with new CAD or progression of CAD on the one hand and those without CAD or progression on the other (VT: p = 0.70; nsVT: p = 0.65; VES: p = 0.14). Furthermore in all subgroups (VT, nsVT, VES), the survival analysis found no difference between patients with a specific treatment of CAD (PCI or CABG) and those without (VT: p = 0.37; nsVT: p = 0.95; VES: p = 0.07).

Conclusion

CAD is diagnosed in a relevant proportion of patients with ventricular arrhythmia but no evidence of an acute coronary syndrome. However, neither the successful detection of a new CAD or the progression of a known CAD nor the specific treatment (PCI or CABG) of a detected significant CAD had an impact on survival outcome. This challenges ventricular arrhythmia as an indication for ICA.Figure 1:Survival Curves
Safety and procedural success of left appendage closure interventions with transesophageal echocardiography microprobes
Authors: Laffond A , Gonzalez Calle D , Blanco Fernandez F , Lopez Tejero S , Antunez Muinos P , Barreira De Sousa G , Nunez Garcia J C , Barreiro Perez M , Diaz Pelaez E , Rodriguez Collado J , Herrero Garibi J , Diego Nieto A , Martin Moreiras J , Sanchez Fernandez P L , Cruz Gonzalez I
Published: November 2023

Introduction

Transesophageal echocardiography (TOE) is the most frequently used imaging technique for intraprocedural guidance in left appendage closure interventions. However, it usually requires the use general anaesthesia and implies an increased risk of bleeding, and of esophageal and upper airway tract lesions. Intracardiac echocardiography and TOE with microprobes (micro-TOE) have been proposed as alternative techniques for procedural imaging.

Purpose

The aim of this study is to compare the results of LAAC interventions in terms of success, safety and hospital stay depending of the imaging technique used for procedural guidance.

Methods

This is a single-center, prospective study, which included patients in which LAAC was performed between the years 2009 and 2021. In the group with conventional TOE guidance, procedure was performed under general anesthesia using the probe Philips X8-2t. In the group with micro-TOE guidance, the procedure was performed under conscious sedation with midazolam and fentanyl with Philips S8-3t microprobe. Image quality was assessed independently by two echocardiographers. Basal characteristics, procedure length, complications and hospital length of stay were analyzed.

Results

Between the years 2009 and 2021, 511 LAAC procedures were performed, of which 357 were guided with TOE and 154 with microTOE. Mean age was of 77.2 ± 8 years, and 63.6% of patients were male. Successful device implantation was achieved in all patients of both groups. In 10 patients in which the scheduled imaging technique was micro-TOE were eventually perfomed with conventional TOE probe due to insufficient image quality. Procedural length was significantly reduced in patients in the micro-TOE (73 vs 51 min, p < 0.001). There were no significant differences in major complications between group. In-hospital length of stay was significantly reduced in patient with micro-TOE guidance (1.15 ± 1.9 days versus 2.2 ± 2.3 days, p < 0.001).

Conclusions

Transesophageal echocardiography with microprobes is a safe and efective imaging technique for procedural guidance for LAAC interventions, with procedural success and complication rates similar to conventional TOE. Furthermore, its use reduces in-hospital length of stay, enabling outpatient procedures.Table 1.Comparison between groups