bluuebunny/crossref_metadata_2025 huggingface dataset:
Global longitudinal strain and chronic kidney disease prognostic impact on acute coronary syndrome
Authors: Morgado Gomes A.R , Campos D , Saleiro C , Gameiro Lopes J , Sousa J.P , Puga L , Antonio N , Goncalves L
Published: November 2020

Background

Impaired left ventricular ejection fraction (LVEF) and chronic kidney disease (CKD) have been associated with poorer outcomes in acute coronary syndrome (ACS). Increasing evidence on global left ventricular longitudinal strain (GLS) suggests superiority over left ventricular ejection fraction (LVEF) in risk stratification.

Methods

This study was based on a retrospective analysis of consecutive patients admitted to a Coronary Care Unit between 2009 and 2016. Baseline characteristics and echocardiographic parameters, including LVEF, were assessed. For each patient, a two-dimensional speckle tracking of the left ventricle was assessed and average GLS was calculated using 2, 3 and 4-chamber views. Blood creatinine was measured during hospital stay and used to estimate glomerular filtration rate (GFR) with Modification of Diet in Renal Disease (MDRD) equation. A cox regression analysis was performed to determine mortality prediction value of average GLS, LVEF and GFR in this population. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC) was estimated.

Results

A total of 85 patients (66.7±12.7 years old; 78.8% males) were enrolled. LVEF mean was 49.4±9.8% and average GLS was −16.0±4.0%. GFR median was 80.0±48.9 ml/min/1.73m2. In cox regression analysis, worse average GLS was associated with greater mortality (HR 0.721; 95% CI 0.599–0.867; P=0.001). GFR was inversely related to death (HR 0.967; 95% CI 0.944–0.991, P=0.008). In cox regression analysis using average GLS and GFR as covariates, both proved to be independent predictors of mortality (for average GLS, HR 0.748; 95% CI 0.610–0.918, P=0.005; for GFR, HR 0.974; 95% CI 0.949–0.999; P=0.044). The AUC of average GLS to predict mortality was 0.78 (P<0.001, sensitivity 50.7% and specificity 100%) and for average GLS and GFR combined was 0.85 (P<0.001, sensitivity 84.0% and specificity 77.8%). Although LVEF proved to be a mortality predictor, the AUC obtained by ROC curve analysis was inferior to average GLS, with statistical significance (P=0.043).

Conclusions

GLS and CKD proved to be independent predictors of mortality in ACS patients. GLS showed superiority when compared to LVEF in risk stratification and in the future it might replace LVEF. The model combining GLS and GFR emphasized the increased risk of CKD patients and how they should be seen as high-risk patients.

ROC curve analysis

Funding Acknowledgement

Type of funding source: None
Gender differences in acute coronary syndrome: experience from the Croatian branch of the ISACS-CT registry
Authors: Loncaric F , Mjehovic P , Sabljak D , Vlahovic V , Vinkovic I , Radic T , Klaric K , Dakic A , Adamovic I , Bunic M , Pavasovic S , Jakus N , Fabijanovic D , Cikes M , Milicic D
Published: November 2020

Background and aim

In recent years, worse outcomes of female acute coronary syndrome (ACS) patients have been recognized. The aim was to explore gender differences in ACS in the Croatian branch of the ISACS-CT registry (NCT01218776).

Methods

From January 2012 to May 2018, 3066 ACS patients were enrolled; 50% (n=1539) presenting with STEMI, 35% (n=1071) with NSTEMI, and 15% (n=456) with unstable angina (UA). In-hospital mortality was defined as the primary endpoint.

Results

At admission women were older, more burdened with comorbidities, with a longer delay from symptom onset to admission (Figure 1), but without differences in signs and symptoms or Troponin T levels (p=0.166). During hospitalization, there were no gender difference in the administration of beta blockers, ACE inhibitors or statins in the first 24 hours. Coronary angiography was performed in a smaller percentage of female patients (86 vs. 92%, p<0.001), however, the finding of no significant stenosis was more common in women (6 vs. 2%, p<0.001). Furthermore, less women underwent primary PCI (pPCI) (67 vs. 77%, p<0.001). While there were no gender differences in the number of the treated lesions (p=0.978), women had a higher incidence of procedural pPCI complications compared to men (13 vs. 8%, p=0.001) – predominantly due to higher occurrence of no reflow, side branch loss and new thrombus formation. Multivariate regression showed gender was not associated with the decision not to perform pPCI, whereas age over 65 years (OR=1.75), diabetes (OR=1.30), hypertension (OR=1.55), chronic kidney disease (OR=2.06) and the delay from onset of symptoms to admission >6h (OR=1.61) were associated. At discharge, there were no gender differences in LV ejection fraction <40% (p=0.259). Women with STEMI had significantly higher in-hospital mortality (10 vs. 4%, p<0.001), whereas no gender differences were seen regarding unstable angina and NSTEMI. After multivariate regression, only age over 65 years (OR=3.61), chronic kidney disease (OR=1.85) and primary PCI (OR=0.49) remained associated with in-hospital mortality.

Conclusion

The findings in the Croatian branch of the ISACS-CT registry demonstrate notable gender differences in ACS. Older age and a substantial burden of comorbidities represent strong influences on disease development, intervention choice and in-hospital mortality when treating women with ACS.

Figure 1

Funding Acknowledgement

Type of funding source: None
The association of smoking to cardiovascular death differs according to age and sex following myocardial infarction complicated by heart failure or left ventricular dysfunction
Authors: Hall T.S , Orn S , Zannad F , Rossignol P , Duarte K , Solomon S , Atar D , Agewall S , Dickstein K , Girerd N
Published: November 2020

Background

Smoking is associated with higher morbidity and mortality following myocardial infarction (MI), but reports of the impact on cardiovascular (CV) death in aged and female patients experiencing MI complicated with left ventricular dysfunction or overt heart failure are limited.

Methods

In an individual patient data meta-analysis of high-risk MI patients, the association of smoking to CV death was investigated. Cox proportional hazard models exploring smoking status and risk according to age and sex were performed to study the relationship of smoking to independently adjudicated CV death endpoints.

Results

28,771 patients from the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials were assessed. 18,325 (64%) reported smoking (9185 (32%) current and 9051 (32%) past), 2662 (9%) were above ≥80 years and 8607 (30%) were women. Overall, using non-smokers as referent, the association of smoking to CV mortality was neutral (HR=1.07, 0.98 to 1.16, p=0.12 for active smoking and HR=1.10, 1.02 to 1.18, p=0.01 for past smoking). The associations for active and past smokers with outcome, adjusted for age and sex in the overall study sample and according to different age and sex categories, are presented in figure 1. In analyses that included interaction terms, the association for active smokers depended on age and sex; the risk of CV mortality was weakened in women (interaction HR=0.81, 0.69 to 0.96, p=0.01) and older age (interaction HR per 10 years increase=0.88, 0,82 to 0.95, p=0.001). In contrast, the association to CV death for past smokers was not modified by sex or age (p=0.86 and p=0.17 respectively).

Conclusions

The association of smoking to CV death differed according to age and sex in MI complicated with left ventricular dysfunction or overt heart failure. Significant association of active and/or past smoking with increased risk of CV death was mainly observed in the 60–69 years category. The underlying reasons of the lack of association of smoking with outcome in older patients in this specific context should be explored further in future studies.

Figure 1

Funding Acknowledgement

Type of funding source: None
Time from ECG Diagnosis to sheath insertion is a strong predictor for mortality in patients with ST elevation myocardial infarction admitted for primary percutaneous coronary intervention
Authors: Larsen A.I , Loland K , Hovland S , Bleie O , Trovik T , Hegbom K , Larsen T , Fossum E , Eek C , Moer R , Juliebo V , Uchto M , Rotevatn S
Published: November 2020

Introduction

If reperfusion can be performed within 120 minutes, pPCI is the ESC guideline recommended treatment in patients with ST-elevation myocardial infarction (STEMI).

Aims

Historically, prognosis is dependent on time from diagnosis to reperfusion in patients with STEMI. We sought to investigate this in a contemporary patient population by assessing mortality as function of time from ECG diagnosis to sheath insertion in the Norwegian registry for invasive cardiology (NORIC).

Methods

NORIC, which is a part of the Norwegian Cardiovascular Disease Registry, is a national, mandatory and non-consensual person-identifiable health registry. Data from NORIC were linked with the National Population Register. Data were registered from 1st of January 2013 to 31st of June 2019.

Results

During this period complete data were available for n=5754 patients with 526 events. ECG diagnosis to sheath insertion was a predictor of mortality with the 4th (>106 min) vs 1st quartile (<54 min) with a HR of 1.74 (95% CI 1.36–2.22), p-value <0.00001. The HR increased by 1.20 (95% CI 1.11–1.30) per quartile (p-value for trend <0.00001).

Nationally 62% percent of the patients received pPCI within the ESC recommended 90 minutes from ECG-diagnosis with large geographical variation (range 38–89%). Nationally 80% received pPCI within 115 minutes (range 75–202 minutes).

Conclusion

In a contemporary STEMI population, time from ECG diagnosis to sheath insertion is a strong predictor for mortality in patients admitted for pPCI for STEMI. However, the data also demonstrate large variations between different geographical health regions in Norway that should be addressed.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Haukeland University Hospital
Spontaneous coronary artery dissection – contemporary management and outcome of a national cohort
Authors: Wilander H , Swahn E , Johnston N , Jonasson L , Pagonis C , Tornvall P , Venetsanos D , Sederholm Lawesson S
Published: November 2020

Background

Spontaneous coronary artery dissection (SCAD) is proposed to cause 1–4% of all acute myocardial infarctions (AMI).

The aim of this study was to conduct a first description of Swedish SCAD patients regarding the prevalence of risk factors, treatment and prognosis.

Method

All patients with AMI registered in the Swedish Coronary Angiography and Angioplasty Register (SCAAR) December 2015 until December 2017 were included. The index angiographies of the SCAD patients were reevaluated by an independent angiographer at each center. Patients with non-SCAD AMI (n=31670) were used for comparison.

Results

SCAD was identified in 137 patients with AMI (100 women, 37 men). The SCAD population was younger than the non-SCAD population 53.9 (51.7–56.1) vs 68.5 (68.3–68.6) years, more often women (73.0 vs 30.7%) and presented with less risk factors: diabetes 2.9 vs 20.8%; hypertension 27.0 vs 57.6%; smoking 41.2 vs 58.1%; statin therapy 12.4 vs 36.9% and previous AMI 7.3 vs 19.6% (p<0.001 for all comparisons).

SCAD patients less frequently underwent percutaneous coronary intervention (PCI) 43.1 vs 70.8% (p<0.001) and received less statin treatment, 78.9 vs 91.5% (p<0.001).

There was no significant difference regarding treatment with aspirin or double antiplatelet therapy at discharge: 93 vs 89.7% (p=0.45) and 86.7 vs 84.2%, respectively (p=0,43).

There was no significant difference in one-year mortality 6.6 vs 8.2% (p=0.57).

Conclusions

With a current prevalence of 0.43% of all Swedish AMIs, data supports SCAD being an underdiagnosed condition with a prognosis resembling that of non-SCAD AMI. Furthermore, SCAD patients are younger and harbor less cardiovascular risk factors. While significant differences in management are present, current therapeutic strategies of the two groups are similar, indicating overtreatment of SCAD.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung foundation, ALF funding
Novel low-delta value troponin algorithms have good precision for rule-out of NSTE-ACS
Authors: Tjora H , Steiro O.T , Langorgen J , Omland T , Collinson P , Bjorneklett R.O , Nygard O.K , Skadberg Ø , Bonarjee V.V.S , Vikenes K , Aakre K.M
Published: November 2020

Background

Rapid rule-out algorithms for non-ST-elevation infarction (NSTEMI) may be beneficial for logistics in the emergency room. Current algorithms are designed to rule-out NSTEMI, but do not differentiate between unstable angina (UAP) in need of revascularization and non-cardiac chest pain patients (NCCP) who could be discharged. Recent improvements in analytical precision of high sensitivity troponin (cTn) assays allow for trialing algorithms with very small delta values.

Purpose

Could the use of lower delta values produce rule-out algorithms for NSTE-ACS with a false negative rate of ≤5%, and a sufficient high rule-out rate of patients with NCCP.

Method

927 patients with suspected NSTE-ACS were consecutively included. Serum samples were collected at 0, 3 and 8–12 hours. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT. The 0- and 3-hour samples were additionally measured for cTnIand cTnI from Singulex Clarity System (cTnI(sgx)). The diagnostic performance to rule-out NSTE-ACS was compared between one low-delta value algorithm from each assay (cTnT, cTnI and cTnT).

Results

The prevalence of NSTEMI was 13.4%, UAP 11.4% and NCCP 60%. Median age was 63 years, 60% males. Fig. 1 shows baseline and 3-hour delta cTn values for the UAP and NCCP patients for the three different assays. The baseline cTn value differed significantly between UAP and NCCP for all assays, p value <0.001. The novel low-delta cTnT algorithm (Table 1) ruled out 8 NSTE-ACS patients (3.5%), the cTnI algorithm and cTnI (sgx) algorithm ruled out 11 (4.8%) and 12 (5.2%) patients with NSTE-ACS, respectively. Moreover, the cTnT algorithm allocated 35.3% of the NCCP patients to discharge. Respective numbers for the cTnI(sgx) and cTnI algorithm were 30.6% and 33.5%. Comparing the ROC curves, the cTnT algorithm had significantly higher AUC compared to the cTnI(sgx) algorithm (p value =0.005, DeLong test).

Conclusion

The low-delta value algorithms correctly ruled in ≥95% of the NSTE-ACS patients whilst >30% of NCCP patients were ruled out. The cTnT algorithm had the best performance with a significant higher AUC compared to the cTnI(sgx) algorithm.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority, Haukeland and Stavanger University hospital
Sex-based differences of copeptin for early rule-out of non-ST-elevation myocardial infarction
Authors: Vargas K.G , Tajsic M , Latsuzbaia A , Andric T , Kassem M , Jaeger B , Huber K
Published: November 2020

Objective

There is paucity of data on the role of sex in the dual biomarker strategy using copeptin and conventional troponin for the early rule-out of non-ST-elevation myocardial infarction (NSTEMI). We aimed to evaluate sex-based differences on copeptin levels, combined negative predictive value (NPV) and predictors of copeptin elevation at admission.

Methods

Biomarkers were measured in 852 adult patients presenting to the emergency department with chest pain and suspected NSTEMI. Logistic regression analyses on predictors of copeptin elevation were evaluated by sex.

Results

Overall, 362 women (42.5%) and 490 men (57.5%) were included. Copeptin levels were higher in men (median 7.36 pmol/L vs. 4.8 pmol/L; P<0.001). Men had a similar NPV (100%) as women (99.6%, CI: 98.8–100) using the dual biomarker rule-out strategy and when compared to troponin alone (men, NPV=98.7%, CI: 97.5–99.8; and women, NPV=98.7%, CI: 97.5–100). Multivariate logistic regression showed positive association of male sex with copeptin elevation (OR=2.37; CI: 1.61–3.49; P<0.001). In men, diastolic blood pressure was a negative predictor of copeptin elevation (OR=0.98, 95% CI: 0.96–0.99), while positive predictors were current MI (OR=2.16, 95% CI: 1.19–3.91), chronic renal insufficiency (OR=3.58, 95% CI: 1.33–9.62), and atrial fibrillation (OR=2.56, 95% CI: 1.23–5.32), respectively (all P<0.05). In women, current MI (OR=2.98, CI: 1.23–7.24), atrial fibrillation (OR=2.90, CI: 1.26–6.70) and syncope (OR=7.56, CI: 2.26–25.30) were significant predictors of copeptin elevation.

Conclusions

Men with suspected NSTEMI have higher copeptin levels. The dual biomarker rule-out strategy has a similar performance in both male and female patients. Certain predictors of copeptin elevation are sex-specific.

Copeptin levels at presentation

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI
Authors: Restan I , Steiro O.T , Tjora H.L , Langoergen J , Omland T , Collinson P , Bjoerneklett R , Vikenes K , Strand H , Skadberg O , Mjelva O.R , Larsen A.I , Bonarjee V.V.S , Aakre K.M
Published: November 2020

Background

NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients.

Purpose

To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI.

Method

971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose

Results

Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value <0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value <0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value <0.001).

Conclusion

Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals
Plaque erosion is associated with less systemic atherosclerosis than other plaque types of acute coronary syndrome
Authors: Kato A , Minami Y , Asakura K , Katamine M , Katsura A , Muramatsu Y , Sato T , Kakizaki R , Hashimoto T , Meguro K , Shimohama T , Ako J
Published: November 2020

Background

Previous studies have demonstrated that plaque erosion is associated with less atheromatous plaque at both culprit and non-culprit lesion than other plaque types of acute coronary syndrome (ACS). However, the status of systemic atherosclerosis in patients with plaque erosion remains to be elucidated.

Purpose

To clarify if plaque erosion is associated with less systemic atherosclerosis than other plaque types of ACS.

Methods

A total of 239 consecutive patients with ACS who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. Patients were classified into either plaque erosion (PE, n=45) or non-plaque erosion (non-PE, n=194) including plaque rupture and calcified nodule based on OCT findings of the culprit lesions. The status of systemic atherosclerosis was assessed by the findings of carotid echography, the severity of aortic arch calcification (AAC; grade 0–3) on chest X-ray, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABPI).

Results

The maximum intima media thickness (IMT) was significantly thinner in the PE group than in the non-PE group (1.9±0.8 vs. 2.3±0.9 mm, p=0.023) (Panel A). The prevalence of heterogeneous plaque and calcified plaque was significantly lower in the PE group than in the non-PE group (25.0 vs. 50.4%, p=0.010, 18.8 vs. 38.5%, p=0.037, respectively). The prevalence of AAC grade was significantly different between the two groups with a tendency toward lower AAC grade in the PE group than the non-PE group (Panel B). The mean baPWV (1588.1±420.6 vs. 1686.5±363.5 cm/sec, p=0.186) and ABPI (1.1±0.1 vs. 1.1±0.1, p=0.270) was comparable between the two groups.

Conclusion

Plaque erosion was associated with less atherosclerosis in carotid artery and aortic arch than non-plaque erosion. These findings may help further clarify the distinct pathophysiology of plaque erosion.

Funding Acknowledgement

Type of funding source: None
Central apneas and Ticagrelor related dyspnea in patients with acute coronary syndrome
Authors: Giannoni A , Borrelli C , Gentile F , Mirizzi G , Coceani M , Paradossi U , Passino C , Emdin M
Published: November 2020

Background

Patients treated with ticagrelor often develop dyspnea of unknown origin. We aim to explore the contribution of central apneas to ticagrelor-related dyspnea in patients with acute coronary syndrome (ACS).

Methods

We consecutively enrolled patients with ACS, preserved left ventricular ejection fraction and no history of obstructive sleep apnea, treated either with ticagrelor 90 mg bid (n=30) or prasugrel 10 mg od (n=24). One week after ACS onset, all patients underwent, beyond thorough cardiovascular and respiratory assessment, 24-hour cardiorespiratory monitoring and assessment of chemosensitivity to hypercapnia.

Results

Patients treated with ticagrelor reported more frequently dyspnea than patients treated with prasugrel (43% versus 4%, p=0.001), despite no difference in demographic, clinical, echocardiographic and pulmonary data. Patients with dyspnea induced by ticagrelor showed higher apnea-hypopnea and central apnea index both at daytime and at nighttime compared to patients treated with ticagrelor but without dyspnea and patients treated with prasugrel (daytime AHI: 26 [7–34] vs 6 [4–14] and 6 [0–11] events/hour; nighttime AHI: 65 [17–72] vs 22 [8–37] and vs 11 [4–23] events/hour; daytime CAI: 5 [1–15] vs 1 [0–6] and 0 [0–1) events/hour; nighttime CAI 34 [2–55] vs 3 [0–9] and 0 [0–1], all p<0.05). Likewise, they also presented with higher hypercapnic ventilatory response (2.4 [1.9–2.7] vs 1.3 [1.1–1.9] and 0.9 [0.5–2.1] L/min/mmHg, all p<0.05).

Conclusions

Central apneas should be considered a likely mechanism of dyspnea in ACS patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability in this setting.

Funding Acknowledgement

Type of funding source: None
Effect of body mass index on ischemic and bleeding events in patients presenting with acute coronary syndromes: insights from the START-ANTIPLATELET registry
Authors: Moscarella E , Calabro P , Gragnano F , Cesaro A , Pafundi P.C , Patti G , Cavallari I , Antonucci E , Cirillo P , Pignatelli P , Palareti G , Sasso F.C , Pengo V , Gresele P , Marcucci R
Published: November 2020

Background

The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding events as possible explanations to the obesity paradox in ACS patients.

Methods

For the purpose of this sub-study, patients enrolled in the START-ANTIPLATELET registry were stratified according to Body Mass Index (BMI) into three groups: normal, BMI <25kg/m2; overweight, BMI: 25–29.9kg/m2; obese, BMI ≥30kg/m2. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, and major bleeding.

Results

Patients were classified as follows: 410 (33.9%) normal, 538 (44.5%) overweight, 261 (21.6%) obese. Compared to the normal weight group, obese and overweight patients had a higher prevalence of cardiovascular risk factors, but were younger, with a better left ventricular ejection fraction (LVEF) and lower PRECISE-DAPT score. At one-year follow-up NACE was more frequently observed in normal than in overweight and obese patients (15.1%,8.6%,and9.6%, respectively; p=0.004), driven by a significantly higher rate of all-cause death (6.3%,2.6%, and 3.8%, respectively; p=0.008), while no significant differences were noted in terms of MI, stroke, and major bleeding. When correcting for confounding variables, BMI loses its power in independently predicting outcomes, failing to confirm the obesity paradox in a real-world ACS population.

Conclusions

Our study conflicts the obesity paradox in real-world ACS population, and suggest that the reduced mortality rate may be explained by a lower bleeding risk in obese patients allowing a more aggressive medical treatment, and by a better LVEF translating into a higher survival rate.

Funding Acknowledgement

Type of funding source: None
De-escalation strategy with half-dose prasugrel or ticagrelor on pharmacodynamics and outcome in East Asians patients with acute coronary syndrome
Authors: Kim M.H , Jin C.D , Song K , Lee K.M , Moon H.Y , Jo Y.S , Yoon C.H , Cho Y.R , Park J.S , Lim K.H
Published: November 2020

Background

East Asians treated with potent P2Y12 inhibitors (prasugrel or ticagrelor) are exposed to more potent platelet inhibitory response. Whether half-dose de-escalation strategy would be benefit for chronic antiplatelet strategy in East Asian patients with acute coronary syndrome (ACS) remain uncertain.

Method

In half-dose de-escalation strategy, 129 Korean ACS patients were assigned to receive standard-dose potent P2Y12 inhibitors (n=86, prasugrel [n=38], ticagrelor [n=48]), followed by half-dose reduction at 1 month for maintenance, and was compared to clopidogrel (n=43) as control. The primary safety outcome was any clinically significant bleeding according to BARC (Bleeding Academic Research Consortium) criteria at 12 months. The pharmacodynamic response is accessed by VerifyNow P2Y12 reaction unit (PRU) at 1 month and 3 months post PCI.

Results

Ticagrelor achieved significantly lower PRU (7 [4–32] vs. 11 [5–76] vs. 167 [97–212]) than prasugrel and clopidogrel, resulting OPR rate 0% vs. 21.6% vs. 58.5%, respectively at 1 month post PCI. Similar results were observed at 3 months (PRU 12 [6–43] in ticagrelor vs. 88 [58–148] in prasugrel vs. 169 [107–199] in clopidogrel), with OPR rate 7.1% vs. 51.5% vs. 65.9%, respectively. At 12 months, the incidence of BARC type-1 or -2 bleeding was significantly higher in potent P2Y12 inhibitors (37.5% in ticagrelor, 34.2% in prasugrel) than in clopidogrel (36.0 vs. 14.0%; HR, 2.86; 95% CI, 1.19–6.87; p=0.018).

Conclusion

In Korean ACS patients, pharmacodynamic response (OPR rate) with half-dose prasugrel appears comparable to that with clopidogrel, whereas ticagrelor still exhibit potent platelet inhibition either standard or half doses. De-escalation strategy with half-dose potent P2Y12 inhibitor was associated with higher incidence of clinically insignificant bleeding compared with clopidogrel. Optimal dose reduction strategies in potent P2Y12 inhibitors to balance safety and effectiveness remain uncertain, and require further studies.

Pharmcodynamics to oral P2Y12 inhibitors

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): National Research Foundation of Korea
Ticagrelor versus Clopidogrel in high bleeding risk patients presenting with Acute Coronary Syndromes: insights from the multicenter START-ANTIPLATELET registry
Authors: Gragnano F , Moscarella E , Calabro' P , Cesaro A , Pafundi P.C , Patti G , Antonucci E , Cirillo P , Pignatelli P , Palareti G , Pelliccia F , Sasso F.C , Pengo V , Gresele P , Marcucci R
Published: November 2020

Background

Optimal dual antiplatelet therapy in high bleeding risk (HBR) patients with acute coronary syndromes (ACS) remains debated. Although current guidelines recommend the use of potent P2Y12 inhibitors in these patients (according to the labeled indications), clopidogrel is frequently used in clinical practice based on a perceived advantage in terms of safety in the HBR population.

Purpose

We sought to investigate the use of clopidogrel versus ticagrelor in consecutive HBR ACS patients and their impact on ischemic and bleeding events at 1 year.

Methods

ACS patients enrolled in the START-ANTIPLATELET registry with at least 1 HBR criterion were included in the present analysis and stratified according to DAPT type (clopidogrel versus ticagrelor). The primary endpoint was net adverse clinical endpoint (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. The secondary endpoints were major adverse cardiac and cerebral events (MACE), defined as a composite of all-cause death, myocardial infarction and stroke, each individual component of NACE and MACE, and target vessel revascularization.

Results

Among a total of 1,209 patients with 1-year follow-up in the registry, 383 patients were considered at HBR, of whom 174 (45.4%) were on clopidogrel and 209 (54.6%) on ticagrelor. Clopidogrel was more likely to be administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group than in the clopidogrel group (10.40±4.29 versus 9.35±5.4; p-value=0.03). At 1-year follow-up, the risk of NACE and MACE events was significantly higher in the clopidogrel than in the ticagrelor group (NACE: HR 1.82; 95% CI 1.07–3.09; p-value=0.02; MACE: HR 1.83; 95% CI 1.04–3.24; p-value=0.03) (Figure). After multivariate adjustment for clinical and procedural characteristics, no difference in NACEs nor MACEs was observed between patients on clopidogrel versus ticagrelor (NACE: adjusted HR 1.27; 95% CI 0.71–2.27; p-value=0.42; MACE: adjusted HR 1.19; 95% CI 0.63–2.24; p-value=0.59) (Figure). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs.

Conclusions

In a real-world ACS registry, approximately 50% of patients are at HBR and frequently treated with clopidogrel. In HBR ACS patients, no difference was observed in ischemic and bleeding events between clopidogrel and ticagrelor after adjustment for potential confounders.

Kaplan-Meier curves at 1-year follow-up.

Funding Acknowledgement

Type of funding source: None
Pharmacodynamic comparison of optimal platelet reactivity by multiple platelet function tests in Korean acute coronary syndrome patients with half-dose ticagrelor or prasugrel treatment
Authors: Kim M.H , Jin C.D , Song K , Lee G.M , Moon H.Y , Jo Y.S , Yoon C.H , Cho Y.R , Park J.S , Lim K.H
Published: November 2020

Background

East Asians treated with potent P2Y12 inhibitors, prasugrel or ticagrelor exhibit more potent platelet inhibition than clopidogrel. Whether half-dose de-escalation strategy would improve optimal platelet reactivity at maintenance in East Asian patients with acute coronary syndrome (ACS) remains uncertain.

Method

In de-escalation strategy single center study, eligible Korean ACS patients (n=96) were assigned to receive standard-dose ticagrelor (n=33), prasugrel (n=28), followed by half-dose reduction at 1 month for maintenance, and clopidogrel (n=35) as control. Platelet reactivity was measured by VerifyNow, light transmittance aggregometry (LTA) and multiple electrode aggregometry (MEA). The investigators aim to compare optimal platelet reactivity status (OPR, defined as 85–208 P2Y12 reaction unit [PRU] for VerifyNow (VN), 16%–47% for LTA and 19–46 U for MEA) among 3 different platelet function tests at 3 months post PCI.

Results

At 3 months, ticagrelor achieved significantly lower PRU (17 [6–51] vs. 95 [61–151] vs. 172 [111–204]) than prasugrel and clopidogrel, resulting OPR rate 10% vs. 57.7% vs. 60.0%, respectively. Similar results were observed at LTA method (2% [0–12] in ticagrelor vs. 18% [13–22] in prasugrel vs. 18% [11–30] in clopidogrel), with OPR rate 11.8% vs. 69.2% vs. 50.0%, respectively. However, platelet reactivity was similar by MEA method (16 [13–20] in ticagrelor vs. 17 [13–22] in prasugrel vs. 19 [14–28] in clopidogrel), with OPR rate 33.3% vs. 40.0% vs. 42.0%, respectively (all p>0.005). Among the three tests, resulting higher correlation between VN and LTA (r=0.745), MEA and LTA vs. MEA and VN showed lower correlations (r=0.412 and r=0.303). (Fig.)

Conclusion

In Korean ACS patients with half-dose de-escalation strategy after 1 month, OPR rate in ticagrelor is still rare during 3-month treatment by VN and LTA methods, however, prasugrel appears comparable to clopidogrel. VN/LTA might overestimate platelet function than MEA or MEA underestimate OPR rate than VN/LTA.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): National Research Foundation of Korea
Sheathless guiding catheter versus “slender” sheath/guiding catheter combination in acute coronary syndrome: a propensity-matched analysis of two downsized devices
Authors: Isawa T , Horie K , Honda T
Published: November 2020

Purpose

We investigated the differences between a sheathless guiding catheter and a Glidesheath slender/guiding catheter combination regarding access-site complications in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS).

Methods

We enrolled consecutive 1108 patients undergoing transradial primary PCI for ACS at our hospital using either a 7.5-Fr sheathless guiding catheter (Sheathless group) or a 7-Fr Glidesheath slender/7-Fr guiding catheter combination (Glidesheath group); 1:1 propensity score matching was performed, and 718 subjects (359 in each group) were included in the propensity-matched sample.

Results

Compared with the Sheathless group, the Glidesheath group had significantly less frequent ultrasound-diagnosed radial artery occlusion at 30 days (Sheathless: 4.7% vs. Glidesheath: 1.4%, p=0.015). No significant differences were observed in severe radial spasm (Sheathless: 1.4% vs. Glidesheath: 2.0%, p=0.77) or access-site bleeding (Sheathless: 9.8% vs. Glidesheath: 8.6%, p=0.70).

Conclusion

Thus, 7-Fr Glidesheath slender/7-Fr guiding catheter combination is clearly more advantageous than 7.5-Fr sheathless guiding catheters for decreased risk of radial artery occlusion in transradial PCI for ACS.

“Sheathless” vs. “Glidesheath slender”

Funding Acknowledgement

Type of funding source: None
Complete versus culprit-only PCI in patients with STEMI and multivessel disease: a systematic review and meta-analysis of randomized controlled trials
Authors: Levett J.Y , Windle S.B , Filion K.B , Cabaussel J , Eisenberg M.J
Published: November 2020

Background

Approximately half of patients with ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (CAD) during primary percutaneous coronary intervention (PCI).

Purpose

To compare the risks of major cardiovascular outcomes and procedural complications in patients with STEMI and multivessel CAD randomized to complete revascularization versus culprit-only PCI.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing complete to culprit-only PCI, identified via a systematic search of MEDLINE, Embase, and the Cochrane Libraries. Count data were pooled using DerSimonian and Laird random-effects models with inverse variance weighting to obtain relative risks (RRs) and corresponding 95% confidence intervals (CIs).

Results

A total of 8 RCTs (n=6,632) were included, with mean/median follow-up times ranging from 6 to 36 months. Compared to culprit-only PCI, complete PCI was associated with a substantial reduction in MACE (12.6% vs. 22.0%), repeat myocardial infarction (4.5% vs. 6.9%), and repeat revascularization (3.3% vs. 12.1%) (Table 1). Complete PCI may also improve all-cause and cardiovascular mortality, but estimates were accompanied by wide 95% CIs. Findings for stroke, major bleeding, and contrast-induced AKI were inconclusive.

Conclusion

Complete revascularization appears to confer benefit over culprit-only PCI in patients with STEMI and multivessel CAD, and should be considered a first-line strategy in these patients.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Mr. Levett is supported by a Dr. Clarke K. McLeod Memorial Scholarship, funded through the McGill University Faculty of Medicine Research Bursary Program. Dr. Filion is supported by a Junior 2 Research Scholar award from the Fonds de recherche du Québec – Santé and a William Dawson Scholar award from McGill University.
Gender in non- ST elevation myocardial infarction and unstable angina: is there any equality?
Authors: Lopes J , Saleiro C , Campos D , Sousa J , Puga L , Gomes A , Ribeiro J , Lourenco C , Silva J , Goncalves L
Published: November 2020

Background

Historically, women (W) with acute coronary syndrome (ACS) have worse outcomes compared with men (M). This fact may occur due to gender-specific differences in the presentation and management of patients (P), which were mainly observed in studies dealing with ST-segment elevation infarction (STEMI). There seems to be a gap of knowledge in gender-specific differences in non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA).

Purpose

Assess gender-specific differences in presentation, treatment and outcomes in NSTEMI and UA patients.

Methods

A retrospective cohort study from consecutive ACS patients enrolled in a multicentre national registry from October 2010 to December 2018 was conducted, identifying 11394 P admitted with NSTEMI or UA. Demographic, clinical and treatment variables were compared between male gender and female gender P.

A Cox multivariate regression was performed to evaluate predictor factors of stablished endpoints: mortality at 1-year (1y) and cardiovascular (CV) hospitalization at 1-year.

Results

A total 11394 P were included, 8145 M (71.5%) and 3249 W (28.5%), mean age of 68±13. W, comparing with M, had higher age (72±12 vs 66±13, p=0.001), higher prevalence of hypertension (85% vs 72%, p=0.001) and diabetes (41% vs 34%, p=0.001) and longer time from symptoms to hospital admission (360 minutes vs 297 minutes, p=0.001). Chest pain was less frequent as first symptom in W (85.6% vs 91.3%, p=0.001). In medical treatment, W had higher chance of not having administration of a loading dose of P2Y12 inhibitor (22.1% vs 18.1, p=0.001) and of being medicated with clopidogrel (85.7% vs 82.1%, p=0.002). At discharge, W were less frequently medicated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (82.6% vs 84.4, p=0.028). Coronary angiography was less frequently performed in W (77.3% vs 85.7%, p=0.001). Coronary artery disease was less frequently found in the female gender (12.4% vs 4.8%, p=0.001).

In-hospital mortality was higher in W (2.9% vs 2.1%), but in the multivariate analysis the female gender was not an independent predictor of in-hospital mortality (OR 1.05 [0.67- 1.65], p=0.823). 1-year mortality was higher in W (9.2% vs 7.3%) and 1-year CV hospitalization was higher in M (16.8% vs 14.4%). After adjusting for covariates in Cox regression analysis, difference was still significant for mortality (HR= 1.274 [1.038 - 1.564], p=0.02) and hospitalization (HR = 0.852 [0.726- 0.998], p=0.047).

Conclusion

In this NSTEMI and UA cohort, there are important gender-specific differences in comorbidities, diagnosis, management and outcomes. Gender was an independent predictor of 1-year mortality and 1-year CV hospitalization, but not an independent predictor for in-hospital mortality.

Funding Acknowledgement

Type of funding source: None
Clinical assessment and angiographic finding in patients with non ST-elevation myocardial infarction
Authors: Elbeyali M
Published: November 2020

Background

Non ST-elevation myocardial infarction is considered the intermediate form of acute coronary syndrome between unstable angina and ST-elevation myocardial infarction. Blockage either occurs in a minor coronary artery or causes partial obstruction of a major coronary artery. The rate of NSTEMI has increased to be 50% of all acute coronary syndrome.

Purpose

To compare some demographic, clinical risk assessments and angiographic data among high, intermediate and low risk NSTEMI patients.

Methods

We classified one hundred twenty (120) NSTEMI patients into 3groups by GRACE risk score (high risk group >140, intermediate risk group from 109 to 140 and low risk group ≤108). The patients were evaluated by personal history taking, risk factors, clinical examination, ECG, laboratory investigations, echocardiography and percutaneous coronary intervention.

Results

We found that low risk group percentage was 47.5%, intermediate risk group percentage was 32.5% and high-risk group percentage was 20%. As regarding culprit lesion, LAD represent most affected artery (48.3% of patients).Recurrent ischemia and MI represent the highest percentage of major adverse cardiac event (MACE) among studied groups. All patients with LM disease have a MACE while 41.2% of MACE patients have significant LAD lesion. As time of intervention delayed the incidence of MACE increases among different groups. High risk group has significantly high percentage of type C lesion and TIMI 0/1 while type A lesion and TIMI III lesion highest among low risk patients. As regarding contour of the lesion, the irregularity increases as the clinical risk increases. Also as regarding occlusion of culprit artery, the incidence of total occlusion increases as the clinical risk increases.

Conclusions

We recommend selection of high-risk NSTEMI patient to direct them for early invasive therapy. Very high-risk directed for immediate revascularization like STEMI patient. NSTEMI considered precursors to STEMI and an early warning signal that aggressive medical intervention needed.

Association between time to intervention

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University budget
Complete revascularization of non-culprit lesions in stemi is associated with improved myocardial salvage and reduced microvascular obstruction: a cardiac magnetic resonance study
Authors: Calvo M , Guzman J , Perez P , Ortega L.G , Mendieta G , Lorenzatti D , Perez N , Gavara J , Marcos Garces V , Brugaletta S , Sabate M , Bodi V , Ortiz Perez J.T
Published: November 2020

Background

The COMPLETE trial showed that routine and complete Percutaneous Coronary Intervention (PCI) of non-infarct related artery (non-IRA) lesions in STEMI was associated with a significant reduction in the rates of death or new myocardial infarction. However, whether this benefit is related to improved myocardial salvage and left ventricular (LV) function is unknown.

Methods

We prospectively included 465 patients with first STEMI reperfused by primary PCI. Late gadolinium-enhanced Cardiac Magnetic Resonance (CMR) was obtained during admission to measure the area at risk (AAR), IRA-infarct size (IS) as % LV mass, and myocardial salvage index (MSI) as % of AAR. The study was repeated in 392 of them at 6 months follow-up to compute LV volumes and ejection fraction (EF).

Results

Patients with three-vessel disease had larger IS than those with two or single vessel disease (25.4±14.5% vs 19.0±13.1% vs 19.0±12.8% LV mass respectively, p<0.05), despite no differences in AAR (33±11% LV mass for all). Accordingly, MSI decreased progressively for one, two or three-vessel disease (42.4±31.4 vs 41.5±30.6 vs 25.1±31.3% AAR respectively, p<0.01). The number of myocardial segments with microvascular obstruction (MVO) was also higher for three-vessel disease (1.9±1.9) than for two (1.1±1.7) or single-vessel disease (1.2±1.8), p<0.05. Mean follow-up EF also decreased progressively with the number of vessels involved (50.7±9.4, 49.1±11.4 and, 44.4±11.2% respectively, p<0.01). A total of 183 patients had multivessel disease. Among them, those with complete revascularization (n=51) had larger MSI (46.4±35.2 vs 34.5±29.3% AAR, p<0.04) and were less likely to have MVO phenomenon (28.6 vs 49.2%, p<0.05). However, no significant differences in the change in EF was observed between both groups (ΔEF:+4.4±6.2 vs +4.3±6.2%, p=0.985 for the interaction).

Conclusion

The presence and extent of multivessel disease influence myocardial salvage and MVO following primary PCI in STEMI. Improvement in myocardial salvage in the IRA territory and a reduction in microvascular obstruction may mediate the beneficial effects of complete revascularization.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Fundaciό La Marato TV3 2015303132, FIS PI15/00531. Partially funded with FEDER funds.
The clinical significance and prognostic value of early second peak of hs-troponin t in patients successfully treated with primary pci
Authors: Ohtaroglu K , Durmaz E , Karadag B , Raimoglu U , Mutlu D , Tokdil H , Karaca O , Polat F , Ozmen E , Koca D , Incesu G , Ongen Z
Published: November 2020

Background

It was previously demonstrated that in patients with ST segment elevation myocardial infarction (STEMI) high-sensitive troponin-T (Hs-cTnT) makes two peaks. However, the clinical significance of the second peak (early vs late) in patients undergoing successful primary percutaneous intervention (pPCI) is not known. We investigated the role of early second peak on clinical outcomes.

Methods

Patients who underwent successful pPCI were included. Baseline characteristics, angiographic variables and kinetics of Hs-cTnT levels following pPCI were recorded. Second peak of Hs-cTnT was defined as re-elevation of troponin levels above plateau levels. The second peak of Hs-cTnT is defined as early second peak, if re-elevation is detected earlier than 72 hours after the diagnosis and late second peak, when re-elevation is detected later than 72 hours.

Results

We included 250 patients divided into two groups; patients with early second peak as group 1 (n=118) and rest of the patients as group 2 (n=132). Baseline characteristics and comorbidities were similar. Peak level of Hs-cTnT, Hs-CRP and pro-BNP levels were significantly lower in group 1 patients. Left ventricular ejection fraction was higher in group 1 patients (47.48±7.7 vs 43.80±9.3, p-value: 0.001). There was no significant difference with respect to new-onset heart failure (24% vs %28, p: 0.503) between groups however cardiac mortality was significantly lower in group 1 patients (%2 vs %11, p: 0.007).

Conclusion

The early second peak of Hs-cTnT in patients with STEMI is associated with successful reperfusion and predictors of better clinical outcome. Moreover, early second peak of Hs-cTnT is associated with decreased cardiac mortality and has a potential to be used as a marker of good prognosis.

Funding Acknowledgement

Type of funding source: None