bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of the pullback pressure gradient (PPG) on PCI planning and decision-making
Authors: Sonck J , Munhoz D , Mizukami T , Tajima A , Sakai K , Storozhenko T , Biscaglia S , Rivero F , Engstrom T , Van Nunen L , Fearon W , Fournier S , Leone A M , De Bruyne B , Collet C
Published: October 2024

Background

Coronary physiology using a distal measurement of fractional flow reserve (FFR) informs about the severity of coronary artery disease (CAD) and, when used for clinical decision-making about revascularisation, is associated with improved outcomes in patients considered for PCI. A second dimension of coronary physiology is available by performing a pullback maneuver, which aids in assessing the presence and location of focal pressure gradients. Yet, the impact of intracoronary physiology guidance with FFR pullbacks on real-time physician decision-making during PCI is not fully known.

Methods

This prospective study was performed at 25 sites and enrolled patients with at least one epicardial lesion with FFR ≤ 0.80 planned to be treated by PCI. A standardized physiological assessment with FFR pullbacks and Pullback Pressure Gradient (PPG) calculation was performed. Treatment plans were recorded for each lesion based on angiography alone and following FFR pullbacks. The goal of this study was to assess the procedural impact of physiology guidance in stable patients scheduled for PCI.

Results

Overall, 993 patients (1044 vessels) underwent complete physiological assessment with FFR and PPG. Decision-making during PCI changed in 47.5% (443/1044) after FFR pullbacks. Decision-making during PCI changed in 32.4% (289/890) after FFR pullbacks. PPG use changed revascularisation decisions in 13.9% (138/993) from PCI to CABG (5%; 50/993), from PCI to CABG in 5% (50/993) and to medical management in 8.9% ( 88/993). The frequency of decision changes was significantly higher in patients with diffuse CAD compared to focal cases (24.8% vs. 44.2%, p < 0.001). Among the subset of 855 patients (involving 880 vessels) who underwent PCI, operators modified decision-making regarding stent length in 22.1% of cases (197 out of 880), with these alterations being more prevalent in patients with diffuse CAD (57.2% vs. 46.3%, p = 0.002). Suboptimal Post-PCI result (FFR < 0.88) was more frequent in cases in which PCI strategy was not adapted based on PPG (55.5% vs. 45.6%, p= 0.016) Importantly, there was no significant change in the overall number of stents per patient after FFR pullbacks.

Conclusion

A standardized coronary physiological assessment impacted PCI decision-making in one-third of the vessels, with a predominant effect in vessels diffusely diseased. The assessment of the distribution of pressure losses along the coronaries modifies the treatment decision and influences PCI strategy in a significant proportion of patients. These findings provide insights into mechanisms by which coronary physiology might improve PCI outcomes.PCI strategy change based on PPGCumulative change of PCI strategy
Gender differences in coronary artery disease patterns
Authors: Brouwers S , Munhoz D , Storozhenko T , Sakai K , Arslani K , Engstrom T , Collison D , Desta L , Yong A , Adjedj J , Escaned J , Nakayama M , Berry C , De Bruyne B , Collet C
Published: October 2024

Background

Gender differences in clinical presentation, natural history, and prognosis of coronary artery disease (CAD) have been reported. Fractional flow reserve (FFR) has also been shown to yield higher values in women than men. However, the gender differences in CAD patterns (focal vs diffuse) defined by coronary physiology remain to be studied.

Methods

This prospective study was performed at 23 sites and enrolled patients with at least one epicardial lesion with an FFR ≤ 0.80 intended to be treated by PCI. All patients underwent a standardized physiological protocol that mandated FFR pullbacks with pullback pressure gradient (PPG) calculation. The aim was to compare CAD patterns, defined by PPG, between genders.

Results

Overall, 1004 patients were included in the analysis, 236 females (250 vessels) and 768 males (794 vessels). Women were older (69.8 ± 10.3 vs. 67.0 ± 10.1, p <0.001), less frequently smokers (9.7% vs. 18.6%, p = 0.002), had less prior PCI in a non-target vessel (19.1% vs. 30.6%, p = 0.001) and had less prior MIs (14.4% vs. 21.5%, p = 0.021). On the baseline seven-item Seattle Angina Questionnaire (SAQ-7), females reported more physical limitation (70.9 ± 29.5 vs. 80.9 ± 25.1, p < 0.001), more frequent angina (76.7 ± 22.9 vs. 81.5 ± 20.3, p = 0.002) and a lower quality of life (51.8 ± 29.4 vs. 57.8 ± 29.1, p = 0.006) than men for the same degree of flow reduction (FFR 0.69 ± 0.12 vs. 0.67 ± 0.11, p=0.098). In women, the pattern of CAD demonstrated a more focal nature compared to men (PPG 0.65 ± 0.16 vs. 0.61 ± 0.16, p = 0.001). Also, women achieved higher post-PCI FFR (0.88 ± 0.07 vs. 0.87 ± 0.07, p = 0.02). The rate of periprocedural MI was not statistically different between genders (5.1% vs. 5.8%, p = 0.79)

Conclusion

Among patients with hemodynamically significant CAD, women report more symptoms and lower quality of life. Despite sharing a similar degree of flow impairment, women exhibited a more focal CAD phenotype than men, leading to superior physiological outcomes after PCI.Study flowchartPRO and Phisiology by gender
Statins have profound effects on the epicardial fat transcriptome
Authors: Hellman U , Buren J , Karlsson M , Olsson T , Soderberg S
Published: October 2024

Background

Epicardial adipose tissue (EAT) has direct contact with the myocardium, which enables a common microcirculation allowing bidirectional signaling between the tissues. It is possible that a change in the balance of protective and damaging mediators produced by EAT is a major driver for myocardial dysfunction. Notably, EAT volume and thickness associate with increased pro-inflammatory secretome and with coronary artery disease (CAD).

Purpose

This aim of this study was to analyze the total transcriptome in EAT and relate putative differences between patient groups to metabolic parameters as well as ongoing medications.

Methods

Between 2011 and 2016, 44 patients (mean age 68.0 years, 18.2% women) had a biopsy taken from the epicardial fat during coronoray by-pass surgery (CABG, n=36), or during elective aortic valvular replacement due to aortic stenosis (AVR, n=8). RNA from epicardial fat biopsis was extracted and sequenced. Differentially expressed genes were obtained by custom scripts that performed a negative binomial distribution test on effective counts. Multivariate regression analysis with orthogonal partial least-squares-discriminant analysis (OPLS-DA) was applied to extract and interpret the systematic variation in the resolved RNA sequencing profiles. To identify enrichment of biologically relevant functional gene sets, our data were entered in evidence-based network enrichment analysis (EviNet).

Results

The CABG surgery was performed approximately 7 days after an acute coronary event (75% acute MI), and 44% of them had previously known CAD. None of the AVR cases had significant CAD. At surgery, 97% of the CABG cases were prescribed statins, and 36% of them had statins alredy before the actual admission (long-term statin treatment). 63% of the AVR cases were on statins at admission.

The OPLS analysis revealed only one medication with significant outcome, i.e., patients with long-term treatment with statins (n=18) versus patients without (n=26). Long-term statin treatment associated with down-regulated gene expression involved in beta-oxidation and triglyceride biosynthesis whereas gene expression involved in extracellular matrix organization were up-regulated. Gene expression involved in MHC class II presentation and interferon signalling were also reduced in patients with long-term treatment with statisn. A downregulation of genes in the interleukin- and complement cascade genes among CABG patient (versus AVR patients) without long-term statin treatment showed normal levels in statin pretreated patients.

Conclusion

Long-term statin treatment has a major influence on transcriptional regulation of genes involved in beta-oxidation, triglyceride biosynthesis, extracellular matrix composition, MHC class II presentation and interferon signalling in epicardial adipose tissue. These findings support important metabolic and immune effects of statins beyond the lipid-lowering function.
Impact of microvascular resistance reserve on post-STEMI cardiac remodelling and diastolic function
Authors: Tsai T , Aldujeli A , Hag A , Knokneris A , Hughes D , Unikas R , Onuma Y , Serruys P
Published: October 2024

Background

Coronary microvascular dysfunction (CMD) is a common sequelae of ST-segment elevation myocardial infarction (STEMI), preventing adequate recovery of left ventricular (LV) perfusion. The interferences of con-commitment epicardial stenosis or hyperemic hemodynamic alterations limit traditional physiologic metrics. The microvascular resistance reserve (MRR) was developed to overcome these shortcomings.

Purpose

We aim to investigate the association between post-STEMI MRR, and the ensuing left ventricle (LV) diastolic dysfunction, and functional remodeling.

Methods

In this prospective, observational study, we enrolled STEMI patients with multivessel disease who successfully underwent primary percutaneous coronary intervention (PCI). At three months post-PCI, all patients received complete revascularization followed by coronary physiology assessment using the bolus thermodilution method to measure the fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR). MRR was calculated using the formula: MRR = (CFR/FFR) × (Pa rest/Pa hyper), where Pa rest and Pa hyper represent resting and hyperemic aortic pressure, respectively(1). CMD was defined as an MRR < 3.0 based on Boerhout et al(2). Diastolic dysfunction was defined according to the ASE 2016 guidelines. Functional LV remodelling (FLVR) was categorized according to Chimed et al(3). The relationship between CMD and the stages of FLVR and diastolic dysfunction was scrutinized over a 12-month follow-up period.

Results

We enrolled 210 patients, of whom 125 (59.5%) were men with a median age of 65 (IQR: 58–76). At the 3-month follow-up, the MRR was 3.46 (IQR 3.00, 3.92), with 56 (26.7%) patients having CMD (MRR<3.0). MRR is significantly correlated with the change of LVEF between primary PCI and 12 months (r=0.48, p<0.001, Fig1A). CMD patients have lower LVEF at 12 months (50.00% vs. 40.00%; p < 0.001) and demonstrated significantly less recovery in LV systolic function (-10.00% vs. 8.00%; p < 0.001, Fig 1B, 1C). CMD patients had a higher prevalence of grade 2 or 3 LV diastolic dysfunction (65.38% vs. 3.95%; p < 0.001, Fig 2A) and a higher incidence of advanced FLVR (Groups 3 and 4) compared to those without CMD (30.77% vs. vs. 10.53%; p < 0.001, Fig 2B). In multivariable logistic regression analysis, MRR was independently associated with LV diastolic dysfunction (0.17, 95%CI 0.08-0.33, p<0.001).

Conclusions

The novel parameter MRR is significantly related to LVEF recovery in STEMI patients and is an independent predictor for advanced LV diastolic dysfunction and FLVR. CMD patients, as diagnosed with MRR, showed a higher prevalence of advanced FLVR and diastolic dysfunction. These results suggest that MRR is a useful parameter for the identification and management of CMD in STEMI patients.
A liberal blood transfusion strategy is safe in patients with myocardial infarction, anemia, and heart failure: lessons from MINT
Authors: Goldsweig A M , Kostis W , Herbert B M , Benatar J , Bouleti C , Figueiredo E L , Huynh T , Potter B , Sims D B , Strom J B , Torosoff M , Vallurupalli S , Carson J L , Brooks M M , Alexander J H
Published: October 2024

Background

In patients with acute myocardial infarction (MI) and anemia, the Myocardial Ischemia and Transfusion (MINT) trial found a trend toward increased 30-day death or recurrent MI with a restrictive compared with a liberal blood transfusion strategy. Patients with and without heart failure (HF) may respond differently to blood transfusion.

Purpose

To characterize the effects of restrictive vs. liberal transfusion strategies on clinical outcomes in patients with MI and anemia with and without baseline HF.

Methods

In the MINT trial, 3504 patients with MI and hemoglobin <10 g/dL were randomized to restrictive (7-8 g/dL) or liberal (10 g/dL) transfusion thresholds. We compared outcomes between patients with and without baseline HF, defined as any history of HF, acute HF, or baseline left ventricular ejection fraction (LVEF) <45%. Outcomes included death or incident HF, death or recurrent MI, death, and incident HF, all at 30 days.

Results

Compared with patients without baseline HF (n=1633), patients with baseline HF (overall n=1871 (history of HF n=1066, acute HF n=780, LVEF <45% n= 1099) were older, more frequently male and Black, and had higher rates of prior PCI, diabetes, and hypertension. In the restrictive strategy, patients with and without baseline HF received an average of 0.63 and 0.80 units of blood and had a median LOS of 6 and 4 days, respectively. In the liberal strategy, patients with and without baseline HF received an average of 2.44 and 2.49 units of blood and had a median LOS of 5 and 4 days, respectively. Patients with baseline HF had higher rates of death or incident HF (18.0% vs. 10.0%, risk ratio [RR]=1.79 [95% confidence interval {CI} 1.50-2.13]), death or recurrent MI (17.6% vs. 13.5%, RR=1.31 [95% CI 1.12-1.53]), and death (10.5% vs. 7.5%, RR 1.41 [95% CI 1.14-1.75]). Among patients with baseline HF, a restrictive transfusion strategy resulted in a trend toward an increase in death or HF and death or MI compared with a liberal transfusion strategy (Table, Figure). Among patients without baseline HF, the risk of incident HF was lower with restrictive than with liberal transfusion strategy.

Conclusions

Among patients with MI and anemia, a restrictive transfusion strategy resulted in a greater increase in death or HF, death or MI, and death in patients with baseline HF than in patients without baseline HF. A liberal transfusion strategy is safe for patients with MI and anemia, including those with prior or acute HF.TableFigure
Effect of nutritional guidance on mortality and composite endpoints in patients with acute myocardial infarction: a single center retrospective cohort study
Authors: Abe H , Miyazaki T , Ajima T , Yasuda K , Ishiwata S , Maki M , Shimai R , Aikawa T , Isogai H , Ozaki D , Takasu K , Takamura K , Yokoyama K , Tokano T , Mianmino T
Published: October 2024

Background/Introduction

Acute myocardial infarction (AMI) stands as a major global cause of mortality. Various intervention strategies, such as pre-hospital care, reperfusion therapies, pharmacological interventions, dietary modifications, and exercise therapies, have been researched to improve patient prognosis (1,2). While reports suggest the efficacy of the Mediterranean diet, there remains a lack of evidence regarding the impact of nutritionist-led dietary guidance on the prognosis of AMI patients.

Purpose

This study aimed to elucidate whether nutritional guidance by nutritionists who have national qualifications would improve the mortality and the primary composite endpoint (including acute decompensated heart failure, stroke, and acute coronary syndrome) of patients following an acute myocardial infarction.

Methods

A retrospective cohort study was conducted, enrolling 446 consecutive AMI patients who underwent emergency coronary angiography and percutaneous coronary interventions between September 1, 2015, and October 31, 2023. Patients meeting the universal definition of myocardial infarction were included (3). After excluding 37 in-hospital deaths, evaluations for all-cause mortality, cardiovascular mortality, and composite endpoints were performed during follow-up in 409 patients. Nutritionists guided 223 patients (54.5%) during hospitalization in this study. The nutritional guidance used in our study was also based on the definition of adequate caloric intake of 25–30 kcal per ideal body weight (kg). Under an appropriate total energy intake, a fat energy ratio of 20–25% and a carbohydrate energy ratio of 50–60% are recommended, with protein and lipid restrictions depending on the disease state.

Results

During a median follow-up of 39 months, 24 cases of all-cause mortality (5.9%) and 6 cases of cardiovascular mortality (1.5%) were recorded. Additionally, 15 cases of nonfatal stroke (3.7%), 17 cases of nonfatal acute coronary syndrome (4.2%), and 20 cases of hospitalizations for acute decompensated heart failure (4.9%) were observed. Kaplan–Meier curves demonstrated significantly higher incidence rates of death and primary composite endpoints among patients without nutritional guidance. The multivariate Cox regression model incorporated all variables exhibiting statistically significant associations with long-term mortality, and the primary composite endpoints. The multivariate Cox regression model revealed nutritional guidance as a significant predictor for long-term mortality but not for primary composite endpoints.

Conclusion

Nutritional guidance for AMI patients may improve overall mortality. Further research is warranted to explore the physiological impacts of improved diets resulting from such guidance and their effects on enhancing prognosis.
Utility of telephone text messages in secondary prevention after acute coronary syndrome
Authors: Lozano Martinez-Luengas I , Morena Salas D , Alvarez Gonzalez C , Garcia Moreira V , Rondan Murillo J , Berizde N , Vegas Valle J M , Enguita Del Toro M I
Published: October 2024

Introduction

The recurrence of events in patients after an acute coronary syndrome (ACS) represents a great challenge for the health systems due to its high prevalence, morbidity and mortality, and cost. For this reason, secondary prevention measures with low cost and easy to implement are necessary. The objective is to evaluate the usefulness of telephone text messages (TTM) in the control of risk factors and reduction of events in the first year after an ACS.

Methods

Single-blind 1:1 randomized clinical trial in consecutive patients discharged with ACS between May 2019 and October 2021 in our center. The intervention group received a monthly TTM for 12 months with the recommendations of the Spanish Society of Cardiology regarding secondary prevention measures. Both groups followed the usual review protocol of our center in a specific ischemic heart disease consultation at 3 and 12 months after discharge. The center lacks cardiac rehabilitation. The objectives of the study at 12 months were: total and cardiovascular death, myocardial infarction, stroke, weight, blood pressure, LDL, HDL, triglycerides, glycosylated hemoglobin, smoking habit, and hours of exercise per week. The evaluator in charge of collecting data after the end of the year was unaware of the assignment group.

Results

N= 370. The patient profile was the usual one for ACS, with a mean age of around 65 years and 25% diabetic, with no differences in any of the baseline characteristics between both groups. An invasive approach was performed in almost all of the subjects, with percutaneous intervention in three-quarters of the cases and also without significant differences in the type of treatment, percentage of multivessel disease, and left main disease between both groups. Only a lower number of stents per patient was recorded in the control group. There were also no differences in medical treatment between both groups. The results are shown in the table.

Conclusions

In our study, monthly TTM had no influence on the control of risk factors or clinical events during the first year of follow-up after an ACS, and therefore it is not cost-effective to allocate resources for this purpose.
Integrating international lifestyle management of acute coronary syndrome and type 2 diabetes mellitus: a rapid review of guidelines
Authors: Kemp B J , Thompson D R , Coates V , Bond S , Ski C F , Monaghan M , Mcguigan K
Published: October 2024

Background

The rising prevalence of comorbidity has been described as an international health priority. There has been a dramatic increase in the levels of Type 2 Diabetes Mellitus (T2DM) among those with Acute Coronary Syndrome (ACS), with approximately 25-40% of patients admitted to hospital for ACS, also having diabetes. Comorbid ACS-T2DM provides a more complex set of symptoms for patients and clinicians to manage, and health policy makers to plan for. Those living with comorbid ACS-T2DM are at increased risk of death, another heart attack, re-hospitalisation, heart failure, reduced physical and psychological health, increased health service use and poorer quality of life.

Due to shared disease determinants such as obesity, low physical activity levels and poorer dietary habits; individuals with ACS are more likely to have a comorbid T2DM. Care for patients with comorbidities is fragmented, siloed and poorly organised as it reflects a tradition of single disease management meaning comorbidity is rarely considered. Robust evidence is required to shape provision and guidance for those with comorbid ACS-T2DM and the clinicians involved in their care; with an emphasis on redesigning service provision and practice to address the needs of this growing population.

Purpose

To identify opportunities in existing clinical guidance to improve integrated care strategies and streamline management for those with comorbid ACS-T2DM.

Methods

Following Cochrane rapid review recommendations, a Population, Concept, and Context (PCC) framework guided eligibility. Guidelines for adults with ACS, T2DM, or both conditions in high-income countries were considered. Nineteen guidelines from the UK, Australia, Canada, Europe, Ireland, New Zealand, and the USA were compared, covering ACS (n = 10), T2DM (n = 6), and comorbid ACS-T2DM (n = 3). Lifestyle factors examined included diet/nutrition, physical activity, weight management, clinical and psychological aspects.

Results

The review identified consistent lifestyle recommendations for both ACS and T2DM, with overlaps in guidance for diet, physical activity, weight management, clinical, and psychological factors. The findings offer opportunity for integrated care strategies, potentially reducing duplicated lifestyle management efforts. The results lay the groundwork for more cohesive management of comorbid ACS-T2DM.

Conclusions

This research is relevant for healthcare providers, policymakers, and patients living with comorbid ACS-T2DM. Understanding the shared lifestyle factors provides valuable insights into the potential for integrated care. Recognising the overlap in existing clinical guidelines points to opportunity for a more streamlined and effective approach to managing comorbid ACS-T2DM. This knowledge can contribute to improved patient outcomes and seek to optimise healthcare resources.
Impact of teleconsultation follow-up to control low-density-lipoprotein cholesterol at one year after acute coronary syndrome: the teleobjectif prospective cohort study
Authors: Lemaitre A , Cauvin J , Albot A , Rebouh I , Schwob L , Heudel T , Legallois D , Roule V , Blanchart K , Bignon M , Joubert M , Beygui F , Milliez P U , Sabatier R , Lemaitre F
Published: October 2024

Context

High level of low-density lipoprotein cholesterol (LDL-c) is one of the most important causal and independent risk factor for recurrent atheromatous cardiovascular events. Despite the availability of several treatments that can reduce LDL-c by up to 85%, less than 30% of patients achieve the LDL-c target < 0.55 g/dl, recommended by the European Society of Cardiology for secondary cardiovascular prevention.

Aim

We hypothesized that teleconsultation monitoring would allow better control of LDL-c blood levels at one year in a population after acute coronary syndrom (ACS).

Methods

This bi-centric prospective cohort study, conducted between december 2019 and december 2021, compared a group that received standard follow-up after an ACS with an interventional group that received regular follow-up by teleconsultation, in addition of usual care, to optimise lipid-lowering treatments.

Results

1602 patients met the inclusion criteria for our study (814 in the usual care group and 788 in the teleconsultation group). The proportion of patients with LDL-c < 0.55 g/L at one year was statistically significant in the teleconsultation group (74.7%) compared with the usual care group (26.6%) (p<0.001). The average (standard deviation) absolute value of LDL-c at 1 year was 0.48 g/L (0.2) in the teleconsultation group and 0.75 g/L (0.32) in the usual care group (p<0.001). In the multivariate analysis, receiving teleconsultation follow-up made it more likely to achieve the LDL-c target (4.88 [4,09 ; 5,85], p<0.001). The use of lipid-lowering treatments, including statins, ezetimibe and anti-PCSK9 inhibitors was much higher in the teleconsultation group (p<0.001). There was a significant difference in overall survival (p=0.016) and cardiovascular survival (p=0.013) in favor of the teleconsultation group.

Conclusion

teleconsultation follow-up after ACS significantly improved lipid control and survival at one year.% patients achieving 1-year LDL-c targetOverall survival
Impact of systolic coronary flow reversal in patients with aortic stenosis: assessment with transthoracic echocardiography
Authors: Suzuki W , Fujimoto M , Mukai K , Ohashi H , Kunimura A , Nakano Y , Ando H , Amano T
Published: October 2024

Background

In patients with aortic stenosis (AS), increased systolic wall stress due to increased afterload reduces systolic coronary flow, often leading to systolic coronary flow reversal (SFR) in epicardial coronary arteries.

Purpose

We used transthoracic echocardiography (TTE) to evaluate severity of AS, left ventricular function, and coronary flow, and investigated echocardiographic indicators associated with SFR.

Methods

We prospectively evaluated consecutively presenting patients who visited our valvular heart disease outpatient clinic or were admitted to our hospital for investigation of AS (July 2023 to February 2024). Based on ESC guidelines, severity of AS and the left ventricular function were assessed with TTE. At the same time, TTE was used to measure distal left anterior descending coronary artery flow. SFR was defined as the presence of a reversal coronary flow component in systole. Based on the presence or absence of SFR in coronary flow measurements, patients were classified into SFR+ or SFR− groups. The inclusion criteria were AS of moderate or greater severity, and the exclusion criteria were known coronary stenosis and the inability to assess coronary flow.

Results

Enrolled 28 patients were classified into SFR+ (7 patients) and SFR − (21 patients) groups. Comparing baseline characteristics between the SFR+ and SFR− groups, although there were no significant differences in left ventricular indicators such as left ventricular mass index, left ventricular ejection fraction, stroke volume index, and E/e’ between the two groups, left ventricular global longitudinal strain was significantly lower in the SFR+ group (12.0±3.1%, 14.9±3.0%, p=0.026) (Table 1). Regarding indexes of AS assessment, aortic valve peak velocity and aortic valve mean pressure gradient values were significantly higher in the SFR+ group than in the SFR − group ([475±68 cm/s, 379±55 cm/s, p<0.001] and [56.2±16.5 mm Hg, 34.8±10.5 mm Hg, p<0.001], respectively) (Table 1). Representative cases show Figure 1.

Conclusion

The presence of SFR in patients with AS assessed using TTE may be a simple echocardiographic index that may be associated with potential decline in left ventricular function and progression of AS.
Acute echocardiographic assessment of patients with ST-elevation myocardial infarction in detecting clinically hidden hemodynamic deterioration
Authors: Holle S , Frydland M , Hassager C , Engstroem T , Moeller J E , Loenborg J , Linde J , Bang L , Holmvang L , Soeholm H
Published: October 2024

Background

Transthoracic echocardiography (TTE) offers an immediate non-invasive assessment of cardiac morphology and function that can be performed bedside. Acute TTE in the catheterization laboratory (cath.lab.) may be helpful to identify markers of subsequent development of cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) in addition to the previously validated ORBI risk score. This relationship has not been investigated thoroughly previously.

Purpose

To investigate the association between acute TTE estimates of left ventricular (LV) function prior to primary percutaneous coronary intervention (pPCI) in STEMI patients and pro-B-type natriuretic peptide (proBNP) as a proxy associated with of CS development.

Method

From September 2023 all non-CS STEMI patients at one tertiary heart center underwent acute bedside TTE in the cath.lab. and ORBI risk score assessing the risk of CS development aiming for inclusion of 500 patients. The 5 minutes TTE-protocol consisted of LV ejection fraction (EF), LV outflow tract velocity time integral (LVOT VTI), mitral inflow (E and E/A), mitral deceleration time, and mitral annular early diastolic velocity é lateral. The primary endpoint was proBNP measured 24 hours (h) after pPCI (12-36h) stratified in quartiles (Q4 vs. Q1-3). The correlation between proBNP and TTE measurements and proBNP and ORBI risk score was examined using univariate linear regression models.

Results

Until now 153 STEMI patients (mean age 64 years, 25% female) were studied. Anterior STEMI was present in 36%, and median time from cath. lab. arrival to first wire over the culprit lesion was 28 minutes (IQR 24; 37). Patients with high proBNP level (Q4 vs. Q1-3) had significantly higher heart rate (median 84 bpm vs. 72 bpm) and Killip Class>1 (16% vs. 0%) at admission, but similar lactate levels (1.8mM vs. 1.5mM), systolic blood pressure (130 mmHg vs. 137 mmHg), and out-of-hospital cardiac arrest (11% vs. 12%). Patients with high proBNP levels (Q4 vs. Q1-3) had significantly lower LVEF (35% vs. 50%), higher E/é lateral (median 11.4 vs. 7.9), and higher ORBI risk score (median 8 vs. 4). LVEF, LVOT VTI, E/é lateral, and ORBI risk score were significantly associated with proBNP (Figure 1). Two patients developed CS after the pPCI; one with high proBNP level Q4, and one deceased prior to proBNP measurement.

Conclusion

Acute TTE is an easy tool for assessment of the acute hemodynamic status in STEMI patients bedside in the cath.lab., and it can be without delaying time to revascularization. LVEF, LVOT VTI, E/é lateral, and ORBI were all parameters associated with increased levels of the hemodynamic biomarker proBNP, and may together with the ORBI risk score improve the assessment and risk stratification of STEMI-patients at risk of CS-development.Figure 1.
Prospective comparison of temporal myocardial function in men vs women after anterior ST-elevation myocardial infarction
Authors: Jha S , Shekka Espinosa A , Molander L , Poller A , Sevastianova V , Simons K , Gudmundsson T , Bobbio E , Zeijlon R , Thorild P , Andersson A , Salahuddin S , Skoglund K , Omerovic E , Redfors B
Published: October 2024

Background

Compared to men, women have been reported to have increased morbidity and mortality after ST-elevation myocardial infarction (STEMI), but sex differences in cardiac function in the acute and subacute phases of STEMI are incompletely understood.

Objective

To prospectively compare changes in cardiac function over the acute and subacute phases after anterior STEMI with timely reperfusion in women versus men.

Methods

The Stunning in Takotsubo versus Acute Myocardial Infarction (STAMI) study prospectively enrolled 94 men and 36 women with anterior STEMI. Echocardiography and blood sampling were performed within 4 hours of admission and at 1, 2, 3, 7, 14 and 30 days after admission. The primary outcome was akinesia recovery, defined as the difference in the per cent akinesia observed at baseline versus follow-up. Secondary outcomes included wall motion score index (WMSI), left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Mixed effects linear regression or zero-inflated tobit models with random intercepts were used to model echocardiographic parameters over time.

Results

Baseline patient characteristics were similar in both groups. The difference between women and men in akinesia recovery at 30 days was 8.4% (95% confidence interval [CI] 1.23-14.99). The covariate-adjusted Bayesian posterior probability that akinesia recovery and WMSI improvement at 30 days are more significant in women than men were 95% and 99%, respectively. Similar but less pronounced trends towards greater improvement in women than men were observed for LVEF and GLS.

Conclusions

After anterior STEMI with timely reperfusion, cardiac dysfunction recovered to a greater extent in women than in men.
Concomitant cardiac arrest on cardiogenic shock patients. Differences in clinical profile and outcomes with non-cardiac arrest patients. The Shock CAT Study
Authors: Garcia-Garcia C , Casquete D , El Ouaddi N , Andrea R , Sanz E , Sanchez-Salado J C , Aboal J , Pastor P , Buera I , Sionis A , Lopez T , Rodriguez J , Ariza A , Baneras J , Rueda F
Published: October 2024

Background

Mortality on cardiogenic shock (CS) remains undesirable, although CS patients with or without concomitant CA may have different prognoses and clinical profile.

Purpose

The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mid-term mortality in CS patients with and without cardiac arrest on admission in a Mediterranean cohort.

Method

Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS), in-hospital and 6 months mortality were analysed comparing patients with and without CA at admission.

Results

A total of 382 CS patients (p) were included: CA 34.8% (n=133 p) and non-CA 65.2% (n=249 p). CA patients were younger than non-CA (61.9 vs 67.4 years, p<0.001) with higher prevalence of men (82% vs 71.8%, p= 0.024). Acute coronary syndrome was the main CS cause (60.7%) and ST elevation myocardial infarction (STEMI) was higher in CA patients than non-CA (55.6% vs 42.6%, p<0.001). In CA group, time to recover of spontaneous circulation was 24 min (IQR: 14-40 min) and hypothermia was performed in 55% of cases. CA patients had less prevalence of cardiovascular risk factors (hypertension, diabetes and dyslipidaemia) and lower pH at admission (7.19 vs 7.31, p<0.001) and higher lactate peak (6.9 vs 5.0, p=0.001) than non-CA patients. MCS was implanted in 35.3% of all CS patients, with lower use in CA patients (23.3% vs 41.8%, p<0.001), mainly due to lower intraaortic balloon pump (19.5% vs 35.5%, p=0.001), without differences in the use of extracorporeal membrane oxygenation (ECMO) (11.4% vs 8.7%, p=0.40) or Impella (10.6% vs 12.8%. p=0.54). Cardshock score was higher in CA patients than non-CA (4.68 vs 4.2, p=0.038), without differences in IABP score (2.31 vs 2.20, p= 0.621) or SCAI D/E (42.1% vs 33.3%, p= 0.090). In-hospital mortality was higher in CA patients (42.9% vs 27.7%, p=0<0.001). Moreover, 6-months mortality remains higher in CA than non-CA patients, although without statistical significance (47.7% vs 38.3%, p=0.079).

Conclusions

In a Mediterranean CS cohort, concomitant CA patients were younger, with higher prevalence in men with STEMI. MCS had a lower used in CA patients, although without differences in ECMO or Impella. In-hospital mortality was 35% higher in CA patients than non-CA, although 6-months mortality only trend to be higher in CA group.
VA-ECMO-related complications seem not causally related to mortality in patients with acute myocardial infarction complicated by cardiogenic shock
Authors: Thevathasan T , Freund A , Akin I , Fichtlscherer S , Zeymer U , Feistritzer H J , Poess J , Jobs A , Jung C , Skurk C , Rassaf T , Ouarrak T , Schneider S , Thiele H , Desch S
Published: October 2024

Background

Recently published randomized controlled trials and an individual patient data meta-analysis showed that the routine use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) did not reduce mortality compared to medical therapy alone in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS).

Purpose

The aim of this study was to investigate as to whether possible VA-ECMO-related medical complications might be associated with an increased mortality risk, which might explain the observed equipoise among mortality outcomes between VA-ECMO and usual care in patients with AMI-CS.

Methods

Using data from the randomized ECLS-SHOCK trial (Extracorporeal Life Support in Infarct-Related Cardiogenic Shock), which compared routine VA-ECMO use versus medical therapy alone. Causal mediation analyses (primary analysis; VA-ECMO-related complications used as a mediator), logistic regression and causes of death analyses (secondary analyses) were utilised to test potential effects of possible VA-ECMO-related complications on 30-day mortality. Analyses were adjusted for risk factors of bleeding and vascular complications.

Results

In total, 417 patients were included in this analysis. Moderate and severe bleeding as well as peripheral vascular complications requiring intervention were identified as possible VA-ECMO-related complications. A total of 88 patients (21.1%) developed possible VA-ECMO-related complications, which mostly occurred within five days after randomisation and more frequently in the VA-ECMO group than in the control group: 49 (23.4%) vs. 20 (9.6%) patients, p<0.001 for bleeding and 23 (11.0%) vs. 8 (3.8%) patients, p=0.01 for peripheral vascular complications, respectively. Causal mediation analyses revealed no significant mediation effect of possible VA-ECMO-related complications on 30-day mortality (p=n.s.; Figure). Logistic regression and causes of death analyses of possible VA-ECMO-related complications confirmed no significant associations between the incidence of VA-ECMO-related complications and mortality (p=n.s.).

Conclusion

VA-ECMO use in patients with AMI-CS was associated with increased incidences of moderate to severe bleeding as well as vascular complications warranting intervention. In this causal mediation analysis, VA-ECMO-related complications do not appear to mediate an increased mortality risk.
Early risk stratification of patients with acute myocardial infarction complicated by severe cardiogenic shock - The ECLS-SHOCK Risk Score
Authors: Thevathasan T , Freund A , Kresoja K P , Akin I , Fichtlscherer S , Zeymer U , Feistritzer H J , Poess J , Jobs A , Jung C , Skurk C , Ouarrak T , Schneider S , Thiele H , Desch S
Published: October 2024

Background

Prognosis after acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains dismal. Timely risk stratification is crucial to make adequate treatment decisions. Existing CS scores are limited to either registry data, included not readily available parameters (such as coronary flow after revascularisation, cystatin C or interleukin-6), or are not tailored to patients with AMI-CS.

Purpose

The aim of this study was to develop a readily available and easy-to-use risk prediction tool for 30-day mortality in patients with severe AMI-CS derived from the ECLS-SHOCK (Extracorporeal Life Support in Infarct-Related Cardiogenic Shock) trial.

Methods

Backward stepwise regression analysis was used to develop the risk score across 43 centres in two countries.

Results

Five variables emerged as independent predictors for 30-day mortality and were used as risk score parameters: age ≥69 years, female sex, ≥3 known cardiovascular risk factors (i.e., hypertension, dyslipidaemia, diabetes, smoking or known vascular disease), baseline arterial lactate ≥7.1 mmol/L and performed resuscitation. Between 1 and 7 points were attributed to each variable, resulting in a score with three risk categories: low (0 to 1), intermediate (2 to 3) and high (4 to 7) (Figure). The observed 30-day mortality rates were 23%, 50% and 80% in each risk category (p<0.001) with a good discrimination at an area under the curve of 0.75. A stepwise increase in mortality between the different risk score categories was observed in Kaplan-Meier analyses (p<0.001 for low vs. intermediate, intermediate vs. high and low vs. high; see Figure).

Conclusion

The ECLS-SHOCK risk score can be easily and promptly calculated in daily clinical practice and correlated with mortality in patients with severe AMI-CS. It may help stratify patient risk for short-term mortality and facilitate early clinical decision making.
Embolic myocardial infarction. Clinical characteristics, etiology, and prognosis
Authors: Calvo-Barcelo M , Rife E , Mila L , Buera I , Vidal M , Sambola A , Uribarri A , Bach-Oller M , Vila R , Tobias P E , Belahnech Y , Garcia-Del-Blanco B , Ferreira I , Barrabes J A
Published: October 2024

Introduction

A small proportion of acute myocardial infarctions (AMI) are of embolic origin. There is limited information about the actual causes of these AMIs, the population they affect, and their prognosis.

Purpose

The purpose of this study is to describe the clinical characteristics of embolic myocardial infarction (EMB-AMI) and compare them with atherosclerotic myocardial infarction (ATH-AMI).

Methods

Retrospective observational study of patients admitted for AMI at our centre (2010-2022). Clinical characteristics, ethology, and prognosis are described, and the EMB-AMI cohort is compared with the ATH-AMI cohort.

Results

Out of 6046 AMIs, 75 (1.2%) were EMB-AMI. Cardiovascular risk factors were similarly distributed in both groups, except for a higher rate of smokers, males, and older age in the ATH-AMI group (figure 1). Additionally, EMB-AMIs more frequently presented as ST-elevation myocardial infarctions.

Hospital mortality for EMB-AMI and ATH-AMI was 10.7% vs. 6.2% (p=0.177), and the rate of mechanical complications was higher in the EMB-AMI group (6.7% vs. 1.8%, p=0.009). Of the EMB-AMIs, 8 (10.7%) had other systemic emboli during admission, including a 5.3% of strokes (vs. 1.4% in the ATH-AMI group, p=0.021).

In EMB-AMIs, coronary embolism was multivessel in 8 (10.7%) patients, 46 (61.3%) had distal vessel involvement, and 66 (88.0%) had initial TIMI 0 flow. Thrombectomy was performed in 51 (68%) patients, with 82% of them being successful. However, final TIMI was 0-1 in 36 (48%) patients and 3 in 32 (42.7%) patients. Angioplasty was performed in 12 (16.0%) patients.

In 52 (67.5%) EMB-AMI patients, atrial fibrillation (AF) was diagnosed at some point during follow-up, and in 43 (57.3%), embolism was exclusively attributed to AF. Nine (12.0%) embolisms were attributed to prosthetic thrombosis, although thrombosis was confirmed by imaging in only one third of cases. Six (8%) embolisms were attributed to endocarditis, and 5 (6.7%) to patent foramen ovale. Rest of embolism causes detected are outlined in figure 2.

During a mean follow-up of 44.8 months, 11 patients experienced new embolic events in the EMB-AMI cohort: 7 strokes, 2 probable coronary embolisms, and 2 systemic embolisms. Twenty-seven (36.0%) patients died during follow-up (38.4% of whom from cardiac causes), and 18 (24.0%) were admitted for heart failure.

Conclusions

EMB-AMI exhibits specific clinical characteristics distinct from ATH-AMI, with varied etiologies, with atrial fibrillation being the most common cause. These AMIs are associated with a higher incidence of complications, including mechanical complications of myocardial infarction and recurrence of embolic events.Characteristics and outcomesEmbolic source
Incidence of MINOCA in the high-sensitivity troponin era: a meta-analysis
Authors: Howden N , Mikhail P , Jeyaprakash P , Meere W , Rowe I , Jaensch S , Bland A , Beltrame J , Ford T J
Published: October 2024

Background and Aim

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is often under-recognised in clinical practice. The reported incidence of MINOCA was estimated to be 6% of MI presentations by Pasupathy et al. in the era preceding adoption of high sensitivity troponin assays. We sought to investigate the incidence of MINOCA in the high-sensitivity troponin era as compared to incidence of MINOCA during the era of traditional cardiac biomarkers (standard troponin assays, CK, CK-MB).

Methods

A prospective systematic review and meta-analysis using MEDLINE and EMBASE to capture relevant papers from 1996-2022 was performed. Papers detailing incidence of MI-CAD and MINOCA as well as the utilised biomarkers were included. Patient demographics, presentation and recorded biomarkers were also analysed for pre-specified analysis.

Results

47 studies detailing the results of 667 850 patients were included. 53 586 patients were identified to have MINOCA with a mean weight incidence of 9.1% (7.3-11.3, 95% CI). MI-CAD patients were more likely to be male (68.5% vs 39.3%, RR (0.59, 0.74)) and had higher incidence of traditional cardiac risk factors. Notably chronic kidney disease was not associated with higher incidence of MICAD over MINOCA (RR 0.72, 0.5-1.03). There were no significant trends in incidence of MINOCA according to median year of study recruitment (ß=-0.18, (-0.76, 0.4) p=0.537). MINOCA patients were more likely to present as NSTEMI (14.5% (11.3-18.3, 95%CI)) rather than STEMI (3.5% (2.7-4.7%)). MINOCA patients had lower cardiac biomarker elevations than patients with MICAD.

Conclusions

The incidence of MINOCA higher than previously estimated in the era of high sensitivity troponin. MINOCA patients are less likely to have traditional cardiac risk factors and more likely to present with NSTEMI and smaller cardiac biomarker elevations than patients with MI-CAD.MINOCA RateMINOCA vs MI-CAD Risk Factors
Difference in long-term mortality after takotsubo syndrome. The role of gender, socioeconomic profile, and psychological distress
Authors: Palm P , Wallach-Kildemoes H , Bang L E , Berg S K
Published: October 2024

Background

While Takotsubo Syndrome is less common in men, their mortality rates surpass those of women. The influence of socioeconomic factors and psychological distress, remains unexplored in this context. The aim of the study was: 1) to investigate gender differences in socioeconomic profile, and psychological distress in patients with incident Takotsubo Syndrome. And 2) to investigate gender differences in survival in patients discharged alive after incident takotsubo syndrome when taking into account differences in socioeconomic profile and psychological distress.

Method

A nationwide cohort study using the Danish national registers was performed. All patients discharged alive from Danish hospitals with an incident Takotsubo Syndrome diagnosis between 2008 and 2018 were eligible. Socioeconomic factors covering marital status, cohabitation status, labour market attachment, highest formal education and family income, and psychological distress was explored, and compared. Multivariable Cox-regression models were performed to assess the mortality risk.

Results

A total of 662 patients with Takotsubo Syndrome were discharged alive from Danish hospitals. Of those, 79 (11.9%) were men with a median age of 67 years (IQR 62-77). Men with Takotsubo Syndrome were socioeconomically disadvantaged compared to their women counterparts, and this disparity was also reflected in mortality rates. Secondly, mortality within three years after an incident Takotsubo Syndrome diagnose was higher among men than women, HR 2.19, 95%CI 1.04-4.61, most pronounced among men with a low family income, HR 2.08, 95% CI 1.03-4.18, and increase in comorbidity score, HR 1.23, 95% CI 1.06-1.43.

Conclusion

Results unveiled notable gender differences in the socioeconomic profile of individuals diagnosed with TS. Furthermore, the identified gender disparities in mortality can be attributed to socioeconomic and sociodemographic factors, the use of psychiatric medication as an indicator of psychological distress, and a greater comorbidity burden.Survival according to socioeconomy