bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk of myocardial infarction following capecitabine treatment in patients with gastrointestinal cancer - a nationwide registry-based study
Authors: Shanmuganathan J , Kristian Hay Kragholm K H K , Morten Schou M S , Christian Torp-Pedersen C T P , Laurids Ostergaard Poulsen L O P , Manan Pareek M P , Gunnar Gislason G G , Lars Kober L K , Dorte Nielsen D N , Tarec Christoffer El-Galaly T C E , Peter Soegaard P S , Mamas A Mamas M A M , Phillip Freeman P F
Published: November 2023

Background

Myocardial infarction is a cardiac adverse event associated with fluoropyrimidines such as 5-fluorouracil and its orally available prodrug capecitabine. There are limited data on the incidence, risk, and prognosis of capecitabine associated myocardial infarction.

Purpose

The aim of this study was to examine the risk of myocardial infarction in patients with gastrointestinal (GI) cancer treated with capecitabine compared with age- and sex-matched population control subjects without cancer (1:2 ratio).

Methods

Patients with GI cancer treated with capecitabine between 2004-2016 were identified within the Danish National Patient Registry. Those with a history of ischemic heart disease were excluded. Absolute and relative risks of myocardial infarction at 6 months and 1 year were derived from multivariable Cox regression with average treatment effect modeling. Estimates were standardized to the distributions of age, sex, selected comorbidities, and pharmacotherapies of all included subjects.

Results

A total of 71,460 patients were included in the final analysis of whom 23,820 had GI cancer treated with capecitabine, and 47,640 were population control subjects without cancer. Differences in the prevalences of selected comorbid conditions, including diabetes, hypertension, and other risk factors for coronary artery disease and antianginal medications were not significant (P>0.05 for all). The 6-month absolute risk (AR) of myocardial infarction was significantly higher for capecitabine-treated patients at 0.6% [95% confidence interval (CI): 0.5%-0.7%] versus 0.3% [95% CI: 0.2%-0.3%] in population control subjects, corresponding to a relative risk (RR) of 2.00 [95% CI 1.53-2.48; P <0.001]. The corresponding 1-year ARs were 0.7% [95% CI: 0.6%-0.9%] versus 0.6% [95% CI: 0.5%-0.6%]; RR 1.28 [95% CI 1.03-1.52; P= 0.03]. Six-month and one-year all-cause mortality ARs for patients treated with capecitabine versus controls were 15.2% vs. 0.7% and 29.7% vs. 1.6% respectively.

Conclusions

The risk of myocardial infarction of capecitabine-treated patients both 6- and 12-month risks were significantly higher compared with population controls. Despite the absolute risk were low, the clinical significance of the differences appears limited in the context of the significant competing risk of death in this population.Risk of Myocardial InfarctionMortality
Adjudicated cardiovascular events in a cotemporary multicenter cohort of patients with COVID-19: findings from the CORONA-VTE Registry
Authors: Bikdeli B , Krishnathasan D , Khairani C D , Bejjani A , Tristani A , Porio N , Assi A , Campia U , Wei E , Tiu B , Hsia J , Vishnevsky A , Lan Z , Goldhaber S , Piazza G
Published: November 2023

Background

Coronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to contemporary event rates particularly given the change in viral variants and COVID-19 therapies, as well as availability of vaccines in later months of the pandemic.

Purpose

To report the cardiovascular complications of COVID-19, and assess results by vaccination status from a large multicenter patient-level US registry.

Methods

Adult patients with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at Mass-General Brigham (MGB) Health system, the largest health system in Massachusetts that serves 1.5 million patients, were eligible for inclusion. Data elements were entered into a centralized database by trained research staff. Each clinical event was adjudicated by two independent physicians. The primary outcome was major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Outcomes were assessed at 30- and 90-day follow-up, shown as cumulative incidence, represented by subdistribution hazard functions. Findings were pre-specified to be assessed separately for patients who were hospitalized with COVID-19 vs outpatients. Vaccination status was ascertained for subgroup-specific analyses.

Results

The study included 4,123 patients from the MGB Health System from 3/13/2020 through 06/03/2022 (mean age: age: 53.5 ± 18 years; 55.9% female, Table). Among hospitalized patients, the cumulative incidence of primary outcome was 17.4% at day 30 (95% CI: 15.2-19.5%). Respective 30-day event rates for outpatients were 1.1% (95% CI: 0.7%-1.5%) (Figure, Panel A). Cumulative incidence of 30-day outcomes based on vaccination status (restricted to cohort from 12/14/2020 onward) is summarized in Panel B.

Conclusions

This multicenter study suggests that 30-day adjudicated cardiovascular events were frequent in hospitalized patients with COVID-19, although event rates were lower in vaccinated patients. Follow-up for 90-day outcomes is being finalized and will be presented at ESC 2023.Table 1.Figure 1.
Relationship between stress hyperglycemia ratio and long-term poor prognosis in patients with multi-vessel coronary artery disease
Authors: Li M , Tang C
Published: November 2023

Background

Stress hyperglycemia ratio (SHR) is a new biomarker of true acute hyperglycemia, which is significantly related to emergency cardiovascular events. However, the relationship between SHR and long-term prognosis of patients with multi-vessel coronary artery disease has not been reported. The purpose of this study is to clarify the relationship between SHR and long-term clinical outcomes in patients with multi-vessel coronary artery disease (MVD).

Methods

A total of 1719 patients with multi-vessel coronary artery disease were included in the final analysis of this study. Patients were divided into three groups according to the SHR quartile: [SHR1 group (SHR ≤ 0.913), (n=573); SHR2 group (SHR 0.913-1.215), n=573; and SHR3 group (SHR ≥ 1.215), n=573]. All patients were followed up. The main end point was 5-year all-cause mortality. The secondary end point was the major cardiovascular and cerebrovascular adverse event (MACCE), defined as the combined result of 5-year all-cause death, myocardial infarction, stroke and subsequent coronary revascularization. Cox regression and Kaplan-Meier curve analysis were used to evaluate the relationship between SHR and all-cause mortality and MACCE. Logistic regression analysis and subject working curve (ROC) analysis were used to obtain the optimal critical value of SHR for predicting all-cause mortality and MACCE.

Results

During the average follow-up period of 4.5 years, 131 patients died of all causes, 121 patients suffered from myocardial infarction, 55 patients suffered from stroke and 247 patients underwent coronary artery revascularization. Compared with SHR1 and SHR2 groups, the all-cause mortality and MACCE in SHR3 group were significantly increased (4.36% and 8.03% and 10.47%; 20.94% and 31.06% and 44.68%, P<0.001, respectively). Kaplan-Meier curve showed that compared with SHR2 and SHR1 patients, SHR3 patients had the highest all-cause mortality and MACCE risk (Logarithmic ranking P<0.001). Multivariate Cox regression analysis showed that SHR was associated with a 1.462 and 1.205 fold increase in all-cause mortality and MACCE risk (HR 1.462; 95% CI 1.104-2.159; HR 1.205; 95% CI 1.073-1.932; P<0.001). ROC curve analysis showed that the best SHR threshold for predicting all-cause mortality and MACCE were 0.92 and 1.03, respectively.

Conclusion

Our data show for the first time that SHR is independently associated with poor long-term prognosis in patients with multi-vessel coronary artery disease. The best SHR thresholds for predicting all-cause mortality and MACCE in patients with MVD were 0.92 and 1.03, respectively. These findings suggest that SHR may play a potential role in the cardiovascular risk stratification of patients with MVD.
Diagonal earlobe crease (Frank's sign) predicts obstructive coronary artery disease with modest accuracy
Authors: Gakovic B , Neskovic S A , Vranic I , Grujicic K , Ljubojevic A , Mijatovic S , Stankovic I
Published: November 2023

Introduction

Traditional risk factors for cardiovascular disease (CVD) play an important role in the clinical evaluation of patients with symptoms suggestive of coronary artery disease (CAD). The utility of anthropometric indices, including diagonal earlobe crease (Frank's sign), in predicting the risk of CAD is controversial.

Purpose

To investigate the association between Frank's sign, traditional CVD risk factors, and obstructive CAD.

Methods

This prospective study included 1401 patients (mean age 65±10 years, 64% male) who underwent invasive coronary angiography for suspected acute or chronic coronary syndromes. In addition to routine clinical assessment, all patients underwent visual examination of both earlobes for the presence of Frank's sign, defined as a diagonal earlobe fold (Figure A, arrow). All assessments were made by three independent readers, with a majority vote in case of disagreement. Obstructive CAD was defined by invasive coronary angiography as >50% diameter stenosis of the left main coronary artery or >70% diameter stenosis of any other major epicardial coronary artery.

Results

Unilateral or bilateral Frank’s sign was observed more frequently in patients with obstructive CAD than in those without it (73% vs 68% for unilateral and 55% vs 47% for bilateral Frank’s sign, p<0.05 for both). In the multivariate logistic regression model (Graph), bilateral Frank’s sign was independently associated with CAD [odds ratio (OR) 1.47, 95% confidence interval (CI) 1.17-1.85], along with smoking (OR 1.74, 95% CI 1.38-2.20), diabetes mellitus (OR 1.70, 95% CI 1.32-2.19), male sex (OR 1.99, 95% CI 1.58-2.52), and dyslipidemia (OR 1.52, 95% CI 1.06-2.19). However, diagnostic accuracy of Frank's sign was modest [area under the curve (AUC) 0.54, 95%CI 0.51-0.57] and resembled that of traditional CVD risk factors (Graph).

Conclusion

Despite being independently associated with obstructive CAD, Frank’s sign is not a reliable clinical marker of CAD due to modest diagnostic accuracy.
Severe periodontal disease is associated with a high-risk phenotype of coronary plaques and a higher severity of coronary atherosclerosis, as assessed by Coronary Computed Tomography Angiography
Authors: Rodean I P , Halatiu V B , Benedek I , Benedek T
Published: November 2023

Introduction

Although incompletely understood, the relationship between coronary heart disease (CHD) and periodontal disease (PD) is well known. A variety of indices can be used to identify periodontal disease. The lack of strict criteria in defining PD represents a challenge in studying the link with CHD. Data from the literature regarding the relationship between different periodontal indices and CHD are extremely limited.

Purpose

To investigate the link between the PD indices, coronary calcifications and plaque features in patients with CHD who underwent coronary computed tomography angiography (CCTA).

Methods

The study included 52 patients with PD in whom (CCTA) revealed CHD. All patients underwent a complex oral examination of the periodontal status and the following indices were assessed: gingival index (GI), plaque index (PqI), calculus index (CI), furcation defects (FI), papillary bleeding index (PBI), tooth mobility, clinical attachment loss (CAL) and probing pocket depth (PPD). The indices were determined for the tooth’s 1.6, 2.1, 2.4, 3.6, 4.1, 4.4 and the final score for each index was obtained by summing the values from the six teeth. The association between the periodontal indices and CCTA features (total coronary artery calcium and vulnerability markers) was evaluated using Graph Pad InStat 3.10 software. The p value was set at 0.05 for statistical significance.

Results

The mean age of the study population was 54.48 ± 12.83 years old with a male to female ratio of 2.46. At the CCTA examination, mean total coronary artery calcium score was 284.20 ± 418.00. An association between the total coronary artery calcium score and GI (r2=0.12, p=0.01), PqI (r2=0.07, p=0.04), CI (r2=0.10, p=0.01), PBI (r2=0.12, p=0.01), PPD (r2=0.08, p=0.03) was found. Assessment of CCTA features of vulnerability at the level of atherosclerotic plaques indicated a strong association between periodontal indexes and plaque vulnerability: p<0.01 for association between CAL and spotty calcification, positive remodeling and napkin ring sign, p=0.009 for association between PPD and spotty calcification, and p=0.01 for association between tooth mobility and positive remodeling.

Conclusions

In patients with concomitant PD and CHD, the severity of periodontal disease seems to be associated with severity of atherosclerotic disease, assessed by the total coronary artery calcium score. At the same time, severity of PD is associated with a more expressed vulnerability of coronary plaques, indicating a high-risk phenotype of atheromatous plaques in patients with concomitant PD, and systemic inflammation is most likely the link between the two conditions.
Diagnosis of coronary microvascular dysfunction using magnetocardiography
Authors: Quesada O , Ziada K , Cho L , Daher E , Malhotra R , Miranda R , Setegn E , Moore B , Uber C , Erasala V , Takla R , Henry T
Published: November 2023

Background

In patients with ischemia and non-obstructive coronary artery disease (INOCA), diagnosing coronary microvascular dysfunction (CMD) is limited to invasive, expensive, and/or difficult to access methods. Magnetocardiography (MCG) is a rest-based scan that measures weak magnetic fields generated by cardiac ionic currents and has been validated for diagnosing ischemia secondary to obstructive coronary artery disease (CAD).

Objectives

The goal of this study was to validate MCG for diagnosing CMD in patients with INOCA as compared to invasive coronary functional angiography (CFA), the gold-standard for evaluation of CMD by coronary flow reserve (CFR).

Methods

Forty-eight patients with INOCA (58 ± 10.5 years of age) underwent both CFA and a noninvasive 36-channel MCG scan. CFA diagnosed 21 patients with CMD (CFR <2 by Doppler wire method or CFR <2.5 by thermodilution method) and 27 patients were confirmed as negative for CMD. Using MCG, patients were classified as either CMD positive or CMD negative using an adaptive rules-based system, originally developed for evaluating ischemia secondary to obstructive coronary artery disease. These rules based on 5 features involve the analysis of depolarization and repolarization to observe regions where electrophysiological heterogeneity exists and action potentials in affected tissue are altered in amplitude and/or rate.

Results

Of the 21 patients confirmed positive for CMD by CFA, 15 had at least one abnormal finding on the MCG. Of the 27 patients confirmed negative for CMD by CFA, 19 had no abnormal findings in the MCG. Using gold standard invasive CFR as reference, MCG had a mean accuracy of 71%, sensitivity of 71% and specificity of 70% for the detection of CMD. Figure 1 shows an example of CMD negative and CMD positive patient. In patients that exhibited more than one abnormal finding on the MCG rules (n =5), accuracy was 80%, with 4 patients correctly characterized as CMD positive, and one patient being characterized as falsely positive.

Conclusions

In INOCA patients, MCG demonstrates ability to noninvasively assess for CMD. An MCG-based diagnostic pathway for CMD merits further clinical evaluation.

Abbreviations and Acronyms: CMD, coronary microvascular dysfunction; MCG, magnetocardiography; CFR, coronary flow reserve; INOCA, ischemia and non-obstructive coronary artery disease; CFA, coronary functional angiographyFigure 1
Pulmonary venous flow changes after Mitraclip implantation is predictor of mid-term right ventricular function improvement
Authors: Bastidas Plaza D , Pozo Osinalde E , Olmos Blanco C , Mahia P , Marcos-Alberca P , Nombela-Franco L , Jimenez-Quevedo P , Tirado G , Luaces M , Gomez De Diego J J , Cobos M A , Fernandez-Ortiz A , Villacastin J , De Agustin Loeches J A
Published: November 2023

Background

Percutaneous mitral valve repair with Mitraclip has become an effective therapeutic alternative to mitral valve surgery in high-risk surgical patients with severe mitral regurgitation. Pulmonary venous flow assessment by pulsed Doppler is widely used to determine the severity of mitral regurgitation and apparently is the best method to evaluate mitral regurgitation after the procedure because device artifacts do not affect it. The main objective of this study was to assess the impact of pulmonary venous flow changes after Mitraclip implantation in right ventricular function in the follow up at 6 months after the procedure.

Methods

This single-center, retrospective study included all consecutive patients with mitral regurgitation ≥ III/IV undergoing percutaneous mitral valve repair with the MitraClip device at our institution between 2010 and 2023. We analyzed the changes in the systolic/diastolic flow velocity time integral ratio in pulmonary veins pre and postprocedure. The tricuspid annular plane systolic excursion (TAPSE) was the method used to assess the right ventricular function in the follow up.

Results

A total of 158 consecutive patients that underwent Mitraclip implantation at our institution were included. Men age was 77 years ±10.3, and 82 patients (52.5%) were women. The etiology of mitral regurgitation was degenerative in 70 patients (44.3%), functional in 60 patients (37.9%) and mixed in 28 patients (17.7%). Preprocedurally, tridimensional effective regurgitant orifice was 0.63 ±0.33cm2, left ventricular end-diastolic volume 145.19 ± 66.14 ml (indexed 80.33 ± 59.59 ml/m2), left ventricular ejection fraction 45.90 ± 15.99%, pulmonary artery systolic pressure (PASP) 48.79 ± 18.12 mmHg and TAPSE 18.59 ± 4.43mm. The change in the pulmonary venous flow assessed by the systolic/diastolic flow velocity time integral ratio, was predictor of a right ventricular function improvement at 6 months (y = -2.7169 + 3.0171 x, r= 0.45, p= 0,006 see figure 1).

Conclusions

Pulmonary venous flow changes after Mitraclip implantation assessed by the systolic/diastolic flow velocity time integral ratio is predictor of mid-term right ventricular function improvement.Figure 1
Multi-vessel Coronary Function Testing increases diagnostic yield in INOCA
Authors: Rehan R , Wong C , Weaver J , Ng M , Yong A
Published: November 2023

Background

Coronary vasomotor disorders (CVDs), comprising endotypes of coronary spasm and/or microcirculatory impairment, are common amongst patients with ischaemia and no obstructive coronary arteries (INOCA). Invasive coronary function testing (CFT) is the gold standard for diagnosing CVDs [1]. Most institutions recommend only testing the left coronary circulation focusing on the left anterior descending (LAD) artery as it typically subtends the largest myocardial territory [2]. Current practice is based on consensus, and it is unknown whether testing multiple coronary territories will increase diagnostic yield.

Purpose

To evaluate the diagnostic yield of multi-vessel, compared to single-vessel CFT in patients with INOCA.

Methods

Multi-vessel CFT was systematically performed in patients with suspected CVD. Vasoreactivity testing was performed through acetylcholine provocation in the left (20-200mcg) and right (20-80mcg) coronary artery. Incremental doses were manually injected via a guiding catheter over 20 seconds. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels (figure 1). Microvascular or vasospastic angina was diagnosed according to previously published international consensus.

Results

A total of 50 patients (57.5+/-12.8years with 60% females) and 147 vessels were included from 2 tertiary referral institutions. Compared to single-vessel CFT, multi-vessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (80% vs 62%, p = <0.0001), vasospastic angina (50% vs 38%, p = 0.04) and microvascular angina (58% vs 38%, p = 0.004) (figure 2). Epicardial vasospasm (n=25) predominated in the left coronary system (n = 19), though isolated right coronary spasm was noted in 20.7% (n=6).Over half the patients (n=28) had coronary microvascular dysfunction (CMD), 50% had 1-vessel CMD, 35.7% had 2-vessel CMD, 14.3% had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all three major coronary vessels (LAD = 36%, LCX = 28%, RCA = 28%, p = 0.648).

Conclusion

Multi-vessel CFT resulted in an increased diagnostic yield in patients with INOCA when compared to single-vessel testing. The results of this study suggest that multi-vessel CFT has a role in the management of patients with INOCA.Multi-vessel CFT algorithmDiagnostic yield of multi-vessel CFT
Hemodynamic assessment of pci using ultrasonic flow ratio in multivessel cad
Authors: Chenniganahosahalli Revaiah P , Kageyama S , Kotoku N , Ninomiya K , Masuda S , Wang B , Xingqiang H , Tsung-Ying T , Wlodarczak A , Moellmann H , Silvestri M , Sharif F , Tu S , Onuma Y , Serruys P W
Published: November 2023

Background

Ultrasonic flow ratio (UFR) is a novel method for fast computation of fractional flow reserve (FFR) from intravascular ultrasound. Recently studies have shown the feasibility of morphofunctional computational methods to reliably estimate coronary physiology stemming from intravascular ultrasound images.

Purpose

The objective of the study was to evaluate the reasons for suboptimal physiological results after PCI using the UFR.

Methods

The study population comprised 150 consecutive patients (283 vessels) who underwent intravascular ultrasound for optimization of PCI in three-vessel-disease as mandated in the ongoing MULTIVESSEL TALENT trial (NCT04390672). The UFR analysis of final IVUS pullback was performed at the CORRIB Core Lab by an analyst who was blinded to the clinical data using a prototype software package (IvusPlus prototype, Shanghai Pulse Medical, Shanghai, China). Suboptimal physiological results were defined as post PCI UFR value of <0.91. UFR drop of ≥0.05 (gradient) was taken as a significant drop either intra or outside of the stent. Based on the definition of the HAWKEYE study, Focal lesions were defined as UFR drop of ≥0.05 in 10mm, diffuse lesions were defined as progressive decline of UFR of ≥0.05 without any clear evidence of focal drop, and mixed lesions were defined as the combination of focal and diffuse lesions.

Results

The median UFR with IQR among 283 vessels was 0.94 (0.91-0.97). Sixty-four (22.61%) of the 283 vessels had a UFR less than 0.91. We measured gradients using the UFR pull back curve intra-stent and outside of stent (Figure 1) in vessels with UFR <0.91. Significant "intra stent gradient", "out of stent gradient", combined "intra stent "and "out of stent" gradients were seen in 28 (44%), 18 (28%), and 10 (16%) vessels respectively. No clearly defined gradients were found in 8 (12%) vessels. Out of the 28 "out of stent" gradients, 20 were diffuse lesions, 5 were focal lesions and 3 was a mixed lesion.

Conclusion

IVUS has been widely used in optimization of PCI especially in scenarios with complex multi vessel disease. Combination of IVUS and FFR enable the operator to conform to the highest standards in PCI. This study has demonstrated that using UFR it is possible to identify the cause(s) of suboptimal PCI results and thereby to further optimize PCI results.
Diet quality and long-term cardiovascular mortality after myocardial infarction in the Alpha Omega Cohort
Authors: Cruijsen E , Van Westing A C , Van Damme I , Geleijnse J M
Published: November 2023

Introduction

A healthy diet is important for the prevention and treatment of cardiovascular disease (CVD). The Dutch Health Council recently defined dietary guidelines for patients with atherosclerotic CVD (ASCVD), which we investigated in relation to long-term mortality after myocardial infarction (MI).

Purpose

We developed the Dutch Healthy Diet index for CVD patients (DHD-CVD index) and examined its relation with mortality in post-MI patients.

Methods

We included 4,365 patients of the Dutch Alpha Omega Cohort (60-80 y, 80% male) with a MI <10 y prior to study enrolment. Dietary intake was assessed at baseline (2002-2006), using a validated 203-item food frequency questionnaire. To create the DHD-CVD index, the existing 2015 Dutch Healthy Diet index was adapted using the 2023 Dutch dietary guidelines for ASCVD patients (scale from 0 to maximal adherence [0-150]). Patients were followed for cause-specific mortality through December 2018. Hazard Ratios (HRs) across quartiles of the DHD-CVD-index (ref = Q1, i.e. low overall diet quality) and per 1-SD increment in score were estimated using Cox proportional hazard models. Associations were adjusted for age, sex, total energy intake, smoking, education and physical activity. Results were additionally stratified for sex, obesity and diabetes.

Results

Of the cohort, 17% smoked, 21% had diabetes and >90% used statins or other CVD drugs. During a follow-up of 48,660 person-years, 2,048 deaths occurred of which 911 were due to CVD. The mean DHD-CVD score was 78.9 (SD 13) points. High diet quality (Q4) was associated with a 29% lower risk of CVD mortality compared to low diet quality (HR: 0.71, 95% CI: 0.56, 0.84), with an HR of 0.88 (95% CI: 0.82, 0.94) per 1-SD. For all-cause mortality, we observed a 14% lower risk for high vs. low diet quality (HR: 0.86, 95% CI: 0.76, 0.98), with an HR of 0.94 (95% CI: 0.90, 0.98) per 1-SD. HRs did not essentially differ between male of female patients, or between obese and non-obese patients. HRs for CVD mortality were stronger in non-diabetic patients (HR: 0.86, 95% CI: 0.79, 0.93; per 1-SD), and no longer statistically significant in patients with diabetes (HR: 0.97, 95% CI: 0.84, 1.11; per 1-SD).

Conclusion

A high diet quality, measured with the DHD-CVD index, was associated with a lower risk of CVD and all-cause mortality after MI in Dutch patients. Adherence to dietary guidelines for CVD patients should be considered on top of medication use.
The efficacy of coronary sinus reduction in refractory angina: A meta-analysis
Authors: Theofilis P , Oikonomou E , Lampsas S , Sagris M , Tsioufis K , Tousoulis D
Published: November 2023

Objectives

Refractory angina is a frequent complain of patients with coronary artery disease. Its management is challenging despite the available pharmacological approaches. Interventional approaches have also been attempted, with coronary sinus reduction (CSR) being the main treatment option.

Purpose

This meta-analysis aimed to assess the efficacy of CSR in improving symptoms and cardiovascular endpoints in patients with refractory angina.

Methods

We searched the Pubmed database till 26/2/2023 for studies assessing the impact of CSR in refractory angina. The primary outcome of interest was the improvement in Canadian Cardiovascular Society (CCS) category by at least one class. Secondary outcomes included the implantation success, the proportion of patients improving by at least two CCS classes, as well as the rates of new myocardial infarction/percutaneous coronary intervention and mortality at follow-up.

Results

The literature search resulted in 190 studies. After screening of title/abstract/full-text, a total of 10 studies (1400 patients) were included in the meta-analysis. The median follow-up was 12.8 months (range: 4-24 months). High rates of implantation success (97%, 95% confidence interval (CI) 95%-98) were reported. Improvement by at least one CCS class was reported by 77% (95% CI 73%-81%). Improvement by at least two CCS classes was seen in 41% (95% CI 36%-47%). The proportion of patients exhibiting a new myocardial infarction/percutaneous coronary intervention was 7% (95% CI 3%-16%), while the mortality rate was 7% (95% CI 3%-14%).

Conclusion

Coronary sinus reduction is a procedure accompanied by high success rates, and is effective in improving symptoms in a considerable proportion of patients with refractory angina.
Percutaneous coronary intervention for chronic total occlusions improves cardiopulmonary exercise capacity
Authors: Ishikawa M , Kawai H , Funato Y , Nagasaka R , Sato Y , Uwatoko T , Toriya T , Matsuwaki Y , Yoshinaga M , Ota H , Yamada A , Yanase M , Muramatsu T , Sarai M , Izawa H
Published: November 2023

Introduction

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is recommended in patients with an expected reduction of angina pectoris. However, whether PCI for CTO improves exercise tolerance remains controversial.

Purpose

To evaluate whether PCI improves cardiopulmonary exercise capacity in patients with CTO.

Methods

We prospectively performed both stress myocardial perfusion scintigraphy (MPS) before PCI and cardiopulmonary exercise testing (CPX) before and 6 months later of PCI in October of 2020 to September of 2022. Myocardial ischemia was defined as summed difference score ≧3.

Results

Of 28 patients (67.9 ± 10.6 y.o., 96% men), 31 major vessels were occluded vessels (right coronary artery 13, left anterior descending 11, and left circumflex 7). Overall, peak VO2 after PCI was higher than that before PCI (18.9 ± 4.2 vs. 17.3 ± 3.7 ml/min/kg, P < 0.05). Peak VO2 was improved in 20 patients and not in 8. Peak VO2 was improved in 13 of 16 patients (81%) with myocardial ischemia in the occluded area and 7 of 12 (58%) without.

Conclusions

PCI for CTO improves cardiopulmonary exercise capacity, especially in the patients with ischemic evidence in the occluded area.
STANLEy score: a new predictive model of 3-year major adverse cardiac events following "Full Metal Jacket" using new-generation drug-eluting stents
Authors: Viegas J M , Grazina A , Teixeira B , Morais L A , Silva T P , Ramos R , Fiarresga A , Sousa L , Cacela D , Ferreira R C
Published: November 2023

Introduction

Percutaneous Coronary Intervention (PCI) using a "Full Metal Jacket" (FMJ) procedure (≥60 mm of continuous stent length) is often required to treat very long lesions, but its clinical efficacy and safety using contemporary drug-eluting stents (DES) remains to be determined.

Objectives

To identify predictors of major adverse cardiac events (MACE) associated with FMJ using new-generation DES. We sought to develop a simple model capable of accurately predict 3-year MACE following FMJ PCI.

Methods

A retrospective single-centre analysis of consecutive FMJ PCI performed between January 2015 and December 2018. Exclusion criteria were use of non-third generation DES, unsuccessful procedure and loss to follow-up. The primary endpoint was a composite of all-cause death, myocardial infarction, and target vessel revascularization. Demographic, clinical, angiographic, and procedural variables were evaluated. Logistic regression analysis was performed to determine independent predictors of outcome. Based on the results, a weighted scoring system was developed.

Results

The derivation cohort included 162 patients, mean age 65.9 ± 11.1 years, 83% male. The mean stent length was 73.8 ± 12.3 mm (range 60 to 116 mm), and the average number of stents was 2.74 ± 0.74 (range 2 to 5). 30-day, 1-year and 3-year MACE were 5.5%, 12.9% and 29.0%, respectively.

Multivariate analysis identified diabEtes mellitus (hazard ratio (HR) 5.92; 95% confidence interval (CI) 1.57-11.54; p=0.011), Smoking habits (HR 8.37; 95%CI 3.05-15.55; p=0.001), Acute coronary syndrome (HR 3.51; 95%CI 1.030-8.98; p=0.045), Non-right coronary artery (HR 4.38; 95%CI 1.09-7.68; p=0.038), osTial lesion (HR 10.01; 95%CI 2.91-19.14; p=0.006) and severe caLcification (HR 8.59; 95%CI 2.65-15.72; p=0.001) as independent predictors of 3-year MACE.

A composite score based on these 6 variables (STANLEy score) was created, ranging from 0 to 10 (Fig.1). High acuity was verified by ROC curve analysis (AUC 0.941, p <0.001). A score ≤ 3 was associated with a reduced probability (<15%) and a score ≥ 7 with high probability (>90%) of 3-year MACE.

Conclusion

The STANLEy score is a good predictive model which relies on 6 simple clinical and angiographic characteristics. This score may assist physicians in selecting high-risk patients for closer monitoring or aggressive antithrombotic strategy.Figure 1
Coronary artery calcification is associated with smaller increases in femoral neck bone mineral density with anti-resorptive therapy
Authors: Rodriguez A , Hii R , Ebeling P , Nerlekar N
Published: November 2023

Introduction

Patients with osteoporosis are at high cardiovascular risk, partly due to vascular calcification, such as in the coronary vessels. It is uncertain if the presence of coronary artery calcification (CAC) effects bone mineral density (BMD) response to anti-resorptive treatment – first line therapy for osteoporosis. We therefore assessed changes in BMD following initiation of anti-resorptive treatment for osteoporosis in patients with and without evidence of CAC.

Methods

Individuals dispensed at least one prescription for an anti-resorptive medication (bisphosphonates or denosumab) at Monash Health between 2009-2022 were identified. Unique record numbers for these individuals were then cross-matched against the cardiac CT imaging service at Monash Heart (HREC#73603). CAC was detected using a 320-slice CT coronary angiogram (CTCA). We included only those patients having a baseline BMD measurement within two years of CTCA. The annualised percentage change in femoral neck BMD was calculated and adjusted for age, sex, height, weight, and number of years on anti-resorptive treatment.

Results

106 individuals were identified of which 85 (women=70 [85%], median age=73 years [interquartile range 64-79 years]) had a follow-up BMD measurement including 19 with, and 66 without, evidence of CAC. Those with CAC were older (76 years versus 64 years, p<0.001). There were 70 bisphosphonate users and 15 denosumab users. Individuals with evidence of CAC experienced, on average, a 1.2% lower increase [(0.345% (0.343 to 0.348) versus -0.881% (-0.883 to -0.879), mean difference -1.226% (-1.493 to -0.959; p<0.05)] in annualised femoral neck BMD with anti-resorptive therapy after adjusting for important clinical risk factors.

Interpretation

These preliminary data suggests that CTCA-determined CAC may negatively impact femoral neck BMD increases with anti-resorptive therapy. This is perhaps consistent with existing and evolving hypotheses of dysregulatory processes driving ectopic calcium deposition, which we surmise would partially counter the effects of anti-resorptive therapy and potentially manifest as CAC. Thus, of particular interest will be the comparison of cardiovascular outcomes of patients with known CAC with and without anti-resorptive therapy, with the hypothesis that anti-resorptive therapy may potentially have cardioprotective effects in context of CAC. Analysis of the full cohort is underway.Table 1
Novel risk score of mortality prediction for critical cardiogenic shock patients
Authors: Wang M T W
Published: November 2023

Background

Patients with critical cardiogenic shock have a high mortality rate. However, evidence for a specific scoring system for mortality prediction is obscure.

Purpose

This study aimed to identify independent predictors to build a reliable scoring system for survival prediction and risk identification in patients with cardiogenic shock.

Methods

This study enrolled critically ill patients with cardiogenic shock in the intensive care unit (ICU) between January 1, 2010, and December 31, 2021. A total of 1,607 patients were enrolled in this study. A novel scoring system for cardiogenic shock mortality prediction, the Kaohsiung Veterans General Hospital Cardiogenic Shock (KVHCS) score,was developed based on independent predictors. Further validation was performed using the Acute Physiology and Chronic Health Evaluation (APACHE) II score.

Results

The mean age of the patients was 67.6 ± 14 years, with male predominance (76%). Patients in the death subgroup were older (72.4 ± 12.8 vs. 66 ± 14 years, P < 0.001), had higher APACHE II (24.1 ± 9.9 vs. 14.6 ± 8.6, P < 0.001) scores, and had more comorbidities. A five-strata KVHCS score was constructed. Compared to the predictive ability of the APACHE II score (AUC = 0.75, P < 0.001) on ICU mortality, the KVHCS score (AUC = 0.87, P < 0.001) had a more powerful performance. It was also more reliable at predicting 30-day mortality (AUC = 0.81 vs. 0.73). Coronary artery disease (CAD) had the greatest contribution to mortality, whereas diabetes mellitus (DM) was a positive predictor of ICU discharge survival but had a negative impact on long-term outcomes.

Conclusions

For critical cardiogenic shock patients in the ICU, CAD was the most important factor negatively affecting ICU survival, whereas DM patients had better survival at ICU discharge but worse long-term outcome. The novel KVHCS score had better risk level prediction for mortality in cardiogenic shock patients than the traditional APACHE II score.Figure 3
Inter-relation between hypoxic liver injury and killip classification in st segment elevation myocardial infarction patients
Authors: Choi S H , Kwon S W , Suh J S , Park S D P , Oh P C O , Jang H J J , Moon J G M , Lee K H L , Kang W C K , Kim T H K , Suh Y J S
Published: November 2023

Purpose

Hypoxic liver injury (HLI) and Killip classification are poor prognosticators of ST segment elevation myocardial infarction (STEMI) patients. We investigated the inter-relationship between hypoxic liver injury (HLI) and Killip classification.

Materials and Methods

4 tertiary hospitals from Incheon-Bucheon province enrolled 1537 STEMI patients who had undergone percutaneous coronary intervention (PCI) from 2007 to 2014. They were divided into 4 groups according to their Killip classification presented at the emergency room (ER). HLI was defined as ≥2-fold increase of serum aspartate transaminase (AST).

Results

Incidence of HLI showed incremental tendency with respect to Killip classification (19.5%, 19.4%, 34.6%, 37.8%, p<0.001) respectively. Left ventricular ejection fraction (LVEF) was below 45% in symptomatic, overt heart failure patients (Killip class II, III and IV). Initial and peak AST level increased in accordance to Killip classification along with cardiac biomarkers. In-hospital mortality and Killip classification were in direct relation (2.3%, 7.3%, 16.3%, 29.2%) with statistical significance. Univariate and multivariate Cox regression analysis showed that both presence of HLI and combined Killip classification III and IV were poor prognosticators even after adjusting for conventional clinical risk factors. Receiver operating characteristics (ROC) analysis showed that combination of HLI and Killip classification was the most sensitive predictor of mortality (AUC 0.832, 95% CI 0.78-0.882). Kaplan-Meier curve showed that patients with HLI were at higher risk of death in both Killip class (I+II) and Killip class(III+IV) group.

Conclusions

Presence of HLI and Killip classification were in direct-relation translating to worst prognosis. Early recognition of HLI and thorough detection of accurate Killip classification is warranted whilst treating STEMI patients.
Predictive value of right ventricular geometry and function evaluated in AI-computed tomography in patients undergoing transcatheter tricuspid valve repair
Authors: Gercek M , Kirchner J , Gesch J , Friedrichs K P , Omran H , Rossnagel T , Piran M , Rudolph V , Rudolph T K
Published: November 2023

Background

The role of cardiac geometry and function for outcome after transcatheter tricuspid valve repair is poorly understood. This study sought to investigate whether right ventricular geometry and function are predictors for clinical outcome in patients undergoing transcatheter tricuspid valve repair (TTVR).

Methods and results

60 Patients (mean age 79 ± 6 years, 53% female) suffering from severe tricuspid regurgitation underwent full cardiac cycle computed tomography (CT) for TTVR procedure planning. In comparison to conventional CT-measuring of left and right ventricle, AI-based data showed excellent correlation of cardiac volumes in diastole and systole (R-value for Pearson´s correlation ranging from 0.926 – 0.991; each P-value for correlation < 0.001).

We tested whether patients with reduced right ventricle function are associated with worse outcome regarding mortality and re-hospitalization after one year. The mean follow-up was 198 ± 143 days. After 1 year the combined endpoint of death and re-hospitalization occurred in significantly fewer patients with >50% RV-EF (12.1% vs. 37%; X²=5.2; P=0.023). Furthermore, enlarged right ventricle with ≥220 ml end diastolic volume (RVEDV) was associated with poor outcome (0% vs. 33.4%; X²=6.842; P=0.009). The right ventricle was classified as "dysfunctional" with RVEDV ≥200 ml and RV-EF <55% or "functional" with RVEDV < 200 ml or RV-EF > 55%. Patients with "dysfunctional" right ventricle showed poorer outcome in comparison to patients with "functional" right ventricle. (11.1% vs. 32.3%; X²=4.916; P=0.027).

Conclusions

AI-based 3D-reconstruction of right ventricular geometry in full cycle cardiac CT shows excellent correlation with conventional cardiac CT-reconstruction. Patients with enlarged ventricle > 220 ml RVEDV or RV-EF ≤ 50 % and patients who have ≥ 200 ml RVEDV and ≤ 55 % were associated with poor outcome after TTVR.Outcome based on RVEDV after TTVROutcome based on RV-EF after TTVR
Anti-MDA-LDL antibody levels indicate protection from coronary CT-derived valve calcification in the SCOT-HEART Trial
Authors: Hartley A , Williams M , Caga-Anan M , Kaura A , Dey D , Dweck M , Newby D , Khamis R
Published: November 2023

Introduction

Coronary CT-derived valve calcification is becoming increasingly important in the multi-modality assessment of valvular disease, especially in aortic and mitral stenosis, where trans-catheter structural heart interventions may be indicated. Separately, natural antibodies targeted against malondialdehyde-modified LDL (MDA-LDL), an important subset of all oxidised low-density lipoproteins, are related to less coronary atherosclerosis and freedom from cardiovascular events.

Purpose

To investigate possible relationships between coronary CT-derived valve calcification and anti-MDA-LDL antibodies.

Methods

In a substudy of the multicentre randomised controlled SCOT-HEART trial (Scottish COmputed Tomography of the HEART), we investigated the association between manually assessed presence or absence of mitral and aortic valve calcification and IgM/ IgG anti-MDA-LDL antibodies. Serological biomarkers were measured using laboratory-developed enzyme-linked immunosorbent assays and assessed in tertiles versus imaging parameters, with adjustment for the ASSIGN cardiovascular risk score.

Results

In 830 patients (53% male, 57.6±9.8 years) with a heavy burden of cardiovascular risk factors (36% hypertension, 12% diabetes mellitus and 55% history of current or ex-smoking), the highest tertile of IgM anti-MDA-LDL related to a lower incidence of aortic valve calcification (odds ratio [95% confidence interval], 0.59 [0.36 – 0.96], p=0.04, p=0.07 for trend across tertiles) and mitral valve calcification (0.26 [0.07–0.72], p=0.02, p=0.05 for trend). There was also a trend for the highest tertile of IgG anti-MDA-LDL antibodies relating to a lower incidence of aortic valve calcification (0.36 [0.10–0.99], p=0.05, p=0.25 for trend), but not for mitral valve calcification.

Conclusions

Anti-MDA-LDL antibody levels were associated with a lower incidence of aortic and mitral valve calcification. Assessment of these novel biomarkers, which are known to relate to freedom from cardiovascular events, may be useful in screening patients prior to coronary CT for planning suitability for trans-catheter structural heart interventions.
Breaking the silence: uncovering the underdiagnosis of SCAD in young women with acute coronary syndromes
Authors: Al-Gully J K M , Montero Cabezas J M , Eikenboom J , Den Exter P L , Al Amri I
Published: November 2023

Background

Spontaneous Coronary Artery Dissection(SCAD) is a recognized cause of Acute Coronary Syndrome (ACS), particularly in young women. Despite increasing awareness, underdiagnosis of SCAD remains common. Given the distinct differences in management and potential outcomes, a prompt and accurate diagnosis of SCAD is crucial for appropriate treatment and follow-up.

Purpose

To assess the prevalence and implications of SCAD underdiagnosis in young women with ACS and to identify potential indicators of SCAD.

Methods

We included consecutive women aged ≤55 years with an ACS referred for coronary angiography (CAG) to a tertiary center from 2012 to 2021. All index CAG’s and when available intracoronary imaging recordings were retrospectively reviewed to identify angiographic signs of SCAD according to the Yip-Saw criteria. Known cardiovascular risk factors, predisposing conditions for SCAD, and major adverse cardiovascular events (hospital visits, recurrent ACS, target vessel revascularization, stroke) were collected during hospitalization and follow-up. SCAD patients were compared to ACS patients without SCAD (atherosclerotic coronary artery disease, coronary spasm, no abnormalities). Subsequentially, the initially recognized SCAD patients were compared to the reclassified SCAD patients.

Results

293 patients (mean age 48±5 years) were included, 217 (74%) presenting as STEMI and 64 (22%) as NSTEMI. Based on retrospective analysis of the (intra)coronary images SCAD was the underlying cause of the ACS in 17% of all patients (n=50/293) while only recognized at initial diagnosis in 26% (n=13/50) of these cases. SCAD type 2a was most frequently missed (30%). Compared to ACS patients without SCAD, SCAD patients were younger (47±6 vs. 49±5 years, p<0.05), had lower rates of smoking (28% vs. 60%, p<0.05) and less often a history of dyslipidemia (10% vs. 24%, p<0.05) and diabetes (2% vs. 16%, p<0.05). Furthermore, the coronary tortuosity score was higher (4.7±2.0 vs. 3.0 ±1.5, p<0.05). Invasively treated SCAD patients often received ≥3 coronary stents when compared to ACS patients without SCAD (28% vs. 15%, p=0.02) mostly due to hematoma extension. Follow-up showed ACS based on atherosclerosis occurred less often in SCAD patients compared to non-SCAD patients (resp. 9% vs. 14%, p<0.05), and recurrent SCAD was only recorded in reclassified SCAD patients (5% vs. 0%, p<0.05). On multi-variate analysis, the coronary tortuosity score (1.58 [1.3-1.88]) was associated with SCAD.

Conclusion

This study reveals that underdiagnosis of SCAD is common in young women with ACS leading to incorrect treatment with specific medication and excessive coronary stenting. Healthcare providers should be cautious for SCAD in young ACS patients with few cardiovascular risk factors and high coronary tortuosity scores. This study emphasizes the need for greater awareness and improved diagnostic methods for SCAD in young women with ACS.