bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic role of inflammatory status in type 2 myocardial infarction
Authors: Sara Amicone S A , Daniele Cavallo D C , Claudio Asta C A , Mariachiara Ciarlantini M C , Leonardo Bavuso L B , Lisa Canton L C , Damiano Fedele D F , Francesca Bodega F B , Giuseppe Pastore G P , Francesco Pio Tattilo F P T , Luca Bergamaschi L B , Andrea Rinaldi A R , Francesco Angeli F A , Pasquale Paolisso P P , Carmine Pizzi C P
Published: October 2024

Background

there is a wealth of evidence on the importance of inflammatory status in destabilization of chronic artery plaques that led to acute myocardial infarction. However, its role in the setting of type 2 myocardial infarction (T2MI) is not yet specifically known.

Purpose

We investigated prognostic role of inflammatory parameters in T2MI.

Methods

We consecutively enrolled 461 T2MI patients from January 2017 to June 2021. T2MI was defined according to the fourth Universal Definition of Myocardial Infarction. We divided the overall population in patients who experience major cardiovascular events (MACE), n=166, and in those who do not (n=277). Receiver operating characteristic (ROC) curve analysis were used to assess the diagnostic accuracy of various inflammatory parameters for predict MACE occurrence during long term follow-up. We divided patients into two groups (high and low inflammatory burden) based on the value associated with the highest Youen index. Cox proportional hazards regression models were constructed to estimate the independent role of these parameters in predict MACE.

Results

We found that patients who experienced MACE had a higher level of inflammatory parameters, in particular hs-CRP (2.21±3.7 vs 1.48 ±3.5, p<0.001) and platelet-to-neutrophil ratio (3.72 ±1.52 vs 3.7±1.43, p=0.02). Using ROC analysis, the area under the curve (AUC) of hs-CRP was the largest among all inflammatory parameters and the optimal threshold, according to Youden’s index, was found to be 1.2 mg/dL. MACE-free survival curves, comparing groups with low hs-CRP (< 1.2 mg/dL) and high hs-CRP (≥ 1.2 mg/dL), showed that high hs-CRP was associated with a worse prognosis (p<0.001). At Cox regression models, hs-CRP value ≥1.2 mg/dL was independently associated with MACE (p=0.01) together with diabetes (p=0.006), chronic obstructive pulmonary disease (p=0.006), previous stroke (p=0.001) and older age (p<0.001).

Conclusion

T2MI patients who experienced MACE exhibited higher levels of inflammatory parameters. Patients with hs-CRP levels ≥1.2 mg/dL had a worse prognosis, independently predicting MACE. These findings underscore the potential utility of hs-CRP as a prognostic biomarker in risk-stratifying patients with T2MI and highlight the importance of addressing inflammatory status in optimizing patient management and improving outcomes.
Predictors of microvascular spasm by spasm provocation testing in patients having angina with no obstructive coronary arteries
Authors: Mineo T , Usui E , Kanaji Y , Hada M , Nagamine T , Ueno H , Nogami K , Setoguchi M , Tahara T , Yonetsu T , Sasano T , Kakuta T
Published: October 2024

Background

Microvascular dysfunction in patients having angina with no obstructive coronary arteries (ANOCA) has been recognized to be associated with poor prognosis, while microvascular spasm (MVS) has not been fully studied due to its diagnostic challenge.

Purpose

We aimed to explore clinical and coronary physiological characteristics of MVS.

Methods

We retrospectively studied patients with ANOCA who underwent spasm provocation test (SPT) with intracoronary acetylcholine administration followed by coronary physiological assessment. Epicardial spasm and MVS were diagnosed in accordance with the latest guideline. Physiological indices such as coronary flow reserve (CFR), index of microcirculatory resistance (IMR) and microvascular resistance reserve (MRR) were assessed by bolus thermodilution method using pressure temperature wire in LAD and RCA.

Results

In a total of 141 patients, 40 (28.4%) patients were diagnosed as epicardial spasm and 22 (15.6%) were diagnosed as MVS according to the diagnostic criteria of the latest guideline. Women was more frequent (63.9% vs 27.3%, P=0.002) and IMR of LAD was significantly higher (34.80 vs 22.95, P=0.005) in patients with versus without MVS. In addition, hypertension tended to be frequent (81.8% vs 60.5%, P=0.089) in patients with MVS. In a multivariable logistic regression analysis, women (odds ratio 5.64 [OR], 95% CI 1.90 – 16.7, P=0.0018) and IMR of LAD (OR 1.02, 95% CI 1.00 – 1.05, P=0.029) were independently associated with the diagnosis of MVS. On the other hand, no clinical characteristics and physiological parameter were significantly associated with epicardial spasm.

In a comparison between microvascular and epicardial spasm, women (OR 8.30, 95%CI 2.23 – 30.9, P=0.0016) and IMR of LAD (OR 1.04, 95%CI 1.00 – 1.08, P=0.0462) were still significantly more frequent in MVS patients in multivariable analysis.

Conclusion

Women and higher IMR of LAD were significantly frequent in patients with versus without MVS, and hypertension tended to be frequent in MVS patients.
Percutaneous revascularization in late-presenting STEMI with absence of viability: effects on left ventricular remodeling and scar
Authors: Valente B P , Coelho B P A , Pinto I M F , Senra T , Junior J R T P , Delamain J H H D , Cervone A C C , Junior J R C , Souto M J S , Naranjo G C S , Sanches F B , Santos B V , Queiroz G S , Valente O P , Farsky P S
Published: October 2024

Introduction

In patients with ST-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should be conducted within 12 hours of symptom onset. The potential benefits attributable to late reperfusion in STEMI fall under the "open artery hypothesis" where the stunned peri-infarction zone after revascularization would restore blood supply and contractility.

Purpose

To estimate the differences on the LV ejection fraction (LVEF), indexed LV end-systolic volume (iLVESV) and scar in patients with STEMI without viabilitity randomized to optimal medical therapy (OMT) alone or OMT and a late percutaneous coronary intervention (PCI) performed between 24 hours and 30 days after the event.

Methods

Patients with non-reperfused STEMI were evaluated from September 2021 to June 2022 at a tertiary cardiology hospital. The patients underwent Cardiac Magnetic Resonance (CMR) to assess myocardial viability and were classified as non-viable if they had only 1 wall segment with less than fifty percent thickness of the affected wall with late gadolinium enhancement. The patients were randomized to PCI or OMT alone. CMR was repeated at 6 months to evaluate LVEF, iLVESV and fibrosis. This summary presents a planned partial analysis of the 6-month results (N=51). Descriptive statistics analysis included central and dispersion estimators, or absolute and relative frequencies. To explore the differences between groups and time, Mann-Whitney and Wilcoxon tests were run, and results were given as point-estimates and confidence intervals at 95% (95% CI). A significance level of 5% was adopted for inferential analysis.

Results

51 patients (60±11 years, 71% male) were included in the analysis. Of this total, 24 were randomized to PCI + OMT, and 27 to isolated OMT. The groups showed balanced distribution regarding clinical characteristics and initial CMR parameters (LVEF, iLVESV, and fibrosis). The difference in LVEF at the end of 6 months between the OMT and PCI groups was 2.07%, favoring the OMT group; however, this difference was not significant (p= 0.677, 95% CI: -5 to 10). Between the groups, the difference at the end of 6 months in iLVESV was -6.82 ml/m², also without statistical significance (p= 0.858, 95% CI: -19 to 11). There was a significant reduction in the amount of fibrosis in both PCI group with -14.68g (p= 0.011) and in the OMT group with -12.57g (p= 0.009). Detailed results are presented in Table 1.

Conclusion

Despite a significant reduction in fibrosis in both groups, there was no superiority observed in late PCI compared to isolated OMT in reducing reverse remodeling and fibrosis in patients with non-viable STEMI when compared to isolated OMT.Remodeling changes.
The distribution and mass index of epicardial adipose tissue were correlated with microvascular obstruction formation in patients with ST-segment elevation myocardial infarction
Authors: Zhao J X , Li Y , Mu D , Kang L N , Xu B
Published: October 2024

Introduction

Epicardial adipose tissue (EAT), refers to a metabolically active fat depot between the visceral pericardium and the outer margin of the myocardium. EAT has gradually emerged as a novel target for risk stratification of coronary artery disease due to its distinctive location and multifaceted metabolic properties. Microvascular obstruction (MVO) after primary percutaneous coronary intervention (pPCI) is identified as an independent risk factor for poor prognosis in patients with acute myocardial infarction. However, the clinical implications of EAT in MVO formation in patients with ST-segment elevation myocardial infarction (STEMI) remain unclear. Recently, cardiac magnetic resonance (CMR) has emerged as the gold standard technique to detect the extent of MVO and evaluate EAT parameters.

Purpose

This study aimed to evaluate the correlation between EAT accumulation and MVO occurrence detected by CMR in STEMI patients.

Methods

A total of 129 STEMI patients who underwent pPCI successfully were enrolled. Clinical characteristics including demographic characteristics, cardiovascular risk factors, laboratory data and angiographic parameters were recorded from each patient by 1 trained physician. All patients underwent CMR within 1 week following pPCI to evaluate infarct size, MVO volume and EAT distribution. All CMR data were transferred to Q-MASS MR 8.1 imaging system (Medis, Leiden, The Netherlands) and interpreted twice by 2 expert radiologists who were blinded to the angiographic and clinical data of patients.

Results

Compared to STEMI patients without MVO, STEMI patients with MVO presented with higher peak troponin T levels, increase of neutrophil lymphocyte ratio (NLR) and C-reactive protein (CRP), larger infarct size and compromised left ventricular ejection fraction. Total EAT volume, EAT mass index, left atrioventricular EAT volume, left atrioventricular EAT mass index and thickness of EAT in the left atrioventricular groove were unanimously associated with the occurrence of MVO. The left atrioventricular EAT mass index in STEMI patients with MVO were significantly larger than that in STEMI patients without MVO (24.72±5.049 g/m2 vs 18.63±3.670 g/m2, P<0.001). Multivariate logistic regression analysis demonstrated that NLR, peak troponin T levels and left atrioventricular EAT mass index were independent predictors of MVO. LV EAT mass index showed a robust and independent relationship with MVO formation and a cutoff value >21.5192 g/m2 predicted the presence of MVO with a sensitivity and specificity of 79.5% and 80.4%, respectively.

Conclusions

Left atrioventricular EAT mass index is an independent predictor of MVO. Measurement of EAT using CMR could be used for risk stratification and might be a promising target in developing new therapies to reduce myocardial reperfusion injury in patients with STEMI.
Sex differences in cardiovascular-related hospital readmissions, adverse events and interventions within 1 year after ST-elevation myocardial infarction
Authors: Foster-Witassek F , Roffi M , Iglesias J , Wenzl F , Loosli J , Pedrazzini G , Rickli H , Radovanovic D
Published: October 2024

Introduction

Reducing cardiovascular (CV)-related hospital readmissions as well as adverse events following ST- elevation myocardial infarction (STEMI) is a critical goal to improve outcomes as well as quality of life and reduce healthcare costs. We aimed to study the rates of CV-related readmissions, adverse events and interventions after STEMI in women and men.

Methods

We included STEMI patients from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry, who underwent percutaneous coronary intervention (PCI) between 2013 and 2022 and participated in a telephone-based follow-up (FU) interview 1-year after hospital admission. Patients were asked if they had hospital readmissions (if yes: planned/emergency/both) during FU for any CV reason, if they suffered a reinfarction or stroke and if they had any or several of the following interventions: PCI, coronary artery bypass graft, pacemaker and/or defibrillator implantation. These self-reported data were analysed using descriptive statistics and logistic regression models were used to study the relationship between patient characteristics and hospital readmissions.

Results

Of 4388 PCI-treated STEMI patients contacted for FU, 275 (6.3%) were unreachable, 118 (2.7%) died, and 223 (5.1%) had no data on readmissions; therefore 3772 patients (78.4% men, 21.6% women) were analysed. Women were older (mean (SD) age at event: 68.4 (12.0) vs. 62.5 (11.5) years) while the Charlson Comorbidity Index (CCI) was similar (CCI>1: 14.0% vs. 12.1%, n.s.). The mean rate of patients readmitted for CV reasons was 22.1%; 20.4% for women and 22.6% for men (p=0.198). Overall, 8.8% had at least one emergency and 13.9% at least one planned readmission. The occurrence of a planned readmission was significantly lower in women (11.1% vs. 14.7%, p=0.008). Patients with a readmission had during the index hospitalisation higher rates of in-hospital complications (18% vs. 14%), heart failure (NYHA III+IV) (2.2% vs. 0.8%), diabetes (18% vs. 14%) and peripheral arterial disease (3.9% vs. 2.5%). A multivariable adjusted model that included these factors together with age and sex identified heart failure (OR: 2.5, CI 1.34-4.66, p=0.004) and in-hospital complications (OR:1.4, CI 1.12-1.70, p=0.003) as independent predictors of hospital readmission.

The rates of the analysed adverse events and interventions were similar between sexes except that women had less often a PCI during the FU period (13.2% vs. 16.6%, p=0.026).

Conclusion

Over the last 10 years, on average 1 in 5 patients had at least one CV-related readmission within 1 year after PCI-treated STEMI, while no overall sex-difference was found. Heart failure and in-hospital complications were independent predictors of readmission. Women had less often planned hospital readmissions and additional PCIs.
Prognostic impact of composite lipid indices in patients with acute coronary syndrome undergoing percutaneous coronary intervention
Authors: Khalaji A , Behnoush A H , Rafati A , Pasebani Y , Arzhangzadeh A , Mahmoodi T , Shamshiri Khamene S , Mohammadkhawajah I , Mehrani M , Vasheghani-Farahani A , Masoudkabir F , Hernandez A V , Hosseini K
Published: October 2024

Background

Composite lipid indices have been reported to have associations with several cardiovascular diseases and their negative adverse events. Among these, there are four novel indices that can be easily calculated, namely, triglyceride-glucose index (TyG, calculated from fasting plasma glucose [FPG] and triglyceride [TG]), lipid accumulation product (LAP, calculated from waist circumference [WC] and TG), visceral adiposity index (VAI, calculated from WC, TG, body mass index [BMI], and high-density lipoprotein [HDL]), and atherogenic index of plasma (AIP, calculated from TG and HDL). Herein, we aimed to investigate the impact of these indices on the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

Methods

All the patients with ACS who underwent PCI at our institution during the 2015-2022 period were included in the analyses. Patients were divided based on each of the TyG, VAI, LAP, and AIP indices quartiles (Q). The median follow-up was 378 days and the outcome assessed was MACCE composed of all-cause mortality, myocardial infarction, stroke, target vessel revascularization, target lesion revascularization, and coronary artery bypass grafting surgery.

Results

There was a total of 13,682 patients with ACS undergoing PCI with a mean age of 62.67 ± 11 years and 72.61% male predominance. Regarding the TyG index, patients in Q4 had a higher incidence of MACCE, compared to those in Q1 (adjusted HR [aHR] 1.271, 95% CI 1.067 – 1.513], p-value < 0.01). While in the crude model, patients in Q2, Q3, and Q4 of LAP had significantly higher rates of MACCE, compared to Q1, this association was not observed in the age- and sex-adjusted model and fully-adjusted model. Similarly, there was no difference among the quartiles of VAI and AIP regarding the incidence of MACCE. Kaplan-Meier curves also show that there were significant differences among TyG and LAP quartiles (p-value = 0.0049 and p-value = 0.035, respectively).

Conclusion

As our findings suggest, patients with higher TyG levels, as a surrogate marker of insulin resistance, had a higher incidence of MACCE. LAP could also play an important role in the incidence of adverse events after PCI. These novel lipid indices could help clinicians in determining the risks of patients with ACS undergoing PCI in order to provide better care to them.Risk of MACCE in different quartilesKaplan Meier Curves for risk of MACCE
The activation of cardiac sympathetic nervous system in the non-culprit lesion is a strong prognostic predictor in patients with acute myocardial infarction
Authors: Kondo T , Watanabe T , Yamada T , Morita T , Kawasaki M , Kikuchi A , Kawai T , Nishimoto Y , Seo M , Nakamura J , Fujita T , Taniichi M , Chang Y , Fukunami M
Published: October 2024

Background

The activation of cardiac sympathetic nervous system is associated with poor prognosis in patients with acute myocardial infarction (AMI). However, it remains to be determined whether regional assessment of cardiac sympathetic nerve activity (CSNA) in the culprit and non-culprit lesion of the cardiac MIBG SPECT imaging could have prognostic value in patients with AMI.

Purpose

The purpose of this study is to investigate the prognostic impact of regional CSNA in patients with AMI.

Methods

We prospectively enrolled 122 patients with AMI who visited our emergency department and underwent primary percutaneous coronary intervention. The late heart-to-mediastinum ratio (HMR) and washout rate (WR) was calculated to assess CSNA in the whole heart from planar images of in the cardiac MIBG imaging. The MIBG SPECT image parameters were calculated for each coronary artery, and the average WR in the culprit and non-culprit lesion were evaluated to assess the regional status of CSNA in patients with AMI. Abnormal WR in planar image was defined as 34% or more, as previously reported. The cut-off value of late HMR in planar image, WR in the culprit and non-culprit lesions were determined by ROC analysis. The primary endpoint was major adverse cardiac event (MACE) including all cause death, myocardial infarction, hospitalization for heart failure and target lesion revascularization.

Results

During a mean follow-up period of 3.1±1.8 years, 25 of 122 patients underwent MACE. The late HMR (p=0.004), WR in planar image (p=0.002), WR in the culprit lesion (p=0.023), and WR in the non-culprit lesion (p<0.001) were significantly associated with MACE at univariate Cox proportional hazard analysis. The increased WR in the non-culprit lesion (defined as 28.3% or more: AUC 0.697 [0.576-0.817]) was significantly independently associated with MACE (hazard ratio: 4.36 [1.45-13.11], p=0.009) even adjusted by late HMR, WR in planar image or WR in the culprit lesion, while decreased HMR, abnormal WR in planar image and increased WR in the culprit lesion showed no significant association with MACE in the multivariate model with WR in the non-culprit lesion. Kaplan-Meier analysis revealed that patients with increased WR in the non-culprit lesion had significantly higher risk for MACE than those without increased WR (45% vs 11% p<0.001).

Conclusion(s)

The activation of cardiac sympathetic nervous system in the non-culprit lesion is particularly associated with poor prognosis in patients with acute myocardial infarction.MACE risk by WR in non-culprit lesion
Addressing disparities in the long-term mortality of non-ST segment myocardial infarction (NSTEMI) patients according to the presence of diabetes mellitus: a nationwide cohort study
Authors: Cole A , Weight N , Mishra S , Grapsa J , Rutter M , Siudak Z , Moledina S , Khunti K , Mamas M
Published: October 2024

Background

Diabetes mellitus (DM) is an important risk factor for non−ST segment elevation myocardial infarction (NSTEMI). How DM is related to management and longer-term clinical outcomes in contemporary NSTEMI cohorts is not well described.

Methods and Results

We analysed data on 456,376 adults hospitalised with NSTEMI from the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) registry, linked with Office for National Statistics (ONS) death registry. We compared outcomes and quality of care by DM status. People with DM were older (median age 74 vs. 73 years, p<0.001) and more commonly of Asian ethnicity (13% vs. 4%, p< 0.001). Those with DM underwent invasive coronary angiography (59% vs. 63%, p <0.001) or revascularization (PCI or CABG) (38% vs. 40%, p <0.001) less frequently. Mortality risks for people with DM were significantly higher at 30-days (HR: 1.06, CI; 1.04-1.09, p <0.001), 1-year, (HR: 1.17, CI; 1.15-1.18, p <0.001) and 5-years, (HR: 1.25, CI; 1.24-1.26, p <0.001), when compared to people without DM. In people with DM, higher-quality inpatient care, assessed by opportunity-based quality-indicator score category (OBQI; poor, fair, good or excellent), was associated with lower mortality rates (good: HR 0.70, CI 0.67-0.73, P<0.001; excellent: HR 0.59, CI 0.57- 0.62, P<0.001), when compared to people receiving poor quality care. In people with DM, "excellent-care", compared to those receiving poor quality care, was associated with the lowest mortality in diet-treated or insulin-treated subgroups (diet-treated: HR 0.55, CI 0.50-0.61, P<0.001)(insulin-treated: 0.60 CI 0.56-0.64, P<0.001).

Conclusion

People with DM experience wide disparities in inpatient care following NSTEMI. They have a higher risk of long-term mortality compared to people without DM, with some evidence that better quality inpatient care is linked to better survival.
The diagnostic role of myocardial work indices in stable coronary disease - global wasted work as a novel important non-invasive parameter?
Authors: Szigyarto I , Fabian A , Ladanyi Z S , Csernak A , Martincsevics I , Lakatos B , Szilveszter B , Sayour A A , Kovacs A , Edes I F , Merkely B , Olah A
Published: October 2024

Introduction

Although the non-invasive diagnostic tools for stable coronary artery disease (CAD) have developed significantly over the past years, there is no resting parameter available to recognize functionally significant CAD. The role of the novel myocardial work index (myocardial work index - MWI) calculated by the pressure-strain loop created with the help of speckle-tracking analysis and blood pressure measurement in the diagnosis of ischemic heart disease is not yet fully clarified. In our research, we examined the parameters of myocardial work analysis in stable coronary disease patients.

Purpose

Clarification of the diagnostic role of the myocardial work analysis, in patients with stable coronary artery disease.

Methods

In our prospective, single-center study, we examined 13 patients who had at least moderate stenosis (≥50%) in one main coronary branch detected on coronary CTA. A fractional flow reserve (FFR) test was performed for functional coronary assessment. Based on this measurement, we divided our patients into FFRneg (FFR value>0.8) and FFRpos groups. Echocardiography was performed before coronary angiography in all patients. In addition to the standard echocardiographic parameters, global myocardial work index (GWI), global constructive work (GCW) and global wasted work (GWW) were calculated. In the case of the FFRpos group, we performed the above examination both before and after revascularization (2 months).

Results

Our results show that neither the standard parameters (GLS, EF), nor the GWI and GCW showed any difference between the FFRpos and FFRneg groups. However, there was a significant difference regarding GWW (172.3±21.8 FFRneg vs. 258.2±38.4 FFRpos, p=0.048) at baseline. In the case of the FFRpos group, the analysis of our data showed that there was no significant difference in EF, GLS, GWI and GWE parameters before and after revascularization. However, global wasted work (GWW) showed a significant improvement after revascularization (preGWW 258.2±38.4 vs. postGWW 139.5±14.5, p=0.041). NT-proBNP levels were normal in our patient population and we could not detect.

Conclusion

Based on our results, the GWW may be suitable for non-invasive assessment of the functional significance of stable coronary disease, as it showed a significant difference in the case of functionally significant and non-significant stenosis and improved after revascularization in patients with single-vessel CAD.
Prognostic significance of plasma molecular lipid species in coronary artery disease patients: A prospective cohort study
Authors: Veiga-Fernandes Mira J , Meuleman V , Akkerhuis M , Oemrawsingh R , Daemen J , Van Mieghem N M , Serruys P , Van Geuns R J , Laaksonen R , Boersma E , Kardys I
Published: October 2024

Background

Circulating plasma lipids are vital indicators for quantifying coronary artery disease (CAD) risk, yet traditional biomarkers like LDL, HDL, and triglycerides often exhibit limited predictive capacity. Advancements in lipidomics have identified novel molecular constituents with the potential to improve prognostication in CAD patients. However, the prognostic value of lipidomics for long-term mortality has not yet been investigated.

Objective

In our study, which was part of the European Collaborative Project on Inflammation and Vascular Wall Remodeling in Atherosclerosis (ATHEROREMO), we aimed to investigate the predictive value of specific molecular lipid species for long-term mortality.

Methods

We utilized data from the 581 CAD patients enrolled in the ATHEROREMO clinical imaging study, who were admitted for either diagnostic coronary angiography or percutaneous coronary intervention. We measured a series of serum lipid species, comprising ceramides (Cer) and cholesteryl esters (CE), by mass spectrometry-based shotgun lipidomics. Long-term all-cause mortality follow-up was conducted in 2022 via the Civil Registry. We used the Kaplan-Meier method and multivariable Cox-proportional hazards regression (correction for age, sex, cardiac risk factors, statin use, hypercholesterolemia, and angiography indication) to assess survival distributions and associations with all-cause mortality.

Results

Mean age was 61.5 years (IQR: 53.5-61.5), 75% were male. A total of 55% patients were diagnosed with acute coronary syndrome (ACS) and 45% with stable angina pectoris (SAP). During a median follow-up of 11 years (IQR: 10.1-13.4) 179 patients died. Five molecular lipid species (two cholesteryl esters, one ceramide and two ceramide ratios) correlated with mortality (see Table). As an example, Figure 1 demonstrates a clear survival difference between patients with Cer(d18:1/16:0)/Cer(d18:1/24:0) ratio below versus above the median. Findings were consistent for ACS and SAP.

Conclusion

Our study demonstrates the prognostic value of specific cholesteryl esters, ceramides and ceramide ratios for 11-year mortality in patients with CAD. To the best of our knowledge, this is the longest follow-up study so far within this domain.Table.Lipid molecule and Mortality 11-yFig.1 Kaplan Meier Ceramide ratio
Triggers of type 2 myocardial infarction: implications for long-term prognosis
Authors: Marinelli V , Ryabenko K , Cavallo D , Casuso Alvarez M , Suma N , Impellizzeri A , Bodega F , Fedele D , Pastore G , Bergamaschi L , Angeli F , Sansonetti A , Rinaldi A , Paolisso P , Pizzi C
Published: October 2024

Background

Type 2 myocardial infarction (T2MI) is characterized by a mismatch between myocardial oxygen supply and demand, unrelated to acute coronary thrombosis.

This discrepancy arises from triggers, which may or may not be of cardiac origin. Common cardiac triggers include coronary artery spasm, coronary embolism, and arrhythmias, whereas non-cardiac triggers encompass factors such as anemia, hypertension/hypotension, sepsis, renal damage, and respiratory failure. However, identifying these triggers isn't always straightforward.

Aim

Our study aimed to identify, whenever possible, the triggers contributing to the oxygen supply-demand mismatch in T2MI cases, as defined by the Fourth Universal Definition of Myocardial Infarction. Additionally, we sought to explore the correlation between these triggers and patient prognosis.

Methods

We enrolled all consecutive patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) who met the criteria for T2MI and underwent coronary angiography within 72 hours of diagnosis. Patients were categorized into three groups based on the trigger causing T2MI: cardiac, non-cardiac, and unidentified. The primary endpoint was the occurrence of major adverse cardiovascular events (MACEs), including all-cause mortality, new myocardial infarction, hospitalization for heart failure, and ischemic stroke, during long-term follow-up. We estimated MACE-free survival using Kaplan-Meier curves and compared it among the three groups using the log-rank test. Multivariable logistic regression analysis was performed to identify independent predictors of MACE.

Results

The final cohort comprised 598 T2MI patients, with 308 having a cardiac trigger, 147 having a non-cardiac trigger, and 143 with an unidentified trigger. The mean age of the overall population was 69.6±13.1 years, with a median follow-up time of 25 (13-49) months.

Kaplan-Meier curves demonstrated statistically significant differences in MACEs based on the trigger causing T2MI (p<0.001). Specifically, patients with an unidentified trigger exhibited a better prognosis, while those with a non-cardiac trigger had a worse prognosis during long-term follow-up. Multivariable logistic regression analysis confirmed that not having an identified trigger is an independent protective factor for MACEs (HR 0.63, 95% CI 0.45-0.89, p=0.009, unidentified trigger vs cardiac + non-cardiac trigger).

Conclusions

T2MI is prevalent in clinical practice, yet reliable outcome predictors remain elusive. Our findings indicate a relationship between the type of trigger precipitating T2MI and patient prognosis, notably demonstrating that the absence of a specific identifiable trigger is linked to a more favorable long-term outcome. Further studies are needed to better define the prognostic stratification of these patients.MACE-free survival Kaplan Meier
An ensemble machine learning approach for predicting heart failure risk in acute coronary syndrome patients: heartguardai
Authors: Petretto G , Porcheddu T , Isgender M , Merella P , Talanas G , Casu G , Navarese E P , Bilotta F
Published: October 2024

Background

Heart failure (HF) constitutes a major post-event morbidity in patients experiencing Acute Coronary Syndrome (ACS), underscoring the imperative for precise risk stratification methodologies. Traditional prognostic models, although beneficial, are limited by their reliance on a narrow scope of variables, thereby overlooking the comprehensive analytical potential afforded by extensive clinical datasets.

Aims

To develop "HeartGuardAI," an ensemble machine learning model that predicts HF risk in ACS patients. By incorporating a wide array of variables including ejection fraction (EF), glomerular filtration rate (GFR), body mas index(BMI), male sex, this model seeks to offer a more practical tool for clinical decision-making.

Methods

We queried ACTION-ACS a large-scale multicenter database of 3335 patients at 10-year follow-up. We employed a feature selection process informed by Random Forest Classifier to identify the most predictive variables. An ensemble model combining the strengths of Random Forest and Gradient Boosting methodologies was then developed. The model's predictive performance was validated through Stratified K-Fold cross-validation, focusing on Area Under the Curve (AUC) and confidence intervals to assess its efficacy. The model's predictive performance was validated through Stratified K-Fold cross-validation, focusing on Area Under the Curve (AUC) and confidence intervals to assess its efficacy.

Results

Demonstrating a mean AUC of 0.76 ± 0.036, "HeartGuardAI" showed a high capability to predict HF risk in post-ACS patients and emphasizes the significance of incorporating multifactorial clinical assessments

Conclusions

HF risk can be predicted by a handy tool developed with advanced machine learning methods. Future studies are needed to prospectively validate this algorithm.Graphic 1Graphic 2
Prognostic implications of N-terminal pro-brain natriuretic peptide in patients with Non-ST segment elevation myocardial infarction
Authors: Kim C , Lee S H , Lee J M
Published: October 2024

Background

Limited data exist regarding prognostic implications of N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) in patients with non-ST segment elevation myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI).

Objectives

The current study sought to evaluate the prognostic implications of NT-proBNP in patients with NSTEMI who underwent PCI.

Methods

Among a total of 13,104 patients from a nationwide, multicenter, and prospective registry of the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH), a total of 3,083 patients with NSTEMI who underwent PCI were selected. The selected patients were classified according to the initial NT-proBNP value (cut-off value of NT-proBNP, 700 pg/ml). Primary endpoint was major adverse cardiovascular events (MACE) at 3 years, a composite of all-cause death, recurrent myocardial infarction (MI), unplanned repeat revascularization, and admission for heart failure.

Results

Among the study population, 1,813 patients (58.8%) were in the low NT-proBNP group (<700 pg/ml) and 1,270 patients (41.2%) were in the high NT-proBNP group (≥700 pg/ml). The high NT-proBNP group showed significantly higher risk of MACE than the low NT-proBNP group (29.5% vs 12.3%; adjusted hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.39-2.07; P<0.001), mainly driven by higher risk of cardiac death or admission for heart failure (15.6% vs. 2.2%; adjusted HR, 2.98; 95% CI, 2.03-4.40; P<0.001). These results were consistent after confounder adjustment by propensity score matching (HR, 1.56; 95% CI, 1.21-2.02; P=0.001) and inverse probability weighting analysis (HR, 1.54; 95% CI, 1.19-2.00; P=0.001).

Conclusion

In patients with NSTEMI who underwent PCI, elevated initial NT-proBNP level was associated with higher risk of MACE at 3 years, mainly driven by the higher risk of cardiac death or admission for heart failure. The current results suggest that the initial NT-proBNP level may have a clinically significant prognostic value in NSTEMI patients undergoing PCI.
Artificial intelligence-guided screening of under-recognized cardiomyopathies adapted for point-of-care echocardiography
Authors: Oikonomou E K , Holste G , Coppi A , Mcnamara R L , Nadkarni G N , Krumholz H M , Wang Z , Miller E J , Khera R
Published: October 2024

Background

Point-of-care ultrasonography (POCUS) enables access to cardiac imaging directly at the bedside but is limited by brief acquisition, variation in acquisition quality, and lack of advanced protocols.

Purpose

To develop and validate deep learning models for detecting underdiagnosed cardiomyopathies on cardiac POCUS, leveraging a novel acquisition quality-adapted modeling strategy.

Methods

To develop the models, we identified transthoracic echocardiograms (TTEs) of patients across five hospitals in a large U.S. health system with transthyretin amyloid cardiomyopathy (ATTR-CM, confirmed by Tc99m-pyrophosphate imaging), hypertrophic cardiomyopathy (HCM, confirmed by cardiac magnetic resonance), and random controls from the same period enriched for the presence of severe AS. In a sample of 290,245 TTE videos, we used novel augmentation approaches and a customized loss function to weigh image and view quality to train a multi-label, view agnostic video-based convolutional neural network (CNN) to discriminate the presence of ATTR-CM, HCM, and/or AS+ and AS- controls. Models were tested across 3,758 real-world POCUS videos from 1,879 studies in 1,330 independent emergency department (ED) patients from 2011 through 2023 (A).

Results

Our multi-label, view-agnostic classifier demonstrated state-of-the-art performance in discriminating ATTR-CM (AUROC 0.98 [95%CI: 0.96-0.99]) and HCM (AUROC 0.95 [95% CI: 0.94-0.96]) on standard TTE studies. Automated metrics of anatomical view correctness confirmed significantly lower quality in POCUS vs TTE videos (median view classifier confidence of 0.63 [IQR: 0.44-0.88] vs 0.93 [IQR: 0.69-1.00], p<0.001). When deployed to POCUS videos, our algorithm effectively discriminated ATTR-CM and HCM with AUROC of up to 0.94 (parasternal long-axis (PLAX)), and 0.85 (apical 4 chamber (A4C)) (B), corresponding to positive diagnostic odds ratios of 46.7, and 25.5, respectively. In total, 18/35 (51.4%) of ATTR-CM and 32/57 (41.1%) of HCM patients in the POCUS cohort had a positive AI screen in the year before their eventual confirmatory imaging (C).

Conclusions

We define and validate an AI framework that enables scalable, opportunistic screening of under-diagnosed cardiomyopathies using POCUS.
Relation of plasma neuropeptide-Y with myocardial function and infarct severity in acute ST-elevation myocardial infarction
Authors: Tiller C , Reindl M , Holzknecht M , Lechner I , Oberhollenzer F , Von Der Emde S , Kremser T , Mayr A , Bauer A , Reinstadler S J , Metzler B
Published: October 2024

Background

Acute myocardial infarction is associated with high levels of cardiac sympathetic stimulation, which leads to the release of the co-transmitter neuropeptide-Y (NPY). NPY acts as a potent vasoconstrictor and an association with increased risk for heart failure and microvascular dysfunction after acute ST-elevation myocardial infarction (STEMI) has been suggested.

Purpose

This study aims to comprehensively evaluate the association of plasma NPY with myocardial function and infarct severity, visualized by cardiac magnetic resonance (CMR) imaging, in STEMI patients revascularized by primary percutaneous coronary intervention (PCI).

Methods

In this observational study, we included 260 STEMI patients treated with primary PCI. Plasma NPY concentrations were measured by an immunoassay 24h after PCI from peripheral venous blood samples. Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), infarct size (IS) and microvascular obstruction (MVO) were determined using CMR imaging 4 days and 4 months after PCI.

Results

Median plasma concentrations of NPY were 70 [interquartile range (IQR): 35-115] pg/ml. NPY levels above median were significantly associated with lower LVEF (48% vs. 52%, p=0.004), decreased GLS (-8.8% vs. -12.6%, p<0.001) and larger IS (17% vs. 13%, p=0.041) in the acute phase after infarction as well as in the chronic stage (LVEF: 50% vs. 52%, p=0.030, GLS: -10.5 vs. -12.9, p<0.001, IS: 13% vs. 10%, p=0.011). In addition, NPY levels were significantly related to presence of MVO (58% vs. 52%, p=0.041). Moreover, in multivariable linear regression analysis, NPY remained significantly associated with all investigated CMR parameters (LVEF: p<0.001, GLS: p<0.001, IS: p=0.003, MVO: p=0.042) independent of other established clinical variables including high-sensitivity cardiac troponin T, pre-interventional TIMI flow 0 and left anterior descending artery as culprit lesion location.

Conclusion

High plasma levels of NPY, measured 24h after STEMI, were independently associated with lower LVEF, decreased GLS, larger IS as well as presence of MVO, indicating plasma NPY as a valuable biomarker for optimized risk stratification.
Cardiac myosin-binding protein-C: assessing fragmentation patterns to differentiate between forms of myocardial injury
Authors: Mcgrath S , Alaour B , Marber M
Published: October 2024

Background

Cardiac myosin-binding protein-C (cMyC) is a novel biomarker of myocardial injury. We hypothesize that fragmentation of cMyC differs according to aetiology of myocardial injury. Assessing the fragmentation pattern of the protein may aid diagnosis of these conditions.

Purpose

This work represents an examination of cMyC fragmentation in human serum, and studies its utility in differentiating between forms of myocardial injury.

Methods

Patients who were admitted to a hospital during October-November 2023 with acute myocardial injury were recruited. Acute myocardial injury was defined as a dynamic troponin rise above the 99th centile (Abbott Alinity: cTnI>34ng/L male, cTnI >16ng/L female).

Following collection, samples were left at room temperature for 30 minutes and then centrifuged. Serum was separated for cMyC measurement, frozen in liquid nitrogen and stored at -80 °C. Recruited patients were followed up during their inpatient journey. Their final diagnosis was defined using the 4th universal definition of MI by two cardiologists, with a third cardiologist acting as adjudicator, if required.

The serum samples were analysed using two separate electrochemiluminescence sandwich ELISA assays detecting different portions of cMyC. One assay formulated for total concentration of cMyC using high affinity mouse N-terminal monoclonal antibodies (mAb) targeting epitopes in close proximity (Limit of Detection (LoD) = 9.0ng/L). The other assay uses a N-terminal and a C-terminal mouse mAb which straddle the major proteolytic cleavage site of cMyC. This assay detects the intact (fuller-length) cMyC (LoD= 14.2ng/L). Both assays perform with good sensitivity, low variability and are capable of detecting cMyC at concentrations well below the 99th centile.

Results

11 patient samples were collected with final diagnoses of; type 1 MI (STEMI n=3, NSTEMI n=4), type 4 MI (alcohol septal ablation n=1), acute myocardial injury (myocarditis n=2) and type 2 MI (chest sepsis with known coronary disease n=2).

Figure one details the percentage of intact cMyC relative to total cMyC measured in serum for each patient, and is split into their adjudicated diagnosis. The bars display the median and interquartile range (IQR).

Our findings suggest that the fragmentation pattern of cMyC could help differentiate between forms of myocardial injury. The ratio of intact: total cMyC was higher in the type 2 MI than any other condition. The results did not reach statistical significance (p = 0.06) due to the small sample size.

Conclusions

The fragmentation pattern of cMyC is dependent on the type of myocardial injury and could aid in the differentiation between type 2 MI and other forms of myocardial injury.Figure One
Myocarditis prognostic score: a new risk assessment tool in patients with myocarditis
Authors: Di Lisi D , Madaudo C , Macaione F , Scelfo D , Alaimo C , Gargano M , Marotta A , Giardina O , Novo G
Published: October 2024

Background

Myocarditis is an inflammatory disease of the myocardium with multiple causes and evolutions. The aim of our study was to design a prognostic multiparametric score in patients with myocarditis, to identify those at higher risk of adverse cardiovascular events (AE).

Methods

A prospective study was performed enrolling 98 patients with myocarditis: 72 M, 26 F; median age 27 [IQR 20–40]. Patients were divided into 2 groups: complicated (CM) and uncomplicated myocarditis (UM). Six months after hospital admission, cardiac magnetic resonance (CMR) and cardiological consultation were repeated. AE (death, hospitalization for heart failure, heart transplant, ICD implantation, heart failure development) were evaluated at 6 months and after 3 years.

Results

We found 67 UM and 31 CM. AE were significantly higher in patients with complicated myocarditis. We found a significant correlation between AE and reduced left ventricular ejection fraction (LVEF) at hospital admission, increased GLS, septal LGE at CMR, longer persistence time of increased troponin, LGE extension progression or persistence 6-month CMR. A myocarditis prognostic score was developed on the basis of these parameters. A score ≥ 5 showed higher sensitivity (100%) and specificity (87%) - AUC 1, to identify AE in patients with myocarditis. A score between 3 and 4 showed high sensitivity but low specificity. A score ≤ 2 was associated with low probability of events.

Conclusion

Our study confirms the high probability of AE in patients with CM and it suggests a myocarditis prognostic score to identify patients at higher risk of AE.
Hs-CRP modifies the impact of stress hyperglycemia ratio on long-term outcomes in patients with acute coronary syndrome
Authors: Zhang K , Li J , Li Y , Yan K , Yuan J , Zhao X
Published: October 2024

Background

In recent years, studies have demonstrated the promising predictive value of stress hyperglycemia ratio (SHR) for adverse outcomes in patients with acute coronary syndrome (ACS). Nevertheless, knowledge regarding the effects of inflammation on the risks associated with SHR remains limited. Considering the potential interplay, we hypothesize that the well-recognized biomarker reflecting residual inflammation, high-sensitivity C-reactive protein (hs-CRP), may exert an influence on SHR-related cardiovascular risks.

Purpose

The objective of this study was to investigate the association between hs-CRP level and SHR-related long-term adverse events in ACS patients.

Methods

Among 10,724 consecutive patients who underwent percutaneous intervention treatment throughout the year 2013, 6149 ACS patients were eventually enrolled. SHR was calculated employing the formula: SHR = admission blood glucose (ABG) / [1.59 x HbA1c (%) – 2.59]. Based on their levels of hs-CRP, patients were stratified into two groups, with the cut-off set at 2 mg/L. The primary endpoint was defined as all-cause mortality, and the secondary endpoint was the major adverse cardiac and cerebrovascular events (MACCE), consisting of all-cause death, non-fatal myocardial infarction, coronary revascularization, and ischemic stroke.

Results

238 (3.7%) all-cause mortality and 1275 (20.0%) MACCE occurred during the 5-year follow-up. The average age of the overall cohort was 58.39 ± 10.38 years, and 4723 (76.8%) were male. After adjusting for the potential confounders, multivariable Cox regression revealed a significant correlation between hs-CRP level and SHR for all-cause mortality (P for interaction = 0.009), and there were diverse associations between SHR and long-term risks depending on the levels of hs-CRP: With hs-CRP < 2mg/L, there was no significant risk of all-cause mortality at any SHR quantiles, while the lowest SHR quantile showed a 1.321-fold increased risk of MACCE [Hazard Ratio (HR): 1.321, 95% confidence interval (CI) 1.034-1.688, P = 0.026]. Conversely, with hs-CRP ≥ 2mg/L, significant association was observed between SHR and all-cause mortality (all P < 0.05). Notably, the highest SHR quantile exhibited the greatest risk for both all-cause mortality (HR: 4.030, 95% CI 1.778-9.134, P < 0.001) and MACCE (HR: 1.299, 95% CI 1.010-1.672, P = 0.042).

Conclusions

This large-scale real-world study was the first to report that the pattern of SHR-associated long-term cardiovascular risks in ACS patients was modified by the levels of hs-CRP, suggesting a potential interaction between inflammation and stress hyperglycemia that contributes to poor prognosis. When applying risk stratification, both factors should be comprehensively considered, and patients exhibiting high SHR along with concomitantly elevated hs-CRP may merit more rigorous risk management.Figure 1.Multivariable COX regression