bluuebunny/crossref_metadata_2025 huggingface dataset:
The trajectory of Coronary-Artery-Bypass-Grafting patient phenotype through 23 years
Authors: Pattakos G , Bampali T , Siminelakis S , Goudevenos J
Published: October 2022

Background

Over 6 decades since the first Coronary-Artery-Bypass-Grafting (CABG) and it is considered as the most common cardiac surgery with established benefits on mortality and morbidity.

Purpose

Following the well-recognized epidemiology of coronary disease, we attempted to capture the difference over time on parameters such as baseline clinical profile, comorbidities, operation characteristics, short-term complications and perioperative mortality.

Methods

In this retrospective study, all adults patients with isolated CABG were included. The study period was from January 1st, 1997 until December 31, 2019. The statistical analysis referred to the prespecified time-points (the first and the last enrolled patient).

Results

14235 consecutively patients underwent isolated CABG during the study period. We reported the trajectory of their baseline clinical, operative and periprocedural outcome's phenotype for 23 years. In this way we captured the current holistic profile of the CABG-patient as a timelapse (Table 1).

Amongst baseline comorbidities we highlight the 40% increase of hypertension. Regarding the surgery parameters the increase in total and cross clamping time likely attests to the increasing difficulty in performing grafting in more diffusely diseased coronary vessels plus the time-forfeit of the increased usage of non-saphenous vein grafts. Notwithstanding, the perioperative mortality did not significantly change over time. Cardiac and neurological complications also remained the same, whereas renal and pulmonary complications rose. A possible explanation is the worsen baseline profile of the patients and the prolongation of operative duration.

Conclusion

Over time, more complicated patients are entering the operation room with increased age, decreased ejection fraction (EF) and additive comorbidities. Nota bene the perioperative mortality did not change over time, despite the worsen clinical profile and the accretion of technical difficulties which are expressed via the increased cross clamp time and the establishment of arterial grafting. Arterial grafting could be the behoof parameter that attenuated the mortality trend. To our knowledge this is one of the largest series on isolated CABG and probably the lone with extended duration beyond two decades.

Funding Acknowledgement

Type of funding sources: None.
Acute and chronic changes in LV performance in patients with primary severe mitral regurgitation undergoing percutaneous mitral valve repair
Authors: Galli E , Hubert P , L'official G , Donal E
Published: October 2022

Background

The non-invasive assessment of myocardial work allows to evaluate LV performance by taking into account the effect of LV load. Aim of this study was to evaluate the acute and chronic impact of percutaneous mitral valve repair (PMVR) on LV performance, in patients with severe primary mitral regurgitation (PMR).

Methods

71 patients (age: 77±9 years, females: 44%) with severe PMR (effective regurgitant orifice: 0.57±0.31 cm2, regurgitant volume: 80±34 ml) and preserved LV ejection fraction (LVEF: 60±10%) underwent PMVR according to current recommendations. Myocardial work indices were evaluated before the procedure, 2 days after the procedure and at 1-year follow-up.

Results

PMVR was associated with an acute reduction in LVEF, global longitudinal strain (GLS), myocardial work index (MWI), and work efficiency (MWE), and a significant increase in myocardial wasted work (MWW) and mechanical dispersion (MD). 1-year after the procedure, LV size significantly decreased, GLS, MWI, MWE and MD improved, whereas GWW remained significantly reduced. LVEF improved but remained significantly altered compared with baseline values (Table 1).

Conclusions

In patients severe PMR undergoing PMVR, the acute reduction in LV preload causes a significant impairment of all parameters of LV performance. After 1-year, progressive LV remodeling is associated a significant improvement in MCW, counterbalanced by a persistently high MWW, which can explain the partial recovery of LVEF.

Funding Acknowledgement

Type of funding sources: None.
Magnetocardiography as a noninvasive diagnostic strategy for suspected coronary microvascular dysfunction
Authors: Quesada O , Pico M , Palmer C , Yildiz M , Miranda R , Malhotra R , Setegn E , Legreaux S , Moore B , Philip R , Shrivastava P , Takla R , Henry T
Published: October 2022

Background

Coronary microvascular dysfunction (CMD) is increasingly recognized as an independent predictor of mortality with a 4-fold higher risk. However current diagnostic modalities are limited by the need for an invasive procedure, access, cost, and exposure of ionizing radiation.

Purpose

To investigate the ability of magnetocardiography (MCG) to identify CMD in patients with suspected ischemia and no obstructive coronary artery disease (INOCA).

Methods

This is an observational, prospective pilot study of patients scheduled for coronary functional angiography (CFA), gold standard for evaluation for CMD (defined as coronary flow reserve (CFR) ≤2). 13 patients underwent both CFA and a noninvasive 36-channel MCG scan. A machine learning model was developed to characterize the presence of CMD in these patients against age matched controls (AMCs). The model consists of a logistic regression classifier which takes features representing the relative strengths of the “characteristic dipoles” of the MCG scan as input. The characteristic dipoles are parameterizations of the three strongest magnetic field map components resulting from a singular value decomposition of the MCG signal. A total of 37 patients were included in this analysis including 13 patients who completed CFA (7 had CMD and 6 had CFR >2 and included in the AMCs group). An additional 24 asymptomatic, healthy patients that did not undergo CFR were also included in the AMC group.

Results

The mean age for AMCs was 57 years (70% women) and mean age for CMD patients was 54 years (100% women). The performance of the model was evaluated using repeated stratified cross-validation with 5 folds and 3 repeats, resulting in 15 different 80%/20% train/test splits. Figure 1 shows the distribution of samples belonging to the CMD and AMC groups in a 2-dimensional representation of the feature space. The clear separation of the two groups and the clustering of the AMCs demonstrates the ability of the model to identify patients with CMD. We found that MCG had a mean accuracy of 94.8% (±6.4%), sensitivity of 100% (±0.0%) and specificity of 93.3% (±8.2%) for the detection of CMD using gold standard CFR ≤2 as reference.

Conclusion(s)

First study to show that MCG can be used with 94.8% accuracy to identify CMD among patients suspicious for INOCA with no exposure to ionization, 90 seconds of scan time and minimal cost. The use of this noninvasive modality to identify CMD warrants further investigation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Genetesis
The predictive value of regional 2D longitudinal strain in determining the localization of coronary artery stenosis in NSTE-ACS patients
Authors: Krizanac S , Kovacic K , Brestovac M , Gasparovic K , Reskovic-Luksic V , Lovric D , Separovic-Hanzevacki J
Published: October 2022

Background and purpose

Previous studies have shown that the role of global longitudinal 2DS in diagnosing and detecting coronary artery disease is modest. However, data on the sensitivity of the regional 2DS assessment is lacking (1–6). The aim of this study was to determine whether in echocardiographic evaluation of myocardial ischemia, regional 2D strain (2DS) assessment is more sensitive and specific in detecting ischemia due to critical stenosis of one or more coronary arteries in comparison with current standard of visual assessment of regional wall motion abnormalities (RWMA).

Material and methods

This retrospective study included 123 patients admitted through the Emergency Department across 36 months with the diagnosis of NSTE-ACS without previously known CAD or LBBB who underwent coronary angiography within the first 24 hours and had an echocardiogram with RWMA analysis done prior to procedure. 2DS analysis of regional longitudinal peak systolic strain (LPSS) according to the 18-segment model was performed by four clinicians, blinded to patient's clinical data.

Results

A significant correlation was found between individual parameters of LPSS and significant stenosis of all three major coronary vessels (>70% narrowing on coronary angiography, Table 1). Lower regional LPSS correlated well anatomically with the supplying arteries; for example, patients with LAD stenosis had significantly lower regional LPSS in all apical segments, lateral, anteroseptal and anterior mid segments and anterior basal segment. Similar patterns were seen in the LCx and RCA regions. Three graphs show the sensitivity and specificity of the most sensitive segments for each artery. The diagnostic accuracy of endocardial and epicardial regional LPSS was similar to the average regional LPSS.

Conclusion

We have shown that regional 2DS could be a good predictor of the presence and localization of coronary stenosis for each of the three main coronary arteries but further studies are needed to confirm this assumption.

Funding Acknowledgement

Type of funding sources: None.
Diagnostic and prognostic role of cardiac magnetic resonance in patients with MINOCA
Authors: Mileva N , Paolisso P , Gallinoro E , Bergamaschi L , Pizzi C , Barbato E , Penicka M , Andreini D , Vassilev D I
Published: October 2022

Background

Myocardial infarction with non-obstructed coronary arteries (MINOCA) is common in current clinical practice and cardiac magnetic resonance (CMR) plays an important role in the present management of this group of patients. However, there are still a lot of controversies concerning the etiology behind the syndrome of MINOCA. Furthermore, the prognostic value of CMR in patients with MINOCA is still undetermined.

Purpose

We aimed to determine the diagnostic and prognostic value of CMR in the management of patients with MINOCA.

Methods

A systematic review was performed to identify studies reporting the results of CMR findings in MINOCA patients (non-obstructive CAD or normal coronary arteries). Random effects models were used to determine the prevalence of different disease entities – myocarditis, myocardial infarction, Takotsubo cardiomyopathy or normal CMR findings. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the prognostic value of CMR diagnosis in the subgroup of studies that reported clinical outcomes. Major adverse clinical events (MACE) were defined based on the specific study definitions and included cardiovascular death, non-fatal myocardial infarction, and cardiovascular hospitalization.

Results

31 studies comprising 4119 patients were included. Mean age was 54.1±3.3, 59% were males. The pooled prevalence of myocarditis was 32% (95% CI 0.25 to 0.39), myocardial infarction (MI) - 21% (95% CI 0.17 to 0.24), Takotsubo cardiomyopathy −12% (95% CI 0.09 to 0.16). Normal findings were found in 23% (95% CI 0.14 to 0.35), figure 1. In a subgroup analysis of seven studies (900 patients) that reported clinical outcomes the prognostic value of the CMR was assessed. CMR diagnosis of myocarditis was not significantly associated with increased risk of MACE (pooled OR, 1.50; 95% CI, 0.46 to 4.87; p=0.459). However, both diagnosis of MI and Takotsubo were significantly associated with increased risk of combined clinical outcomes (pooled OR, 1.75; 95% CI, 1.12 to 3.59; p<0.05 and pooled OR, 2.19; 95% CI, 1.34 to 5.27; p<0.001).

Conclusion

In patients with MINOCA CMR brings important diagnostic and prognostic role. The pooled prevalence of myocarditis was 32%, of MI – 21% and of Takotsubo – 12%. The CMR diagnosis of MI and Takotsubo was associated with increased risk of MACE.

Funding Acknowledgement

Type of funding sources: None.
Morphological and clinical implications of the optical coherence tomography-derived lipid core burden index
Authors: Biccire F G , Budassi S , Ozaki Y , Boi A , Romagnoli E , Di Pietro R , Debelak C , Sammartini E , Versaci F , Fabbiocchi F , Burzotta F , Crea F , Arbustini E , Alfonso F , Prati F
Published: October 2022

Background

Intracoronary optical coherence tomography (OCT) is a valuable tool for vulnerable plaque assessment and morphology-guided risk stratification. However the groundbreaking impact of OCT in clinical practice may be offset by its inherent limitation, the subjectivity in plaque interpretation. Recent studies reported a semi-automated method to assess fibrous cap thickness but data regarding an automated assessment of lipid component at OCT, such a lipid core burden index (LCBI), are lacking.

Purpose

The aim of this study was to assess the morphological characteristics and prognostic implications of an OCT-derived LCBI (OCT-LCBI).

Methods

In order to assess OCT-LCBI in 1003 patients with 1-year follow-up from the CLIMA multicenter registry (clinicaltrial.gov identifier NCT02883088) we used a novel previously validated software able to automate obtain a maximum OCT-LCBI in 4 mm (maxOCT-LCBI4mm). A maxOCT-LCBI4mm cut-off of 400 was used, based on previous literature on this topic. Primary composite clinical endpoint included cardiac death, myocardial infarction and target vessel revascularization. A secondary analysis using clinical outcomes of CLIMA study was performed.

Results

Patients with a maxOCT-LCBI4mm ≥400 showed higher prevalence of fibrous cap thickness <75μm (FCT, odds ratio [OR] 1.43, 95% confidence interval [CI] 1.03–1.99; p=0.034), lipid pool arc >180°(OR 3.93, 95% CI 2.97–5.21; p<0.001), minimum lumen area <3.5 mm2 (OR 1.5, 1.16–1.94; p=0.002), macrophage infiltration (OR 2.38, 95% CI 1.81–3.13; p<0.001) and intra-plaque intimal vasculature (OR 1.34, 95% CI 1.05–1.72, p=0.021). A maxOCT-LCBI4mm ≥400 predicted the primary endpoint (adjusted hazard ratio [HR] 1.86, 95% CI 1.1–3.2; p=0.019) as well as the CLIMA endpoint (HR 2.56, 95% CI 1.24–5.29; p=0.011). Patients with high lipid content and thin FCT <75 μm were at higher risk for adverse events (HR 4.88, 95% CI 2.44–9.72; p<0.001) (Figure 1).

Conclusions

We applied for the first time in a large population with clinical follow-up a software able to automatically obtain a maxOCT-LCBI4mm. A high maxOCT-LCBI4mm was related to vulnerable plaque features and further clinical events. This study represents a step further towards a comprehensive automated assessment of the coronary plaque risk profile.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Supported by a grant from the Centro per la Lotta contro l'Infarto – Fondazione Onlus, Rome, Italy
Characterization of lipidic plaque materials at calcified atheroma: its association with calcification thickness evaluated by optical coherence tomography and near-infrared spectroscopy imaging
Authors: Mitsui K , Kataoka Y , Murai K , Kitahara S , Iwai T , Sawada K , Matama H , Honda S , Fujino M , Takagi K , Yoneda S , Otsuka F , Asaumi Y , Tsujita K , Noguchi T
Published: October 2022

Introduction

The degree of calcification and its thickness have been considered to affect stent expansion, leading to an increases risk of repeat revascularization in patients receiving PCI. Pathophysiologically, accumulation of lipidic materials within vessel wall could trigger the formation of plaque calcification. Elucidating characteristics of lipidic plaque components at calcified atheroma may enable to identify phenotypes with thick calcification which less likely responds to PCI.

Purpose

This study investigated the relationship of calcification thickness with lipidic plaque materials at calcified atheroma by using OCT and near-infrared spectroscopy (NIRS) imaging.

Methods

We analyzed 52 calcified lesions (culprit/non culprit lesions=44/8) in 47 CAD patients (stable CAD/ACS=36/11) from the REASSURE-NIRS registry (NCT04864171). OCT and NIRS imaging evaluated 4-mm segment exhibiting maximum superficial calcification arc. Calcification thickness on OCT imaging, its arc on IVUS imaging, and NIRS-derived lipid arc were analyzed at every 1-mm interval cross-sectional images. In addition, yellow-calcification ratio (YCR = lipid arc/calcification arc) was calculated (Figure 1).

Results

53% of study subjects exhibited chronic kidney disease and 70% of them received a statin (averaged on-treatment LDL-C =89mg/dL). Throughout OCT and NIRS/IVUS imaging analysis of 260 cross-sectional images, the averaged calcification arc, its maximum thickness, lipid arc and YCR were 210° (167–285°), 0.78mm (0.62–0.95mm), 95° (31–169°) and 0.33 (0.09–0.59), respectively. As expected, thicker calcification more likely exhibited a greater calcification arc (r=0.30, p<0.001). Furthermore, a greater thickness of calcification was associated with smaller lipidic plaque burden, reflected by yellow arc (r=−0.36, p<0.001) and YCR (r=−0.36, p<0.001) (Figure 2). After adjusting age, gender and ACS, calcification arc (p<0.001) and YCR (p<0.001) continued to predict thicker calcification.

Conclusion

Thickening of calcification was associated with severer calcification arc, which was accompanied by the shrinkage of lipidic plaques. Our findings suggest the evaluation of lipidic plaque component as a potential tool to identify calcified atheroma harbouring thick calcification, which may cause a greater risk of stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.
Impact of high intensity interval training on coronary atheromatous plaques evaluated by IVUS – a randomized trial
Authors: Vesterbekkmo E K , Aksetoy I L A , Follestad T , Nilsen H O , Hegbom K , Wisloff U , Wiseth R , Madssen E
Published: October 2022

Background

Coronary atheromatous plaque geometry, expressed as plaque burden (PB) or total atheroma volume (TAV) are both strongly related to the risk of acute and recurrent coronary events and outcomes in coronary artery disease (CAD). Exercise training is a cornerstone in the primary and secondary prevention of atherosclerotic complications, but the knowledge of the effect from exercise on coronary atheromatous plaques is sparse.

Purpose

We assessed the effect of six months supervised high intensity interval training (HIIT) on coronary plaque geometry using intravascular ultrasound in patients with stable CAD following percutaneous coronary intervention (PCI).

Methods

Sixty patients were randomized to two sessions weekly of supervised HIIT at 85–95% of peak heart rate (n=30) or to follow contemporary preventive guidelines (control group, n=30). The primary endpoint was change in PB and TAV normalized for segment length (TAVnorm) at six-month follow-up. All included patients were on stable lipid lowering therapy at least six weeks prior to inclusion with no further adjustments throughout the study.

Results

When comparing matched coronary segments at baseline and follow-up, there was a 1.4 percent points larger reduction in average PB (95% CI: 2.7 to 0.1, p=0.036) in the HIIT group compared to the control group. TAVnorm was reduced by 9 mm3 (95% CI: 14.7 to 3.4, p=0.002) after HIIT, with a between group difference of 12 mm3 (95% CI: 19.9 to 4.2, p=0.003). VO2peak improved more in the HIIT group with a difference in delta VO2 peak between groups of 1.7 mL kg–1 min–1 (95% CI: 0.1 to 3.3, p=0.039). There was also a significant larger reduction in body mass index and waist circumference in the HIIT group compared to the control group (both, p=0.021). In both groups a modest, although significant increase was observed for both HDL-cholesterol and ApoA1, but no significant changes in the LDL, ApoB or HbA1c levels were found.

Conclusions

In patients with established CAD, a regression of PB and TAV was observed in patients undergoing six months of supervised HIIT compared with patients following contemporary preventive guidelines. Our study indicates that exercise increasing VO2 peak counteracts atherosclerotic coronary disease progression and reduces PB and TAV in coronary atheromatous plaques following PCI.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study was funded by the Liaison Committee for Central Norway Regional Health Authority, the Norwegian University of Science and Technology (NTNU), and the Research Fund at St. Olavs University Hospital
Coronary sinus reducer device for the treatment of refractory angina therapy. A multicentric initial experience
Authors: Dias Ferreira Reis J P , Brizido C , Madeira S , Ramos R , Almeida M , Cacela D
Published: October 2022

Introduction

The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting.

Methods

Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy.

Results

Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010).

Conclusion

In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA.

Funding Acknowledgement

Type of funding sources: None.
Sodium-glucose co-transporter-2 inhibitors after acute myocardial infarction in type 2 diabetes patients: a population-based investigation from South Korea
Authors: Kwon O , Myong J P , Lee Y , Choi Y J , Yi J E , Seo S M , Jang S W , Kim P J , Lee J M
Published: October 2022

Background

Whether the early use of sodium-glucose co-transporter-2 (SGLT2) inhibitors has cardioprotective effects following acute myocardial infarction (AMI) is unknown.

Purpose

We aimed to evaluate the association between the early initiation of SGLT2 inhibitors and cardiac event rates in diabetes patients with AMI undergoing percutaneous coronary intervention (PCI).

Methods

Based on the National Health Insurance claims data in South Korea, patients aged 18 years or older who had undergone PCI for the diagnosis of AMI between 2014 and 2018 were analyzed. Patients treated with SGLT2 inhibitors or other glucose-lowering drugs were matched based on a propensity score. The primary endpoint was a composite of all-cause mortality and hospitalizations for heart failure (HF). Major adverse cardiac events (MACE; a composite of all-cause death, non-fatal MI, and ischemic stroke) were compared as the secondary endpoint.

Results

After 1:2 propensity score matching, a total of 26,814 patients were assigned to the SGLT2 inhibitors group (938 patients) and the no use of SGLT2 inhibitors group (1,876 patients), respectively. During a median follow-up of 2.1 years, compared to no use of SGLT2 inhibitors, the early use of SGLT2 inhibitors was associated with lower risks of both the primary endpoint (9.8% vs. 13.9%, adjusted hazard ratio [HR] = 0.68, 95% confidence interval [CI]: 0.54 to 0.87, p=0.002) and secondary endpoint (9.1% vs. 11.6%, adjusted HR = 0.77, 95% CI: 0.60 to 0.99, p=0.04) (Figure 1). All-cause mortality and hospitalizations for HF were significantly lower in the early use of SLGT2 inhibitors group (adjusted HR = 0.55; 95% CI: 0.37 to 0.80; p=0.002; and HR = 0.74; 95% CI: 0.56 to 0.98; p=0.03, respectively). The incidence of non-fatal MI and ischemic stroke were not statistically different (Figure 2).

Conclusions

The early use of SGLT2 inhibitors in diabetes patients treated with PCI for AMI was associated with a significantly lower risk of cardiovascular events including all-cause mortality, hospitalizations for HF, and MACE. Our results suggest that the use of SGLT2 inhibitors could expand to the acute phase of AMI survivors with diabetes to reduce mortality and the subsequent development of congestive HF and ischemic events.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This work was partly supported by the Research Institute of Medical Science, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea.
Thrombin generation and endothelial progenitor cell function among patients with acute myocardial infarction treated with prasugrel versus ticagrelor
Authors: Wiessman M , Kheifetz M , Schamroth Pravda N , Leshem Lev D , Ziv E , Kornowski R , Spectre G , Perl L
Published: October 2022

Objectives

To compare the effects of prasugrel and ticagrelor on thrombin generation (TG) and circulating endothelial progenitor cells (EPCs) in the acute phase of ST-segment elevation myocardial infarction (STEMI).

Background

TG, platelet function and EPCs have an important role in the pathophysiology of coronary artery disease (CAD). To date, the effect of novel P2Y12 inhibitors on these coagulation mediators has only been studied in the sub-acute phase following acute myocardial infarction.

Methods

Patients presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI) were randomized to either ticagrelor or prasugrel treatment. TG, platelet reactivity and EPC were tested prior to P2Y12 inhibitor loading dose (T0), and 24 hours following PPCI (T1).

Results

Between December 2018 and July 2021, 83 consecutive STEMI patients were randomized to ticagrelor (N=42) or prasugrel (N=41) treatment. No differences were observed at T0 for all measurements. At T1, prasugrel was found to be a more potent TG inhibitor: lower thrombin peak levels (319.5±237.7 nmol/L vs. 433.5±264.3 nmol/L, p=0.06), longer time to peak (14.1±12.6 min vs. 8.3±9.7 min, p=0.03), longer lag time to TG initiation (7.7±7.5 min vs. 3.9±2.1 min, p<0.01) and a smaller AUC (2186.1±1123.1 vs. 3362.5±2108.5, p<0.01). Furthermore, levels of CD34 (2.6±4.1 vs. 1.1±1.1, p=0.01), CD133 (2.3±1.8 vs. 1.4±1.5, p=0.01) and CFUs (2.1±1.5 vs. 1.1±1.0, p<0.01) were significantly higher in the prasugrel group, as compared to the ticagrelor group.

Conclusion

Among STEMI patients treated with PPCI, treatment with prasugrel as compared to ticagrelor was associated with more potent inhibition of TG and improved EPCs count and function.

Funding Acknowledgement

Type of funding sources: None.
Impact of left ventricular ejection fraction on hospital and long term outcomes after coronary artery bypass graft surgery
Authors: Laimoud M , Al-Mutlaq S , Maghirang M , Althibait S , Alanazi M , Alanazi B , Alhalees Z
Published: October 2022

Background

Coronary artery bypass surgery is recommended for patients with extensive coronary artery disease and severely impaired left ventricular ejection fraction (LVEF). Short term clinical outcomes improved due to advanced surgical techniques and perioperative management.

Objective

To study the impact of pre-operative left ventricular ejection fraction (LV EF) on clinical outcomes during postoperative hospitalization and for 5 years follow up.

Methods

The study was a retrospective analysis of patients underwent CABG at our tertiary care hospital between January 2016 and August 2020.The primary outcome was mortality and the secondary outcomes included acute cerebrovascular stroke, length of hospitalization, subsequent revascularization, and heart failure.

Results

The study included 410 patients with a median age of 60 (55–68) years, a hospital mortality of 2.7%, postoperative stroke of 7.6%, acute kidney injury (AKI) of 25.6% and new need dialysis of 5.9%. The patients were divided into 4 groups: 75 (18.3%) patients had LV EF less than 35%, 88 (21.5%) had LV EF 35–45%, 106 (25.9%) had LV EF 45–55% and 141 (34.4%) had LV EF more than 55% with significant differences in frequencies of chronic kidney disease (29.3% vs. 40.9% vs. 23.6% vs. 24.1%, p=0.026), prior cerebral stroke (9.3% vs. 11.4% vs. 8.5% vs. 1.4%, p=0.015), Peripheral vascular disease (8% vs. 18.2% vs. 4.7% vs. 12.1%, p=0.019) respectively. The hospital mortality occurred in (6.7% vs. 0% vs. 0.9% vs. 3.5%, p=0.03), acute cerebrovascular stroke occurred in (14.7% vs. 6.8% vs. 3.8% vs. 7.1%, p=0.031), AKI occurred in (36% vs. 43.2% vs. 17.9% vs. 14.9%, p<0.001), new dialysis was used in (12% vs. 5.7% vs. 1.9% vs. 5.7%, p=0.04), ICU stay was [5 (3–7) vs. 4 (3–11) vs. 4 (3–5) vs. 3 (2–5), p<0.001], post ICU stay was [6 (3–10) vs. 5 (4–8) vs. 4 (3–6) vs. 4 (3–6), p=0.009] in patients with LV EF <35%, LV EF 35–45%, LV EF 45–55% and LV EF >55% respectively. Mortality during follow up occurred in (20% vs. 4.5% vs. 2.8% vs.4.3%, p<0.001), stroke occurred in (8% vs. 4.5% vs.0.9 5% vs. 2.8%, p=0.031), revascularization was done in (2.7% vs. 23.9% vs. 18.9% vs. 12.8%, p=0.009) and readmission with heart failure occurred in (52% vs. 34.1% vs. 10.4% vs. 4.3%, p<0.001) in patients with LV EF <35%, LV EF 35–45%, LV EF 45–55% and LV EF >55% respectively.

Conclusion

Reduced LV EF was associated with increased hospital mortality, frequent morbidities, and prolonged hospitalization after CABG with higher composite rate of death, stroke, heart failure at 5 years compared with normal or mildly reduced LV EF.

Funding Acknowledgement

Type of funding sources: None.
Proprotein convertase subtilisin/kexin type 9 (PCSK9), platelet activation and interaction with the vascular endothelium: the impact of PCSK9 inhibition with evolocumab in acute coronary syndrome
Authors: Ziogos E , Chelko S P , Walsh E , Engel M , Gerstenblith G , Halushka M K , Leucker T M
Published: October 2022

Background/Introduction

Platelet activation and endothelial dysfunction may contribute to adverse outcomes in patients with acute myocardial infarction. Pre-clinical studies indicate PCSK9 enhances platelet activation.

Purpose

Our goals were (1) to examine the role of PCSK9 as a potential mediator of platelet activation in patients with acute coronary syndrome (ACS) and (2) to perform immunohistochemical studies of left internal mammary artery (LIMA) specimens to examine interactions among PCSK9, platelets, and endothelial cells in specimens obtained during coronary bypass surgery.

Methods

Participants from the Evolocumab in Acute Coronary Syndrome trials (EVACS; NCT03515304, NCT04082442), with a NSTEMI and a troponin-I of >5 ng/ml or a STEMI were randomized to placebo or to 420 mg SC of evolocumab, a monoclonal anti-PCSK9 antibody, within 24 hours of hospitalization. We performed serial ex vivo analysis of PF4, a marker of platelet activation, in serum samples obtained at baseline (prior to study drug administration) and at day 30. PF4 values were normalized to total platelet count. All of the participants were on guideline-directed therapies for ACS. Additionally, LIMA samples from patients undergoing coronary bypass surgery were immunostained with PCSK9, the endothelial cell transmembrane glycoprotein CD31 (platelet endothelial cell adhesion molecule-1) and the platelet surface marker CD61 (integrin beta-3). Outcome data were summarized using medians and interquartile ranges.

Results

Forty-six participants were randomized in a 1:1 fashion to placebo or to evolocumab. Mean (±SD) age of the cohort was 60±13 years, 48% were women and 22% were African American. Baseline PF4 levels (expressed as ng/1k platelets) were similar between the two groups (placebo: 9.3 [4–12] vs evolocumab 8.0 [4–12], p=0.8). In the placebo group, there was a significant increase in PF4 at 30 days to 13.1 [11–14], p<0.01 (baseline vs 30 days). In contrast, there was no significant change from baseline in the evolocumab group at 30 days (10.7 [6–13]), which was significantly lower than the placebo group (p=0.04). Furthermore, immunostaining of LIMA specimens obtained from patients during coronary artery bypass surgery revealed colocalization of PCSK9, CD31, and CD61 on the vascular endothelial cell surface (see Figure).

Conclusion

PCSK9 inhibition with evolocumab decreases platelet activation in ACS patients on dual anti-platelet therapy. PCSK9 is associated with platelets and endothelial cells at the vascular endothelium. PCSK9 is a potential mediator of the interaction between platelets and vascular endothelial cells in patients with coronary artery disease.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Amgen
Exercise induced coronary inflammation in masters athletes
Authors: Papatheodorou E , Kissel C , Merghani A , Hughes R , Torlasco C , Bakalakos A , Downs E , Parry-Williams G , Finocchiaro G , Malhotra A , Moon J C , Papadakis M , Al Fakih K , Dey D , Sharma S
Published: October 2022

Background

Chronic endurance exercise has been linked to increased prevalence of coronary artery disease (CAD) in male master athletes. Data are limited regarding the presence of exercise-induced coronary inflammation and its association with atherosclerosis in master endurance athletes. Human coronary inflammation can be detected non-invasively by imaging pericoronary adipose tissue (PCAT). We tested the hypothesis that chronic endurance exercise leads to increased prevalence of atherosclerosis via coronary inflammation.

Methods

Computed tomography coronary angiogram CTCA scans from 2 cohorts of master athletes and age-matched controls, without known risk factors for CAD, were analysed post-hoc and the PCAT attenuation index was calculated around the proximal right coronary artery (FAIRCA). The athletes and the healthy controls also underwent an electrocardiogram, an echocardiogram, a cardiopulmonary exercise test (CPET), a 24-hour Holter tape and a Cardiac Magnetic Resonance (CMR) scan.

Results

Scans from 243 masters endurance athletes (62% females) and 58 age and Framingham CAD risk score matched healthy controls were analysed. FAIRCA was significantly higher (less negative) in male masters athletes vs female masters athletes [−61.3 Hounsfield Units (HU) vs −62.8 HU, p=0.01], in male athletes vs male controls (−61.3 HU vs −68.6 HU, p<0.001) and in female athletes vs female controls (−62,8 HU vs −67.5 HU, p=0.005). In female masters athletes, peak oxygen consumption during CPET (peak VO2) statistically significantly predicted the FAIRCA, F(1,146) = 22.62, p<0.0001. There was no correlation between the FAIRCA and presence of atherosclerosis in male masters athletes.

Conclusions

Masters athletes show increased markers of coronary inflammation. This effect appears to be greater in male masters athletes and is associated with a higher peak VO2 in female masters athletes. However, we did not identify a link between coronary inflammation and coronary atherosclerosis in this cohort.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiac Risk in the Young, UK
Reduced antioxiadant high-density lipoprotein function in patients with acute coronary syndrome
Authors: Pagonas N , Weiland L , Jaensch M , Dammernmann W , Christ M , Ritter O , Westhoff T , Kelesidis T , Sasko B
Published: October 2022

Background

High-density lipoprotein (HDL) function rather than concentration plays an important role in the pathogenesis of cardiovascular diseases associated with oxidative stress and inflammation such as coronary artery disease (CAD). In the last years, inflammation has been identified to have a pivotal role in the pathogenesis of acute coronary syndrome (ACS).

Purpose

The aim of the present study is to determine whether reduced antioxidant function of HDL is associated with ACS.

Methods

197 patients with ACS were prospectively recruited and blood samples were taken in the first 48h after enrollment. Patients with chronic coronary syndrome CCS (n=727) and with invasively excluded CAD (no CAD, n=498) from another cohort from our group served as control patients. A validated cell-free biochemical assay was used to determine reduced HDL antioxidant function as assessed by increased HDL-lipid peroxide content (HDLox) normalized by HDL-C levels and the mean value of a pooled serum control from healthy participants (nHDLox; no units).

Results

Patients with ACS had significantly increased HDLox blood levels compared to patients with CCS and to patients without CAD (p<0.001, Figure 1A). Prior intake of statins did not influenc the differences of HDLox among the groups (Figure 1B). In the regression analysis increased HDLox was a strong risk factor for the presence of ACS compared to CCS (odds ratio 4.09 (2.98–5.62), p<0.001, Figure 2).

Conclusions

HDL peroxidation is associated with the presence of ACS independent of the presence of other traditional risk factors.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): BIOX
Pressure-recovery adjustment of aortic valve area does not improve risk prediction in aortic stenosis
Authors: Lindow T , Playford D , Strange G , Kozor R , Ugander M
Published: October 2022

Background

In aortic stenosis (AS), overestimation of pressure gradients by Doppler compared to catheter-based measurement can be adjusted for by accounting for the pressure-recovery, expressed as an energy-loss index (ELI). However, evidence of improved risk assessment by ELI instead of aortic valve area indexed by body-surface area (AVAi) is scarce.

Purpose

We aimed to evaluate the prognostic performance of ELI and AVAi in a head-to-head comparison using large-scale, real-world data.

Methods

In the multi-center, mortality-data linked National Echocardiography Database of Australia (NEDA), patients with AS and requisite aortic area measurements were identified. The prognostic value of AVAi and ELI, respectively, was analyzed using Cox regression and compared by difference in C statistics.

Results

In patients with mild AS (n=3,179), moderate AS (n=4,194), and severe AS (n=3,120), there were 4,229 deaths of which 2,359 were cardiovascular deaths (median [interquartile range] follow-up 2.5 [1.1–4.5] years). There was an association with increased mortality risk per 0.1 cm2/m2 decrement for both AVAi (hazard ratio CV mortality [95% confidence interval] 1.18 [1.16–1.20]) and ELI (1.10 [1.09–1.12]). Prognostic performance for 5-year CV mortality did not improve by using ELI compared to AVAi (C statistic 0.626 vs 0.626, p=0.96).

Conclusions

In aortic stenosis, ELI was not associated with improved prognostic performance compared to AVAi using large-scale, real-world clinical data. These data do not support routine calculation of pressure recovery in echocardiographic reporting.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung Foundationthe Swedish Cardiac Society
The obesity paradox in patients with acute coronary syndromes – is it still applicable to the current era? The ACSIS registry 2000–2018
Authors: Gurevitz C , Mohsen J , Ovdat T , Zwas D R , Fluk Gmach S , Beigel R , Eisen A
Published: October 2022

Background

Obesity is a major epidemic which is associated with major cardiovascular (CV) risk factors. Nevertheless, substantial data, mostly published more than a decade ago, have demonstrated an obesity paradox, where obese patients generally have a better short- and long-term prognosis than do their leaner counterparts with the same CV profile. As for the obesity paradox in acute coronary syndrome (ACS), prior studies demonstrated that the body-mass index (BMI)-mortality association followed a “U” shape curve: it is the highest in underweight (BMI<19) or severely obese (BMI >44), and is the lowest in overweight or mildly obese patients (BMI 30–34 and BMI 35–39) [1–2]. It is not fully elucidated whether the obesity paradox is still relevant in the current era in patients with ACS. We aimed to examine temporal trends in the clinical outcomes of ACS patients by their BMI status.

Methods

Data from the ACSIS registry including all patients with calculated BMI data between the years 2000–2018. Patients were stratified by BMI groups to underweight, normal, overweight and obese. Clinical endpoints included 30d MACE, and 1-year mortality. Temporal trends were examined in the late (2010–2018) vs. the early period (2000–2008). Multivariable models examined factors associated with clinical outcomes by BMI status.

Results

Among the 13,816 patients from the ACSIS registry with available BMI data, 104 were underweight, 3921 were normal, 6224 were overweight and 3567 were obese. 1-year mortality was highest among underweight patients (24.8%), as compared to normal weight patients (10.7%) and lowest among overweight and obese patients (7.1% and 7.5% respectively; p for trend <0.001) [Figure 1]. 30-day MACE rates were qualitatively similar (24.3% for underweight, 13.6% for normal weight, 11.6% for overweight, and 11.7% for obese; p for trend<0.001). Comparing the 2 time-periods, 30-day MACE was significantly lower in the late period in all BMI groups, excluding patients who were underweight. Similarly, 1-year mortality has not changed during the years in underweight patients, and has decreased in normal weight and obese patients.

Conclusions

In ACS patients, during 2-decades, 30-day MACE and 1-year mortality were lower among overweight and obese patients compared with underweight and normal weight patients. During time, 30-day MACE and 1-year mortality have decreased among the majority of BMI groups, excluding the underweight patients, in which the rates were consistently high. Our findings suggest that the obesity paradox is still relevant in ACS patients in the current era.

Funding Acknowledgement

Type of funding sources: None.
Impact of chronic GLP-1 receptor agonist and SGLT-2 inhibitor therapy on in-hospital outcomes of patients with diabetes mellitus hospitalized with acute myocardial infarction
Authors: Trombara F , Cosentino N , Genovese S , Bonomi A , Ludergnani M , Poggio P , Agostoni P G , Marenzi G
Published: October 2022

Background

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium glucose cotransporter-2 inhibitors (SGLT-2i) demonstrated cardiovascular and renal protection in addition to their glucose-lowering effect. Whether their benefits occur also in patients with diabetes mellitus (DM) during hospitalisation with acute myocardial infarction (AMI) has not been investigated yet.

Purpose

We evaluated in-hospital outcomes of patients hospitalised with AMI according to their chronic use (before hospitalisation) of GLP-1 RA and SGLT-2i therapy.

Methods

Using administrative healthcare databases, we analysed patients hospitalised with a primary diagnosis of AMI from 2010 to 2019 in the Lombardy region, Italy. Patients were stratified according to their DM status, then divided into three cohorts: Group 1 (non-DM patients); Group 2 (DM patients taking GLP-1 RA or SGLT-2i); and Group 3 (DM patients not taking GLP-1 RA and/or SGLT-2i). Patients were matched in a 1:1:1 ratio using a propensity score including all available variables. The primary endpoint of the study was the composite of in-hospital mortality, acute heart failure, and acute kidney injury requiring renal replacement therapy.

Results

We identified 146,800 patients hospitalised with AMI (26% of them with DM). After propensity score matching, 1,030 patients were included in each group. The primary endpoint rate in the overall population was 16% (n=502) and it significantly increased going from Group 1 to Group 3 (13%, 16%, and 20% respectively; p for trend <0.0001). The risk of the composite endpoint significantly increased from Group 1 to Group 3 (P for trend <0.0001). In comparison with Group 2, Group 3 had a significant higher risk of the composite endpoint (OR 1.40 [95% CI 1.11–1.77]).

Conclusions

Our study shows that DM patients hospitalised with AMI and on chronic GLP-1 RA and/or SGLT-2i therapy have a better in-hospital clinical outcome than DM patients without them.

Funding Acknowledgement

Type of funding sources: None.
Development in long-term prognosis of first-time myocardial infarction in relation to use of guideline-recommended treatments: Danish total population cohort study
Authors: Christensen D M , Schjerning A , Smedegaard L , Charlot M , Phelps M , Gerds T , Gislason G , Sehested T S G
Published: October 2022

Background

Evidence from randomized trials during the previous decades have led to several improvements in acute and secondary preventive treatments for myocardial infarction (MI). However, there is a lack of recent knowledge about the implementation of these treatments and how they affected developments in the long-term prognosis of MI.

Purpose

To investigate developments in long-term outcomes after first-time MI and their relation to use of guideline-recommended treatments in a contemporary total population cohort.

Methods

All patients with a first-time MI from 2001 to 2018 were identified through Danish nationwide registries with follow-up through October 6, 2021. The study period was divided into 3-year periods. In each period, the Aalen-Johansen method was used to estimate the absolute 1-year risk for mortality, recurrent MI, heart failure, bleeding hospitalization, and ischemic stroke. The relative frequencies of pharmaceutical treatments and use of coronary procedures were calculated. In each calendar period, the 1-year mortality and recurrent MI risk was standardized to the 2016–2018 distribution of patient characteristics, procedure use, and treatment initiation. Treatment, standardized risks, and recurrent MI risk were evaluated in patients who survived to day 28 post discharge.

Results

In total, 134,884 patients (median age 69 years, 36.5% female) were included and 120,473 survived to day 28 post discharge (median age 68 years, 35.2% female). From 2001–2003 to 2016–2018, the 1-year risks of mortality (23.5% to 12.1%), recurrent MI (6.8% to 3.2%), and ischemic stroke (1.8% to 1.3%) decreased. Risk of heart failure remained relatively stable, whereas the 1-year risk of bleeding hospitalization increased from 2.1% to 3.0%. This pattern remained consistent during very long durations of follow-up (Figure 1). Initiation of statins (58.0% to 86.4%) and adenosine diphosphate receptor inhibitors (42.5% to 85.6%) increased considerably. Use of coronary angiography (37.3% to 84.5%) and percutaneous coronary intervention (24.8% to 63.5%) also increased. There was an attenuated decrease in the standardized 1-year risks of mortality and recurrent MI compared to the observed reference risks: from 8.7% (reference: 11.1%) in 2001–2003 to 6.1% in 2016–2018 for mortality and from 5.6% (reference: 6.8%) in 2001–2003 to 3.1% in 2016–2018 for recurrent MI (Figure 2).

Conclusions

There was a substantial improvement in the long-term risk of mortality and recurrent MI for patients with first-time MI. This improved prognosis was related to an increased use of guideline recommended treatments.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Foundation