bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of early versus delayed invasive strategy in dialysis patients with non-ST-elevation acute coronary syndrome
Authors: Xie E , Ye Z , Wu Y , Yu C , Zhao X , Gao Y , Zheng J
Published: November 2023

Background

The association of early invasive strategy with improved outcomes in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) was previously established, particularly those at high risk. This benefit has not been evaluated in dialysis patients presenting with NSTE-ACS.

Purpose

This study aimed to investigate the prognostic impact of early invasive strategy in maintenance dialysis patients with NSTE-ACS.

Methods

This is a retrospective analysis of 455 617 consecutive cardiac catheterizations performed at 30 cardiac centers in China between January 2015 and June 2021. Patients were excluded if they did not receive dialysis therapy or received dialysis for less than 3 months, had normal coronary anatomy, or were admitted repeatedly . Patients were dichotomized into two groups based on the time interval from admission to invasive assessment: early (within 24 hours) invasive and delayed (more than 24 hours) invasive groups. The primary outcome of interest was all-cause mortality during follow-up. Standard univariate and survival methods were used. Propensity score matching and inverse probability of treatment weighting were used to diminish baseline differences.

Results

Overall, 1 012 patients met the final criteria, with a mean age of 61.7±10.4 years, and 398 (39.3%) of them received early invasive treatment. After a median follow-up of 21.8 months (interquartile range 12.6-34.9 months), 334 (33.0%) deaths were identified. Similar all-cause mortality rate was observed in the early invasive group compared with delayed invasive group (33.9% vs. 31.7%, respectively). After adjusting for baseline risk factors, early invasive was not associated with reduced all-cause mortality (hazard ratio 0.86, 95% confidence interval 0.69-1.08, p=0.198). Similar results were identified in the propensity score matching cohort and inverse Probability of Treatment Weighting cohort. Furthermore, no significant interaction was observed between the timing of invasive assessment and the Global Registry of Acute Coronary Events risk score (≤140 vs.>140) on the risk of all-cause death (p for interaction =0.858).

Conclusion

This multicenter study demonstrated comparable all-cause mortality between early invasive and delayed invasive groups in dialysis patients with NSTE-ACS. These findings were inconsistent with previous studies on NSTE-ACS patients with normal renal function, and further prospective studies are needed to confirm.
Circulating dipeptidyl peptidase 3 predicts hemodynamic impairment and premature death in acute coronary syndromes: insights from the prospective multicenter SPUM-ACS study
Authors: Wenzl F A , Kraler S , Raeber L , Muller O , Bergmann A , Bourgeois K , Akhmedov A , Camici G G , Matter C M , Von Eckardstein A , Roffi M , Gencer B , Templin C , Luescher T F
Published: November 2023

Background

Dipeptidyl peptidase 3 (DPP3) is mechanistically involved in the degradation of angiotensin II and in the depression of systolic left ventricular function thereby disturbing peripheral blood pressure regulation. Small pilot studies suggested that circulating DPP3 (cDPP3) portends poor outcomes in acute heart failure and may refine risk assessment in patients with acute coronary syndromes (ACS).

Purpose

We aimed to assess the predictive value of cDPP3 in contemporary patients with ACS.

Methods

Circulating DPP3 was studied in 4311 patients with ACS in the prospective multicentre SPUM-ACS study. DPP3 levels were centrally measured in EDTA plasma by blinded study personnel using an established sandwich-type luminometric immunoassay. Kaplan-Meier survival curves and multivariable-adjusted regression models adjusted for sex, age, heart rate, systolic blood pressure, history of diabetes, levels of creatinine, centrally measured high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein, and the Global Registry of Acute Coronary Events (GRACE) risk score.

Results

At baseline, median cDPP3 levels were 19.0 ng/ml (interquartile range [IQR] 15.0-26.0) with higher levels observed in patients with ST-segment elevation myocardial infarction than in those with non-ST-segment elevation ACS (20.1 [15.9-28.2] vs. 18.0 [14.1-23.9], respectively, P<0.001). High cDPP3 was linked to longer hospitalization and higher risk to require vasopressor use or mechanical circulatory support (per log2 increase: odds ratio [OR] 1.91, 95% confidence interval [CI] 1.62-2.24, P<0.001; adjusted OR 1.35 95% CI 1.08-1.69, P=0.008). In line, high cDPP was strongly associated with increased mortality at 30 days (per log2 increase: hazard ratio [HR] 1.96, 95% CI 1.48-2.59, P<0.001) and at 1 year (HR 1.51, 95% CI 1.24-1.83, P<0.001). When accounting for established risk factors, cDPP3 remained an independent predictor of premature death with doubling in cDPP3 levels translating into an 58% and 40% increase in 30-day and 1-year mortality risk, respectively (adjusted HR 1.58, 95% CI 1.06-2.34, P<0.023, adjusted HR 1.40, 95% CI 1.10-1.77, P=0.006, respectively).

Conclusion

We identified cDPP3 as a novel marker of cardiogenic shock and increased mortality in patients with ACS. Circulating DPP3 provides prognostic information beyond established risk factors and improves early risk assessment.DPP3 is linked to hemodynamic impairmentDPP3 independently predicts mortality
Sex-based differences in ST-segment elevation myocardial infarction: a multicentre national registry analysis
Authors: Miguel Goncalves C , Carvalho M , Vazao A , Cabral M , Martins A , Fernandes S , Pernencar S , Saraiva F , Morais J
Published: November 2023

Background

Sex differences in ST-segment elevation myocardial infarction (STEMI) are not fully understood. Female patients appear to have higher mortality.

Purpose

To establish sex-differences in Portuguese STEMI patients.

Material and methods

Retrospective multicentre analysis of STEMI patients included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and October 2022. Two cohorts were defined according to sex. Baseline characteristics, clinical findings, treatment and mortality were compared. Multivariate analysis was performed to assess predictors of mortality.

Results

A total of 14470 patients were included with a mean age of 64 ± 14 years, of which 26% were female. Female patients were significantly older (p<0.001) and with higher prevalence of several cardiovascular risk factors such as: high blood pressure (p<0.001), diabetes (p<0.001) and dyslipidemia (p=0.015), as well as higher reported past medical history, namely ischemic stroke/transient ischemic attack (p=0.001), renal disease (p<0.001) and dementia (p<0.001). On the other hand, previous coronary artery disease was less common comparing to men. Reperfusion therapy was less frequent in females (p<0.001), with less cases of multivessel disease (p=0.004). Regarding inpatient medical treatment women were less frequently prescribed medical therapy and more frequently needed inotropes (p<0.001). Regarding discharge medication, similar tendencies were observed, and women were less frequently referred to cardiac rehabilitation programs (p<0.001).

Concerning prognosis, women had more complications while at hospital, namely, congestive heart failure (p<0.001), ischemic stroke (p<0.001) and intra-hospital mortality (p<0.001). Similarly, women had higher thirty-day and one-year mortality (p<0.001) and non-cardiac hospital readmission (p<0.001). After multivariate analysis, female sex (OR=1.633; CI 95% [1.065-2.504]; p=0.025) remained as an independent factor for intra-hospital mortality but not for thirty-day and one-year mortality.

Conclusions

In our population, female patients had statistically significant differences in comparison to men regarding clinical characteristics, treatment and prognosis. Nevertheless, female sex was an independent risk factor only for intra-hospital mortality.
No-reflow, acute heart failure and ventricular fibrillation are more common in STEMI patients in wartime conditions
Authors: Lutay I , Parkhomenko A , Irkin O , Shumakov O , Skarzhenskyi O , Khomiakov D , Bilyi D , Stepura A
Published: November 2023

Stress and logistical problems during the wartime can change the course of STEMI and contribute to the development of in-hospital complications.

The aim of our work was to analyze in-hospital complications in STEMI pts admitted during the first months of full-scale invasion of Ukraine and compare them with patients hospitalized during the same period of 2019 (pre COVID-19 era).

The total number of STEMI patients hospitalized in 2022 was half as much as in 2019 (49 vs. 98 patients), which can be partly explained by civilian migration and mobilization. The average age of patients (61.0±10.7 in 2019 vs 63.5±11.7 in 2022, p=0.197) and the number of women (20.4% vs 26.5%, p=0.420) did not change. There were no significant differences in other main clinical characteristics between groups. The GRACE score in groups was almost the same (154.3±33.0 pts vs 160.8±43.5 pts, p=0.366) and about 50% of pts had anterior MI. Acute heart failure (Killip 2-3) at admission was diagnosed in 27.4% and 20.4%, cardiogenic shock (Killip 4) in 9.4% and 8.2% in 2019 and 2022, accordingly. Despite the absence of a significant difference in the level of arterial pressure, heart rate at admission was 10 bpm more during the wartime (84,0±15,4 bpm vs 74,9±20,6 bpm, p=0.005). 11.3% of STEMI pts in 2019 and 24.5% of pts in 2022 (p=0.064) were admitted after the first 24 hrs from symptoms onset. The mean time to hospitalization in pts admitted during the first 24 hrs was 4.4±3.8 hrs in 2019 and 6.4±5.6 hrs in 2022 (p=0.044). This time delay led to a lower number of pPCI made during the wartime (82.5% vs. 59.2%, p=0.005), despite the same total number of coronary angiographies (90.7% in 2019 vs. 91.5% in 2022, p=0.821) and total PCI numbers (86.6% in 2019 vs. 79.6% in 2022=0.304). No-reflow (determined as TIMI<3 or MBG<2) was registered in 34.3% of pts in 2022 and 12.9% in 2019, p=0.039. There were no differences in medical treatment between groups. DAPT was used in 97.6% and 100% (>80% ticagrelor), high intensity statins in 98.0% and 98.0%, beta-blockers in 89.5% and 90.9%, ACREI/ARB in 89.5% and 91.1%, MRA in 56.0% and 55.6% in 2019 and 2022, accordingly. In-hospital mortality in STEMI pts in wartime period was two times higher (but not significant) than in 2019 (4.9% in 2019 vs 10.2% in 2022, p=0.302). Patients with STEMI hospitalized during the first three months of the war had significantly higher rate of ventricular fibrillations (4.3% in 2019 vs 15.3% in 2022, p=0.043). Despite the lack of differences at admission acute heart failure was also significantly higher in pts treated during wartime on the 3d day of STEMI (11.2% in 2019 vs 24.5% in 2022, p=0.049).

During hostilities, patients with STEMI are hospitalized later, have worse results of revascularization and a greater number of in-hospital complications.
Every third patient with advanced renal failure dies within one year following non st-segment elevation myocardial infarction treated with percutaneous coronary intervention
Authors: Januszek R , Bujak K , Kasprzycki K , Gasior M , Bartus S
Published: November 2023

Background and Aims

Kidney failure is highly prevalent in patients with the non-ST-elevation myocardial infarction (NSTEMI). The aim of the study was to evaluate the prognostic significance of baseline renal function regarding in-hospital and 1-year mortality among patients with NSTEMI who were treated with percutaneous coronary intervention (PCI).

Methods

Data were obtained from the Polish Registry of Acute Coronary Syndromes (PL-ACS). We extracted all patients with NSTEMI (n=47,052) who were treated with PCI between 2017 and 2021. The cumulative incidence of all-cause mortality during the 1-year follow-up was presented using the Kaplan-Meier curves. The linearity of the association between the Esimated Glomerular Filtration Rate (eGFR) with all-cause mortality was evaluated using a likelihood ratio test. The multivariate Cox regression model was created to adjust the relationship between eGFR and all-cause mortality for potential confounders.

Results

After considering the exclusion criteria, 20,834 cases were evaluated, with a median eGFR of 72.7 (IQR 56.6-87.5) mL/min/1.73 m². The median age was 69 (62-76) years. The study comprised 4,505 patients with normal (90-120), 10,189 with mild (60-89), 5,539 with moderate eGFR (30-59), and 601 with severe renal impairment (15-29). There was a stepwise increase in the crude all-cause death rates across the groups at 1 year. The cox regression model revealed that the relationship between eGFR and the risk of death at 1 year was non-linear (reverse J-shaped, Fig. 1), and the risk was the lowest in patients with eGFR∼90 mL/min/1.73 m².

Conclusions

There is a J-curve relationship between the eGFR value and 1-year all-cause mortality in patients with NSTEMI and treated with PCI.
Validation of the GRACE 3.0 score and redefinition of the risk threshold for early invasive treatment in non-ST-segment elevation acute coronary syndromes: a modelling study from five countries
Authors: Wenzl F A , Bruno F , Kofoed K F , Raeber L , Roffi M , Stellos K , Camici G G , Kraler S , Engstroem T , Giannitsis E , Mueller-Hennessen M , Fox K A A , D'ascenzo F , Koeber L V , Luescher T F
Published: November 2023

Background

Clinical use of the GRACE scoring system is recommended across international guidelines to guide early treatment stratification in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Recently, the machine learning-based GRACE 3.0 score was derived from patients with NSTE-ACS undergoing contemporary treatment approaches. External validation studies and the reassessment of clinical risk categories are lacking.

Purpose

We aimed to evaluate the predictive performance of the GRACE 3.0 score and to explore clinically meaningful risk groups in contemporary patients with NSTE-ACS.

Methods

We studied the GRACE 3.0 score in 8070 patients with NSTE-ACS in contemporary ACS cohorts from Denmark (VERDICT, n=2147), Germany (Heidelberg-ACS, n=2034), Italy and Spain (CORALYS, n=1650), and Switzerland (SPUM-ACS, n=2239). Heterogeneity in the treatment effect of very early invasive management (within 12 hours) or standard invasive management (within 48 to 72 hours) on the primary composite outcome of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure in relation to baseline mortality risk was assessed in 2147 patients enrolled in the VERDICT trial who were randomized to different timing of invasive treatment.

Results

The GRACE 3.0 score showed excellent discriminatory properties with an area under the receiver operating characteristic curve (AUC) for in-hospital death of 0.89 (95% CI, 0.85–0.93) in the total study cohort. Similar results were observed in Denmark (AUC 0.93, 95% CI, 0.88–0.98), Germany (AUC 0.90, 95% CI, 0.85–0.94), and Italy and Spain (AUC 0.85, 95% CI, 0.77–0.94), and Switzerland (AUC 0.93, 95% CI, 0.86–1.00). Early invasive treatment reduced the composite endpoint (absolute risk reduction: 0.12, 95% CI, 0.03–0.21, P=0.011) in patients at high risk (≥1.7%), but not in those with lower risk profiles (P interaction=0.033). Based on this new high-risk threshold, GRACE 3.0 stratified 475 (42.2%) more patients into the high-risk group, as compared to traditional GRACE risk categories (P<0.001).

Conclusion

GRACE 3.0 shows unprecedented predictive performance in patients with NSTE-ACS. In the context of a comprehensive clinical evaluation, GRACE 3.0 can support clinical decision making for the timing of invasive treatment. The high-risk group of patients with NSTE-ACS who benefit from early invasive treatment is substantially larger than previously described.ROC curve and risk groupsRestratfication towards high risk group
Current concepts of treatment for left ventricular thrombus: A sys-tematic meta-analysis comparing direct oral anticoagulants versus vitamin K-antagonists
Authors: Seiler T , Madanchi M , Attinger A , Wolfrum M , Moccetti F , Staempfli S , De Boeck B , Toggweiler S , Cuculi F , Bossard M
Published: November 2023

Background/Introduction

Left ventricular thrombus (LVT) is a dreaded complication after myocardial infarction (MI) and is traditionally treated with Vitamin K antagonists (VKAs) for 3-6 months. Despite a gap of evidence, the broad use of direct oral anticoagulants (DOACs) for other thromboembolic disorders has triggered an increasing off-label use for DOACs in LVTs and has stimulated for expanding research focusing on DOAC´s utility for patients with LVT.

Purpose

To assess the safety and efficacy of DOACs versus VKAs for the treatment of LVT with a systematic meta-analysis.

Methods

We conducted a systematic search according to the PRISMA guidelines to identify all existing studies comparing DOACs and VKAs for the treatment of LVT. Forest plots and pooled odds ratios have been calculated for major bleeding events, strokes and systemic embolism, and for thrombus resolution.

Results

We have included a total of 13 studies with a pooled sample size of 2243 patients. 601 patients (26.8%) were treated with DOACs and 1642 patients (73.2%) with VKAs. The mean age was 55 and 59 years in the DOACs and VKAs group and sex was equally distributed with a male predominance of 81% in both groups. As underlying heart disease, most patients suffered from acute or chronic ischemic cardiomyopathy and presented with a mean left ventricular ejection fraction (LVEF) of 32% at admission. Baseline characteristics of patients included in each primary study are summarized in table 1. The pooled odds ratio of stroke or systemic embolism in patients treated with DOACs versus VKAs was 0.84 (95% CI 0.59-1.19) (p= 0.32). Compared to VKAs, we suggest that the use of DOACs may be associated with a reduced risk for major bleeding incidents without reaching statistical significance (OR 0.63 (95% CI 0.39-1.04) (p = 0.07). LVT resolution was similar and independent of the antithrombotic regimen (OR 0.91 (95% CI 0.7-1.19), p=0.50).

Conclusions

Based on our meta-analysis we conclude that DOACs seem to be non-inferior to VKAs for the treatment of LVT in terms of thrombus resolution, stroke and systemic embolism, and bleeding incidents. Despite these promising findings, several important aspects such as the duration of anticoagulation, and the type and dosing of the DOAC agent are still poorly understood. To close the lack of evidence for DOACs in LVTs, an adequately powered, randomized trial is needed.
Prognostic value of preprocedural pericoronary adipose tissue CT-Attenuation in patients with non ST-elevation acute coronary syndrome
Authors: Hoshino M , Usui E , Hada M , Nagamine T , Hanyu Y , Ueno H , Nogami K , Matsuda K , Sakamoto T , Yonetsu T , Sasano T , Kakuta T
Published: November 2023

Background

Pericoronary adipose tissue attenuation expressed by fat attenuation index (FAI) on coronary CT angiography (CCTA) reflects pericoronary inflammation. FAI has been reported to be associated with cardiac mortality in patients with suspected coronary artery disease. However, the prognostic value of FAI in patients with non ST-elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI) remains elusive.

Methods

This retrospective single-center observational study included a total of 358 patients with NSTE-ACS who underwent preprocedural 320-slice CCTA and emergent PCI within 24 hours from admission. Perivascular fat attenuation mapping was done around the three major coronary arteries-the proximal (4cm) right coronary artery (RCA), the left anterior descending artery (LAD), and the left circumflex artery (LCx). We assessed the prognostic value of FAI for all-cause and cardiac mortality. Clinical outcomes were assessed by death and cardiac death.

Results

During a median follow-up period of 1715 days (1008-2538), death and cardiac death occurred in 36 (10.1%) patients and 18 (5.0%) patients, respectively. High FAI values around LAD and LCx (but not around RCA) were predictive of all-cause mortality. High FAI values around RCA, LAD, and LCx were predictive of cardiac mortality. FAI in culprit vessels and average FAI values in three vessels were predictive of all-cause and cardiac mortality. ROC analysis revealed that the best cut-off FAI value in three vessels for predicting cardiac death is -65.8 (AUC: 0.752, 0.637-0.867.) Kaplan-Meier analysis revealed that patients with average FAI values in three vessels >-65.8 were significantly associated with poor prognosis of cardiac mortality. (P<0.001).

Conclusion

High perivascular FAI values are an indicator of increased cardiac mortality and, therefore, could guide early targeted secondary prevention and intensive medical management in patients with NSTE-ACS after PCI.Kaplan Meier analysis for cardiac death
Association of medical therapy with cardiovascular outcomes in patients with myocardial infarction with nonobstructive coronary arteries
Authors: Tao M , Dhaliwal S , Miller A , Ghosalkar D , Masson R , Rahman T , Pyo R
Published: November 2023

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of medical therapy with cardiovascular outcomes in patients with MINOCA.

Methods

A literature search was conducted for studies reporting on the association of medical therapy with clinical endpoints in patients with MINOCA. Clinical endpoints include all-cause mortality, recurrence of acute coronary syndrome (ACS), and major adverse cardiovascular events (MACE). Databases searched included Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar.

Results

A total of 9 studies with 27731 MINOCA patients (17816 on medical therapy, 9915 not on medical therapy) met inclusion criteria. Mean follow-up duration was 56 months, mean age was 63 years old, 52% were men. Medical therapy did not significantly reduce risk of MACE compared to no medical therapy (OR 0.99, 95% CI 0.91-1.07; p=0.73). Subgroup analysis demonstrated no significant reduction in risk of MACE regardless of ACE inhibitors/ARBs, antiplatelet therapy, or beta blocker therapy (OR 1.03, 95% CI 0.91-1.17; p=0.62; OR 1.00, 95% CI 0.87-1.14; p=0.98; OR 0.92, 95% CI 0.79-1.06; p=0.22). However, there is a trend toward lower risk of MACE in MINOCA patients on beta blocker therapy.

Analysis of MINOCA patients by presence of vasospasm did not demonstrate any significant reduction in risk of MACE with antiplatelet use in either subgroups (OR 1.03, 95% CI 0.71-1.49; p=0.89 without vasospasm; OR 0.92, 95% CI 0.74-1.14; p=0.44 with vasospasm). Use of antiplatelet therapy in patients with vasospasm did not significantly reduce risk of mortality or recurrent ACS (OR 0.80, 95% CI 0.37-1.75; p=0.58; OR 1.21, 95% CI 0.89-1.64; p=0.22).

Conclusions

Standard medical therapy using antiplatelet agents, beta blockers, or ACE inhibitors/ARBs are not associated with lower risk of cardiovascular outcomes in patients with MINOCA regardless of presence of vasospasm. However, there is a paucity in literature evaluating agents other than antiplatelet therapies. Additional high-quality studies are required to evaluate the utility of specific medication classes for treatment of specific etiologies of MINOCA.
Machine-learning score to predict in-hospital outcomes in patients Hospitalized in Intensive Cardiac Care Unit
Authors: Weizman O , Pezel T , Hamzi K , Schurtz G , Hauguel-Moreau M , Trimaille A , Toupin S , Bochaton T , Attou S , Meune C , Boccara F , Pasdeloup B , El Ouahidi Y , Dillinger J G , Henry P
Published: November 2023

Background

While few scores are available for risk stratification of patients hospitalized in Intensive Cardiac Care Unit (ICCU) using traditional statistical methods, the potential benefit of machine learning is not established.

Purpose

To investigate the feasibility and accuracy of machine-learning (ML) to predict in-hospital major adverse events (MAE) in patients hospitalized in ICCU and compare its performance with existing scores.

Methods

From April 7 to 22, 2021, a French nationwide, multicenter, prospective, study involving 39 centers included all consecutive patients admitted in ICCU (N=1499). The primary outcome was in-hospital MAE defined as a composite outcome including all-cause in-hospital mortality, cardiogenic shock and resuscitated cardiac arrest (severe ventricular arrhythmia requiring defibrillation or anti-arrhythmic agents). Twenty-eight clinical, biological, ECG, and echocardiographic variables were considered for the Boruta variable selection algorithm. Using 31 centers randomly as an index cohort, several ML algorithms (logistic regression, ridge regression, boosted cost-sensitive C5.0 and XGBoost. C5.0 ) were evaluated to build a ML-score to predict in-hospital MAE. The other 8 centers formed the external validation cohort of the ML-score.

Results

Among 1499 consecutive patients included (age 63.3±14.9 years, 69.6% male), 61 had in-hospital MAE (4.3%). Out of 28 variables included in the feature selection, seven were selected as of particular importance to predict MAE in the training set (N=844) including: illicit drug use, mean arterial pressure, Killip stage, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio. Boosted cost-sensitive C5.0 technique showed the best performance compared with other ML-techniques (area under the curve [AUC]=0.90, PR-AUC=0.57, F1 score=0.5), using 5 of the 7 above mentioned variables: mean arterial pressure, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio. Our ML-score exhibited a higher AUC compared with existing scores for MAE prediction (ML score: 0.90 vs TIMI-score: 0.56, GRACE-score: 0.52, Acute HF-score: 0.65; all p<0.001). ML-score also exhibited a good AUC in the external cohort (AUC 0.97).

Conclusions

Including five simple clinical and echocardiographic variables (mean arterial pressure, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio) routinely assessed in patients admitted in ICCU, the ML score exhibited a better prognostic value to predict in-hospital outcomes compared with existing scores.ML model and existing scores: ROC curveML model and existing scores: PR curve
Early versus deferred coronary angiography in patients with out-of-hospital cardiac arrest - a systematic review and meta-analysis
Authors: Goel V , Bloom J , Dawson L , Shirwaiker A , Bernard S , Nehme Z , Donner D , Hauw-Berlemont C , Vilfaillot A , Chan W , Kaye D , Spaulding C , Stub D
Published: November 2023

Background

The role of early coronary angiography (CAG) compared with deferred CAG on mortality and neurological outcomes in patients presenting with out of hospital cardiac arrest (OHCA) and no ST-elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) remains disputed.

Purpose

The aim of this meta-analysis was to evaluate the impact of early versus deferred CAG on mortality and neurological outcomes in patients with OHCA and no STEMI.

Methods

OVID MEDLINE, EMBASE, Web of Science and Cochrane Library Register were searched from inception until July 18, 2022. Randomized clinical trials (RCTs) of patients with OHCA without STEMI that compared early CAG with deferred CAG were included. The primary endpoint was 30-day mortality. Secondary endpoints included mortality at discharge or 30-days, favorable neurology at 30-days, major bleeding, renal failure and recurrent cardiac arrest. A random-effects model was used with effect sizes presented as odds ratios (ORs).

Results

Of the 7,998 citations, a total of 5 trials randomizing 1524 patients to either early CAG or deferred CAG were included. There were 404 (26.5%) females. All studies were deemed to have at least a moderate risk of bias. Meta-analysis showed no significant difference in 30-day mortality with early versus deferred CAG (OR 1.17, CI 0.91 – 1.49 I2 = 27%) (figure 1). There was no observed difference in favorable neurological outcome at 30 days (OR 0.88, CI 0.52 – 1.49, I2 = 63%), major bleeding (OR 0.94, CI 0.33 – 2.68, I2 = 39%), renal failure (OR 1.14, CI 0.77 – 1.69, I2 = 0%), and recurrent cardiac arrest (OR 1.39, CI 0.79 – 2.43, I2 = 0%) when comparing early and deferred CAG (figure 2).

Conclusions

In this study, early CAG was not associated with improved survival and neurological outcomes among patients with OHCA without STEMI. This meta-analysis does not support routinely performing early CAG in this select patient cohort. Future studies are needed to identify a subgroup of patients who may benefit from an early CAG strategy in this high-risk population.Figure 1Primary OutcomeFigure 2Secondary Outcomes
High versus low mean arterial pressure targets after out-of-hospital cardiac arrest: a meta-analysis of randomized controlled trials
Authors: Abuelazm M , Ali S , Mahmoud A , Mechi A , Kadhim H , Katamesh B E , Elzeftawy M A , Ibrahim M , Abdelazeem B
Published: November 2023

Background

Out-of-hospital cardiac arrest (OHCA) is a significant healthcare burden, with an average global incidence of 55 per 100,000 person-years among adults. OHCA patients require blood pressure support to maintain effective mean arterial pressure (MAP) for cerebral reperfusion, which is usually achieved by intravascular fluids and vasopressors in the intensive care unit (ICU). Targeting a specific MAP has been evaluated as a treatment strategy after OHCA; however, the current evidence lacks clear guidelines regarding the optimal MAP target after OHCA.

Purpose

We aim to evaluate the efficacy of targeting a high MAP (>70 mmHg) versus a low MAP target (< 65 mmHg) after OHCA resuscitation.

Methods

We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching: PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through January 18th, 2023. Continuous and dichotomous outcomes were pooled using mean difference (MD) and risk ratio (RR) along with confidence interval (CI), using Revman V. 5.4 software. Our review protocol was prospectively published on PROSPERO with ID: CRD42023395333.

Results

Four RCTs with a total of 1070 patients (531 in the high MAP target group and 534 in the low MAP target group) were included in our analysis. High MAP target was significantly associated with decreased ICU length of stay (MD: -0.78 with a 95 CI [-1.54, -0.02], P= .04) and mechanical ventilation duration (MD: -0.91 with a 95 CI of [-1.51, -0.31], P= .003). However, There was no difference between targeting a high MAP versus low MAP regarding all-cause mortality (RR: 1.07 with a 95% CI [0.91, 1.27], P= 0.4), favorable neurological recovery (cerebral categories scale (CPC) ≤ 2) (RR: 1.02 with a 95% CI [0.93, 1.13], P= 0.68), and neuron-specific enolase (NSE) at 48 hours (MD: 0.54 with 95% CI [-1.67, 2.75], P = 0.63), the incidence of adverse events, including any bleeding (RR: 0.89 with a 95% CI [0.69, 1.36], P= 0.39); arrhythmia (RR: 0.91 with a 95% CI [0.46, 1.82], P= 0.79), or acute kidney injury (RR: 0.80 with a 95% CI [0.36, 1.76] and P = 0.58).

Conclusion

In patients with OHCA who have been resuscitated, targeting a higher MAP significantly reduced the ICU length of stay and mechanical ventilation, implying potential clinical benefit with an acceptable safety margin. However, there was no difference between targeting a high MAP versus a low MAP regarding all-cause mortality, favorable neurological recovery, and NSE. Therefore, further RCTs are still warranted to elucidate the potential clinical benefit of targeting a high MAP after OHCA before endorsement in clinical practice.Figure 1Figure 2
Novel miRNAs are key predictors of heart failure and mortality in functional tricuspid regurgitation
Authors: Hinojar Baydes R , Moreno-Gomez-Toledano R , Gonzalez-Gomez A , Garcia-Martin A , Monteagudo J M , Rivas S , Sanroman M , Fernandez-Golfin C , Zaragoza C , Zamorano J L
Published: November 2023

Background

Functional tricuspid regurgitation (FTR) is associated with high risk of cardiovascular events, in particular heart failure (HF), but optimal timing for intervention remains controversial. Surgery is often performed late mainly because symptoms might go unnoticed until advance stage of the disease. While microRNA have been recently identified as prognostic biomarkers in different cardiovascular conditions, no study has been focus on patients with TR.

Purpose

To evaluate the potential role of circulating miRNAs as prognostic biomarkers in patients with severe FTR.

Methods

Consecutive patients with severe FTR evaluated in the Heart Valve Clinic were prospectively included and underwent a comprehensive clinical protocol. Patients with non-valvular permanent atrial fibrillation (and no TR) undergoing anticoagulant therapy unit were prospectively recruited as a control group. The experimental design included a first screening phase in 16 subjects (8 atrial FTR and 8 AF controls) to identify candidate miRNAs differentially expressed in a miRNA qPCR panel containing 192 specific miRNAs, and a second validation phase in which selected miRNAs were screened for further validation by qRT-PCR in 118 additional patients (77 FTR and 41 controls). A combined endpoint of hospital admission due to HF and all-cause mortality at follow-up was defined.

Results

The initial screening revealed 16 differentially expressed miRNAs in atrial FTR vs. AF subjects matched by age, gender and atrial dimensions. The candidate miRNAs were subsequently validated in 118 subjects. After a median follow up of 20.4 months (ICR 8-35 months), 25 (32%) reached the combined endpoint. Patients with events showed different levels of miR-15a-5p, miR-152-3p, miR101-3p, miR-92a-3p, miR-363-3p, miR-324-3p and miR-22-3p (Table 1, p<0.05 for all). Based on the high or low relative expression of selected miRNAs (below or above the median value) patients were stratified; those patients with low relative expression of miR-15a-5p, miR-92a-3p, miR101-3p, and miR-363-3p, miR-324-3p and miR-22-3p, showed significantly higher rates of events (log rank test for all p < 0.01, figure). In a multivariate cox regression the analysis, the level of miR-15a-5p (HR: 3.97 [1.58-9.96], miR-92a-3p (HR: 2.64 [1.13-6.13] , and miR-363-3p (HR: 2.41 [1.04-5.60] were predictive of events independently of NYHA functional class and RV dimensions (p < 0.05 for all).

Conclusions

We identify for the first time circulating miRNAs in patients with severe FTR. We further show that several miRNA predict heart failure and all-cause mortality independently of RV dimension and symptomatic status. These novel biomarkers may help to identify those patients that benefit from earlier valve interventions.Differences in patients with eventsKaplan Meier Curves
Enhanced expression of iNOS is associated with aortic valve stenosis in patients with bicuspid aortic valve
Authors: Kashima Y , Hayashi Y , Saito T , Nakagawa M , Shimeno K , Matsumoto R , Matsumura Y , Abe Y , Naruko T , Ueda M
Published: November 2023

Background

A congenital bicuspid aortic valve (BAV) is one of the most common congenital cardiac abnormalities, with a prevalence estimated between 0.5% and 2%. Aortic valve stenosis (AS) is the most common complication in patients with BAV. The mechanisms responsible for the rapid progression of AS in patients with BAV relative to those with a tricuspid aortic valve (TAV) are unknown. A previous study showed that the pathogenesis of AS in patients with BAV is associated with a more aggressive inflammatory process, with increased macrophage infiltration and neo-vascularization when compared with that seen in patients with TAV. A considerable number of human diseases have an inflammatory component, and a key mediator of immune activation and inflammation is inducible nitric oxide synthase (iNOS). Overexpressed iNOS has been implicated in the pathogenesis of numerous conditions, including coronary plaque destabilization. To elucidate the role of iNOS in the aortic valve of patients with AS, we carried out an immunohistochemical study of the presence of iNOS in aortic valve specimens from patients with AS with either TAV or BAV.

Methods

Frozen aortic valve samples were obtained surgically from patients with AS with TAV (n=34) or BAV (n=34), and stained with antibodies against macrophages, microvessels, iNOS and 4-hydroxy-2-nonenal (4-HNE), an index of lipid peroxidation. The immunoreactivity of macrophages, microvessels, iNOS and 4-HNE was quantified using computer-aided polarimetry. Double immunostaining was also performed to identify cell types that stained positive for iNOS.

Results

Quantitative analysis demonstrated that macrophage-, iNOS-, and 4-HNE-positive areas, as well as the number of microvessels, were significantly higher in patients with AS with BAV than with TAV (macrophages, P<0.001; microvessels, P<0.05; 4-HNE, P<0.05; iNOS, P<0.001). The iNOS-positive area was positively correlated with the 4-HNE-positive area (R=0.43, P<0.0001). Double immunostaining for both iNOS and macrophages identified iNOS-positive cells as macrophages.

Conclusions

These findings suggest that accumulation of iNOS in macrophages may increase oxidative stress and contribute to the rapid progression of AS in patients with BAV.
Reduction in systolic pulmonary artery pressure after TAVI is associated with lower cardiovascular mortality in patients with severe aortic stenosis
Authors: Hu K , Liu D , Huegel E , Sokalski V , Lau K , Kreipl M , Lengenfelder B , Ertl G , Frantz S , Nordbeck P
Published: November 2023

Background

Elevated systolic pulmonary artery pressure (sPAP), assessed by echocardiography, is associated with increased mortality, irrespective of the aetiology.

Purpose

The purpose of this study was to explore the association between dynamic change in sPAP after transcatheter aortic valve implantation (TAVI) and cardiovascular mortality in patients with severe aortic stenosis (AS).

Methods

We screened 688 AS patients who underwent TAVI in our hospital between July 2009 and December 2018. Patients, who performed echocardiography examinations before TAVI (T0) and within 7 days after TAVI (T1), and completed ≥12 months clinical follow-up, were included in this study. Patients who died within 30 days after TAVI were excluded (n=27). Patients with no measurable tricuspid regurgitation for assessment of sPAP were not included. 477 TAVI patients were finally included for further analysis (mean age 81.4±5.9 years, 46.3% male). Primary endpoint was defined as cardiovascular (CV) death up to 5 years after TAVI.

Results

During 34 (20-55) months follow-up, all-cause mortality and CV mortality was 34.0% and 18.9%, respectively in these patients. 18.7% of patients had COPD, and COPD was identified as a risk factor for increased CV mortality risk (Hazard ratio, HR=2.152, 95% CI 1.376-3.365, P<0.001). Baseline septal trans-mitral early filling velocity to mitral annular early-diastolic velocity ratio (E/E´) was identified as echocardiographic parameter associated with CV mortality (HR=1.028, 95% CI 1.009-1.047, P=0.003).

sPAP at 7 days after TAVI was significantly reduced in no CV-death group (median 38.9 vs. 36.0 mmHg, P<0.001), while remained unchanged in CV-death group (40.7 vs. 41.0 mmHg, P=0.966). We further grouped the patients according to sPAP change trend after TAVI: Group 1, sPAP at T0 <40 mmHg and sPAP at T1 <40 mmHg; Group 2, sPAP at T0 ≥40 mmHg and sPAP at T1 <40 mmHg; Group 3 sPAP at T0 <40 mmHg and sPAP at T1 ≥40 mmHg; Group 4, sPAP at T0 ≥40 mmHg and sPAP at T1 ≥40 mmHg. CV mortality was the highest in the group 4 (28.3%), and significantly lower in the group 2 than in the group 4 (13.6% vs. 28.3%, P<0.001, Figure 1). Multivariable Cox regression analysis showed that TAVI patients with a reduction trend in sPAP at 7 days after TAVI (group 2) were independently associated with reduced CV mortality compared to patients with a consistent elevated sPAP (group 4, HR=2.470, 95% CI 1.260-4.832, P=0.008), after adjusted for age, sex, COPD, and septal E/E´.

Conclusion

TAVI patients with consistently elevated sPAP before and after TAVI are associated with the worst CV outcome. Reduction in sPAP at 7 days after TAVI is associated with reduced CV mortality in patients with severe AS.
Comparison of effective regurgitant orifice area by the PISA method and tricuspid coaptation gap measurement to identify very severe tricuspid regurgitation and stratify mortality risk
Authors: Bohbot Y , Tordjman L , Dreyfus J , Le Tourneau T , Lavie Badie Y , Selton Suty C , Elegamandji B , L'official G , Fraix A , Aghezzaf S , Turgeon P Y , Enriquez Sarano M , Coisne A , Donal E , Tribouilloy C
Published: November 2023

Background

Various definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes.

Purpose

To compare EROA and TCG for outcome prediction in patients with severe TR.

Methods

In this French multicentre retrospective study, we included 606 patients with ≥ moderate-to-severe isolated TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm²) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality.

Results

The relationship between the EROA and TCG was poor (R²=0.21), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA <60 mm² vs. ≥ 60 mm² (67±3% vs. 64±4%, p=0.64), even after adjustment, for all-cause (p=0.72) and cardiovascular mortality (p=0.18). A TCG ≥10 mm was associated with lower four-year survival than a TCG <10 mm (53±7% vs. 69±3%, p<0.001). After adjustment for covariates, including age, comorbidity, right heart failure, dose of diuretics, and right ventricular dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95%CI]=1.46[1.15-2.18], p=0.015) and cardiovascular mortality (adjusted HR[95%CI]=1.95[1.22-3.14], p <0.001), whereas an EROA ≥60 mm² was not associated with all-cause or cardiovascular mortality (adjusted HR[95%CI]:1.07[0.75-1.51], p=0.720, and adjusted HR[95%CI]:1.35[0.87-2.09], p=0.176, respectively).

Conclusion

The correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated TR.Correlation between EROA and TCGEvent free survival curves
Elderly patients with severe aortic stenosis - does moderate mitral regurgitation require simultaneous surgical intervention?
Authors: Kwiecien A , Kubacki K A , Krason M Z , Kaczmarczyk M , Glanowski M , Hirnle G , Rychter J , Pakula R J , Aidibi A , Jakimowicz K M , Barnak A , Hrapkowicz T B
Published: November 2023

Introduction

Some patients undergoing aortic valve replacement present additional moderate mitral valve regurgitation (MVI). The guidelines do not precise whether, in the case of coexisting moderate MVI in patients undergoing aortic valve surgery, mitral valve intervention should also be considered. In the group of older patients, an additional procedure may significantly increase the operative risk.

Purpose

The aim of the study was to assess whether elderly patients with severe aortic stenosis and moderate mitral regurgitation who undergo aortic valve replacement surgery have a worse prognosis than patients without mitral valve disease?

Methods

The study is a retrospective analysis of patients (n=441) over 74 years of age with significant aortic stenosis, who underwent isolated aortic valve replacement surgery between February 2006 and July 2021. The average age in the entire group was 78,1 year (SD=2.71, min.75, max.88). Patients were divided into 2 groups depending on the presence of moderate mitral regurgitation (n=61) or its absence (n=365). The incidence of perioperative complications, early mortality and long-term survival were assessed.

Results

Patients did not differ in most preoperative burdens. There were no differences between the study groups in terms of perioperative mortality, postoperative complications and MACE (myocardial infarction, stroke, pacemaker implantation and death) and long-term survival. The predictors of long-term mortality in the entire study population were age and the need for post-operative haemofiltration.

Conclusion

The coexistence of moderate mitral regurgitation does not require additional intervention during aortic valve replacement surgery in the population of elderly patients, as its presence does not impair early outcomes or long-term survival.