bluuebunny/crossref_metadata_2025 huggingface dataset:
Validation and potential usefulness of the updated PROMISE minimal risk tool in patients with suspected coronary artery disease undergoing coronary CT angiography
Authors: Lima M R L , Lopes P L , Albuquerque F A , Presume J P , Freitas P F , Silva C S , Guerreiro S G , Abecasis J A , Saraiva C S , Coutinho Santos A C S , Goncalves P A G , Mendes M M , Ferreira A F , Marques H M
Published: November 2023

Introduction

The steady decline in test positivity among patients with suspected coronary artery disease (CAD) has raised interest in developing strategies to identify patients who may not require testing. The updated PROMISE minimal-risk tool (PMRT) was developed specifically for this purpose, but never tested in our population.

The aim of this study was to assess the diagnostic performance of this new tool, and to compare it with the guideline-recommended pre-test probability (PTP) and with the risk factor-weighted clinical likelihood (RF-CL) model in a Portuguese cohort of symptomatic patients undergoing coronary computed tomography angiography (CCTA).

Methods

We conducted a two-centre cross-sectional study of symptomatic patients undergoing CCTA for suspected CAD. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome or symptoms other than chest pain or dyspnoea. A simplified version of the updated PMRT (without HDL-C), the guideline PTP, and RF-CL score were calculated for each patient. Obstructive CAD was defined as any luminal stenosis ≥ 50% on CCTA. ‘Low risk’ was defined as absence of obstructive CAD and coronary artery calcium (CAC) score < 100 (both conditions present, where CCTA results are unlikely to change patient management). The cut-off value of the PMRT with 95% positive predictive value for identifying patients with ‘Low risk’ was identified in ROC curve analysis.

Results

A total of 2162 patients (mean age 60±11years, 59% female) were included. Overall, 14.9% (N=323) of patients had obstructive CAD, and 73.5% (N=1589) fulfilled the criteria for ‘Low risk’. Patients with ‘Low risk’ were more frequently female, had higher prevalence of non-anginal chest pain and had fewer cardiovascular risk factors.

For obstructive CAD, the discriminative power of the updated PMRT was similar to the one provided by the guideline PTP and RF-CL models (Figure 1A). However, for identifying patients with ‘Low risk’, the updated PMRT showed greater discriminative power than the guideline PTP and RF-CL models (Figure1B).

The PMRT cut-off value with 95% positive predictive value for detecting patients at "Low risk" was identified as >46%. A total of 458 patients (21.2%) had a PMRT >46%.

Conclusion

In this cohort of symptomatic patients undergoing CCTA, the updated PMRT showed similar discriminative power for obstructive CAD, but greater discriminative power to identify "Low risk" than the guideline-recommended PTP and the RF-CL models. The criterion that identified "Low Risk" with 95% positive predictive value was present in roughly one fifth of patients undergoing CCTA, who would derive less benefit from testing.
Does prediabetes diagnosed by hemoglobinA1c or oral glucose tolerance test predict coronary artery disease in patients suspected of chronic coronary syndrome?
Authors: Overgaard K , Andersen T , Mohamed R , Heinsen L , Binderup H , Moller S , Auscher S , Lambrechtsen J , Egstrup K
Published: November 2023

Introduction

The presence of prediabetes worsens the prognosis of coronary artery disease, as patients with prediabetes are known to have an almost doubled cardiovascular mortality risk compared to normoglycemic patients. In clinical practice, HemoglobinA1c (HbA1c) has replaced the oral glucose tolerance test (OGTT) in the diagnosis of prediabetes. However, the background for the HbA1c threshold is based on the development of microvascular complications and progression to established diabetes. It remains unclear whether the substitution of OGTT with HbA1c results in an underestimation of prediabetics with a high risk of coronary artery disease, or if HbA1c is associated with macrovascular complications in prediabetic patients.

Purpose

We aimed to investigate whether HbA1c- or OGTT-diagnosed prediabetes could predict presence and severity of coronary artery disease in patients suspected of chronic coronary syndrome.

Methods

This was a descriptive cross-sectional study of 702 patients referred to a coronary CT angiography due to suspicion of chronic coronary syndrome. Coronary artery calcification (CAC)-score, presence of plaque and significant stenosis (>50%), and plaque characteristics were evaluated. All patients had a fasting OGTT and blood samples performed. Patients were categorized according to glycemic status by HbA1c and OGTT, and compared to their test-specific range.

Results

Prediabetes was detected by HbA1c 167 (24%) or OGTT 272 (39%), and an overlap in classification by both tests was seen in 98 (22%) of participants. Both classifications of prediabetes showed increased presence of plaques, significant stenosis, calcified plaques, and correspondingly, a low frequency of a CAC-score=0 compared to their test-specific normal. Additionally, the HbA1c-prediabetics had an increased frequency of a high CAC score >400 compared to normal HbA1c (23% vs. 10%, p<0.0001). In the multiple logistic regression analysis the HbA1c-prediabetics had an odds ratio (OR) of 1.5 for plaque presence (confidence interval (CI) 1.0;2.4) and OR 2.1 for a CAC-score >400 (CI 1.3;3.5). None of the associations for the OGTT-prediabetics were significant in the logistic regression analysis. Receiver operating characteristic curves were applied to the significant logistic associations. The HbA1c-prediabetics had an area under the curve (AUC)=0.77 for plaque presence and AUC=0.81 for CAC-score >400.

Conclusion

Prediabetes defined by HbA1c can predict presence and severity of coronary artery disease. Although OGTT identified more patients as having prediabetes, their risk of coronary artery disease was not attributable to prediabetes. Thus, our results support the replacement of OGTT with HbA1c in clinical practice.
The prognostic role of left atrial strain in young patients after ST elevation myocardial infarction: a 3D echocardiographic study
Authors: Scarlatescu A I , Micheu M M , Popa-Fotea N M , Petre I G , Oprescu N , Mihail A M , Dorobantu M
Published: November 2023

Background

LA volume previously demonstrated its role as significant predictor of adverse events after AMI. The prognostic value of LA strain is less studied. Left atrial strain has been used as a more accurate alternative to assessing LA performance. 3D echocardiography compared with 2D measurements better reflect the entire atrial myocardium, leading to a more accurate estimation of LA function.

Purpose

In this study we aimed to assess the prognostic value of LA strain parameters determined by 3D echocardiography in young patients after STEMI.

Patients and methods: We enrolled 112 patients in this study - 84 young patients with a first STEMI treated by primary PCI and 28 healthy age and sex matched controls. All patients underwent standard transthoracic echocardiography. In addition to conventional echocardiographic parameters, 3D acquisitions of the left atrium were performed. 3D LA longitudinal strain parameters were determined using the automated function 4D Auto LAQ. Patients were followed up for one year after STEMI, the primary endpoint being the occurrence of MACE.

Results

Compared to the control group, patients with STEMI had lower values of all LA strain parameters. There were also significant differences between MACE and non-MACE groups. Patients with MACE at follow up had lower reservoir strain (15.16 ± 2.58 vs. 22.71 ± 5.25), lower conduction strain (-8.62 ± 1.77 vs. -10.97 ± 1.44) and lower pumps strain (-9.36 ± 1.51 vs. -12.73 ± 2.53), compared to those from the non-MACE group. All LA strain parameters proved to have very good predictive abilities for MACE in ROC analysis (AUC = 0.894, 95 %CI, P < 0.0001 for LASr 3D, AUC = 0.854, 95 %CI, P < 0.0001 for LASct 3D, and AUC = 0.883, 95%CI, P < 0.0001 for LAScd 3D). For each variable we determined a cut off value as follows: 17.5 (Sb 91.7%, Sp 86.7%) for LASr 3D, -10.5 (Sb 75% Sp 86.7%) for LASct 3D, and -9.05 (Sb 75% Sp 91.7%) for LAScd 3D. LASr 3D under 17, and LASct 3D over -10.5 determined an approximately 2-fold increase in adverse events after STEMI. Univariate COX regression analysis showed that all parameters had a significant effect on MACE, while multivariate analysis identified only reservoir and pump functions as independent predictors for adverse events.

LASr 3D values showed a proportional decrease with worsening diastolic dysfunction, demonstrating significant differences between diastolic dysfunction grades. We determined LASr 3D cut-off values for discriminating between different degrees of diastolic dysfunction.

Conclusion

3D LA reservoir and pump strain proved to be independent predictors for MACE at one year follow up after STEMI in young patients. Beyond its prognostic role, LASr 3D may be helpful as a complementary method to evaluate diastolic dysfunction in young STEMI patients. Further larger scale studies are needed to validate these findings.
Diagnostic performance of machine learning on 12-lead electrocardiogram for predicting multi-vessel coronary vasospastic angina
Authors: Shimizu M , Misu Y , Tsunoda T , Miyazaki H , Tateishi R , Yamaguchi M , Yamakami Y , Kato N , Shimada H , Isshiki A , Kimura S , Fujii H , Suzuki M , Nishizaki M , Sasano T
Published: November 2023

Background

Multi-vessel coronary vasospastic angina (multi-VSA) is life-threatening disease. However, 12-leads electrocardiogram (ECG) in no chest symptom period was considered to have no predictive value for the multi-VSA. We tried to predict multi-VSA by machine learning (ML) on parameters of the 12-lead electrocardiogram.

Purpose

To predict multi-VSA by machine learning on ECG parameters in no chest pain period.

Methods

We recruited 227 consecutive sinus-rhythm patients (63.6±12.9years, 136men) who underwent acetylcholine-provocation test in coronary angiography (CAG). Multi-VSA was defined as spasm in at least 2 major branches which was provoked by ACh. ECG was recorded before CAG in no chest pain period. ML was performed on table data of ECG parameters (ex. ST level ant J point, R wave amplitude, and/or J wave in each lead) using several ensemble learning methods.

Results

79 patients (35%) showed multi-VSA, and the breakdown of the multi-VSA was as follows: double vessel 44, triple vessel 35, including LAD 73, LCx 47, RCA73. Univariate logistic regression analysis extracted 23 significant but weak predictors, the highest area under receiver operating characteristics curve (AUROC) was 0.673 of Q wave amplitude in lead aVL. Conversely, ML demonstrated high diagnostic performance (AUROC of extra trees classifier: 0.817). Shapley additive explanation method in the extra trees showed male, QTc, J wave in lead II, and low amplitude of Q wave in lead I/aVL played essential roles to build the ML model.

Conclusion

Several parameters of 12-lead ECG in multi-VSA patients contains potential features of VSA, and their aggregation and ensemble learning can predict VSA with high diagnostic performance.
A context-aware deep network for automated characterization of coronary artery plaque from coronary CT angiography
Authors: Leng S , Wang X H , Baskaran L , Teo L , Yew M S , Lu Z K , Huang S , Lee B H , Chan M Y Y , Ngiam K Y , Lee H K , Vaughan R , Tan S Y , Huang W M , Zhong L
Published: November 2023

Background

Identifying various types of plaque, including calcified, non-calcified, and mixed, can furnish crucial insights into a patient's susceptibility to cardiovascular disease and aid in making treatment decisions. Manual quantification of coronary artery plaque on coronary CT angiography (CCTA) poses several challenges, including subjectivity, time consumption, and potential measurement errors.

Purpose

Our objective was to develop a context-aware deep network (CADN) that could automatically evaluate coronary artery plaque in a sizable, multi-center prospective CCTA cohort.

Methods

The APOLLO study is a multi-center study involving CCTA scans of 5,000 Asian patients. At the present stage of this study, CCTA analysis was performed on a subset of 474 patients (138 females; mean age of 58 ± 11 years), of whom 76% were Chinese, 17% were Indian/Malay, and 7% were of other ethnicities. Additionally, 53% had hypertension, 20% had diabetes, 70% had hyperlipidemia, and 27% were obese. A total of 2,983 lesions in 1,422 arteries were analyzed, including 473 non-calcified, 1,612 mixed, and 898 calcified plaques. The CADN combines a 3D convolutional neural network with a Transformer and incorporates contextual information along with local features (Figure 1). The network was trained and tested in 379 and 95 patients, respectively.

Results

The CADN method showed a high level accuracy in detecting plaque, achieving a lesion-level area under the receiver operating characteristic curve of 0.87. Furthermore, the CADN method demonstrated a lesion-level diagnostic accuracy, F1 score, and intra-class correlation coefficient of 0.74, 0.71, and 0.90, respectively, in characterizing plaque into categories of no plaque, non-calcified, mixed, and calcified. When analyzing its performance in each coronary artery, the CADN method was able to accurately characterize the plaque into multiple categories in the LAD, LCX, and RCA with accuracies of 0.70, 0.73, and 0.77, respectively.

Conclusion

The context-aware deep network is a novel approach that demonstrates good diagnostic performance in detecting and characterizing coronary artery plaque.Figure 1.CADN for coronary plaque.
Direct comparison of the safety and efficacy of the ESC 0/1h-algorithm and the High-STEACS pathway for early rule-out of myocardial infarction
Authors: Glaeser J , Lopez-Ayala P , Nestelberger T , Boeddinghaus J , Koechlin L , Miro O , Martin-Sanchez F J , Christ M , Keller D , Mueller C
Published: November 2023

Background

The optimal approach for early rule out of myocardial infarction (MI) is still uncertain. The European Society of Cardiology (ESC) 0/1h-algorithm and the High-Sensitivity Troponin in the Evaluation of Patients with Acute Coronary Syndrome (High-STEACS) pathway, have both been validated individually in large studies. However, as a direct comparison of both strategies has not been performed until now, it is largely unknown whether one is preferable to the other.

Purpose

To directly compare the safety and efficacy of the ESC 0/1h-algorithm with the High-STEACS pathway.

Methods

Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up, cardiac imaging and serial hs-cTnI. Hs-cTnI (Architect) concentrations were measured at presentation, after 1h and 3h. The primary diagnostic endpoint was safety, assessed as the sensitivity and negative predictive value of ruling out index NSTEMI. The primary diagnostic endpoint was evaluated in prespecified subgroups stratified by sex, age, coronary artery disease, time of chest pain onset and glomerular filtration rate. Co-primary prognostic endpoint was 30- and 730- days all-cause mortality. Findings were externally validated in a large single center study.

Results

Among 5377 eligible patients, 1088 (20.2%) were finally adjudicated with the diagnosis of NSTEMI. Application of the ESC 0/1h-hs-cTnI-algorithm provided higher sensitivity (99.7 % [95% CI, 99.4-100]) compared to the High-STEACS pathway (99.0% [95% CI, 98.4 – 99.6], difference in sensitivity 0.7 [1.3-0.2], P-value for difference < 0.01), but left 846 patients (15.7%) without final triage towards rule-out or rule-in. Three patients with NSTEMI were missed by the ESC pathway compared to 11 patients missed by the High-STEACS algorithm (Figure). High safety and accuracy for the ESC pathway were confirmed in all subgroups and in the external validation cohort, whereas performance parameters for the High-STEACS pathway dropped considerably in the subgroup- and external validation analysis. Both strategies allowed reliable prediction of short and long-term mortality risk (log-rank test <0.001).

Conclusion

While the High-STEACS pathway identifies more patients at low-risk, the ESC 0/1h-algorithm provides higher sensitivity and NPV for rule-out of index NSTEMI.Performance of the ESC 0/1-h algorithmPerformance of the High-STEACS pathway
Sex-Differences in Long-term Mortality in Patients with ST-Segment elevation myocardial infarction with and without obstructive coronary arteries
Authors: Quesada O , Pico M , Yildiz M , Henry T , Stanberry L , Chambers J , Palmer C , Garberich R , Murthy A , Aguirre F , Garcia S , Sharkey S
Published: November 2023

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and understudied syndrome that disproportionally affects females. Studies to date evaluating sex-differences in ST-segment elevation MINOCA (STE-MINOCA) are limited; therefore, it remains uncertain whether the sex disparities observed in STEMI due to obstructive coronary arteries (STEMI-Obstruction) are also present in STE-MINOCA patients.

Objectives

Compare clinical characteristics and long-term mortality risk in male versus female patients presenting with STE-MINOCA and STEMI-Obstruction.

Methods

A multicenter registry-based cohort study enrolled consecutive STEMI patients at three regional, tertiary STEMI centers from 2003 to 2020. STE-MINOCA inluded patients with (1) coronary stenosis less than 60% as determined by coronary angiography, (2) evidence of ischemia with elevated troponin, and (3) no alternative diagnosis. Survival times between males and females with each diagnosis (STE-MINOCA & STEMI-Obstruction) were estimated using the Kaplan Meier method and compared using log-rank tests. The risk of 5-year mortality in patients surviving to discharge was estimated from a Cox regression model with the interaction term for sex and diagnosis STE-MINOCA or STEMI-Obstruction) and adjusted for age, hypertension, diabetes, dyslipidemia, year of event and clustered by the study site.

Results

Out of 8,566 STEMI patients, 420 (4.9%) had STE-MINOCA of whom 52.9% were female and 8146 (95.1%) had STEMI-Obstruction of whom 29.3% were female. Median follow-up was 7.1 years. Females had significantly higher 5-year mortality risk compared to male counterparts in both STE-MINOCA [HR 2.37 (1.37-4.11, p=0.002)] and STEMI-Obstruction [HR 1.81 (1.59-2.07, p<0.001)] (Figure). After adjusting for confounding variables, the sex difference in mortality risk were not significant: HR 1.04 (0.60-1.81, p=0.89) in STE-MINOCA and HR 1.06 (0.92-1.21, p=0.45) in STEMI-Obstruction.

Conclusions

In this first study of consecutive STEMI patients examining sex differences by obstructive and non-obstructive mechanism, we report higher 5-year mortality risk in females presenting with STE-MINOCA and STEMI-Obstruction that was attenuated when accounting for age and baseline comorbidities. This study highlights the importance of standardized STEMI protocols to eliminate sex disparities.

Abbreviations and Acronyms:

Myocardial infarction with non-obstructive coronary arteries (MINOCA),

ST-segment elevation MINOCA (STE-MINOCA)

STEMI due to obstructive coronary arteries (STEMI-Obstruction)Figure
Impact of coronary artery calcium score level in prediction of major adverse cardiovascular events
Authors: Bjelobrk M B , Kovacevic M K , Cankovic M C , Ilic A I , Miljkovic T M , Preveden A P , Bjelic S B , Grkovic D G , Komazec N K , Milovancev A M , Dabovic D D , Stojsic S S
Published: November 2023

Background

Elevated coronary artery calcium (CAC) is associated with an increased risk of cardiovascular (CV) and total mortality, while the coronary artery calcium score (CACS) significantly increases the sensitivity and specificity of traditional risk factors and risk scores in asymptomatic patients with intermediate risk.

Purpose

The aim of the study was to determine an association between the CACS and risk of major adverse CV events (MACE), as well as which value of CACS could be added in a prediction model based on traditional cardiovascular risk factors (CVRFs) in patients without established coronary artery disease (CAD) to improve risk stratification.

Methods

The study was performed as retrospective study, included patients of both sexes, aged over 40 years, with at least one traditional CVRF who underwent MSCT coronarography with follow up of 3 years. All patients were monitored for the presence of CVRFs, use of antihypertensive, statin and antiplatelet therapy, atherosclerotic cardiovascular disease risk score (ASCVD), 10-Year Coronary Heart Disease Risk with Coronary Artery Calcification (MESA score) and CACS.

Results

Of the 100 included patients, 61 (61%) were male and the mean age was 57.1±10.7 years. Most of patients (47%) had an intermediate ASCVD risk, average CACS value of 65.0 (0.0 - 383.3), mean value of CACS of 327.8±653.2, mean MESA score of 13.4±10.1 and a total of 29% MACE, with hospitalization as a most common (24%). There was an association between MACE and ASCVD score (p = 0.037), as well as CACS (p = 0.022). Logistic regression showed that the occurrence of MACE is influenced by: glucose level ([OR] (95%CI) 1.330 (1.003-1.762), (p = 0.047)), ASCVD score (([OR] (95%CI) 1.881(1.161- 3.048, (p =0.010)), MESA score (([OR] (95%CI) 1.055(1.004-1.109) (p = 0.033) and CACS (([OR] (95%CI) 1.902(1.170-3.092) (p = 0.010), where an increase in CACS by one increases the risk of MACE by almost 2 times.

Conclusions

The occurrence of cardiovascular outcomes is influenced by CACS, MESA score, ASCVD score, glucose level and age. Additional research is needed, with larger number of patients, to develop a predictive model based on traditional CVRFs and CACS values, in asymptomatic patients, in order to improve risk stratification.
Poor prognosis of patients with acute coronary syndrome presenting optical coherence tomography-defined calcified nodule at culprit lesions after emergent percutaneous coronary intervention
Authors: Hada M , Kakuta T , Sugiyama T , Usui E , Kimura S , Mizukami T , Yamamoto M , Kondo S , Wakabayashi K , Suwa S , Kobayashi N , Higuma T , Mori H , Yonetsu T , Shinke T
Published: November 2023

Background

Optical coherence tomography (OCT) enables the diagnosis of underlying causes of acute coronary syndrome (ACS). Calcified nodule (CN) is reported to be a rare but important cause of ACS, although its prognostic impact on clinical outcomes after emergent percutaneous coronary intervention (EPCI) remains undetermined. TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 22 hospitals in Japan to clarify the prevalence of underlying causes of ACS defined by OCT (plaque rupture [PR], plaque erosion [PE] and CN) and its impact on clinical outcomes, and assess the feasibility of OCT-guided emergent PCI (UMIN-CTR, ID 000039050).

Purpose

This study aimed to clarify the prevalence of CN at the culprit lesions in ACS patients and its prognostication after EPCI in a large prospective registry.

Methods

We assessed 702 patients enrolled in TACTICS registry who underwent OCT assessment of the culprit lesion during EPCI. Advanced chronic kidney disease (CKD) was defined as those with creatinine clearance <30 ml/min/1.73m2. The prevalence of OCT-defined CN and occurrence of MACE, defined as a composite of cardiovascular death, myocardial infarction, heart failure, or ischemia-driven unplanned revascularization at 1 year were compared between patients with and without advanced CKD.

Result

Patients with advanced CKD was found in 5.4% of a total cohort. The prevalence of CN was 3.0% in patients with non-advanced CKD and 21.1% in those with advanced CKD (p<0.001). In advanced CKD, MACE occurred most frequently in patients with CN (87.5%), followed by plaque rupture (11.8%) and plaque erosion (10.0%) (p<0.001). In Cox hazard analysis, CN was a significant predictor for MACE in advanced CKD (hazard ratio [HR], 12.94 (3.31-50.67), p<0.001). In contrast, CN was not significant predictor for MACE in non-advanced CKD (HR1.931 (0.706-5.281), p=0.200).

Conclusion

CN is significantly more frequently found at the culprit lesions of ACS in advanced CKD patients. CN was associated with poor outcome in advanced CKD patients.
Road map fusion imaging in PCI reduces contrast medium exposure irrespective of investigator's experience level
Authors: Phinicarides R P , Quast C Q , Afzal S A , Veulemans V V , Klein K K , Berisha N B , Leuders P L , Erkens R E , Jung C J , Boenner F B , Kelm M K , Zeus T Z , Polzin A P
Published: November 2023

Background/Introduction

Dynamic Coronary Roadmap (DCR) is a software tool that creates a real-time dynamic coronary artery overlay on the fluoroscopic image. Its efficacy in significantly reducing contrast medium use during percutaneous coronary interventions (PCI) has already been shown.

Purpose

The purpose of this study is to investigate whether the positive effects of DCR persist irrespective of the investigator’s experience level.

Methods

In this sub-analysis of a monocentric, open-label, randomized trial, 130 patients with hemodynamically relevant coronary type A and B lesions were randomized (1:1 ratio) and conducted with or without DCR software. PCI was randomly allocated and performed by an investigator with high (A) or medium (B) experience level.

Results

Overall, the primary endpoint contrast medium use was significantly reduced by both investigators in the +DCR group (Investigator A: –DCR 68.62 +/- 23.86ml vs. +DCR 43.39 +/- 21.91ml; Investigator B: –DCR 70.80 +/- 31.77ml vs. +DCR 29.46 +/- 12.26ml, p < 0.0001). With the software, Investigator B used significantly less contrast medium than Investigator A (p = 0.0468). The DCR software is not accompanied by increased radiation exposure for the patients or the teams. On the contrary, the dose area product was reduced by both investigators but was significantly reduced with DCR in the highly experienced investigator (Investigator A: –DCR 2415.25 +/- 1413.30 cGycm² vs. +DCR 1727.17 +/- 1148.69 cGycm², p = 0.0284). Fluoroscopy time was not different between investigators. Procedural success was 100%. Serious in-hospital adverse events were not observed. One patient of Investigator A suffered from post-procedural acute kidney injury in the –DCR group.

Conclusion(s)

DCR significantly reduces contrast medium use during PCI irrespective of the investigator’s experience level. Efficacy and safety do not differ between investigators’ experience levels. Whether these excellent results can also be translated into more complex lesion settings has to be evaluated in future trials.Operating principle of DCRPrimary and secondary endpoints
Impact of revascularization on non-flow limiting lesions
Authors: Boerhout C K M , Van De Hoef T P , Piek J J
Published: November 2023

Background

Physiology-guided decision-making markedly improves outcomes in patients with coronary artery disease (CAD). The fractional flow reserve (FFR) and the coronary flow reserve (CFR) can be used to estimate the reduction in myocardial blood flow by a stenosis and both were validated against non-invasive modalities to identify ischemia. Nevertheless, discordance between FFR and CFR in stenosis classification occurs in 30-40%. Recent studies showed that patients with non-flow limiting lesions (abnormal FFR, normal CFR) deferred from revascularization had similar outcomes to those vessels that underwent revascularization.

However, the direct impact of revascularization in these vessels remains unclear.

Purpose

We aimed to identify the impact of revascularization in vessels with non-flow limiting lesions (abnormal FFR and normal CFR).

Methods

We selected those patients with non-flow limiting lesions from the global ILIAS Registry, a comprehensive pooled data set of patients whom underwent clinically indicated coronary angiography and complete physiological assessment. The primary outcomes consist of the composite endpoints of MACE and TVF at 5-year follow-up.

Results

A total of N=526 patients were included in the current analysis. Mean age was 64±10 and 74% were men. The mean FFR was 0.79±0.09 and the mean CFR 2.38±1.12. Of these, 53% (N=276) underwent revascularization and (47%) had no revascularization of the target vessel during the index procedure. Both groups had a similarly increased risk for MACE and TVF at 5-years (HR 2.4 [95% CI 1.6 – 3.5] and HR 2.2 [95% CI 1.5 – 3.4] respectively, p<0.005 for both, and p=0.787 for the difference between both).

Conclusions

We found that revascularization did not impact the association between non-flow limiting lesions and MACE or TVF at 5-year follow-up. Although these results should be interpreted with caution, it indicates the need for a more inclusive assessment of coronary hemodynamic when considering revascularization therapy.Figure 1
Clinical outcomes of physiology-guided coronary revascularization in patients undergoing TAVR
Authors: Matsuo Y , Wada T , Nishi T , Kuwabara K , Tanaka A
Published: November 2023

Background

Coronary artery disease frequently coexists with severe aortic valve stenosis (AS). Although an fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in native coronary artery has been shown to be associated with better clinical outcomes as compared with an angiography-guided PCI, it is unknown whether this applies to severe AS patients.

Purpose

The purpose of this study was to compare the outcomes of different revascularization strategies between FFR-guided and angiography-guided PCI in AS patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

In this retrospective analysis, we included 401 patients with severe AS undergoing TAVR who had coexisting coronary artery disease at invasive coronary angiography. A total of 156 patients was considered to have significant coronary artery lesions (>50% of diameter stenosis) due to the visual estimation. Patients were divided into 2 groups: physiology-guided (n=96, PCI performed in case of FFR ≤0.80 or diameter stenosis ≥90%) and angiography-guided PCI (n=60, PCI performed based on angiographic evaluation). Patients were clinically followed up and evaluated for the occurrence of major adverse cardiac and cerebrovascular event (MACCE; defined as a composite of death, non-fatal myocardial infarction, target vessel failure, and cerebrovascular accident) and major bleeding event defined as ≥VARC-3 type 2.

Results

Most lesions (62/96; 65%) in the physiology-guided group had negative results and were deferred. During a median follow-up of 743 [from 400 to 1,186] days, physiology-guided group had a significantly lower rate of MACCE compared with the angiography-guided groups (adjusted hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.20-0.83; P<0.01). In addition, physiology-guided group showed a lower major bleeding event rate compared with the angiography-guided group (adjusted HR, 0.12; 95% CI, 0.04-0.40; P<0.01).

Conclusion

Physiology-guided PCI resulted in better clinical outcomes and lower bleeding events than angiography-guided PCI in patients with AS undergoing TAVR.
Incremental prognostic value of metabolic dysfunction-associated fatty liver disease over coronary computed tomography angiography findings in patients with suspected coronary artery disease
Authors: Nishihara T , Miyoshi T , Nakashima M , Miki T , Osawa K , Yoshida M , Toda H , Nakamura K , Ito H
Published: November 2023

Background

Fatty liver caused by nutritional metabolic disorders regardless of other chronic liver diseases has been proposed as a new liver disease concept, metabolic dysfunction-associated fatty liver disease (MAFLD). With the alteration from non-alcoholic fatty liver disease to MAFLD, MAFLD can be recognized as higher CVD risk. However, the association of MAFLD with adverse coronary CT angiography (CCTA) findings, such as the presence of obstructive and high-risk plaque, and cardiovascular events has not been fully elucidated.

Purpose

This study was aimed to investigate additional risk stratification benefits of MAFLD diagnosed by hepatic steatosis assessed during CCTA in patients with suspected coronary artery disease (CAD).

Methods

A total of 2289 patients without a history of CAD who underwent CCTA in our institute from August 2011 and December 2016 were enrolled. Hepatic steatosis, defined on CT as a hepatic-to-spleen attenuation ratio of <1.0, was examined just before the evaluation of CCTA. Adverse CCTA findings were defined as obstructive and/or high-risk plaque. The major adverse cardiovascular events (MACE) were composite coronary events including cardiovascular death, acute coronary syndrome, and late coronary revascularization. The incremental predictive value of MAFLD was evaluated using the global chi-square values and C-statistic.

Results

Among 2289 patients (60% men, mean age 68 years), MAFLD was identified in 382 (17%) patients. The presence of adverse CCTA findings in patients with MAFLD was significantly greater than that in patients without MAFLD (40% and 35%, p=0.039). During a median follow-up of 4.4 years, 103 (4.4%) MACE were observed. In the multivariate Cox regression analysis, MAFLD was significantly associated with MACE in a model included traditional risk factors and adverse CCTA findings (HR 1.73, 95%CI 1.10–2.72, P = 0.017). The Kaplan–Meier analysis showed that patients with both MAFLD and adverse CCTA findings had highest event rates compared with patients without MAFLD or adverse CTA findings (log rank test, p=0.004). By adding MAFLD to a prediction model including adverse CCTA findings, the global chi-square values and C-statistic significantly increased from 80.6 to 86.2 (P = 0.017) and 0.72 to 0.74 (P = 0.044), respectively.

Conclusions

MAFLD concurrently assessed during CCTA enables more accurate detection of patients at higher risk of MACE In patients with suspected stable CAD.
Impact of transfusion on platelet aggregation and biomarkers in myocardial infarction patients with anemia: an ancillary study of the randomized REALITY trial
Authors: Silvain J , Lattuca B , Puymirat E , Ducrocq G , Dillinger J G , Lhermusier T , Cachanado M , Drouet E , Abergel H , Danchin N , Montalescot G , Simon T , Steg P G
Published: November 2023

Importance

Higher rates of thrombotic events have been reported in patients with myocardial infarction (MI) requiring blood transfusion. The impact of transfusion strategies on biomarkers of thrombosis and inflammation is still unknown.

Objective

Compare the impact of a liberal vs a restrictive transfusion strategy in anemic MI patients on P2Y12 mediated platelet reactivity and biomarkers of thrombosis and inflammation.

Design and Setting: Prespecified ancillary study of the multicentric randomized REALITY trial, performed in 6 French centers between February 2018 and September 2019 (Figure). Patients randomized to a liberal (hemoglobin ≤10g/dL) or a restrictive (hemoglobin ≤8g/dL) transfusion strategy had platelet reactivity measured at baseline and after randomization.

Participants: One hundred anemic acute MI patients from the REALITY trial (666 randomized patients).

Measurements: Measurements of platelet reactivity included a centralized blinded VASP-PRI assay and PRU measured locally using encrypted VerifyNow assay. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the two randomized groups.

Results

Among 100 patients included (n=50 in each group), the most frequent P2Y12 inhibitors used was clopidogrel (48%) while 16% of the patients did not receive any P2Y12 inhibitors. Transfused patients received on average 2.4±1.6 units of packed red blood cells. We found no differences between groups in change in P2Y12-mediated platelet aggregation before and after randomization, measured either by the VASP PRI (difference 4.3%; 95% CI (-5.4% to 14.1%)) or by the PRU (difference 23.5; 95% CI (-20.8 to 67.8)). Similar results were found in transfused patients (n=71) regardless of the randomized group, VASP PRI (difference 1.6%; 95% CI (-6.7% to 10.0%)) or PRU (difference -17.6; 95% CI (-41.0 to 5.7)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF and TNF-α.

Conclusion and Relevance

A liberal or a restrictive transfusion strategy does not impact platelet reactivity and biomarkers in MI patients with anemia, supporting the lack of clinically relevant difference in thrombotic risk between both strategies.
Vitamin D status and 12-year mortality risk after myocardial infarction
Authors: Cruijsen E , Van Pijkeren C S , Evers I , Visseren F L J , Geleijnse J M
Published: November 2023

Introduction

Vitamin D deficiency has been associated with an increased risk of cardiovascular disease (CVD) mortality in healthy populations. Whether this association is also present in patients with established CVD is not yet clear.

Purpose

We examined the association of serum 25-hydroxyvitamin D [25(OH)D] as an indicator of vitamin D status with 12-year risk of CVD and all-cause mortality in post-myocardial infarction (MI) patients.

Methods

A prospective analysis was carried out in 4,479 Dutch patients from the Alpha Omega Cohort (aged 60-80 y) who had an MI ≤10 y prior to study enrolment. Non-fasting venous blood was sampled at baseline (2002-2006) for the assessment of 25(OH)D using LC-MS/MS. Patients were followed for cause-specific mortality through December 2018. Hazard ratios (HRs) for CVD and all-cause mortality were obtained in sex-specific 25(OH)D tertiles using Cox regression models, adjusted for age, education, physical activity, smoking status, alcohol intake, adherence to dietary guidelines (i.e. 2015 Dutch Healthy Diet index [DHD15]), prevalent diabetes and kidney function (eGFR). Restricted cubic splines (RCS) analysis was performed for continuous associations, using median 25(OH)D as the reference.

Results

Patients were 69.0 ± 5.6 y old, 78% was male, 17% were current smokers, 18% had diabetes and 8% used vitamin-D containing supplements. A total of 2,091 deaths occurred during a median follow-up period of 12.4 y (49,529 person-years), including 924 from CVD as a primary or contributing cause. Median 25(OH)D was 21.3 ng/mL, and tertile cut-offs were 18.3 and 26.2 ng/mL for males and 15.2 and 22.0 ng/mL for females. Of the cohort, 44% were vitamin D deficient (<20 ng/mL). Lower risks of CVD mortality were observed in the mid tertile (HR: 0.76, 95%CI:0.65-0.88) and upper tertile (HR: 0.67, 95%CI:0.57-0.79) of 25(OH)D, compared to the lower tertile. RCS showed a roughly linear association (P-non-linearity = 0.08), with a 11% lower risk of CVD mortality per 5 ng/mL-increment in 25(OH)D (HR: 0.89, 95%CI: 0.86-0.93). Inverse associations were more pronounced in patients with a higher calcium intake (>845 g/d; 0.87, 95%CI:0.96-0.98; per 5 ng/mL) and in patients who were more physically active (HR: 0.88, 95%CI: 0.83-0.93; per 5 ng/mL). Exclusion of 378 vitamin D supplement users did not materially change the associations. For all-cause mortality, multivariable HRs were 0.74 (95%CI: 0.67-0.82) in the mid tertile, and 0.65 (95%CI: 0.58-0.73) in the upper tertile, compared to the lower tertile.

Conclusion

A low vitamin D serum concentration is related to a higher risk of recurrent CVD and all-cause mortality in patients with coronary artery disease. Causality remains to be determined preferably in a clinical trial to evaluate the effect of oral suppletion of vitamin D on recurrent CVD and mortality risk in these patients.
Treatment of microvascular angina with the coronary sinus reducer: a first experience
Authors: Gnan E , Cioffi G M , Bossard M , Madanchi M , Majcen I , Zhi Y , Gjergjizi V , Seiler T , Cuculi F , Attinger A
Published: November 2023

The Coronary Sinus Reducer (CSR) is an hourglass-shaped device approved for the treatment of refractory angina. Its percutaneous implantation in the coronary sinus leads to a retrograde increase in venous pressure, which is thought to improve capillary recruitment and perfusion to the ischemic myocardium. No data is however available on the use of the CSR to treat microvascular angina, an increasingly recognized but still poorly understood condition. In this preliminary study, we evaluated the efficacy of the CSR in a small cohort of patients with non-obstructive disease.

We screened consecutive patients from the prospective COMPLEX registry that received a CSR for refractory angina between June 2018 and November 2022. Inclusion criteria were the absence of obstructive coronary artery disease (<50% narrowing in all coronary arteries, or a negative intracoronary fractional flow reserve test) and no prior history of revascularization. Endpoints were angina and dyspnea symptoms, evaluated with the Canadian Cardiovascular Society (CCS) and the New York Hearth Association (NYHA) scores respectively, procedural success rate, and major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, cardiovascular death, acute coronary syndromes (ACS) and heart failure (HF) hospitalizations.

We ultimately enrolled 8 patients; 6 (75%) were females and mean age was 67.8±9.9 years. Their baseline characteristics are further depicted in table 1. Microvascular dysfunction was invasively confirmed in 5 (62.5%) patients; mean index of microvascular resistance (IMR) was 32.8±15.7 and mean coronary flow reserve (CFR) was 1.7±0.7. In one patient, reduced global CFR (1.4) was evident on cardiac magnetic resonance examination. At baseline, mean CCS class was 2.9±0.6, NYHA class 2±0.9, and number of antianginal drugs 2.6±1.6. Procedural success was 100%, with only one patient experiencing a procedure-related complication (sternocleidomastoid muscle hematoma requiring no intervention). At a median follow-up of 647.5 days (IQR 132-732), mean CCS class was 1.5±0.8, NYHA class 1.9±0.9 and number of antianginal drugs 1.9±1.1. All patients improved by ≥1 CCS class and 3 (37.5%) by ≥2 CCS classes. No MACE was observed.

To the best of our knowledge, we present the first report of CSR implantation for the treatment of microvascular angina. Our positive results are particularly promising given the paucity of treatment options currently available for the condition, but larger studies are needed to confirm these findings.table 1figure 1
Optimal antiplatelet therapy for patients after antiplatelet therapy-induced gastrointestinal bleeding: when to resume?
Authors: Huang R , Xiao B , Ye Z S , Cheng R , Han Z , Wu S S , Wang G X , Li Z Y , Liang T , Zhang S T
Published: November 2023

Background

Adjusting antiplatelet strategies after antiplatelet-associated gastrointestinal bleeding (GIB) is a complex clinical challenge. there is no uniform answer to the question of when it is safe to restart antiplatelet therapy after GIB.

Objective

To assess the risk of outcomes at different times of resumption of antiplatelet therapy and explored the optimal time to resume therapy.

Methods

The study analyzed consecutive patients with antiplatelet-associated GIB from our hospital information system between October 2019 and June 2022. The primary outcomes were recurrent bleeding, major adverse cardiovascular and cerebrovascular events (MACE), and all-cause death. Multivariate-adjusted Cox proportional hazards models were used to evaluate the risks of these outcomes. The receiver operating characteristic curve was used to find the optimal time to resume treatment.

Results

Of the 617 patients with GIB after antiplatelet therapy successfully followed up, the median follow-up was 246 (interquartile range: 120–466) days, The mean age was 68.38 ± 10.68 years, 70.99% were male, and the age-adjusted Charlson comorbidity index score was 7.16 ± 1.96 points. Most patients (87.36%) interrupted therapy after GIB and 45.22% resumed within 90 days, of which 35.13% resumed within 7 days and 64.87% resumed after 7 days. Resumption therapy had a low risk of recurrent bleeding (uninterrupted as a reference: HR 0.32, 95% CI 0.15–0.67, p = 0.003), MACE (no resumption as a reference: HR 0.66, 95% CI 0.45–0.98, p = 0.037), and all-cause death (no resumption as a reference: HR 0.18, 95% CI 0.08–0.40, p＜0.001). And resuming therapy within 7 days had a lower risk of MACE (HR 0.18, 95% CI 0.08–0.44, p＜0.001) than after 7 days without a significantly higher risk of re-bleeding. The optimal time point for resuming therapy in this study was 9 days.

Conclusion

Resuming antiplatelet therapy after GIB provides a higher net clinical benefit. Early resumption of antiplatelet therapy (<7 days) significantly reduces the risk of MACE events. Although the risk of re-bleeding is increased, it is not statistically significant and has good clinical benefit. After analyzing the composite endpoint events, 9 days might be the optimal time to resume therapy for the antiplatelet population, especially for the single antiplatelet population. Our study provides new clinical data for the antiplatelet population after GIB to help physicians make better clinical decisions.
Computed tomography plaque analysis identifies residual inflammation in recent acute myocardial infarction patients
Authors: Wang X , Yew M S , Adamson P D , Chan M Y Y , Raffiee N A S , Yap H T , Loong Y T , Elankovan A , Leng S , Huang W , Lee H K , Teo L L S , Zhong L , Hausenloy D J , Baskaran L
Published: November 2023

Introduction

Residual inflammatory risk (RIR) following acute myocardial infarction (AMI) patients is associated with recurrent major adverse cardiovascular events. Atherosclerotic plaque quantification using computed tomographic coronary angiography (CTCA) can specifically identify inflamed plaque characteristics. We compared plaque burden and tissue composition in AMI patients with those of stable coronary artery disease (CAD) patients to identify imaging markers of RIR.

Purpose

We aimed to identify signs of residual inflammation in recent AMI patients via CTCA atheroma quantification. We hypothesised that recent AMI patients have plaque characteristics suggestive of inflammation.

Methods

108 patients recruited from multiple sites with AMI <1 month were propensity-matched via CAD risk factors (age, gender, diabetes, hypertension, hyperlipidaemia, smoking and family history of CAD) with stable CAD patients in a 1:1 ratio. Propensity matched recent AMI and stable CAD patient cohorts had similar profiles: age (60±9.7 vs 57±10.0 years), gender (91.7% vs 92.6% male), diabetes (13.9% vs 15.7%), hypertension (44.4% vs 50.9%) and hyperlipidaemia (50.9% vs 63.9%, p>0.05 for all). Total plaque burden (total lesion volume/total vessel volume) and plaque composition (fibrous fatty [fibrofatty, FF, 31 – 130 HU], necrotic core [NC, -30 – 30 HU], fibrous [131 – 350 HU] and calcium [> 350 HU]) were extracted from CTCA scans and aggregated per patient. Culprit lesions of recent AMI patients were excluded from the analysis due to the fact that coronary stents would affect plaque characterisation. Multivariate linear regression, corrected for CAD risk factors, was used to compare these parameters between the two cohorts.

Results

Recent AMI patients and stable CAD patients had similar total plaque burden (β=0.001±0.013, p=0.950, Figure 1a). Patients with recent AMI had higher non-calcified plaque volume ratio (β=0.071±0.026, p<0.05, Figure 1b) due to higher FF (β=0.094±0.019, Figure 1d) and NC (β=0.025 ± 0.005, Figure 1e) plaque volume (p<0.05 for all), but less fibrous plaque volume (β = -0.048±0.019, p<0.05, Figure 1c).

Conclusions

Recent AMI patients had a greater non-calcified plaque burden than stable CAD patients due to larger FF and NC plaque burden. Since FF and NC components indicate ongoing inflammation in the plaque, while fibrous content indicates resolved inflammation; increased NC and FF burden suggest increased coronary plaque inflammation in non-culprit lesions of recent AMI patients, supporting the presence of residual inflammation in recent AMI patients.Figure 1