bluuebunny/crossref_metadata_2025 huggingface dataset:
Chemerin in coronary artery disease patients
Authors: Szpakowicz A , Kaminski K.A , Szpakowicz M , Lapinska M , Paniczko M , Lawicki S , Glazewska K , Raczkowski A , Kondraciuk M , Sawicka E , Kozuch M , Poludniewski M , Kowalska I
Published: November 2020

Background

Chemerin – a recently described hormone is secreted by adipose tissue. It exerts proinflammatory action, leads to insulin resistance, but also has potentially favorable effects: it increases eNOS activity and is pro-angiogenic. Increased serum concentrations of chemerin was observed in patients with coronary artery disease (CAD). The role of chemerin in pathogenesis of CAD is not well understood.

Purpose

The aim of this pilot study was to assess the role of chemerin in pathogenesis of atherosclerosis, its impact on condition of large arteries and prognosis in CAD.

Methods

We included in the study patients with stable CAD who underwent percutaneous coronary intervention (PCI) in the past. Chemerin levels were measured with ELISA method. All patients had routine blood tests and insulin levels measured. Patients without history of diabetes also had OGTT. Status of large arteries was evaluated with carotid ultrasound, pulse-wave velocity (PWV) and ankle-brachial index (ABI). Body composition was assessed wit DEXA method. Anatomical severity of CAD was evaluated with SYNTAX score. One-year composite endpoint included death, myocardial infarction, revascularization, stroke and hospitalization for cardiovascular reasons.

Results

The study group comprised 163 patients (mean age 59.8± years, 26% of females, n=43). Mean chemerin level was 284.8 ng/ml. There was no significant difference in chemerin concentrations between patients with diabetes and remaining ones (with prediabetes and with normal glucose levels) 306.8±121 vs 274.15±109 pg/ml, p=0.1. In Spearman test chemerin level correlated with total fat mass (R=0.15, p=0.047), trunk fat mass (R=0.16, p=0.039), android fat mass (R=0.16, p=0.036), and BMI (R=0.18, p=0.028). Chemerin also correlated with white blood cells (WBC) count (R=0.34, p<0.0001), hsCRP (R=0.16, p=0.03), total cholesterol (R=0.17, p=0.028), LDL cholesterol (R=0.19, p=0.01), HDL cholesterol (R=−0.21, p=0.006), triglicerides (R=0.3, p<0.0001), platelet count (R=0.23, p=0.002), fasting insulin (R=0.22, p=0.004) and c-peptide (R=0.26, p=0.0005). There was no significant difference in chemerin levels between patients with carotid atherosclerosis (n=93) and patients with normal carotid arteries (n=70), (300±124 vs 263±94 ng/ml, p=0.07). There were no significant associations between chemerin levels and PWV, ABI measurements, SYNTAX score, or 1-year prognosis.

Conclusions

This is the first study to show that in patients with CAD chemerin levels correlate with WBC and with android fat tissue mass. Additionally, chemerin levels positively correlated with other inflammation or insulin resistance markers, and with unfavourable lipid profile.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The National Science Centre
A real-world comparison of outcomes between fractional flow reserve-guided versus angiography-guided percutaneous coronary intervention
Authors: Wong C , Ng A , Ada C , Chow V , Fearon W , Ng M , Kritharides L , Yong A
Published: November 2020

Background

Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) has been shown to be superior to angiography-guided PCI in randomized controlled studies. However, real-world data on the use and outcomes of FFR-guided PCI remain limited.

Purpose

To investigate the outcomes of patients undergoing FFR-guided PCI compared to angiography-guided PCI in a large, state-wide unselected cohort.

Methods

All patients undergoing PCI between June 2017 and June 2018 recorded by the Centre for Health Record Linkage (CHeReL) were included in the study. The CHeReL database is one of the largest data linkage systems in Australia, capturing health data from ≥97% of all healthcare facilities in the state of New South Wales, which has a population of 7.5 million people. The PCI cohort was stratified into the FFR-guided group when a concomitant FFR procedure was performed, and the angiography-guided group when no FFR was performed. The primary endpoint was a combined endpoint of death or myocardial infarction (MI). Secondary endpoints included all-cause death, cardiovascular (CV) death, and MI.

Results

The cohort comprised 10,304 patients, of which 542 (5%) underwent FFR-guided PCI. There were no significant differences in age, gender, or comorbidities between the two groups. During a mean follow-up of 12±4 months, the FFR-guided PCI group had reduced occurrence of the primary endpoint (3% vs 8%, P<0.001), all-cause death (1% vs 4%, P=0.001), CV death (1% vs 3%, P=0.01), and MI (2% vs 4%, P=0.01) (Figure). Multivariable Cox regression analysis demonstrated FFR-guidance to be an independent predictor of the primary endpoint (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.28–0.78, P=0.004), after adjusting for age, clinical presentation, comorbidities, and multi-vessel PCI. A sensitivity analysis was performed excluding patients that presented with acute MI, leading to a smaller cohort of 5,850 patients, of which 448 (8%) underwent FFR-guided PCI. FFR-guidance remained an independent predictor of the primary endpoint in this cohort of stable patients (HR 0.36, 95% CI 0.17–0.77, P=0.01).

Conclusion

In this real-world study of patients undergoing PCI, FFR-guidance was associated with improved clinical outcomes, driven by the lower hard endpoint of death or MI. The use of FFR-guided PCI remains limited worldwide, and efforts should be directed to increase adoption of this technique in future.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of Australia Health Professional Scholarship
Comparison of clinical characteristics between patients with microvascular and epicardial coronary artery spasm
Authors: Kato K , Tateishi K , Saito Y , Kitahara H , Fujimoto Y , Kobayashi Y
Published: November 2020

Background

Coronary functional abnormalities including both epicardial and microvascular coronary artery spasm represent an important role responsible for myocardial ischemia in patients with angina and nonobstructive coronary artery disease. However, clinical characteristics associated with microvascular spasm (MVS) have not been fully evaluated.

Purpose

The aim of this study was to assess differences in clinical features between patients with MVS and epicardial coronary spasm.

Methods

A total of 732 consecutive patients with suspected angina who presented nonobstructive coronary arteries and underwent intracoronary acetylcholine provocation test were retrospectively enrolled in this study. Epicardial coronary spasm was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine provocation test. MVS was diagnosed when chest pain and/or ischemic electrocardiographic changes developed after administration of acetylcholine in the absence of epicardial coronary spasm. Clinical characteristics were compared between patients with MVS and epicardial coronary spasm.

Results

Of all patients, 83 patients (11%) had MVS, 367 (50%) had epicardial coronary spasm, and the other patients (39%) showed neither MVS nor epicardial coronary spasm. Patients with MVS tended to be older (65.6±12.7 vs. 63.0±12.3 years, P=0.088) and were more frequently female (60.2% vs. 41.1%, P=0.0016) in comparison with patients with epicardial coronary spasm. Patients with MVS were less likely to be smokers (8.6% vs. 22.9%, P=0.0018), while there were no significant differences in the other coronary risk factors such as hypertension, dyslipidemia, and diabetes mellitus. Serum uric acid were significantly lower in patients with MVS (4.9±1.1 vs. 5.4±1.3 mg/dl, P=0.0018).

Conclusion

Our study demonstrated that patients with MVS had distinctive clinical background from those with epicardial coronary spasm, suggesting different mechanisms may involve the development of MVS.

Funding Acknowledgement

Type of funding source: None
Unveiling coronary inflammation by perivascular fat angio-CT: a propensity-matched score analysis
Authors: Lopes Da Cunha G.J , Rocha B.M.L , Freitas P.N , Lopes P.M.D , Santos A.C , Guerreiro S , Abecasis J , Aguiar C.M.T , Andrade M.J , Saraiva C , Mendes M , Ferreira A
Published: November 2020

Background

Inflammation plays a pivotal role in the atherogenic process and recently has been the target of successful clinical trials. A new CT angiography method allows the identification of inflammatory pericoronary fat, which is associated with cardiovascular events. We aimed to determine whether patients with obstructive coronary artery disease (CAD) have a higher pericoronary inflammatory milieu when compared to those without CAD.

Methods

From a prospective CT angiography registry of patients with suspected obstructive CAD, those with a luminal stenosis >70% confirmed by invasive coronary angiography were screened (previous coronary artery bypass grafting was an exclusion criteria). Subsequently, we applied a 1:1 propensity score (PS) without replacement protocol to match obstructive CAD patients with those without CAD (non-CAD), using age, gender, BMI, hypertension, dyslipidemia, diabetes and smoking status as covariates. Similar to previous reports, pericoronary fat characterization by CT angiography was performed by analyzing the fat attenuation index (FAI) at the −30 to −190 HU range. Inflammatory fat was defined by a FAI >−70 HU. The proximal 50mm of the right coronary artery (RCA) was used to perform fat quantification and characterization. The perivascular fat was defined as the adipose tissue within a radial distance from the outer vessel wall equal to the diameter of the vessel.

Results

A matched cohort of 48 patients was identified (mean age 63 years; 77% males) – 24 obstructive CAD and 24 non-CAD patients. Mean FAI was numerically higher in obstructive CAD compared to the non-CAD cohort (−74±7 vs −78±7; p=0.083). Although not statistically significant, those with obstructive CAD had an increased proportion of inflammatory fat (51±10 vs 46±10%; p=0.107). After adjustment for body surface area (BSA), differences in the inflammatory fat proportion became apparent between obstructive CAD and non-CAD patients (28±6 vs 24±5%/m2; p=0.024). Furthermore, we observed a significant correlation between the inflammatory fat proportion (both absolute value and BSA adjusted) and the total number of RCA plaques (r=0.458; p=0.003; and r=0.451; p=0.003, respectively). Finally, there was 1 additional plaque observed in the RCA for each increase in 10% of proportion of inflammatory fat (p=0.018).

Conclusions

Perivascular coronary inflammation, as measured by FAI, seems significantly heightened in patients with obstructive CAD compared to a matched cohort of non-CAD patients. Further studies are needed to ascertain the mechanisms and possible implications of this association.

Funding Acknowledgement

Type of funding source: None
Risk stratification based on academic research consortium high bleeding risk criteria for long-term bleeding event after everolimus-eluting stent implantation
Authors: Miura K , Shimada T , Ohya M , Murai R , Amano H , Kubo S , Tada T , Tanaka H , Fuku Y , Goto T , Kadota K
Published: November 2020

Background

Recently, the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria has been suggested as the standard definition of HBR.

Purpose

We aimed to investigate the risk stratification based on ARC-HBR Criteria for long-term bleeding event after everolimus-eluting stent implantation

Methods

The study population comprised 1193 patients treated with EES without in-hospital event between 2010 and 2011. Individual ARC-HBR criteria was retrospectively assessed. Major bleeding were defined as the occurrence of a Bleeding Academic Research Consortium type 3 or 5 bleeding event. The mean follow-up period was 2996±433 days.

Results

There were 656 patients (55.0%) in HBR-groups. Cumulative incidence of major bleeding was significantly higher in HBR-group (8.1% vs 3.4% at 4 year, and 16.2% vs 5.7% at 8 year, P<0.001). Cumulative rate of major bleeding tend to be higher as the number of ARC-HBR criteria increased (≥2 Majors: 24.3%, 1 Major: 17.0%, ≥2 Minors:11.7%, and Non-HBR: 5.7%, P<0.001).

Conclusion

ARC-HBR criteria successfully stratified the long-term bleeding risk after drug-eluting stent implantation in real-world practice.

Funding Acknowledgement

Type of funding source: None
European differences in characteristics, treatments and outcomes in patients with non-ST-elevation myocardial infarction – novel insights from four national real-world registries
Authors: Edfors R , Jernberg T , Lewinter C , Eha J , Asser P , Andreka P , Janosi A , Jortveit J , Halvorsen S
Published: November 2020

Background

Large-scale collection of standardized variables in patients with myocardial infarction (MI) in national real-world registries are only available in a few European countries and there is lack of cross-country comparisons.

Purpose

To compare demography, risk factors, hospital treatment and short- and long-term survival in patients hospitalized for non-ST elevation MI (NSTEMI) in four different European countries.

Methods

NSTEMI patients hospitalized and enrolled in national MI registries; EMIR (Estonia), HUMIR (Hungary), NORMI (Norway (2013–2016)) and SWEDEHEART (Sweden) from 2014 to 2017 were included.

Results

In total 119,191 patients with NSTEMI were included. The mean age at admission ranged from 70 years (Hungary) to 75 years (Estonia). The proportion of women was 36% in Sweden and 44% in Estonia. In Norway 24% were smokers, as compared to 17% in Sweden. Patients in Hungary had a high rate of diabetes mellitus (37%) and antihypertensive treatment (84%) but a low rate of lipid lowering treatment (32%). The proportion of patients with prior MI ranged from 28% (Norway) to 37% (Sweden). The presence of previous peripheral artery disease ranged from 7% (Sweden) to 17% (Hungary). The absolute proportion of performed coronary angiographies (58% versus 75%) and percutaneous coronary interventions (38% versus 56%), differed most between Norway and Hungary. Dual antiplatelet therapy ranged from 60% (Estonia) to 81% (Hungary) and statins from 78% (Norway) to 89% (Hungary), at discharge. The crude mortality rates at 1 month and 1 year are listed in table 1.

Conclusion

Cross-comparison of four national European MI registries provide new insights in differences in risk factors, treatment and outcomes. Possible reasons for the observed differences, include differences in the underlying expected mortality in the populations, inclusion-criteria and coverage of the registries and variable definitions, that need to be further explored.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council
Lymphopenia and risk for long-term mortality among patients undergoing coronary angiography
Authors: Zafrir B , Jaffe R , Sliman H , Barnett-Griness O , Saliba W
Published: November 2020

Background

Lymphopenia has been shown to be associated with adverse prognosis in chronic disease states that are related to immune dysregulation.

Purpose

We aimed to determine the association between lymphopenia and all-cause mortality in patients presenting to coronary angiography with or without acute coronary syndromes (ACS). We also investigated whether elevated red blood cell distribution width (RDW), an established cardiovascular prognostic marker, further refines risk stratification and improves predictive accuracy beyond lymphocytes count.

Methods

Retrospective cohort analysis of patients undergoing coronary angiography for evaluation or treatment of coronary artery disease between 2003 and 2018. Long-term mortality risk associated with relative (1000–1500 /μL) or severe (<1000 /μL) lymphopenia was analyzed using Cox proportional hazards regression models, adjusting for comorbidities, ACS and RDW.

Results

Overall, 15179 patients underwent coronary angiography, at a mean age of 65±12 years. On cross-sectional analysis, lymphopenia was associated with kidney disease, cancer, heart failure and presentation with ACS, but lower rates of smoking and obesity. During a median follow-up of 7 (IQR 3.5–11.5) years, 4253 patients died. Compared to normal lymphocytes count (1500–5000 /μL), the multivariable adjusted hazard ratio (HR) (95% confidence interval) for mortality was 1.31 (1.21–1.41) and 1.97 (1.75–2.22) for relative and severe lymphopenia, respectively. The increase in mortality associated with severe lymphopenia was significant in patients presenting with non-ACS [HR 2.18 (1.74–2.73)], ST-segment elevation myocardial infarction (STEMI) [HR 1.59 (1.15–2.21)], or unstable angina/non-STEMI [HR 2.00 (1.70–2.34)]; p-for-interaction 0.626. The association of lymphopenia with mortality remained significant after additional adjustment to RDW. High RDW (>14.5%) was associated with increased mortality risk in each of the lymphocytes count groups, and improved the predictive accuracy with AUC increase from 0.609 (0.601–0.616) to 0.646 (0.639–0.654) (p<0.001).

Conclusions

Lymphopenia is associated with increased risk for long-term mortality in patients undergoing coronary angiography, regardless of coronary presentation. High RDW may enhance the predictive ability of lymphopenia.

Lymphocyte count and mortality risk

Funding Acknowledgement

Type of funding source: None
Evolution of hospital discharge medication and 6 months outcomes of ST-Segment Elevation Myocardial Infarction patients in Portugal over the years
Authors: De Sousa Bispo J.P , Mota T.F , Fernandes R , Azevedo P , Carvalho D , Bento D , Marques N , Mimoso J , Jesus I
Published: November 2020

Objectives

To assess the evolution of hospital discharge management, 6 months hospitalization and mortality over the years of all patients admitted with ST segment elevation myocardial infarction (STEMI) in Portugal.

Methods

A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of Acute Coronary Syndrome since 2002 until 2018 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical status, revascularization strategy, discharge medication and 6 months hospitalization and mortality were obtained. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess trends in categorical variables, and Kruskal-Wallis tests were used to assess trends in numerical variables. A p-value <0.05 was considered statistically significant.

Results

During the study, a total of 23807 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years.

We report a progressive and significant increase the use of primary angioplasty versus fibrinolysis (24.3% to 98.4%, p<0.001), in coronary angioplasties (36.4% to 73.2%, p<0.001), in the use of drug-eluting stents (0% to 70.1%, p<0.001), and a decrease in the patients that underwent surgery (6.8% to 1.3%, p<0.001) and intra-aortic balloon pump (1.8% to 0%, p=0.009), resulting in a decrease in in-hospital mortality from 9.9% to 6.1% (p<0.001).

At discharge, we report a progressive increase in the prescription of P2Y12 inhibitors (21.1% to 95.2%, p<0.001), beta-blockers (68.8% to 83.8%, p<0.001), RAAS inhibitors (69.5% to 86.7%, p<0.001) and statins (79.6% to 94.9%, p<0.001), while the prescription of aspirin (94.1% para 94.8%, p=0.428), calcium channel blockers (5.3% to 5.6%, p<0.684) stayed stable, and there was a decrease in the prescription of nitrates (52.9% to 5.8%, p<0.001). Hospital admissions at 6 months consistently and progressively reduced over time (18.6% to 8.5%, p<0.001) as well as mortality (6.7% para 4.3%, p<0.001).

Conclusion

Post discharge treatment of STEMI patients in Portuguese hospitals has evolved according to guidelines, with higher prescription of medication proven to reduce outcomes, resulting in lower hospitalization rates and mortality.

6 Month Outcomes over the years

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Sociedade Portuguesa de Cardiologia
Treatment delay in STEMI is associated with heart failure and mortality. National data from the Norwegian myocardial infarction register
Authors: Halle K.K , Govatsmark R.E.S , Bonaa K.H
Published: November 2020

Background

European guidelines in ST-segment elevation acute myocardial infarction (STEMI) recommends a primary PCI (P-PCI) strategy if wire crossing of the occluded artery can be performed within 120 min of ECG diagnosis. A large proportion of the Norwegian population lives in remote geographical areas where P-PCI may not be performed expeditiously. Time delay from first medical contact to primary PCI is expected to be related to outcomes like heart failure and mortality. Norwegian hospitals are by law required to register clinical data for all patients treated for acute myocardial infarction in the Norwegian Myocardial Infarction. The register includes >90% of eligible patients.

Purpose

The aim of the study was to investigate the association of time from first medical contact (FMC) to P-PCI with heart failure (EF <50%) and mortality.

Methods

The study includes all patients registered during 2015–2018 in the Norwegian Myocardial Infarction Registry with STEMI who were <85 years of age and had <12 hours from symptom onset to FMC. For patients with missing values, FMC was calculated as time of prehospital ECG minus 10 minutes. The primary outcome variable was heart failure (defined as ejection fraction <50% during hospitalization) or all-cause mortality within 1 year after hospitalization. We calculated ORs (95% CI) adjusted for age, gender, and history of myocardial infarction, hypertension, diabetes, and heart failure.

Results

During 2015–2018 a total of 6398 STEMI patients <85 years of age were registered in the Norwegian Myocardial Infarction Registry with less than 12 hours from symptom onset to FMC. Time delay from FMC to P-PCI were <90 minutes, 90–119 minutes, and >120 minutes in 40%, 25%, and 35% of the patients, respectively. Compared to patients with P-PCI within 90 minutes after FMC, the multivariable adjusted OR (95% CI; p-value) for heart failure or 1 year mortality was 1.05 (1.02–1.08; p<0.01) for patients with P-PCI within 90–119 minutes after FMC, and 1.05 (1.02–1.08; p<0.001) for patients with P-PCI >120 minutes after FMC. The corresponding ORs for 1 year mortality were 1.01 (0.99–1.02) and 1.03 (1.02–1.04), respectively, and the corresponding ORs for EF<50% were 1.07 (1.04–1.11) and 1.07 (1.04–1.11).

Conclusion

In Norway, only 40% of STEMI patients undergo P-PCI within 90 minutes after FMC, and 35% of patients undergoes P-PCI >120 minutes after FMC. Time delays of more than 90 minutes after FMC are associated with increased risk of heart failure and mortality. A fibrinolysis strategy may be preferred over P-PCI for a substantial proportion of STEMI patients.

Funding Acknowledgement

Type of funding source: None
Plasma desmosine, a biomarker of elastin degradation, predicts outcomes in coronary artery disease
Authors: Iskandar Z , Patel S , Lancefield T , Freeman M , Horrigan M , Farouque O , Huang J.T.J , Lang C.C , Burrell L.M , Choy A.M
Published: November 2020

Background

Recent evidence from animal studies suggests that elastin degradation accelerates atherosclerosis and increases risk of plaque rupture and subsequent myocardial infarction and stroke. Desmosine is an elastin-specific degradation product. We analysed the prognostic value of plasma desmosine (pDES) in a cohort of patients with coronary artery disease (CAD).

Methods

Patients with CAD (n=400) undergoing elective coronary angiography were prospectively recruited over 3 years and had bloods drawn for analysis of pDES using a validated stable isotope dilution liquid chromatography-tandem mass spectrometry method. Patients were followed up for 12 months for major adverse cardiovascular events (MACE: composite of death, myocardial infarction, target vessel repeat revascularisation, target lesion revascularisation, and heart failure hospital admission). The upper limit of normal for pDES is 0.35 ng/mL. The predictive value of pDES for MACE was analysed with Cox-proportional hazards ratio (HR) model and Kaplan-Meier survival analysis.

Results

During follow-up, there were 36 MACE events. Median pDES level across the entire cohort was 0.3 ng/mL (IQR 0.23–0.41 ng/mL). Patients with a pDES level >0.35 ng/mL were more likely to be male and older with a mean age of 69.7±10.3 years, have a history of prior stroke or transient ischaemic attack (TIA) and COPD. In univariable analysis, a pDES level of >0.35 ng/mL was associated with an increased risk of MACE (HR 4.76, 95% CI: 2.34–9.68, p<0.001). In multivariable analysis, pDES >0.35 ng/mL was associated with risk of MACE after adjustment for age, sex, COPD status and previous stroke and TIA (HR 3.97; 95% CI: 1.82–8.67, p=0.001) (Figure).

Conclusion

Increased elastin degradation as measured by elevated pDES levels, predicts outcomes in patients with CAD independent of traditional cardiovascular risk factors and may play a role as a future biomarker in these patients.

Kaplan-Meier survival analysis

Funding Acknowledgement

Type of funding source: None
The role of plateletcrit and red blood cell distribution width as a predictor of in-hospital mortality in patients with acute coronary syndrome
Authors: Sudharsono A , Khairina D , Fajar Muzakkir A , Hakim Alkatiri A , Muzakkir Amir M.Z
Published: November 2020

Introduction

Red Blood Cell Distribution Width (RDW CV) and Plateletcrit (PCT) are part of complete blood count (CBC) examination. There are few studies have been reported the use of these parameters to predict clinical outcome including mortality, but none of them conducted in Asian population. We seek to investigate the role of PCT and RDW CV as a potential objective biomarker to predict in hospital mortality coincide with Global Registry of Acute Cardiac Events (GRACE) score in Acute Coronary Syndrome (ACS).

Methods

We respectively analysed patients with ACS who were admitted to the coronary care unit between June 2018 and December 2019. The GRACE and CBC were taken consecutively.

Results

A total of 1053 patients with ACS (46% non-ST elevated ACS (NSTE-ACS) and 54% ST elevated myocardial infarction (STEMI)] were enrolled in this study. PCT and RDW-CV was found to be significantly correlated with mortality (p<0.001). Further analysis showed significant higher level of PCT in patients with event compared to the other group (0.32 vs 0.24, p<0.001). Similar result was found for RDW (14.1 vs 13.2, p<0.001). ROC curve analysis for PCT and RDW-CV levels showed an AUC of 0.65, (cut off value: 0.25. p<0.001) and 0.69 (cut off value 13.05, p<0.001), respectively. High PCT and RDW-CV level were found to be a good predictor of mortality in ACS patients. (OR 2.6 and OR 3.4 respectively, p<0.001) In patients with high risk GRACE risk categories, we found a significantly higher levels of PCT (0.27 vs 0.24, p<0.001) and RDW-CV (13.8 vs 13.2, p<0.001) compared to low-intermediate risk group.

Conclusion(s)

We found that both PCT and RDW-CV may act as novel and promising tool to predict in hospital mortality directly proportional with GRACE Score among ACS patient.

Figure 1. ROC curve for PCT and RDW-CV.

Funding Acknowledgement

Type of funding source: None
Diagnostic performance and clinical implications for enhancing a hybrid quantitative flow ratio and fractional flow reserve revascularization decision making strategy
Authors: Peper J , Van Hamersvelt R.W , Rensing B.J.M.W , Van Kuijk J.P , Voskuil M , Ten Berg J.M , Schaap J , Kelder J.C , Grobbee D.E , Leiner T , Swaans M.J
Published: November 2020

Background

Fractional flow reserve (FFR) adoption persists low mainly due to procedural and operator related factors as well as costs. An alternative for FFR, quantitative flow ratio (QFR) achieves a high accuracy mainly outside the intermediate zone without the need for hyperemia and wire-use. Currently, no outcome trials assess the role of QFR in the guidance of revascularization. Therefore, we evaluate a QFR-FFR hybrid strategy in which FFR is measured inside of the intermediate zone.

Methods

This retrospective multi-center study included consecutive patients who underwent both invasive coronary angiography and FFR in the participating centers. QFR was calculated for all vessels in which FFR was measured. Diagnostic performance of QFR was assessed using an FFR cut-off of 0.80 as reference standard. The QFR-FFR hybrid approach was modeled using the intermediate zone of 0.77 to 0.87 assuming that lesions within the intermediate zone follow the FFR binary cutoff.

Results

In total, 381 vessels in 289 patients were analyzed. The sensitivity, specificity and accuracy on a per vessel-based analysis were 84.6%, 86.3% and 85.6% for QFR and 91.1%, 95.3% and 93.4% for the QFR-FFR hybrid approach. The diagnostic accuracy of QFR-FFR hybrid strategy with invasive FFR measurement is 93.4% and results in a FFR reduction of 56.7%.

Conclusion

QFR has a good correlation and agreement with invasive FFR and a high diagnostic accuracy. A hybrid QFR-FFR approach could extend the use of QFR and reduces the proportion of invasive FFR-measurements needed while maintaining a high accuracy.

Hybrid QFR-FFR strategy

Funding Acknowledgement

Type of funding source: None
A bolus of saline injection leads to increase in coronary flow based on the viscosity reduction effect: the mechanism of saline induced Pd/Pa ratio
Authors: Baba T , Fujimori Y , Kurihara K , Yamanaka Y , Hashimoto S , Terasawa Y , Hata H , Yokota D , Wakabayashi T , Imai T
Published: November 2020

Background

In conjunction with fractional flow reserve (FFR), our previous study has shown the accuracy and utility of saline induced Pd/Pa ratio (SPR) for the assessment of myocardial ischemia. However, the potential mechanism how saline injection leads to increase in coronary flow remains speculative.

Purpose

This study aimed to clarify the underlying mechanism of SPR by using swine models.

Methods

The study was conducted in four swine models, and bolus of 25°C saline, 40°C saline, and 25°C dextran was injected at rates of 40mL/5sec through a catheter inserted into the superior mesenteric artery. Its peripheral arterioles were observed and recorded by a digital microscope, and transit time of each fluid and a luminal diameter of arterioles before and after injection were measured.

Results

The result from arterioles diameters of pre- and post-injection (0.049±0.016mm vs. 0.050±0.016mm; P=0.636) indicated that luminal diameters remained unchanged regardless of fluid administration. The transit time of 25°C saline was significantly shorter than 25°C dextran (3.19±0.68sec vs. 6.15±1.19sec; P<0.0001). Although the result showed no significance, the transit time of 40°C saline with lower viscosity was shorten compared to 25°C saline (3.1±0.43sec vs. 3.65±0.46sec; P=0.088).

Conclusions

Compared to 25°C dextran (viscosity of 4.991mPa·s) having the same viscosity as 37°C whole blood, 25°C saline (viscosity of 1.012mPa·s) caused increasing to double the intravascular flow volume without dilating arterioles. The results strongly suggested that the potential mechanism of SPR was viscosity reduction effect. Combined with FFR which is based on vasodilation-mediated hyperemia, these findings may contribute to clarifying the pathophysiology and especially the microcirculation in coronary artery diseases.

Funding Acknowledgement

Type of funding source: None
Low-density lipoprotein cholesterol goal attainment and treatment patterns in a cohort of >143,000 patients with atherosclerotic cardiovascular disease in Ontario, Canada
Authors: Fairbairn M , Oh P , Goeree R , Rogoza R.M , Packalen M , Pericleous L , Motsepe-Ditshego P , Colgan S , Goodman S.G
Published: November 2020

Background/Introduction

Limited real-world data are available on attainment of low-density lipoprotein cholesterol (LDL-C) treatment goals in patients with atherosclerotic cardiovascular disease (ASCVD) in Canada.

Purpose

A retrospective observational study was conducted to describe types of ASCVD events/procedures, time between events and use of lipid lowering treatment (LLT) in patients who did not achieve LDL-C goal.

Methods

Patients in Ontario ≥65 years with a primary ASCVD event/procedure between 1 Apr 2005 and 31 Mar 2016, treated with an LLT and with index and follow up LDL-C values were identified from claims data at the Institute for Clinical Evaluative Sciences data repository. Patients were assessed over a 1-year follow up period for LDL-C goal attainment (<2.0 mmol/L or 50% reduction from index LDL-C) and analysed by LLT and by index event type.

Results

Overall, 28% of 143,302 patients ≥65 years on LLT failed to attain LDL-C goal at follow up (Figure). The proportion of patients failing to achieve LDL-C goal decreased from 35% to 22% over the 11-year study period. Mean time between index and follow up LDL-C (based on lowest score >2 weeks and up to 1 year after index LDL-C) was 203±97 days. When analysed by low-, moderate- or high-intensity statin, 57%, 30%, and 22% of patients failed to achieve LDL-C goal at follow up, respectively.

Conclusions

In this study, more than 1 in 4 patients with ASCVD in Ontario failed to achieve guideline recommended LDL-C goal despite treatment. In particular, ∼1 in 3 patients with cerebral and peripheral arterial disease were not at goal. An opportunity exists to better manage these high risk ASCVD patients with further statin intensification and additional LLTs

This study made use of de-identified data from the ICES Data Repository, which is managed by the Institute for Clinical Evaluative Sciences with support from its funders and partners: Canada's Strategy for Patient-Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research and the Government of Ontario. The opinions, results and conclusions reported are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen Canada Inc.
Cardiopreventive effects of mitochondrial dynamics modulators in pre-diabetic rats subjected to cardiac ischaemia-reperfusion injury
Authors: Maneechote C , Palee S , Jaiwongkam T , Kerdphoo S , Chattipakorn S.C , Chattipakorn N
Published: November 2020

Background

Chronic exposure to a high-fat diet (HFD) consumption causes alteration of cardiac mitochondrial dynamics and function, leading to the abnormal left ventricular (LV) function. Since excessive mitochondrial fission and reduced mitochondrial fusion are correlated with both obesity and myocardial ischaemia, targeting mitochondrial fission and fusion could be an effective cardioprotective strategy. We previously showed that acute inhibition of mitochondrial fission and promotion of mitochondrial fusion exerted cardioprotection in obese rats. However, the chronic treatment with mitochondrial fission inhibitor (Mdivi-1) and mitochondrial fusion promoter (M1) in pre-diabetic rats subjected to cardiac ischaemia-reperfusion (I/R) injury has never been investigated.

Purpose

We investigated the cardiopreventive effects of chronic Mdivi-1 and M1 treatment in pre-diabetic rats with cardiac I/R injury on infarct size, mitochondrial function, and LV contractility.

Methods

Wistar rats (n=32, male) were fed with HFD for 12 weeks, then randomly divided into: 1) HFV (Vehicle, 0.1% DMSO), 2) HFMdivi1 (Mdivi-1, 1.2 mg/kg), and 3) HFM1 (M1, 2 mg/kg) with intraperitoneal injection. After 2 weeks of drugs administration, all rats underwent 30 min of left anterior descending coronary artery occlusion followed by reperfusion for 120 min. LV function was monitored throughout the experiment. At the end, the heart was removed to determine infarct size and mitochondrial function.

Results

Chronic treatment with Mdivi-1 and M1 similarly showed a decrease in mitochondrial reactive oxygen species and infarct size, leading to an improvement in LV function in HFD rats, as indicated by increased ejection fraction, when compared to HFV rats (Figure).

Conclusion

Mitochondrial fission inhibitor and fusion promoter exerted similar efficacy in protecting pre-diabetic rat hearts against cardiac I/R injury through attenuating mitochondrial dysfunction, reducing infarct size and increasing LV contractility.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The National Science and Technology Development Agency Thailand
Comparison between intracoronary versus intravenous bolus injection of tirofiban on infarct size during primary PCI in patients with acute anterior ST segment elevation myocardial infarction
Authors: Osman M , Yassen I , Elhefny E.H.A.B
Published: November 2020

Background

The latest guidelines considered glycoprotein IIb/IIIa inhibitors (GPI) as a bailout strategy in selected situations in patients presented with acute ST segment elevation myocardial infarction (STEMI) however, did not recommend route of administration over another and did not correlate it to infarct size. Infarct size correlates generally with prognosis following acute myocardial infarction and Reduction in infarct size can boost clinical outcomes and decrease rate of heart failure hospitalization.

Purpose

To evaluate intracoronary vs intravenous use of tirofiban on reduction of infarct size in STEMI treated with primary PCI.

Methods

Between February, 2018, and October, 2019, one hundred patients presented within 6 hours of anterior STEMI undergoing primary PCI after exclusion of (rescue PCI, TIMI flow less than II post PCI, Previous MI, Stent thrombosis, Previous CABG, Significant left main occlusion, Pulmonary edema and Cardiogenic shock).

Group (A): 50 patients who were treated by intracoronary bolus infusion of tirofiban followed by IV maintenance dose infusion of tirofiban.

Group (B): 50 patients who were treated by intravenous bolus infusion of tirofiban followed by IV maintenance dose infusion of tirofiban.

Primary endpoint: Infarct size was assessed 1 month after randomization by SPECT.

Secondary endpoint: Major adverse cardiovascular events (MACE) during hospital stay (cardiac death, MI, stroke or target vessel revascularization), heart failure and bleeding.

Results

Patients randomized to intracoronary tirofiban compared with intravenous tirofiban had a significant decrease in the primary end point of infarct size (mean [SD], 14.46% [7.79%] vs 18.06% [7.83%]; P=0.02). Also associated with lower incidence of heart failure (number [%], 8 [16%] vs 17 [34%]; P=0.037). There were no significant differences in any of the MACE or bleeding between the randomized groups at 30 days.

Conclusions

In patients with anterior STEMI presenting early after symptom onset, intracoronary tirofiban administration when compared to intravenous route during primary PCI resulted in infarction size reduction and lower heart failure incidence mainly driven by enhanced left ventricular systolic function however no distinction between two strategies on MACE or bleeding risk.

Results

Funding Acknowledgement

Type of funding source: None
Incidence and risk factors for major bleeding among patients undergoing percutaneous coronary intervention: findings from the Norwegian coronary stent trial (NORSTENT)
Authors: Samuelsen P , Eggen A.E , Steigen T , Wilsgaard T , Kristensen A , Skogsholm A , Holme E , Van Den Heuvel C , Nordrehaug J.E , Bendz B , Nilsen D.W.T , Bonaa K.H
Published: November 2020

Introduction

Bleeding is a concern after percutaneous coronary intervention (PCI) and subsequent dual antiplatelet therapy (DAPT).

Purpose

We herein report the incidence and risk factors for major bleeding in the Norwegian Coronary Stent Trial (NORSTENT).

Materials and methods

NORSTENT was a randomized, double blind, pragmatic randomized trial among patients with acute coronary syndrome or stable coronary disease undergoing PCI during 2008–11. The patients (N=9,013) were randomized to receive either a drug eluting stent or a bare metal stent, and were treated with at least 9 months of DAPT. The patients were followed for a median of five years, with BARC 3–5 major bleeding as one of the safety endpoints. We estimated cumulative incidence by a competing risks model and risk factors through cause-specific Cox models.

Results

The 12-month cumulative incidence of major bleeding was 2.3%. Independent risk factors for major bleeding were chronic kidney disease (CKD), underweight (<60 kilograms), diabetes mellitus, and advanced age (>80 years). A myocardial infarction (MI) or PCI during follow-up increased the risk of major bleeding (HR = 1.7, 95% CI 1–3-2.2).

Conclusions

The 12-month cumulative incidence of major bleeding in NORSTENT was higher than reported in previous, explanatory trials. This analysis strengthens the role of CKD, advanced age, and underweight as risk factors for major bleeding among patients receiving DAPT after PCI. The presence of diabetes mellitus or recurrent MI among patients is furthermore a signal of increased bleeding risk.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Northern Norway Regional Health Authority (Helse Nord RHF)
Efficacy of fractional flow reserve-guided percutaneous coronary intervention for patients with angina pectoris: a network meta-analysis
Authors: Shinohara H , Kodera S , Kiyosue A , Ando J , Morita H , Komuro I
Published: November 2020

Background

Evaluation of hemodynamic parameters, such as fractional flow reserve (FFR), is recommended before percutaneous coronary intervention (PCI) for patients with angina pectoris (AP). However, the advantage of FFR-guided PCI has not been fully established. A network meta-analysis (NMA) synthesizes the results of studies on multiple competing interventions. Moreover, no NMA has evaluated randomized controlled trials for AP to compare FFR-guided PCI and other treatments. To clarify whether FFR-guided PCI improves the prognosis in patients with AP, we performed this study.

Methods

Multiple databases were searched for studies published from 2000 to 2018. The search terms were based on Medical Subject Headings and keywords including “angioplasty”, “coronary artery bypass”, “percutaneous coronary intervention”, “coronary disease”, and “randomized controlled trial”. And an NMA was performed to compare outcomes of FFR-guided PCI, non-FFR-guided PCI, coronary artery bypass grafting (CABG), and medical treatment (MT) for AP based on estimated odds ratios (ORs). The primary endpoint was all-cause mortality. The secondary endpoints were the occurrence of MI. Treatments were ranked by the surface under the cumulative ranking curve.

Results

The study included 18,093 patients from 15 randomized controlled trials. No evidence of inconsistency was observed among the studies. The NMA showed that the all-cause mortality of FFR-guided PCI was not significantly different from that of the other treatment groups (CABG: OR, 1.1; 95% confidence interval [CI], 0.67–1.7; non-FFR-guided PCI: OR, 0.85; 95% CI, 0.53–1.4; and MT: OR, 0.83; 95% CI, 0.52–1.3). The NMA for myocardial infarction, which included 13,548 patients from 11 randomized controlled trials, showed that FFR-guided PCI tended to reduce the occurrence of myocardial infarction compared with MT (OR, 0.60; 95% CI, 0.36–1.0). According to the surface under the cumulative ranking curve, CABG was the best treatment, followed by FFR-guided PCI, non-FFR-guided PCI, and MT.

Conclusions

FFR-guided PCI for AP showed no significant prognostic improvement compared with non-FFR-guided PCI, CABG, and MT. CABG was the best treatment for AP, followed by FFR-guided PCI, non-FFR-guided PCI, and MT.

Network plot and interval plot

Funding Acknowledgement

Type of funding source: None
Impact of complete revascularization for acute myocardial infarction with multivessel coronary artery disease in diabetes mellitus patients
Authors: Kang J , Park K.W , Rhee T.M , Lee H.S , Ki Y.J , Han J.K , Yang H.M , Kang H.J , Koo B.K , Kim H.S
Published: November 2020

Background

Clinical benefits of complete revascularization (CR) in acute myocardial infarction (AMI) patients are unclear. Moreover, the benefit of CR is unknown in AMI with Diabetes Mellitus (DM) patient.

Objectives

We sought to compare prognosis of CR and incomplete revascularization (IR) in patients with AMI and multivessel disease, according to the presence of DM.

Methods

A total of 2,150 AMI patients with multivessel coronary artery disease were analyzed. CR was defined based on angiographic image. The primary endpoints of this study was patient oriented composite outcome (POCO) defined as a composite of all cause death, any myocardial infarction, and any revascularization within 3 years.

Results

Overall, 3-year POCO were significantly lower in patients receiving angiographic CR (985 patients, 45.8%) compared with IR (1165 patients, 54.2%). When divided into subgroups according to the presence of DM, CR reduced 3-year clinical outcomes in the non-DM group but not in the DM group (POCO: 11.7% vs. 23.2%, p<0.001, any revascularization: 7.2% vs. 10.8%, p=0.024 in the non-DM group, POCO: 24.3% vs. 27.8%, p=0.295, any revascularization: 13.3% vs. 11.3%, p=0.448 in the DM group, for CR vs. IR). Multivariate analysis showed that CR significantly reduced 3-year POCO (HR 0.52, 95% CI 0.38–0.71) only in the non-DM group.

Conclusion

In AMI patients with multivessel disease, CR may be ineffective in improving clinical outcomes in patients with DM.

Funding Acknowledgement

Type of funding source: None