bluuebunny/crossref_metadata_2025 huggingface dataset:
Combined impact of residual inflammatory risk and chronic kidney disease on long-term clinical outcomes in patients undergoing percutaneous coronary intervention
Authors: Takahashi N , Dohi T , Funamizu T , Endo H , Wada H , Doi S , Kato Y , Ogita M , Okai I , Iwata H , Okazaki S , Isoda K , Miyauchi K , Shimada K
Published: November 2020

Background

Inflammatory status pre-percutaneous coronary intervention (PCI) and post-PCI has been reported not only associated with poor prognosis, but also to impair renal function. Statins reduce cardiovascular events by lowering lipids and have anti-inflammatory impacts, but residual inflammatory risk (RIR) exists. It remains unclear that the synergistic effect of RIR and chronic kidney disease (CKD) on long-term clinical outcome in stable coronary artery disease (CAD) patients undergoing PCI in statin era.

Aim

The aim of this study was to investigate the long-term combined impact of RIR evaluating hs-CRP at follow-up and CKD among stable CAD patients undergoing PCI in statin era.

Methods

This is a single-center, observational, retrospective cohort study assessing consecutive 2,984 stable CAD patients who underwent first PCI from 2000 to 2016. We analyzed 2,087 patients for whom hs-CRP at follow-up (6–9 months later) was available. High residual inflammatory risk was defined as hs-CRP >0.6 mg/L according to the median value at follow up. Patients were assigned to four groups as Group1 (high RIR and CKD), Group2 (low RIR and CKD), Group3 (high RIR and non-CKD) or Group4 (low RIR and non-CKD). We evaluated all-cause death and major adverse cardiac events (MACE), defined as a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and non-fatal stroke.

Results

Of patients (83% men; mean age 67 years), there were 299 (14.3%) patients in group 1, 201 (9.6%) patients in group 2, 754 (36.1%) patients in group 3, and 833 (39.9%) patients in group 4. The median follow-up period was 5.2 years (IQR, 1.9–9.9 years). In total, 189 (frequency, 16.1%) cases of all-cause death and 128 (11.2%) MACE were identified during follow-up, including 53 (4.6%) CV deaths, 27 (2.4%) MIs and 52 (4.8%) strokes. The rate of all-cause death and MACE in group 1 was significantly higher than other groups (p<0.001, respectively). There was a stepwise increase in the incidence rates of all-cause death and MACE. After adjustment for important covariates, the presence of high RIR and/or CKD were independently associated with higher incidence of MACE and higher all-cause mortality. (shown on figure).

Conclusion

The presence of both high RIR and CKD conferred a synergistic adverse effect on the risk for long-term adverse cardiac events in patients undergoing PCI.

Kaplan-Meier curve

Funding Acknowledgement

Type of funding source: None
Ten-year cardiovascular risk in patients with stable angina pectoris but without coronary artery disease by coronary angiography
Authors: Olesen K.K.W , Botker H.E , Sorensen H.T , Maeng M
Published: November 2020

Background

Patients with stable angina pectoris who do not have obstructive coronary artery disease (CAD) by coronary angiography are presumed to have a continued high cardiovascular risk despite no CAD.

Purpose

We examined the 10-year risk of myocardial infarction (MI), major adverse cardiovascular events (MACE), and death in elective patients with stable angina pectoris, but without CAD by coronary angiography compared to an age and sex matched general population cohort from Western Denmark.

Methods

We performed a cohort study of patients with stable angina pectoris without obstructive CAD by elective CAG examined between 2003 and 2016 in Western Denmark. Patients were compared to an age and sex matched general population comparison cohort without previous MI or coronary revascularization. Outcomes were MI, MACE (a composite of MI, ischemic stroke, and cardiac death), and death. Maximum follow-up was 10 years. Adjusted incidence rate ratios (IRRs) were computed using conditional Poisson regression. We also did a stratified analysis by sex and levels of comorbidity.

Results

A total of 18,491 patients suspected of angina pectoris without obstructive CAD, and 92,387 individuals from the general population were included in the study. Median follow-up was 8.6 years. Patients with chest pain but without CAD had reduced risk of MI (adjusted IRR 0.59, 95% CI 0.50–0.70, Figure), MACE (adjusted IRR 0.64, 95% CI 0.57–0.80), and death (adjusted IRR 0.62, 95% CI 0.59–0.67) compared to the general population when adjusting for potential confounders. Results were consistent when stratifying by sex and levels of comorbidity.

Conclusions

Absence of angiographic obstructive CAD in patients with symptoms of stable angina pectoris was associated with favorable low 10-year cardiovascular risk and mortality compared to the general population without known coronary status.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital
Prognostic value of age-adjusted d-dimer cutoff thresholds in patients with myocardial infarction treated by percutaneous coronary intervention
Authors: Chen R , Liu C , Zhou P , Tan Y , Sheng Z , Li J , Zhou J , Chen Y , Song L , Zhao H , Yan H
Published: November 2020

Introduction

The association between D-dimer and outcomes of patients with myocardial infarction (MI) remains controversial. Using age-adjusted D-dimer cutoff thresholds significantly improves the accuracy of diagnosis for thrombotic diseases. This study aimed to investigate the prognostic value of age-adjusted D-dimer in MI patients treated by percutaneous coronary intervention (PCI).

Methods

In this observational study, 3614 consecutive patients with MI treated by PCI were retrospectively recruited. The baseline age-adjusted D-dimer threshold was 500 ng/mL, and was calculated as age × 10 in patients older than 50 years. Cox regression was used for outcome analysis. The primary outcome was all-cause death. Discrimination and reclassification were calculated to assess the additional prognostic value of D-dimer when combined with established clinical risk factors and the Global Registry of Acute Coronary Events (GRACE) risk score.

Results

During a median follow-up of 652 days, a total of 194 deaths occurred. High D-dimer level, as defined by age-adjusted thresholds, was an independent predictor for all-cause death (hazard ratio:1.67, 95% confidence interval: 1.23–2.27, P=0.001). Addition of D-dimer level (high or low) significantly improved risk classification for death when combined with established clinical risk factors (net reclassification index [NRI]: 0.601, P<0.001; integrated discrimination improvement [IDI]: 0.011, P=0.046) and GRACE score (NRI: 0.618, P<0.001; IDI: 0.015, P=0.011).

Conclusions

In patients with MI treated by PCI, D-dimer elevation defined by age-adjusted thresholds was an independent predictor for adverse outcomes, and provided additional prognostic value when combined with clinical risk factors and GRACE score.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Chinese Academy of Medical Sciences
Impact of chronic total occlusion in non-culprit vessels on long-term survival of patients with acute myocardial infarction
Authors: Nakazato K , Ando T , Kiko T , Shimizu T , Oikawa M , Yamaki T , Kunii H , Yoshihisa A , Takeishi Y
Published: November 2020

Background

Around 10% of patients with acute myocardial infarction (AMI) have chronic total occlusion (CTO) in non-infarct-related vessels, and they are known to be associated with higher mortality in acute phase. However, its impact on long-term prognosis after discharge remains unclear.

Purpose

The purpose of this study was to investigate the influence of presenting CTO lesion on long-term prognosis in patients with AMI.

Method

Consecutive 552 patients with AMI (male 78.3%, age 68±13 years), who had been discharged alive from our hospital, were analyzed. We divided the patients into two groups based on whether they had CTO lesion in a non-infarct-related artery or not: CTO + (n=49) and CTO - (n=503).

Results

Kaplan-Meier analysis (mean follow-up 1,424 days) revealed that all-cause mortality was significantly higher in CTO + group than in CTO - group (Figure, P<0.001). Cox hazard ratio was 2.740, indicating a higher risk of all-cause death in the CTO + group (95% CI 1.606–4.651, P<0.001).

Conclusion

Concurrent coronary CTO lesions in non-culprit arteries were associated with increased long-term mortality in patients with AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None
Occurrence and clinical course of peri-stent contrast staining: comparison between second-generation drug-eluting stents and third generation drug-eluting stents
Authors: Mori S , Ito Y , Kishida T , Fukagawa T , Nakano T , Makino K , Mizusawa M , Shirai S , Honda Y , Tsutsumi M , Sakamoto Y , Kobayashi N , Araki M , Yamawaki M , Hirano K
Published: November 2020

Background

Peri-stent contrast staining (PSS) has been reported to be associated with very late stent thrombosis.

The aims of this study was to compare the occurrence rate of PSS between second generation drug-eluting stents (2nd DES) and third generation drug-eluting stents (3rd DES), and to identify clinical characteristics associated with PSS.

Methods and results

This study comprised 1899 patients with 2493 de novo lesions treated with 2nd or 3rd DES from October 2015 to September 2018. Follow-up angiography was available for 1883 lesions (75.5%). There were 725 patients with 968 lesions treated with 2nd DES, and 716 patients with 915 lesions treated with 3rd DES. The occurrence of PSS, types of PSS, and VLST related to PSS were compared between 2nd and 3rd DES implantation. Mean follow-up period was 30±12 months. The occurrence rate of PSS and segmental type of PSS were similar between two groups (2nd DES vs. 3rd DES, 1.5% vs. 1.7%, p=0.73, 47% vs. 50%, p=0.85, and respectively). The VLST related to PSS occurred in only one case in 3rd DES group. (0% vs. 6.3%, p=0.33).

Conclusion

The occurrence rate of PSS and clinical course were similar between 2nd and 3rd DES.

Funding Acknowledgement

Type of funding source: None
High parathormone levels are associated with adverse cardiovascular events in coronary patients with high fibroblast growth factor-23
Authors: Gutierrez C , Acena A , Pello A , Martinez-Milla J , Gonzalez-Lorenzo O , Tarin N , Cristobal C , Huelmos A , Lopez-Castillo M , Alonso J , Gonzalez-Parra E , Egido J , Mahillo-Fernandez I , Lorenzo O , Tunon J
Published: November 2020

Background

Disturbances of the components of the mineral metabolism (MM) (vitamin D, phosphate, parathormone [PTH], fibroblast growth factor-23 [FGF23] and klotho) have been linked to cardiovascular disease. However, the available data are controversial, probably because most studies deal with individual rather than with the whole MM components.

Purpose

To the study the relationship between MM components and cardiovascular events, after controlling for other well-known markers (N-Terminal pro-brain natriuretic peptide [NT-proBNP], high-sensitivity troponin I [hs-TnI], and high-sensitivity c-reactive protein [hs-CRP]), and relevant clinical variables in stable coronary artery disease (CAD) patients.

Methods

We analyzed the aforementioned markers in 964 CAD patients and followed them subsequently. The primary outcome (PO) was the composite of ischemic events (acute coronary syndrome, stroke or transient ischemic attack), heart failure and death. Secondary outcomes were any ischemic event and the composite of heart failure and death.

Results

Median follow-up was 5.39 years (2.81 - 6.92). Age was 60 (52–72) years and 76.2% patients were male. Median glomerular filtration rate was 80.4 (65.3–93.1) ml/min/1.73 m2. 185 patients developed the PO.

At the univariate analysis PTH, FGF23, NT-proBNP and hs-TnI were directly associated with the PO, while calcidiol and Klotho were inversely related, and phosphate did not reach statistical significance. However, only PTH (HR 1.058 [CI 1.021–1.097]; p=0.002) and NT-proBNP (HR 1.020 [CI 1.012–1.028]; p<0.001) were independent predictors of the PO at multivariate Cox regression analysis. Both PTH and NT-proBNP were also independent predictors of HF or death (HR 1.066 [1.016 - 1.119]; p=0.009 and HR 1.024 [1.014 - 1.034]; p<0.001 respectively), while only PTH predicted ischemic events (HR 1.052 [1.010–1.096]; p=0.016).

After dividing patients in two subgroups according to whether they had FGF23 plasma levels above the median (85.5 RU/ml) or not, PTH remained as a predictor of the PO only in the subgroup with FGF23 >85.5 RU/ml (p<0.001), but not in patients with FGF23 ≤85.5 RU/ml (p=0.551). There was a significant interaction between FGF23 and PTH plasma levels (p=0.002).

Conclusion

PTH predicts cardiovascular events in CAD patients with elevated FGF23 levels even after taking into account all the other components of MM and controlling for NT-ProBNP, hs-CPR and TnI. There is an interaction between PTH and FGF23 levels, and they should be assessed together when exploring their potential predictive power.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Fondo de Investigaciones Sanitarias
Higher BNP/NT-proBNP levels stratify prognosis in patients with coronary artery disease but without heart failure
Authors: Hendricks S , Dykun I , Balcer B , Al-Rashid F , Luedike P , Totzeck M , Rassaf T , Mahabadi A.A
Published: November 2020

Background

Natriuretic peptides (BNP/NT-proBNP) are routinely used for the diagnosis of heart failure and predicts outcome in patients with both heart failure with preserved and reduced ejection fraction. In addition, natriuretic peptides are associated with incident cardiovascular disease manifestation in primary prevention cohorts. Whether the assessment of BNP/NT-proBNP is of value in patients with coronary artery disease but without heart failure has not been investigated in detail. We here evaluate the association of BNP/NT-pro BNP with mortality patients with coronary artery disease but without known chronic heart failure.

Methods

The present analysis is based on the ECAD registry of patients undergoing conventional coronary angiography at the Department of Cardiology and Vascular Medicine between 2004 and 2019. For this analysis, we excluded all patients with a diagnosis of heart failure or with elevated BNP/NT-proBNP values at baseline (>100pg/nl for BNP, >400pg/nl for NTproBNP). Moreover, patients with missing follow-up information or without BNP/NT-proBNP levels at admission were excluded. As either BNP or NT-proBNP was available for singular patients, we standardized BNP and NT pro BNP levels based on percentile rank in levels from 0 to 99. Cox regression analysis was used to determine the association of BNP/NT-proBNP with morality in unadjusted and risk factor adjusted models with effect sizes depicted per one standard deviation change in BNP/NT-proBNP rank.

Results

Overall, 3738 patients (mean age: 62.8±12.6 years, 71% male) were included in our analysis. During a mean follow-up of 2.6±3.5 years, 172 deaths of any cause occurred. Patients without fatal events had significantly lower BNP/NT-prBNP values compared to patients who died (48.4±28.8 vs. 58.4±27.5, p<0.0001). In unadjusted cox regression analysis, BNP/NT-proBNP increase by one standard deviation was associated with a 47% increased risk of morality (HR (95% CI): 1.47 (1.25–1.72), p<0.0001). Upon adjustment for cardiovascular risk factors, the significant link between BNP/NT-proBNP levels and morality remained (HR (95% CI): 1.38 (1.14–1.66). Effect sizes were similar for patients receiving coronary revascularization therapy as part of the coronary angiography (1.32 [1.03–1.70], p=0.03) as well as for patients with purely diagnostic procedures (1.58 [1.28–1.94], p<0.0001).

Conclusion

In patients without heart failure undergoing coronary angiography, BNP/NT-proBNP levels stratify mortality risk independently of traditional cardiovascular risk factors. Our results support the routine assessment of natriuretic peptides also in patients without heart failure to identify patients at increased risk.

Funding Acknowledgement

Type of funding source: None
Prognostic impact of initial serum albumin for newly developing heart failure after acute myocardial infarction
Authors: Shinzato K , Yoshioka G , Watanabe N , Shibata Y , Node K
Published: November 2020

Background/Introduction

Previous studies have shown that poor nutritional status relate to the clinical outcomes in patients with heart failure (HF). However, relationships between initial serum albumin and newly developing HF after acute myocardial infarction (AMI) remain unclear.

Methods

We evaluated 2289 consecutive patients with AMI in our hospital. Primary outcome was HF hospitalization after AMI. We analyzed the predictive impact of initial serum albumin using multivariate analysis, both in all AMI patients and subgroup of AMI patient without known risk factors of HF (LMT, peak CK >8000, eGFR <30, and LVEF <35%).

Result

In the remote-phase(median follow-up: 754 days), 5.4% of all AMI patients were hospitalized due to HF. Multivariate analysis showed that low albumin (<4.0g/dl) was an independent predictor of HF hospitalization after AMI in all patients, as well as other known risk factors. Interestingly, low albumin still showed the predictive value even in the no-HF risk subgroup. Kaplan-meier curve of no-HF risk group is shown in the Figure.

Conclusions

Low initial albumin level would be an useful predictor of newly developing HF in the remote-phase after AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None
The effect of obstructive sleep apnoea on timing of acute coronary syndrome
Authors: Muhmad Hamidi M.H , Sani H , Ibrahim M.A , Ibrahim K.S , Md Radzi A.B , Raja Shariff R.E , Najme Khir R , Ismail A.I , Kassim S
Published: November 2020

Background and objective

Acute coronary syndrome (ACS) remains the principal cause of death in Malaysia. It is estimated about 20% of ACS occurs at nighttime during sleep between 12am to 6am. Factors associated with nocturnal ACS are unknown. Acute nocturnal pathophysiological response to obstructive sleep apnea (OSA) may increase risk of nocturnal ACS. We hypothesized that OSA risk is associated with timing of ACS onset.

Methodology

This study included 200 patients with ACS who underwent coronary angiogram for which the time of chest pain onset was clearly identified and divided into 2 groups; nocturnal ACS (12am-5.59am) and non-nocturnal ACS (6am–11.59pm). Two validated questionnaires, STOP-BANG and Epworth Sleepiness Scale (ESS) were self-administered by subjects to determine OSA risk. All subjects timing of ACS onset, OSA risk, demography, anthropometric measurements, comorbidities and echocardiographic characteristics were analyzed.

Results

Acute coronary syndrome occurs nocturnally in 19% of ACS patients. The prevalence of high risk OSA individuals among ACS patients is 43%. There is significantly higher prevalence of high risk OSA individuals in nocturnal ACS group of 95% compared to 30% of high risk OSA individuals in non-nocturnal ACS group (p=0.001). Nocturnal ACS patients was significantly younger (50.1±8.7yrs, p=0.001), had higher BMI (33.9±4.3kg/m2, p=0.005), waist circumference (106.7±10.3cm, p=0.003) and larger neck circumference (44.6±3.3cm, p=0.001) compared to non-nocturnal ACS group. These groups had similar prevalence of other comorbidities for ACS and showed no significant difference between left and right ventricular systolic function. In multiple logistic regression analysis, the most significant predictors for nocturnal ACS are OSA risk, neck circumference and age.

Conclusion

There is a strong association between high risk OSA individuals and nocturnal ACS onset. Patient with nocturnal ACS onset should be screened for OSA and prioritized for polysomnography.

OSA prevalence according to ACS onset

Funding Acknowledgement

Type of funding source: None
Effect of plaque characteristics on ischemia by invasive fractional flow reserve in nonobstructive versus obstructive coronary artery disease: results from the CREDENCE trial
Authors: Gianni U , Van Den Hoogen I.J , Van Rosendael A.R , Bax A.M , Tantawy S.W , Chang H.J , Genereux P , Pontone G , Berman D.S , Narula J , Knaapen P , Lin F.Y , Min J.K , Bax J.J , Shaw L.J
Published: November 2020

Background

Mismatches between the severity of coronary stenosis and the presence of ischemia by invasive fractional flow reserve (FFR) are frequently reported.

Purpose

To investigate whether plaque characteristics as evaluated with coronary computed tomography angiography (CCTA) may explain this discordance in nonobstructive versus obstructive coronary artery disease (CAD).

Methods

From the CREDENCE trial, 612 patients with suspected CAD at 13 sites (64±10 years, 70% men) underwent CCTA with semi-automated whole heart quantification and invasive coronary angiography with 3-vessel FFR measurements. Obstructive CAD was visually defined as ≥50% stenosis. The primary endpoint of coronary vessel-specific ischemia was defined as FFR ≤0.80. Generalized estimating equations were calculated to evaluate the effect of plaque characteristics on coronary vessel-specific ischemia. Interactions were tested by obstructive CAD, adjusted for age.

Results

Among 1,686 vessels, ischemia was present in 436 (26%) vessels. In both nonobstructive and obstructive CAD, the majority of plaque characteristics were associated with coronary vessel-specific ischemia (p≤0.005, Figure 1). In nonobstructive CAD, odds for ischemia were significantly higher for total percent atheroma volume (PAV, p<0.001), calcified PAV (p<0.001), noncalcified PAV <350 and <130 HU (p≤0.043), the number of lesions at a bifurcation (p=0.009) and the number of lesions with high-risk plaque (HRP, p=0.033) when compared with obstructive CAD.

Conclusion

Our findings reveal that ischemia by FFR is documented in the setting of both nonobstructive and obstructive CAD on CCTA. Detection of atherosclerotic plaque characteristics associated with ischemia can potentially improve diagnostic certainty and guide management of symptomatic patients with nonobstructive CAD.

Figure 1. Odds ratios for ischemia.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health - National Heart, Lung, and Blood Institute
Prognostic value of unrecognized myocardial infarction and hyperemic coronary sinus flow in patients undergoing elective percutaneous coronary intervention
Authors: Nogami K , Kanaji Y , Sugiyama T , Hoshino M , Yamaguchi M , Hada M , Sumino Y , Misawa T , Hirano H , Ueno H , Kakuta T
Published: November 2020

Background

Cardiac magnetic resonance (CMR) imaging is a useful instrument for the assessment of pathological and functional conditions without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Both unrecognized myocardial infarction (UMI) and impaired global myocardial blood flow (g-MBF) have been reported to be strongly associated with worse outcome in patients with cardiovascular disease. However, their combined efficacy remains undetermined.

Purpose

We sought to assess the prognostic value of the presence of UMI and pre-procedural hyperemic g-MBF evaluated by phase-contrast cine magnetic resonance imaging (PC-CMR) in patients with chronic coronary syndrome who underwent elective percutaneous coronary intervention (PCI).

Methods

A total of 177 patients with de novo functionally significant stenosis who underwent pre-PCI CMR and PCI between September, 2016 and March, 2019 were retrospectively studied. UMI was defined as a scar detected by late gadolinium enhancement (LGE) without previously diagnosed MI. g-MBF was assessed by quantifying coronary sinus flow using PC-CMR at rest and hyperemic state. The predictors of major adverse cardiac events (MACE; cardiac death, nonfatal myocardial infarction, clinically driven unplanned revascularization, or hospitalization for congestive heart failure) during follow-up were investigated.

Results

UMI was detected in 40 (27.7%) patients and rest and maximal hyperemic g-MBF evaluated by the coronary sinus flow obtained by PC-CMR were 0.95 ml/min/g and 2.26 ml/min/g, respectively. During the median follow-up of 26 months, cardiovascular death occurred in 1 patient (0.6%), nonfatal myocardial infarction occurred in 4 patients (2.3%), and clinically driven revascularization and hospitalization due to congestive heart failure occurred in 25 patients (14.1%) and 3 patients (1.7%) patients, respectively. In patients with MACE, hyperemic g-MBF was significantly lower and the prevalence of UMI were significantly higher compared with those without MACE (1.94 ml/min/g vs 2.36 ml/min/g P=0.014; 48.3% vs 23.6%, P=0.011). Cox proportional hazards model indicated that impaired hyperemic g-MBF (<2.00 ml/min/g) and the presence of UMI were significant predictors of MACE (HR 2.22, 95% CI 1.060–4.640, P=0.034; HR 2.660, 95% CI 1.290–5.470, P=0.008). During follow-up, cardiac event-free survival was significantly worse in patients with impaired hyperemic g-MBF (<2.00 ml/min/g) and UMI (log-rank χ2=11.0, P=0.010).

Conclusion

In patients with chronic coronary syndrome undergoing elective PCI, the combined assessment of UMI and hyperemic g-MBF obtained by preprocedural noninvasive CMR may provide significant prognostic information.

Funding Acknowledgement

Type of funding source: None
Diagnostic accuracy of left ventricular diastolic transverse strain imaging by speckle tracking echocardiography for diagnosing chest pain in diabetic patients
Authors: Ishii K , Yoshikawa Y , Hyodo E , Seo Y , Ishizu T , Kihara H , Daimon M , Tanaka A , Watanabe H , Akasaka T , Ito H , Yoshikawa J
Published: November 2020

Background

Two-dimensional speckle tracking echocardiography (2D-STE) has been reported to be useful for the diagnosis of myocardial ischemia by detecting delayed relaxation (diastolic stunning) after an episode of angina. 2D-longitudinal strain is not specific besides ischemia such as diastolic dysfunction, and diabetes have been associated with abnormal longitudinal fibers. The aim is to evaluate the diagnostic accuracy of Left ventricular (LV) diastolic transverse strain imaging by STE to detect the presence of acute coronary syndrome (ACS) in diabetic patients with acute chest pain.

Methods

385 consecutive patients with acute chest pain and without wall motion abnormality, who were admitted to an emergency department (ED) at 1 of 12 clinical sites in Japan, were enrolled and underwent 2D-STE at ED. Left ventricular (LV) transverse strain values at aortic valve closure (A) and one-third of diastole duration (B) were measured. The strain imaging diastolic index (SI-DI) was value was determined as: (A − B)/A × 100% to assess the LV diastolic strain imaging and was used to identify the regional LV delayed relaxation. All patients underwent coronary CT or coronary angiography to establish the diagnosis of ACS. Clinicians were blinded to the 2D-STE results.

Results

Out of 385 patients, 2D-STE analysis was possible in 365 patients (94%). 76 patients were diabetic (DM+), and 289 patients were non-diabetic (DM-). With assessment of coronary CT or coronary angiography, ACS was diagnosed in 125 patients (34%). 2D-STE was obtained at a mean of 5.3 hours after chest pain episode. Transverse SI-DI of ischemic segments were significantly lower than those of non-ischemic segments (p value <0.001) in both diabetic and non-diabetic patients, and transverse SI-DI of both diabetic and non-diabetic patients demonstrated high area under curve (AUC) for detection of myocardial ischemia (Figure: RCA; right coronary artery, LAD; left anterior descending artery, LCX; left circumferencial artery). In diabetic patients, sensitivity, specificity, and negative predictive value for ACS of transverse SI-DI are 100%, 95%, 100% in RCA (a cut-off value of 36.2), and 86.4%, 95%, 93% in LAD (a cut-off value of 50.2), and 75%, 85%, 94% in LCX (a cut-off value of 52), respectively.

Conclusion

LV diastolic transverse strain imaging by 2D-STE at ED increase the sensitivity, specificity and accuracy to predict the presence of ACS in diabetic patients with chest pain, as well as non-diabetic patients. (UMIN000013859).

Figure 1. Transverse Strain (SI-DI): AUC (95% CI)

Funding Acknowledgement

Type of funding source: None
The clinical impact of serum sLOX-1 level in coronary artery disease patients as inferred from its implication in the in vitro protective effects of metoprolol against hypoxic injury of HUVECs
Authors: Ali Sheikh M.S , Alduraywish A , Almaeen A , Salma U , Fei L , Ke X , Yang T
Published: November 2020

Background

Ischemic coronary artery disease (CAD) is a major public health problem across the world. Early detection and appropriate management significantly reduced CAD-induced morbidities and death. Endothelial cells are pathogenically implicated.

Purpose

Our study was designed to investigate the role of the soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) in the in vitro protective effect of Metoprolol against hypoxia-induced injury of Human umbilical vein endothelial cells (HUVECs). Secondly, the clinical significance of variations in serum levels of sLOX-1 in patients with CAD was assessed.

Methods

In vitro, hypoxic injury model of HUVECs was established in an atmosphere of 1% O2, 95% N2, and 5% CO2 for 24 hours. The protective effect and mechanism of action of the cardio-selective beta-blocker Metoprolol at 10–6 μM concentration was investigated.

Consented stable atherosclerotic CAD (n=150) and unstable angina pectoris patients (n=75) along with 150 healthy volunteer subjects were voluntarily enrolled in this ethically approved study. Invasive coronary angiogram with ≥50% stenosis at least in one major coronary artery was used for diagnosis. ESC/ACC/AHC/practical protocols were used for categorizing patients into stable or unstable CAD. Serum sLOX-1 level was measured using specific ELISA kit. The diagnostic significance of serum sLOX-1 levels was assessed by analyzing its area under the curve (AUC).

Results

In vitro hypoxic conditions induced high rate of cellular apoptosis, high levels of LOX-1 expression, reactive oxygen species (ROS) generation and LDH release from HUVECs after 24 hours incubation, compared to normoxic control cells. Metoprolol significantly decreased LOX-1 levels, and prevented the release of LDH and generation of ROS. This culminated into marked improvement in cellular viability of hypoxia-exposed HUVECs (p<0.001).

Compared to healthy subjects, serum levels of sLOX-1s were significantly elevated in atherosclerotic stable and unstable CAD patients (p<0.001). Serum sLOX-1 levels were increased by 4.21 folds in stable CAD patients and by 6.373 folds in atherosclerotic unstable angina patients vs. healthy participants. Moreover, the levels in the two patients' groups were significantly different (p<0.001). In stable angina CAD patients, sLOX-1 AUC = 0.929; and in unstable CAD patients, AUC = 0.944, indicating that serum sLOX-1 levels clearly differentiated patients from healthy participants with high specificity and sensitivity.

Conclusions

Extrapolated from HUVECs hypoxia-induced injury model and the protective effect of Metoprolol, elevation of the circulating levels of sLOX-1 correlated with increased risks for atherosclerotic CAD and is a highly sensitive and specific biomarker for early detection of the disease.

Funding Acknowledgement

Type of funding source: None
Spontaneous coronary artery dissection: insights from intravascular ultrasound
Authors: Ciurica E.S , Jackson R , Premawardhana D , Persu A , Adlam D
Published: November 2020

Introduction

Spontaneous Coronary Artery Dissection (SCAD) may be at the origin of up to 25% of acute coronary events in women <50 yo with no or few risk factors. The diagnosis of SCAD is challenging and in some cases it may be ascertained only by intracoronary imaging such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS is widely available and has a better depth penetration compared to OCT, showing the extent of the false lumen and the aspect of the adventitia but its lower resolution does not always allow the visualization of smaller structures such as fenestrations. In a previous study we investigated the role of OCT in understanding the pathophysiology of SCAD and we reported a number of OCT complications. It is not known if these also apply to IVUS but since IVUS does not require additional contrast injection, the risk of false lumen (FL) propagation should be lower.

Aim of the study

To analyze the value of IVUS in the assessment of key features of SCAD and to explore the feasibility of three-dimensional (3D) reconstruction using IVUS imaging.

Methods

We collated the imaging findings of 15 cases of SCAD for which IVUS was used as part of routine clinical care. Images were assessed to determine the visualisation of the true lumen, the false lumen extent and its contents, the intima-media membrane, the presence of fenestrations, the external elastic lamina and underlying adventitia. Furthermore, we performed a 3D reconstruction of a type 2a dissection of the right coronary artery. The IVUS images were exported in DICOM format. The segmentation of the true and false lumens in the regions of interest was manually done using the ImageJ software. Subsequent images were processed using 3D Slicer and Paraview in order to obtain the 3D reconstruction of the dissected segment.

Results

The false lumen was entirely visible in 13/15 cases (87%) and the external elastic lamina in 12/15 cases (80%). In 3/15 cases (20%) the dissection was circumferential. The false lumen content had lower echogenicity compared to the surrounding tissue in all 15 cases. There was no visible fenestration. The 3D reconstruction (Figure 1) showed that the false lumen was larger than the true lumen. The general cross-sectional appearance was that of a “horseshoe” dissection but there was also a short segment of circumferential dissection and the intima-media membrane looked thickened.

Conclusion

Despite its resolution being lower than OCT, IVUS has a deep penetration and provides adequate imaging of the key features of SCAD.

Perspectives

We plan to further expand these findings in a larger series, intending to better characterize the false lumen and the adventitia in SCAD.

IVUS findings in SCAD, 3D reconstruction

Funding Acknowledgement

Type of funding source: None
Clinical outcomes of patients with diffuse coronary artery disease following physiology-guided treatment strategy: insights from AJIP registry
Authors: Warisawa T , Cook C.M , Howard J.P , Nour D , Doi S , Nakayama M , Uetani T , Yamanaka F , Kikuta Y , Shiono Y , Nishina H , Matsuo H , Escaned J , Akashi Y.J , Davies J.E
Published: November 2020

Background

Physiology-guided treatment strategy improves clinical outcomes of patients with coronary artery disease. However, it has not been fully evaluated whether such guideline-based strategy is useful for patients with diffuse coronary artery disease as well, which is known to be one of the major factors affecting morbidity and mortality.

Purpose

The aim of this study was to clarify clinical outcomes of patients with diffuse coronary artery disease whose treatment strategy was based on coronary physiology.

Methods

From an international multicentre registry of iFR-pullback, consecutive 1067 patients (1185 vessels) with stable angina were included in whom coronary lesions were deferred or revascularized according to the iFR cutoff: 0.89. The physiological pattern of disease was classified according to the iFR-pullback recording as predominantly physiologically diffuse (n=463) or predominantly physiologically focal (n=722). Major adverse cardiovascular events (MACEs), defined as a composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization during follow-up period, were compared between diffuse and focal groups, in both deferred and revascularized groups, respectively.

Results

Mean age was 67.1±10.7 years and 75.8% of patients were men. Median iFR was 0.88 (interquartile range: 0.80 to 0.92). At a median follow-up period of 18 months, no significant differences in MACEs were found between diffuse and focal groups, in both iFR-based deferred and revascularized groups. In the deferred group (n=480), MACEs occurred in 6.9% patients (15/217) in the diffuse group and 8.0% patients (21/263) in the focal group (p=0.44). In the revascularized group (n=705), MACEs occurred in 8.9% patients (22/246) in the diffuse group and 7.2% patients (33/459) in the focal group (p=0.49).

Conclusions

Despite potentially higher risks in patients with diffuse coronary artery disease, clinical outcomes of those patients were comparable to those of patients without diffuse disease, as long as treatment strategy was based on the physiology guidance, which is globally recommended by international guidelines.

Funding Acknowledgement

Type of funding source: None
Impact of high-density lipoprotein levels in males and females undergoing percutaneous coronary intervention with drug eluting stents
Authors: Roumeliotis A , Mehran R , Claessen B , Sartori S , Cao D , Chandiramani R , Nicolas J , Goel R , Reisman A , Baber U , Sweeny J , Barman N , Dangas G , Sharma S , Kini A
Published: November 2020

Background/Introduction

Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in multiple epidemiological studies. Evidence regarding the role of HDL in males and females with established coronary artery disease undergoing percutaneous coronary intervention (PCI) with drug eluting stents (DES) is scarce.

Purpose

We sought to investigate the impact of low HDL levels on 1-year cardiovascular outcomes in males and females undergoing PCI with DES.

Methods

We screened all patients undergoing PCI in our center from 2012 to 2017. Exclusion criteria were: unavailable baseline HDL measurement, age <18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, coexisting neoplastic disease and treatment without a stent or with a bare metal stent. The final population was divided by gender and further stratified to the high or low HDL group according to baseline HDL levels. Cut-offs were 40mg/dL in males and 50mg/dL in females, per the most recent ACC/AHA guideline recommendations. The primary endpoint of the analysis was major adverse cardiovascular events (MACE) at 1 year, defined as death, MI or target vessel revascularization (TVR). To account for potential clinical and anatomical confounders the outcomes were also adjusted for age, Caucasian ethnicity, hypertension, diabetes mellitus (DM), body mass index, smoking, prior MI, multi-vessel disease and type B2/C lesions.

Results

Out of the 10,843 patients included, 7,718 (71.2%) were male and 3,125 (28.8%) were female. Low HDL was noted in 58.5% of males and 63.8% of females. Patients with low HDL were younger and had a higher prevalence of DM, prior MI, smoking and multi-vessel disease. When comparing low to high HDL groups in terms of 1-year MACE a borderline significant difference was shown in males (7.4% vs. 6.0%; p-value=0.08) but not in females (7.7% vs 8.1%; p-value=0.90) [Panel A]. The numerically higher incidence of MACE in males with low HDL was primarily driven by TVR (5.4% vs 3.7%; p-value=0.005) while the rates of Death (1.4% vs. 1.3%; p=0.96) and MI (2.0% vs. 1.8%; p-value=0.89) were similar between the two groups. After adjustment the male low HDL subgroup remained at a higher risk for 1-year TVR but not 1-year MACE compared to the male high HDL subgroup [Panel B]. No difference for any individual component of MACE was shown between low and high HDL subgroups in females [Panel C].

Conclusion(s)

High HDL levels were associated with a lower incidence of TVR and borderline reduction of MACE in male but not female patients undergoing PCI with DES. No difference was demonstrated in terms of death or MI between the high and low HDL subgroups at 1-year follow-up.

Impact of HDL levels according to gender

Funding Acknowledgement

Type of funding source: None
Muse cells, endogenous reparative pluripotent stem cells, are mobilized into the peripheral blood after percutaneous coronary intervention in patients with coronary artery disease
Authors: Satake A , Yasuda S , Murase H , Yoshizumi R , Komaki H , Baba S , Kubota T , Ojio S , Nishigaki K , Minatoguchi S , Tanaka T , Okura H , Minatoguchi S
Published: November 2020

Background

Multilineage-differentiating stress enduring (Muse) cells, endogenous reparative pluripotent stem cells, are defined as stage-specific embryonic antigen 3+ (SSEA3+) and CD105+ double-positive cells. We previously reported that intravenously injected Muse cells home to the damaged heart and differentiate into cardiomyocytes and vessels, and reduce the infarct size and improve cardiac function in a rabbit model of acute myocardial infarction (AMI) (Circ Res 2018), and that endogenous Muse cells are mobilized into the peripheral blood in the acute phase of patients with AMI, which improve left ventricular (LV) function and attenuate LV remodeling in the chronic phase at 6 months (Circ J 2018). However, whether Muse cells are mobilized into the peripheral blood after percutaneous coronary intervention (PCI) in patients with coronary artery disease.

Methods

Muse cells in the peripheral blood was measured by fluorescence-activated cell sorting (FACS) as SSEA3+ and CD105+ double-positive cells in patients with coronary artery disease with 75% coronary stenosis who underwent PCI (n=18) with a mean age of 73.0±7.2 (14 male and 4 female). Blood samples were collected from the antecubital vein in patients with coronary artery disease before, and 1 and 24 h after PCI. Since the majority of Muse cells were detected in the monocyte area and few Muse cells if any were detected in the lymphocyte area, we counted the Muse cells in the monocyte area by FACS. The number of Muse cells was expressed as cells per 100 μL of blood, as follows: absolute number of Muse cells (/100 μL) = white blood cells (/100 μL) × monocytes (%) × SSEA3+/CD105+ double-positive cells (%).

Results

Typical case of SSEA3+/CD105+ double-positive Muse cells measured by FACS shows that majority of Muse cells exist in the monocyte area (Fig, 1-A). The number of Muse cells in the peripheral blood was significantly greater (p<0.05) at 1 h (58.6±23.8 /100 μL) or 24 h after PCI (69.7±43.1/100 μL) as compared with that before PCI (46.3±19.0/100 μL) (Fig. 1-B).

Conclusion

Muse cells, endogenous pluripotent stem cells, are mobilized into the peripheral circulating blood 1 h and 24 h after PCI in patients with coronary artery disease. Mobilized Muse cells after PCI might be contributing to repair the damaged coronary artery.

Figure 1

Funding Acknowledgement

Type of funding source: None
Effects of targeted hydration on risk of major adverse renal and cardiac events: a systematic review and meta-analysis of randomized controlled trials
Authors: Guo Z , Lei L , Liu J , Song F , He Y , Chen S , Sun G , Liu B , Liu L , Chen G , Xue Y , Huang H , Liu Y , Tan N , Chen J
Published: November 2020

Background

Inconsistent results have been published that have evaluated the preventive effect of targeted hydration in major adverse renal and cardiac events among patients exposed to contrast agents.

Methods

Online databases were searched up to October, 2019, for randomized controlled trials (RCTs). The primary outcome was the incidence of contrast-induced acute kidney injury (CI-AKI), and the secondary outcomes were all-cause in-hospital mortality, all-cause long-term mortality, requirement for dialysis, acute pulmonary edema and stroke/transient ischemic attack (TIA).

Results

9 high quality trials were identified including 2424 patients. Overall, compared with general hydration, targeted hydration significantly reduced the incidence of CI-AKI by 58% (RR 0.42; 95% CI: 0.33–0.54, p<0.01), the requirement for dialysis by 68% (RR 0.32, 95% CI: 0.17–0.62, p<0.01) and the all-cause long-term mortality by 55% (RR 0.45; 95% CI: 0.26–0.76, p<0.01). The effect on all-cause in-hospital mortality was not statistically significant. The effect on acute pulmonary edema and stroke/TIA also showed no difference between two groups (RR: 0.54, 95% CI: 0.28–1.03, p=0.18; RR: 0.61, 95% CI: 0.14–2.61, p=0.49, respectively). Trial sequential analysis confirmed that an additional 3900 study participants would need to be recruited to demonstrate a statistically significant improvement for all-cause in-hospital mortality.

Conclusions

Targeted hydration likely reduces the incidence of CI-AKI, dialysis and all-cause long-term mortality in patients exposed to contrast agents. However, further independent high-quality RCTs should elucidate the effectiveness and safety of this prophylactic strategy in interventional cardiology.

Funding Acknowledgement

Type of funding source: None
Combination of fondaparinux with radial access is associated with low rates of in-hospital MACE and major bleeding events in patients with acute coronary syndrome
Authors: Santos Pereira Ramos J.V , Fonteles Ritt L , Sahade Darze E , Viana M.A , Oliveira M.C , Borges De Oliveira Q , Martins De Oliveira A , Lima Freitas E , Delacio Lopes R
Published: November 2020

Background

Fondaparinux and radial access use were associated with lower rates of cardiovascular events in patients with acute coronary syndrome (ACS). The benefits of combining these two treatment strategies are not well described.

Methods

In 1167 consecutive patients admitted for ACS who underwent an invasive treatment strategy, data on the primary combined endpoint – major bleeding (OASIS-5 criteria) and major adverse cardiovascular events (MACE) – were prospectively collected for the hospitalization period and compared according to anticoagulation regimen (Fondaparinux or Enoxaparin) and arterial access site (femoral vs radial).

Results

Overall, mean age was 65±12 years, 57% were male, 32% had diabetes and 17% presented with ST segment elevation myocardial infarction (STEMI). Fondaparinux and radial access were used in 756 (65%) and 554 (48%) patients, respectively. An endpoint occurred in 112 patients (9.6%) – MACE in 79 (6.8%) and major bleeding in 42 (3.6%). Endpoint was 3.4% in Fondaparinux plus radial access, 9.9% for Fondaparinux plus femoral access, 8% Enoxaparin plus radial access and 19.9% in enoxaparin plus femoral access (p<0.001). Fondaparinux use was associated with a significant reduction in the rate of the primary endpoint in both radial (RR 0.42 CI 95% 0.19–0.90; p<0.05) and femoral (RR 0.5 CI 95% 0.33–0.79; p<0.001) access patients. The primary endpoint was also reduced in the radial access patients regardless if Fondaparinux (RR 0.33 CI 95% 0.18–0.62; p<0.001) or Enoxaparin (RR 0.40 CI 95% 0.21–0.74; p<0.01) was used. In multivariable analysis (adjusted for age, sex, diabetes, heart failure, previous CABG, creatinine, ejection fraction, haemoglobin, STEMI, and hospital length of stay) Fondaparinux (OR 0.50 CI 95% 0.31–0.79; p<0.01) and radial access (OR 0.39 CI 95% 0.23–0.66; p<0.001) where both independently associated with lower rates of primary endpoint. There was no interaction between both variables (p=0.83).

Conclusion

The use of fondaparinux plus radial access was associated with the lowest rates of MACE and major bleeding when compared with either strategy alone and therefore, is a very attractive approach to be used routinely in patients with ACS.

Funding Acknowledgement

Type of funding source: None