bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of extracorporeal membrane oxygenation with or without left ventricular unloading devices in patients with non-myocardial infarction cardiogenic shock
Authors: Kurpad K K , Sohal S S , Mehta H M , Visveswaran G V , Tayal R T , Wasty N W , Cohen M C , Waxman S W
Published: October 2021

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is being increasingly used to treat cardiogenic shock, however its effect on increasing left ventricular (LV) afterload may slow myocardial recovery and negatively affect survival. Percutaneous mechanical support devices have been utilized for LV unloading by reducing afterload in an attempt to improve outcomes. While the use of LV unloading devices remains debatable, its use has not been specifically studied in patients with non-acute myocardial infarction cardiogenic shock (non-AMICS).

Purpose

To study the outcomes of VA-ECMO with or without LV unloading devices in patients with non-AMICS patients.

Methods

National inpatient sample database from years 2015 to 2018 was queried to select patients admitted with non-AMICS. Patients were included in the study if they underwent VA-ECMO during admission and later categorized into 3 groups i.e. VA-ECMO, VA-ECMO plus Impella and VA-ECMO plus intra-aortic balloon pump (IABP). Baseline demographics and in-hospital outcomes were compared between the 3 pre-specified groups. Statistical significance was assigned at p<0.05.

Results

178,605 patients met criteria for non-AMICS. Of these, 2190 (1.23%) patients received VA-ECMO alone, 965 (0.54%) received VA-ECMO plus IABP and 414 (0.23%) received VA-ECMO plus Impella. On univariate analysis, patients who received VA-ECMO alone had higher rates of inpatient mortality as compared to those who received VA-ECMO plus IABP or VA-ECMO plus Impella (39.04%, 33.72% and 25.81% respectively, p=0.001). On multivariate analysis, the patients who received VA-ECMO plus IABP or VA-ECMO plus Impella had lower odds of mortality when compared to VA-ECMO alone (OR: 0.61 (0.39–0.96), p=0.03), OR: 0.51 (0.23–1.08), p=0.08). The length of stay and cost were significantly higher for patients with VA-ECMO with unloading devices (IABP or Impella) compared with VA-ECMO alone (24.77±2.44 and 27.74±3.55 days vs 23.70±1.25 days respectively. p=0.001, $846,404±71169 and 860,999±121942 vs $740,274±43644 respectively, p=0.001).

Conclusions

Non AMICS patients who received VA-ECMO along with LV unloading devices (esp IABP) had lower in-hospital mortality as compared to those who received VA-ECMO alone despite having longer length of stay and higher cost. Use of LV unloading devices like IABP or Impella may improve outcomes in patients requiring VA-ECMO support for non-myocardial infarction cardiogenic shock. Further studies are needed to identify specific patient subsets that may benefit from this approach.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular global longitudinal strain as an indicator of myocardial injury in non-hospitalized COVID-19 survivors
Authors: Hassan Abdelnabi M , Abdelgawad H , Saleh Y , Almaghraby A
Published: October 2021

Introduction

The incidence of acute cardiac injury in COVID-19 patients is frequently subclinical and can be identified by cardiac magnetic resonance imaging. Left ventricular global longitudinal strain (LV-GLS) using two-dimensional speckle-tracking echocardiography (2D-STE) provides an accurate validated method for early detection of subclinical myocardial dysfunction. So far, long-term cardiovascular complications of COVID-19 are undetermined therefore several validated methods should be used for early diagnosis and intervention in those patients.

Purpose

The aim of this work was to describe GLS as an indicator of myocardial injury in a case series of non-hospitalized COVID-19 patients complaining of persistent dyspnea after resolution of COVID-19 infection.

Methods

A total number of 18 patients who were diagnosed with COVID-19 and were not indicated for hospital admission due to mild symptoms presenting with residual persistent dyspnea following COVID-19 infection resolution. Through clinical examination and standard 2D transthoracic echocardiography with STE emphasizing on LV-GLS was performed using Philips Epic - Qlab 10 software.

Results

The mean age of the included patients was 37.44±6.33 years, the mean time from COVID-19 diagnosis was 48.1±15.45 days, all patients (100%) had persistent dyspnea grade II. The mean left ventricular ejection fraction (LVEF) was 62.9±3.46% while the mean LV-GLS was −15.55±2.16%. Clinical and echocardiographic data is presented in Table 1.

Conclusion

In a case series of non-hospitalized COVID-19 survivors who complained of persistent dyspnea, GLS was low in comparison to the normally reported values of LV-GLS although they had normal LVEF indicating the persistence of myocardial injury even in mild cases of COVID-19 long after infection resolution. Further close follow-up of even mild and moderate COVID-19 survivors is certainly required to detect long-term cardiovascular sequelae. 2D STE with LV-GLS can be used as a readily available validated technique to detect early or persistent myocardial dysfunction succeeding COVID-19 infection.

Funding Acknowledgement

Type of funding sources: None.
Is GLP-1 insufficiency a coronary risk factor? A multicenter observational study, BOREAS-CAD2
Authors: Nagase C , Tanno M , Kouzu H , Miki T , Nishida J , Murakami N , Kokubu N , Nagano N , Nishikawa R , Yoshioka N , Tsuchida A , Kita H , Ohnishi H , Miura T
Published: October 2021

Background and aim

Glucagon-like peptide-1 (GLP-1) regulates insulin secretion and also affords pleiotropic effects including protective effects on blood vessels. Multiple factors regulate GLP-1 secretion after meals, but a group of apparently healthy subjects showed blunted responses of GLP-1 secretion in our previous study. In this study, we examined the possibility that the reduced capacity of GLP-1 secretion is associated with increased extent of coronary artery stenosis in non-diabetic patients.

Methods and results

Non-diabetic patients who were admitted for coronary angiography without a history of coronary interventions were enrolled. Coronary artery stenosis was quantified by Gensini score (GS), and GS ≥10 was used as an outcome variable based on results of earlier studies indicating its predictive value for cardiovascular events. The patients (mean age, 66.5±8.8 years; 71% males, n=173) underwent oral 75 g-glucose tolerant tests for determination of glucose, insulin and active GLP-1 levels. The area under the curve of plasma active GLP-1 (AUC-GLP-1) was determined as an index of GLP-1 secretion capacity. AUC-GLP-1 was not correlated with fasting glucose, AUC-glucose, serum lipids, indices of insulin sensitivity or estimated glomerular filtration rate. In multivariate logistic regression analysis for GS ≥10, AUC-GLP-1 < median, age and hypertension were selected as explanatory variables, though fasting GLP-1 level was not selected.

Conclusion

The findings indicate significant association of reduced GLP-1 secretion capacity with increased extent of coronary artery stenosis in non-diabetic patients. A causal relationship between change in GLP-1 secretion capacity and coronary stenosis remains to be examined by a longitudinal study

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp./MSD K.K.
Mechanisms of cardiac protection by pirfenidone in the post-myocardial infarction setting
Authors: Aimo A , Iborra Egea O , Bayes-Genis A , Galvez-Monton C , Burchielli S , Passino C , Emdin M
Published: October 2021

Background

A high proportion of patients with ST-segment elevation myocardial infarction (STEMI) experience adverse left ventricular (LV) remodelling despite guideline-recommended therapy. An excessive and dysregulated fibrotic response is involved in LV remodelling, and could be targeted by anti-fibrotic drugs such as pirfenidone, which is an approved treatment for idiopathic pulmonary fibrosis.

Methods

We evaluated the mechanisms of action of pirfenidone in the post-MI setting through sampling method-based mathematical models, enriched with transcriptomic data of swine experimental models of MI translated to the human proteome.

Results

The analysis of proteins modulated by pirfenidone shows that pirfenidone has a strong impact on several pathways involved in post-MI remodeling (Figure). The inhibition of p38γ-MAPK12 and furin displays the most prominent role on post-MI remodeling when compared to the other pirfenidone targets (PAI-1 and GLI2). p38γ-MAPK12 blockade inhibits cardiomyocyte apoptosis mediated by BCL2 and BAX. Myocardial hypertrophy and inflammation might be modulated by pirfenidone through the regulation of proteins downstream to p38γ-MAPK12, such as the NFATC1/NFATC2/NFATC3 pathway, and the transcription factors FOXO1, FOXO3 and NFκB, which are involved in TNFα regulation. The transcription factor AP-1 (homo-heterodimers of c-JUN/c-FOS), also downstream to p38γ-MAPK12, regulate the expression of genes involved in hypertrophy, fibrosis and inflammation (for example, IFNγ) By blocking both p38γ-MAPK12 and furin, pirfenidone can modulate extracellular matrix remodelling and cardiac fibrosis by targeting the TGFβ1-SMAD2/3 pathway, known to be highly involved in the progression of myocardial fibrosis, and other effector proteins such as MMP2 and MMP14 metalloproteases, PDGFA/B, and IGF1, many found to be involved also in myocardial fibrosis, impaired myocyte contractility and cell hypertrophic response.

Conclusions

We have identified several possible mechanisms of action of pirfenidone with beneficial effects in the post-MI LV remodelling. These findings support future research regarding pirfenidone's clinical benefit in post-MI patients.

Funding Acknowledgement

Type of funding sources: None.
Clinical characteristics and prognosis in patients with multi-vessel coronary spasm – comparison with those in patients with single-vessel coronary spasm
Authors: Teragawa H , Oshita C , Akazawa R , Uchimura Y , Orita Y
Published: October 2021

Background

We have sometimes experienced patients with vasospastic angina (VSA), who showed multi-vessel spasm (MVS) on coronary angiography (CAG) and spasm provocation test (SPT). However, it has not been clarified what clinical characteristics VSA patients with MVS have or whether such patients have poor prognosis. Therefore, we compared the clinical characteristics and prognosis in VSA patients with MVS with those in VSA patients with single-vessel spasm (SVS).

Methods

One hundred and fifty-two patients (mean age: 67 yrs, 74 men and 78 women) with VSA, in which presence of coronary spasm was assessed in both left coronary artery (LCA) and right coronary artery (RCA) on SPT, were subjected. We defined VSA as the presence of more than 90% narrowing of the epicardial coronary artery on angiograms, accompanied by the usual chest symptoms and/or ischemic ST-T changes on electrocardiogram. On SPT, MVS was defined as the presence of spasm on ≥ two major coronary arteries. Base on the presence of MVS, patients were divided into the following 2 groups: MVS group and SVS group. The frequencies of conventional coronary risk factors, the average times of anginal attack (per month), the findings of SPT such as spasm provocation induced by low dose of acetylcholine (LDA) and total occlusion due to coronary spasm (TOC), the number of coronary vasodilators at discharge, and the major cardiovascular events (MACE) including death of any cause and readmission due to heart failure, acute coronary syndrome and unstable angina, were compared in the two groups.

Results

There were 98 patients (64%) in the MVS group and 54 patients (36%) in the SVS groups. The frequencies of conventional coronary risk factors and the average times of anginal attacks (4/month in both groups) were not different in the two groups. The frequencies of LDA (33% in MVS and 17% in SVS, p<0.05) and TOC (12% in MVS, 0% in SVS, p<0.01) were higher in the MVS group than in the SVS group. The average numbers of coronary vasodilators was higher in the MVS group (1.1±0.4) than in the SVS group (0.9±0.4, p<0.01). The frequency of MACE did not differ in the two groups as follows (figure).

Conclusions

These findings suggest that there was no clinical characteristic, suggesting the presence of MVS in VSA patients. Such patients may have higher VSA activity on SPT and have more aggressive medications, leading to the similar prognosis in VSA patient with SVS.

Funding Acknowledgement

Type of funding sources: None.
Impact of wall shear stress affected by anatomical difference between acute and chronic coronary syndrome in patients with LAD proximal disease
Authors: Naniwa S , Yamada S , Awano K , Yoshida A , Takami K , Tagashira T , Tsuda S , Terashita D , Takada H , Akita T , Takata K , Kunigita T , Nishijo K
Published: October 2021

Recent hemodynamic studies have demonstrated that progression of coronary atherosclerosis occurs at low wall share-stress site, whereas plaque rupture frequently occurs at high share stress site. It is well recognized that wall shear stress is relatively low along the outer walls of the bifurcation.

We investigated consecutive 140 patients (77 with acute coronary syndrome (ACS) and 63 with chronic coronary syndrome (CCS) performed PCI for LAD proximal lesions (AHA seg.6) from January 2016 to December 2019. In CCS group, entry criteria included stenosis of at least 90% in the LAD proximal lesion or at least 70% in the LAD proximal lesion and objective evidence of myocardial ischemia (inducible ischemia with either exercise or pharmacologic vasodilator stress or with pressure wire). Exclusion criteria were patients with maintenance dialysis, chronic total occlusion lesions, in-stent restenosis, and clinically diagnosed unstable angina without troponin I elevation. We measured the distance from LMT distal carina to the culprit site (Distance) and plaque location (Location) with intravascular ultrasound and angle between LMT and LAD with cardiovascular angiography analysis system (CAAS) (Angle).

The two groups were generally well balanced with regard to baseline clinical characteristics. The mean (±SD) age of the patients was 69.0±11.8 years, and 75% were men. Medication at baseline was also similar between two groups except higher prevalence of statin prescription in CCS group. The Distance was shorter and Angle was steeper in CCS group than in ACS group. The number of patients with Angle less than 150 degrees and with Location in the lateral wall side was much more in CCS group.

In this study, plaques in CCS were frequently observed at low shear stress site, whereas those in ACS at high shear stress site. Plaque progression in CCS may be associated with low wall shear stress, and high shear stress may play key role in plaque rupture in ACS. This anatomical difference can partly explain the different mechanisms of onset between of ACS and CCS.

Funding Acknowledgement

Type of funding sources: None. Anatomical differenceCharacteristics and results
Angiography vs physiology-based deferral of revascularization in patients with reduced left ventricular ejection fraction: a 10-year clinical follow-up
Authors: Gallinoro E , Paolisso P , Bermpeis K , Peregrina E F , Candreva A , Esposito G , Fabbricatore D , Sonck J , Di Gioia G , Vanderheyden M , Bartunek J , Collet C , De Bruyne B , Barbato E
Published: October 2021

Background

Deferring percutaneous coronary intervention (PCI) in patients with non-ischemic coronary stenoses based on fractional flow reserve (FFR) and preserved left ventricular ejection fraction (LVEF) is associated with favorable long-term clinical outcomes. In patients with reduced LVEF, the role of reversible/residual ischemia in deferring revascularization is still debated.

Purpose

To investigate whether FFR provides additive clinical benefit compared to coronary angiography in deferring revascularization in patients with intermediate coronary stenoses and reduced LVEF.

Methods

Among 4577 coronary angiographies performed between 2002 and 2010, consecutive patients with reduced LVEF (≤50%) and at least one intermediate coronary stenosis [diameter stenosis (DS)% 40–70%] in whom revascularization was deferred based either on FFR (FFR-guided) or angiography (Angiography-guided) were screened. The primary endpoint of the study was cumulative incidence of death at 10 years.

Results

A total of 843 patients were included (209 in the FFR-guided and 634 in the Angio-guided group). Median clinical follow-up was 7.1 years (IQR 3.2–11.2 years). After 1:1 propensity score matching, baseline characteristics between the two groups were similar. All-cause death at 10 years was significantly lower in the FFR-guided compared with the Angiography-guided group (94 [45%] vs 115 [55%], HR 0.72 [95% CI 0.55–0.95], p<0.05). Similarly, the incidence of major adverse cardiovascular and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, any revascularization and stroke) was lower in the FFR guided group (125 [60%] vs 140 [67%], HR 0.77 [95% CI 0.61–0.98], p<0.05).

Conclusions

In patients with reduced LVEF and associated coronary artery disease, deferring revascularization of intermediate stenoses based on FFR is associated with lower incidence of death and MACCE at 10 years.

Funding Acknowledgement

Type of funding sources: None.
Effect of PM2.5 on circulating inflammatory cells and microRNA expression in acute coronary syndrome
Authors: Cecconi A , De La Fuente H , Blanco Dominguez R , Navarrete G , Garcia-Guimaraes M , Vera A , Lopez Melgar B , Rivero F , Sanz Garcia A , Lozano Prieto M , Martin P , Sanchez-Madrid F , Alfonso F , Jimenez-Borreguero L J
Published: October 2021

Background

Air pollutants increase the risk of myocardial infarction. Air pollution-induced atherosclerotic plaque destabilization may be related to inflammation, but the specific inflammatory alterations remain unclear.

Purpose

The aim of this prospective study was to assess the inflammatory changes in circulating immune cells and microRNAs in patients with acute coronary syndrome related to short-term exposure to PM2.5.

Methods

We prospectively included all consecutive patients admitted between March 2017 and July 2018 with the diagnosis of acute coronary syndrome (STEMI, NSTEMI, unstable angina) and coronary angiography in the acute phase of the disease. We also included a control group of patients with stable angina. For each patient we collected air concentrations of PM2.5 from the closest meteorological station to the patient residence obtaining the previous 24-hour average before hospital admission. All patients underwent systematic circulating inflammatory cell analysis. A selection of patients underwent miRNAs analysis.

Results

A total of 261 patients were included. According to PM2.5 exposure, 31 patients were selected for miRNA analyses. STEMI patients exposed to PM2.5 showed a reduction of CD4+ regulatory T (Treg) cells (Figure 1A). In the microRNA assessment, PM2.5 exposure was associated with higher circulating levels of let-7f-5p, miR-223-3p, miR-423-3p, miR-197-3p, miR-335–5, miR-376c-3p and miR-501-3p. Regarding clinical presentation, PM2.5 exposure in STEMI and NSTEMI patients was associated with an increase of miR-let-7f-5p, whereas miR-423-3p and miR-146a-5p were increased only in STEMI patients (Figure 1B).

Conclusions

STEMI related to PM2.5 short-term exposure is associated to specific changes involving CD4+CD25+Foxp3+ Treg cells and miR-146a-5p.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Ministerio de Ciencia e Innovaciόn; Fundaciόn BBVA Equipos de Investigaciόn Científica 2018 and from Caixa Banking Foundation; Sociedad Espanola de Cardiologia; Ministerio de Ciencia, Innovaciόn y Universidades, Carlos III Institute of Health-Fondo de Investigaciόn Sanitaria; Comunidad de Madrid; Fondo Europeo de Desarrollo Regional
Differential prognostic value of resistin for cardiovascular death in patients with stable coronary artery disease according to the presence of metabolic syndrome
Authors: Kosmas N , Katsimardos A , Kountouri A , Zolindaki M , Rallidis L
Published: October 2021

Background

Resistin is associated with atherosclerosis progression by affecting inflammation and insulin resistance. There are controversial data regarding the prognostic value of resistin in patients with coronary artery disease (CAD).

Purpose

We prospectively investigated the long-term prognostic value of resistin in patients with stable CAD.

Methods

A total 741 consecutive patients with stable CAD were followed for a median of 5.5 years. Serum resistin, lipids, high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) levels were measured at baseline. Primary endpoints were cardiac death (CD) and secondary hospitalizations for acute coronary syndrome, arrhythmic event or stroke.

Results

Follow-up data were obtained from 703 patients of whom 79 had a CD (11.2%) and 205 (29.2%) met the secondary endpoints. Resistin was positively correlated with hsCRP (r=0.159, p<0.001) and IL-6 (r=0.165, p=0.002), and negatively with HDL-cholesterol (r=−0.176, p<0.001). Resistin levels could not predict CD [HR: 1.044; 95% CI: 0.994 to 1.096; p=0.087] neither secondary endpoints [HR: 1.025; 95% CI: 0.983 to 1.068; p=0.250). Among 298 patients (42.4%) with metabolic syndrome (MS) resistin levels were independent predictors of CD after adjustment for conventional risk factors and left ventricular ejection fraction (LVEF) [HR: 1.145; 95% CI: 1.057 to 1.240; p=0.001]. Patients with resistin values ≥7.6 ng/mL (median level) had 2.8 times higher risk of CD compared to those with resistin levels <7.6 ng/mL after adjustment for traditional risk factors and LVEF (HR: 2.882; 95% CI: 1.311 to 6.336; p=0.008).

Conclusions

Resistin is an independent long-term predictor of CD in patients with stable CAD and MS.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Long term outcome after a first myocardial infarction
Authors: Almosawi M , Ferrannini G , Buhlin K , Gustafsson A , Kjellstrom B , Klinge B , Nygren Å , Nasman P , Svenungsson E , Ryden L , Norhammar A
Published: October 2021

Background

Prognosis after a myocardial infarction (MI) have improved consistently over the last decades. In parallel, the incidence of cardiovascular (CV) events has been reduced and life expectancy in people free from CV disease improved.

Purpose

To explore the long-term mortality and burden of cardiovascular disease in patients after a first MI compared to matched controls in a contemporary setting.

Methods

The Swedish case-control study PAROKRANK recruited 805 patients <75 years with a first MI and 805 age-, gender- and area-matched controls from 2010 to 2014. All participants were followed by means of registry-based information. The primary endpoint was the first of a composite of all-cause death, non-fatal MI, non-fatal stroke and heart failure hospitalization. Data on the outcomes were provided via linkage to the National Patient Registries and the Cause of Death Registry. Hazard Ratios (HR) for the first composite event were calculated by means of a Cox regression model, subsequently adjusted for smoking, education level and marital status at baseline. Event curves for the time-to-first event in patients and controls were computed by Kaplan-Meier curves and the two groups were compared by means of the log-rank test.

Results

Data from 804 patients and 800 controls (mean age in both groups 62 years; women 19%) were complete for an average period of 6.2 years (0.2–8.5 years). The total number of events was 211. Patients had a higher event rate than controls (log rank p<0.0001). Unadjusted HR for the primary outcome was 2.08 (95% confidence interval (CI) 1.56–2.77) while the adjusted HR was 2.04 (95% CI 1.52–2.73). Mortality did not differ significantly between patients (n=38; 4.7%) and controls (n=35; 4.4%). In total, 82.5% of the patients and 91.3% of the controls were event-free during follow-up.

Conclusion

This long-term follow-up of a contemporary, nationwide case-control cohort illustrates that the likelihood for CV events is higher in patients with a first MI compared to their matched controls while mortality did not differ. The access to high quality of care and cardiac rehabilitation might explain the low rates of adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): AFA Insurance, Swedish Heart-Lung Foundation, Swedish Research Council, Swedish Society of Medicine, Stockholm County Council (ALF project and Steering committee KI/SLL for odontological research), and The Baltic Child Foundation. Figure 1. Kaplan-Meier curves
Clinical characteristics and outcomes in young patients with myocardial infarction
Authors: Lv J , Zhao Q , Ni L , Yang Y , Xu H
Published: October 2021

Background

Young people hold a stable or increasing percentage of patients with acute myocardial infarction in many countries. However, data on clinical characteristics and outcomes in young patients are lacking.

Purpose

To compare clinical characteristics and outcomes between patients aged ≤45 years and those aged >45 years with acute myocardial infarction.

Methods

A total of 24125 patients with acute myocardial infarction between January 2013 and September 2014 from China Acute Myocardial Infarction (CAMI) registry were included in this study. Clinical characteristics, in-hospital and 2-year outcomes were compared between patients aged ≤45 years (young) and those aged >45 years (older). Gender disparity in prognosis of myocardial infarction was analyzed among young patients.

Results

Of 24125 patients, 2042 (8.5%, 116 female) were aged ≤45 years. Compared with patients aged >45 years, young patients were more often male, current smokers, having medical history of hyperlipidemia and family history of premature coronary artery disease. Young patients were significantly more likely to have clear trigger factor, present with persistent chest pain and suffer ST-segment elevation myocardial infarction. Symptom onset to admission time was shorter in patients aged ≤45 years. For patients undergoing emergency coronary angiography, those aged ≤45 years were more likely to suffer left anterior descending coronary artery related myocardial infarction. Young patients were significantly more likely to receive percutaneous coronary intervention and other medications at discharge, including dual antiplatelet therapy, statins, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers and β blockers. Compared with patients aged >45 years, young patients experienced significantly lower in-hospital and 2-year mortality and major adverse cardiac and cerebrovascular events (MACCE, a composite of death, reinfarction and stroke) rates (Table 1). Among young patients, women experienced higher in-hospital mortality and MACCE rates than men (Table 2). Women who survived at discharge experienced significantly higher 2-year mortality (1.4% vs 3.8%, Log-rank P=0.0412, Table 2).

Conclusions

Compared with the older patients, young patients were more likely to present with typical symptoms and receive guideline-recommended medications. Clinical outcomes of patients aged ≤45 years were significantly better than older patients. However, our results showed significant gender disparity in both short- and long-term outcomes of young patients. More efforts are needed to improve prognosis in young patients with acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Twelfth Five-Year Planning Project of the Scientific and Technological Department of China
Predictive value of neutrophil percentage-to-albumin ratio for contrast-associated acute kidney injury in patients without chronic kidney disease undergoing elective percutaneous coronary intervention
Authors: He H , Lin X , Luo M , He C , Zhang S , Lin M , Lin K , Guo Y
Published: October 2021

Background

Although previous studies have demonstrated that neutrophil and albumin are biomarkers of inflammation and malnutrition, which are highly related with contrast-associated acute kidney injury (CA-AKI). However, there has been no study investigated the combined evaluation of neutrophil and albumin in predicting CA-AKI.

Purpose

To explore the predictive value of neutrophil percentage-to-albumin ratio (NPAR) for CA-AKI in patients undergoing elective percutaneous coronary intervention (PCI).

Methods

We prospectively observed 5083 consenting patients without chronic kidney disease (CKD) undergoing elective PCI from January 2012 to December 2018. NPAR was calculated as neutrophil percentage numerator divided by serum albumin concentration. CA-AKI was defined as an increase in serum creatinine (SCr) ≥50% or 0.3 mg/dL within 48 hours after contrast medium exposure. The association between NPAR and CA-AKI was investigated by logistic regression analysis. The area under the receiver-operating characteristic curve (AUC), continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to make comparison for CA-AKI prediction.

Result

The incidence of CA-AKI was 5.6% (n=286). The median NPAR was 14.9 (13.0–17.1). According to the receiver operating characteristic curves (ROC), the best cut-off value of NPAR for predicting CA-AKI was 15.7 with 66.8% sensitivity and 61.9% specificity (C statistic=0.679; 95% CI, 0.666–0.691). NPAR displayed higher AUC value in comparison to neutrophil percentage (p<0.001), but not albumin (P=0.063), as a predictor of CA-AKI. However, NPAR significantly improved the prediction of CA-AKI in the continuous NRI and IDI over neutrophil percentage (NRI: 0.353, 95% CI: 0.234–0.472, P<0.001; IDI: 0.017, 95% CI: 0.010–0.024, p<0.001) and albumin (NRI: 0.141, 95% CI: 0.022–0.260, P=0.020; IDI: 0.009, 95% CI: 0.003–0.015, p=0.003) alone. After adjusting for potential confounding risk factors of CA-AKI, multivariable logistic analysis showed that NPAR >15.7 was a strong independent predictor of CA-AKI (OR=1.998, 95% CI, 1.511–2.643, p<0.001).

Conclusion

NPAR is an independent predictor of CA-AKI, which significantly improved the prediction of CA-AKI over neutrophil and albumin alone in patients without CKD undergoing elective PCI.

Funding Acknowledgement

Type of funding sources: None. ROC for NPAR to predict CA-AKIPredictors of CA-AKI
Acute and long-term outcomes of ST-elevation myocardial infarction in cancer patients
Authors: Lange S A , Feld J , Kuehnemund L , Koeppe J , Makowski L , Engelbertz C H , Gerss J , Droege P , Ruhnke T H , Guenster C H , Freisinger E , Reinecke H
Published: October 2021

Background

Myocardial infarctions (MI) and cancer are each very serious morbidities. To evaluate their interaction in the “real world”, a retrospective analysis was performed in patients with ST-elevation MI (STEMI) and pre-existing cancer.

Methods

Anonymized data from patients admitted to hospital between 2010 and 2017 due to STEMI were analyzed from 24 months before and up to nine years after the index hospitalization by one of Germany's largest statutory Health Insurance Funds (Allgemeine Ortskrankenkasse - AOK). Qualitative data were tested via two-sided Chi-squared test and quantitative data were tested using a two- sided Wilcoxon test. The eight year overall survival (OS) rate was determined with a Kaplan Meier estimator. The endpoint OS was analysed using multivariable Cox-regression model.

Results

From 175,262 STEMI patients, 27,213 had cancer (15.5%). Most frequent were skin (24.9%), prostate (17.0%), colon (11.0%), breast (10.9%), urinary tract (10.6%), and lung cancer (5.2%). STEMI patients with malignancies were older, presented more often with coronary three-vessel-disease, classical risk factors, atrial arrhythmias, kidney disease, heart failure, cerebrovascular and peripheral artery disease (PAD) (each p<0.001). They showed more often previous MI, percutaneous coronary interventions (PCI), cardiac surgery, and stroke (all p<0.001). Acute PCIs were applied approximately 2–6 percent points less frequently compared to those without (w/o) cancer, with less drug-eluting and more often bare metal stents (all p<0.001). In-hospital adverse events occurred more frequently in cancer. Eight-year survival was 57.3% (95% CI 57.0% – 57.7%) w/o cancer, and ranged between 41.2% and 19.2% in distinct cancer types. Multivariable Cox regression for death during follow-up found e.g. lung cancer (HR 2.04, 95% CI 1.92–2.17), PAD stage 4–6 (HR 1.78, 95% CI 1.72–1.84) and previous stroke (HR 1.44, 95% CI 1.31–1.54) to have the strongest effect, while obesity (HR 0.95, 95% CI 0.93–0.97) was associated with lower mortality (all p<0.001).

Conclusion

In this large “real world” health insurance data from Germany, prognosis after STEMI was markedly reduced but differed widely between cancer types. No withholding of revascularization therapies in cancer patients could be observed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051).
Acute coronary syndrome outside and during the COVID-19 pandemic
Authors: Maltcev A I , Koriagina N A , Koriagin V S , Prokhorov K V , Spasenkov G N
Published: October 2021

Objective

To analyze the register of patients with acute coronary syndrome (ACS) at the clinical cardiological dispensary from september to november 2018–2019 and 2020 during COVID-19.

Materials and methods

A retrospective study was conducted, the registry included 952 patients with ACS in 2018 and 1033 patients in 2019, as well as 964 patients in 2020 during the COVID-19 pandemic. Statistical analysis of the material was performed using the Statistica 11.0 software.

Results

When analyzing the provision of specialized care to patients with ACS in 2018, the average age of patients was 67 years, the mortality rate was 3.94%. The structure of ACS in 2018 was dominated by patients with ST-segment elevation myocardial infarction (STEMI) - 47%, myocardial infarction without ST-segment elevation (STEMI) occurred in 23%. The proportion of patients with unstable angina pectoris (NS) was 30%. Only 43.6% were registered with coronary heart disease (CHD) before ACS. 12.5% had a history of diabetes mellitus (DM), 31.2% had arterial hypertension (AH). This cardiovascular event recurred in 4% of patients. Average bed-days 9.73. In 2019, the average age of patients was 68 years, the mortality rate was 4.35%. In the structure of ACS in 2019, patients with STEMI were more common 47.5% than with STEMI 28%. The proportion of patients with HC was 24.5%. 52.1% of patients were registered at the dispensary before ACS with a diagnosis of coronary artery disease. A history of diabetes mellitus was in 13.0%, AH in 39.6% of patients. For 3.8% of patients, myocardial infarction in 2019 became recurrent. The average bed-days was 9.92. In 2020, the average age of patients was 66 years, the mortality rate was 6.25%. The structure of patients was dominated by patients with STEMI - 50.5%, STEMI was less common - in 17.5%. The proportion of patients with unstable angina pectoris was 32%. It was revealed that 54.4% were registered in the dispensary before ACS with coronary artery disease. 28.5% had a history of diabetes mellitus, 40.8% - AH. This event was repeated for 4.7% of patients. Average rate, bed-days rate is 8.85.

Conclusions

Initial analysis reveals that the group of patients with ACS in 2020 was younger than the group of patients in 2019–2020. ACS in combination with diabetes during the pandemic occurred 2 times more often than in the same period of 2018–2019. The proportion of patients registered with the dispensary increased over the period 2018–2019–2020, however, the mortality rate in the 2020 group had a clear upward trend, which may be due to various reasons, incl. the COVID-19 pandemic. The average number of bed-days also objectively decreased when comparing the 2020 and 2019–2018 patient cohorts, which may be due to the burden on the healthcare system during the pandemic.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Clinical Cardiology Dispensary
Association of high-sensitivity Troponin T and I blood levels with outcome of coronary artery disease – results from the INTERCATH cohort
Authors: Bay B , Blaum C M , Kroeger F , Gossling A , Koppe L , Max L , Lorenz T , Koester L , Westermann D , Zeller T , Kirchhof P , Blankenberg S , Seiffert M , Waldeyer C , Brunner F J
Published: October 2021

Background

High-sensitivity Troponin T and I (hsTnT/I) concentration is independently associated with coronary artery disease (CAD) severity and cardiovascular outcome. Here we explored whether hsTnT/I blood levels add predictive information irrespective of CAD severity and further confounders in unselected stable patients with angiographically characterized CAD.

Methods

Between 2015 and 2020, 3,012 patients undergoing coronary angiography were included in the observational Hamburg INTERCATH study. In 2,209 consecutive patients Troponin levels were quantified for hsTnT (Roche Diagnostics Elecsys) and hsTnI (Abbott Diagnostics ARCHITECT STAT). Patients presenting with acute coronary syndromes and heart transplant recipients were excluded, leaving 1,841 patients for analyses. CAD severity was graded according to the Gensini score. Major adverse cardiac events (MACE) as a composite of cardiovascular death, stroke, myocardial infarction, and coronary revascularization were defined as endpoint. Kaplan-Meier analyses stratified by hsTnT/I quartiles were performed. Multivariable Cox models were computed for the association of hsTnT/I with MACE adjusting for age, gender, arterial hypertension, hyperlipoproteinemia, smoking, diabetes mellitus, body-mass index, eGFR and Gensini Score.

Results

Mean age was 68.5±10.9 years (27.9% female). 81.1% were diagnosed with CAD by coronary angiography. Gensini score was 21.0±30.2. Median follow-up time was 4.42 years. hsTnT quartiles differentiated MACE across all categories (Figure 1A). For hsTnI, cardiovascular risk was differentiated between the lowest and highest quartiles as well as the 1st and 2nd quartile particularly beyond 24 months of follow-up (Figure 1B). However, MACE after 3 years was not associated with hsTnT after adjustment for classical cardiovascular risk factors and CAD severity (Figure 1C), whereas the hazard of MACE was increased in the 3rd and 4th hsTnI quartiles compared to the 1st quartile (HR 1.3, IQR 1.1–1.6 for both categories; Figure 1D).

Conclusion

Increasing hsTn concentration was related to intermediate term cardiovascular outcome in unselected stable patients. Only hsTnI concentration remained as independent predictor after testing for most possible confounders, including CAD severity. This data underpins the role of hsTnI in outcome prediction.

Funding Acknowledgement

Type of funding sources: None.
Association of growth differential factor-15, hs-cardiac troponin T and N-terminal pro-brain natriuretic peptide with coronary artery disease in patients undergoing elective coronary angiography
Authors: Souaid T , Hijazi Z , Barakett V , Sarkis A , Kadri Z , Batra G , Lindback J , Abdelmassih T , Noujaim M , Azar R R
Published: October 2021

Background

Although the importance of conventional risk factors is well established, a significant proportion of patients with coronary artery disease (CAD) lack any of these factors and many patients without CAD have one or more of them. Better tools are needed to improve risk stratification of patients.

Purpose

We aimed to investigate the association between plasma levels of growth differentiation factor 15 (GDF-15), a marker of stress and inflammation, high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with the presence of CAD in stable patients referred for elective coronary angiography.

Methods

Plasma levels of the three biomarkers were measured in 252 consecutive patients. Patients with known CAD, acute coronary syndrome, or with chronic inflammatory conditions were excluded. CAD was defined by the presence of at least one lesion causing >50% stenosis. The outcome was defined as an ordinal variable with 3 levels: no CAD, 1- or 2-vessel CAD and 3-vessel or left main CAD.

Results

Median age was 63 years (56–71), and 35% of patients were females. Among conventional risk factors, hypertension was the most prevalent (70%), followed by hyperlipidemia (69%), smoking (42%), diabetes (33%) and family history of CAD (32%). Of the 252 patients enrolled, 153 (61%) had no CAD, 81 (32%) 1- or 2-vessel CAD, and 18 (7%) 3-vessel or left main CAD. Plasma levels of GDF-15, hs-cTnT and NT-proBNP in each of the 3 groups of CAD are summarized in table 1. In unadjusted ordinal logistic regression analysis, GDF-15 and hs-cTnT were statistically significantly associated with the presence and extent of CAD, while NT-proBNP was not (table 1). However, in a multivariable analysis including age, sex and traditional risk factors, the association of GDF-15 and hs-cTnT with angiographic CAD was attenuated and no longer statistically significant. Age, male sex, family history of premature CAD and the presence of hyperlipidemia, were independent predictors of the presence and extent of CAD (table 2).

Conclusion

In stable patients referred for coronary angiography, plasma levels of GDF-15 and hs-cTnT could predict the presence of CAD when evaluated separately. However, that association was attenuated by clinical characteristics.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Roche Diagnostics International LtdForrenstrasse 26343 RotkreuzSwitzerland Table 1Table 2
Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors
Authors: Shiyovich A , Cohen T , Hamdan A , Klempfner R , Skalsky K , Porter A , Orvin K , Kornowski R , Eisen A
Published: October 2021

Introduction

Approximately 5–15% patients presenting with acute coronary syndrome were found to have no traditional cardiovascular risk factors (RFs). Data regarding the determinants, management and outcomes of these patients are scarce.

Purpose

To evaluate the management, outcomes and time dependent changes of ACS patients without RFs.

Methods

Evaluation of clinical characteristics, management strategies, and outcomes as well as time dependent changes (by 3 time periods: early [2000–2006], mid [2008–2013], and late [2016–2018]) of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of IHD and current or past smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (RF−) to those ≥1 RFs (RF+).

Results

Overall 583 out of 10,324 (5.6%) eligible ACS patients did not have any RFs (median age 64 [IQR 52–77], 25% females]. The RF− group were older, more educated, with lower BMI and prevalence of another cardiovascular comorbidity and chronic kidney disease compared with the RF+ group. The in-hospital PCI rates were lower among the RF− vs. the RF+ group (55% vs. 66%, respectively p<0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge were prescribed in the RF− vs. the RF+ group. The rate of in-hospital complications was greater in the RF− vs. RF+ group (31.4% vs. 26.1%, respectively p=0.006). The rates of 30-day major adverse cardiac events (MACE) were significantly higher among patients with RF− vs. RF+ (18.1% vs.12.8%, respectively p<0.001). Similarly, the rates of 30-day and 1-year all-cause mortality (figure 1) were higher among patients with RF− vs. RF+ (8.7% vs. 4.2%, p<0.001 and 11.9% vs. 7.7% p<0.001 respectively). A trend of decline in the rate of MACE was observed between the early and the late study period in the RF− group (22% vs. 10.7% p=0.002 respectively). One-year mortality did not decrease significantly in the RF− group during the study periods (13.6% vs. 10% early vs. late period respectively p=0.16).

Conclusions

ACS patients without traditional cardiovascular risk factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse short-and long-term outcomes. Additional research to identify unique risk factors and targets for interventions to improve outcomes of this group of patients is warranted.

Funding Acknowledgement

Type of funding sources: None.
The prognostic value of the ESC quality indicators in patients with acute myocardial infarction: a systematic review
Authors: Perello-Bordoy A , Masso-Van Roessel A , Mas-Llado C , Ramis-Barcelo M F , Vives-Borras M , Pons J , Peral V , Rossello X
Published: October 2021

Background

Quality indicators (QIs) provide a mechanism for measuring opportunities to improve cardiovascular care and outcomes. To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set 20 QIs to evaluate several dimensions of care. These 20 QIs are organized in 3 areas and 7 domain defined in structural, performance measures including patient's feedback and outcomes. Several registries have reported their performance using real-world data, and some of them reported their prognostic value. For this purpose, we systematically reviewed the literature evaluating the 2017 ESC ACVC set of QIs in previous observational studies, with the aim to summarise their prognostic value.

Methods

A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Inclusion criteria were studies providing original data, and studies evaluating the 2017 ESC ACVC set of QIs in patients with AMI (STEMI or NSTEMI). The main exclusion criterion was for non-original articles and studies evaluating a different set of QIs. Adjusted estimates (odds or hazard ratio) for the association between QIs and mortality were used to report the prognostic value of QIs.

Results

Among de 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from 3 different continents (31 countries) between 2003 and 2018. The association between QIs and mortality have been reported in three cohorts: EPICOR, FAST-MI and MINAP. EPICOR evaluated this association for 15 QIs and 2-year mortality, whereas FAST-MI evaluated the relationship for 11 QIs and 30-day mortality, and MINAP for 9 QIs and 3-year mortality. In general, higher compliance was associated with better prognosis in most QIs (Figure 1). The association between mortality and some QIs (1.3, 3.1, 3.2, and QI 6) was not reported in any study, and their prognostic value is therefore unknown to date. Composite QIs, which combine individual indicators from domains 1–6 to summarise the multiple dimensions of quality of care, were associated with mortality in all comparisons (7.1 was tested in the 3 studies, whereas 7.2 was only tested in EPICOR).

Conclusions

Our review has shown a consistent association between higher attainment of QIs and decreased mortality in the three cohorts that evaluated this association. These data support the use of QIs as a useful tool for assessing quality of care across centres and countries. There is a need to design registries and surveys specifically assessing QIs to have a more accurate picture about the implementation of ESC QIs.

Funding Acknowledgement

Type of funding sources: None. Figure 1