bluuebunny/crossref_metadata_2025 huggingface dataset:
Association of heart failure readmission with results of lung ultrasound at discharge and follow-up
Authors: Zisis G , Yang Y , Whitmore K , Lay M , Huynh Q , Neil C , Carrington M , Marwick T H
Published: October 2021

Background

Attainment of euvolemia at discharge and maintaining it after discharge are fundamental to avoiding readmission in heart failure (HF). Lung ultrasound (LUS) is potentially of value to detect congestion but the role of sequential LUS is undefined.

Purpose

To determine the predictive value of discharge and follow-up LUS.

Methods

98 pts (mean age 72.8±12.3, mean ejection fraction 41.4%±18.4, gender male 56%) admitted with HF or fluid overload, underwent pre-discharge LUS to evaluate pulmonary (presence of ≥10 B lines) and peripheral (IVC diameter) congestion. LUS was repeated at home follow-up visits at 2 weeks post-discharge. Associations were sought between pre-discharge and follow-up LUS and 90 day outcomes (readmission or mortality).

Results

Overall, there was an increase in the total number of B-lines from baseline to week 2 [mean change in B-lines 3.82 [95% confidence intervals (CI), 0.30, 7.33) p=0.036] followed by a small decrease between scan 2 and scan 3 [mean change in B-lines −0.25 (95% CI, −0.17, 7.68), p=0.94]. Of 73 with <10 B-lines pre-discharge, 26 (36%) had events by 90 days, compared with 14 of the 25 with ≥10 pre-discharge B-lines (56%, p=0.07). However, all of those with ≥10 B lines at 2 weeks had events, compared with 25% of those with <10 B lines (p=0.04).

Conclusions

Attainment and preservation of euvolemia after index hospitalization for HF is challenging and requires appropriate patient support. Detection of residual congestion, as well as detection of early re-congestion after hospital discharge.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The University of MelbourneBaker Heart & Diabetes Institute Readmission risk ratio
Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era
Authors: Nan Tie E , Dinh D , Clark D , Ajani A E , Brennan A , Cohen N , Dagan M , Shaw J , Sebastian M , Freeman M , Oqueli E , Reid C , Kaye D , Stub D , Duffy S J
Published: October 2021

Background

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.

Purpose

This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.

Methods

Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.

Results

Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (<35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p<0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p<0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).

Conclusions

Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group
Incidence, predictors and prognostic role of complications occurring during provocative testing with acetylcholine in patients with myocardial ischemia and non-obstructive coronary arteries
Authors: Montone R A , Rinaldi M , Del Buono M , Camilli M , Gurgoglione F , La Vecchia G , Iannaccone G , Russo M , Caffe' A , Trani C , Lanza G A , Niccoli G , Crea F
Published: October 2021

Background

Coronary provocative test with acetylcholine (ACh) is of utmost importance and increasingly used in patients with myocardial ischemia and non-obstructive coronary arteries. However, data on safety, predictors and prognostic role of complications during intracoronary provocative testing are scarce.

Purpose

We assessed the safety of ACh provocative test in patients with myocardial ischemia and non-obstructive coronary arteries. Moreover, we evaluated the predictors and the prognostic implications of complications occurring during the provocative test.

Methods

We prospectively enrolled consecutive patients undergoing intracoronary ACh provocative test for suspected myocardial ischaemia with angiographic evidence of non-obstructive coronary arteries. Complications during the ACh test were collected. Occurrence of major adverse cardiac events (MACE), arrhythmic events at 24-hours ECG dynamic Holter monitoring and angina status were assessed at follow-up.

Results

We enrolled 310 patients (mean age 60.6±11.9; 169 [54.5%] chronic coronary syndromes [CCS] and 141 [45.5%] with myocardial infarction and non-obstructive coronary arteries [MINOCA]). The overall incidence of complications was low (9%) with a similar incidence in MINOCA and CCS (10 [7.1%] vs 18 [10.7%], p=0.276, respectively). At multivariate logistic regression analysis, a previous history of paroxysmal atrial fibrillation (Odds Ratio [OR] 12.324, Confidence Interval [CI] 95% [4.641; 32.722], p=0.015) and moderate/severe diastolic dysfunction (OR 3.827, CI95% [1.296; 11.304], p=0.015) were independent predictors for occurrence of complications. The occurrence of complications was not associated with a worse clinical outcome at follow-up (median follow-up 22 months) in terms of both MACE, arrhythmic events and angina burden.

Conclusion

Intracoronary provocative testing with ACh test is safe in patients with myocardial ischemia and non-obstructive coronary arteries, without differences between MINOCA and CCS. History of paroxysmal atrial fibrillation and moderate/severe diastolic dysfunction predicted the occurrence of complications during ACh test. Of importance, our data can reassure clinicians, as the occurrence of complications did not portend a worse prognosis at follow-up in terms of MACE, arrhythmic events and angina burden.

Funding Acknowledgement

Type of funding sources: None. Complications and clinical presentationClinical outcome at follow-up
The De-Ritis ratio is associated with contrast-associated acute kidney injury in patients undergoing elective percutaneous coronary intervention
Authors: He H , Rao J , Lin M , He C , Zhang S , Luo M , Lin K , Guo Y
Published: October 2021

Background

Preoperative liver dysfunction has been demonstrated as a poor prognostic factor after major surgery. Recent researches discovered that an increased De-Ritis ratio (aspartate aminotransferase-to-alanine aminotransferase ratio) reflects the liver dysfunction and was associated with adverse cardiovascular and renal outcomes. However, there is a lack of data exploring the predictive value of the De-Ritis ratio on contrast-associated acute kidney injury (CA-AKI) in patients undergoing elective percutaneous coronary intervention (PCI).

Purpose

To evaluate the predictive value of the De-Ritis ratio for CA-AKI in patients undergoing elective PCI.

Methods

We conducted a prospective, observational study with 5780 consenting patients undergoing elective PCI from January 2012 to December 2018. CA-AKI was defined as an increase in serum creatinine (SCr) ≥50% or 0.3 mg/dL within 48 hours after contrast medium exposure. The relationship between the De-Ritis ratio and CA-AKI was investigated by logistic regression analysis. The predictive utility of the De-Ritis ratio was determined and compared using the area under the receiver-operating characteristic curve (AUC).

Result

CA-AKI developed in 363 (6.3%) patients. The median De-Ritis ratio was 1.00 (0.77–1.33). The De-Ritis ratio showed an AUC of 0.636 (95% confidence interval (CI): 0.624–0.649; P<0.001) in predicting CA-AKI, which was significantly greater than aspartate aminotransferase (AST) (AUC: 0.636 vs 0.589, p=0.015) and alanine aminotransferase (ALT) (AUC: 0.636 vs 0.506, p<0.001). The best cut-off value of the De-Ritis ratio for predicting CA-AKI was 1.30 with 47.1% sensitivity and 74.7% specificity. Multivariable logistic analysis showed that the De-Ritis ratio >1.30 was a remarkable independent predictor of CA-AKI (OR=1.757, 95% CI, 1.385–2.229, p<0.001) even after adjusting for other CA-AKI risk factors.

Conclusion

The De-Ritis ratio is an independent risk factor for predicting CA-AKI in patients undergoing elective PCI.

Funding Acknowledgement

Type of funding sources: None. ROC for De-Ritis ratio to predict CA-AKIPredictors of CA-AKI
Comparison of clinical outcomes between percutaneous coronary intervention for the de novo lesion versus in-stent restenosis lesion
Authors: Takeuchi M , Dohi T , Fukase T , Nishio R , Takahashi N , Endo H , Doi S , Kato Y , Okai I , Iwata H , Okazaki S , Isoda K , Miyauchi K , Minamino T
Published: October 2021

Background and objective

Percutaneous coronary intervention (PCI) with metallic coronary stent (bare-metal stents [BMS] and drug-eluting stents [DES]) implantation is most frequently performed therapeutic procedures for coronary artery disease. In-stent restenosis (ISR) is a critical drawback of metallic coronary stents. Incidence of ISR has been reported in up to 30% after BMS implantation. The use of DES has greatly reduced the proportion of restenosis compared with the BMS. However, ISR still remains the primary concern after PCI even in the contemporary DES era, and thought to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare.

Purpose

The aim of the present study was to compare the clinical outcomes after PCI for the de novo lesion and the ISR lesion.

Methods

We performed a retrospective analysis of patients who underwent PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death were evaluated. MACCE was defined as composite of cardiovascular death, non-fatal myocardial infarction, and stroke.

Results

In this study, 1538 patients were enrolled and divided into two groups: PCI for de novo lesion group (n=1258, 81.8%), and PCI for ISR lesion group (n=280, 18.2%). Patients in the ISR lesion group were significantly older and had higher prevalence of hypertension, diabetes mellitus, dyslipidemia and chronic kidney disease than patients in the de novo lesion group. During a median follow-up period of 1.9 years, Kaplan-Meier curves showed no significant differences in the incidences of MACCE (log-rank, p=0.86) and all-cause death (p=0.84) between two groups. After adjustment for other covariates, PCI for ISR lesion were not significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI], 0.61–1.97; p=0.76) and all-cause death (HR, 0.93; 95% CI, 0.56–1.56; p=0.79)

Conclusion

PCI for the ISR lesion was not associated with worse clinical outcomes compared with PCI for the de novo lesion.

Funding Acknowledgement

Type of funding sources: None.
Contemporary management strategies and outcomes in patients with Non ST elevation myocardial infarction
Authors: Orso F , Casolo G , Szasz C , Forni S , D'Arienzo S , Gemmi F
Published: October 2021

Background

Non-ST-elevation myocardial infarction (NSTEMI) is a condition that is associated with a high morbidity and mortality burden. The aim of the present study is to analyze clinical characteristics and outcomes of a large contemporary population of NSTEMI patients according to treatment strategy in a large administrative database.

Methods

This retrospective observational study included patients living in the region of Tuscany, aged 18 years or older who were discharged from a regional hospital with a diagnosis of NSTEMI (principal diagnosis ICD-9-CM codes 410.7 or 411.1 in HDA) between January 2016 and December 2018. According to management strategy patients were classified in two main groups: a conservative strategy (CON) group and an invasive strategy (INV) group which was further categorized in three subgroups: a PCI group, a CABG group and a group were patients were invasively managed but medically treated.

Results

The study population was composed by 15.208 patients. Mean age was 76±9 years, with 50% aged 75+ years, females were 38.5%. Management strategies groups composition was: CON strategy 24.9% and among INV strategy (75.1%) 67.3% were treated by PCI, 8.8% by CABG and 24% were invasively managed but medically treated. Compared to INV managed patients, patients in the CON group were older (mean age 85 vs 72 years, p<0.0001), more frequently female (54% vs 33%, p<0.0001), had a higher cardiovascular and non-cardiovascular comorbidity burden (eg. hypertension, diabetes, heart failure, atrial fibrillation, renal insufficiency, cancer, dementia and COPD, all <0.0001). In-hospital, 30-days and 1-year all-cause mortality rates (Figure) were 3%, 4.9% and 15.3% resulting significantly higher in the CON management strategy group compared to the INV strategy group: 8.9% vs 1.1; 14.0 vs 1.9%; all p<0.0001. Analyzing all-cause mortality rates among the three INV subgroups we found no differences both in-hospital and at 30 days, while at 1-year we found, all-cause mortality there was a significant difference among the three groups with a slightly higher mortality rate in the INV medically treated group compared to the PCI and the CABG subgroups: 8.9% vs 7.2% vs 7.5% respectively, p=0.011.

Conclusions

Real-world evidence show that patients with NSTEMI have significantly different characteristics and outcomes according to management strategy. Patients managed non-invasively have more complex features and worse outcomes both in-hospital and post-discharge. Patients which were managed invasively but medically treated represent an interesting subgroup which may deserve further evaluation.

Funding Acknowledgement

Type of funding sources: None.
Elevated soluble lectin-like oxidised low-density lipoprotein receptor-1 (sLOX-1) associated with increased risk for heart failure and MACE after an acute coronary event
Authors: Schiopu A , Svedlund S , Yndigegn T , Varma V , Ongstad E L , Collen A , George R T , Wang X , Goncalves I , Nilsson J , Gan L M
Published: October 2021

Background/Introduction

The lectin-like oxidised low-density lipoprotein receptor (LOX-1) is involved in atherosclerotic plaque inflammation and vulnerability. Plasma levels of soluble LOX-1 (sLOX-1) have previously been associated with increased risk for recurrent coronary events and mortality in patients with acute coronary syndrome (ACS).

Purpose

To assess the association of sLOX-1 with the development of heart failure (HF) post-ACS.

Methods

We measured sLOX-1 in 524 patients with ACS within 24 hours after the acute event. A subgroup of 97 of these patients completed a follow-up echocardiogram after one year. The incidence of HF-related hospitalisation and recurrent major adverse cardiovascular events (MACE), defined as recurrent ACS or cardiovascular death, was followed for a mean period of two years. In a separate cohort of 363 patients with ACS and percutaneous coronary intervention (PCI), we studied the correlations between sLOX-1, coronary flow reserve, left ventricular systolic function and systemic inflammation at two follow-up visits within four weeks and 16 weeks post-ACS, respectively.

Results

Baseline sLOX-1 was positively associated with the risk of HF and MACE, independently of traditional cardiovascular risk factors, revascularisation and medication. The hazard ratios and 95% confidence intervals were 1.57 (1.10–2.23), p=0.012 for HF and 1.36 (1.08–1.71), p=0.009 for MACE per standard deviation baseline sLOX-1 increase. Elevated sLOX-1 was also negatively associated with lower-left ventricular ejection fraction at one year (r=−0.263, p=0.009). In the second ACS cohort, we found that plasma sLOX-1 measured at the two follow-up visits was negatively associated with coronary flow reserve and left ventricular systolic function, and positively correlated with biomarkers of systemic inflammation and cardiac overload.

Conclusion

Elevated sLOX-1 is associated with the development of HF and recurrent cardiovascular events in patients with ACS. Although this association study cannot confirm causality, the results suggest LOX-1 as a potential biomarker and treatment target in patients with ACS.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): • Swedish Research Council • The Swedish Heart and Lung foundation• Swedish Foundation for Strategic Research Dnr IRC15-0067 • Marianne and Marcus Wallenberg Foundation • Bundy Academy at Lund University
Incidence, determinants and impact of acute kidney injury in ACS patients with versus without diabetes mellitus
Authors: Shiyovich A , Skalsky K , Steinmetz T , Eisen A , Samara A , Beigel R , Kornowski R , Orvin K
Published: October 2021

Introduction

Acute kidney injury (AKI) is a common complication in patients presenting with acute coronary syndrome (ACS), particularly following percutaneous coronary intervention (PCI). Patients with diabetes mellitus (DM) are considered to be at increased risk for AKI in this setting. However, data regarding the incidence, risk factors and outcomes of AKI in diabetic patients compared to non-diabetics presenting with ACS is scarce.

Purpose

To evaluate the incidence, risk factors and outcomes of AKI in patients with vs. without DM who are admitted with ACS.

Methods

ACS patients enrolled in the biannual ACS Israeli Surveys (ACSIS) between 2000 and 2018 were analyzed. AKI was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or above 1.5 mg/dL or new renal replacement therapy upon admission with ACS. Outcomes included 30-day major adverse cardiovascular events (MACE) and 1-year all-cause mortality.

Results

The current study included a total of 16,879 patients, median age 64 (IQR 54–74), 77% males, 36% with DM. The incidence of AKI was significantly higher among patients with vs. without DM (8.4% vs. 4.7%, p<0.001). The rates of 30-day MACE (40.8% vs. 13.4%, p<0.001) and 1-year mortality (43.7% vs. 10%, p<0.001) were significantly greater among patients who developed vs. those that did not develop AKI respectively yet very similar in diabetics and non-diabetics.

Multivariate analyses (figure 1) adjusted to potential confounders showed similar independent predictors of AKI among patients with and without DM comprising; older age, chronic kidney disease, congestive heart failure, and peripheral arterial disease

Conclusions

Although patients with DM are at greater risk for AKI when admitted with ACS, the independent predictors of AKI and the worse patient outcomes when AKI occurs, are similar and irrespective to DM.

Funding Acknowledgement

Type of funding sources: None.
Between-hospital variation in outcomes of coronary artery bypass grafting in China, 2013–2019
Authors: Zhang D W , Gu D C , Qu J Y , Zhang H , Zheng Z ,   the Chinese Cardiac Surgery Registry Collaborative Group
Published: October 2021

Background

Coronary artery bypass grafting (CABG) is widely performed across China. Understanding current between-hospital variation is important for further quality improving initiatives.

Purpose

To assess the between-hospital variation comprehensively on outcomes of isolated CABG, and explore hospital-level characteristics and practice patterns explaining the variation.

Methods

We used the data of Chinese Cardiac Surgery Registry (2013–2019) to examine the between-hospital variation of outcomes, including in-hospital mortality (or treatment withdrawal) and major complications (mortality, postoperative myocardial infarction, stroke, renal failure, mediastinal infection, and reoperation for bleeding). Multilevel mixed-effect models and propensity score adjusting technique were used to quantify the variability and study hospital-level factors associated with the variation. Risk-standardized mortality rate (RSMR) was used to classify hospital performance.

Results

Among 60876 patients (62.6 years old, 75.4% male) undergoing isolated CABG in 70 hospitals, the mortality was 2.0% and 5.3% had major complications. After adjusting for patient case-mix, the median hospital RSMR was 2.1% (inter-quartile range [IQR], 1.3%-3.1%), with the median odds ratio (MOR) of 2.1; and 5.7% (IQR, 3.7%-7.5%) for risk-standardized major complications, with the MOR of 1.9. Compared with patients admitted in average-performance hospitals, patients undergoing CABG in worse-performance hospitals had a nearly twofold higher odds of in-hospital mortality (adjusted odds ratio [AOR]=1.92; 95% confidence interval (CI), 1.37–2.69), whereas patients in better-performance hospital had an approximately 60% lower odds (AOR=0.41; 95% CI, 0.30–0.57). Hospital location and average surgeon volume explained 20.2% of the between-hospital variation, where hospital-level perioperative blood transfusion rate and use of secondary prevention medication further contributed to the proportion change variance of 3.3% and 2.3%, respectively. Similar results were obtained for major complications.

Conclusion(s)

Consistent between-hospital variation of CABG performance exists in China. Improving the clinical practice management and reducing variability may better the overall outcomes.

Funding Acknowledgement

Type of funding sources: None.
Long-term prognostic value of non-invasive lesion-specific hemodynamic index
Authors: Yang S Y , Choi G C , Lesina K L , Doh J H D , Zarins C Z , Jegere S J , Erglis A E , Leipsic J L , Taylor C T , Koo B K K
Published: October 2021

Background

With advancement in computational fluid dynamics (CFD) technology, novel lesion-specific hemodynamic parameters can be estimated non-invasively. However, their long-term prognostic implications have not been fully defined.

Purpose

We sought to investigate the ten-year outcomes of lesion-specific hemodynamic indices derived-from coronary CT angiography (CCTA).

Methods

A total of 145 vessels (95 patients) with stable coronary artery disease who underwent fractional flow reserve (FFR) derived by coronary computed tomographic angiography (FFRCT) and invasive FFR measurement was included from the first-in-human study of FFRCT. Study participants were enrolled from October 2009 to January 2011 and were followed up until December 2020. A total of 340 lesions with % diameter stenosis ≥30% were identified, and wall shear stress (WSS) and change FFRCT across the lesion (ΔFFRCT) were obtained using CFD techniques by an independent core laboratory. The optimal cut-off for WSS and ΔFFRCT was applied for outcome analysis. The primary endpoint was target lesion failure (TLF) including cardiovascular death, target vessel myocardial infarction, and target lesion revascularization at 10 years.

Results

The median WSS and ΔFFRCT was 183.3 [112.8; 273.9] and 0.06 [0.03; 0.13]. WSS and ΔFFRCT was mildly correlated with FFRCT (r=−0.18, P=0.001 for WSS; r=−0.36, P<0.001 for ΔFFRCT). Of 179 lesions with deferral of revascularization at the index procedure of FFR measurement, TLF occurred in 16 (8.9%) lesions. In prediction of 10-year TLF, % diameter stenosis (per-lesion) ≥50%, FFRCT ≤0.80, WSS ≥256.1 dyn/cm2, and ΔFFRCT ≥0.06 were significant predictors. However, in multivariate analyses with those predictors, % diameter stenosis (per-lesion) ≥50%, FFRCT ≤0.80 became insignificant, and lesion-specific hemodynamic indices were only predictive of 10-year TLF (adjusted hazard ratio [aHR] 2.66, 95% confidence interval [CI] 0.98–7.22, P=0.055 for WSS ≥256.1 dyn/cm2; aHR 5.88, 95% CI 1.10–33.25, P=0.045 for ΔFFRCT ≥0.06). WSS ≥256.1 dyn/cm2 and ΔFFRCT ≥0.06 had higher information gain in predicting outcomes than % diameter stenosis (per-lesion) ≥50% and FFRCT ≤0.80, and both improved predictability for 10-year TLF risk of the model with % diameter stenosis (per-lesion) ≥50% and FFRCT ≤0.80 (P=0.068 for WSS ≥256.1 dyn/cm2; P=0.011 for ΔFFRCT ≥0.06) (Figure).

Conclusions

Non-invasive lesion-specific hemodynamic indices (i.e., high WSS and high ΔFFRCT) were the robust predictors of 10-year outcomes of a target lesion with incremental predictability over anatomical severity and low FFRCT. Clinical application of non-invasive hemodynamic indices will provide better long-term risk stratification over the current prognostication scheme before an invasive procedure.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott, Philips, HeartFlow
Gender-specific difference of clinical and plaque characteristics in myocardial infarction with non-obstructive artery (MINOCA): insights from optical coherence tomography
Authors: Zeng M , Hu S , Meng W , Zhao C , Wang S , Weng Z , He L , Qin Y , Feng X , Chen X , Xu Y , Yi B , Jia H , Yu B
Published: October 2021

Background

To date, sparse data are available with regard to gender differences in coronary plaque morphology and composition as underlying mechanism of MINOCA.

Purpose

To assess the differences in coronary plaque morphology in culprit lesion between women and men with MINOCA using intravascular optical coherence tomography.

Methods

Totally, 7404 consecutives acute myocardial infarction patients who underwent emergency coronary angiography between 2016 and 2019 were screened. MINOCA were identified in 292 patients (mean age: 72.6% male, 54.1% with ST-segment elevation). Optical coherence tomography was performed in 190 patients (men, n=142).

Results

Women with MINOCA were older (62.5±10.6 vs. 54.0±11.5, P<0.001) and more over 55 years (75.3% vs. 43.6%, P<0.001). Although women with MINOCA more frequently presented with NSTEMI (56.8% vs. 41.7%, P=0.025) and prior coronary artery disease (CAD) (33.3% vs. 6.3%, P<0.001), they were less likely smoker (27.2% vs. 58.8%, P<0.001). There was no significant difference in incidence of plaque rupture, erosion and calcified nodule between men and women. However, women were more likely to have thin-cap fibroatheroma (TCFA) (39.6% vs. 22.5%, P=0.025).

Conclusion

Women with MINOCA were older, more frequently presented with NSTEMI and less smoking compared to men. Besides, more TCFA were observed in women.

Funding Acknowledgement

Type of funding sources: None. Clinical and OCT plaque profilesProportion of clinical and OCT profiles
Evaluation of myocardial reperfusion in patients undergoing cangrelor supported primary PCI for STEMI
Authors: Muraca I , Pennesi M , Mattesini A , Migliorini A , Carrabba N , Scudiero F , Virgili G , Bruscoli F , Pontecorboli G , Marchionni N , Di Mario C , Valenti R
Published: October 2021

Background

Optimal myocardial reperfusion is the main goal of pharmaco-invasive treatment in STEMI patients. Cangrelor is a new intravenous P2Y12 inhibitor, mainly used in intra-procedural PCI setting of STEMI patients. Intracoronary cangrelor bolus application results in high local drug concentrations and may be more effective than a standard intravenous bolus.

Aim

This study aims to investigate the potential benefits of intracoronary versus intravenous cangrelor bolus in STEMI patients undergoing to primary PCI (p-PCI).

Materials and methods

Overall, 71 consecutive STEMI patients undergoing p-PCI were treated with intracoronary (n=37) or intravenous (n=34) bolus cangrelor administration with subsequent 2-hour intravenous infusion. The primary end point was ST-elevation reduction (STR) ≥50% at 30 minutes and at 24 hours after p-PCI. Secondary end points were STR ≥70% at 30 min after p-PC, TIMI frame count, and the QT dispersion (QTd). Moreover, stent thrombosis, bleeding events according to BARC classification, and 30-day mortality have been evaluated as safety explorative end points.

Results

STEMI patients treated with intravenous Cangrelor bolus had a higher rate of STR ≥50% either at 30 minutes (72% vs. 45%; p=0.033) or at 24 hours after p-PCI (87.1% vs. 63.6%; p=0.030) as compared to patients treated with intracoronary Cangrelor bolus; similarly, STR ≥70% at 30 minutes was more frequent in the intravenous bolus group as compared to intracoronary one (67% vs. 29% p=0.02). Furthermore, multivariable analysis demonstrated that intravenous Cangrelor bolus administration was an independent predictor of STR ≥50% (OR 3.586; 95% CI 1.134 to 11.335; p=0.030). No differences according to the TIMI frame count and the QTd were found. No stent thrombosis were observed at 30 days. The incidence of mortality and bleeding events (BARC 3–5) were comparable among study groups (30 days-death: 2.9% vs 5.4%, p=0.606; BARC 3–5 bleedings: 17.6% vs 13.5% p=0.630).

Conclusion

Intravenous coronary bolus administration of cangrelor in primary PCI is superior to intracoronary treatment with respect to extent of microvascular obstruction, and perfusion.

Funding Acknowledgement

Type of funding sources: None.
The clinical significance of procedural myocardial infarction in stable ischemic heart disease patients and implications for interpretation of Ischemia trial a registry analysis
Authors: Das S , Tran Q , Moosavi V , Itty C , Farshid A
Published: October 2021

Background

The definition, incidence, and clinical significance of procedural myocardial infarction (MI) remains controversial. Interpretations from landmark trials such as “Ischemia” was found to be sensitive to the definition of procedural MI used (1).

Purpose

Evaluation of the incidence of procedural MIs in our institution according to the standard definitions of Society of Cardiovascular Angiography & Intervention (SCAI) (2), Fourth Universal Definition of Myocardial Infarction (UDMI) (3) and Ischemia trial (4) and whether they predicted major adverse cardiovascular events (MACE) to validate clinical relevance of these definitions. Moreover, the study also explored the possibility whether HS-troponin alone could predict MACE thereby simplifying the definition of procedural MIs in the context of its wide-spread availability and its role as a standard biochemical marker of myocardial damage.

Methods

We analysed ECGs, coronary angiograms and next day HS troponin-I results on consecutive patients who underwent elective percutaneous coronary intervention for stable Ischaemic Heart Disease during 2014–2018. Primary outcome was MACE including death, MI, stent thrombosis and need for repeat revascularisation within 12 months from index procedure.

Results

We treated 909 patients with a mean age of 67.5 years and 78.4% were males. The proportion of patients in our cohort that met the troponin-based definition of procedural MI based on the Ischemia trial, SCAI and 4th UDMI were 10.1%, 6.3% and 25.1%. Occurrence of procedural MI according to these standard definitions were not predictive of MACE at 1 year (8.1% v 8.7% p=0.8; 11.1% v 8.5% p=0.5; 10.2% v 8.1%, p=0.3) (Table 1). The one-year MACE rate in the entire cohort was 8.5%. MACE rates were steady at troponin I levels below 2000 ng/L after which was there was a significant increase in MACE rates to 13.2% at troponin >2500, 19.1% for troponin levels >5000 and 33.3% for troponin>10,000 ng/L.

Conclusions

Procedural MI according to the Ischemia Trial definition was not predictive of MACE at 1 year, whereas troponin elevations above 2000 ng/L were associated with higher incidence of MACE in our cohort. These findings have significant implications for the interpretation of the Ischemia Trial. Moreover, potential of HS-troponin I level as a stand-alone and clinically relevant criteria for procedural MIs may be explored.

Funding Acknowledgement

Type of funding sources: None.
Differences in biomarker concentrations and prediction of long-term outcome in patients with ST-elevation and non-ST-elevation myocardial infarction
Authors: Hjort M , Eggers K M , Lindhagen L , Baron T , Erlinge D , Jernberg T , Marko-Varga G , Rezeli M , Spaak J , Lindahl B
Published: October 2021

Background

Biomarkers offer insights into the pathobiology of myocardial infarction (MI). Differences in biomarker concentrations and its prognostic implications in ST-elevation MI (STEMI) and non-STEMI (NSTEMI) are incompletely understood and may offer insights into tailored treatment.

Purpose

We aimed to characterise differences in activation of pathophysiologic pathways in patients with acute STEMI versus NSTEMI by comparing multiple biomarkers, and investigating their prognostic implications.

Methods

538 STEMI and 544 NSTEMI patients were included in our hospitals between 2008–2014. Blood samples were collected shortly after admission and 92 biomarkers were analysed using Proximity Extension Assay and 87 biomarkers using Multiple Reaction Monitoring mass spectrometry. Adjusted Lasso analysis (penalized logistic regression) was used to select biomarkers that discriminated STEMI from NSTEMI patients. For biomarkers that were identified by the Lasso analysis, concentrations (log2-transformed) were then evaluated in adjusted Cox regressions on associations with death or major cardiovascular events (MACE), a composite of death, hospitalization for MI, ischemic stroke or heart failure.

Results

Eleven biomarkers differed between STEMI and NSTEMI patients (Table) with higher OR (>1.00–1.42) and concentrations in STEMI patients of myoglobin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), serum amyloid A-1 (SAA1) and serum amyloid A-2 (SAA2) protein, ST2 protein, interleukin-6 (IL-6) and chitinase-3-like protein 1 (CHI3L1). NSTEMI patients had lower OR (0.83-<1.00) and higher concentrations of fibroblast growth factor 23 (FGF 23), membrane-bound aminopeptidase P (MAMP), tumour necrosis factor-related activation-induced cytokine (TRANCE) and apolipoprotein C-I. During up to 6.6 years of prognostic follow-up, all of the biomarkers except MAMP displayed significant prognostic information in STEMI and/or NSTEMI patients. However, interaction analyses indicated that all biomarkers were similarly predictive (p>0.05) of death or MACE between MI groups.

Conclusions

In the acute setting, biomarkers indicated greater myocardial dysfunction and inflammation in STEMI patients, whereas NSTEMI patients displayed a heterogeneous and more ambiguous activation of pathophysiologic pathways. These biomarkers were not associated with prognostic differences between STEMI and NSTEMI patients. Therefore, the results do not support treating STEMI and NSTEMI patients differently based on these biomarkers.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Foundation for Strategic Research. Swedish Association of Local Authorities and Regions. Table 1
Implications of left ventricular function on short-term outcomes in COVID-19 patients with myocardial injury
Authors: Medranda G , Case B C , Rappaport H , Zhang C , Yerasi C , Forrestal B J , Chezar-Azzerad C , Weintraub W S , Waksman R
Published: October 2021

Background/Introduction

Myocardial injury is a complication of coronavirus disease 2019 (COVID-19).

Purpose

We sought to describe a large multi-centre experience of COVID-19 patients with myocardial injury, examining the prognostic role left ventricular function plays on short-term outcomes.

Methods

We included adult COVID-19 patients admitted to our health system with evidence of myocardial injury and who underwent a transthoracic echocardiogram (TTE) during index admission. Patients were dichotomized into those with reduced ejection fraction (EF; <50%) and preserved EF (>50%).

Results

Across our 11-hospital system, 5032 adult patients were admitted with COVID-19 from March-September 2020. Of these, 235 had evidence of myocardial injury (troponin >1 ng/mL). Included were 134 patients who underwent TTE, of whom 43.3% (n=58) had reduced EF and 56.7% (n=76) preserved EF (Figure 1). A subset of 6 patients had newly reduced EF, with 5 demonstrating evidence of stress cardiomyopathy and subsequently dying. Overall, mortality was high in those with reduced EF and preserved EF (in-hospital: 34.5% vs. 28.9%; p=0.494; 6 months: 63.6% vs. 50.0%; p=0.167; Kaplan-Meier estimates: p=0.2886). Readmissions were frequent in both groups (30 days: 22.2% vs. 26.0%; p=0.162; 6 months: 52.0% vs. 54.5%; p=0.839) (Figure 2).

Conclusions

Many COVID-19 patients admitted with evidence of myocardial injury did not undergo TTE. For those who did, short-term mortality was high. Patients who survived hospitalisation had frequent readmissions. In patients with newly reduced EF, most had evidence of stress cardiomyopathy and expired. Larger studies are needed to fully evaluate the prognosis of COVID-19 patients with evidence of myocardial injury and left ventricular dysfunction.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Correlation of chest CT severity score with D-dimer levels in patients with COVID-19
Authors: Inamdar A V
Published: October 2021

Background

Coronavirus disease 2019 (COVID 19) caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) predominantly affects lungs and leads to COVID-19 pneumonia. Studies have shown that COVID 19 is hypercoagulative prothrombotic state. The innate tropism of SARS CoV-2 for vascular endothelial cells and their consequent damage, together with the intense activation of inflammatory responses and of coagulation pathways, may explain the intense pro-coagulative state. It ultimately predisposes to systemic micro-thrombotic alterations and gives rise to the consistent rate of multi-organ failure, DIC and ARDS in severe COVID-19 patients.

Purpose

Aims of this retrospective study were to determine the correlation between a CT-based semi-quantitative score of pulmonary involvement in COVID-19 pneumonia with D-dimer and CRP levels.

Materials and methods

174 symptomatic SARS-CoV-2 patients were enrolled from August 4 to October 12, 2020, for this single-center analysis in rural India and chest CT examinations were retrospectively evaluated. The COVID 19 positivity was defined on the basis of RTPCR done at ICMR (Indian Council of Medical Research) approved laboratory. A semi-quantitative CT score was calculated based on the extent of lobar involvement (0:0%; 1: <5%; 2: 5–25%; 3: 26–50%; 4: 51–75%; 5: >75%; range 0–5; global score 0–25). D-dimer and CRP were done at the time of admission. One way ANOVA and post hoc Tukey test were performed to compare the variables of Chest CT score in percentage to various other variables.

Results

CT score had significant positive correlation with D-dimer levels (p=0.002, r: 0.237). CT score was significantly correlated with CRP (p<0.001, r: 0.392) levels. Subgroup analysis by post hoc Tukey test further showed that D-dimer levels were significantly elevated in 51–75% and >75% lobar involvement groups on Chest CT with statistically significant p value of <0.001.

Conclusions

This study data suggests that CT score has significant positive correlation with D-dimer and CRP. D-dimer is significantly elevated in the group where lobar involvement is more significant on Chest CT. D-dimer is an indirect marker of active coagulation and thrombin formation. Elevated D-dimer represents activation of endovascular thrombotic processes. This hypercoagulative infection-induced state is systemic, and may lead to various clinical manifestations such as myocardial infarction, stroke, limb ischemia and DIC. Monitoring of pro-thrombotic activity of SARS-CoV-2 with tests such as D-dimer, with consequent labelled administration of adjusted doses of anticoagulants are of paramount importance in order to prevent worsening of global conditions due to vascular parenchymal or systemic thrombotic dysfunction in COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.
Inflammation-frailty linkage and its long-term prognostic impact in patients with acute coronary syndrome
Authors: Satou R , Matsuzawa Y , Akiyama E , Konishi M , Yoshii T , Nakahashi H , Minamimoto Y , Okada K , Maejima N , Iwahashi N , Hibi K , Kosuge M , Ebina T , Tamura K , Kimura K
Published: October 2021

Introduction

Chronic inflammation has been receiving considerable attention as an emerging risk factor for cardiovascular disease. In contrast, with the aging of the population, frailty has been also attracting a great deal of attention as the residual risk for cardiovascular disease. Although inflammation and frailty exacerbate each other and have an adverse effect on many diseases, the relationship between chronic inflammation and frailty and the impact of these combination on long-term prognosis in patients with acute coronary syndrome (ACS) are not elucidated.

Purpose

The aims of this study were to determine the association between chronic inflammation and frailty and its impact on long-term cardiovascular outcomes in patients with ACS.

Methods

A total of 482 consecutive ACS patients with obstructive coronary artery disease (age 66±12 years, male 81%) were enrolled in this observational study. We evaluated patients' gait speed as a measure of frailty before discharge. C-reactive protein (CRP) levels at 1 month after discharge were also evaluated as inflammation in the chronic phase. According to commonly used criteria of the residual inflammation (CRP>0.2 mg/dL) and the definition of the European Working Group for Sarcopenia (gait speed ≤0.8 m/sec), patients were stratified by 4 subgroups: low/high CRP with slow/normal gait speed. The primary endpoint was composite outcomes of cardiovascular death, myocardial infarction and ischemic stroke.

Results

While there was no significant association between CRP levels and gait speed in all patients, a significant negative association between two variables was observed in the high CRP group (Spearman's ρ = −0.31, p=0.001). During the median follow-up of 6 years, primary endpoints have occurred in 82 patients. Overall, event-free rates differed significantly among the 4 groups, demonstrating the lowest event-free rate in the patients with high CRP and slow gait speed (p<0.0001; Figure). In the multivariate analysis, high CRP (adjusted HR 1.99, 95% CI 1.14–3.46, p=0.02) and slow gait speed (adjusted HR 1.82, 95% CI 1.09–3.04, p=0.02) were independently and significantly associated with the primary endpoint. Moreover, the patients with both high CRP and slow gait speed had a 2.6-fold higher risk of cardiovascular events compared to others (adjusted HR 2.62, 95% CI 1.36–5.05, p=0.004).

Conclusion

In the patients with ACS, CRP levels and gait speed were negatively associated in the high CRP group. Chronic inflammation and frailty were both associated with poor prognosis in ACS and in particular, the combination of these factors was strongly associated with poor prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1
HSP90 pathway in intermediate mononuclear cells causes plaque erosion via induction of neutrophil hyper-responsiveness
Authors: Ding H R , Qian J , Tong J , Tang J N , Lin H , Chu J P , Zhu G Q , Chen F , Liu X B
Published: October 2021

Aim

To explore the function(s) of HSP90 in intermediate monocyte-mediated plaque erosion.

Materials and methods

We used single-cell RNA sequencing to map cardiac immune response composition in patients with plaque rupture and plaque erosion. By focusing our analyses on CD14 positive monocytes, we obtained a higher resolution identification of the immune cell subsets in patients experiencing plaque erosion and rupture. We interpreted our findings with analyses using gene ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) databases and by performing receiver operating characteristic (ROC) curve analysis.

Results

Single-cell sequencing analysis of mononuclear cells in the peripheral blood of five ACS patients experiencing plaque erosion and rupture confirmed that CD14 positive monocytes were the main immune cells leading to ACS. Interestingly, our results suggested a significant increase in the proportion of atypical monocytes (C4 subsets) in patients with plaque rupture, which was a novel finding. This increase may be caused by increased migration of atypical monocytes into a plaque during plaque rupture. We found that intermediate monocyte activation was most obvious in patients with plaque erosion (C1, C10, and C11), and the proportion of C1 subgroup monocytes (FCGR3B/CMTM2 double strong positive; subsequently defined as intermediate monocytes) was very high. To further explore the role of C1 subgroup intermediate monocytes in plaque erosion, GO and KEGG pathway analyses were performed. GO analysis indicated that C1 subgroup intermediate monocytes are highly involved in neutrophil metabolism. Because neutrophils are the main effector cells that induce plaque erosion, we reasonably infer that intermediate monocytes can induce plaque erosion. KEGG pathway analysis indicated that all subtypes of HSP90 were highly expressed in C1 subgroup intermediate monocytes. We thus collected peripheral blood from ACS patients with plaque rupture (n=150) and plaque erosion (n=150) for mononuclear cell transcriptomics and intracellular proteomics analysis. ROC curve analysis demonstrated that the area under the curve for HSP90-based prediction was 0.86, indicating that HSP90 could be used to predict if patients would experience plaque erosion.

Conclusion

Activation of intermediate mononuclear HSP90 expression may be the crucial event that induces neutrophil hyper-responsiveness and leads to plaque erosion.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): China,Shanghai Science and Technology Commission