bluuebunny/crossref_metadata_2025 huggingface dataset:
Coronary CT angiography a new promising tool in Heart transplanted patients: from clinical and economical benefits to coronary inflammation detection
Authors: Dellino C M , Cozza E , Amato F , Savo M , De Conti G , Tarantini G , Tessari C , Pradegan N , Motta R , Gerosa G , Iliceto S , Pergola V
Published: November 2023

Background

Heart transplanted patients are usually monitored with invasive diagnostic techniques for detecting cardiac allograft vasculopathy (CAV). However coronary CT angiography (CCTA) is a new promising tool in the initial stages of CAV bringing clinical and economical benefits.

Purpose

1) assess the non-inferiority of CCTA in comparison to coronary angiography (CA), in terms of radiation and contrast dose, costs, hospitalization hours, complications and diagnostic accuracy; 2) analyse the different role of immunological and non-immunological risk factors predicting CAV in patients undergoing CCTA; 3) Investigate the rule of coronary inflammation through the pericoronary-fat-attenuation-index (pFAI) at CCTA in the progression of CAV.

Methods

179 heart transplanted patients were retrospectively analysed: 78 performed a CCTA and 101 performed a CA between March 2021 and May 2022.

Results

CCTA and CA showed similar radiation doses (8.47 [1.46-30] versus 8.15 [1.38-87.34]; p=0.796) and rate of complications (0 (0%) vs 3 (3%); p=0,258). CCTA in comparison with CA required less hours of hospitalization (0.5 hours versus 23.7 12.31 hours; p<0.001), lower costs (120 euros versus 2800 euros; p<0.001) and less contrast agent (60.4 8.7 ml versus 95.68 47.6ml; p<0.001). Diagnostic accuracy was similar between CCTA and CA (95% vs 100%; p=0,169). Among the non immunological risk factors for CAV, only smoking showed a statistically significance in predicting CAV (p=0.015). Among immunological risk factors, TNF was the only independent predictor in the progression of CAV (HR 8.23; IC 95% 1.47-45.81; p=0.019). There were no statistically correlation between pFAI at CCTA either as a continuous variable or as a categorical variable (>-70.1HU) and the progression of CAV (p=NS).

Conclusions

CCTA is similar to CA in terms of radiation dose and rate of complications and is superior in terms of hospitalization hours, costs and contrast agent injected. Diagnostic accurancy was equivalent between CCTA and CA. TNF was the only independent predictor in the progression of CAV. Pericoronary inflammation assessed by pFAI at CCTA was not associated with the progression of CAV.
STEMI patients after out-of-hospital cardiac arrest: should we cool?
Authors: Jarakovic M , Kacavenda G , Petrovic M , Bjelica S , Kovacevic M , Dimic S , Keca S , Trajkovic M
Published: November 2023

Introduction

Patients who have been successfully resuscitated after out-of-hospital cardiac arrest (OHCA) due to ST-segment elevation myocardial infarction (STEMI) have a high risk of death and poor neurological outcome. Application of therapeutic hypothermia (TTM) is recommended in addition to the reperfusion strategies in patients who remain comatose after resuscitation. However, data analysis in STEMI patients successfully resuscitated after OHCA who remain comatose are inconsistent and still a subject of discussion.

Objective

The aim of this research was to examine the impact of TTM on in-hospital survival and neurological outcome in comatose STEMI patients after OHCA.

Methods

The study was conducted as a retrospective observational analysis of data taken from a hospital OHCA registry. The examined sample consisted of 141 patients hospitalized from January 2007 to December 2021 due to STEMI complicated by OHCA and who remained comatose upon admission. Inclusion criteria for analysis were STEMI of any localisation and unresponsiveness on admission defined as Glasgow Coma Score (GCS) ≤ 8. Favorable neurological outcome was defined as Cerebral Performance Category Score (CPC) ≤ 2.

Results

Our research included 141 comatose survivors of OHCA due to STEMI, among whom 91 (64.5%) were men, and TTM was applied in 82 (58.2%) patients. Witnessed cardiac arrest (48.7% vs. 23.1%, p = 0.027), duration of resuscitation ≤ 20 minutes (66.1% vs. 28.4%, p < 0.0005), initial shockable rhythm (55.2% vs. 22.9%, p = 0.001) and performed urgent percutaneous coronary intervention (PCI) (56.2% vs. 23.1%, p < 0.0005) had a statistically significant influence on in-hospital survival, while good neurological recovery was influenced only by the duration of resuscitation ≤ 20 minutes (69.2% vs. 36.7%, p = 0.008). TTM was applied more often when the resuscitation lasted ≤ 20 minutes (51.2% vs. 29.3%, p = 0.015), with an initial shockable rhythm (85.4% vs. 14.6%, p < 0.0005) and when urgent PCI was performed (82.9% vs. 35.6%, p < 0.0005). TTM had a statistically significant effect on in-hospital survival (58.5% vs. 23.7%, p < 0.0005), while it had no effect on favorable neurological outcome (54.7% vs. 56.3%, p = 1.000).

Conclusion

In our examined group of STEMI patients successfully resuscitated after OHCA who remained comatose at admission, TTM significantly improved in-hospital survival, but had no effect on favorable neurological outcome.
The natural history and prediction of 10-year plaque progression on serial coronary CT angiography
Authors: Nurmohamed N , Bom M J , Ibrahim S , Gaillard E L , De Groot R J , Jukema R A , Van Diemen P A , De Winter R W , Min J K , Earls J P , Danad I , Planken R N , Stroes E S G , Choi A D , Knaapen P
Published: November 2023

Background

Several studies have shown that plaque subcomponents such as low-attenuation or non-calcified plaque volume from coronary CT angiography (CCTA) are associated with the occurrence of major adverse cardiovascular events. However, it remains unknown how plaque morphology progresses over the long-term. Furthermore, it is unknown which plaque characteristics put patients at increased risk of plaque progression which would require more intensive image-guided follow-up. This study investigated the natural history and predictors of long-term coronary plaque progression in a serial CCTA cohort of patients with suspected coronary artery disease (CAD).

Methods

In this follow-up study, 539 patients from an earlier published CCTA cohort (Diemen, 2021) were invited for repeat CCTA imaging per-protocol, regardless of symptoms. A total of 299 patients underwent follow-up CCTA imaging with a median scan interval of 10.2 [8.7-11.2] years. Patients who underwent coronary artery bypass grafting (CABG) between baseline and follow-up imaging were excluded. All scans were analyzed using artificial intelligence-guided quantitative CCTA (AI-QCT). Revascularized vessels were excluded. Quantitative plaque volumes (total, low-density, non-calcified and calcified plaque) depicted by AI-QCT were divided by the total vessel volume to represent percent atheroma volume (PAV). PAV progression was calculated subtracting baseline PAV from follow-up PAV. The association of the plaque components with PAV progression was evaluated in a multivariate linear regression model adjusted for clinical risk characteristics (age, sex, hypertension, hypercholesterolemia, diabetes, BMI, smoking, family history of CAD and statin use).

Results

In total, 274 patients without CABG were used for the serial analysis, mean age was 57 years, 42% were women. At baseline, median PAV was 2.5% [IQR 0.7-8.1], which increased to 6.1% [IQR 1.2-12.9] at follow-up (Figure). The mean PAV progression was 0.4±0.5% per year. Adjusted for clinical risk characteristics and other plaque volumes, baseline percent non-calcified plaque volume (NCP) was the only plaque volume associated with PAV progression (0.5% PAV progression increase per % increase in baseline non-calcified plaque volume).

Conclusion

Using an unique long-term serial CCTA cohort undergoing per-protocol repeat imaging with a 10-year scan interval, we found that coronary plaque burden more than doubled. Interestingly, the amount of non-calcified plaque volume at baseline was the only predictor for disease progression.Figure
Fifteen-year mortality outcomes in the APEX-AMI trial compared to the general ST-elevation myocardial infarction population in Canada: Exploring lessons from numerators and denominators
Authors: Kaul P , Dover D C , Westerhout C M , Welsh R C , Armstrong P W
Published: November 2023

Background

It is well established that patients enrolled in clinical trials tend to be younger, more likely male, and have fewer comorbidities. Moreover, sites that enroll patients in randomized trials (RT) are often tertiary care centres in urban areas especially in the setting of STEMI. The impact of these potential selection biases on clinical outcomes both within and well beyond the proscribed RT follow-up window have not been adequately explored.

Objective

To compare 15-year mortality of ST elevation myocardial infarction of Canadian (STEMI) patients with high-risk electrocardiographic findings enrolled within 6 hours of symptom onset undergoing primary PCI in the APEX-AMI clinical trial of Pexelizumab (APEX-AMI group) with STEMI patients presenting to 25 APEX-AMI enrolling sites (APEX-AMI sites group); and STEMI patients presenting to 400 other sites (non-APEX-AMI site group).

Methods

APEX-AMI enrolled patients between 07/13/2004 – 05/11/2006. We conducted a probabilistic linkage (based on admission date, discharge date, age, sex, province, diagnosis of MI, presence of comorbidities) between APEX-AMI and the Canadian national Discharge Abstract Database (DAD), excluding Quebec, for the same time period. These data were further linked to tax files (for socio-economic data) and vital statistics data to obtain mortality status as of 2020.

Results

Of the 335 Canadian participants in APEX-AMI, 143 were from Quebec and were excluded. Of the remaining 192 patients, 188 (97.9%) were linked with the DAD. There were 8,470 patients in the APEX-AMI sites and 10,940 in the non-APEX-AMI sites groups, respectively (Table 1). Patients enrolled in APEX-AMI were less likely to be female, more affluent, have a lower comorbidity burden as measured by the Charlson Comorbidity Index, and higher PCI rates. Ninety-day all-cause mortality in the three groups was 4.3%, 8.5%, 12.7% in the APEX-AMI, APEX-AMI site, and non-APEX-AMI site groups, respectively. At 15-years, mortality rates were 34.0%, 45.8%, and 52.2% in the three groups (p<0.01, Figure). Enrollment in APEX-AMI was associated with an unadjusted 45% reduction in risk of 15-year mortality (HR 0.55, 95% CI: 0.43-0.70). However, this association was attenuated after adjusting for demographic and clinical factors (adjusted HR (aHR), 0.69, 95% CI: 0.54-0.88), and completely nullified after adjusting for PCI (aHR, 0.82, 95% CI: 0.64-1.05).

Conclusions

Our study demonstrates the feasibility and value of extending clinical trial follow-up via linkage with routinely collected administrative data. While enrollment in clinical trials appears to be associated with better long-term outcomes, our findings highlight the need to be vigilant to the potential for selection bias, the generalizability of trial findings and the potential to more broadly enhance long-term STEMI outcomes.
Life expectancy in women and men after STEMI: a comparison to a matched general population
Authors: Thrane P , Olesen K K W , Gyldenkerne C , Hansen M K , Thim T , Kristensen S D , Maeng M
Published: November 2023

Background/Introduction

ST-elevation myocardial infarction (STEMI) is considered a risk factor for short- and long-term mortality. Further, studies indicate that female sex is associated with increased mortality among STEMI patients. Our aim was to assess the impact of female and male sex on short- and long-term excess mortality in comparison to matched general populations.

Methods

We identified all patients undergoing first-time percutaneous coronary intervention (PCI) who were treated with primary PCI (pPCI) for STEMI from 2003 to 2018 in the Western Denmark Heart Registry (covering approximately 3.3 million inhabitants). Each patient was matched in a 1:5 ratio by age and sex with individuals from the Western Denmark general population without prior myocardial infarction or coronary revascularization. To assess excess mortality after STEMI, we compared mortality in women and men to their matched general population using a stratified Cox proportional hazards model. Excess mortality was assessed in the periods from 0-30 days, 31-90 days, and 91 days – 4 years of follow-up.

Results

A total of 18,216 pPCI-treated STEMI patients were included, 4,833 (26.5%) women and 13,382 (73.5%) men. The matched general population cohort consisted of 91,075 individuals, 24,165 women and 66,910 men. Median age at STEMI diagnosis was 68 years (IQR 58-78) in women and 62 years (54-71) in men. Excess mortality was markedly higher in the first 30 days after STEMI with the relative risk being 35 times higher for both women (hazard ratio (HR) 34.63, 95% CI 26.11-45.95) and men (HR 35.18, 28.48-43.48) compared to their matched general populations. From 31-90 days, the excess mortality remained higher after STEMI for women (HR 3.58, 2.58-4.97) and men (HR 2.00, 1.58-2.55). However, in the 91 days - 4 years follow-up period there was only a marginal unadjusted 13% excess mortality in women (HR 1.13, 1.02-1.25) while an 8% lower mortality was observed in men (HR 0.92, 0.86-0.98; p for interaction<0.05). After adjusting for comorbidities in the 91 days - 4 years period, an excess mortality in women was no longer observed (HR 1.03, 0.93-1.14), while men with STEMI remained at lower risk than the general population (HR 0.87, 0.81-0.94).

Conclusions

In a large, contemporary STEMI cohort mortality within the first 30 days were 35 times higher in both women and men when compared to mortality in an age- and sex- matched general population. However, STEMI patients surviving the first 90 days were no longer at higher risk than their matched general population individuals; the latter most likely reflecting guideline-directed prophylactic interventions.Excess mortality in women with STEMIExcess mortality in men with STEMI
Impact of very high doses of contrast media on acute kidney injury rates in patients admitted with ST-elevation myocardial infarctions
Authors: Schmucker J , Lutz J , Fach A , Osteresch R , Ruehle S , Hambrecht R , Wienbergen H
Published: November 2023

Introduction

Previous studies have shown that in patients with ST-elevation myocardial infarctions (STEMI) maybe the main contributor of acute kidney injury (AKI) is the STEMI itself with its hemodynamic sequelae and to a lesser extent contrast media induced nephropathy (CIN). However, the possible impact of very high doses of contrast media (CM) on kidney function in this context remains unclear. Aim of the present study was therefore to investigate, how very high doses of CM influenced AKI-rates in patients admitted with STEMI.

Methods

Patients admitted with STEMI between 2006 and 2022 to a large German heart center entered analysis. A very high dose of contrast media was defined as >250 ml. AKI was defined by KDIGO-criteria (2012). To minimize impact of confounders patients were grouped by initial TIMI-risk-score and initial renal function (glomerular filtration rate (GFR)) in a 3x3 format.

Results

Of a total of 8845 patients included, 547 patients (6.2%) received a CM-dose >250 ml with an average CM-amount of 318.2±64 ml vs. 135.8±48 ml in the control group. A multivariate model revealed that patients receiving very high CM-doses were more likely to be older (OR 1.31, 95% CI 1.1-1.6, p<0.01) and to have more extensive STEMIs (CK>2000 U/ml: OR 1.33, 95% CI 1.1-1.6), while they were less likely to be female (0.77, 95% CI 0.6-0.9,p=0.01) and less likely to have undergone successful percutaneous coronary intervention (PCI): OR 0.51, 95% CI 0.4-0.6, p<0.01. Patients receiving very high doses of CM were more likely to develop AKI: 21.6% vs. 14.9,%, p<0.01. This significant impact remained after adjusting in a multivariate model (OR 1.42 95% CI 1.1-1.9, p<0.01). When stratifying patients into nine groups (3x3) both, initial TIMI-risk-score for STEMI and a lower GFR were associated with a marked increase in AKI-rates, with the lowest AKI-rate at 3.4% in patients with a low TIMI-risk and an initial GFR of 60-89 ml/min and the highest AKI rate at 37.8% in patients with a high TIMI-risk score and a GFR<60 ml/min (table (A)). However, the impact of very high CM-amounts on AKI-rates in this pre-stratified cohorts was inconsistent and only independently associated with a higher AKI-risk in 1 out of 9 groups (marked by astrisk*, table (B)).

Conclusions

STEMI-Patients receiving very high amounts of contrast media during emergency cardiac catheterization were on average older with larger infarctions and showed lower rates of successful percutaneous coronary interventions (PCI). For the majority of these patients even very high amounts of contrast media were not independently associated with higher rates of acute kidney injury. AKI-rates were more likely to be determined by overall risk and initial renal function.
Sonothrombolysis delivered before percutaneous coronary intervention improves myocardial salvage in ST elevation myocardial infarction
Authors: Nirthanakumaran D , Jeyaprakash P , Pathan F , Sivapathan S , Madronio C , Yu C , Ozawa K , Nundlall N , Hallani H , Madan K , Khor L , Loh H , Negishi K
Published: November 2023

Background

Sonothrombolysis (STL) is the application of high mechanical index ultrasound whilst infusing an ultrasound contrast agent. Prior studies have shown that STL delivered pre & post primary percutaneous coronary intervention (pPCI) can reduce infarct size, and improve myocardial salvage in the setting of ST Elevation Myocardial Infarction (STEMI). However, it remains unclear whether this benefit is proportionately dependent on the amount of STL delivered, and whether the timing of STL relative to pPCI is important.

Purpose

To determine if there is a dose and time dependent relationship between sonothrombolysis delivery and myocardial salvage in patients presenting with STEMI.

Methods

We conducted a double-blind, pilot randomised controlled trial of STEMI patients (symptoms <6 hrs, age 30-80). Patients were randomised (1:1:1) into 3 arms; Group 1 received STL pre & post pPCI, Group 2 received sham echo pre and STL post pPCI, while Group 3 received Sham echo pre and post pPCI. Measured endpoints were Infarct Percent and Myocardial Salvage Index (MSI) assessed with CMR at day 4±2 and 6±1 months. We performed a regression analysis using R Version 4.2.2 to determine if the number of delivered STL cycles were associated with an improvement in myocardial salvage.

Results

51 patients (Age 60, Male 82%) were recruited into Group 1 (n=16), Group 2 (n=19) or Group 3 (n=16). MSI was higher in Group 1 (79% [64, 85]) than Group 2 (51% [45, 70]) and Group 3 (48% [37, 73]) (p=0.047). Regression analysis (Figure 1) showed a non-significant trend towards improved myocardial salvage with more delivered cycles (β=0.32 [95%CI -0.15, 0.80]). Subgroup analyses of post pPCI STL (Figure 2) shows a fixed and sustained benefit in myocardial salvage with pre & post pPCI STL delivery, compared to post pPCI STL delivery alone. Given the regression lines for Group 1 and 2 are approximately parallel, we compared alpha intercept values to determine that pre & post PCI STL conferred an additional 17 percentage points (75% versus 58%) of myocardial salvage compared to post pPCI STL alone. No major adverse cardiac events occurred amongst included participants.

Conclusion

Pre pPCI sonothrombolysis appears to be an essential component of improving myocardial salvage in the REDUCE Pilot trial, and may improve myocardial salvage by an additional 17% compared to post pPCI STL alone. This benefit is independent of post pPCI sonothrombolysis duration.Figure 1:The relationship between numbeFigure 2:Group 1 and Group 2 sub-analys
Prevalence and outcome of clinical misdiagnosis of non-ST-elevation myocardial infarction
Authors: Boeddinghaus J , Sanzone A , Lopez-Ayala P , Koechlin L , Nestelberger T , Rubini Gimenez M , Wildi K , Keller D , Miro O , Christ M , Mueller C
Published: November 2023

Background

The prevalence of clinical misdiagnosis of non-ST-elevation myocardial infarction (NSTEMI) and its impact on patient outcomes is largely unknown.

Methods

We prospectively enrolled adult patients presenting with suspected acute coronary syndromes at 12 sites in five European countries. All patients provided written informed consent and were managed as per local clinical care using conventional, sensitive or high-sensitivity cardiac troponin (hs-cTn) assays. Study blood samples were taken at presentation and serially thereafter for measurements of hs-cTn concentrations. Final diagnoses were adjudicated by two independent cardiologists according to current guidelines and the 4th universal definition of myocardial infarction using all information including serial hs-cTnT measurements and imaging. The primary diagnostic endpoint was the prevalence of clinical NSTEMI misdiagnosis. Co-primary prognostic endpoints were 30 day and two year all-cause and cardiovascular (CV) death.

Results

In 7,678 patients (median age 61 [IQR 48-73], 34% women), the prevalence of adjudicated and clinical NSTEMI was 17.8% and 12.3%, respectively (P<0.001). Among 1,363 patients with an adjudicated NSTEMI (77% type 1 MI, 23% type 2 MI), 470/1,363 (34%) had a clinical NSTEMI misdiagnosis. These patients were older, more often female, had lower median cTn concentrations, and were more likely managed at centers using non-hs-cTn assays at time of enrolment. Compared to patients with an adjudicated and clinical NSTEMI diagnosis, missed patients were less likely to undergo coronary angiography or revascularization and less often discharged on evidence-based treatment (dual antiplatelet therapy 24% vs 79%, statin 64% vs 92%, betablocker 68% vs 81%, all P<0.001). Finally, patients with a clinical NSTEMI misdiagnosis were at much higher risk of premature all-cause (HR 1.51, 95% CI 1.18-1.94, P<0.001) and CV (HR 1.93, 95%CI 1.42-2.63, P<0.001) death.

Conclusion

One out of three adjudicated NSTEMI patients was misdiagnosed in routine clinical care. Clinical NSTEMI misdiagnosis was associated with lower use of guideline-recommended therapies and a substantial increase in premature death.Alluvial plotAll-cause death at 2-years
Discovering pericoronary adipose tissue differences between normal and atherosclerotic coronary segments with radiomics analysis
Authors: Shieh A , Tsai Y T , Cheng Y T , Lee W J , Wang T D
Published: November 2023

Introduction

Pericoronary adipose tissue (PCAT) extracted from coronary CT angiography (CCTA) is a novel marker for coronary inflammation. Establishing correlation between PCAT changes and the vascular lesion itself is essential for using PCAT to monitor clinical and subclinical disease status. Past studies focused on patient-level and vessel-level PCAT differences. However, lesion-level PCAT differences beyond mean attenuation values are not well understood.

Purpose

To investigate the differences between PCAT adjacent to atherosclerotic plaques and PCAT adjacent to normal coronary segments using radiomics analysis.

Material and Methods

This study enrolled 100 consecutive patients who underwent CCTA. A total of 446 plaques were successfully annotated in 89 patients. The PCAT of these 446 plaques and also their normal segment counterparts were extracted. Following prior literature, adipose tissue was defined as voxels with attenuation ranging -190 to -30 HU. PCAT was extracted within 3 mm distance from the vessel wall, along the middle 10 mm of each plaque. The PCAT of normal coronary artery segments were extracted both proximal and distal with distance D mm to the plaque with 10 mm length. We used 3 different distances to define the normal segments (D={10, 20, 30}). PyRadiomics was used to generate radiomics features and the random forest classifier from Scikit-Learn was used to distinguish PCAT extracted adjacent to atherosclerotic plaques and PCAT adjacent to normal coronary segments. To minimize bias due to vessel diameter or shape and focus on the texture of PCAT, we included only the First Order, GLCM, GLDM, GLRLM, GLSZM and NGTDM features (total 93 features) from PyRadiomics. We used 5-fold cross validation splitted at patient-level to develop the classifier.

Result

The radiomics model achieved acceptable discrimination for D=30 mm (mean AUROC = 0.70), borderline discrimination for D=20 mm (mean AUROC=0.68) and D=10 mm (mean AUROC = 0.60). These results suggest a trend toward greater differences between PCAT further away from the lesion compared with PCAT adjacent to the lesion. The feature "Gray Level Size Zone Matrix (GLSZM): Low Gray Level Zone Emphasis" had the highest importance in 4 out of 5 folds in our D = 30 mm experiment. The mean value of this feature is significantly different for the PCAT adjacent to the lesions compared to PCAT extracted from the normal segments (0.152 vs 0.166, p=0.001).

Conclusion

We investigated the difference between PCAT adjacent to atherosclerotic plaques and PCAT adjacent to normal coronary segments using radiomics analysis. We found greater discrimination when the normal segments were extracted further away from the lesion, suggesting PCAT changes due to atherosclerosis may exist beyond the length of the plaque. Moreover, "Gray Level Size Zone Matrix (GLSZM): Low Gray Level Zone Emphasis" could serve as a novel radiomic biomarker to correlate PCAT changes to atherosclerosis.
Hospital discharge after uncomplicated ST elevation acute myocardial infarction: How early is safe?
Authors: Certo Pereira J , Presume J , Ferreira J , Trabulo M , Tralhao A , Almeida M , Mendes M
Published: November 2023

Background

International guidelines recommend that hospital discharge within 48–72h is appropriate in selected low-risk patients admitted for ST elevation acute myocardial infarction (STEMI).

Objectives

To assess the safety of hospital discharge after 24 hours of admission in patients with uncomplicated STEMI submitted to primary percutaneous coronary intervention (PPCI).

Methods

We conducted a single-centre retrospective study enrolling consecutive patients admitted for STEMI from 2016 to 2018 submitted to PPCI. We defined clinically uncomplicated STEMI (UMI) as the absence of cardiorespiratory arrest, mechanical complications, tachy- and bradyarrhythmias, heart failure (Killip class > 1 [HF]), reinfarction and types 2 or 3 Bleeding Academic Research Consortium. Additionally, we included the criterion of preserved left preserved ejection fraction (LVEF>50%). Patients referred for coronary surgery (CABG) were excluded. Cumulative rates of death and clinical events defining UMI were reported at days 1, 2, 3, and 4. Death, clinical events defining UMI or repeat coronary revascularization at 1-year were reported after days 1, 2, 3, and 4.

Results

A total of 356 patients submitted to PPCI were included, with 64±14 years, 73% male. Median in-hospital stay was 4 [3;7] days. Applying UMI criteria we identified 271 patients (76%) in day-1, 249 (70%) in day-2, 244 (69%) in day-3, and 240 (67%) patients in day 4. Using UMI criteria, discharge after day 1 would be associated with 2.0% of early clinical events, 1.6% after day-2, and 1% after day-3. Post-discharge 1-year incidence of death, clinical events defining UMI or repeat coronary revascularization was roughly similar after day-2 (Table). Adding LVEF>50% to UMI, we identified 176 patients (49%) in day-1, 168 (47%) in day-2, 165 (46%) in day-3 and 164 (46%) in day-4. Discharge after day 1 would be associated with 1.8% of early clinical events, 0.6% after day-2 and 0.6% after day-3. Post-discharge 1-year incidence of death, clinical events defining UMI or repeat coronary revascularization was similar after day-2.

Conclusions

In our cohort of patients with STEMI submitted to PPCI, clinically uncomplicated criteria identified 69% of patients eligible for safe discharge after day-3. The addition of preserved left ventricular ejection fraction criterion can anticipate a safe discharge after day-2 in almost 50% of patients.
Association of myocardial infarction with nonobstructive coronary arteries with in-hospital outcomes
Authors: Tao M , Miller A , Price J , Dhaliwal S , Masson R , Rahman T , Bench T J , Pyo R
Published: November 2023

Background

Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) is a disease classification that is not uncommonly encountered yet poorly characterized. The association of MINOCA with in-hospital cardiovascular outcomes has been inconsistently assessed with studies reporting conflicting results. The purpose of this meta-analysis is to evaluate the association of MINOCA with in-hospital cardiovascular outcomes.

Methods

A literature search was conducted for studies reporting on the association of MINOCA with clinical endpoints as compared to obstructive coronary artery disease (OCAD). The primary end-point was in-hospital mortality. Secondary endpoints included cardiogenic shock (CS) on admission and congestive heart failure (CHF) during hospitalization. Databases searched included Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status.

Results

19 studies with 851,886 patients who had acute myocardial infarction (AMI) (45,475 patients with MINOCA, 80,6411 with OCAD) met inclusion criteria. Mean age was 63, 64% were male. Patients with MINOCA had significantly lower risk of in-hospital mortality compared to patients with OCAD (OR 0.42, 95% CI 0.31-0.57; p<0.01), the overall effect size was large (z=5.59). Patients with MINOCA had significantly lower risk of having cardiogenic shock on presentation compared to OCAD, however had no difference in risk of developing CHF during hospitalization (OR 0.45, 95% CI 0.35-0.58; p<0.01; OR 0.78, 95% CI 0.55-1.10; p=0.15).

Conclusions

Our results suggest that MINOCA is associated with lower risk of in-hospital mortality and lower risk of presentation with cardiogenic shock compared to OCAD. However, patients with MINOCA appear to have a similar risk of developing CHF during hospitalization compared to patients with OCAD.
Long-term outcome and characteristics of patients with NSTEMI and non-obstructive coronary arteries
Authors: Boukerche F
Published: November 2023

Introduction

Discordant data have been reported on the prognosis of myocardial infarction with nonobstructive coronary arteries (MINOCA).

Purpose

The objectives of this study were to assess characteristics and prognostic impact on the long-term follow-up of the diagnosis of MINOCA.

Methods

We included 274 consecutive patients with non–ST-segment elevation myocardial infarction (NSTEMI) who underwent coronary angiography between November 2015 and October 2016. MINOCA was classified according to angiographic findings as smooth coronary arteries, mild irregularities (< 30% stenosis), and moderate atherosclerosis (30%-49% stenosis). The primary endpoint was a composite of cardiovascular mortality, nonfatal myocardial infarction, and revascularization (MACE) at a median of 6 years of follow-up.

Results

A total of 74 patients (27.0%) showed no obstructive lesions. Patients with MINOCA are characterized by younger age, a predominance of females, less diabetes mellitus, dyslipidemia, and smoking, lower GRACE score at admission, less marked electrocardiographic and echocardiographic changes, and lower troponin levels. MINOCA was associated with a lower occurrence of MACE (P< 10-3; HR, 0.085; 95%CI, 0.031-0.231) and was confirmed as an independent factor in the multivariate analysis (P< 10-3; HR, 0.121; 95%CI, 0.042-0.354). On analysis of the separate components of the main endpoint, MINOCA was significantly associated with a lower rate of cardiovascular mortality, myocardial infarction, and revascularization.

Conclusions

MINOCA is characterized by a low-risk profile at admission except for the positivity of troponin and is associated with a lower rate of MACE at the long-term follow-up.Table:Characteristics6-year outcomes
Impact of gender-related differences in outcomes in acute myocardial infarction: non-obstructive coronary arteries versus obstructive coronary arteries
Authors: Fedele D , Canton L , Armillotta M , Tattilo F P , Di Iuorio O , Suma N , Bodega F , Foa A , Rinaldi A , Angeli F , Bergamaschi L , Casella G , Paolisso P , Galie N , Pizzi C
Published: November 2023

Background

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) represents 6-10% of acute myocardial infarction (AMI) and is more prevalent in females. The impact of gender on the outcomes of MINOCA patients has been poorly understood.

Purpose

To evaluate the impact of gender on the prognosis of MINOCA.

Methods

We enrolled 2455 patients with AMI undergoing coronary angiography from January 2016 to June 2021. Patients were divided according to type of AMI and gender: male (n=1593) and female (n=607) in AMI with obstructive coronary arteries (MIOCA); male (n=87) and female (n=168) in MINOCA. Each cohort was further stratified based on age (<=/> 70 years).

The primary endpoint was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (MACE) at 5-year follow-up. Secondary outcomes included: all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization and stroke.

Results

MINOCA patients were more likely to be females compared to MIOCA ones (p<0.001). The incidence of MACEs was significantly higher in females compared to males, both in MINOCA (p=0.018) and MIOCA cohorts (p=0.002). Age was an independent predictor of MACEs in both cohorts. No difference in outcomes was found comparing females to males >70 years, in both MINOCA and MIOCA. MINOCA females <70 years old had a higher incidence of MACEs (p=0.003), mainly driven by a higher prevalence of re-hospitalization for HF (p=0.045) and recurrence of AMI (p=0.006). Only in this sub-group of MINOCA patients, female gender was an independent predictor of MACEs (HR=3.09; 95%CI: 1.02-9.59; p=0.040). MINOCA females <70 years old had worse outcomes than MIOCA peers.

Conclusion

MINOCA females <70 years old had a significantly higher incidence of MACEs, compared to males and MIOCA peers, likely due to the different pathophysiology of the ischemic event.Survival curves in MINOCA and MIOCASurvival curves stratified for age
Utility of fractional flow reserve computed tomography angiography in patients with stable coronary artery disease
Authors: Tao M , Liu Y , Dhaliwal S , Ghosalkar D , Masson R , Al-Sadawi M , Rahman T , Pyo R
Published: November 2023

Introduction

Coronary CT angiography (CTA) has been established as an effective non-invasive modality for evaluation of patients with low-intermediate pretest probability of coronary artery disease (CAD). The utility of CTA is limited due to certain lesion characteristics. Fractional Flow Reserve Computed Tomography (FFRCT) may be useful in these situations, however the association of FFRCT with clinical outcomes has not been well established. The purpose of this study is to evaluate the association of FFRT with clinical outcomes in patients with stable coronary artery disease.

Methods

A literature search was conducted for studies reporting the association between FFRCT measurements and all-cause mortality, major adverse cardiac events (MACE), acute myocardial infarction (AMI), and need for revascularization. FFRCT value of ≤0.80 was considered positive, FFRCT value >0.80 was considered negative. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status.

Results

A total of 10 studies with 10919 patients with stable CAD (6919 FFRCT positive vs 4000 FFRCT negative) were included; mean follow-up was 17 months (ranging 3-56 months). There was no difference in risk of all-cause mortality in patients with FFRCT positive lesions compared to FFRCT negative lesions (OR 1.53, 95% CI 0.62-3.79; p=0.35). However, FFRCT positive lesions were associated with increased risk of MACE, AMI, and need for revascularization with PCI or CABG (OR 2.37, 95% CI 1.48-3.80; p<0.01; OR 4.6, 95% CI 1.58-13.41; p<0.01; OR 9.56, 95% CI 3.18-28.71; p<0.01). The overall incidence of revascularization in FFRCT negative patients was low compared to FFRCT positive patients (2.8% vs 31.7%).

Conclusion

FFRCT is a useful adjunctive modality for further risk stratification of patients with stable CAD. FFRCT positive lesions are associated with increased risk of MACE, AMI, and coronary lesions requiring revascularization.Figure 1
Myocardial infarction with non obstructive coronary arteries (MINOCA): clinical profile and prognosis
Authors: Gil Mancebo N , Mata Caballero R , Fraile Sanz A , Izquierdo Coronel B , Rodriguez Montes P , Martin Munoz M , Alvarez Bello Munoz M , Perela Alvarez C , Nieto Ibanez D , Abad Romero R , Olsen Rodriguez R , Espinosa Pascual M , Moreno Vinues C , Awamleh Garcia P , Alonso Martin J J
Published: November 2023

Background

MINOCA is a clinical condition that has grown interest in the last few years. The aim of this study is to compare the clinical profile, treatment and prognosis of MINOCA patients and those with myocardial infarction (MI) with obstructive coronary artery disease (MICAD).

Methods

We analyzed all consecutive patients with MI who underwent coronary angiography admitted in our Hospital. The database and all the patient's angiographies were revised by a group of experts in order to adequate MINOCA definition to 2020 ESC Guidelines definition and American Heart Association consensus statement.

Results

We included 915 patients, of whom 108 (12%) were MINOCA, with a median follow-up of 45 [21-65] months (see table 1). The underlying mechanism in MINOCA was coronary spasm (15%), plaque rupture (9.3%), coronary embolism (4.7%), coronary dissection (5.6%), type II infarction (17.8%) or unknown (43.8%). A total of 58.3% had angiographically smooth coronary arteries and 38.9% had plaques <50%. MINOCA patients in our study were younger and mostly female, with higher prevalence of connective tissue diseases, migraine or patient-reported stress and less smoking, diabetes and chronic kidney disease compared to patients with obstructive coronary artery disease. Symptoms at admission did not differ between both groups, although MINOCA had EKG with fewer alterations, most had a diagnosis of non-ST-elevation MI (NSTEMI) and significantly lower myocardial injury biomarkers’ levels (Troponine T hs peak 176 [37.25-430] vs 860 [187.50- 2640.50] ng/L, p<0.001 and CK 179 [86.75-342.75] vs 435 [159.50-1090] U/L, p<0.001). They had fewer cardiovascular complications during hospitalization such as inotropic requirements (0% vs 8%, P=0.003), cardiogenic shock (0% vs 6.4%, P=0.007) or left ventricular dysfunction (11.1% vs 29.6%, P<0.001). There were no significant differences in MACE (25.3% vs 34.7%, p=0,086): death (10.7% vs 15.5%, p=0.25), readmission (19% vs 28.7%, p=0.06), AMI (8.3 % vs 7.3%, p=0.74) and stroke (2.4% vs 3.4%, p=0.61) in both groups at follow-up.

Conclusions

1) MINOCA is frequent (12% of MI), 2) the clinical profile of MINOCA patients is different than MICAD (lower cardiovascular risk factors burden, younger and more females), 3) the severity of myocardial infarction is lower (more diagnosis of NSTEMI, lower myocardial injury biomarkers’ levels, fewer complications during hospitalization and less left ventricular dysfunction), 4) we found no differences in prognosis in both groups.Table 1
Impact of COVID-19 pandemics on the incidence and mortality in Takotsubo syndrome: a report from Swedish Coronary Angiography and Angioplasty Registry
Authors: Omerovic E , Gudmundsson T , Redfors B , Angeras O , Petursson P , Rawshani A , Frobert O , Alfredsson J , Ekenbeck C , Henareh L , Skoglund K , Ljungman C , Mohammad M , Jernberg T , Erlinge D
Published: November 2023

Background

The COVID-19 pandemic resulted in severe psychological, social, and economic stress. Countries applied different anti-pandemic strategies that substantially impacted citizens' psychosocial stress and health. Takotsubo syndrome (TS) is frequently triggered by emotional stress. Previous studies from the USA have reported a severalfold increase in TS incidence during pandemics.

Purpose

To determine the incidence and outcomes of TS in Sweden before (2015-March 2020) and during (April 2020-December 2022) the pandemic.

Methods

We assessed the incidence rate ratio (IRR) for all patients with TS referred for coronary angiography in Sweden using the nationwide Swedish Coronary Angiography and Angioplasty Registry. Incidence rate ratios (IRRs) before and during the pandemic were calculated with Poisson regression adjusted for age and sex. We evaluated mortality with multivariable Cox proportional hazards regression, which accounted for clustering of patients within hospitals. The following variables were used for adjustment: age, sex, diabetes, smoking status, hypertension, hyperlipidemia, previous myocardial infarction, and Killip class.

Results

We identified 3,180 patients (2,128 [76.0%] women) hospitalized with TS during the study period; 2,189 (69%) pre-pandemic and 991 (31%) during the pandemic. The average age was 68.3 ± 11.2 years. The median follow-up time was 1250 days (IQR 562-1995). The crude all-cause mortality rate was 2.57% at 30 days and 15.5% after long-term follow-up. The incidence of TS was 11% lower during the pandemic compared with the pre-pandemic period (IRR 0.90, 95% CI 0.83-0.98, P=0.009, Fig. 1). We found no difference in 30-day mortality (adjusted HR 1.12, 95% CI 0.69-1.78, P= 0.642) or long-term mortality (adjusted HR 0.96, 95% CI 0.73-1.28, P= 0.816) among patients with TS between the pre-pandemic and pandemic periods. When only data after 2016 are used, we found no difference in TS incidence (IRR 1.00, 95% CI 0.92-1.08, P=1.00).

Conclusions

In this observational study, the incidence of TS was lower during than before the pandemic but mortality was unchanged. The lower incidence of TS could be related to the specific anti-pandemic strategies applied at the national level in Sweden.Figure 1
Importance of hospital and clinical factors in predicting of 30-day mortality in Takotsubo syndrome: data from the Swedish Coronary Angiography and Angioplasty Registry
Authors: Gudmundsson T , Redfors B , Angeras O , Petursson P , Rawshani A , Frobert O , Alfredsson J , Henareh L , Skoglund K , Ljungman C , Jernberg T , Erlinge D , Omerovic E
Published: November 2023

Background

Takotsubo syndrome (TS) is an acute heart failure condition that presents with symptoms similar to acute myocardial infarction. TS is often triggered by emotional or physical stress and is an important cause of morbidity and mortality but predictors of mortality in TS patients are not well understood. There is a need to identify high-risk patients and tailor treatment accordingly.

Purpose

The purpose of this study was to assess the importance of various clinical factors in predicting 30-day mortality in TS patients using a machine-learning algorithm capable of identifying complex relationships between variables.

Methods

We analyzed data from the nationwide Swedish Coronary Angiography and Angioplasty Registry for all TS patients between 2015-2022. Gradient boosting was used to assess the relative importance of variables in predicting 30-day mortality in TS patients.

Results

Of the 3,180 hospitalized TS patients, 76% were women. The average age was 68.3 ± 11.2 years. The crude all-cause mortality rate was 2.57% at 30 days. The most important variable in predicting 30-day mortality was the hospital where the patient was treated, with a relative importance of 35.5%. This was followed by the clinical presentation for angiography (21.1%), creatinine level (11.9%), Killip class (8.9%), and age at angioplasty (6.5%). Other less important factors included weight, height, and certain medical conditions such as hyperlipidemia, smoking status, and hypertension. Gender and previous stroke history had a low impact on 30-day mortality in TS patients.

Conclusions

The treating hospital was the most important factor in predicting 30-day mortality in TS. Since the level of evidence for recommended treatments of TS is low, our findings highlight the importance of conducting randomized studies in this patient group to improve care.
Recovery of left ventricular ejection fraction in Takotsubo Syndrome
Authors: Bernardo M , Rocha Carvalho P , Carvalho C , Moreira I , Magalhaes P , Goncalves F , Mateus P , Silva Carvalho S , Moreira J I
Published: November 2023

Introduction

Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Left ventricular ejection fraction (LVEF) recovery in TTS occurs over a wide-range interval, varying from days to weeks.

Purpose

Our purpose was to access the prognostic impact of delayed recovery of LVEF in patients with TTS.

Methods

We performed a retrospective analysis of patients admitted in a single centre between 2008 and 2022 with the diagnosis of TTS, with a LVEF <50% at admission. Patients were divided into two groups: Group A- patients with the recovery of ejection fraction during hospitalization (LV EF ≥ 50% at the pre-discharge echocardiogram) and Group B- patients that had a delay in recovery, with LV EF <50% at the pre-discharge echocardiogram. Major adverse cardiovascular events (MACCE) included heart failure hospitalization, cardiovascular mortality, stroke and TTS recurrence.

Results

We included 63 pts, 88,9% females, mean age of 69,38 ±12,5 years. Group A included 27 pts, with a median LV EF of 37% (IQR 33-41) and group B included 36 pts with a median LV EF of 36% (IQR 33-38,8), with no statistically significant difference between the two groups (p= 0,347).

The median pre-discharge LV EF was 60,0% (IQR 56-65,6) in group A and 42,0% (IQR 37-47) in group B (p<0,005). The hospitalization length (HL)was similar between the two groups (mean HL of 7,9 ±7,8 in group A versus 8,1 ±8,4 days in group B, p= 0,93).

The two groups were similar in terms of basal characteristics, with more prevalence of psychiatric disease in group A (13,9% vs 33,3%, p= 0,066).

We found no statistically differences in clinical presentation and evolution during hospitalization (Killip class, cardiogenic shock, ventricular arrhythmias) and in the rates of concomitant coronary artery disease (14,8% group A versus 26,5% group B, p= 0,270). Also, the in-hospital medication and at discharge (Angiotensin-converting enzyme inhibitors, beta blockers, spironolactone and aspirin) were identical between the two groups. There was a tendency for more prescription of anticoagulants at discharge in group B (45,7% versus 22,2%, p = 0,055).

During a median follow-up of 41,0 months (IQR 14,0-54,5), group B had a higher rate of MACCE (34,4% versus 20,0%, log rank p= 0,033). In a multivariate analysis, after adjusting for possible confounders, delayed recovery of LV EF was an independent predictor of MACCE with a HR 6,1 (95% CI: 1,50-24,9, p= 0,012) (Fig.1).

Conclusions

In this population, delayed recovery of LV EF in TTS was an independent predictor of major adverse cardiovascular events. These findings suggest that this population should be targeted in clinical trials to investigate possible interventions and these patients should have a closer follow-up.