bluuebunny/crossref_metadata_2025 huggingface dataset:
PCI of chronic total occlusions: what is the clinical benefit and impact on quality of life?
Authors: Costa H , Martins J , Mota T , Santo M E , Fernandes R , Carvalho D , Palmeiro H , Bispo J , Franco P , Marto S , Guedes J , Marreiros A , Mimoso J , Vinhas H , Jesus I
Published: October 2022

Introduction

Coronary chronic total occlusions (CTO) are relatively common findings in the context of coronary angiography. The indication for revascularization of this type of lesions remains controversial. The recommendations of international cardiology societies consider the treatment of CTO by percutaneous coronary intervention (PCI) in selected patients, but this technique is not yet widely used in this context.

Objectives

To evaluate the clinical and quality of life impact of patients undergoing PCI-CTO, including angina, heart failure (HF), acute myocardial infarction (AMI), mortality and improved quality of life (QoL) after the procedure.

Methods

Retrospective study for biennium 2019/2020, composed of n=177 patients undergoing PCI-CTO. A descriptive and comparative analysis of the sample regarding the demographic and clinical characteristics of patients was performed, to whom a quality of life questionnaire (WHOQOL-Brief) was applied. The descriptive analysis was based on means and standard deviations and on the analysis of statistical tests, t-Student and Mann-Whitney were performed according to the parametric and non-parametric context, respectively.

Results

A total of 177 patients were identified, with a mean age of 65.7±11.2 years, 51.5% female. 75% of patients showed high blood pressure, 39% diabetes and 80.5% NSTEMI. At 30 days after PCI only 21% of patients had symptoms (angina or HF), with clinical improvement at 180 days to 10% symptomatic. Regarding QoL, an average score of 4.3 (maximum of 5) was obtained for the 2 questions that independently assess the patient's perception of their QoL after the procedure. High levels of scores were also obtained by domains (QoL>70%), with marked improvement in the Physical, Environmental and Psychological domains, becoming more evident in the latter at 30 days after the procedure in patients who remained asymptomatic (75.2%, p=0.023). This benefit was accompanied by improvement in left ventricular function (LVEF), being more evident in asymptomatic patients and without events after procedure. Mortality and AMI occurred in 6% and 2%, respectively.

Conclusion

The majority of patients had clinical benefit and expressed improvement in QoL after undergoing PCI-CTO, which was accompanied by improvement in LVEF, reinforcing the usefulness of the technique and the approach of this type of lesions in selected patients.

Funding Acknowledgement

Type of funding sources: None.
Thiamine as an outcome predictor in postoperative CABG patients
Authors: Garcia L R , Garzesi A M , Affonso P H D V , Tonon C R , Felicio M L , Brito F S , Martins A S , Campos N L K L , Okoshi M P , Paiva S A R , Minicucci M F , Polegato B F , Zornoff L A M
Published: October 2022

Introduction

Coronary artery bypass graft surgery (CABG) is one of the most performed cardiovascular procedures worldwide. Despite good outcomes, CABG induces systemic inflammation, increases oxidative stress and increases catabolism. As thiamine act as a cofactor in glucose metabolism and glutathione synthesis, its deficiency could have a high prevalence in critically ill patients.

Purpose

To assess the association between plasma thiamine concentrations and clinical outcomes and 30-day mortality in patients undergoing non-emergency CABG.

Methods

Prospective and observational study that included consecutive patients older than 18 years undergoing CABG that assigned the consent form. Plasma thiamine concentrations were determined before and 24 hours after the procedure by the high-performance liquid chromatography method. The clinical outcomes evaluated were perioperative acute myocardial infarction, heart failure, cardiogenic shock, arrhythmias, stroke and acute kidney injury. Mortality was evaluated on the 30th day after CABG.

Results

The study included 131 patients submitted to CABG. The mean age was 61±9.1 years, 73.3% were men, and the mean EuroScore II value was 1.78±1.3%. Before CABG, plasmatic thiamine concentration was 33±15ng/ml, and 15% of the patients had thiamine deficiency. After CABG, plasmatic thiamine concentration was 20±8ng/ml. All patients diminished plasmatic thiamine concentration after CABG. Mortality was 16% and 24% of patients presented acute kidney injury. Combined outcomes, which included the presence of acute myocardial infarction, heart failure, cardiogenic shock, arrhythmias, stroke, acute kidney injury or death, was present in 52% of the patients. Percentage of thiamine variation between before and after CABG was not associated with mortality (34±14 vs 41±10%; p=0.063); however, it was associated with acute kidney injury (40±14 vs 34±13%; p=0.027) and combined outcomes (37±13 vs 33±14%; p=0.035).

Conclusion

Percentage of thiamine variation from before to after CABG was associated with acute kidney injury and combined outcomes in these patients.

Funding Acknowledgement

Type of funding sources: None.
BMI modifies the effect of HDL on outcomes after coronary artery bypass grafting surgery
Authors: Fallahzadeh A , Sheikhy A , Rezaee M , Behnoush A H , Jameie M , Hosseini K
Published: October 2022

Background

While the important role of both high-density lipoprotein cholesterol (HDL-C) and body mass index (BMI) in the prognosis of coronary artery disease (CAD) is well known, the impact of BMI on the association between HDL-C and cardiovascular outcomes remains unclear.

Purpose

In this regard, we aimed to investigate whether BMI can modify the correlation between HDL-C levels and outcomes in patients who underwent coronary artery bypass grafting (CABG).

Methods

The present registry-based cohort study included patients who underwent isolated, elective, and first time CABG with 18≤BMI<35 kg/m2. The median follow-up period was 76.62 (75.71–77.52) months. The participants categorized into three groups based on BMI: 18.5≤BMI<25 kg/m2, 25≤BMI<30 kg/m2, and 30≤BMI<35 kg/m2. The Cox proportional hazards models and Restricted Cubic Splines (RCS) in the Cox models were applied to evaluate the association between HDL-C and all-cause mortality and occurrence of major adverse cardio-cerebrovascular events (MACCE) in different BMI categories.

Results

From 2006 to 2016, a total of 17309 patients (73% male, mean age 66.17±9.98) were included. Compared to other groups, diabetes, hypertension, dyslipidemia, and family history of coronary disease were more prevalent in patients with 30≤BMI<35 kg/m2 (P<0.05). Cox proportional hazards models did not show a significant correlation between each 1 mg/dl increase in HDL-C and risk of all-cause mortality and MACCE. In contrast, the results of RCS in the Cox models demonstrated a non-linear relationship between HDL-C and outcomes in patients with 30≤BMI<35 kg/m2, with higher levels of HDL-C, were paradoxically associated with a higher risk of all-cause mortality and MACCE in this BMI category. In the 3D presentation of the association between BMI, HDL-C and all-cause mortality, the highest risk of all-cause mortality was seen in low levels of HDL-C (HDL-C <20 mg/dl) and low or very high levels of BMI.

Conclusions

Very high HDL-C levels could be associated with a higher risk of adverse outcomes after CABG, in patients with 30≤BMI<35 kg/m2. These findings suggest a role of obesity in the function and properties of HDL-C thereby, it seems necessary to consider the concomitant conditions such as BMI when evaluating the risk of cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.
Comparison of trans-radial access and femoral access in cardiogenic shock patient who had undergone primary percutaneous coronary intervention from SMART RESCUE trial
Authors: Choi S H , Park S D , Lee M J , Lee K J
Published: October 2022

Introduction

Throughout the years of percutaneous coronary intervention (PCI), the debate regarding access route, whether it being trasns-radial or femoral, is an ongoing agenda yet to be solved. Recent guidelines suggest trans-radial approach as an option to be considered in acute coronary syndrome (ACS). However, data on cardiogenic shock patients undergoing PCI is relatively sparse.

Purpose

Compare the clinical implication of trans-radial and femoral approach in cardiogenic shock patients who had undergone PCI.

Method

Cardiogenic shock patients who had undergone PCI from January 2014 to December of 2018 were enrolled. Patients were divided according to their access route respectfully. Primary outcome was composite endpoints including all-cause death, re-admission due to heart failure, myocardial infarction (MI) and cerebrovascular accident.

Result

A total of 694 (572 via femoral approach, 122 via radial approach) cardiogenic shock patients who received PCI were enrolled. Mean age femoral and radial groups was 66.59±12.51 and 66.66±12.8 respectfully. Disease severity was higher for femoral patients compared to radial patients as represented by their LM involvement, mechanical organ support (extracorporeal membrane oxygenation, continuous renal replacement therapy, mechanical ventilation), left ventricular ejection fraction (LVEF) and vasoactive inotropic score. Cox regression analysis after adjusting for conventional risk factors showed that femoral route was a poor prognosticator with respect to composite endpoints (HR=2.059, 95% CI 1.249–3.397, p value = 0.005). Radial approach patients had higher survival probability compared to femoral approach patients (Figure 1).

Conclusion

Radial approach in cardiogenic shock patients who are in need for PCI with relatively less severe clinical condition could be a reasonable option for access route.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University Hospital
Medical therapy for secondary prevention in patients with myocardial infarction with non-obstructive coronary artery disease: long-term outcome of a Portuguese centre
Authors: De Campos D , Saleiro C , Teixeira R , Botelho A , Lopes J , Goncalves L
Published: October 2022

Background

The outcomes of dual anti-platelet therapy (DAPT), β-blocker, renin-angiotensin-aldosterone system (RAAS) inhibitor and statin therapy are unknown in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). The aim of this study was to examine the effects of secondary prevention therapy at discharge on long-term outcomes in MINOCA.

Methods

Patients with MINOCA undergoing early coronary angiography between 2009 and 2016 were extracted from a clinical database. Patients were followed until 2018 for outcome events. All patients with a MINOCA diagnosis and without history of atrial fibrillation were included. A total of 646 consecutive patients were enrolled. The primary end point was major adverse cardiac events (MACE) defined as all-cause mortality, myocardial infarction (MI), stroke, and heart failure (HF). Secondary endpoints comprised all individual endpoints for the composite end-point. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis and Cox regression models.

Results

Mean age was 67.9±13.4 years and 31.6% were women. No patient was lost to follow-up. Mean left ventricular ejection fraction was 47.8±13.1%. At discharge, 87.2%, 82.5% and 79.5% of the patients were on statins, RAAS inhibitors and β-blockers, respectively. The majority (72.8%) were discharged on DAPT. During follow-up (Mdn 59 months), 303 (46.9%) patients experienced a MACE and 208 (33.4%) died. MI occurred in 98 patients (17.8%) and stroke in 31 patients (5.6%). HF admissions were also common (82, 14.9%). The hazard ratio (HR) for major adverse cardiac events was 0.31 (0.23–0.41) in patients on statins, RAAS inhibitors and β-blockers. For patients on DAPT the HR was 0.61 (0.48–0.78). In univariate Cox regression analyses, a reduced risk of MACE was found in patients using combined secondary prevention therapies (HR 0.58, 0.46–0.74). Regarding the individual endpoints, combined secondary prevention therapy reduced the risk of stroke (HR 0.45, 0.22–0.99, P=0.04) but not risk of future MI nor HF admissions. Patients in the combined therapy group had a higher median survival (66 months, IQR 27–82 months) than the group without secondary prevention (34.5 months, IQR 6.8–74 months; P<0.001 of Log Rank test for equality of survivor functions). In a multiple Cox regression analysis including RAAS inhibitors, statins, DAPT and β-blockers in the model, none of these drugs was associated with lower MACE, except for RAAS inhibitors.

Conclusions

The results indicate long-term beneficial effects of treatment with secondary prevention medical therapies in patients with MINOCA. Properly powered randomized clinical trials are warranted.

Funding Acknowledgement

Type of funding sources: None.
Impact of metabolic syndrome and its components on clinical severity and long-term prognosis in patients with premature myocardial infarction
Authors: Wang Y , Wu X Y , Cui Y , Zou Z H , Liang Y , Li W Q , Yang Y N , Liu Y , Gao J
Published: October 2022

Background

Metabolic syndrome (MetS) is involved in the occurrence, development and prognosis of cardiovascular diseases, especially acute myocardial infarction (AMI). In recent years, the trend of AMI at a younger age has gradually attracted people's attention. Relevant studies have confirmed that MetS affects the prognosis of people aged ≥45 with AMI. However, there is still a lack of research on MetS in people with premature myocardial infarction (PMI).

Purpose

To explore the impact of MetS and its components on clinical severity and long-term prognosis in PMI patients.

Methods

772 Patients with AMI who aged ≤45 years old from 2015 to 2020 in a hospital were enrolled. The patients were divided into MetS group (n=417) and non-MetS group (n=355) according to the criteria proposed by NCEP ATP III in 2005 (Any 3 of the following 5): 1) Hypertension: BP ≥130/85 mmHg or consistent hypertensive patients undergoing treatment; 2) Hypertriglyceridemia: fasting plasma triglyceride ≥1.7 mmol/L; 3) Fasting HDL-C <1.0 mmol/L in men and <1.3 mmol/L in women. 4) Hyperglycemia: fasting blood glucose level ≥6.1 mmol/L or known diabetic patients undergoing treatment; 5) Central obesity: BMI ≥28.0 kg/m2. Patients were followed for median of 42 months for major adverse cardiovascular events (MACE). The parameters of clinical severity were compared using logistic regression analysis. Cox regression were used to analyze the relationship between MetS and its components and prognosis.

Results

A total of 772 patients were included in the analysis. Hyperglycemia was associated with multi-vessel disease (OR=1.700, 95% CI 1.172–2.464, P=0.005) and Syntax score ≥33 (OR=2.736, 95% CI 1.241–6.032, P=0.013).Increased MACE were observed in the MetS group (17.9% vs 10.3%, P=0.004) after 42 months follow-up. The Kaplan-Meier curve also showed significant differences (P<0.001). MetS was an independent risk factor for MACE (HR=2.181, 95% CI 1.392–3.418, P=0.001). Of each component of the definition, BMI ≥28.0 kg/m2 (HR=2.047, 95% CI 1.229–3.410, P=0.006) and hyperglycemia (HR=2.911, 95% CI 1.850–4.580, P<0.001) were independent risk factors for MACE.

Conclusions

In patients with PMI, (1) hyperglycemia usually indicates more severe lesions; (2) MetS as a whole was an independent risk factor for MACE; (3) Of each component of the MetS, BMI ≥28.0 kg/m2 and hyperglycemia were associated with MACE.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This research was supported by the Key Project of Scientific and Technological Support Plan of Tianjin in 2020
Lipoprotein(a) levels and risk of adverse events after myocardial infarction in patients with and without diabetes
Authors: Esposito L , Cancro F P , Silverio A , Di Maio M , Bellino M , Romei S , Tedeschi M , Ciccarelli M , Vecchione C , Galasso G
Published: October 2022

Background

There is a positive continuous association between Lipoprotein(a) (Lp[a]) levels and the risk of recurrent ischemic events in patients with recent myocardial infarction (MI). However, the prognostic significance of the association between high Lp(a) levels and diabetes has been poorly investigated after MI.

Purpose

The aim of this study was to evaluate the association of Lp(a) levels with the long-term risk of adverse events in post-MI patients, and to investigate whether diabetes may influence this association.

Methods

Consecutive MI patients who underwent urgent/emergent coronary angiography at our Institution from February 2013 to June 2019 were prospectively collected. Lp(a) serum concentrations was expressed for increasing range values (≤10, >10–30, >30–50, >50–70, and ≥70 mg/dL). The primary outcome was the recurrence of MI; the secondary outcome was all-cause death. The propensity score weighting technique was used to account for potential confounding between patients with and without diabetes.

Results

The study population consisted of 1018 post-MI patients (median age: 63 years; 76% males). Diabetes was reported in 280 patients (27.5%). The median value of Lp(a) was 10 mg/dL, and patients with diabetes showed significantly lower Lp(a) levels than patients without diabetes (p=0.025). At a median follow-up of 1121 days, the primary outcome was reported in 109 patients (10.7%), and the secondary outcome in 100 (9.8%). After propensity score weighting, there was a significant association between increasing Lp(a) range values and the primary outcome both in the overall population (p trend = 0.030) and in non-diabetic patients (p trend = 0.009), but not in diabetics.

Conversely, no significant association with the risk of all-cause mortality across increasing Lp(a) categories both in the overall population and in the study groups according to the presence or not of diabetes was found.

Compared with the lowest Lp(a) category, Lp(a) plasma levels >70 mg/dL were independently associated with the risk of recurrent MI (HR: 3.222; 95% CI, 1.225–8.478, p=0.018) and all-cause death (HR: 2.656; 95% CI, 1.009–6.991, p=0.048) in non-diabetic patients, but not in diabetics.

Conclusions

In this real-world post-MI population, Lp(a) serum levels were lower in diabetic than in non-diabetic patients. Increasing Lp(a) levels were significantly associated with the risk of recurrent MI, and very high Lp(a) serum concentration (>70 mg/dL) independently predicted recurrent MI and death in non-diabetic patients, but not in diabetics. These results reinforce the importance of routine assessment of Lp(a) levels after MI, particularly in patients without diabetes.

Funding Acknowledgement

Type of funding sources: None.
Hemadsorption treatment for antithrombotic drug removal in emergency cardiac surgery – cost-benefit analysis comparing patient outcomes
Authors: Hassan K , Bruening T , Bein B , Caspary M , Wohlmuth P , Geidel S , Schmoeckel M
Published: October 2022

Background

Intraoperative hemadsorption is indicated for ticagrelor and rivaroxaban removal in patients undergoing urgent cardiac surgery and has been previously shown to reduce bleeding complications. However, whether this application is cost effective is currently unknown.

Methods

Between June 2017 and June 2021, we evaluated the outcomes of 72 consecutive patients (age 65±11 years) with acute coronary syndrome (ACS) pretreated with ticagrelor who underwent urgent coronary artery bypass grafting (CABG) at our institution. Intraoperative hemoadsorption (IH) was used in all cases (IH-Pat). We estimated the mean cost per patient, and a bootstrap analysis was performed based on individual data from the case series. We compared the results with “historical patients” who were operated under the same conditions between June 2015 and June 2017 but without IH (n=22).

Results

Bilateral internal mammary artery (BIMA) was used in 67.7% of all cases. Use of IH was associated with significantly shorter operation times (277±65 min vs. 320±75 min; P=0.014) and significantly less postoperative 24-hours chest tube drainage (277±65 mL vs. 866±262 mL; P<0.001). Only two rethoracotomies (2.8%) had to be performed. In addition, patients operated without IH required significantly more blood products and had a significantly higher rate of rethoracotomy, resulting in longer ICU stays. The variable that had the highest impact on the level of cost savings was the operation duration. The overall cost saving with IH were calculated at over 4200±1100€ with operation time, ICU stay and blood product costs being the top contributors.

Conclusions

The results suggest that the clinical benefits derived from IH in ticagrelor-treated patients requiring urgent cardiac surgery patients could result in significant cost savings of over 4200±1100 € per patient.

Funding Acknowledgement

Type of funding sources: None.
Bleeding outcomes with ticagrelor versus clopidogrel in patients with acute coronary syndrome; a focused analysis from the multicenter CREA ARIAM Andalucia registry
Authors: Padilla Rodriguez G , Hernandez Meneses B G , Gomez Gonzalez A , Lucas Garcia M , Arboleda Sanchez J A , Rodriguez Yanez J C , Soto Blanco J M , Fernandez Garcia I , Castillo Caballero J A , Hidalgo Urbano R J , Garcia Rubira J C , Almendro Delia M
Published: October 2022

Background/Introduction

With the advent of more potent antithrombotic agents, bleeding has emerged as an important safety concern in patients with acute coronary syndrome (ACS). Moreover, hemorrhagic complications have been strongly linked with subsequent mortality in this clinical scenario.

Purpose

We sought to determine the incidence, types, timing and prognostic relevance of major bleeding events in ACS patients treated with ticagrelor or clopidogrel in contemporary practice.

Methods

Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive a 12-month DAPT course with ticagrelor or clopidogrel. Major bleeding was defined as a type 3 or 5 bleed using the Bleeding Academic Research Consortium (BARC) definition. Bleeding was further classified according to the anatomic location. All bleeding episodes were analysed accounting for death as a competing event, using competing risk regression models based on the on-treatment principle (i.e., according to the P2Y12 inhibitor actually received from date of index admission until either time of DAPT cessation plus 14 days or censoring, whichever occurred first).

Results

Among 2070 patients surviving to hospital discharge (mean age 63 years, 27% women, 62.5% STEMI), 106 (5.3%, 0.6%/year) experienced major bleeding event at a median time of 92 days (interquartile range, 6–187 days) after discharge. Most events (n=59, 55.7%) were BARC type 3a bleeds with 2 fatal bleeds (type 5b). In most cases (53%), the site of bleeding was gastrointestinal, followed by intracranial (n=13, 12%). After adjustments for baseline predictors, ticagrelor was associated with increased but not statistically significant risk of major bleeding compared with clopidogrel (5.6% vs 5.2%, adjusted hazard ratio [aHR] 1.40, 95% CI 0.96–2.05; P=0.075). Major bleeding was significantly associated with nearly 2-fold higher risk of mortality (aHR 1.94; 95% CI 1.32–2.86; P=0.001), irrespective of P2Y12 inhibitor treatment (P interaction = 0.159).

Conclusion(s)

Bleeding was not rare within 1 year after index ACS, with incidence rates peaked at 30 to 60 days post-index admission. The most common bleeding site was gastrointestinal followed by intracranial haemorrhage. Ticagrelor use was not associated with significantly increased risk of major bleeding compared with clopidogrel whereas bleeding led to a nearly 2-fold higher risk of major bleeding.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Astra-Zeneca
Biomarkers associated with vulnerable plaques
Authors: Sharma T , Maehara A , Ben-Yehuda O , Maeng M , Kjoller-Hansen L , Engstrom T , Matsumura M , Frobert O , Persson J , Wiseth R , Larsen A I , James S K , Ali Z A , Stone G W , Erlinge D
Published: October 2022

Background

Cardiovascular heart disease is the leading cause of mortality worldwide, with the rupture or thrombosis of an atherosclerotic plaque being the main reason behind an acute coronary syndrome. It has already been established that the morphology of atherosclerotic plaques determine their stability. A lipid rich lesion with a thin fibrous cap is more prone to rupture compared to solid fibrous lesions. In the PROSPECTII study we used Near infrared spectroscopy (NIRS) and Intravascular ultrasound (IVUS) to identify atherosclerotic plaques in the coronary arteries; NIRS-derived lipid core burden index (LCBI) and IVUS-derived plaque burden (PB) identified plaques that caused adverse cardiovascular events.

Purpose

Our aim is to find biomarkers associated with LCBI or PB, to understand the development of vulnerable plaques.

Methods

902 patients were enrolled in this study after successful percutaneous coronary intervention (PCI). A combined NIRS-IVUS catheter was then used to analyze approximately 200m of coronary arteries. Blood samples for biomarker analysis were taken before the PCI procedure and plasma levels of 182 proteins associated with cardiovascular disease were assessed using a novel method for measuring proximity extension assay. Adjusted linear regression models were calculated between the biomarkers and the outcomes of interest, followed by a false discovery rate (FDR) correction.

Results

We found 24 proteins associated with plaque burden and 28 proteins associated with LCBI after using a cut off of two tailed P value <0.05. An overlap of 8 biomarkers could be seen between the two groups. After adjusting the P values with FDR, Angiopoeitin like 3 (ANGPTL3) retained its association to LCBI, and Interleukin 18 receptor 1 (IL18R1) and colony stimulating factor 1 (CSF-1) to plaque burden.

Conclusion

We were able to identify different biomarker patterns associated with plaque burden compared to lipid rich vulnerable plaques. ANGPTL3 was shown to only have an association with lipid rich plaques and not with solid fibrous lesions which further supports its role in vulnerable plaques.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Vascular, Infraredx, and The Medicines Company
Air pollution and coronary vasomotor disorders in patients with myocardial ischemia and non-obstructive coronary arteries
Authors: Camilli M , Russo M , Rinaldi R , Iannaccone G , Del Buono M G , Lavecchia G , Crea F , Montone R A
Published: October 2022

Background

Coronary vasomotor abnormalities are an important cause of myocardial ischemia in patients with non-obstructive coronary artery disease (NOCAD). However, the role of air pollution in determining vasomotor disorders has never been investigated.

Purpose

In this study, we evaluated the association between long-term exposure to particulate matter (PM) PM2.5 and PM10 and coronary vasomotor disorders in NOCAD patients.

Methods

Patients with myocardial ischemia and NOCAD undergoing intracoronary provocative test with acetylcholine (ACh) were prospectively enrolled. The test was considered positive for epicardial coronary spasm in the presence of focal or diffuse epicardial coronary diameter reduction ≥90% in comparison with the relaxed state following intracoronary nitroglycerin administration given to relieve the spasm, associated with the reproduction of the patient's symptoms and ischaemic ECG shifts. Both patients with chronic myocardial ischemia (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) were enrolled. Based on each case's home address, exposure to PM2.5 and PM10 was assessed. Only patients with >2 years of available data on air pollution exposure prior to coronary angiography were included.

Results

We enrolled 287 patients (median age 62.0 years [52.0–70.0], 149 [51.9%] males): 161 (56.1%) INOCA and 126 (43.9%) MINOCA. One hundred seventy-six patients (61.3%) had positive provocative test. Exposure to PM2.5 (Figure 1) and PM10 was higher in patients with a positive provocative test (p<0.001). PM2.5 and PM10 were independent predictors of a positive coronary provocative test after adjustment for confounders. Interestingly, among patients with a positive provocative test, PM2.5 and PM10 were both independent predictors of MINOCA (p<0.001 and p=0.001, respectively; Figure 2) as clinical presentation, while only PM2.5 was independently associated with the occurrence of epicardial spasm as opposed to microvascular spasm (p<0.001).

Conclusions

We provide novel insights into the missing link between air pollution and ischemic heart disease. In particular, higher exposure to air pollution in patients with myocardial ischemia and NOCAD is associated with coronary vasomotor abnormalities, and PM2.5 is an independent risk factor for the occurrence of epicardial spasm and for MINOCA as clinical presentation.

Funding Acknowledgement

Type of funding sources: None.
Epicardial adipose tissue, infarct size, microvascular obstruction and ventricular remodelling after ST-segment elevation myocardial infarction
Authors: Aimo A , Gavara J , Lopez-Lereu M P , Monmeneu J V , De Dios E , Perez-Sole N , Marcos-Garces V , Rios-Navarro C , Emdin M , Lupon J , Bayes-Genis A , Bodi V
Published: October 2022

Background

Epicardial adipose tissue (EAT) is a biologically active fat deposit contained beneath the pericardium promoting coronary atherosclerosis. EAT can be accurately measured through cardiac magnetic resonance (CMR), which also enables an accurate quantification of infarct size, microvascular obstruction (MVO), left ventricular (LV) ejection fraction (EF) and volumes in patients with ST-elevation myocardial infarction (STEMI).

Purpose

We performed a systematic assessment of the correlates of EAT volume at baseline and after 6 months in a homogeneous cohort of patients with STEMI.

Methods

We prospectively enrolled patients with a first anterior STEMI reperfused within 12 hours from symptom onset. These patients underwent a first CMR exam after 1 week from the MI and after 6 months.

Results

Patients (n=138) were more often men (81%), with a median age of 58 years (interquartile range 48–66). EAT volume was 30 mL/m2 (23–41). Patients with EAT >30 mL/m2 (n=69) were older (60±12 vs. 55±11 years, p=0.02), more often diabetic (26% vs. 12%, p=0.03), and showed a worse baseline risk profile (Thrombolysis in Myocardial Infarction risk score 3 [2–5] vs. 2 [1–4], p=0.05). Patients with EAT >30 mL/m2 also displayed a larger IS (33±15 vs. 23±16% of LV mass, p=0.001) and MVO (1.5 [0–6.8] vs. 0% [0–2.2], p=0.008). Again in patients with EAT >30 mL/m2, EAT volume independently predicted infarct size (standardized beta coefficient=0.30, p<0.001) and MVO area (standardized beta coefficient=0.36, p<0.001) after adjusting for age, sex and infarct characteristics at 1 week (Figure 1). Despite these correlations with infarct size and MVO, patients with EAT >30 mL/m2 did not display more depressed LVEF or larger LV volumes than those with EAT ≤30 mL/m2, either at 1 week or at 6-month CMR (p>0.1 for all comparisons).

Conclusions

In a cohort of patients with first anterior STEMI undergoing timely reperfusion, those with a greater EAT volume have a larger infarct size and a larger area of MVO. Despite these correlates of EAT volume size, patients with larger EAT do not have a higher risk of adverse LV remodelling.

Funding Acknowledgement

Type of funding sources: None.
Temporal trends in the treatment and outcomes of patients with acute coronary syndrome according to bleeding risk
Authors: Arow Z , Gabarin M , Landa D , Giladi E , Losin I , Beeri G , Omlechenko A , Neuman Y , Assali A , Pereg D
Published: October 2022

Background

High bleeding risk is associated with adverse clinical outcomes in patients with ACS. We aimed to evaluate temporal trends in the treatment and outcomes of ACS patients according to bleeding risk.

Methods

Included were ACS patients enrolled in the ACSIS survey. Bleeding risk was calculated using the CRUSADE score. Patients were divided into 3 groups according to enrolment period: early (2002–2004), mid (2006–2010) and recent (2012–2018). Each group was further divided into 3 sub-groups according to bleeding risk (low, intermediate and high). The primary endpoints were 30-day MACE and 1-year all-cause mortality.

Results

Included were 13,058 ACS patients. Patients at high bleeding risk were more frequently treated with guideline-based medications and coronary revascularization regardless of enrollment period. ACS patients at high bleeding risk had higher rates of 30-day MACE and 1-year all-cause mortality in all enrolment periods. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p<0.001), Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p<0.001), and for patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p<0.001) in low, moderate and high bleeding risk group, respectively. Furthermore, among patients enrolled in early period, 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p<0.001), Among patients enrolled in mid period, 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p<0.001), and for patients enrolled in recent period, 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p<0.001) in low, moderate and high bleeding risk group, respectively. These differences remained significant following a multivariate analysis.

Conclusions

Despite the improvement in the treatment of ACS patients in recent years, high bleeding risk remains a very strong predictor of adverse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.
Prognostic importance of NT-proBNP following high-risk myocardial infarction in the PARADISE-MI Trial
Authors: Jering K , Claggett B , Pfeffer M A , Granger C , Kober L , Lewis E F , Maggioni A P , Mann D L , McMurray J J V , Prescott M F , Rouleau J L , Solomon S D , Steg P G , Von Lewinski D , Braunwald E
Published: October 2022

Background/Introduction

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a marker of ventricular wall stress and a potent predictor of death and heart failure (HF) across multiple populations (from healthy insurance applicants to various disease entities).

Purpose

To evaluate the prognostic importance of NT-proBNP in patients with acute myocardial infarction (AMI) complicated by left ventricular systolic dysfunction, pulmonary congestion, or both and ≥1 of 8 predefined risk-augmenting factors (age ≥70 years, diabetes, previous MI, eGFR <60 ml/min/1.73 m2, atrial fibrillation, LVEF <30%, Killip class III/IV, or ST elevation MI without reperfusion) enrolled in PARADISE-MI.

Methods

Patients were randomized to sacubitril/valsartan 200mg or ramipril 5mg twice daily within 0.5 to 7 days of presenting with an AMI. Patients with prior HF were excluded. NT-proBNP and high-sensitivity troponin T (hsTnT) were collected at randomization in a prespecified sub-study of 1129 patients. The primary endpoint of PARADISE-MI was a time-to-first composite of cardiovascular (CV) death or incident HF (hospitalization or outpatient symptomatic HF); secondary endpoints included all-cause death and the composite of fatal or non-fatal MI or stroke.

Results

Median NT-proBNP was 1757 pg/ml [interquartile range, 896–3462 pg/ml] at randomization (4.0±1.8 days after presentation with the index MI). Patients with higher NT-proBNP levels at baseline were older, more commonly women and more frequently had hypertension, atrial fibrillation, renal dysfunction, and pulmonary congestion at randomization (all p<0.001). NT-proBNP concentrations were only weakly correlated with levels of hsTnT at randomization (r=0.38, p<0.001). NT-proBNP at baseline was strongly associated with the primary composite endpoint (adjusted HR 1.45 per doubling NT-proBNP; 95% CI, 1.23–1.70), independent of clinical variables as well as hsTnT (Figure). NT-proBNP was also independently associated with all-cause death (aHR 1.74; 95% CI, 1.38–2.21) and fatal or non-fatal MI or stroke (aHR 1.24; 95% CI, 1.05–1.45). The relative effect of sacubitril/valsartan versus ramipril on the primary composite endpoint was not statistically different across the spectrum of NT-proBNP (p-interaction = 0.46).

Conclusions

When assessed within the first week of a high risk AMI NT-proBNP is not only associated with incident HF and death but also with atherosclerotic events and provides prognostic information that is independent of hsTnT in this post AMI population.

Funding Acknowledgement

Type of funding sources: None.
Trends and outcomes of veno-arterial extracorporeal membrane oxygenation for acute myocardial infarction-cardiogenic shock
Authors: Buda K G , Sedhom R , Elbadawi A , Louka L , Mukundan S , Garcia S , Brilakis E S , Alaswad K , Basir M B , Megaly M S
Published: October 2022

Background

Mortality for acute myocardial infarction-cardiogenic shock (AMI-CS) remains high. Trends of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use and outcomes as a function of ECMO requirement are not well described.

Purpose

To identify the trends and outcomes of VA-ECMO use for AMI-CS in the United States.

Methods

We used the Nationwide Readmissions Database (NRD) and the Healthcare Cost and Utilization Project (HCUP) to obtain our cohort. We identified patients with AMI-CS requiring VA-ECMO using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10 CM) and procedure (ICD 10-PCS) codes. We excluded patients with missing data on in-hospital mortality.

Results

During the study period (2016–2019), 2,005,607 records with myocardial infarction (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) were identified (national estimate of 3,674,083 records), 127,939 records (6.4%) had concomitant CS (national estimate of 234,630 patients), and 3,469 records (national estimate of 6,365 records) (2.7%) received VA-ECMO for CS support. Impella and Intra-aortic balloon pump were used within the same admission in 34.5% and 38.1% of VA-ECMO cases, respectively. VA-ECMO use for AMI-CS significantly increased over the study period (from 2.3% in the first quarter of 2016 to 3.3% in the last quarter of 2019, p=0.001) (Figure 1).

In unadjusted analysis, patients undergoing VA-ECMO for AMI-CS were more likely to be male, have hypertension, congestive heart failure, and coagulopathy, present with STEMI, and receive multivessel PCI. Other comorbid conditions including diabetes, atrial fibrillation, end-stage renal disease, and prior MI, CABG, and stroke were less common in the VA-ECMO cohort. Medicare patients were less likely to receive VA-ECMO (39.4% vs. 63.8%, p<0.001), whereas patients at large or teaching hospitals were more likely. Patients requiring VA-ECMO had higher in-hospital mortality, length of stay, and rates of complications (Table 1).

Conclusion

Utilization of VA-ECMO for AMI-CS is increasing, and in one out three patients, VA-ECMO is used in combination with other MCS devices. Patients with underlying medical comorbidities and Medicare are less likely to receive VA-ECMO. Critically ill patients requiring VA-ECMO for AMI-CS are more likely to present with STEMI and have high morbidity and mortality.

Funding Acknowledgement

Type of funding sources: None.
Sex difference in 5-year relative survival following percutaneous coronary intervention
Authors: Choi J H , Lee S H , Choi J M , Kim H Y , Shin E S
Published: October 2022

Background

Sex-specific survival following percutaneous coronary intervention (PCI) varies among studies. This might be clarified using relative survival, which adjusts observed survival in relation to that seen in sex- and age-matched general population. We investigated sex-specific relative survival after PCI.

Methods

A total of 48,783 patients were enrolled in the year 2011 Korean nationwide PCI cohort. Primary outcome was all-cause death. Observed and relative survival at 5 years conditional on surviving 0 days, 30 days, 1 year, and 2 years were assessed. Sex-specific differences in cardiovascular risk factors were adjusted via age-group stratified propensity score matching.

Results

In the unadjusted analyses, 15,710 female patients had a higher frequency of cardiovascular risk factors compared with 33,073 male patients. Both observed survival (hazard ratio [HR]=1.28, 95% confidence interval [CI]=1.22–1.34) and relative survival (HR=1.21, 95% CI: 1.16–1.27) were worse in female compared with male (p<0.001, all). In analyses of propensity score-matched 14,454 pairs, female showed a higher observed survival (HR=0.78, 95% CI: 0.74–0.82) but a lower relative survival (HR=1.19, 95% CI: 1.13–1.26) compared with male (p<0.001, all). Neither observed nor relative survival differed between female of age≤50s and age-matched male, but they were lower in female of age≥60s than age-matched male. These findings were consistent in further analyses conditional on surviving 30 days, 1 year, and 2 years.

Conclusions

The 5-year relative survival of female aged≥60 years adjusted by clinical risk factors was lower than that of age-matched male, which mandates the need for the excessive risk reduction in older female undergoing PCI.

Funding Acknowledgement

Type of funding sources: None.
Long-term mayor adverse cardiovascular events after COVID-19 infection: a clinical score from a cohort of 2575 patients enrolled in the multicenter international HOPE 2 registry
Authors: Santoro F , Di Nunno N , Centola A , Cetera R , Le Rose V , Perez-Villacastin J , Fernandez-Ortiz A , Nunez Gil I , Brunetti N D
Published: October 2022

Background

Long-term consequences of COVID-19 infection are still partly known. According to some studies several patients may experience long term symptoms; however, predictors of long-term mayor adverse cardiovascular events among (MACE) patients with previous COVID-19 infection are .

Aim of the study

To derive a simple clinical score for risk prediction of long-term MACE among patients with previous covid-19 infection.

Methods

2575 consecutive patients were enrolled in a multicenter, international registry (HOPE-2) from February 2020 to April 2021, and followed-up at long-term. A risk score was developed using a stepwise multivariable regression analysis.

Results

Out of 2575 patients enrolled in the HOPE-2 registry, 1481 (58%) were male, with mean age of 60±16 years. At long-term follow-up overall rate of MACE was 7.9% (202 of 2545 pts, 3.3% death, 2.4% inflammatory myocardial disease, 1.3% arterial thrombosis, 0.7% venous thrombosis). After multivariable regression analysis, independent predictors of MACE were used to derive a simple prognostic score: The HOPE-2 prognostic score may be calculated by giving: ½ point for every 10 years of age, 2 points for previous cardiovascular disease, 1 point for increased troponin serum levels during hospitalization, 2.5 points for heart failure and 3 points for sepsis during hospitalization, −1.5 points for vaccination at follow-up. Score accuracy at receiver operating characteristic curve analysis was 0.81.

Stratification into 3 risk groups (0–2, 3–5, and >5 points) classified into low, intermediate and high risk. The observed MACE rates were 0.5% for low-risk patients, 4% for intermediate-risk patients, and 19.5% for high-risk patients (log-Rank p<0.001, Figure 1).

Conclusions

The HOPE-2 prognostic score may be useful for long-term risk stratification in patients with previous COVID-19 infection. High-risk patients may require a strict cardiological follow-up.

Funding Acknowledgement

Type of funding sources: None.
Performance of high-sensitivity cardiac troponin T versus I for the early diagnosis of myocardial infarction
Authors: Koechlin L , Boeddinghaus J , Lopez-Ayala P , Nestelberger T , Miro O , Wussler D , Zimmermann T , Strebel I , Christ M , Wildi K , Rubini Gimenez M , Martin-Sanchez J , Keller D , Twerenbold R , Mueller C
Published: October 2022

Background

Clinical practice guidelines assume that both cardiac troponin (cTn) T and cTnI concentrations reflect identical pathophysiological processes and are equally effective in the detection of myocardial injury. However, there are differences between cTnT and cTnI that have been reported.

Purpose

The aim of this study was to directly compare the diagnostic performance of high-sensitivity cardiac troponin (hs-cTn) T versus hs-cTnI for the early diagnosis of acute myocardial infarction (MI).

Methods

In a prospective multicentre study, diagnostic and prognostic accuracies of hs-cTnT and I were analyzed in consecutive patients presenting to the emergency department with acute chest pain. The final diagnosis was adjudicated by two independent cardiologists using all information pertaining to the individual patient according to the fourth universal definition of MI. Adjudication of the final diagnoses was performed twice: once using serial measurements of hs-cTnT and once using hs-cTnI. Furthermore, the clinical performance of hs-cTnT/I when embedded in the European Society of Cardiology (ESC) 0/1h-algorithm was assessed.

Results

Among 5087 consecutive patients (median [Interquartile range, IQR] age 61 [49.0, 74.0] years, 33.2% female), 951 (18.7%) and 901 patients (17.7%) had an adjudicated final diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) when using serial measurements of hs-cTnT and hs-cTnI for adjudication, respectively. Diagnostic accuracy was very high for both hs-cTnT and hs-cTnI and comparable when using hs-cTnT for adjudication (hs-cTnT: area under the curve [AUC] 0.93 [95% CI 0.92–0.94] versus hs-cTnI AUC 0.93 [95% CI 0.92–0.94]; p=0.891). However, when using serial measurements of hs-cTnI for adjudication, diagnostic accuracy was significantly higher for hs-cTnI (AUC 0.93 [95% CI 0.92–0.94] versus AUC 0.94 [95% CI 0.94–0.95], p<0.001; Figure 1). This was confirmed in subgroup analyses including early presenter (≤3h), patients with renal failure, known coronary artery disease and elderly (≥70 years). However, both assays performed excellent with very high safety for rule-out and high accuracy for rule-in MI when embedded in the ESC 0/1h-algorithm. Prognostic accuracies for 730-day all-cause mortality and cardiovascular death were significantly higher for hs-cTnT compared to hs-cTnI (Figure 2).

Conclusions

While there seem to be differences between hs-cTnT and hs-cTnI in their diagnostic and prognostic performance, clinical relevance needs to be further evaluated since both assays performed excellent when embedded in their respective early triage algorithms.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swiss National Foundation, Swiss Heart Foundation