bluuebunny/crossref_metadata_2025 huggingface dataset:
A practical nomogram and risk stratification system for predicting in-hospital mortality of patients with non-acute myocardial infarction related cardiogenic shock
Authors: Wang X K , Wu Y , Li T , Shi X , Che S P
Published: October 2024

Background

The morbidity and mortality of Cardiogenic Shock(CS) remain high despite the advance in management these years1.As acute myocardial infarction (AMI) is considered to be the most common reason for cardiogenic shock,Non-AMI related CS is excluded from the majority of CS studies and remains largely understudied2. Considering its inherent complexity and hemodynamically multiplicity, it is needed to focusing on these patients to identify specific risk factors, which may be conducive to the promotion of critically CS patients with early decision and timely intervention.

Purpose

In this study,we sought to investigate the variables which are predictive of in hospital mortality in non AMI related CS patients, developed and validated a practical nomogram for risk quantification.

Methods

1298 patients and 548 patients with cardiogenic shock from the MIMIC-IV (version 1.0) and MIMIC-III(version1.4) databaes were included in the study after excluding acute myocardial infarction. We used in-hospital death and 30 day survival as the end points. Lasson and logistic regression analysis were used to identify statistically significant predictors which were finally involved in the nomogram. The predictive performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration after comparing with commonly used ICU scores for in-hospital death.Lastly, we plotted Kaplan-Meier curves of three subgroup classified by the identified cutoff values of the nomogram to further assess the discriminative ability of the prognosis.

Results

The in-hospital mortality of patients with non-AMI related CS is about 36.6%.After the analysis of regression, age, heart rate, wbc, albumin, lactic acid, GCS score, urine volume, using vasopressor were identified as the most critical factors for the in-hospital death. Based on the these results, a nomogram for predicting in-hospital death was established.The calibration plot also shows good consistency between nomogram prediction and actual in-hospital mortality.In addition, compared with other scores, the AUC value of nomogram was 0.806 (95% CI = 0.799-0.831) in the training queue, 0.814 (95% CI = 0.771-0.852) in the internal validation queue and 0.730 (95% CI = 0.690-0.767) in the external validation set, which was significantly higher than other commonly used ICU scoring systems(SAPSII, APSIII and SOFA).Also, three risk subgroups were created using two boundary points (303 and 339) of the nomogram score and the survival curve shows that there were significant differences in the 30 day survival of each subgroup.

Conclusion

A prognostic nomogram and risk stratification system of non-AMI related CS were established and verified, which can provide a practical tool for individualized clinical management of patients.Workflow of the study.Nomogram for non-AMI related CS patients
Dysregulation of sympathoadrenal system activity in patients with microvascular angina
Authors: Nasirdinov N , Uzbekova N R , Usmanov B B , Ruzimatov S H G
Published: October 2024

Introduction

Recent studies have highlighted that a significant proportion of patients (up to 47%) undergoing coronary angiography due to clinical indications do not exhibit significant stenosis in epicardial vessels. Among these patients, up to 50% may suffer from microvascular angina (MVA). Despite the absence of intramural coronary artery lesions typically associated with atherosclerosis, the occurrence of transient myocardial ischemia and cardiac pain syndrome raises interest due to the incomplete understanding of their underlying mechanisms.

Objective

This study aims to comprehensively investigate sympathoadrenal system activity in patients with microvascular angina.

Materials and Methods

A total of 40 patients diagnosed with MVA, aged 35-76 years, including 11 (27.5%) men and 29 (72.5%) women, were enrolled, along with 20 healthy individuals. Assessment of sympathoadrenal system (SAS) activity involved determining daily urinary excretion levels of free and conjugated catecholamine fractions (CA) using solid-phase enzyme immunoassay: adrenaline (A), noradrenaline (NA), dopamine (DA), and DOFA. Additionally, catecholamine deamination enzyme activity—monoamine oxidase (MAO)—was determined using solid-phase EIA.

Results

Patients with MVA exhibited a significant increase in the excretion of all CA fractions. Specifically, adrenaline (A) excretion increased by 56.7%, surpassing the control by 1.7 times (p<0.001). Noradrenaline (NA) levels were elevated by 59.5% in MVA patients, which was 1.6 times higher than the control group (p<0.001). Dopamine (DA) levels in MVA patients increased by 31.0%, surpassing control values by 1.36 times (p<0.001). Moderate elevation in DOFA levels by 19.7% was observed, which was 1.23 times higher than the control (p<0.01). Ratios of CA sulfocatecholamine formation processes indicated pronounced deviations from normal. Gender differences revealed marked changes in sympathoadrenal activity, particularly in women (p<0.001). Studies of MAO activity on the first day identified a moderate decrease in its activity in MVA patients—0.03±0.002 units/ext. (p<0.01), while healthy individuals exhibited an activity level of 0.07±0.001 units/ext.

Conclusion

The findings underscore the crucial pathogenetic role of SAS in the development of MVA. The study demonstrates that the severity of ischemia correlates with disruptions in SAS components. Notably, these disruptions are pronounced in MVA, indicating an overload of the sympathoadrenal system—a critical component of organismal homeostasis. Under conditions of SAS overload, the pivotal enzyme in biogenic amine oxidation, MAO, undergoes significant transformation, leading to reduced activity towards monoamines. These findings were consistent with our clinical investigation.
Prevalence of coronary microvascular disease in myocardial infarction with non-obstructive coronary artery disease
Authors: Carrington J , Moustafa A , Lerman A , Raphael C E
Published: October 2024

Background

Six percent of patients presenting with acute myocardial infarction (MI) have MI with non-obstructed coronary artery disease (MINOCA). Coronary microvascular disease (CMD) is common in angina with non-obstructive coronary artery disease (ANOCA), but its prevalence and severity in MINOCA is undefined.

Purpose

Patients with CMD may have elevated risk of myocardial infarction despite no significant stenosis. We tested the hypothesis that patients with MINOCA have more significant burden of CMD than patients with ANOCA.

Methods

A retrospective case-control study was performed on patients who underwent invasive testing for signs of coronary ischemia and found to have non-obstructive disease (stenoses< 50%). Cases of MI were classified as MINOCA (n=87) and compared to patients with ANOCA (n=552). Patients with spontaneous coronary artery dissection, myocarditis, Takotsubo cardiomyopathy or prior atherothrombotic MI were excluded. Coronary catheterization was performed followed by invasive provocation testing with adenosine and acetylcholine using a Doppler flow wire. CMD was subdivided into endothelium-independent, defined as coronary flow reserve (CFR) < 2.5 with intra-coronary adenosine, and endothelium dependent, defined as < 50% increase in coronary blood flow with acetylcholine. Epicardial vasoconstriction > 90% with typical anginal symptoms was classified as epicardial vasospasm.

Results

There was no difference in age, sex or traditional coronary risk factors between the MINOCA and ANOCA groups (Table 1). Fifty (57%) of patients with MINOCA had type 2 MI secondary to supply-demand mismatch. Both MINOCA and suspected ANOCA patients had a high prevalence of CMD (71% vs 67%) and endothelium-independent CMD is more prevalent in MINOCA (64.5% vs 50.4%). Although odds of endothelium-dependent CMD were similar, the CFR within this group and CMD overall was worse in MINOCA patients (Figure 1). There was no difference in epicardial spasm.

Conclusion

Coronary microvascular disease and vasomotor dysfunction are common in patients with MINOCA, with a higher prevalence of endothelium-independent CMD and more severe CMD overall compared to patients with ANOCA. Treatment of CMD in patients with MINOCA may help reduce recurrence and warrants further investigation.
Role of inflammation and cholesterol efflux in myocardial infarction patients without standard modifiable risk factors
Authors: Roule V , Beygui F , Guerin M , Materne C , Procopi N , Rahoual G , Guedeney P , Zeitouni M , Kerneis M , Montalescot G , Silvain J
Published: October 2024

Background

A substantial proportion of ST-segment elevation myocardial infarction (STEMI) patients has no standard modifiable cardiovascular risk factors (SMuRF) at admission. Knowledge on pathogenesis and risk markers of mortality in these patients remain limited.

Aims

We described the characteristics and prognosis of SMuRF-less patients admitted for a first STEMI in the light of recent prognostic biomarkers.

Methods

Baseline characteristics including interleukin (IL)-1β, hs-CRP and serum cholesterol efflux capacity were compared between patients with and without SMuRF. Determinants of 1-year all-cause mortality were assessed using univariable and multivariable Cox regression analyses.

Results

Among the 1604 patients included, 178 (11.1%) were SMuRF-less. SMuRF-less patients were older (66.9 ± 15.3 vs 61.9 ± 13.9, p<0.001), less often men (66.9 vs 75.9%, p<0.001) and had lower body mass index (24.2 ± 3.9 vs 26.0 ± 4.4, p<0.001) compared to patients with ≥1 SMuRFs. SMuRF-less patients presented higher rates of altered LVEF<45% and killip≥2 at admission (31.8% vs 22.8%, p=0.014 and 19 vs 12.9%, respectively, p=0.027) without differences in proportions of late STEMI presenters (symptoms-to-balloon time >360 min) did not differ between groups. SMuRF-less patients had lower rates of revascularization (82 vs 92.3%, p<0.001) and received less guidelines recommended medications (statins, β-blockers or angiotensin-converting enzyme (ACE) inhibitors) at discharge; p<0.001 for all. Compared to patients with SMuRF, SMuRF-less patients had lower serum cholesterol efflux capacity (0.79 ± 0.16 vs 0.83 ± 0.16, respectively, p<0.001), were more often in the highest tertile of IL-1β (28.7% vs 18.9%, respectively, p=0.002) with a trend towards more patients within the highest hs-CRP level tertile (24.7% vs 19.1%, respectively, p=0.077). Crude rates of mortality were more than doubled in the SMuRF-less group (18.5% vs 7.7%, respectively, p<0.001). After multivariable adjustment SMuRF-less status was associated with a higher rate of mortality at one year aHR 1.87 [1.05-2.38], p=0.029) as well as inflammation biomarkers IL-1β (HR 1.81 [1.23-2.66], p=0.003) and high tertiles of hs-CRP (HR 1.87 [1.31-2.66], p<0.001) whereas having a high serum cholesterol efflux capacity was associated with a lower mortality (HR 0.27 [0.09-0.87], p=0.0208).

Conclusion

In STEMI patients, SMuRF-less patients have higher levels of inflammatory biomarkers and more frequent defective serum cholesterol efflux capacity, are undertreated, and have higher rate of mortality than patients with standard modifiable cardiovascular risk factors. Optimized management of such patients is needed.
Edge-to-edge repair for tricuspid valve regurgitation: 1-year follow up and clinical implications from the TR- Interventional Study (TRIS)
Authors: Carpenito M , De Luca V , Cammalleri V , Piscione M , Antonelli G , Gaudio D , Coletti F , Nobile E , Strumia A , Di Pumpo A L , Mega S , Carassiti M , Grigioni F , Ussia G P
Published: October 2024

Background

Tricuspid regurgitation (TR) affects 7% of the population, contributing significantly to heart failure-related hospitalizations. Traditional treatments have several limitations, prompting the exploration of innovative interventions.

Purpose

The present study aims to investigate the efficacy of tricuspid valve transcatheter edge-to-edge repair (T-TEER) in real-world patients with severe and symptomatic TR deemed at high surgical risk. Primary objectives focus on assessing T-TEER-induced TR reduction and reverse structural remodeling of the RV. Secondary objectives include assessment of functional status, quality of life, and residual regurgitation during the 12-month follow-up period.

Methods

The TR-Interventional study (TRIS) is a prospective, single-arm study. From January 2021 to December 2023, we enrolled 44 symptomatic patients with at least severe TR referred for TEER. Outcomes included safety and effectiveness along with assessment of clinical status.

Results

The study cohort had a mean age of 78.3±7 years, with 77.3% women and a mean TRISCORE of 5.1±1.9. Seventeen patients (38.6%) had massive, 7 (15.9%) had torrential, and 20 (45.5%) patients had severe TR. Etiologies included functional (40.9%), degenerative (13.64%), lead-induced (15.9%), and mixed (29.54%) origin. The primary efficacy endpoint, which assesses the successful implantation and performance of the device at the 30-day mark, was attained in 82.9% of patients. The secondary efficacy endpoint, assessing the stability of TR reduction at the 12-month, was achieved in 82,3% of patients. Post-procedural TR reduction of at least 2 degrees was achieved in 84% of patients. Echocardiographic assessments indicate ongoing beneficial remodeling over the one-year follow-up (Figure 1). Effects on RV remodeling also became apparent at the one-year follow-up, including reductions in the RV end-diastolic basal (p<0.01) and medium (p= 0.04) diameters of the TA septal-lateral diameter (p< 0.01). Significant reduction in vena contracta width (9 mm to 3 mm; p=<0.01), regurgitant volume (58 ml to 30 ml; p<0.01), and effective regurgitant orifice area (EROA) (0.6 cm2 to 0.3 cm2; p<0.01), occurred between baseline and one-year follow-up (Figure 2). The NYHA Functional Class and KCCQ scores were improved from 30 days to 1 year (Figure 2).

Conclusion

TRIS suggests that T-TEER is a durable, effective, and safe therapeutic option for high-risk patients with severe TR. The enduring nature of TR reduction at one year correlates with sustained clinical benefits and reverse structural remodeling of the right ventricle.TR reductionNYHA and functional status
In-hospital outcomes of acute myocardial infarction patients without standard modifiable cardiovascular risk factors across varying body mass index
Authors: Yang Y , Ma X , Gao F , Wang Z
Published: October 2024

Background

Individuals who present with acute myocardial infarction (AMI) in the absence of standard modifiable cardiovascular risk factors (i.e., SMuRF-less) seem to have a significantly increased risk of mortality; however, it remains unclear whether the ‘SMuRF paradox’ would be influenced by patients’ baseline body mass index (BMI) status.

Purpose

To assess the disparities in the prevalence and prognostic implications of SMuRF-less among patients with newly diagnosed AMI across varying body mass index (BMI).

Methods

Using data from the Improving Care for Cardiovascular Disease in China–Acute Coronary Syndrome (CCC–ACS) project, we retrospectively analyzed AMI patients with and without SMuRFs and categorized their baseline BMI as underweight (<18.5kg/m2), normal weight (18.5-24kg/m2), overweight (24-28kg/m2), and obese (>28kg/m2). The primary outcome was in-hospital all-cause mortality. Multivariable logistic regression models were used to estimate BMI-stratified associations between SMuRF-less and each outcome, sequentially adjusting for demographic, clinical characteristics, and prevention strategies.

Results

Between 2014 and 2019, 44,538 adult patients hospitalized for first-presentation AMI were included, of which 4,454 (10.0%) were SMuRF-less. The incidence of SMuRF-less declined from 16.2% to 6.5% as BMI increased by category, and it prevailed more frequently among females and elders regardless of their BMI status. During the median hospital stay of 9 days, SMuRF-less patients had a significant increase in in-hospital mortality than patients with one or more SMuRF (2.1% vs. 1.0%, adjusted odds ratio [OR], 1.750 [95% CI 1.057–2.896], P<0.001). The highest mortality rate was observed in the SMuRF-less underweight group (3.5%). Took ≥1 SMuRF and obese as the reference group as they presented the finest outcome, SMuRF-less underweight group exhibited the highest increase in mortality (3.5% vs 0.5%, adjusted odds ratio [OR], 3.854 [95% CI 2.130–6.973], P<0.001). However, interaction analyses provided no evidence that BMI significantly modifies SMuRF-less’s association with in-hospital mortality (P for interaction=0.247).

Conclusion

Approximately one-tenth of first-presentation AMI patients had no SMuRF, who were more frequently women, elders, and underweight. Compared with those with at least one SMuRF, SMuRF-less patients have a significantly higher risk of in-hospital mortality, especially in those underweight, while in-hospital survival was the most favorable among ≥1 SMuRF and obese patients.
The prognostic value of metabolic dysfunction associated steatotic liver disease in acute myocardial infarction
Authors: Kong G , Cao G , Koh J , Zhang A , Koo H C , Ping C , Low A F , Lee C H , Yeo T C , Yip J , Foo R , Tan H C , Chan M Y , Loh P H , Chew N W S
Published: October 2024

Background

Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are at increased risk of incident cardiovascular disease. However, the clinical characteristics and prognostic importance of MASLD in patients presenting with acute myocardial infarction (AMI) have yet to be examined.

Methods

This study compared the characteristics, and outcomes of patients with and without MASLD presenting with AMI at a tertiary centre in Singapore. MASLD was defined as hepatic steatosis, with at least one of five metabolic criteria. Hepatic steatosis was determined using the Hepatic Steatosis Index. Propensity score matching was performed to adjust for age and sex. Kaplan-Meier curve was constructed for long-term all-cause mortality. Cox regression analysis was used to investigate independent predictors of long-term all-cause mortality.

Results

In this study of 4446 patients with AMI, 2223 patients with MASLD were matched with patients without MASLD using propensity scores. The mean follow-up duration was 3.4 ± 24 years. The MASLD group had higher rates of obesity, diabetes, and chronic kidney disease than their counterparts. Patients with MASLD had early excess all-cause mortality (6.8% vs 3.6%, p<0.001) at 30 days, with unfavorable mortality rates sustained in the long-term (18.3% vs 14.5%, p=0.001) compared to those without MASLD. After adjustment, MASLD remained independently associated with higher long-term all-cause mortality (HR 1.338, 95% CI 1.115-1.604).

Conclusion

MASLD embodies a higher burden of metabolic dysfunction and is an independent predictor of long-term mortality in the AMI population. Its early identification may be beneficial for risk stratification and provide therapeutic targets for secondary preventive strategies in AMI.Kaplan Meier curve of long-term all-caus
Prevalance and impact of concomitant atrial fibrillation in patients undergoing percutaneous coronary intervention for acute myocardial infarction
Authors: Mahajan S , Sharma H , Nadir A , Shakeel I , Tashfeen R , Iqbal H , Hodson J , Ludman P , Townend J , Steeds R , Doshi S
Published: October 2024

Introduction

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with coronary artery disease (CAD) and myocardial infarction (MI). The prevalence of AF in patients following acute MI varies, with conflicting evidence on its impact on outcomes. Concomitant atrial fibrillation is associated with an adverse prognosis in patients with acute myocardial infarction (MI). However, it remains unclear whether this is due to a causal effect of AF, or whether AF acts as a surrogate marker for comorbidities in this population Also, there are limited data on whether coronary artery disease distribution impacts the risk of developing AF.

Purpose

This large cohort study aims to determine the prevalence of AF in acute MI patients treated with PCI, assess its independent prognostic value for MACCE, investigate the association of AF with CAD distribution patterns, and provide insights into the long-term outcomes of AF in this patient population.

Methods

A cohort of 1000 consecutive MI patients treated with PCI was retrospectively analyzed. Data on demographics, medical history, presentation, treatment, and outcomes was collected. Propensity score matching was used to adjust for baseline differences between AF and non-AF groups. CAD distribution, major adverse events, and MACCE were assessed using statistical analyses.

Results

Amongst the studied population, 6.5% people had AF (65/1000) and it was noted that those with AF had a worse outcome. However, on statistical analyses (both on multivariable cox and propensity matching) accounting for risk factors, outcomes were not significantly different between those with and without AF. Hence, this negated key baseline differences between AF and non-AF groups, with no significant differences in demographics or presentation.

Patients with AF had a higher prevalence of severe CAD in the left main stem (LMS) and left circumflex artery (LCx). The association of AF with MACCE was not significant in the matched groups. Long-term follow-up revealed similar rates of MACCE between AF and non-AF groups.

Discussion

AF in acute MI patients undergoing PCI is associated with a higher prevalence of severe CAD in the LMS and LCx. AF appears to be a surrogate marker of other risk factors, rather than an independent risk factor for MACCE. The study highlights the need for tailored aggressive treatment for risk factor modification in AF patients with MI.

Conclusions

AF is associated with an increased risk of MACCE in acute MI patients undergoing PCI. However, this association is primarily driven by the burden of comorbidities associated with AF, emphasizing the importance of tailored treatment strategies for AF patients. Prospective studies with routine ambulatory monitoring are recommended to validate these findings and guide future practice.
Predictors of percutaneous coronary intervention derived from CCTA in patients with chronic coronary syndrome
Authors: Belmonte M , Paolisso P , Gallinoro E , Caglioni S , Leone A , Viscusi M M , Mileva N , Sonck J , Wyffels E , Vanderheyden M , Collet C , De Bruyne B , Andreini D , Penicka M , Barbato E
Published: October 2024

Background

To identify anatomical and morphological plaque features predictors of percutaneous coronary intervention (PCI) and create a multiparametric score to increase the predictive yield. Moreover, we assessed the incremental predictive value of FFRCT (Fractional Flow Reserve derived from CCTA) trans-lesion gradient (ΔFFRCT) when integrated into the score.

Methods

Observational cohort study including patients undergoing CCTA for suspected coronary artery disease, with FFRCT available, referred to invasive coronary angiogram and assessment of fractional flow reserve. Plaque analysis was performed using validated semi-automated software. Logistic regression was performed to identify anatomical and morphological plaque features predictive of PCI. Optimal thresholds were defined by area under the receiver-operating characteristics curve (AUC) analysis. A scoring system was developed in a derivation cohort (70% of the study population) and tested in a validation cohort (30% of patients).

Results

The overall study population included 340 patients (455 vessels), among which 238 patients (320 vessels) were included in the derivation cohort. At multivariate logistic regression analysis, absence of left main disease, diameter stenosis (DS), non-calcified plaque (NCP) volume, and percent atheroma volume (PAV) were independent predictors of PCI. Optimal thresholds were: DS³50%, volume of NCP>113 mm3 and PAV>17%. A weighted score (CT-PCI Score) ranging from 0 to 11 was obtained. The AUC of the score was 0.80 (95%CI 0.74-0.86). The integration of ΔFFRCT in the CT-PCI score led to a mild albeit not significant increase in the AUC (0.82, 95%CI 0.77-0.87, p=0.328).

Conclusions

Plaque anatomy and morphology derived from CCTA could aid in identifying patients amenable to PCI.Central IllustrationPredictive accuracy of the CT-PCI score
Age stratified differences in coronary artery plaque phenotype in women and men with non-obstructive coronary artery disease
Authors: Berge Hondros C A , Khan I , Solvik M , Hanseth S , Pedersen E K R , Hovland S , Larsen T H , Lonnebakken M T
Published: October 2024

Background

Development of coronary artery disease (CAD) and risk of acute cardiac events differ between women and men during the life span. The aim of this study was therefore to characterize sex differences in coronary artery plaque phenotype among patients with symptomatic non-obstructive CAD in different age groups.

Methods

Advanced coronary artery plaque phenotyping by coronary computed tomography angiography was performed in 606 patients (31% women) with symptomatic non-obstructive CAD from the Norwegian Registry of Invasive Cardiology. A 1:1 sex-matched study design ensured equal distribution of the sexes in the different age groups. We assessed total plaque burden adjusted for vessel volume and plaque composition consisting of dense calcium, fibrous, fibro-fatty, and necrotic core. Patients were further stratified into age groups of ≤50, 51-64, and ≥65 years to explore the relationship between age and sex on coronary artery plaque phenotype.

Results

In the study population, patients ≥65 years had a higher prevalence of hypertension, higher calcium score, coronary artery segment involvement score and total plaque burden, whereas the prevalence of obesity was lower compared to patients aged 51-64 and ≤50 years (all p<0.05). The prevalence of smoking, diabetes and statin treatment was similar between groups. A two-way analysis of variance demonstrated an interaction between sex and age group on total plaque burden (F [2, 600] =3.431, p=0.33), where women aged 51-64 and ≥65 years had a higher total plaque burden compared to men (p=0.002 and p<0.001, respectively, Figure 1). Plaque composition in women ≥65 years was characterized by an increased proportion of stable dense calcified plaques compared to men and younger women (all p<0.05), whereas men ≥65 years had a higher proportion of vulnerable necrotic core plaque phenotype (p<0.001). Women showed consistently lower proportions of more vulnerable fibro-fatty plaques compared to men across all age groups (all p<0.05, Figure 2).

Conclusions

In non-obstructive CAD, higher total plaque burden was associated with older age and female sex. Women had a lower proportion of vulnerable fibro-fatty plaques across all age groups and a higher proportion of stable dense calcified plaques at an older age compared to men. Future longitudinal studies on coronary artery plaque phenotype during the life span will increase the understanding of sex differences in CAD development and may contribute to customise risk stratification in women and men.Figure 1.Total plaque burdenFigure 2.Compositional plaque burden
Prognostic implication of computational angiography-derived fractional flow reserve in patients with non-obstructive coronary artery disease
Authors: Hung Y , Xuan H , Yiu K
Published: October 2024

Background

Non-obstructive coronary artery disease (NOCAD) is proved to have high association with rate of major adverse cardiovascular events (MACE) in recent studies, yet risk stratification of symptomatic Non-Obstructive Coronary Artery Disease (NOCAD) patients remains uncertain.

Objectives

Our study assessed clinical value of single-vessel, multi-vessel, and three-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in NOCAD patients.

Methods

We enrolled patients with ≤ 50% stenosis with a caFFR value ≥ 0.8 in all three coronary arteries on coronary angiography. The sum of caFFR values in the three vessels was computed for each patient. Patient stratification was based on median value of the following criteria: single vessel analysis, multi-vessel analysis, 3-vessel (3V) analysis. The primary endpoint of this study was major adverse cardiac events (MACE) at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization.

Results

A total of 490 patients were included (mean age 64.39 ± 11.16, 55.5% male). The 5-year MACE rates in single-vessel analysis were statistically insignificant between low and high caFFR groups (Left anterior descending artery (P=0.163); Left circumflex artery (P=0.797); Right coronary artery (P=0.127)). In multi-vessel analysis, patients in multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) show an increased risk of 5-year MACE than patients in single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR] 2.648, 95% confidence interval [CI] 1.141 - 6.145, P = 0.023). In 3-vessel analysis, patients in the low 3V-caFFR group demonstrated a greater 5-year MACE risk than the high 3V-caFFR group ([HR] 2.43, 95% 95%[CI] 1.087 - 5.433, P = 0.031).

Conclusion

In patients with NOCAD, the higher count of vessels exhibiting with low caFFR values and the low 3V-caFFR values have been found to be associated with increased rate of MACE over a 5-year period. We demonstrated that both multiple-vessel and 3V-caFFR measurements serve as valuable prognostic indicators for risk assessment in NOCAD patients.
Comparison of vessel-Fractional Flow Reserve (vFFR) and Quantitative Flow Ratio (QFR) using instantaneous wave-Free Ratio (iFR) or Resting Full-cycle Ratio (RFR) as reference
Authors: Antoniadis M , Weissenseel L , Stader J , Ussat M , Wachter R , Laufs U , Lenk K
Published: October 2024

Background

Angiography-based functional assessment remains the state of the art to assess the hemodynamic relevance of intermediate coronary stenoses. In addition to fractional flow reserve (FFR), adenosin free indices like instantaneous wave-free ratio (iFR) or resting full-cycle ratio (RFR) are widely used for the invasive evaluation. Although these methods are widely accepted, they are underused in clinical routine due to costs, their invasive nature, longer procedural times, and lack of availability. Vessel-fractional flow reserve (vFFR) and quantitative flow ratio (QFR) are new software-based methods for the evaluation of coronary-physiology. The aim of this study is to compare vFFR and QFR with the established invasive methods iFR or RFR.

Methods

We prospectively analyzed 95 Patients in our QFR-Registry vFFR- and QFR-computation was performed three-times by two certified, blinded, and independent experts using the QAngio XA 3D 3.2- and CAAS-software, respectively.

Results: 101 main epicardial coronary arteries (52 LAD; 19 LCx; 30 RCA) were analyzed using vFFR, QFR and iFR or RFR. vFFR showed a good correlation with adenosine-free indices in all 3 measurements (AUC 0.883 with r=0.672, p<0.001; AUC 0.841 with r=0.618 p<0.001; AUC 0.840 with r=0.592, p<0.001 respectively). The diagnostic accuracy between the three vFFR-measurements and iFR/RFR was 83%; 81% and 79% respectively. QFR-computations showed a similar correlation with iFR/RFR (AUC 0.899 with r=0.720, p<0.001; AUC 0.919 with r=0.649, p<0.001; AUC 0.930 with r=0.703, p<0.001 respectively) with a diagnostic accuracy 88%, 89% and 88% respectively. The intra- and inter-observer reliability for vFFR (intra: mean difference 0.002±0.0568; inter: 0.024±0.054) and QFR (intra: mean difference 0.018±0.071; inter: 0.016±0.075) analyzed in a Bland-Altman Blot showed a good correlation between virtual assessments and invasive measurements with iFR/RFR.

Conclusion

The data show a good diagnostic agreement between vFFR and QFR and adenosine free invasive assessments. vFFR and QFR appear reasonable alternative approaches for the evaluation of intermediate stenoses. These data provide the rational to prospectively test for a clinical noninferiority of the non-invasive flow measurements.Diagnostic performance of vFFR/cQFR
Fractional flow reserve in saphenous vein grafts for the detection of myocardial ischemia determined by perfusion imaging
Authors: Hoek R , De Winter R W , Peters R T , Somsen Y B O , Van Diemen P A , Jukema R A , Twisk J W , Verouden N J , Nap A , Danad I , Knaapen P
Published: October 2024

Background

Fractional flow reserve (FFR) is recommended to guide revascularization of native coronary arteries. Revascularization decision-making for saphenous vein grafts (SVGs), however, is based on angiographic estimation of lesion severity, as studies exploring the value of FFR to detect perfusion imaging defined myocardial ischemia in SVGs are scarce.

Purpose

We aimed to define an optimal FFR threshold and compare its diagnostic performance with the traditional FFR cutoff and with percentage diameter stenosis (%DS) in patients evaluated for SVG disease using myocardial perfusion imaging (MPI) as the reference standard.

Methods

Symptomatic patients with prior coronary artery bypass grafting (CABG) who underwent single-photon emission computed tomography, positron emission tomography or stress perfusion cardiac magnetic resonance imaging, and had FFR measurements of one or more SVGs were included. Angiographic lesion severity of the SVG was measured using 2D quantitative invasive coronary angiography. We allocated and matched the myocardial territory subtended by the SVG to compare the values of FFR and %DS with ischemia determined by MPI.

Results

Included were 77 patients (mean age 72 ± 7 years; 86% male) with 91 SVGs. A total of 38 SVGs (42%) supplied an ischemic coronary territory. FFR and %DS correlated moderately (r= -0.51, P<0.001). The optimal cutoff value of FFR was ≤0.94, resulting in a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 63%, 75%, 65%, 74% and 70%, respectively (Figure 1). Corresponding values of FFR≤0.80 and DS%≥50 are shown in Figure 1 as well. Sensitivity, NPV and accuracy of FFR ≤0.94 outperformed that of FFR≤0.80, whereas specificity was lower. FFR≤0.94 outperformed %DS≥50 only in terms of sensitivity.

Conclusions

The optimal cutoff value of FFR for the detection of MPI-defined disease in SVGs is higher than the traditional FFR cutoff used to guide native coronary artery revascularization. Importantly, the increased sensitivity led to a higher diagnostic performance of the adjusted cutoff. However, the high prevalence of ischemia in post-CABG patients questions whether the optimal cutoff reflects ischemia caused by SVG obstruction.Diagnostic performance of FFR and %DS
Efficacy and safety of of SGLT2 ihibtors in post mi patients: a systematic review and meta-analysis of RCTs
Authors: Khan U , Mazen Amin A , Mohamed Taha A , Albarakat M M , Elewidi M , Abuelazm M , Abdelazeem B , Abouzid M
Published: October 2024

Introduction

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have demonstrated a decrease in cardiovascular (CV) events, especially in diabetic patients. However, it remains unclear whether the early administration of SGLT2is confers cardioprotective benefits following acute myocardial infarction (AMI).

Purpose

Our objective is to explore the in-hospital and long-term prognoses of patients presenting with AMI who are treated with SGLT2is compared to non-SGLT2is users.

Methods

We conducted comprehensive searches across PubMed, CENTRAL, WOS, Scopus, and EMBASE until October 2023. Pooled data were reported using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, along with a 95% confidence interval (CI). This systematic review and meta-analysis is registered with PROSPERO.

Results

We included 14 studies with a total of 37,038 patients. Compared to non-SGLT-2 inhibitors, SGLT-2 inhibitors were associated with a decreased incidence of major adverse cardiovascular events (MACE) (RR: 0.60 with 95% CI [0.45, 0.82], P< 0.01), all-cause mortality (RR: 0.67 with 95% CI [0.55, 0.81], P< 0.01), heart failure (RR: 0.68 with 95% CI [0.57, 0.80], P< 0.01), stroke (RR: 0.67 with 95% CI [0.45, 0.99], P= 0.04), increased left ventricular ejection fraction (MD: 2.45 with 95% CI [0.81, 4.09], P< 0.01), and decreased left ventricular end-systolic volume (MD: -5.72 with 95% CI [-10.76, -0.67], P= 0.03).

Conclusion

SGLT-2 inhibitors significantly decrease MACE, all-cause mortality, heart failure, left ventricular ejection fraction, and left ventricular end-systolic volume in myocardial infarction patients.Figure 1Figure 2
Impact of procedural and patient-related risks on 1-year outcomes for patients with 1-month DAPT followed by P2Y12 inhibitor monotherapy after biodegradable-polymer drug-eluting stent implantation
Authors: Shimada R , Ishida M , Taguchi Y , Takahashi F , Sasaki W , Ninomiya R , Koeda Y , Kimura T , Niiyama M , Ishisone T , Osaki T , Nishiyama O , Endo H , Itoh T , Morino Y
Published: October 2024

Background

While early de-escalation of dual antiplatelet therapy (DAPT) and P2Y12 inhibitor monotherapy following short DAPT are becoming standard treatments for patients after percutaneous coronary intervention (PCI), the impact of procedural and patient-related risks on clinical outcomes of PCI for patients receiving the above DAPT regimen has never been established.

Purpose

To evaluate the impact of procedural and patient-related risk factors on 1-year cardiovascular and bleeding outcomes in patients with 1-month DAPT followed by P2Y12 inhibitor monotherapy after biodegradable-polymer drug-eluting stent (BP-DES) implantation.

Methods

Using data from the multi-centre regional-wide REIWA registry, we assessed clinical outcomes according to each risk factor and compared between patients with and without either procedural or patient-related risk factors. The primary end point was net adverse clinical events (NACE), defined as a composite of cardiovascular outcomes (cardiovascular death, myocardial infarction, definite stent thrombosis, ischemic or hemorrhagic stroke) and bleeding outcomes (TIMI major or minor bleeding), which was same with that for STOPDAPT-2 trial. Procedural risk was defined as a factor of complex PCI which was previously published and included the follows: treatment of three vessels, three or more lesions, three or more stents, bifurcation with two stents, long stenting (total stent length >60 mm) and target of chronic total occlusion. Additionally, patient-related risk factors were defined as chronic kidney disease, anaemia, peripheral vascular disease, heart failure and advanced age (≧75 years).

Results

Among 1,202 patients treated BP-DES with 1-month DAPT, 276 patients (23.0%) had at least one procedural factors and 510 patients (42.4%) had one or more patient-related risks. Compared with each risk factor, patients with patient-related risk factor were more likely to have higher NACE rates, whereas low NACE rates were observed in patients with each procedural risk factor (Figure 1). In addition, during 1-year follow-up, patients with patient-related risk factors had a significantly higher incidence of NACE compared with patients without such risks (4.90 % vs. 1.73 %, p = 0.002) (Figure 2). However, no significant differences in NACE rates was observed between patients with and without procedural risk factors (2.54% vs. 3.24%, p = 0.555).

Conclusion

In patients undergoing BP-DES implantation and 1 month DAPT followed by P2Y12 inhibitor monotherapy, patient-related risk factors had an impact on 1-year clinical outcomes, while procedural risk factors no longer had small impact on those outcomes.
To shock or to drill: comparison of intravascular lithotripsy and rotational atherectomy - a meta-analysis
Authors: Shabbir M A , Hamza M , Naseer U , Ehtesham M , Basit J , Arshad M H , Malik S
Published: October 2024

Background

Coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA) are potent tools for calcified plaque modification before stenting. While IVL uses pressure waves to breakup calcium, RA mechanically disrupts calcium to promote vascular compliance. It is unclear if one has superior clinical outcomes than the other for calcified coronary lesion preparation before percutaneous coronary intervention (PCI).

Methods

All relevant studies from PubMed and Embase were included with patients (age >18 years) undergoing PCI for calcified coronary plaque treated with either IVL or RA. All-cause mortality, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE) (mortality, myocardial infarction, TLR, stroke, and in-stent thrombosis) were assessed. The pooled odds ratio (OR) for binary outcomes was computed using the Mantel-Haenszel method. Random effects model was used with 95% confidence interval (CI) for statistical significance. Heterogeneity was marked by Higgins I-squared (I2) statistic. Analysis was done on Comprehensive R Archive Network in R (CRAN-R) software.

Results

Three studies were included (IVL n=351, RA n=118). Compared to RA, IVL had similar all-cause mortality (OR 1.0, CI 0.3-3.0, p 0.9), TLR (OR 2.1, CI 0.26-18.2, p 0.4), and MACE (OR 2.0, CI 0.9-4.1, p 0.6). There was a trend towards favorable outcomes for RA, although statistically insignificant (figure 1).

Conclusion

For patients undergoing PCI for calcified coronary lesions, IVL and RA demonstrated comparable clinical outcomes including all-cause mortality. Large-scale prospective studies are needed to understand the differences in clinical outcomes.
Cardiopulmonary long-term effects 6, 18 and 30 months after severe COVID-19 infection
Authors: Niebauer J H , Iscel A , Schedl S , Charwat-Resl S , Capelle C , Kahr M , Schamilow S , Srdits M , Faltas J , Lichtenauer M , Zoufaly A , Valenta R , Krestan C , Wenisch C , Bonderman D
Published: October 2024

Background

SARS-CoV-2 infection affects the cardiopulmonary system in both the acute and long-term phase. This study aimed to comprehensively assess symptoms and potential longterm impairments 6, 18 and 30 months in patients previously hospitalized for severe Covid-19 infection.

Methods

This prospective registry included patients hospitalized for PCR-confirmed Covid-19 infection. Approximately 6 months post-discharge, follow-up examination included patient history, clinical examination, echocardiography, electrocardiogram, cardiac magnetic resonance imaging (cMRI), chest computed tomography (CT) scan, pulmonary function test (PFT), six-minute walk test (6MWT) and a comprehensive laboratory panel. Patients with pathologic findings during the first visit underwent a second (at 18 months) and third (at 30 months) follow-up examination. Those without pathologic findings or who refused further medical examinations were contacted via phone to inquire about symptoms.

Results

Between July 2020 and April 2022, 200 patients (91% general ward, 9% intensive care unit) were recruited. Due to dropouts, the second visit was conducted in 170 patients and the third visit in 139 (74 in person, 65 via telephone). Long Covid criteria were fulfilled by 73% at 6 months, 52% at 18 months and 49% at 30 months post-discharge, with fatigue being the most common symptom (Figure 1). Echocardiography at 6 months showed impaired left ventricular function in 15 patients, with normalization in 80% at 18 months and further 66% at 30 months (Figure 2). cMRI revealed pericardial effusions in 28 patients at 6 months, which resolved in 47% at 18 months and in further 60% at 30 months. Signs of peri- or myocarditis were present in 7 patients at 6 months and were resolved in all 4 patients who attended control studies at 18 months. PFT at 6 months detected reduced vital capacity in 17 patients, of whom 10% returned to normal at 18 months and a further 66% showed normalization at 30 months. Chest CT scans at 6 months identified post-infectious residues in 41 patients, with full recovery in 20% at 18 months without further normalization after 30 months. The length of in-hospital stay was identified as a significant predictor for persisting Long Covid 6 months after discharge (95% CI: 1.005 - 1.12, p=0.03). No predictors have been found for Long Covid at 18 and 30 months.

Conclusion

While the prevalence of Long Covid decreased over time, a significant symptom burden persisted at 6, 18 and even 30 months after severe Covid-19 infection. Structural and functional abnormalities were less frequent compared to reported symptoms, posing a challenge in substantiating the causes of these symptoms.
Alginate-chitosan hydrogel formulations for VEGFA expressed baculovirus delivery promoting angiogenesis for wound healing and revascularization
Authors: Schaly S , Islam P , Prakash S
Published: October 2024

Background

Baculoviruses, engineered to express growth factors, offer a promising avenue for short-term gene therapy, such as wound dressings, due to their safety and specificity. Encapsulation in natural polymers like alginate and chitosan addresses limitations like serum inactivation and fragility, while promoting sustained delivery and shielding from immune inactivation. Wound healing involves complex processes that can be enhanced by maintaining an antimicrobial, moist environment, which promotes cell migration and angiogenesis. Vascular endothelial cell growth factor A (VEGFA) is known to be one of the most potent pro-angiogenic factors and plays a key role in wound healing.

Purpose

This investigation seeks to enhance wound healing and angiogenesis, support the revascularization process, and provide anti-inflammatory and anti-microbial effects. Additionally, it aims to assess the preclinical efficacy and safety of the approach.

Methods

Ionic cross-linking was used for virus encapsulation under aseptic conditions. The capsules were assessed for their surface morphology, particle size, zeta potential, and in vitro release profile. Additionally, their therapeutic potential was studied using cell lines. The efficacy of hydrogel delivery of VEGFA-expressing baculoviruses in promoting cell migration and angiogenesis for wound healing applications was investigated on Human Umbilical Vein Endothelial Cells (HUVECs). Hydrogel morphology, swelling, and encapsulation efficiency were evaluated, along with endothelial tube formation assays and hemocompatibility studies on HUVECs.

Results

Encapsulation of baculovirus expressing the VEGFA gene in alginate and chitosan–alginate hydrogels achieve a high encapsulation efficiency of 99.9%. This allows for prolonged virus delivery and an increased therapeutic window. The encapsulated baculovirus maintains activity and is released over eight days, with a transduction efficiency of over 40%. This promotes tube formation, cell proliferation, and cell migration for angiogenesis, particularly beneficial for chronic wound-healing applications. The hydrogels also prevented E. coli and C. albicans growth directly below and inhibited C. albicans growth surrounding the alginate–chitosan hydrogels. The hydrogels demonstrated no cytotoxicity and good blood compatibility.

Conclusion

This proof of concept underscores the potential of encapsulated baculovirus delivery systems for various gene therapy applications including cardiovascular tissue regeneration and revascularization.