bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical burden of MACE in patients with multivessel disease during the early period following acute myocardial infarction
Authors: Gabriel S , Herepath M , Zhang X , Were J J , Ruzangi J , O'Connell S P
Published: October 2021

Background

Despite numerous interventions that have improved outcomes in acute myocardial infarction (AMI) patients, the first 90 days after AMI remains a high-risk period for recurrent events. Due to higher disease burden and suboptimal outcomes, it is crucial to characterize the clinical burden upon patients with multivessel disease (MVD) and various comorbidities.

Purpose

To describe the post-AMI clinical burden of major adverse cardiovascular events (MACE) in patients with MVD at 30, 90, and 365 days.

Methods

This was a retrospective cohort study (1st January, 2008 to 31st December, 2018) using data from a longitudinal, representative UK population health dataset comprising primary care data from the Clinical Practice Research Datalink (CPRD). This was linked to data from the Hospital Episode Statistics (HES) and Office of National Statistics (ONS) databases to identify patients with a confirmed diagnosis code of MVD. A MACE was defined as any one of non-fatal MI, non-fatal stroke, or cardiovascular death. The prevalence of MACE among post-AMI patients with MVD and the effect of concurrent risk factors was quantified.

Results

403,631 patients with MVD were identified (21.69% of the total study population), nearly one-fifth of whom (n=78,128; 19.35%) experienced an AMI after their first recorded diagnosis of MVD (MVD+). The mean and median age of MVD+ patients was 66 years, and the majority (72.9%) were male. Almost half (48.9%) had a Charlson co-morbidity score of at least 1, and 99.8% had an index of multiple deprivation recorded, distributed evenly across the quintiles. At least one of the composite MACE occurred in 9,533 (12.2%), 11,694 (14.9%), and 15,188 (19.4%) MVD+ patients within 30, 90, and 365 days, respectively. In MVD+ patients with 2 or more additional risk factors (peripheral artery disease [PAD], age >65, prior AMI; w/out comorbid diabetes; n=7,531), the proportion of MACE within 90 days was substantially higher (42.7%). Non-fatal MI was the most common MACE episode in MVD+ patients, occurring in 7,696, (9.8%), 8,924 (11.4%), and 10,673 (13.7%) MVD+ patients at 30, 90, and 365 days, respectively. Within 90 days of AMI, 39.1% of MVD+ patients with 2 or more risk factors experienced non-fatal MI.

Conclusions

MVD patients have a considerable clinically relevant burden of MACE following AMI. The majority of 1-year recurrent events occurred within 90 days of MACE, with 90-day risk almost 3-fold higher in patients with two additional risk factors. For patients with MVD and other risk factors, opportunities remain for treatments that may reduce the risk of recurrent events in the early period following AMI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): CSL Behring
Hospital readmissions and economic burden associated with multivessel disease in the early period following acute myocardial infarction
Authors: Gabriel S , Herepath M , Zhang X , Were J J , Ruzangi J , O'Connell S P
Published: October 2021

Background

There is emerging evidence that particularly high rates of major adverse cardiovascular events (MACE) occur in the 90-day period after acute myocardial infarction (AMI). Post-AMI MACE are associated with additional resource utilization and economic burden for healthcare systems, with multivessel disease (MVD) conferring a 3- to 4-fold increase in risk of recurrent MACE in the first year post AMI vs. single vessel disease. Thus, characterizing the prevalence and outcomes of patients with MVD and various comorbidities is crucial to predict and mitigate clinical risk and associated costs.

Purpose

To describe post-AMI readmissions and economic burden in MVD patients at 30, 90, and 365 days.

Methods

This was a retrospective cohort study (1st January, 2008 to 31st December, 2018). Patients with MVD were identified by a confirmed diagnosis code from a longitudinal, representative UK population health dataset comprising primary care data from the Clinical Practice Research Datalink (CPRD), which was linked to secondary care data from the Hospital Episode Statistics (HES) and Office of National Statistics (ONS) databases. Patients who experienced at least one AMI after their first recorded MVD diagnosis were defined as MVD+. A MACE was defined as any one of non-fatal MI, non-fatal stroke, or cardiovascular death. Readmissions were defined as non-elective admissions with a MACE outcome diagnosis occurring up to 28 days from a previous admission with the same treatment speciality.

Results

The study population included 78,128 MVD+ patients (4.2% of the total patient population). In the MVD+ cohort, 3,753 (4.8%) patients were readmitted with at least one MACE event or other non-elective admission within the cardiovascular specialty: 2,394 (63.8%), 2,562 (68.3%), and 2,830 (75.4%) readmissions occurred within 30, 90, and 365 days, respectively. The mean length of hospital stay per patient, per readmission for MACE within 30, 90, and 365 days was 7.22, 7.46, and 7.74 days, respectively. The mean cost per MACE admission within 90 days of index AMI was £3,926.52. Non-fatal MI was the most common reason for readmission at all timepoints. Percutaneous transluminal balloon angioplasty and saphenous vein graft procedures (coronary artery bypass graft, CABG) were among the most common cardiac procedures in MVD+ patients, at 70,276 (22.7%) and 15,418 (5.0%), respectively.

Conclusions

In patients with MVD who suffer an AMI, there is high resource utilization and cost, particularly in the first 90-days post AMI; therefore, the 90-day post-AMI period represents significant economic costs to healthcare systems.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): CSL Behring
Mortality and major cardiovascular events among patients with multiple myeloma: analysis from a nationwide French medical information database
Authors: Cottin Y , Boulin M , Doisy C , Mounier M , Caillot D , Chretien M L , Bodin A , Herbert J , Bonnotte B , Zeller M , Maynadie M , Fauchier L
Published: October 2021

Background

Cardiovascular disease (CVD) in patients with multiple myeloma (MM) may derive from multiple factors unrelated to the disease (age, diabetes, dyslipidemia, obesity, prior CV diseases), related to the disease and/or related to antimyeloma treatment. Based on a nationwide hospitalization database, we aimed to assess the risk of all-cause death, and CV outcomes in MM patients.

Methods

From 1st January 2013 to 31st December 2013, 3,381,472 adults (age ≥18 years) were hospitalized for any reason in French hospitals and then had at least 5 years of complete follow-up (or suffered death earlier). We identified 15,774 patients diagnosed with known MM at baseline. The outcome analysis (all-cause death, cardiovascular [CV] death, myocardial infarction (MI), ischemic stroke or hospitalization for major bleeding) was performed with follow-up starting at the time of last event. For each patient with MM, a propensity score-matched patient with no MM was selected (1:1) using the one-to-one nearest neighbor method.

Findings

The mean follow-up in the propensity-score-matched population was 3.7±2.3 years, median 5.0, IQR 1.3–5.7 years. During follow-up, matched patients with MM (15 774 patients) had a higher risk of all-death (yearly rate 20.02 vs 11.39%/year) than patients without MM. No difference was observed between MM group and no myeloma group for CV death (2.00 vs 2.02%/year). The rate of MI and stroke was markedly lower in the MM group, respectively for incidence rate, 0.86 vs 0.97%/year and 0.85 vs 1.10%/year. In contrast, MM group had a higher rate of rehospitalization for major bleeding with an incidence rate of 3.61 vs 2.24%/yr and a higher risk of intracranial bleeding (1.03 vs 0.84%/yr). Results were similar in sensitivity analysis limited to patients with recent MM (i.e. diagnosed within the 3 previous months).

Interpretation

From a large nationwide database, we show that although patients with MM are not at higher risk of CV death, they had a higher risk of mortality due to major bleeding and intracranial bleeding. Our findings highlight the key issue of anticoagulation treatment management in patients with MM.

Funding Acknowledgement

Type of funding sources: None.
Long-term validation of the GRACE and PRECISE-DAPT scores in patients with non-ST elevation acute coronary syndrome
Authors: Garcia-Rodeja Arias F , Alvarez Alvarez B , Gonzalez Ferrero T , Abou Jokh Casas C , Otero Garcia O , Martinon Martinez J , Jimenez Ramos V , Garcia Acuna J M , Rigueiro Veloso P , Agra Bermejo R M , Iglesias Alvarez D , Cacho Antonio C , Antunez Muinos P J , Tasende Rey P , Gonzalez Juanatey J R
Published: October 2021

Introduction and objectives

There is insufficient data regarding risk scores validation in patients with diabetes mellitus and non-ST elevation acute coronary syndrome (NSTEACS). We performed a diabetes mellitus-specific analysis of cardiovascular outcomes after NSTEACS using a large contemporary cohort of patients from two tertiary hospitals.

Methods

This work is a retrospective analysis from a prospective registry, that included 7415 consecutive NSTEACS patients from two Spanish Universitary Hospitals between the years 2003 and 2017. We tested the predictive power of the GRACE and PRECISE DAPT score, calculating the area under the ROC curve among with and without diabetes mellitus patients.

Results

Among the study participants, 2124 patients (28.0%) were diabetic. The median follow up was 54,3 months (IQR 24.7–80.0 months). Diabetic patients were more women (30.5% vs 25.7%) and older (70.0±10.8 vs 65.3±13.2 years old); they had higher GRACE (146±36 vs 137±36), PRECISE DAPT (15±7 vs 18±9) and CRUSADE (17±14 vs 30±18) at admission. Early invasive coronary angiography (≤24 hours after admission) was performed more frequently in non-diabetic. We tested the predictive power of the GRACE and PRECISE DAPT risk scores among diabetic and non-diabetic. PRECISE DAPT risk score showed a good predictive power for all-cause mortality, cardiovascular mortality and MACE in diabetic admitted with NSTEACS, without differences compared to non diabetic.

Conclusions

PRECISE DAPT risk score has an appropriate predictive power in diabetic patients admitted with NSTEACS compared to non diabetic NSTEACS. However, GRACE would be predictive worse in non diabetic during long term follow up in a large contemporary registry.

Funding Acknowledgement

Type of funding sources: None.
Long-term outcome of patients with myocardial infraction with nonobstructive coronary arteries
Authors: Barrett O , Edry Nadiv O , Peles I , Abramowitz Y , Cafri C , Rosenstein G , Merkin M , Zahger D , Koifman E
Published: October 2021

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a condition of growing interest and research. We aimed to evaluate the long-term prognosis of MINOCA patients and identify possible risk factors associated with long term mortality in this patient's population.

Methods

We performed a retrospective observational cohort study including all patients aged ≥18 years hospitalized to a large tertiary center between 2005–2018 with a primary diagnosis of acute myocardial infarction (AMI) and non-obstructive lesions with less than <50% stenosis in all coronary arteries. The aim of the study was to assess the long-term mortality and to evaluate factors associated with increased mortality in this population.

Results

MINOCA was diagnosed in 1544 patients during the study period. Mean age of patients was 61±12.3 and 46% were female. Common comorbidities were dyslipidemia (32.6%) and hypertension (21.2%) and 17% had prior PCI. More than third of the patients were treated with statins (37.2%), micropirin (32.7%) and angiotensin converting enzyme (ACE)-inhibitors (30.4%). While short-term prognosis was favorable with only 1.2% mortality at 30-days, 1-year mortality was 3.9% and 19.9% mortality at mean follow-up time of 8.5 years. While many factors were associated with unfavorable long-term outcome in the univariate analysis, only advanced age (HR =1.05, 95% confidence interval (CI) 1.02–1.07; p<0.001) and congestive heart failure (HR=3.53, 95% CI 1.74–7.18; P<0.001) were independently associated with increased mortality risk in the adjusted model.

Conclusions

MINOCA is not an infrequent condition that carries a good short-term outcome, but long-term outcome may be comparable to patients with obstructive coronary disease. Further research should be performed to elucidate the various mechanisms of MINOCA.

Funding Acknowledgement

Type of funding sources: None.
Is it justified to remove the intermediate risk group in the latest European guidelines for NSTEACS?
Authors: Gonzalez Ferrero T , Alvarez Alvarez B , Ave M T , Cordero A , Sampedro F G , Gonzalez Juanatey J
Published: October 2021

Background

Risk stratification in patients with non-ST elevation acute coronary syndrome (NSTEACS), becomes a priority after its diagnosis, due to the fact that it gives us information about prognosis and has crucial implications. The latest guidelines of European Society of Cardiology (ESC) suggest a new proposal of risk stratification dividing patients in three different groups: “low”, “high” and “very high risk”. Thus, they remove the intermediate risk group that defended the previous guidelines (2015).

Purpose

Our aim was to identify an intermediate risk group following the recommendations of the previous guidelines about risk stratification. We believe that the risk stratification in four groups if more accurate that the latest proposed in 2020 in three groups, because the “intermediate risk group” has a different prognosis that the subgroup nowadays considered “low risk”.

Methods

We included a cohort of 7 597 patients with NSTEACS admitted in two different Cardiology departments between 2003 and 2017 with 4,4±2,7 mean years of follow-up. Subsequently, a classification of the patients in four different risk groups was made following the 2015 guidelines and events during follow-up was assigned in the next categories:first adverse major cardiovascular event (MACE),all-cause mortality and cardiovascular mortality.

Results

Stratified analysis brought up that patients included in the intermediate risk group, had a different prognosis to the categories of “low” and “high risk” patients and we obtained the following results:

Mean incidence rate for total mortality measured in cases per 100 person-year [confidence interval (CI 95%)] was 1.96; for “low risk” patients CI95% 1.30–2.95, “intermediate risk” 3.91; (CI95% 3.28–4.57), “high risk” 4.94; CI95% 4.87–5.21 and “very high risk” 8.74; CI95% 7.75- 9.85.

Incidence rate for cardiovascular mortality for “low”, “intermediate”, “high” and “very high” was 1.02; (CI95% 0.58–1.18); 2.64 (CI95% 2.13–3.26); 3.32 (CI95% 3.11–3.55) and 6.71 (CI95% 4.84–7.69), respectively.

Using Cox analysis, the “intermediate risk group” (refference), still achieved statistical significance. Results expressed in hazard ratio demonstrated that:

Conclusion

These findings suggest that the four categories proposal could have better ability for risk stratification in NSTEACS patients and make us doubt about the new three groups classification displayed in the current ESC guidelines, particularly the “intermediate risk” group exclusion that would be reassessed as “low risk”.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): No funding sources.
Relationship between Lactobacillus and prognosis of acute myocardial infarction patients treated by percutaneous coronary intervention and its possible mechanism
Authors: Cai J.-J , Liu Y , Wang J , Wang J.-X , Wang Y , Xu S.-B , Cui Z , Gao J ,   Cardiovascular Institute
Published: October 2021

Background

Our previous study had found that the abundance of Lactobacillaceae in stool of acute coronary syndrome patients was significantly decreased. Experiments have confirmed that Lactobacillus has the effects of anti-inflammation, regulating blood lipids and improving cardiac injury after myocardial infarction.

Purpose

To explore the relationship between Lactobacillus and prognosis of acute myocardial infarction (AMI) patients treated by percutaneous coronary intervention (PCI) and its possible mechanism.

Methods

Patients with AMI who received emergency PCI from July 2017 to December 2018 in department of CCU were enrolled.Stool and blood samples were collected from all patients. The fecal 16S rDNA gene sequencing data from subjects were analyzed and subjects were categorized into Low, Medium and High level groups according to stool Lactobacillus measurements. The primary endpoints were major adverse cardiac events (MACE). Univariate and multivariate Cox regression were used to analyze the relationship between Lactobacillus and prognosis. Kaplan-Meier survival curve was used to characterize the association between the risk of MACE and Lactobacillus levels. Spearman correlation analysis and trend test were used to assess the relationship between Lactobacillus and Clinical index.

Results

A total of 254 patients were included in the analysis. The age was 65.90±11.56 years old,and 152 (59.84%) were male. The follow-up time was 652 (548.25, 753) days. Multivariate Cox regression showed that patients with Lactobacillus >7.1 copies/g presented lower risk of MACE (HR=0.179, 95% CI 0.076–0.422, P<0.001), compared to patients with Lactobacillus ≤3.6 copies/g.This difference was statistically significant in STEMI (HR=0.210, 95% CI 0.082–0.542, P=0.001). Subgroup analysis indicated that Lactobacillus was a protective factor,whereas the value was more evident for male smokers over 60 years old and whose BNP over 1000 pg/mL.Spearman correlation analysis showed that Lactobacillus was negatively correlated with WBC, NEUT, hs-CRP, TNT, CK, CK-MB and BNP, while positively correlated with LVEF. With the increasing of Lactobacillus, WBC, NEUT, hs-CRP, TNT, CK, CK-MB and BNP showed a downward trend, while LVEF had an upward trend.

Conclusion

Lactobacillus can significantly reduce the risk of MACE in STEMI patients treated by PCI, especially for male smokers over 60 years old. The underlying mechanism may be related to the fact that Lactobacillus can reduce inflammatory reaction, lessen cardiac injury and improve cardiac function.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): the Key Project of Scientific and Technological Support Plan of Tianjin in 2020 Correlation analysis between LactobacillSubgroup analysis in different patients
A pooled multi-national validation study of a machine learning, high-sensitivity troponin-based multi-proteomic model to predict the presence of obstructive coronary artery disease
Authors: Neumann J T , Sorenson N A , McCarthy C P , Magaret C A , Rhyne R F , Peters C C , Barnes G , Defilippi C R , Westermann D , Januzzi J L
Published: October 2021

Background

Undetected obstructive coronary artery disease (oCAD) is a global health problem associated with significant morbidity and mortality. A need exists for an accurate and easily accessible diagnostic test for oCAD. Using machine learning, a multi-biomarker blood diagnostic test for oCAD based on high-sensitivity cardiac troponin-I (hs-cTnI) has been developed.

Purpose

To validate the performance of a previously developed, algorithmically weighted, multiple protein diagnostic panel to diagnose oCAD in a pooled multi-national cohort and to compare the diagnostic panel's performance to predict oCAD to hs-cTnI alone.

Methods

Three clinical factors (sex, age, and previous coronary percutaneous intervention) and three biomarkers (hs-cTnI, Adiponectin, and Kidney Injury Molecule-1) were combined. hs-cTnI blood samples were assayed on the Siemens Atellica and Abbott Diagnostics ARCHITECT immunoassay platforms. Adiponectin and Kidney Injury Molecule-1 were measured with a multiplex assay on blood samples via the Luminex 100/200 xMAP platform. Individual data from a total of 924 patients with a mixture of acute and lesser acute presentations from three centers were pooled (Table 1). oCAD was defined as >50% coronary obstruction in at least one coronary artery (for the University Hospital Hamburg-Eppendorf cohort) or >70% coronary obstruction in at least one coronary artery (for the other two cohorts). The multiple biomarker diagnostic panel's performance to predict oCAD was also compared to hs-cTnI alone.

Results

The multiple protein panel had an area under the receiver-operating characteristic curve of 0.80 (95% CI, 0.77, 0.83, p<0.001) for the presence of oCAD (Figure 1). At optimal cutoff, the score had 74% sensitivity, 72% specificity, and a positive predictive value of 81% for oCAD. The multiple biomarker panel had a diagnostic odds ratio of 7.48 (95% CI 5.55, 10.09, p<0.001). In comparison, in patients without an acute MI, hs-cTnI alone had an area under the receiver-operating characteristic curve of 0.63 (95% CI, 0.60, 0.67, p<0.001)) for oCAD (Figure 1).

Conclusions

In this multinational pooled cohort, a previously described novel machine learning, multiple biomarker panel provided high accuracy to diagnose patients for oCAD.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Prevencio, Inc. Table 1. Pooled Variable DataFigure 1. ROC for HART CADhs and hs-cTnI
Diagnostic validation of a high-sensitivity troponin I assay and its use in a guideline-consistent rapid diagnostic protocol
Authors: Soerensen N A , Gossling A , Neumann J T , Hartikainen T S , Haller P M , Scharlemann L , Lehmacher J , Ziegler A , Blankenberg S , Zeller T , Nordholt G , Renne T , Westermann D
Published: October 2021

Background

Current ESC guidelines on management of non-ST-elevation myocardial infarction (NSTEMI) recommend rapid diagnostic protocols using validated high-sensitivity cardiac troponin (hs-cTn) assays (1). While established protocols are available for several hs-cTn assays, data on the diagnostic performance of the Siemens Atellica IM High-Sensitivity Cardiac Troponin I assay is limited.

Methods

In a cohort study including 1,800 patients presenting with suspected acute MI. Final diagnosis of MI was adjudicated by two cardiologists separately in accordance with the fourth universal definition of MI (2). We developed and validated a 0/1h diagnostic algorithm using the Siemens Atellica assay. The algorithm was established in the first 928 patients and validated in the following 872 patients.

Results

ROC analyses for the diagnosis of NSTEMI revealed high discriminatory ability of the Siemens hs-cTnI assay with an area under the curve of 0.88 (95% confidence interval (CI): 0.86–0.90) at 0h, 0.93 (CI: 0.91–0.94) after 1h and 0.95 (CI: 0.93–0.96) after 3h (Figure 1).

The derived algorithm consisted of a baseline rule-out of non-ST elevation MI using a cutoff <3 ng/L in patients with a symptom onset ≥3h or an admission troponin I <6 ng/L with a delta change from 0h to 1h <3 ng/L. For rule-in, an admission troponin I ≥120 ng/L or an increase within the first hour ≥12 ng/L was required. Application of the algorithm to the validation cohort showed a negative predictive value of 99.8% (CI 98.7%-100.0%), a sensitivity of 99.1% (CI 95.1%–100.0%) and 48.3% of patients ruled out, whereas 15.1% were ruled in with a positive predictive value of 68.0% (CI 59.1%-75.9%) and a specificity of 94.4% (92.5%–96.0%). The diagnostic performance was comparable to guideline-recommended application of an established hs-cTnI assay in a rapid 0/1h strategy (1).

Conclusion

The Siemens hs-cTnI assay is well-suited for application in rapid diagnostic stratification of patients with suspected MI and showed similar performance when compared with an established hs-cTnI assay using an algorithm recommended by recent ESC guidelines.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart foundation Figure 1
Serum cholesterol efflux capacity is associated with coronary plaque progression in patients with coronary heart disease
Authors: Wang X Q , Feng S , Shu X Y , Yang C D , Zhang R Y
Published: October 2021

Background

Coronary plaque progression is a major risk factor of adverse cardiac events in patients with coronary heart disease (CHD). Emerging evidence showed that attenuated high-density lipoprotein (HDL) function measured by cholesterol efflux capacity (CEC) was associated with development of atherosclerosis independent of HDL cholesterol level. In this study, we sought to investigate whether CEC is a predictor for coronary plaque progression in CHD patients.

Methods

We consecutively enrolled CHD patients from January 2017 to August 2019 in our Hospital who underwent elective percutaneous coronary intervention and had at least one non-target coronary lesion. Follow-up coronary angiography were performed at around 12 months. Fluorescence-labeled cholesterol and J774 macrophages were used to measure the CEC of ApoB-depleted serum sample from all patients. Quantitative coronary angiography (QCA) was performed both at baseline and follow-up to analyze the plaque progression.

Results

A total of 430 CHD patients with 586 non-target coronary lesions were included in the final analysis. During a mean follow-up time of 381.04±59.52 days, patients with decreased CEC presented more severe plaque progression (net luminal loss in highest to lowest CEC quartile: 0.22±0.42mm vs 0.20±0.41mm vs 0.13±0.36mm vs 0.11±0.34mm, p=0.035). In multivariate analysis, baseline CEC was independently associated with coronary plaque progression after adjustment for traditional risk factors including HDL cholesterol and ApoA-I, no matter treated as categorical variable (OR: 0.382 [95% CI 0.180–0.781] for highest to lowest quartile) or continuous variable (OR: 0.522 [95% CI 0.373–0.714] for per SD increase]. Furthermore, CEC demonstrated a better power in predicting coronary plaque progression compared with HDL cholesterol concentration (AUC=0.644 vs 0.514).

Conclusions

This study suggests that HDL function reflected by serum CEC is an independent predictor for coronary plaque progression in CHD patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Natural Science Foundation of China, Shanghai Municipal Commission of Health and Family Planning
Accuracy of estimating left ventricular ejection fraction in clinical routine. A SWEDEHEART registry validation study
Authors: Lenell J , Lindahl B , Karlsson P , Batra G , Erlinge D , Jernberg T , Spaak J , Baron T
Published: October 2021

Objective

Patients admitted to Swedish hospitals with myocardial infarction (MI) are reported to the nationwide Swedish registry for MI (SWEDEHEART). During hospital stay an echocardiography is routinely performed, and left ventricular ejection fraction (LVEF) is assessed according to the clinical praxis. LVEF is categorized as normal (>50%) or mild, moderate or severely impaired (40–49%, 30–39% and <30%, respectively) and reported to the registry by the treating center. The purpose of this study was to validate the reported LVEF assessments against independent echocardiography re-evaluation as this has never previously been done.

Methods

A random sample of 130 patient from three different hospitals were included. LVEF re-evaluation was performed by two independent reviewers using the modified biplane Simpson method and their mean LVEF was compared to the SWEDEHEART LVEF. Agreement between reported and re-evaluated LVEF was assessed using Gwet's AC2 statistics.

Results

Analysis showed good agreement between reported and reevaluated LVEF (AC2: 0.76 [95% CI 0.69–0.84]). The LVEF re-evaluations corresponded with registry reported categorized LVEF in 66.0% of cases. In 25.4% of cases the SWEDEHEART LVEF was lower than re-evaluated LVEF. The opposite relation was found in 8.6% of cases (p<0.005).

Conclusion

Independent validation of SWEDEHEART-reported LVEF shows an overall good agreement with the re-evaluated LVEF. However, a tendency to underestimation of LVEF was observed in patients with impaired LV systolic function, in whom the reported assessment of LVEF should be interpreted more cautiously.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Selanders Stiftelse
Prevalence, predictors, and clinical prognosis of macrophage infiltrates in patients with ST-segment elevation myocardial infarction caused by plaque erosion as assessed by OCT
Authors: Zhao C , Hu S , Weng Z , Chen X , Zeng M , He L , Feng X , Xu Y , Ren X , Yu H , Li L , Zhang S , Hou J , Jia H , Yu B
Published: October 2021

Background

Autopsy series showed that one of most common plaque phenotypes underlying coronary thrombi was plaque erosion. Identification of erosion may permit a less invasive management. Chronic inflammation is a common process in atherosclerosis. The severity of plaque inflammation can be assessed by optical coherence tomography (OCT) defined macrophages density. The impact of macrophage infiltrates (MØI) in ST-segment elevation myocardial infarction (STEMI) patients caused by plaque erosion was still unknown.

Purpose

The aim of this study was to evaluate plaque morphology and clinical prognosis associated with MØI as assessed by optical coherence tomography in STEMI patients caused by plaque erosion.

Methods

From October 2014 to December 2017, 1561 STEMI with OCT imaging before percutaneous coronary intervention were enrolled in this study. Finally, 312 STEMI patients caused by plaque erosion were split into two group according to the presence of MØI in culprit eroded plaques.

Results

163 (52.2%) STEMI patients presented plaque erosion with MØI, whereas 149 (47.8%) patients had no evidence of MØI. MØI were more frequency appeared in older patients (p=0.015). The severity and vulnerability of culprit lesions were higher in patients with MØI characterized by more aggressive and vulnerable features. Patients with MØI had worse long-term prognosis, compared with patient without MØI, mainly driven by a higher rate of target lesion revascularization (p=0.046), especially in STEMI patients presented plaque erosion with intensive antiplatelet therapy (p=0.035).

Conclusions

In the present study, we demonstrated that macrophage infiltrates at the site of erode plaques were associated with severity and vulnerability of culprit lesions. The long-term prognosis in patients with MØI were poorer especially in patients without stent implantation.

Funding Acknowledgement

Type of funding sources: None. Study flow chartPredictors of plaque erosion with MØI
Comparison of peripheral artery plaque characteristics between ACS patients with plaque rupture and plaque erosion in culprit coronary artery: an OCT and ultrasound study
Authors: Weng Z Q , Hu S N , Zhao C , Qin Y H , Feng X , He L P , Xu Y S , Yu H , Ren X F , Hou J B , Jia H B , Yu B
Published: October 2021

Background

Recent research has found that the characteristics of peripheral arterial plaque are related to the increased risk of cardiovascular disease, however, the relationship of plaque characteristics between peripheral artery and coronary is still unknown.

Purpose

To assess the correlation between coronary plaque characteristics assessed by optical coherence tomography (OCT) and peripheral artery plaque characteristics assessed by ultrasound.

Methods

150 patients with acute coronary syndrome (ACS) underwent coronary angiography were prospectively enrolled. OCT imaging of culprit vessel were performed during the procedure and ultrasound examination of bilateral carotid, iliofemoral and popliteal arteries was performed during hospitalization after procedure. Panvascular disease was defined as the presence of observable plaques in two or more vascular beds. Patients were divided into plaque rupture (PR) group and plaque erosion (PE) group according to culprit plaque characteristics on OCT.

Results

There were 132 (88%) ACS patients had panvascular disease in which 36 (24%) with generalized atherosclerosis (4 sites) and the prevalence of panvascular atherosclerosis in PR group was significantly higher than in PE group especially in carotid arteries and iliofemoral arteries (Figure 1, Figure 2). Compared to PE group, PR group had higher carotid plaque score (p=0.001) which indicates more plaques and severer atherosclerosis. Moreover, there were larger intima-media thickness (IMT) of iliofemoral arteries (6.9±1.4mm vs. 6.5±1.1mm, p=0.036) and more calcified plaques in PR group.

Conclusions

Panvascular disease is highly prevalent in ACS patients especially in patients with plaque rupture in culprit vessel, in which more than half of the patients had plaques in more than 3 sites of vascular beds. In addition, patients with plaque rupture had thicker iliofemoral IMT and higher panvascular atherosclerosis burden, which indicates that characteristics of coronary plaques are the focal expression of plaques in the whole panvcascular system.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Key R&D Program of China Figure 1. Prevalence of panvascular disease in ACSFigure 2. Comparison of peripheral artery plaques
Prognostic value of per-vessel treatment adherence in stable coronary artery disease based on novel computational pressure-flow dynamics derived fractional flow reserve
Authors: Leung C K L , Lam L Y , Li K Y , Yu A S Y , Wu M Z , Ren Q W , Wong P F , Tse Y K , Yu S S Y , Li H L , Feng Y , Huo Y , Tse H F , Yiu K H
Published: October 2021

Background

Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel index developed to evaluate the extent of myocardial ischemia in patients with coronary artery disease (CAD), which eliminates the need of invasive pressure guidewire and hyperaemic stimulus in conventional fractional flow reserve (FFR) measurement. Studies have shown improved clinical outcomes associated with adherence to functional myocardial ischemia assessment when deciding to perform percutaneous coronary intervention (PCI) at a per-patient level. However, the clinical significance of such treatment adherence at a per-vessel level remains uncertain.

Methods

A total of 928 patients (mean age 66.2±10.5, male 72.7%) with stable CAD were included in this study. The caFFR of all three major coronary vessels were obtained for every patient, and the FFR threshold of 0.8 was adopted as the threshold for caFFR to indicate functionally significant artery stenosis which warrants PCI, and vice versa. Based on the caFFR of each major coronary vessel and whether PCI was performed to the respective vessel, patients were stratified into 0–1 vessel with treatment adherence group (group 1) (n=105), 2 vessels with treatment adherence group (group 2) (n=338), and 3 vessels with treatment adherence group (group 3) (n=485). The primary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause mortality, non-fatal myocardial infarction and any subsequent revascularization.

Results

The severity of CAD based on SYNTAX score assessment was 18.6±10.2 in group 1, 14.6±8.9 in group 2, and 11.5±9.9 in group 3 (P<0.001). The rates of MACE at 3 years were significantly different across groups 1, 2 and 3 (17.1% vs. 12.1% vs. 7.4%; P=0.004). With reference to group 3, the risk of MACE at 3 years was increased in group 2 (adjusted hazard ratio [HR]=1.597; 95% confidence interval [CI]=1.020–2.501; P=0.041), and further increased in group 1 (adjusted HR=1.933; 95% CI=1.081–3.457; P=0.026).

Conclusion

In stable CAD patients, the risk of MACE is incremental when fewer major coronary vessels are treated with adherence to caFFR threshold of 0.8. Per-vessel treatment adherence significantly affects clinical outcomes in terms of MACE.

Funding Acknowledgement

Type of funding sources: None.
Outcomes of patients with high bleeding risks characteristics presenting with acute coronary syndrome undergoing percutaneous coronary intervention
Authors: Fu A , Barry Q , Boudreau R , Clifford C , Chow A , Simard T , Chong A Y , Dick A , Froeschl M , Glover C , Hibbert B , Labinaz M , Le May M , Russo J , So D
Published: October 2021

Background

Patients with high bleeding risk characteristics (HBR) presenting with acute coronary syndrome (ACS) pose a clinical challenge to balance risk for recurrent ischemic events versus incurring bleeding with dual antiplatelet therapy.

Purpose

We seek to determine the incidence and predictors of short and long term ischemic and bleeding outcomes in patients with HBR factors presenting with ACS after percutaneous coronary intervention (PCI).

Method

Consecutive patients over a 1-year period, who underwent PCI for ACS were categorized as having HBR based on: age ≥75, anemia (hemoglobin<110g/L), thrombocytopenia (platelet<100x109/L), renal failure (eGFR<30umol/L) or concurrent use of oral anticoagulation. Primary outcome was major adverse cardiovascular event (MACE) defined as composite of cardiovascular death, myocardial infarction, and stroke at 1 year. Key secondary outcomes include significant bleeding defined as Bleeding Academic Research Consortium (BARC) type 3 or 5, and net adverse cardiovascular event (NACE), as a composite of MACE and significant bleeding.

Results

Of 1351 patients presented with ACS, 389 (28.8%) had at least one HBR criteria. At 1 year, patients with HBR, compared to those without, had increased MACE (11.1% vs 4.2%, p<0.001) and cardiovascular death (5.7% vs 1.7%, p<0.001). Patients with HBR had increased significant bleeding (3.6% vs 2.3%, p=0.011) and NACE (14.4% vs 5.4%, p<0.001). Multivariate analysis showed the presence of HBR and prior history of myocardial infarction were predictors for 1-year MACE (OR 2.67, CI [1.62–4.42], p<0.001 and OR 2.18, CI [1.29–3.70], p=0.004, respectively), whereas the use of second-generation antiplatelet agent was not. Increased MACE and NACE were observed in HBR patients beyond 1 month of DAPT.

Conclusion

Among patients with ACS undergoing PCI, those with HBR had higher risk for both ischemic and bleeding complications. Novel strategies need to be considered for this high-risk group. Current guidelines, recommending 1 year of DAPT for patients with ACS, should be re-evaluated among patients with HBR.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve for 1 year MACEKaplan-Meier curve for 1 year death
Incidence and one year outcome of periprocedural myocardial infarction following cardiac surgery: are the universal definition and SCAI criteria fit for purpose?
Authors: Hinton J , Augustine M , Gabara L , Mariathas M , Allan R , Borca F , Nicholas Z , Ikwoube J , Gillett N , Kwok C S , Cook P , Grocott M P W , Mamas M , Curzen N
Published: October 2021

Introduction

The diagnosis and clinical implication of periprocedural myocardial infarction (PPMI) following coronary artery bypass grafting (CABG) is contentious, especially given its importance in the interpretation of trial data. Two accepted definitions of PPMI yield discrepant results. Little is known about the association between the diagnosis of PPMI, using high sensitivity troponin (hs-cTn), and medium term mortality in patients who undergo CABG, either alone or in conjunction with another procedure. In addition, there are currently no criteria for the diagnosis of PPMI following non-CABG surgery.

Method

Consecutive patients admitted to a cardiothoracic critical care unit (CCCU) over a six month period following open cardiac surgery had hs-cTnI assay performed on admission and every day for forty-eight hours, regardless of whether there was a clinical indication. Patients were categorised as PPMI using both the Universal Definition of MI (UDMI) and Society of Cardiovascular Angiography and Interventions (SCAI) criteria. Comorbidity data, surgical details and clinical progress in CCCU were recorded. One year mortality data were obtained from NHS Digital.

Results

There were 245 CABG patients, of whom 20.4% met criteria for UDMI PPMI and 87.6% for SCAI UDMI (figure 1). The diagnosis of UDMI PPMI was independently associated with one year mortality (hazard ratio 4.175 (95% confidence interval 1.281 – 13.608)), whereas there was no association between SCAI PPMI and one year mortality (figure 2). Of the 243 patients who had non CABG cardiac surgery, 11.4% met criteria for UDMI PPMI and 85.2% for SCAI PPMI (figure1) but neither was associated with one year mortality.

Conclusions

The incidence of SCAI PPMI in a real world cohort of cardiac surgery patients is so high as to be of limited clinical value. By contrast, a diagnosis of UDMI PPMI post CABG is independently associated with one year mortality, so may have clinical utility.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Beckman Coulter - supplied the assays used in the study but had no role in the study Figure 1. Frequency of PPMIFigure 2. Kaplan Meier curves
The effect of early invasive strategy on mortality outcome in patients with chronic kidney disease presenting with non-ST segment elevation myocardial infarction
Authors: Sharon A , Fishman B , Itelman E , Fefer P , Barbash I , Segev A , Matetzky S , Guetta V , Grossman E , Maor E
Published: October 2021

Background

Current guidelines recommend an early invasive strategy for patients with non-ST segment elevation myocardial infarction (NSTEMI).

Purpose

To evaluate whether early invasive strategy is associated with better outcome among patients with chronic kidney disease (CKD).

Methods

Retrospective cohort analysis of consecutive patients with NSTEMI between 2008 and 2021. Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation. Invasively treated patients were dichotomized into early (<24 hours) and non-early groups. Mortality data was available for all patients from a national registry. Multivariate Cox regression models with interaction analysis were applied.

Results

Final study population comprised 7,107 NSTEMI patients, of whom 3,172 (45%) had eGFR <60 ml/min/1.73m2. 1,988 (28%) and 973 (14%) patients had eGFR under 45 and 30 ml/min/1.73m2, respectively. 3,529 (50%) patients were treated invasively, among them 1837 (52%) underwent early invasive strategy. Patients in the early invasive group were younger (64 vs. 68 years, p<0.001) and were less likely to have comorbidities including kidney disease. During a median follow-up of 3 years (IQR 1.2–5.2), 2,552 (36%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death was 50%, 15%, and 6% among patients in the conservative, non-early, and early invasive groups respectively (p Log-rank <0.001). Subgroup analysis of invasively managed patients showed that early invasive strategy was associated with a significant 32% reduced risk of death in a multivariate model (95% CI 0.56–0.82, p<0.001), but this associated benefit was modified by eGFR (p for interaction 0.045). The modification effect of CKD on the association of early invasive strategy with outcome was most pronounced among invasively treated patients with eGFR <45 ml/min/1.73m2, with no survival benefit for early invasive approach in these patients (HR 0.8, 95% CI 0.57–1.14, p=0.221 vs. HR 0.6 95% CI 0.45–0.72, p<0.001; p for interaction=0.046).

Conclusion

Among invasively treated NSTEMI patients, the benefit of early invasive strategy is modified by CKD, and limited to those with eGFR ≥45 ml/min/1.73m2.

Funding Acknowledgement

Type of funding sources: None.
Gender based outcome of IABP implantation in patients with acute coronary syndrome and cardiogenic shock: a national inpatient sample database analysis
Authors: Patel N , Amgai B , Chakraborty S , Hajra A , Aryal B , Patel Z , Ashish K , Reddy M , Aronow W , Khalid M
Published: October 2021

Background

Intra-Aortic Balloon counter-pulsation is frequently used as a circulatory support device in patients requiring hemodynamic support - in cardiogenic shock and in patients at risk of hemodynamic decompensation during a high-risk coronary intervention. Impact of IABP in this patient population has been variable. Certain studies have shown a beneficial effect of IABP on selected populations having acute coronary syndrome with cardiogenic shock (1–3). Our objective was to compare the outcomes based on gender in the ACS population with cardiogenic shock and IABP placement.

Methods

We analyzed the National Inpatient Sample database from Oct-2015 to Dec-2017 released under Healthcare Cost utilization Project in the USA using Stata 16.0. The population was identified using respective ICD-10 codes. We excluded the population with sudden cardiac arrest, pulmonary embolism, and patients with anatomical post-MI complications. Multivariate logistic regression analysis was done to determine the difference in outcomes based on gender using clinically relevant variables. Later, propensity-matched cohort analysis was performed based on the regression variables.

Results

Of 36, 990 patients who met our inclusion criteria 25,670 (69%) were male and 11,320 (31%) were female. The average age for male and female populations was 66±11 and 69±12 years. Femnales were more likely to have higher Charlson co-morbidity index three or above. We found higher mortality in the female population [3,146 (27.79%)] compared to male [5,884 (22.92%)] in univariate analyses. Propensity-matched multivariate regression analysis showed no difference [OR: 1.06 (0.91–1.22) with P-value: 0.482] in mortality after adjusting for clinically relevant variables. Subgroup analysis in STEMI and NSTEMI populations did not show a difference. The average hospital stay was similar in both cohorts, with the male having a higher cost per stay. We found no difference in most of the complications included in our study except for higher coronary artery dissection [OR: 2.98 (1.73–5.13), P-value: <0.001] and lower rates of AKI [OR: 0.72 (0.63–0.83), P-value: <0.001], AKI requiring hemodialysis [OR: 0.74 (0.56–0.97), P-value:0.031] and ventricular tachycardia [OR: 0.73 (0.64–0.84), P-value: <0.001] in the female population.

Conclusion

The inpatient population of ACS with Cardiogenic shock and IABP insertion showed no significant difference in mortality between males and females which was valid for subgroup analysis of NSTEMI and STEMI groups. Complications such as coronary artery dissection were higher, whereas AKI, AKI requiring hemodialysis, and ventricular tachycardias, were lower in females than males.

Funding Acknowledgement

Type of funding sources: None.