bluuebunny/crossref_metadata_2025 huggingface dataset:
Sex differences in acute coronary syndromes: a never ending same old story or sign for improvement
Authors: Radovanovic D , Schoenenberger-Berzins R , Roffi M , Pedrazzini G , Eberli F , Erne P , Rickli H
Published: October 2022

Introduction

We previously described sex differences in baseline characteristics, interventional therapy and mortality in patients admitted for acute coronary syndromes (ASC) in Swiss hospitals and enrolled in the AMIS Plus registry between 1997 and 2006 (1). This present analysis aimed to reassess whether anything changed over the last 15 years.

Method

All AMIS Plus patients enrolled between 2007 and 2021 were included. Baseline characteristics, therapy and outcome were analysed according to sex and age groups. Multivariate analyses were performed to assess independent predictors of in-hospital mortality.

Results

Among 42,471 patients, 10,825 (25.5%) were women. Women were still older (71.6±12.6y vs. 64.2±12.6y for men), had more comorbidities (Charlson Comorbidity Index>1: 26.5% vs. 21.7%), were less likely to receive drug therapy (e.g., P2Y12 inhibitors 83.3% vs. 89.2% or statins 73.0% vs. 78.5%) and underwent percutaneous coronary intervention (PCI) less frequently (OR 0.77; 95% CI 0.73–0.83). These findings paralleled our observations for the period 1997–2006. However, the increase in PCI use over the years, particularly in women, led to a marked decrease in differences between men and women with respect to revascularization, from 16.6% in 2006 down to 2.0% in 2020. Unadjusted in-hospital mortality was higher in women (OR 1.55; 95% CI 1.41–1.70), but this significance disappeared after adjustment for baseline differences (OR 1.07; (95% CI 0.96–1.20)). However, in women under the age of 50 years, crude mortality (3.1% versus 1.6%) was significantly higher than in same-aged men; adjusted OR 1.78 (95% CI 0.99–3.20).

Conclusions

Sex differences in the baseline characteristics of ACS patients and the use of evidence-based drugs persisted but the sex gap in PCI access slowly but surely diminished. Female sex per se was not an independent predictor of in-hospital mortality in the overall population but it showed a strong trend among patients younger than 50 years of age.

Funding Acknowledgement

Type of funding sources: None.
Associations between DAPT score and long-term mortality post PCI
Authors: Tan M , Dinh D , Gayed D , Liang D , Brennan A , Duffy S , Clark D , Ajani A , Oqueli E , Roberts L , Reid C , Freeman M , Chandrasekhar J
Published: October 2022

Introduction

The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score <2) from DAPT beyond 1-year post PCI. There is no study which looked at the DAPT score and long term outcomes post PCI in Australia.

Purpose

We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines.

Methods

We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or <2. Long-term mortality was assessed from National Death Index linkage. The primary endpoint was long-term mortality examined using survival analysis. Secondary endpoints included 30-day ischaemic outcomes and in-hospital major bleeding.

Results

Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p<0.001 for all).

Conclusion

A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies.

Funding Acknowledgement

Type of funding sources: None.
Effects of intravenous lysine acetylsalicylate versus oral aspirin on platelet responsiveness in patients with ST-segment elevation myocardial infarction
Authors: Vivas D , Jimenez J , Martin-Asenjo R , Bernardo E , Ortega-Pozzi A , Gomez-Polo J C , Moreno G , Vilacosta I , Perez-Villacastin J , Fernandez-Ortiz A
Published: October 2022

Background

Prasugrel and ticagrelor, new P2Y12-ADP receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events in patients with an acute coronary syndrome. However, evidence is lacked about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared to oral aspirin on prasugrel inhibited platelets in patients with an ST-segment elevation myocardial infarction (STEMI).

Methods

This is a prospective, randomized, multicenter, open platelet function study conducted. STEMI patients were randomly assigned to receive a loading dose (LD) of intravenous LA 450mg plus oral ticagrelor 180mg, or LD of aspirin 300mg plus ticagrelor 180mg orally. Platelet function was evaluated at baseline, 30 min, 1h, and 24h using multiple electrode aggregometry and vasodilator-stimulated phosphoprotein phosphorylation (VASP). The primary endpoint of the study is the inhibition of platelet aggregation after arachidonic acid (AA) 1.5mM at 30 min. Secondary endopoints are the inhibition of platelet aggregation after AA baseline and at 1h, and 24h, and measurement of aggregation with other platelet test (ADP, collagen and VASP).

Results

A total of 32 STEMI patients were randomized (16 LA, 16 aspirin). The inhibition of platelet aggregation after AA 1.5 mM at 30 min was greater in subjects treated with LA compared with aspirin: 166 vs. 412 respectively, p=0.001. This differential effect was observed at 1 hour (p=0.01), but not at 24 hours. Subjects treated with LA presented less variability and faster and greater inhibition of platelet aggregation with AA compared with aspirin (Figure 1).

Conclusions

The administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin on ticagrelor inhibited platelets in patients with STEMI. Loading dose of LA achieves an earlier platelet inhibition, and with less variability than aspirin.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the CTU-SCReN (Clinical Trial Unit – Spanish Clinical Research Network) from San Carlos University Hospital (Madrid, Spain), financed by the ISCII (Project PI16/00191)
Positive predictive value of the crusade score for bleeding events in patients with acute coronary syndromes on dual antiplatelet therapy with acetylsalicylic acid and clopidogrel
Authors: Monteiro J J , Chemba J M , Carvalho P , Carvalho C , Bernardo M , Moreira I , Ribeiro H , Moreira J I
Published: October 2022

Introduction

Crusade score (CS) quantifies intrahospital major bleeding (IHMB) risk in patients admitted with acute coronary syndrome (ACS). Hemorrhagic risk after ACS increases with age, although, it's not considered in score estimation.

Purpose

Evaluate CS ability to predict IHBM risk according to different patient ages (higher or lower than 75 years) admitted with ACS diagnosis and submitted to double antiagreggation therapy with acetylsalicylic acid and Clopidogrel.

Methods

A retrospective study based on the Portuguese National Registry of ACS, including patients (pts) hospitalized with ACS and treated with double antiagreggation therapy with acetylsalicylic acid (AAS) and clopidogrel between October 2010 and January 2021 (n=8401). Were excluded patients submitted to coronary artery bypass grafting, with ticagrelor or prasugrel switch to clopidogrel during hospitalization.

Patients were divided into two groups according to their age (above or below 75 years) and then subdivided in 5 groups according to CS category of IHBM risk estimation: very low (CS ≤20, 3,1% risk predicted by the score), low (21 ≤ CS≤30, 5,5%), moderate (31 ≤ CS≤40, 8,6%), high (41 ≤ CS≤50, 11,9%) and very high risk (CS≥51, 19,5%). Then, the incidence of IHMB observed in each group during hospitalization (mean 5 days) was compared to the IHBM risk predicted by the CS.

Results

The IHMB rate was 1.78%, significantly lower than predicted by the Crusade score (7.1%, p<0.001). Bleeding rates in each group of patients (above or below 75 years and according to CS calculation are depicted in Figure 1. CS revealed more power to predict IHMB in the prespecified group of patients older than 75 years, than in the group of patients younger than 75 years (see Figure 2).

Conclusion

As shown in different literature, crusade score overestimate bleeding risk after ACS compared to real-life cohorts. Despite the same trend observed in our cohort of patients, in this retrospective study, CS revealed more power to predict IHMB in the prespecified group of patients older than 75 years, than in the group of patients younger than 75 years in patients submitted to double antiaggregation with AAS and clopidogrel.

Funding Acknowledgement

Type of funding sources: None.
Perioperative risk and benefit of antiplatelet therapy in patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention with second-generation drug-eluting stents
Authors: Lee S , Kim C , Kim H , Ahn S G , Cho S , Park J K , Moon J Y , Won H , Suh Y , Cho J R , Cho Y H , Oh S J , Lee B K , Kime J S
Published: October 2022

Background

Antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) after percutaneous coronary intervention (PCI) is still on debate due to its opposite effects which are to prevent from cardiovascular events and to cause bleeding. There is no apparent consensus on how to determine perioperative APT strategy within 1 year after PCI. Therefore, we investigated the risk and benefit of APT in NCS within 1 year after PCI.

Methods

Patients undergoing NCS after PCI with second-generation drug-eluting stents are retrospectively included from multicenter cohort of 8 medical centers in Korea. Perioperative clinical event within 30 days after NCS was recorded. Net adverse clinical event (NACE) including all cause death, major adverse cardiac event (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and major bleeding were evaluated. To overcome bias, propensity score covariate adjustment was performed using logistic regression analysis to generate propensity scores for patients of both APT strategies.

Results

Total 1130 patients (median age 69 years, female 30.5%) undergoing NCS within 1 year after PCI were eligible in the cohort. Study population included 55.1% patients suffered from ACS and 22.5% underwent complex PCI. NCS included 45.8% intermediate-to-high risk surgery and 10.7% urgent or emergent surgery. APT was continued during NCS in 62.7% of the patients. More patients continued DAPT (48% vs. 32%, p<0.001) among the patients who underwent NCS within 6 months after PCI than those who underwent NCS after 6 months. There were 49 NACE (4.3%), 16 MACE (1.4%) and 23 major bleeding events (2.0%), respectively. Continuing APT was associated with a lower risk of NACE (Adjusted hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.27–0.89; p=0.020)) and MACE (Adjusted HR, 0.35; 95 CI, 0.12–0.96; p=0.042). Subgroup analysis showed a tendency that continuing APT might be favorable than discontinuing APT in terms of MACE in patients who were diagnosed with ACS, underwent complex PCI, or underwent NCS within 6 months after PCI.

Conclusions

About two thirds of the patients were continuing APT during NCS. Our findings may support a careful consideration of APT continuation for some of the patients who are undergoing NCS within 1 year after PCI.

Funding Acknowledgement

Type of funding sources: None.
Mitral annulus strain by 3D echo reveals regional annular dysfunction in Barlow's disease
Authors: Aguilera H M , Persson R M , Haaverstad R , Skallerud B , Prot V , Urheim S
Published: October 2022

Background

Barlow's disease (BD) provides both diagnostic and therapeutic challenges. Annular dilation is typically seen in BD, however, data on regional deformation is lacking.

Purpose

We hypothesized that mitral annulus dilates non-homogenously during ventricular systole in BD. A method to calculate annular regional strain was developed and applied in a subset of BD patients and healthy controls.

Methods

Ten patients with BD and late systolic mitral regurgitation and nine healthy controls were studied. For each subject, the mitral annulus was segmented throughout the cardiac cycle using 3D echocardiography. Twelve evenly distributed geometrical points were annotated along the annular perimeter, enabling the creation of periodic degree-3 spline curves parameterized by arc length at each discrete time-frame. The motion of the mitral annulus was then acquired by assuming that heterogeneity in annular strain is small and finding the point-wise map that minimized the total displacement between the consecutive curves. Then, the end-diastolic annular curve was divided into 200 evenly distributed points around the annular perimeter, and the point-wise mapping was implemented to create a continuous movement of the discretized annulus throughout the cycle. Annular strain was then calculated for each individual line segment. The method presented herein is validated by comparing the strain between sonomicrometric crystals in pigs and the method described above. The timescale was normalized from ED (end-diastole) to mitral valve opening for each individual. The regional strains of the annulus were calculated with the ED configuration as reference.

Results

Hemodynamic data are presented in Table 1. In BD annulus area increased from 16.6±3.2 to 21.7±4.2 cm2 at end-diastole and peak systole, respectively (p<0.001). In controls, annulus area at end-diastole and end-systole was 9.6±2.2 cm2 and 9.2±1.8 cm2, respectively (NS). Figure 1 demonstrates non-homogenous regional strain at peak systole, with the most severe deformation in the posteromedial region. In healthy controls, peak systolic strain was similar in all segments.

Conclusions

In the present study, we have applied a novel non-invasive method to demonstrate non-homogenous deformation of the mitral annulus in Barlow patients. On average, the most severe deformation was seen in the posteromedial region. This finding may reveal further insight into the mechanisms of late systolic mitral regurgitation in BD as well as the design of annuloplasty in the future.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Trond Mohn Foundation
Ticagrelor or prasugrel in patients with acute coronary syndrome and prior myocardial infarction
Authors: Scalamogna M , Lahu S , Ndrepepa G , Mayer K , Gewalt S , Menichelli M , Bernlochner I , Joner M , Xhepa E , Kufner S , Laugwitz K L , Neumann F J , Schunkert H , Kastrati A , Cassese S
Published: October 2022

Objectives

To investigate the efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome (ACS) and prior myocardial infarction (MI).

Background

The efficacy and safety of ticagrelor versus prasugrel in ACS patients with prior MI remains unstudied.

Methods

Patients with ACS scheduled for an invasive strategy and randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial with available information concerning prior MI were included in the present analysis. The primary endpoint was the composite of all-cause death, myocardial infarction, or stroke; the secondary endpoint was Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding. Endpoints were assessed 12 months after randomization.

Results

A total of 4,015 patients were included in this analysis (prior MI= 631 patients; no prior MI = 3,384 patients). As compared to patients without prior MI, the primary endpoint occurred more frequently in patients with prior MI (12.6% vs. 7.2%; hazard ratio [HR] = 1.78, 95% confidence interval [CI] 1.38–2.29; p= <0.001) without significant difference in terms of secondary endpoint between groups (5.8% vs. 5.7%; HR=1.02 [0.71–1.45]; p=0.921). Patients with prior MI randomized to ticagrelor versus prasugrel displayed higher risk for primary (HR=1.62 [1.03–2.55]) but not secondary endpoint (HR=1.28 [0.56–2.91]). Patients without prior MI randomized to ticagrelor or prasugrel displayed no significant difference in terms of primary (HR=1.28 [0.99–1.65]) or secondary endpoints (HR=1.13 [0.82–1.55]). There was no treatment assignment-by-prior MI status interaction with respect to the primary (p for interaction = 0.373) and the secondary (p for interaction= 0.786) endpoints.

Conclusions

Patients with ACS and prior MI are at higher risk for recurrent ischemic but not bleeding events. The history of MI does not affect the relative efficacy and safety of ticagrelor versus prasugrel in patients with ACS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research (DZHK)Deutsches Herzzentrum München
Abbreviated dual antiplatelet therapy after PCI in patients at high bleeding risk: a collaborative meta-analysis of randomized trials
Authors: Costa F , Montalto C , Bhatt D , Steg P G , Feres F , Cao D , Micari A , Stone G , Mehran R , Valgimigli M
Published: October 2022

Aims

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. We appraised an abbreviated compared with a more prolonged DAPT regimen in this setting by using the totality of existing evidence.

Methods and results

A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated (i.e., short [3 months] or very-short [1 month]) with standard (≥6 months) DAPT in HBR patients. Six trials with 8,409 patients were included. Major or clinically relevant non-major bleeding (MCRB) and major adverse cardiovascular events (MACE) were the co-primary safety and efficacy endpoints. MCRB was lower with abbreviated compared to standard DAPT (risk ratio [RR] 0.63, 95% CI 0.41–0.95; I2=74%). No difference in terms of MACE (RR 1.03, 95% CI 0.89–1.20; I2=0%) all-cause death, cardiovascular death, stent thrombosis or myocardial infarction were observed. Network meta-analysis showed short or very-short DAPT to have the highest probability to prevent bleeding in HBR patients.

Conclusion

Abbreviated DAPT reduced bleeding without apparent increase in ischemic events in HBR patients undergoing PCI. Three-month or one-month DAPT courses appeared similarly effective to optimize the trade-off for ischemia and bleeding in this population.

Funding Acknowledgement

Type of funding sources: None.
Procedural and long-term outcomes of stent post dilatation during primary percutaneous coronary interventions
Authors: El Amrawy A , Zaki A , Sadaka M , Wagdy S
Published: October 2022

Background

The role of stent post dilatation (SPD) during primary percutaneous intervention (PPCI) is controversial. Currently there are no clear guidelines or consensus regarding when to perform SPD and it is left to the operator decision.

Purpose

The aim of this study was to evaluate the procedural and long terms outcomes of SPD during PPCI.

Methods

We collected retrospectively data of 614 STEMI patients who presented to two tertiary centers during one year period. All patients underwent PPCI. We excluded patients with cardiogenic shock, prior CABG, severe LM disease. Patients were divided into two groups according to SPD procedure. Group 1: who had SPD included 424 patients (69.1%). Group 2: no SPD included 190 patients (30.9%). Both groups were well matched with regard to demographic data and lesion characteristics. Procedural outcomes and clinical outcomes at one year were collected.

Results

SPD patients had significantly higher incidence of no reflow during the procedure (33.7% in group 1 vs. 21.6% in group 2, P=0.026), but the final TIMI flow was similar between two groups. Also, there was no significant difference between two groups regarding other procedural outcomes as dissection, perforation, or cardiac death. After one year follow up SPD patients had significantly higher incidence of reinfarction (5.6% of group 1 vs. 1.5% in group 2, P=0.03) and significantly more target vessel revascularization (TVR) (16.7% in group 1 vs. 4.7% in group 2 P<0.001). There was no significant difference between the two groups regarding the incidence cerebrovascular stroke (CVS), heart failure or cardiac death.

Conclusion

Our study shows that SPD during PPCI is associated with an increased risk of procedural no reflow and increased risk of reinfarction as well as need for TVR after 1 year follow up. Finally, SPD did not improve clinical outcomes after 1 year follow up. Nonetheless, large-scale randomized trials are required to establish the role of SPD during PPCI.

Funding Acknowledgement

Type of funding sources: None.
Intracoronary Imaging in left main stent percutaneous coronary intervention has a clear survival benefit particularly in more complex patients
Authors: Khan K , Abdulelah Z , Murad S , Hsu Y U K A I , Leung J , Shahid F , Khan S
Published: October 2022

Background

Left Main Stem Disease (LMS) is prognostically important coronary artery disease that is managed either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI). Use of intracoronary imaging (ICI) modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve outcomes with PCI revascularization.

The primary objective of this study was to evaluate the impact of ICI on outcomes following LMS PCI.

Methods

Retrospective observation study of 498 (5.1% of all PCI cases) patients who had undergone LMS PCI at our tertiary primary PCI centre hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records. Follow-up was also obtained through linkage with the Office of National Statistics.

Results

The mean age at the time of enrolment was 70.7±11.5 years. Majority of the patients were male 351 (70.5%). 353 (70.9%) of cases had acute coronary syndrome (ACS) presentation while the remainder were elective procedures. Mean follow-up duration was 3.75±3.06 years. Survival calculated by Kaplan-Meier was 70%. 87 patients (17.5%) deceased during first year of enrolment. 344 (69.1%) patients had ICI, with IVUS in 316 (63.5%) and OCT in 28 (5.6%) patients. IVUS comprised 91.9% of ICI procedures. Protected LMS (OR 0.175, 95% CI: 0.037–0.833, P-value=0.029) and the use of left ventricular mechanical support device (OR 0.324, 95% CI: 0.122–0.859, P-value=0.024) were associated with decreased odds of undergoing an ICI.

Patients undergoing ICI had significantly better survival compared to those without ICI (HR: 0.54, P<0.001). Moreover, OCT showed significantly better survival compared with IVUS (HR: 0.181, P=0.017). Use of ICI was associated with better survival in patients who had Rotablation (HR: 0.455, 95% CI: 0.232–0.892, P=0.022), ACS (HR: 0.523, 95% CI: 0.383–0.714, P<0.001) or comorbidities of diabetes and stroke (HR: 0.551, 95% CI: 0.337–0.807, P=0.002).

Conclusion

ICI in LMS PCI has a significant survival benefit in our dataset. This is especially the case in patients presenting with ACS, those with comorbidities of Diabetes mellitus and stroke and those undergoing rotablation.

Funding Acknowledgement

Type of funding sources: None.
Atrial functional mitral regurgitation during exercise is associated with impaired longitudinal left ventricular systolic function and annular dilation: an exercise echocardiographic study
Authors: De Schutter S , Van Damme E , Van Hout G , Pype L L , Claeys M J , Van De Heyning C M
Published: October 2022

Background

Atrial functional mitral regurgitation (AF-MR) has recently been recognized as a new disease entity in patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). This MR subtype is characterised by structurally normal leaflets, normal left ventricular size and mitral annular dilation. It is hypothesised that AF-MR results from mitral annulus area/leaflet area imbalance caused by annular dilation and impaired mitral annular dynamics, but precise mechanisms and determinants remain unclear. Also, very little is known about the influence of exercise.

Purpose

To investigate the impact of exercise on the severity of AF-MR and to identify its determinants by exercise echocardiography.

Methods

Patients with HFpEF and/or AF were scheduled for a symptom-limited exercise echocardiography. We assessed mitral annular dimensions (antero-lateral diameter), AF-MR severity (multi-integrative approach), and parameters of systolic and diastolic function at rest and during maximal exercise.

Results

47 patients with HFpEF (n=39) and/or AF (n=22) were enrolled. As compared to rest, we noticed an increase in AF-MR severity of ≥1 grade in 20 patients (43%) during maximal exercise. Patients with progression of AF-MR at maximal exercise had significantly less progression of tissue Doppler-derived imaging peak systolic velocity at the medial mitral annulus (Med S') compared to patients without AF-MR progression (+1.1±1.7 cm/s vs +2.7±1.9 cm/s; p-value 0.005). This was accompanied by a greater systolic mitral annular diameter at maximal exercise (+0,5±4,2 mm), while the systolic annular diameter generally decreased in patients without AF-MR progression (−1,6±3,9 mm). Furthermore, patients with ≥moderate AF-MR during exercise (n=19; 40%) had lower Med S' (6.9±1.7 cm/s vs 8.9±2.6 cm/s; p-value 0.013), a greater systolic mitral annular diameter (26.0±4.3 mm vs 23.2±4.3 mm; p-value 0.042), reduced TAPSE (19.4±3.7 mm vs 24.3±3.2 mm; p-value 0.001) and a greater prevalence of ≥moderate TR (93% vs 45%; p-value 0.047) compared to patients with no or mild MR during exercise. No significant correlation was found between AF-MR severity at exercise and blood pressures, LVEF or parameters of diastolic function.

Conclusions

AF-MR is a dynamic condition which may worsen during exercise. Deterioration of AF-MR at maximal exercise was associated with impaired longitudinal left ventricular contractile reserve and greater mitral annular dimensions. As impaired left ventricular longitudinal function may influence systolic mitral annular dynamics, this attributes to the hypothesis that AF-MR results from mitral annulus area/leaflet area imbalance caused by both annular dilation and impaired mitral annular dynamics.

Funding Acknowledgement

Type of funding sources: None.
Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data
Authors: Chew N W S , Ng C H , Xiao J L , Chan K H , Loh P H , Low A , Lee C H , Tan H C , Chan M Y
Published: October 2022

Background and aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p<0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p<0.001; HR: 1.856, 1.380–2.497, p<0.001 respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Funding Acknowledgement

Type of funding sources: None.
Early detection of inflammation-prone STEMI patients using the CRP Troponin Test (CTT)
Authors: Brzezinski R Y , Melloul A , Berliner S , Goldiner I , Stark M , Rogowski O , Banai S , Shenhar-Tsarfaty S , Shacham Y
Published: October 2022

Background

Elevated concentrations of C-reactive protein (CRP) early after acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI using the CRP Troponin test (CTT) and determine their short- and long-term outcome.

Material and methods

We retrospectively examined 1,186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 hours apart), all within the first 48 hours of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality.

Results

Patients with high CRP concentrations (above 90th percentile, >33mg/L) had higher 30 day- and all-cause mortality rates regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs 2.7%, p<0.01. Furthermore, patients with both high CRP and high Troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p<0.01. These patients also had the highest all-cause mortality rates after a median follow up of 4.5 years compared to the rest of the cohort; 42.9% vs 12.7%, p<0.01 (Figure 1).

Conclusions

In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CRP Troponin-test (CTT) as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-IL-1β agents.

Funding Acknowledgement

Type of funding sources: None.
COVID-19 pandemic affects STEMI numbers and in-hospital mortality: results of a nationwide analysis in Germany
Authors: Oettinger V , Heidenreich A , Zehender M , Bode C , Stachon P , Kaier K , Von Zur Muehlen C
Published: October 2022

Background

The COVID-19 pandemic led to extensive restrictions in Germany in 2020, including the postponement of elective interventions. We examined the impact on ST-elevation myocardial infarction (STEMI) as an acute and non-postponable disease.

Methods

Using German national records, all STEMI between 2017 and 2020 were identified. Using the number of STEMI cases between 2017 and 2019, we created a forecast for 2020 using poisson regression models and compared it with the observed number of STEMI in 2020.

Results

From 2017 to 2020, 248,062 patients were treated for a STEMI in Germany. Mean age was 65.21 years and 28.36% were female. When comparing forecasted and observed STEMI in 2020, a correlation can be seen: Noticeably fewer STEMI were treated in those weeks respectively months with an increasing COVID-19 hospitalization rate (monthly percentage decrease in STEMI: March −14.85% April −13.39%, November −11.92%, December −22.95%). At the same time, the risk-adjusted in-hospital mortality increased significantly at the peaks of the first and second waves (monthly in-hospital mortality: April RR=1.11 [95% CI 1.02; 1.21], November 1.13 [1.04; 1.24], December 1.16 [1.06; 1.27]).

Conclusion

The COVID-19 pandemic led to a noticeable decrease in the number of STEMI interventions in Germany at the peaks of the first and second waves in 2020, corresponding to an increase in COVID-19 hospitalizations. At the same time, in-hospital mortality after STEMI increased significantly in these phases.

Funding Acknowledgement

Type of funding sources: None.
A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction
Authors: Gaspardone C , Romagnolo D , Fasolino A , Falasconi G , Beneduce A , Fiore G , Fortunato F , Galdieri C , Savastano S , Posteraro G A , Agricola E , Oppizzi M , Gaspardone A , Pappone C , Montorfano M
Published: October 2022

Background

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI).

Purpose

The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance and reliability in real-world clinical practice.

Methods

We analyzed ECG and angiographic data from 408 consecutive STEMI patients submitted to primary percutaneous coronary intervention, dividing the overall population into derivation (306 patients) and validation (102 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance and reliability in the validation cohort.

Results

In the derivation cohort, the algorithm correctly predicted the IRA in 91% of cases and both the IRA and its occlusion level (proximal vs. mid-distal) in 73% of cases. When applied to the validation cohort, the algorithm resulted in 90% and 69% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (p=0.026 vs. best cardiologist and p<0.001 vs.best emergency medicine doctor). The algorithm showed almost perfect reliability (Cohen's kappa 0.86) between a cardiologist and an ambulance paramedic.

Conclusions

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Funding Acknowledgement

Type of funding sources: None.
Early changes in myocardial stunning and biomarkers after ST-elevation myocardial infarction compared to the takotsubo syndrome
Authors: Jha S , Poller A , Shekka Espinosa A , Thorleifsson S , Zeijlon R , Hussain S , Bobbio E , Martinsson A , Pirazzi C , Rydenstam Mellberg T , Elmahdy A , Kakaei Y , Kalani M , Omerovic E , Redfors B
Published: October 2022

Background

Takotsubo syndrome (TS) and ST-elevation myocardial infarction (STEMI) are both characterized by sudden cessation of myocardial contractions (myocardial stunning) as well as elevation of cardiac troponins and B-type natriuretic peptides (BNP). Whereas STEMI results in variable degrees of necrosis and persistent cardiac dysfunction, TS results in little to any necrosis and full recovery of cardiac function. No “head-to-head” comparison of the temporal resolution of myocardial stunning and serum biomarkers in STEMI versus takotsubo has been done.

Purpose

To compare the time course of the recovery of cardiac function and serum biomarkers over the acute and subacute phases of takotsubo and STEMI, with patients with STEMI further subdivided into anterior and non-anterior STEMI.

Method

The Stunning In Takotsubo and Acute Myocardial Infarction (STAMI) study is a prospective, multi-center study that enrolls patients with TS or STEMI without known pre-existing cardiac dysfunction. Echocardiography, laboratory testing (including troponins and NT-proBNP), and ECG are acquired within 4 hours after acute coronary angiography and at 24±6, 48±12, 72±12 hours and 7±1, 14±2, and 30±2 days. The primary endpoint is the proportion of reversible myocardial akinesia resolved after 72 hours (Figure 1), as determined by echocardiography. Secondary endpoints include troponin-I, troponin-T, and NT-proBNP.

Results

Preliminary results from 155 patients with STEMI (78 anterior STEMI and 77 non-anterior STEMI) and 32 patients with TS are presented in Figure 1. Mean (SD) age was similar for patients with takotsubo (67±14), anterior STEMI (68±11), and non-anterior STEMI (68±10). All 3 groups showed substantial recovery of cardiac function over the course of the study, with the most pronounced recovery of cardiac function in TS. Compared to both STEMI groups, the TS group also had lower troponin-I to troponin-T ratio, and higher NT-proBNP (Figure 2). The proportion of reversible akinesia that had recovered at 72 hours was similar in patients with TS, anterior STEMI and non-anterior STEMI (p=0.8414).

Conclusion

The STAMI study will provide the comprehensive assessment of cardiac function and serum biomarker profile of patients with takotsubo and STEMI over the early course of the disease. Preliminary data from the study suggest that early myocardial functional recovery is more substantial but follows a similar time-course in takotsubo and STEMI. The differences in the magnitude of troponin elevation after takotsubo versus STEMI were more pronounced for troponin-I than T.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ERC - European Research Council
Gender differences on 10-year outcomes following ST-segment elevation myocardial infarction: a subgroup analysis from the examination extend trial
Authors: Gabani R , Spione F , Arevalos V , Ortega L , Brugaletta S , Grima Sopesens N , Sabate M , Gomez Lara J , Jimenez M , Jimenez Quevedo P
Published: October 2022

Background

Short-term outcomes of women following STEMI are worse than men, with specifically a higher mortality rate. However, it is unknown if gender may play a role in long-term outcomes. We aim to assess whether very long-term outcomes following STEMI treatment may be still influenced by gender.

Methods

The EXAMINATION-EXTEND study was an investigator-driven 10-year follow-up of the EXAMINATION trial, which randomly 1:1 assigned 1498 STEMI patients to receive either EES (n=751) or bare metal stent (BMS) (n=747). This is a sub-analysis of this study, according to gender. Primary endpoint was the composite patient-oriented endpoint (POCE, all-cause death, any myocardial infarction, or any revascularization) at 10-year. Secondary endpoints were individual components of the primary endpoint. All the endpoints were adjusted for age.

Results

Out of 1498 STEMI patient, 254 (17%) were women. Overall, women were older, with more arterial hypertension and less smoking history than men. At 10-year, no difference was observed between women and men in terms of POCE (40.6% vs. 34.2%; adjusted hazard ratio (HR) 95% confidence interval [CI]1.14 [0.91–1.42], p=0.259). There was a trend toward a higher all-cause death in women vs. men (27.6%, vs. 19.4%; adjusted HR [95% CI] 1.30 [0.99–1.71], p=0.063), without difference in cardiac death. No differences were present in terms of the other endpoints.

Conclusions

At very long-term follow-up there were no differences in the combined patient-oriented endpoint between women and men, with a trend towards a higher all-cause death in women. These findings may suggest that very long-term healthcare attention following STEMI in women should go beyond reduction of cardiac events.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Public hospital
Time to coronary angiography in a real-life cohort of NSTEACS patients: are guidelines too optimistic?
Authors: Arbas Redondo E , Jurado Roman A , Jimenez Valero S , Galeote Garcia G , Moreno Gomez R , Tebar Marquez D , Poveda Pinedo I D , Rivero Santana B , Garcia Escobar A , Vera Vera S , Armada Romero E , Rey Blas J R , Garcia Garcia A , Gonzalez Davia R , Lopez De Sa E
Published: October 2022

Background and purpose

In 2020, new recommendations against routine use of pretreatment in NSTEACS have been established, especially if an early invasive strategy (within first 24 hours) is planned [1]. These recommendations are mainly based on evidence from clinical trials that have included short intervals of time to coronary angiography (CA) [2,3]. However, this timing seems hard to achieve in daily clinical practice, above all, when high-risk NSTEACS patients are now advised for an early invasive strategy. We aimed to assess the feasibility of these recommendations in real-world clinical practice.

Methods

We performed a retrospective analysis of a real-life cohort of NSTEACS patients referred to CA in a tertiary-level hospital between January and December 2020.

Results

We analysed 347 consecutive NSTEACS patients referred to CA (21.7% unstable angina, 78.3% NSTEMI). Percutaneous coronary intervention was performed in 60.5% and the radial or cubital artery access were exclusively used in 86.7%. Median time from hospital admission to CA was 39.4 hours (IQR: 20.7–67.0 hours) and 31.4% patients had the CA performed within first 24 hours (Figure 1). Main differences regarding clinical and risk-related variables among those patients who underwent CA before and after first 24 hours are shown in Table 1. More patients with NSTEMI and dynamic changes in ECG tended to be referred earlier to CA, while those with impaired renal function were more likely to receive a delayed strategy. There were 282 patients (82.7%) who met the high-risk criteria from current ESC guidelines on NSTEACS (GRACE risk score >140, ST transient elevation or depression in ECG, raise of cardiac troponin levels above the 99th percentile of the upper reference limit, cardiogenic shock or cardiac arrest at presentation); of whom, only 95 (33.7%) were referred to CA in the first 24 hours. No differences were found according to patients being admitted to PCI or non-PCI centres (32.1% vs. 30.9% had the CA performed within first 24 hours, p=0.81) or receiving pretreatment with a P2Y12 receptor inhibitor or not (31.7% vs. 31.0% of the CA ≤24 hours group; p=0.87).

Conclusion

Evidence from this real-life registry shows that median time from admission to CA is far from current recommendations for high-risk NSTEACS patients. This might represent an important limitation at the moment of translating guidelines to daily clinical practice, especially those who presume patients to have a CA performed within first 24 hours.

Funding Acknowledgement

Type of funding sources: None.
Incidence and impact of totally occluded culprit coronary artery in patients with non-ST segment elevation myocardial infarction acute coronary syndrome
Authors: El Amrawy A , El Zawawy T , Loutfi M , Naguib A , Wagdy S
Published: October 2022

Background

Significance of totally occluded culprit coronary artery in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI) is underestimated.

Purpose

The aim of this study was to evaluate the incidence and impact of totally occluded culprit artery on in-hospital and 6 months follow-up outcomes of NSTEMI acute coronary syndrome (ACS) patients.

Methods

We collected retrospectively data of 500 NSTEMI patients who presented to our hospital from June 2016 to June 2017. All patients underwent PCI within 72 h of presentation. We excluded patients with cardiogenic shock, prior CABG, and STEMI. Patients were divided into two groups according to pre-procedural culprit vessel thrombolysis in myocardial infarction (TIMI) flow. Group 1, TIMI flow 0 total coronary occlusion, included 112 patients (22.4%). Group 2, TIMI flow 1–3 non-total occlusion, included 388 patients (77.6%).

Results

Group 1 patients had significantly higher incidence of smoking (p=0.01), significantly higher level of cardiac enzymes (p<0.001), significantly more collaterals (p<0.001), and significantly more LCX and RCA as the culprit vessel (p<0.01), while group 2 patients had significantly higher incidence of diabetes (p=0.02) and significantly more LAD as the culprit vessel. There were no significant differences between the two groups regarding the major adverse cardiac and cerebrovascular events (MACCE) in-hospital (5.3% in totally occluded group vs. 1% in non-totally occluded group, p=0.07), but group 1 patients had significantly higher incidence of in-hospital arrhythmia (8.9% in group 1 vs. 1% in group 2, p=0.007). After 6 months follow-up, there were no significant differences regarding MACCE between the 2 groups after 6 months follow-up (5.4% in group 1 vs. 4.6% of group 2, P=0.24).

Conclusion

22.4% of NSTEMI patients have a totally occluded culprit artery. The presence of an occluded culprit artery did not significantly affect the clinical outcomes of NSTEMI patients either in-hospital or after 6 months follow-up but was associated with significantly higher incidence of in-hospital arrhythmia.

Funding Acknowledgement

Type of funding sources: None.
Prognostic factors of patients with myocardial infarction with nonobstructive coronary artery disease: a seven-year longitudinal follow-up
Authors: Tsaban G , Barret O , Peles I , Abramowitz Y , Shmueli H , Cafri C , Zahger D , Koifman E
Published: October 2022

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a common condition associated with major adverse events (MAE). Unlike obstructive coronary artery disease (OCAD), data regarding the prognosis of MINOCA are scarce.

Methods

We conducted a retrospective study among consecutive patients with MINOCA in a large tertiary medical center in Israel between the years 2005–2018. We assessed parameters associated with MAE, defined as all-cause mortality or recurrent MI. Patients with probable alternative cause for myocardial injury, as stress-induced cardiomyopathy and myocarditis, were excluded.

Results

Among 36,501 admitted with AMI during the study period, 1,544 patients (4.2%) had MINOCA. The mean age was 61±13, and 710 (46%) were females. At a median follow-up of 7 years, the MAE rate was 17%, as 153 (9.9%) died, and 117 (7.5%) had recurrent MI. ST-elevation MI at presentation and older age were associated with increased 30-day MAE. In multivariate models, independent factors associated with MAE were female gender (HR=0.58; 95% CI 0.43–0.76), age (HR=1.04; 95% CI 1.03–1.05), left ventricular ejection fraction (LVEF) <40% (HR=2.68; 95% CI 1.74–4.12), increased serum-creatinine (HR=1.11; 95% CI 1.02–1.21), higher hemoglobin (HR=0.81; 95% CI 0.76–0.88), and documented sinus rhythm (HR=0.58; 95% CI 0.38–0.86).

Conclusion

MINOCA carries an increased risk for long-term MAE. Among MINOCA patients older age, LVEF <40%, and increased serum-creatinine are associated with increased MAE risk, while female gender, higher hemoglobin, and sinus rhythm are associated with lower MAE risk.

Funding Acknowledgement

Type of funding sources: None.