bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 4140858: Racial Disparities in Cardiovascular Outcomes Among Hospitalized Patients with Diabetes Mellitus
Authors: Nebuwa Chikodili , Bolaji Olayiwola , ECHARI BLANCHE , Mohammad Hazique , AGBEDIA-EJUGHEMRE UFUOMA , Shenoy Vishnu , Shoar Saeed , Alraies M Chadi
Published: November 2024

Introduction:
Patients with diabetes mellitus (DM) experience diverse cardiovascular outcomes; this study aimed to evaluate the racial disparities in cardiovascular outcomes among patients with diabetes mellitus.

Method:
We conducted a retrospective cohort study using the National Inpatient Sample (NIS) database 2016-2021 and ICD 10 code and identified patients with DM, categorized them based on their race. Baseline characteristics were compared using Pearson's χ2 tests and univariable linear regression. The cardiovascular outcomes were examined using multivariable logistic regression. Group comparisons were carried out using Wilcoxson signed-rank test for continuous and Pearson's χ2 tests for categorical variables.

Result:
We analyzed data from 47,384,595 hospitalizations for DM across racial groups in the US between 2016 and 2021. Baseline characteristics of DM among racial groups over the study period is illustrated in Table 1. The mean age was oldest among Whites (67.7 years) and Asian/Pacific Islanders (68.1 years). Cardiovascular outcomes differed across groups (Table 2). In-hospital mortality was highest among Asian/Pacific Islanders (4.3%) and lowest among Blacks (2.9%, p<0.001). Heart failure was most prevalent in Blacks (34.2%), while myocardial infarction rates were highest among Asian/Pacific Islanders (6.3%, p<0.001). Blacks and Native Americans had higher rates of ESRD (15.6% and 15.2%) than other groups, especially compared to Whites (5.8%). Amputation rates were also higher among Native Americans (6.7%) and Blacks (4.8%) than Whites (3.3%). After adjusting for demographics, hospital characteristics and comorbidities, racial minorities remained at higher risk for adverse outcomes compared to Whites. Blacks (aOR 2.19, 95%CI 2.16-2.21), Hispanics (aOR 2.54, 95%CI 2.50-2.58), Asian/Pacific Islanders (aOR 2.56, 95%CI 2.51-2.61) and Native Americans (aOR 2.87, 95%CI 2.72-3.01) all had over double the odds of ESRD. Blacks, Hispanics and Native Americans also had significantly higher adjusted odds of amputation. However, Blacks (aOR 0.66, 95%CI 0.64-0.69) and Hispanics (aOR 0.89, 95%CI 0.86-0.93) had lower odds of in-hospital mortality than Whites.

Conclusion:
This study highlights racial disparities in cardiovascular outcomes among hospitalizations of patients with DM. Further research should be done to explore contributing factors to these disparities to improve and curb these outcomes.
Abstract 4140859: Reverse Takotsubo Syndrome in Women at Different Stages after In Vitro Fertilization
Authors: Lee Alexander , Singh Siddharth , Wei Janet
Published: November 2024

Case Descriptions:
Takotsubo Syndrome (TTS) typically occurs in postmenopausal women who experience acute transient left ventricular (LV) systolic dysfunction that is most commonly apical, but may occur with other patterns such as a basal and midventricular “reverse” type. TTS pathophysiology has been attributed to catecholamine cardiotoxicity, microvascular dysfunction, and estrogen deficiency, although the mechanisms for reverse TTS (rTTS) remain to be elucidated. Here, we share rTTS cases of premenopausal women who underwent recent in vitro fertilization (IVF), suggesting a link between altered hormone milieu and basal LV dysfunction in the setting of TTS.

Patient 1:
A 35-year-old G0P0 woman presented immediately after IVF egg retrieval for hypotension and hemoperitoneum. TTE revealed EF 18% with basal-mid LV akinesis and preserved LV apical contraction. After 5 days of diuresis and vasopressor weaning, TTE showed improved EF 38%. TTE 15 days later demonstrated recovery of wall motion, EF 50%.

Patient 2:
A 36-year-old G3P1011 woman at 16 weeks gestation from IVF pregnancy was admitted with acute respiratory failure. TTE showed EF <20% with basal-mid LV hypokinesis and apical sparing. Her worsening respiratory failure required intubation and ultimately ECMO. TTE 6 days later showed EF 63% without wall motion abnormalities.

Discussion:
Previous studies suggest that rTTS has higher prevalence in pregnant and younger women compared to apical TTS. Hypotheses of contributing mechanisms are two-fold: 1) estrogen is protective against catecholamine surges, and 2) estrogen receptors have increased concentration towards the LV apex. IVF and pregnancy are both associated with high estrogen levels. As such, our cases provide additional support for estrogen’s cardioprotective role, which may disproportionately assist the LV apex, favoring the rTTS variant. Both cases had emotional and/or physical stressors, no EKG ST elevation, and no coronary artery lesions or preexisting heart disease. Estrogen and catecholamine levels were not drawn, thus limiting our understanding. Although these cases suggest a hormonal influence on rTTS variant, the pathophysiology of TTS variants remains elusive and is likely multifactorial.
Abstract 4140865: Clinical Outcomes Of P2Y12 Inhibitor Monotherapy Versus Dual Antiplatelet Therapy After Percutaneous Coronary Intervention In Patients With Acute Coronary Syndrome: A Meta-Analysis Of Randomized Controlled Trials
Authors: Gupta Soumya , Thakkar Aditya , Aggarwal Devika , Bhatia Kirtipal , Choi James , Carter Kristen , kaur Arpanjeet , Casso Abel
Published: November 2024

Introduction:
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended after percutaneous coronary intervention (PCI) to lower the risk of cardiovascular events. However, prolonged DAPT has been shown to increase bleeding risk, while some studies have shown that shorter-duration of DAPT followed by aspirin alone increases ischemic risk.

Research question:
This study aimed to compare the risks and benefits of monotherapy with P2Y12 inhibitors and DAPT after PCI.

Methods:
We searched the Medline, Embase, and Cochrane databases for randomized controlled trials (RCTs) involving adult patients hospitalized with ACS who underwent PCI. Our primary outcome was the composite of death, myocardial infarction (MI), and stroke. The secondary outcomes were net adverse clinical events (NACEs which is the primary outcome and risk of major bleeding), all-cause mortality, cardiac death, MI, stroke, stent thrombosis, target vessel revascularization, clinically relevant bleeding, and major bleeding. We used Review Manager 5.4 for the statistical analysis, employing risk ratios (RRs) with 95% confidence intervals (CIs).

Results:
Nine RCTs were included, involving a total of 34,322 patients, with 48.9% receiving P2Y12 inhibitor monotherapy after 1–3 months of DAPT. Regarding the primary outcomes, the risk of the composite of all-cause mortality, MI and stroke was significantly lower in patients receiving P2Y12 monotherapy as compared to patients on DAPT (RR 0.91[95% CI 0.84–0.98], I2=0%, p=0.01).

With respect to the secondary outcomes, there was a significantly lower risk of NACEs (RR 0.86 [95% CI 0.76–0.97], I2=58%, p=0.01), clinically relevant bleeding (RR 0.59 [95% CI 0.38–0.93], I2=92%, p<0.00001), major bleeding (RR 0.57 [95% CI 0.40–0.82], I2=79%, p=0.002) as well as cardiac death (RR 0.80 [95% CI 0.64–0.99], I2=0%, p=0.04) in patients receiving P2Y12 inhibitor monotherapy. There was no significant difference in the risk of all-cause mortality, MI, stroke, target vessel revascularization, and stent thrombosis between the 2 groups.

Conclusion:
This meta-analysis found a significant decrease in the risk of the composite of death, MI, and stroke in patients receiving P2Y12 inhibitor monotherapy. It also showed that the risk of net adverse clinical events and major bleeding is lower in patients receiving P2Y12 inhibitor monotherapy.
Abstract 4140880: Clinical Hepatic Scores as Predictors of Major Adverse Cardiovascular Events in a SMuRFless Population
Authors: Alebna Pamela , Ambrosio Mathew , Sebastian Blessan , Bolden Gabrielle , Akakpo Divine , Chew Nicholas , Mehta Anurag
Published: November 2024

Background:
Recent evidence suggests that a significant proportion of individuals presenting with myocardial infarction lack standard modifiable cardiovascular disease risk factors (SMuRFs). This SMuRFless population has an elevated risk of mortality, highlighting the need for identifying novel risk markers. Liver steatosis and fibrosis are potential non-traditional markers that have not been evaluated in this population. Therefore, this study investigates clinical hepatic scores as proxies for metabolic liver disease and their association with major adverse cardiovascular events (MACE) in a SMuRFless population within the UK Biobank.

Methods:
We analyzed data from the UK Biobank, a population-based cohort study with a median follow-up of 11 years. The Fatty Liver Index (FLI), Hepatic Steatosis Index (HSI), and Fibrosis Index Based on 4 Factors (FIB-4) were used as non-invasive measures to predict metabolic dysfunction-associated steatotic liver disease, hepatic steatosis, and hepatic fibrosis, respectively. Participants with hypertension, hyperlipidemia, diabetes, or cigarette smoking (SMuRFs) were excluded. Cox proportional hazards models were used to assess the association between FLI, HSI, and FIB-4 scores and MACE, defined as fatal and non-fatal myocardial infarction, stroke, and peripheral artery disease.

Results:
Among 81,339 SMuRFless participants, the mean age was 51.5 years (SD 7.9), and 50,347 (62%) were women. In unadjusted models, higher liver scores (FLI, HSI, and FIB-4) were significantly associated with MACE. Participants with FLI > 60 had a hazard ratio (HR) of 2.01 (95% CI: 1.68-2.41) compared to those with FLI < 60. Those with HSI > 36 had HR of 1.38 (95% CI: 1.14-1.54) compared to HSI < 36, and participants with FIB-4 > 2.67 had an HR of 4.17 (95% CI: 3.27-5.31) compared to FIB-4 < 1.3. However, after adjusting for age, race, hemoglobin A1C, triglycerides, LDL-cholesterol, total cholesterol, body mass index (BMI), and creatinine, these associations were attenuated, and HRs were not statistically significant (Table).

Conclusion:
FLI, HSI, and FIB-4 scores are not significant predictors of MACE in a SMuRFless asymptomatic population after adjusting for confounders.
Abstract 4140895: Pre-procedural Red Cell Distribution Width As A Prognostic Biomarker In Patients Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta Analysis
Authors: Subramanian Lakshmi , Srikanth Sashwath , Devaprasad Nikitha , Liu Jinye , Shan Zoofi , Podduturi Pavan Vihar Reddy , Jindal Urmi , Patel Divyank , Desai Rupak
Published: November 2024

Background:
Red cell distribution width (RDW) is a measurement of variability in erythrocyte size and volume, routinely reported as part of a complete blood count. Recently, it has gained popularity as a novel prognostic biomarker for cardiovascular disease outcomes. Our study investigates the predictive value of pre-procedural RDW for all-cause mortality (ACM) within one year for patients undergoing transcatheter aortic valve implantation (TAVI).

Methods:
We comprehensively reviewed databases like PubMed, Google Scholar, Embase, and Scopus until May 2024, looking for studies reporting an association between pre-procedural RDW and outcomes in TAVI. A binary random effects model was used to calculate the pooled adjusted odds ratio (aOR), and subgroup analysis was performed. I2 statistics were used to determine the heterogeneity of studies, further enhancing the robustness of our research.

Results:
Our systematic review and meta-analysis included five studies (three retrospective, two prospective) encompassing 2,565 patients with a mean age of 81.32 years. Our study showed a slight female predominance (52%). The mean follow-up period was one year. Comorbidities like coronary artery disease, diabetes melitus, atrial fibrillation, prior myocardial infarction were commonly reported among the study population. Higher pre-procedural RDW was associated with increased odds of ACM at the end of one year with an unadjusted pooled OR 1.86 (95% CI: 1.30-2.67, p<0.01) and adjusted pooled aOR 2.21 (95% CI: 1.81-2.69, p< 0.01) (Figure 1). Leave one out sensitivity analysis confirmed the robustness of the meta-analysis, as no single study disproportionately affected the overall results.

Conclusion:
Our study demonstrates the potential of pre-procedural RDW as a prognostic biomarker for predicting 1-year ACM in post-TAVI patients. However, further research is warranted to fully elucidate the role and mechanism of RDW in this context.
Abstract 4140896: Variations in BNP Levels (35-100 pg/mL) and Their Implications for Predicting Future Heart Failure in Pre-clinical Stages A/B: Novel Risk Stratification Methods from the CHART-2 Study
Authors: Takahama Hiroyuki , Nochioka Kotaro , Miyata Satoshi , Hayashi Hideka , Inoue Takumi , Susukita Kai , Oyama Kazuma , Shiroto Takashi , takahashi jun , Shimokawa Hiroaki , Yasuda Satoshi
Published: November 2024

Background:
Recent revisions in the guidelines for pre-clinical heart failure (HF), particularly concerning B-type natriuretic peptide (BNP) levels between 35-100 pg/mL, indicate a more detailed approach.

Research question:
1) BNP is influenced by several factors, including age, leading to potential variation in BNP's predictive value for future HF events. 2) Risk stratification for HF in the pre-HF state (BNP levels: 35-100 pg/mL) has not been established.

Hypothesis:
We hypothesized that variations in BNP values predicting HF events exist in association with specific clinical variables.

Methods:
We prospectively evaluated consecutive HF patients in Stage A/B (stage A/B: 731/4,537) from the multicenter observational CHART-2 (Chronic Heart Failure Registry and Analysis in the Tohoku District-2) Study. Previous studies identified the following parameters for BNP levels: age, body mass index (BMI), and estimated glomerular filtration rate (eGFR). We assessed their 10-year HF-related events.

Results:
The enrolled patients had the following characteristics: mean age 67.6±12.0 years, 71.1% male, BMI 24.2±12.0 kg/m
2
, and eGFR 67.4±19.2 ml/min/1.73m
2
. As shown in
Figures 1A-C
, variations in AUC and cut-off values exist in each category (A: age quartiles, B: BMI per WHO criteria, and C: eGFR). The minimum cut-off value was 38.25 pg/mL in the youngest quartile. We performed risk stratification for those with BNP values of 35-100 pg/mL (n=1412) using classification and regression tree (CART) methods, identifying these cut-off values as shown in
Figure 2
. The hazard ratios (HR) for HF events were significantly higher in type 2 (age <74.5 years, eGFR <45.5 ml/min/1.73m
2
) (HR: 3.97, 95% CI: 2.43-6.50) and 4 (age >74.5 years, BNP >50.9 pg/mL) (HR: 3.94, 95% CI: 2.88-5.38) compared to type 1 (both, P<0.001).

Conclusion:
Although variations in BNP cut-off values predicting HF events exist, the guideline-recommended value (>35 pg/mL) encompasses all at-risk patients in Stage A/B.
Abstract 4140903: Long-Term Clinical Outcomes in Definite versus Intermediate Ergovonine Provocation response in Multivessel Vasospastic Angina Patients
Authors: Joo DongHyeon , Ahn Youngkeun , Kim Ju Han , Sim Doo Sun , Hong Young Joon , Cho Kyung-Hoon , Ahn Joon Ho , Lee Seung Hun , Hyun Dae Young , Lim Yongwhan , Oh Seok , Lee Yong-Kyu , Park Seong Ho
Published: November 2024

Background:
Patients with multivessel coronary spasm showed relatively poor outcomes in vasospastic angina. Recent report also revealed that Ergovonine response definite group showed poor clinical outcomes compared to the Ergovonine response intermediate group. The purpose of this study is to evaluate the clinical impact of Ergovonine provocation definite or intermediate response in multivessel vasospastic angina patients.

Methods:
A total of 428 patients between May 2010 to November 2013, diagnosed as multivessel vasospastic angina who were registered in the Vasospastic Angina Korea (VA-KOREA) were enrolled. Patients were divided into Ergovonine provocation response definite group (n=111) and intermediate group (n=317). The primary endpoint was cumulative incidece of cardiac death, new onset arrhythmia, acute coronary syndrome, re-admission due to chest pain during 3 years follow-up.

Results:
In the baseline clinical chracteristics, Ergovonine response definite group had less proportion of male patients (32.4% vs. 49.8%, p=0.002). Other conventional cardiovascular risk factors were similar between two groups. In the angiographic characteristics, electrocardiogram changes during Ergovonine provocation was higher in the deinite group including ST change (18% vs 10.7%; p=0.046), ST elevation (16.2% vs 2.8%; p<0.001), ST depression (7.2% vs 2.5%; p=0.009), induced arrhythmia (27.9% vs 15.5%; p=0.004). Combined atherosclerotic lesion was also higher in the definite group (29.7% vs 15.5%; p=0.001). Prescrpition rate of Calcium channel blocker was lower in the intermediate group compared to the definite group (93.7% vs. 83.6%; p=0.008). The incidence of primary end point was not statistically signficant in both groups (10.8% vs. 14.5%; p=0.327). Multivariative cox regression analysis revealed that Ergovonine provocation response had no significant clinical impact in multivessel vasospastic angina patients (adjusted harzard ratio [HR] 0.64; 95% confidence interval [CI] 0.32 – 1.28; p=0.207).

Conclusion:
The present study indicates that Ergovonine provocation response is not an independent prognostic factor in multivessel vasospastic angina patients. Thus, intensive medical treatment and risk control should be carried out in both patient groups.
Abstract 4140909: In vitro model of restrictive cardiomyopathy using engineered heart tissue reflecting impaired relaxation
Authors: Hasegawa Moyu , Miki Kenji , Kawamura Takuji , Tsuchida Masaru , Kashino Kunio , Ishida Hidekazu , Miyagawa Shigeru
Published: November 2024

Introduction:
Restrictive cardiomyopathy (RCM) is a rare cardiomyopathy characterized by ventricular diastolic dysfunction. There is limited research on RCM due to the lack of an in vitro model for diastolic dysfunction. Recently, engineered heart tissue (EHT) has significantly advanced disease modeling and drug discovery as a model reflecting contractile dynamics in vivo. Here, we evaluate the relaxation impairment of EHTs generated from an RCM patient using the Phase-Only Correlation (POC) method.

Methods:
An iPSC line from a pediatric patient with severe RCM harboring the TNNI3 R170W mutation (R170W-iPSC) was generated. An isogenic iPSC line corrected for the mutation was also established using CRISPR/Cas9 technology. The EHTs were created by casting into pillar system using cardiomyocytes differentiated from iPSCs (Figure 1). Video microscopy was used to track one-dimensional pillar deflection under 1 Hz stimulation. The force generation of EHTs was analyzed with POC method, a template-based image matching technique that estimates displacement between two images with subpixel accuracy by locating the correlation peak. We defined the contractile force and the relaxation force using the force waveform calculated from the pillar deflection (Figure 2a).

Results:
The calculated force at the maximum pillar deflection, showed no difference between R170W-EHT and Isogenic-EHT (Figure 2b). The time for the pillar deflection to decrease from 100% to 20% during relaxation, the time to relaxation, was significantly longer in R170W-EHT than in Isogenic-EHT (Figure 2c). These findings indicated impaired relaxation of R170W-EHT. Furthermore, the ratio of contractile force to total force was lower and the ratio of relaxation force to total force was higher in R170W-EHT than in Isogenic-ETH (Figure 3a and 3b). In addition, the ratio of relaxation force to contractile force was significantly higher in R170W-EHT (Figure 3c). These data showed that R170W-EHT required greater force to dilate.

Conclusions:
Our EHT model with POC method reflects the clinical manifestation of RCM with diastolic dysfunction by comparing the contractile and relaxation forces and their ratio in vitro.
Abstract 4140912: Patient Demographics and Appropriateness of Elective Percutaneous Coronary Intervention in a Brazilian Cardiology Center
Authors: Del Vecchio Ziotti Sara , Pereira Thiago , grobe sarah , Serrano Carlos , CESAR LUIZ , Abizaid Alexandre , Gowdak Luis Henrique
Published: November 2024

Background:
The “Appropriate Use Criteria for Coronary Revascularization” guide clinicians in delivering high-quality care and optimizing medical resource utilization. While previous studies have indicated an approximately 10% rate of inappropriateness of non-acute percutaneous coronary interventions (PCI), there is a lack of similar data in Brazil.

Research Question:
This study sought to determine the rate of appropriate elective PCI at a cardiology reference hospital in Brazil.

Goals:
The primary goal was to ascertain the frequency of elective PCI categorized as appropriate, potentially or rarely appropriate. The secondary objective aimed to identify patient characteristics associated with PCI inappropriateness.

Methods:
In this retrospective study, we included stable patients with chronic coronary syndromes (CCS) who underwent elective PCI between 2017 and 2020 at a cardiology hospital in Sao Paulo, Brazil. The appropriateness of the PCI was assessed using the ACC/AHA criteria proposed in 2017. The adequacy of the procedure was assessed at the “territory level” of the coronary arteries (left main [LM], left anterior descending [LAD], circumflex [CX], and right coronary artery [RCA]). Clinical variables associated with rarely appropriate PCI were identified from the cohort of patients with single-vessel procedure.

Results:
467 patients underwent 474 elective PCI with 543 treated coronary territories. We classified 59 (10.9%), 263 (48.4%), and 221 (40.7%) PCI as rarely appropriate, possibly appropriate, and appropriate, respectively. Single-vessel PCI was found in 332 patients. Factors associated with an increased rate of rarely appropriate were male (OR 2.83, 95% CI 1.14-7.02), no symptoms (OR 8.24, 95% CI 3.79-17.91), and having a positive functional test (OR 13.12, 95% CI 3.94-43.72). Factors associated with a decreased rate of rarely appropriate were depending on the public health system (OR 0.20, 95% CI 0.095-0.43), previous myocardial infarction (OR 0.21, 95% CI 0.07-0.6), previous PCI (OR 0.22, 95% CI 0.08-0.63), and current use of beta-blockers (OR 0.24, 95% CI 0.12-0.49).

Conclusion:
Rarely appropriate PCI was more prevalent among asymptomatic men with no previous myocardial infarction, not adequately medicated, and having a private health plan. These findings suggest a possible overuse of elective PCI in those patients, prompting health care providers to carefully review the indications of a costly, potentially risky procedure such as PCI.
Abstract 4140921: Characteristics and Outcomes for Patients with Adult Congenital Heart Disease after Initiation of Dialysis for End-Stage Kidney Disease
Authors: Vasudeva Rhythm , Chan Wan Chi , Vlach Michael , Patel Kunal , Majmundar Monil , Alarfaj Mohammad , Vindhyal Mohinder Reddy , gupta Kamal , Serfas John
Published: November 2024

Background:
In a growing and aging adult population with congenital heart disease (CHD), the prevalence of renal dysfunction is increasing. There is paucity of information regarding the prevalence, spectrum of and outcomes in adult CHD patients with end-stage kidney disease (ESKD).

Aims:
To determine baseline characteristics of adult patients with ESKD and CHD, grouped by complexity, and to compare their mortality and morbidity outcomes to non-CHD patients.

Methods:
We analyzed the United States Renal Data System to identify patients ≥ 18 years of age initiating long-term dialysis between 2006 and 2020. Patients were grouped by complexity of CHD - Simple, Moderate and Complex based on ICD codes. We assessed mortality and hospitalization outcomes at 1 and 3 years by comparing percentages and adjusted hazard ratios using the Fine-Gray sub distribution hazard model. Kaplan-Meier curves were also generated.

Results:
A total of 1513 patients with CHD were identified. The mean age was 65.8 years with complex CHD being the youngest cohort. About 55% of patients were male and White race was the most prevalent. While patients with CHD had a higher prevalence of heart failure and arrhythmias at baseline, patients with complex CHD had especially unique characteristics. They demonstrated a higher prevalence of liver disease, thromboembolism, and causes of ESKD not related to hypertension or diabetes; a lower prevalence of CAD and CVA/TIA; and a shorter time to first hospitalization. Patients with simple [HR 0.67 95% CI (0.53 – 0.85)] and moderate CHD [HR 0.70 (0.60 – 0.81)] had significantly less mortality at 1 year compared to non-CHD patients, with similar findings at 3 years. Hospitalization rates and admissions for CHF exacerbation at 1 year and 3 years were significantly higher amongst all CHD patients, especially in complex CHD (80.4% vs 61.4% in non-CHD patients at 1 year). Kaplan-Meier curves (see Figure) over a 10-year follow-up showed significantly lesser mortality and increased hospitalizations amongst CHD patients (p <0.0001).

Conclusion:
Patients with CHD and ESKD have better long-term survival than patients without CHD upon initiating dialysis despite higher rates of hospitalizations and heart failure admissions.
Abstract 4140929: The Usefulness of the Quick Forrester Classification with Respiratory Rate and Serum Lactate Levels for Predicting Decreased Left Ventricular Function in Patients with ST-elevation Myocardial Infarction
Authors: Matsumoto Yosuke , Kawakami Shoji , Koga Hidenobu , Yamada Tetsuhisa , Nishi Jun-ichiro
Published: November 2024

Background:
Although respiratory rate (RR) is one of the vital signs, few studies have evaluated the association between respiratory rate at hospital arrival and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). Serum lactate levels, which can be rapidly measured in the emergency department, have been reported to be associated with prognosis in STEMI patients with or without cardiogenic shock. We hypothesized that profiling by RR, which reflects hypoxia or metabolic acidosis, and serum lactate level, which reflects tissue perfusion, at hospital arrival named the Quick Forrester Classification (QFC), would be associated with clinical outcomes in STEMI patients.

Methods:
This is a retrospective analysis of STEMI patients between 2018 and 2023. Patients were divided into 4 classifications: RR <22/min and lactate <2.0mmol/L (Class-1), RR ≧22/min and lactate <2.0mmol/L (Class-2), RR <22/min and lactate ≧2.0mmol/L (Class-3), RR ≧22/min and lactate ≧2.0mmol/L (Class-4) as the QFC. The primary outcome was decreased cardiac function (left ventricular ejection fraction [LVEF] less than 45% measured during hospitalization).

Results:
Of 592 STEMI patients (age, 71±13 years; male, 72%), 569 patients were classified by QFC (Class-1, n=156; Class-2, n=52; Class-3, n=213; Class-4, n=148). The proportion of patients with decreased cardiac function increased from 15% in Class-1, 13% in Class-2, 16% in Class-3 to 30% in Class-4 (P=0.003 for trend). Multivariable analysis revealed that a patient in QFC Class-4 was a significantly predictor of decreased LVEF when compared with a patient in QFC Class-1(Odds ratio [OR] 2.29, 95% confidence interval [CI] 1.15-4.55, p=0.018) as were age (OR 1.03, 95%CI 1.01-1.06, p=0.003), heart rate at hospital arrival (OR 1.03, 95%CI 1.02-1.05, p<0.001), and anterior wall infarction (OR 2.21, 95%CI 1.31-3.73, p=0.003).

Conclusion:
In STEMI patients, the QFC with RR and serum lactate level at hospital arrival was significantly associated with decreased LVEF.
Abstract 4140939: Platelet-to-Lymphocyte Ratio (PLR) as a Predictor of In-Hospital Mortality in Patients with First-Ever Acute Ischemic Stroke: A cross-sectional study from Ecuador.
Authors: Mautong Hans , Martinez Emilio , Banga Akshat , Noboa Carlos , Zevallos Juan
Published: November 2024

Background:
In-hospital mortality from acute ischemic stroke (AIS) remains a major concern in developing countries where access to thrombectomy or fibrinolytics is limited. Platelet-to-lymphocyte ratio (PLR) has been suggested as an inflammatory marker associated with poor outcomes in AIS. Therefore, we aim to evaluate the value of PLR as a predictor of in-hospital mortality in first-ever AIS.

Methods:
We evaluated the records of 293 patients with a first-ever AIS from a third-level hospital in Ecuador from 2016-2022. Immunocompromised patients, those who had active infections, autoimmune diseases, or malignancies were excluded. The PLR was calculated by dividing platelet by lymphocyte count. Participants were classified into low or high PLR groups based on the median. Univariate and multivariate logistic analyses were used to determine predictors of in-hospital mortality. A ROC curve analysis was performed to identify the optimal cutoff value of PLR for predicting the outcome.

Results:
140 patients were eligible for the study. Most patients were male (67.1%) and the median age was 63 years. The median length of hospitalization was 11 days (6-19), and 35% of patients required ICU admission. In-hospital mortality was 20%. Deceased patients were significantly older and had higher rates of ICU admission and NIHSS than survivors. A high PLR was associated with an increased risk of in-hospital mortality (OR =8.30; p= 0.001) in the univariate model. After adjusting for potential confounders, only high PLR (OR =6.02; p= 0.022), ICU admission, and NIHSS remained statistically significant. The ROC curve showed that the optimal cutoff value of PLR for predicting in-hospital mortality was 159.44, with an AUC of 0.799 (Sensitivity: 85.7%, Specificity:77.7%).

Conclusion:
Our results suggest that PLR is an independent predictor for in-hospital mortality in patients with a first-ever AIS. This biomarker could be useful in developing countries where stroke mortality is still high.
Abstract 4140981: In-Hospital Outcomes of Left Atrial Appendage Occlusion (LAAO) among patients with Atrial Fibrillation and Hematological Malignancy; Insight from The National Inpatient Database (2015-2020)
Authors: Osama Muhammad , Naeem Nauman , ahmed asmaa , Chuprun Dmitry , Depta Jeremiah , Rao Mohan
Published: November 2024

Introduction/Background:
Patients with hematological malignancies are at a higher risk of developing atrial fibrillation. Additionally, it can predispose to an increased risk of bleeding limiting anticoagulation for stroke prevention. LAAO has been successfully utilized among patients with atrial fibrillation and contraindication to anticoagulation.

Research Question:
What are the outcomes and in-hospital complications of left atrial appendage occlusion (LAAO) among patients with atrial fibrillation and hematological malignancy?

Methods:
The National Inpatient Sample (NIS) was analyzed from 2015-2020 to identify admissions for LAAO among patients with and without a hematological malignancy. Baseline characteristics were compared between the two groups and multivariate logistic regression was used to analyze hospitalization outcomes.

Results:
We identified 89,920 weighted admissions for LAAO procedures of which 1,665 patients (1.85%) had a hematological malignancy. In the adjusted analysis, the odds of MACCE (aOR 1.86, 95% CI 1.10-3.14, p 0.0205), cardiogenic shock (aOR 3.76, 95% CI 1.95-7.24, p <0.001), cardiac tamponade (aOR 2.42, 95% CI 1.61-3.65, p <0.001), pericardial drainage (aOR 2.54, 95% CI 1.50-4.29, p 0.005), ventricular arrhythmia (aOR 1.61, 95% CI 1.14-2.27, p 0.00061), and AKI (aOR 1.58, 95% CI 1.22-2.03, p 0.0004) was higher in the hematological malignancy cohort.

Conclusion:
The presence of a hematological malignancy was associated with higher rates of MACCE and other periprocedural complications among patients undergoing LAAO. These complications should be taken into account during clinical decision making and management of these patients.
Abstract 4140997: Exercise Right Ventricular to Pulmonary Circulation Uncoupling and NT-pro-BNP Levels Correlations In Heart Failure
Authors: CRISCI GIULIA , Serrantoni Violetta , Losito Maurizio , Zagarra Tania , Ginelli Daniele , Bursi Francesca , Guazzi Marco
Published: November 2024

Aim:
Right ventricle to pulmonary circulation (RV-Pc) uncoupling represents a mainstay in staging progression of heart failure (HF), being an independent predictor of mortality. In addition, N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is a well-established diagnostic and prognostic serum biomarker. In lack of clear clinical evidences on the relationship between exercise levels of NT-proBNP and RV-Pc uncoupling, this represents the aim of our investigation.

Methods and Results:
A cohort of 13 HF stable patients (mean age 71.6 ± 8.1; 48% female, mean left ventricular ejection fraction 57±13%) underwent maximal exercise stress echocardiographic and cardiopulmonary exercise testing (iCPET) with RV 3D-imaging analysis and were compared with a control population. Natriuretic peptides levels were obtained at rest and peak exercise. RV-Pc coupling was addressed by using the length-force relationship TAPSE/PASP ratio (tricuspid annular plane systolic/excursion pulmonary arterial systolic pressure). As expected, HF patients exhibited a higher level of NT-pro-BNP compared to controls (mean 831 ng/ml vs 131 ng/ml, at rest; mean 793.3 vs 138 ng/ml at peak). In HF, TAPSE/PAPS at peak exercise decreased compared to rest (0.73 ± 0.19 vs 0.47 ± 0.15 respectively) with an inverse correlation between NT-pro-BNP and TAPSE/PAPS exercise (r=0.60, p<0.01). See figure.

Conclusion:
Our investigation demonstrates a parallel trend between peak TAPSE/PASP and peak NT-pro-BNP. These findings suggest that natriuretic peptide may serve as a surrogate of underlying RV to Pc uncoupling and the right heart plays a crucial role in the biomarker activity during maximal exercise in advanced HF.
Abstract 4141007: Incidence of positive cardiac positron emission tomography in genotype-positive patients: A Cardiovascular Genetics Clinic lens
Authors: Trinh Kathleen , Wang Jessica
Published: November 2024

Background:
Positron emission tomography-computed tomography (PET-CT) is widely used to diagnose cardiac sarcoidosis (CS) for treatment. There is increasing recognition of myocardial inflammation in genetic arrhythmogenic cardiomyopathy (ACM) masquerading as CS. Since our institution is a high-volume arrhythmia center that frequently utilizes cardiac PET-CT studies to assess for CS and genetic evaluation to diagnose genetic cardiomyopathy (GNC), our clinical cohort is enriched for patients with both studies.

Research Question:
We hypothesize cardiac PET positivity is a unique feature of ACM among GNC, accompanied by markers of myocardial injury and improvement after anti-inflammatory therapy. (Steroids currently do not play a role in ACM treatment.)

Goals:
This investigation seeks to delineate the potential role of PET-CT and anti-inflammatory therapy in ACM.

Methods:
All UCLA Cardiovascular Genetics Clinic patients who underwent a cardiomyopathy gene panel were included. Patient genotypes were classified as positive – harboring at least a pathogenic (P) or likely pathogenic (LP) variant, uncertain – at least a variant of uncertain significance, or negative. Genes were grouped into ACM or non-ACM based on the 2019 Heart Rhythm Society consensus. Patients were screened for PET-CT scans before genetic testing. PET-CT positivity was defined by cardiac FDG uptake without extracardiac uptake.

Results:
Forty-eight patients received a PET-CT scan, with 58% (28/48) harboring a positive genotype. Of 320 patients with P/LP variants, 28 (8.8%) underwent PET-CT scans (11 ACM, 17 non-ACM). Six scans were positive, including 3 ACM genes. PET-CT positivity rates were 27.3% (3/11) for P/LP ACM genes and 17.6% (3/17) for P/LP non-ACM genes. Among the 6 PET-CT-positive patients, 3 (
FLNC
,
GAA
,
MYH7
) received immunosuppressive therapy with variable response. Our
FLNC
patient showed no improvement after 6 months of steroids.

Conclusion:
We recommend genetic testing for suspected CS cases with positive cardiac PET-CT without extracardiac manifestation. Cardiac PET-CT positivity led to a high genetic diagnostic yield (58%) in our clinic, where the genetic finding was enriched for but not limited to ACM gene mutations. Our limited sample of steroid treatment yielded varied results. A consortium approach to delineate patient characteristics, immunosuppressive responsiveness, and randomized control trials may help address these knowledge gaps in the future.
Abstract 4141009: Novel role of Nrf3 in platelet activation and thrombo-inflammation by regulating platelet energy metabolism
Authors: Zhou Meng , Zhou Xiaoyue , Chen Qishan , Zhang Li
Published: November 2024

Background:
Thrombotic diseases such as myocardial infarction and stroke are closely associated with immune inflammation and high prevalent in COVID-19 and sepsis. The pathologic mechanism is due to dysregulation and hyperactivation of platelet induced thrombotic inflammation and vascular occlusion. We surprisingly found elevated expression of Nrf3 (Nuclear factor erythroid 2-related factor 3) in platelets from COVID-19 patients and septic mouse. Considering that the role of Nrf3 still remains unknown, we aimed to investigate the pathological mechanisms of Nrf3 in platelet and thrombo-inflammation.

METHODS:
Nrf3 global knockout mice and Nrf3 megakaryocyte/platelet-specific knockout mice were used for research. Platelet aggregation/secretion, integrin αIIbβ3 activation, spreading, clot retraction and calcium flux were measured. In vivo thrombus formation was detected in carotid thrombosis and pulmonary embolism. Lipopolysaccharide (LPS) intravenous injection was used to establish septic model and explore the effects of Nrf3 on platelet-induced thrombo-inflammation.

RESULTS:
We found that Nrf3 expression was increased in inflammation-stimulated platelets and positively correlated with increased platelet activity. In vitro detection indicated that deficiency of Nrf3 attenuated platelet activation without significant effects on platelet counts and other types of peripheral blood cells. Nrf3
-/-
mice showed reduced thrombus formation with little tendency to hemorrhage. Additionally, we demonstrated that loss of Nrf3 reduced pro-inflammatory chemokines content (IL-1β, TNF-α and S100A4), platelet-leukocyte complex and neutrophil extracellular traps (NETs), and further alleviated micro-thrombosis and inflammatory infiltration in sepsis-induced multi-organ injury. Meanwhile, Nrf3
-/-
platelets exhibited lower ATP content, oxygen consumption rate (OCR) and extracellular acidification rate (ECAR), indicating that Nrf3 is closely involved in platelet energy metabolism.

CONCLUSION:
Collectively, these results demonstrated that Nrf3 regulated platelet activity, thrombosis and platelet-induced inflammation by influencing energy metabolism, suggesting that Nrf3 could be a potential target for therapeutic intervention in patients at risk of thrombo-inflammation.
Abstract 4141024: Safety and Efficacy with DOACs versus Warfarin in Patients with Atrial Fibrillation and Liver Cirrhosis: A Systematic Review and Meta-Analysis
Authors: Sattar Zeeshan , Khan Shahryar , Sattar Farhan , Zia Laila , Khan Mashal Alam , Shah M Danial Ali , Noheria Amit
Published: November 2024

Background:
Atrial fibrillation (AF) is increasingly prevalent in patients with liver cirrhosis, which is associated with both bleeding and thromboembolism. Patients with cirrhosis have been excluded from randomized controlled trials on the efficacy and safety of anticoagulants in AF. We performed a systematic review to compare direct oral anticoagulants (DOACs) with warfarin in patients with AF and concomitant cirrhosis.

Methods:
We systematically searched Pubmed and Embase from inception to the present. The primary outcome of interest was the hazard ratio of major bleeding. Secondary outcomes included gastrointestinal bleeding, all-cause bleeding, and ischemic stroke/systemic embolism[AN1] . Random effects models were used to calculate the weighted pooled hazard ratios for the outcomes. A two-tailed p<0.05 was considered statistically significant. Heterogeneity was assessed using the I2 index. Data analysis was performed using Revman version 5.4.1 (Cochrane).

Results:
We included 5 non-randomized observational studies on patients with AF and cirrhosis (N=13,838). Among these, 7,641 were on DOACs and 6,326 were on warfarin. Men comprised 69.8% of the DOACs group and 69.1% of the warfarin group. The average age was 70.4±8.27 years in the DOACs group and 69.72±7.76 years in the warfarin group. Patients using antiplatelets comprised 26.7% of the DOAC group and 24.1% of the warfarin group. The mean HAS-BLED score was 3.00 in the DOACs group and 2.99 in the warfarin group. Compared to warfarin, DOACs used for AF in patients with cirrhosis were associated with a lower risk of major bleeding (HR 0.67, 95% CI [0.59, 0.76], I2=0%, p<0.00001), gastrointestinal bleeding (HR 0.64 [0.45, 0.91], I2=54%, p=0.01), and all-cause bleeding (HR 0.81 [0.72, 0.92], I2=16%, p=0.001). No difference was found in the incidence of ischemic stroke/systemic embolism (HR 1.09 [0.55, 2.15], I2=85%, p=0.81).

Conclusion:
Our systematic review of non-randomized studies demonstrates that DOACs, as compared to warfarin, reduce the risk of bleeding in patients with AF and concomitant liver cirrhosis, without any difference in risk of stroke.
Abstract 4141033: Acute clinical outcomes following virtual reality implementation in the electrophysiology laboratory
Authors: Romano Letizia , Calvelli Pierangelo , Quirino Gianluca , Tomaselli Caterina , Talarico Antonello , Pasqua Pino , Curcio Antonio
Published: November 2024

Introduction:
Pain discomfort increases procedural time in electrophysiology laboratory and prolongs surgical length. Virtual reality-based analgesia (VR-A) improves patient’s acceptance of the procedural steps, mostly in the emergency context. To date, routine adoption of VR-A is limited in cardiology since it is recommended for other surgeries.

Hypothesis:
we postulated that administration of VR-A would facilitate patient’s compliance, allowing to increasing number of electrophysiology procedures, to reducing burden of complications, and to accelerating discharge.

Methods:
from April 2024 to May 2024 patients admitted to our academic hospital for cardiac rhythm disorders requiring pacemaker (PM) or implantable cardioverter/defibrillator (ICD) were enrolled. They were randomized in two groups (allocation ratio 1:1) by including either standard sedation protocol, or VR-A for cardiac device implants. Numeric rating scale score was used to assess pain. Variation of vital parameters was measured at baseline, 15, 30 and 60 min after procedural start, as well as at 30 min after procedural ending for an objective evaluation of pain. Statistical analysis was performed with SPSS.

Results:
Baseline clinical characteristics did not differ between groups. Patients underwent PM (N=12) and ICD (N=8) implantations, showing similar allocation and mean procedural durations (69.5±23.4 min vs 69.5±10.9 min,
p
=0.3), but significant difference in numeric rating scale score (4.5±0.8 vs.5.9±1.7,
p
=0.02) in VR-A vs standard group. Standard protocol registered significant differences in blood pressure [F(4, 45)=6.95;
p
<0.001] and in heart rate [F(4, 45)=12.55;
p
<0.001] during interventions, with greater variation between the baseline and 60-min determinations at post-hoc analysis (
p
<0.001). No significant differences were found in VR-A group for blood pressure [F(4, 45)=1.61;
p
=0.19] and heart rate [F(4, 45)=0.47;
p
=0.78]. Leadless PM (2/12, 17%) and subcutaneous ICD (2/8, 25%) while less invasive and well tolerated procedures allowed discharge during the same day of the intervention, by simply combining VR-A and remote patient monitoring provided at that time.

Conclusions:
VR-A has shown to be an effective tool for pain management during electrophysiology procedures. Participants immersed in VR-A experienced lower pain, less distressed and unpleasant feelings, without psychological impairment, until declaring to prefer VR-A for potential future medical procedures.
Abstract 4141052: Rare Combo: An Unusual Case of a 54-year-old Filipino with Coronary Artery Fistula from Left Anterior Descending Artery to Main Pulmonary Artery and Acute Cerebellar Infarct: A Cardio – Cerebral Infarction Syndrome - Case Report
Authors: Bonilla Michael
Published: November 2024

Introduction:
Cardio-cerebral infarction, a rare clinical presentation involving simultaneous acute ischemic stroke and acute myocardial infarction, poses significant therapeutic challenges. The incidence of this dual infarction is currently unknown due to its rarity. Delaying intervention for one condition to address the other can lead to permanent morbidity, disability, or even death. Coronary artery fistulas are uncommon with estimated incidence of 0.3%. Among these, a fistula between the left anterior descending artery and the pulmonary artery is the rarest variant, comprising about 17% of all coronary artery fistula cases.

Case:
A 54-year-old male, with a known history of atrial fibrillation and hypertension, presented to our emergency department with non-rotatory dizziness. Physical examination was unremarkable, but neurological examination revealed medial rectus palsy and left facial asymmetry. A cranial MRI indicated a hyperacute infarction in the left cerebellum. Laboratory tests showed markedly elevated troponin I levels (>50 ng/ml) and atrial fibrillation, along with inferior wall ST elevation on the electrocardiogram. Due to the high risk of hemorrhagic conversion, the loading of antiplatelets was deferred. Instead, the patient was treated with Aspirin 80 mg once daily, Clopidogrel 75 mg once daily, and Enoxaparin 0.4 ml subcutaneously once daily. A 2D echocardiogram revealed an ejection fraction of 43%, hypokinesia of the anterior and intraventricular septum from base to apex, and severe mitral stenosis. Cardiac catheterization identified a coronary artery fistula from the left anterior descending coronary artery to the main pulmonary artery. Treatment for acute coronary syndrome and acute cerebellar infarct continued. An open-heart surgery was considered. However, during his hospital stay, the patient experienced hemorrhagic conversion and altered sensorium. His condition further deteriorated, necessitating a tracheostomy and long-term care.

Conclusion:
Cardio-cerebral infarction is an extremely rare and poorly studied syndrome that presents significant treatment challenges and carries a grave prognosis if not addressed immediately. The medical conundrum of deciding which condition to treat first underscores the need for further research. Both interventional cardiologists and interventional neuroradiologists play crucial roles in the effective management of this emergency condition.