bluuebunny/crossref_metadata_2025 huggingface dataset:
Applicability of ISCHEMIA to the daily practice of a Swiss University Hospital
Authors: Meier D , Mahendiran T , Muller O , Fournier S
Published: November 2020

Introduction

The ISCHEMIA trial found that an invasive strategy was not associated with a reduction in major adverse cardiovascular events when compared with optimal medical treatment (OMT) alone among patients with moderate/severe ischemia. However, given the extensive exclusion criteria of the study, we sought to investigate if these results would actually change our daily practice.

Methods

We performed a retrospective analysis of the last 1,000 consecutive PCIs undertaken in our university hospital in Switzerland. We applied the ISCHEMIA exclusion criteria to this population in order to estimate the proportion of patients that would have been excluded from the trial.

Results

Between October 2018 and November 2019, 1,000 PCIs were performed in a population with a mean age of 65.5 (IQR 51.0–76.0) years, of which 76.8% were men. Among these procedures, 603 (60.3%) were performed for an acute coronary syndrome (ACS) and 197 (19.7%) in the context of either an ACS within 2 months (n=131), or a PCI/CABG within 12 months (n=66) (Figure 1). A further 84 (8.4%) procedures were performed in patients with other high-risk features (ventricular arrhythmias, cardiac arrest, NYHA III-IV, eGFR <30 ml/min or LVEF <35%). Finally, 25 (2.5%) were performed in patients with unacceptable angina whilst on OMT, a cardiac transplant, a recent stroke, or another exclusion criterion. This left only 91 patients (9.1%) without any ISCHEMIA exclusion criteria. When considering only patients with SCAD (n=320), 229 (71.6%) would have been excluded due to the presence of at least one exclusion criterion.

Conclusion

In this retrospective analysis of 1,000 consecutive PCIs, the vast majority were performed in patients with at least one ISCHEMIA exclusion criterion. These results suggest that the impact of ISCHEMIA on the real-world practice of a medium-sized PCI center like ours is likely to be limited.

Figure 1

Funding Acknowledgement

Type of funding source: None
Temporal trends of acute kidney injury in patients undergoing percutaneous coronary intervention over a span of 12 years
Authors: Skalsky K , Bental T , Vaknin-Assa H , Assali A , Greenberg G , Codner P , Samara A , Ben Gal T , Eisen A , Kornowski R , Perl L
Published: November 2020

Background

Acute kidney injury (AKI) is a known complication following percutaneous coronary intervention (PCI), and is associated with higher rates of complications. We sought to determine the potential impact of temporal changes on the rates of AKI over time, as well as possible determinants of risk.

Methods

From a large prospective registry of patients undergoing PCI, 20,032 consecutive patients were assessed at two time periods: 2006–2012 and 2012–2018. Of these, included were cases for which data existed regarding change in creatinine levels from baseline to 48 hours after PCI. AKI was defined according to two methods- a relative elevation of ≥25% in serum creatinine or an absolute elevation of ≥0.5 mg/dL in serum creatinine at 48 hours.

Results

15,153 patients were available for final analysis, 7,913 in the first period and 7,240 in the second. Mean age was 65.0y and 66.0y (p<0.01) and baseline creatinine was 1.08 mg/dL and 1.15 mg/dL respectively (p<0.01, table 1).

AKI according to 25% relative rise in serum creatinine was documented in 11.1% in the early period and in 7.3% of the patients in the late period, p<0.01. According to the definition of 0.5 mg/dL absolute rise in serum creatinine, respective rates were 3% and 2.9%, p=0.82 (figure 1). Multivariate analysis demonstrated a lower risk of AKI in the late period (OR- 0.72; CI 0.61–0.85, P<0.01). Factors associated with risk of AKI included reduced ejection fraction (OR-0.98; CI 0.976–0.99, p<0.01), older age (OR-1.01; CI 1.005–1.02, p=0.01) and female gender (OR- 1.73; CI 1.46–2.06, p<0.01).

Conclusions

We have witnessed an improvement in the rates of post-PCI AKI over time. Further research is warranted, to further reduce peri-procedural AKI.

Figure 1. Change in the rates of AKI

Funding Acknowledgement

Type of funding source: None
Prognostic implication of baseline and 30-day anemia in patients with coronary artery disease undergoing percutaneous coronary intervention
Authors: Kang M.G , Cho S.Y , Kim K.H , Ahn J.H , Park H.W , Koh J.S , Park J.R , Park Y.W , Hwang S.J , Hwang J.Y , Jeong Y.H
Published: November 2020

Background

Anemia correlates with the risk of ischemic and bleeding event in coronary artery disease (CAD) following percutaneous coronary intervention (PCI).

Methods

We defined anemia by World Health Organization criteria (hemoglobin <13 g/dL in men and <12 g/dL in women). Major bleeding event was defined as Bleeding Academic Research Consortium (BARC) 3 or 5. Major adverse cardiovascular event (MACE) was defined as a composite of cardiovascular death, non-fatal myocardial infarct, and revascularization. The primary end-point was the MACE rate and the major bleeding rate.

Results

Among the 5,809 patients who underwent the PCI, 32.1% of the baseline anemia and 33.5% of the 30-day anemia were identified. With a median follow-up of 26.8 [15.9–42.3] months, and the MACE rate was 11.6% and the major bleeding event rate was 2.2%. 30-day anemia rather than baseline anemia showed a significant risk of MACE and major bleeding event (MACE, adjusted HR 1.28, p=0.036 vs. adjusted HR 1.09, p=0.389; major bleeding event, adjusted HR 2.72, p<0.001 vs. adjusted HR 1.73, p=0.006) (Figure). The MACE and major bleeding event rate at 5-year was significantly increased in patients with 30-day anemia (18.4% vs. 12.1%, p<0.001; 10.4% vs. 2.3%, p<0.001).

Conclusion

Anemia during the first 30-day was strongly associated with higher rate of long-term MACE and major bleeding event. These findings could have a clinical relevance in making a pharmacologic strategies to avoid the future ischemic and bleeding event following PCI.

Funding Acknowledgement

Type of funding source: None
Oxidation of HDL in patients with coronary artery disease
Authors: Pagonas N , Mueller R , Weiland L , Jaensch M , Westhoff T.H , Buschmann I.R , Sasko B , Ritter O , Kelesidis T.H
Published: November 2020

The function of high-density lipoprotein (HDL) cholesterol may play a more important role in the prevention of cardiovascular disease compared to the concentration of the HDL. The aim of the present study is to assess a novel cell-free test to quantify oxidation of HDL and its association to coronary artery disease (CAD).

We performed a prospective trial by including patients undergoing elective cardiac catheterization and healthy controls. A total of 895 subjects were included. In 483 patients CAD was confirmed (CAD group) and in 241 patients CAD was ruled-out (no CAD). Control patients (n=171) had no known CAD, had no diabetes and were not smokers. HDL function was measured in serum samples by determining its HDL-lipid peroxidation by a novel fluorometric cell-free biochemical assay. HDL lipid peroxide content (HDLox) is adjusted for the HDL cholesterol and has no units.

Patients with confirmed CAD had higher levels of HDLox (0.92±0.58, no units) compared to patients with no CAD (0.8±0.46, no units) and controls (0.78±0.41, no units, p=0.003). HDL-Cholesterol was lower in the CAD group (50.7±17.7mg/dl) compared to no CAD (58.4±17.6mg/dl) and healthy subjects (59.1±15.9mg/dl, p<0.001). HDLox was a strong predictor of coronary artery disease status (odds ratio for coronary disease 1.69; 95% confidence interval [CI], 1.24 to 2.38; P=0.001).

Oxidation of HDL, a metric of HDL function, measured by a cell-free biochemical assay, is increased in patients with CAD and is a predictor of the disease.

Logistic Regression analysis

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical School of Brandenburg
Acquired von Willebrand Syndrome in left Impella supported cardiogenic shock patients
Authors: Vandenbriele C , Balthazar T , Engelen M , Adriaenssens T , Verhamme P , Peerlinck K , Janssens S , Jacquemin M
Published: November 2020

Background

Bleeding is a main cause of morbidity and mortality in critically ill cardiogenic shock patients, supported by short-term percutaneous mechanical circulatory support (pMCS) devices. Bleeding not only occurs because of obligatory heparin and antiplatelet therapy (both required in the prevention of pump and stent thrombosis) but possibly also results from device-related coagulopathy. Similar to long-term ventricular assist devices, mechanical shear-induced acquired von Willebrand syndrome (AVWS) might further increase the bleeding risk. Therefore, we aimed to investigate the effect of left Impella percutaneous continuous flow pumps on the development of AVWS due to shear-induced excessive cleavage of large vWF multimers by the metalloproteinase ADAMTS-13, resulting in loss of high-molecular-weight vWF multimers.

Methods

Between March 2019 and January 2020, all cardiogenic shock patients supported by a left Impella and referred to a single tertiary ICU were studied. Both vWF Antigen (vWF:Ag) and vWF:GPIbR (ristocetin-induced binding of vWF to a recombinant wildtype Glycoprotein Ib fragment) levels were measured by chemiluminescent immunoassays using an AcuStar (Werfen) assay to determine the vWF:GPIbR /vWF:Ag ratio (normal range ≥1.0). VWF multimer analysis was performed by electrophoresis. On-pump analyses were performed 12h after implantation and off-pump analyses 12h after Impella explantation. Patients who died on-pump were excluded because of lack of paired data after explantation.

Results

Eight left Impella patients (four Impella CP, four Impella 5.0) were analyzed for AVWS. The vWF:GPIbR /vWF:Ag ratio was <1.0 in all patients on-pump (mean±SD 0.68±0.1 versus 1.1±0.15 off-pump (panel A; p=0.0018)) and thus AVWS was detected in all Impella-supported patients. The presence of AVSW was also confirmed by loss of large vWF multimers on-pump (panel B). Four patients (50%) had mucosal bleeds (epistaxis or gastrointestinal), none of them requiring transfusion. The mean rise in ratio 12h after pump removal was 0.35 which was also reflected by recovery of large multimers by electrophoresis (panel B).

Conclusions

Our data highlight the rapid onset and reversal of AVWS in all studied cardiogenic shock patients, supported by a left Impella pump. The determination of the GPIbR /vWF:Ag ratio with the AcuStar appears a reliable and faster test to detect AVWS as compared to vWF multimers electrophoresis. Further research into innovative pharmacological interventions (e.g. ADAMTS-13 inhibitors) should target pMCS-induced AVWS in an effort to reduce hemostatic complications in this critically ill ICU population.

AVWS in Impella supported patients

Funding Acknowledgement

Type of funding source: None
Intravenously delivered mesenchymal stem cells prevent MVO formation after myocardial ischemia/reperfusion injury
Authors: Xie J
Published: November 2020

Microvascular obstruction (MVO) after primary PCI is identified as an independent risk factor for prognosis in AMI patients. Inflammatory response induced by ischemia and reperfusion injury (I/R injury) was considered as one of main mechanisms for MVO formation. Mesenchymal stem cells (MSCs) are a unique stromal cell type that confers immunomodulatory effect in cardiac disease. Here we investigate whether intravenously and immediately delivered MSC could be used as potential therapeutic method to attenuate MVO formation. A cardiac-catheterization-induced porcine model of myocardial I/R injury was established, and allograft MSCs were delivered intravenously and immediately. Cardiac magnetic resonance imaging was performed 2 days and 7 days after operation to determine infarct area, MVO and cardiac function. We observed that the animals with allograft MSC delivering revealed decreased MVO and infarct size, as well as improved LVEF. In histology analysis, decreased myocytes area, fibrosis and inflammatory cell infiltration were observed in peri-infarct zone of animals with allograft MSC delivering. Meanwhile, the concentrations of IL-6, CRP and IL-1β in the serum were reduced in the allograft MSC group versus the control group. Flow cytometry indicated that decreased NK cells in the peripheral blood and ischemic heart tissue in the animals with allograft MSC delivering. In summary, we observed that allograft MSC delivering intravenously and immediately after myocardium I/R injury could attenuate MVO formation in porcine by NK cells depression.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Natural Science Foundation of China
Age-related differences and vascular function test findings in patients with vasospastic angina
Authors: Kato K , Tateishi K , Saito Y , Kitahara H , Fujimoto Y , Kobayashi Y
Published: November 2020

Background

Vasospastic angina (VSA) accounts for the majority of angina cases with no epicardial stenosis and develops amongawide range of age, which is reportedly induced by coronary functional abnormalities including endothelial dysfunction and smooth muscle hypercontraction. However, the relation of noninvasive vascular function tests to VSA remains to be fully elucidated.

Purpose

The aim of this study was to assess differences in clinical characteristics and findings from noninvasive vascular function tests among groups by age in patients with VSA.

Methods

We enrolled a total of 732 patients with angina who underwent intracoronary acetylcholine provocation test. VSA was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine administration. Patients with VSA were divided into 3 groups by age (young [<50 years], intermediate [50–64 years], and elderly group [≥65 years]). Noninvasive vascular function test findings such as ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), andpercentage of mean arterial pressure (%MAP) were compared among groups by age in patients with VSA.

Results

Of all patients, 367 (50.1%) were diagnosed as VSA with intracoronary acetylcholine test, including 66 (18.0%), 113 (30.8%), and 188 (51.2%) patients in the young, intermediate, and elderly groups. Among groups by age, there was no significant difference in gender (female, 31.8% vs. 40.7% vs. 44.7%, P=0.19). Patients in the young group were more often smokers and alcohol drinkers than those in the intermediate and elderly groups, while the prevalence of hypertension, dyslipidemia, and diabetes were lower in younger patients. A history of percutaneous coronary intervention was less frequently found in the young group compared tothe intermediate and elderly groups (7.6% vs. 16.8% vs. 20.7%, P=0.033). The baPWV was higher in the elderly group (1424±232 vs. 1537±247 vs. 1774±358 cm/s, P<0.0001), while there was no difference in ABI between the 3 groups. %MAP at arms was significantly and progressively decreased with an increase in age (54.0±4.5% vs. 53.0±2.6% vs. 51.2±2.8%, P<0.0001).

Conclusion

Our study demonstrated that there were distinct age-related differences in clinical characteristics of patients with VSA. The higher %MAP in younger patients suggests that more impaired endothelial dysfunction may play a role in the development of VSA in this age group.

Funding Acknowledgement

Type of funding source: None
Progressive left ventricular post-infarction remodelling: impact on outcome
Authors: Van Der Bijl P , Abou R , Goedemans L , Gersh B.J , Holmes D.R , Pellikka P.A , Ajmone Marsan N , Delgado V , Bax J.J
Published: November 2020

Background

While the presence left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) is known to worsen prognosis, the impact of progressive vs. stable LV remodelling on outcome has not been established.

Purpose

To investigate the impact of progressive LV remodelling on outcome in STEMI patients who were treated with primary percutaneous coronary intervention (PCI) and optimal pharmacotherapy.

Methods

Baseline, 3-, 6- and 12-month echocardiograms were analysed. Early LV remodelling (ER) was defined as a ≥20% increase in LV end-diastolic volume (EDV) during the first 3 months post-STEMI, and mid-term remodelling (MTR) as ≥20% LVEDV change by 6 months. Progressive LV remodelling was defined according to spline curve analyses: ≥0% LVEDV increase by 6 months (i.e. further increase after 3 months) for ER, and ≥20% by 12 months (i.e. an additional increase after 6 months) for MTR. The impact of progressive LV remodelling on outcome was evaluated with a Log rank test.

Results

589 STEMI patients (mean age 61±12 years, 78% male) who demonstrated LV remodelling in the first 6 months post-infarct, were analysed: 408 (69%) ER and 181 (31%) MTR. Progressive LV remodelling occurred in 146 (36%) ER and in 12 (7%) MTR. After a median follow-up of 90 (IQR 64–117) months, 39 (10%) ER were hospitalised for heart failure. 25 (14%) MTR remodellers died after a median follow-up of 86 (IQR 66–112) months. Progressive LV remodelling in ER led to a higher rate of heart failure hospitalisation (P=0.017 vs. non-progressive ER, Fig. 1A) but no mortality difference (P=0.10 vs. non-progressive ER). In contrast, MTR with progressive LV remodelling experienced worse survival (P=0.01 vs. non-progressive MTR, Fig. 1B) but no increase in heart failure hospitalisation (P=0.65 vs. non-progressive MTR).

Conclusions

Progressive LV remodelling causes an increased risk of heart failure in ER post-infarct, vs. higher mortality in MTR. These two patterns of progressive, post-infarct LV remodelling possibly represent different underlying pathophysiological mechanisms: i.e. evolution of true post-infarct remodelling in ER, vs. natural history of established heart failure in MTR.

Figure 1

Funding Acknowledgement

Type of funding source: None
Clinical factors associated with microvascular obstruction in early presenters of ST-segment elevation myocardial infarction
Authors: Rivero Monteagudo A.L , Arroyo Rivera B , Garcia Talavera C , Cortes Garcia M , Franco Pelaez J.A , Navarro Del Amo F , Tunon Fernandez J
Published: November 2020

Background

Microvascular obstruction (MVO) is a phenomenon that occurs frequently even after primary coronary intervention with recanalization of the infarct-related artery (IRA) and it has been shown to increase the risk of adverse cardiovascular events in ST-segment elevation myocardial infarction (STEMI) patients. The most important clinical predictor of MVO is ischemia duration, but there is a lack of information regarding predictor factors in promptly revascularized patients.

Methods

From January 2007 to October 2017, 987 patients with STEMI that underwent urgent coronary angiography were retrospectively enlisted. We included 321 patients that were revascularized in ≤3 hours from symptom onset. Clinical and angiographic data were taken from hospital records. A univariate and multivariate Cox regression analysis was made to assess the relationship between MVO (defined as final TIMI <3 in IRA) and potential predictors.

Results

From the 321 patients included, 76.9% were male and the mean age was 63.6±13.4 years. LVEF at admission was 46.2±12%. The mean time between symptom onset and wire crossing was 2.2±0.6 hours and MVO was found in 43 cases (13.4%). Descriptive data of predictor factors and their association with MVO are shown in Table 1. After the multivariate Cox regression analysis, smoking was a protector factor of MVO (OR 0.39 [0.16–0.96]). Age (OR 1.03 [1.01–1.06]) and Killip class III-IV at admission (OR 5.96 [2.1–16.4]) were directly associated with MVO. No other clinical variables were independently associated with the occurrence of MVO.

Conclusions

In very early presenters of STEMI, age and Killip class III-IV at admission were clinical predictor factors of MVO. Current smoking could carry a protector mechanism for MVO in this population, that is yet to be confirmed with prospective studies.

Funding Acknowledgement

Type of funding source: None
ACTION and NCDR risk models outperform GRACE for prediction of in-hospital mortality in acute coronary syndrome – a retrospective analysis from a German Heart Center
Authors: Parco C , Kosejian L , Quade J , Bader S , Lin Y , Karathanos A , Krieger T , Brockmeyer M , Icks A , Perings S , Kelm M , Schulze V , Wolff G
Published: November 2020

Background

Risk prediction with the GRACE risk model is guideline-recommended clinical practice in acute coronary syndrome (ACS). However, more modern risk models such as ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry–GWTG (Get With the Guidelines) and National Cardiovascular Data Registry (NCDR) risk models are available. We aimed to compare these models to the established GRACE risk model in ACS.

Methods and results

In-hospital mortality was retrospectively assessed in 1,138 patients undergoing cardiac catheterization for Non-ST-Elevation Myocardial Infarction (NSTEMI, 566 patients, 70.7% male) or ST-Elevation Myocardial Infarction (STEMI, 572 patients, 69.1% male) at a German University Hospital from 2014 to 2017. In-hospital mortality was 14.7% for STEMI and 3.7% for NSTEMI, respectively. GRACE, ACTION and NCDR risk models for prediction of in-hospital mortality were calculated for individual patients, 0.75% missing data were imputed. ACTION risk model showed a good discrimination of risk (c-index 0.85, 95% confidence interval (CI) 0.83–0.87) with a slight numerical advantage in NSTEMI (c-index 0.92, 95% CI 0.86–0.98) over STEMI patients (c-index 0.83, 95% CI 0.79–0.88). The NCDR risk model showed comparable performance in the overall cohort (c-index 0.86, 95% CI 0.84–0.88; NCDR vs. ACTION p=0.4097), also with superior performance in NSTEMI (c-index 0.89, 95% CI 0.86–0.91) vs. STEMI (c-index 0.81, 95% CI 0.78–0.84). The GRACE risk model showed significantly worse performance in the overall cohort (c-index 0.76, 95% CI 0.74–0.79; vs ACTION p<0.0001; vs. NCDR p<0.0001) and in STEMI patients (c-index 0.72, 95% CI 0.69–0.76; vs ACTION p<0.0001; vs. NCDR p=0.0018). In NSTEMI patients, GRACE discrimination performance was comparable to NCDR (c-index 0.87, 95% CI 0.84–0.90, p=0.73), but still inferior to ACTION (p=0.04). The ACTION risk model showed a good calibration whereas NCDR and GRACE models lacked accuracy in our cohort.

Conclusion

In a contemporary German patient population with acute coronary syndrome, ACTION and NCDR risk models outperform the established GRACE risk model for prediction of in-hospital mortality. This performance difference was more pronounced in STEMI than in NSTEMI.

Funding Acknowledgement

Type of funding source: None
The vegf-a gene polymorphism in prognosis of outcomes in patients with stemi
Authors: Kutya I , Hilova Y , Rodionova J , Kopytsya M , Petyunina O
Published: November 2020

One of the promising parameter for the prognosis in patients with STEMI can be suggested the VEGF-A gene polymorphism.

Purpose

Estimate the role of the VEGF-A gene polymorphism in the prediction of outcomes in patients with STEMI.

Methods

The study involved 135 STEMI patients (80.7% male and 19.3% female) with an average age of 59.21±8.92 years. Control group of 30 healthy volunteers included. Patients were divided into two groups: the first one – “case” group, those who reached the end point, and the second group – “control”, those who did not reached. The combined endpoint included cardiovascular death, recurrent myocardial infarction, the occurrence / progression of heart failure that required hospitalization. The study of the VEGF-A gene polymorphism (rs 2010963) was carried out by polymerase chain reaction (PCR). Follow-up period was 6 month. VEGF-A level was measured by ELISA.

Results

The patients from the “case” group had significantly elevated VEGF-A levels compared to controls (217.40 [102.54–473.78] pg/ml; 311.45 [204.20–680.86] pg/ml; p=0.046). Multivariate linear regression analyses demonstrated that polymorphism G634C (rs2010963) of VEGF-A gene (G634C+C634C) – β=0.8079, CI [1.1907 to 5.6490] p=0.0465; and LVEF <50.60% – β=0.0488 CI [0.9179 to 0.9882], p=0.0096 are significantly associated with negative outcomes (combined endpoints).

Conclusions

STEMI patients with G634C+C634C polymorphism G634C (rs2010963) of VEGF-A gene, and with LVEF <50.60% have greater chances for adverse outcomes. Further investigations of the VEGF-A gene polymorphism are the perspective direction in the development of prevention and treatment of STEMI.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): GI “L.T. Malaya Therapy National Institute NAMSU”
Frequency and prognostic impact of right ventricular involvement in acute myocardial infarction
Authors: Stiermaier T , Backhaus S.J , Matz J , Koschalka A , Kowallick J.T , De Waha-Thiele S , Desch S , Hasenfuss G , Thiele H , Eitel I , Schuster A
Published: November 2020

Background

Right ventricular (RV) involvement complicating myocardial infarction (MI) is thought to impact prognosis, but potent RV markers for risk stratification are lacking.

Purpose

To assess the frequency and prognostic implications of concomitant structural and functional RV injury in MI.

Methods

Cardiac magnetic resonance (CMR) was performed in 1235 patients with MI (STEMI: n=795; NSTEMI: n=440) 3 days after reperfusion by primary percutaneous coronary intervention. Central core laboratory-masked analyses included structural (edema representing reversible ischemia, irreversible infarction, microvascular obstruction [MVO]) and functional (ejection fraction, global longitudinal strain [GLS]) RV alterations. The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE).

Results

RV ischemia and infarction were observed in 19.6% and 12.1% of patients, respectively, suggesting complete myocardial salvage in one-third of patients. RV ischemia was associated with a significantly increased risk of MACE (10.1% versus 6.2%; p=0.035), while patients with RV infarction showed only numerically increased event rates (p=0.075). RV MVO was observed in 2.4% and not linked to outcome (p=0.894). Stratification according to median RV GLS (10.2% versus 3.8%; p<0.001) but not RV ejection fraction (p=0.175) resulted in elevated MACE rates. Multivariable analysis including clinical and left ventricular MI characteristics identified RV GLS as an independent predictor of outcome (hazard ratio 1.05, 95% confidence interval 1.00–1.09; p=0.034) in addition to age (p=0.001), Killip class (p=0.020), and left ventricular GLS (p=0.001), while RV ischemia was not independently associated with outcome.

Conclusions

RV GLS is a predictor of post-infarction adverse events over and above established risk factors, while structural RV involvement was not independently associated with outcome.

Funding Acknowledgement

Type of funding source: None
Angiopoietin-like 4 protein is a long-term predictor of outcome in chest-pain patients with suspected acute coronary syndrome
Authors: Aarsetoey R , Ueland T , Aukrust P , Michelsen A.E , Ponitz V , Brugger-Andersen T , Leon De La Fuente R , Grundt H , Staines H , Nilsen D.W.T
Published: November 2020

Introduction

Angiopoietin-like 4 protein (ANGPTL4) has multiple physiological functions including modulation of angiogenesis, vascular permeability and lipid-metabolism. Acting as an inhibitor of lipoprotein lipase, ANGPTL4 has previously been found to be associated with lipid levels and risk of coronary artery disease.

Purpose

To assess the prognostic value of ANGPTL4 for long-term outcome, in addition to conventional clinical risk factors, in chest-pain patients admitted with clinically suspected acute coronary syndrome (ACS).

Methods

1853 patients from Norway and Northern-Argentina were consecutively included in this prospective 2-center cohort study. ANGPTL4 concentrations were measured in 1829 admission-samples by enzyme immunoassay. Data were pooled for analysis. Multivariable Cox proportional-hazards models were fitted for the analysis of all-cause mortality, cardiac death and sudden cardiac death (SCD) within 24-months, comparing event rates across ANGPTL4-quartiles (Q1–4). Of patients with suspected ACS, 845 had a troponin T (TnT) value above the detection-limit. Subgroup analysis was performed for all-cause mortality in patients stratified according to TnT release >/≤0.01 ng/mL.

Results

During 24-months follow-up, 254 patients (13.9%) died, of which 150 (8.2%) suffered cardiac death and 76 (4.2%) SCD. Patients who died had significantly higher admission-levels of ANGPTL4 compared to long-term survivors [4.99 (3.54–8.37) ng/mL versus 3.18 (2.14–4.78) ng/mL (median, 25 and 75% percentiles), p<0.001]. A stepwise increase in risk of all-cause death was seen with increasing quartiles of ANGPTL4, Figure 1. For cardiac death, ANGPTL4-levels in Q4 [Hazard Ratio (HR) 2.86 (95% confidence interval (CI); 1.10–7.45), p=0.031] as compared to Q1 were found to be an independent predictor of outcome. Similar results were seen for SCD in adjusted analysis for ANGPTL4-Q4 [HR 7.37 (95% CI: 1.75–31.1), p=0.007] as compared to Q1. In subgroup analysis, ANGPTL4 concentrations in the highest quartile were significantly associated with increased risk of all-cause mortality in patients with TnT-release [HR 2.07 (95% CI: 1.06–4.02), p=0.032], but not in patients without TnT-release.

Conclusion

High admission-levels of ANGPTL4 were found to be an independent long-term predictor of all-cause mortality, cardiac death and SCD in patients with suspected ACS.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Western Norway Regional Health Authority
Infarct-related artery and long-term mortality following recurrent ST-elevation myocardial infarction; insights from a Polish nationwide registry
Authors: Wolny R , Desperak P , Kwiecinski J , Gasior M , Witkowski A
Published: November 2020

Background

Recurrent ST-elevation myocardial infarction (rSTEMI) occurs either as an acute thrombotic event in the same (target-vessel, TV-STEMI) or different vessel (non-target, nonTV-STEMI) compared with the first infarction. Little is known about the frequency of rSTEMI in the era of primary percutaneous coronary intervention (PCI) and about the impact of the infarct-related artery (IRA) on long-term prognosis.

Purpose

We hypothesized that long-term mortality after rSTEMI varies according to IRA (either same or different compared with first STEMI).

Methods

We retrospectively analysed data from the Polish Registry of Acute Coronary Syndromes (PL-ACS) and identified survivors of first STEMI treated with PCI who experienced rSTEMI and were discharged home. We divided rSTEMI into TV-STEMI and nonTV-STEMI group. We compared baseline clinical, angiographic and procedural characteristics and utilized propensity score matching to adjust for baseline differences. 1-, 3- and 5-year all-cause mortality was obtained from the Polish National Health Fund. Categorical variables were presented as counts and percentages and compared using Chi2 test. Continuous variables were presented as medians and interquartile ranges and compared using Mann-Whitney test. The registry was approved by local Ethics Committee and meets the conditions of the Declaration of Helsinki

Results

Between January 2003 and August 2019 a total of 3517 patients (mean age 62.9 years, 75% male) had rSTEMI, of whom 1941 (55%) had TV- and 1576 (45%) had nonTV-STEMI after 615 (77, 1683) days since first infarction (Figure 1). Patients with nonTV-STEMI had higher BMI (27.2 vs 26.8 kg/m2, p=0.03), more hypertension (76.9 vs. 73.5%, p=0.02) and atrial fibrillation (4.7 vs. 3.3%, p=0.04), but had lower left ventricular ejection fraction (43 [35,50] vs. 45 [38,50], p<0.001) compared with TV-STEMI. On coronary angiography nonTV-STEMI had more frequently TIMI flow ≥1 (44.9 vs. 28.0%, p<0.001), multivessel disease (51.8 vs. 41.1%, p=0.003), culprit lesion located in circumflex artery (15.2 vs. 4.8, p<0.001) and more frequently underwent stenting (88.4 vs. 76.1%, p<0.001) compared with TV-STEMI. There was no difference in unadjusted 1-, 3- and 5-year mortality between nonTV-STEMI and TV-STEMI group (14.9 vs. 14.7%, p=0.9; 23.4 vs. 24.2%, p=0.64 and 29.6 vs. 32.9%, p=0.1 respectively). The propensity-score matching of 825 patients with TV- and 826 patients with nonTV STEMI suppressed all baseline differences, but adjusted mortality remained similar between study groups (Figure 1).

Conclusion

While patients with recurrent nonTV-STEMI have different clinical and angiographic characteristics compared with TV-STEMI, the long-term mortality in these groups is similar.

Figure 1

Funding Acknowledgement

Type of funding source: None
Probability of coronary disease and clinical outcomes in patients with type 2 myocardial infarction
Authors: Wereski R , Hung J , Shah A.S.V , Anand A , Strachan F.E , Mills N.L , Chapman A.R
Published: November 2020

Background

Type 2 myocardial infarction is common in clinical practice. However, despite these patients having a similar rate of major adverse cardiovascular events as those with atherothrombotic type 1 myocardial infarction, there is currently no consensus on how these patients should be evaluated or managed. Whether risk assessment for coronary artery disease can identify patients at increased risk of death is unclear.

Methods

The High-STEACS trial was a stepped wedge cluster randomised controlled trial in ten hospitals across Scotland, including 48,282 consecutive patients with suspected acute coronary syndrome. The index diagnosis was adjudicated in all patients and the likelihood of underlying coronary artery disease recorded as either low-probability, high-probability, or known based on the clinical history, risk factors and comorbidities. The adjudicators were blinded to the primary and secondary outcomes including all-cause mortality at one year.

Results

High-sensitivity cardiac troponin I concentrations were above the sex-specific 99th centile in 22% (10,360/48,282) of patients. The adjudicated diagnosis was type 1 and type 2 myocardial infarction in 55% (4,981/9,115) and 12% (1,121/9,115), respectively. Compared to patients with type 1 myocardial infarction, those with type 2 myocardial infarction were older and more likely to be women. In patients with type 2 myocardial infarction, 20% were low-probability, 55% were high-probability and 25% had known coronary artery disease. All-cause mortality was highest in patients with known or suspected coronary artery disease (22.5% and 23.3%, respectively). Those with a low-probability of coronary artery disease had the lowest event rate (8.8%), even compared to those with type 1 myocardial infarction (Figure).

Discussion

A simple clinical assessment of whether patients have a low- or high-probability of coronary artery disease is associated with future risk of death in patients with type 2 myocardial infarction. Whether incorporating this assessment into clinical practice to guide secondary prevention could improve outcomes requires prospective evaluation.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation
Analysis of hospital mortality in acute coronary syndrome in elderly and long-lived patients
Authors: Kruchinova S , Raff S.A , Kosmacheva E.D
Published: November 2020

Objective

To evaluate the effect of clinical and medical history, laboratory and instrumental indicators, patient management tactics on the level of hospital mortality in patients with ACS in senile patients and long-livers.

Materials and methods

The study included 1520 senile patients (75–90 years old) and 96 long-livers (90–103 years old) hospitalized with a diagnosis of ACS. Depending on the management tactics, each age group was divided into 2 subgroups - invasive management - balloon angioplasty and stenting of the coronary arteries (n=670 in the group of old age, n=12 in the group of long-livers) and conservative management - patients who refused invasive intervention (n=850 in the group of senile age, n=84 in the group of centenarians).

Results

Hospital mortality rates in elderly patients were 11%, long-livers were significantly higher - 30%, significantly differing in the subgroups of invasive and conservative treatment in elderly patients (7.5% vs 14.5%; p=0.0368) while in long-livers these differences did not reach statistical significance (15.8% vs 38.7%; p=0.1175). Most patients of both age groups died during the first days of hospitalization - 68.2% and 73.5% of cases for senile age and long-livers, respectively, while the level of pre-mortality was comparable with conservative and invasive approaches to treatment. Clinical-anamnestic, laboratory and instrumental indicators that had a significant impact on the level of hospital mortality in elderly patients, regardless of management tactics, included the presence of clinically manifest multifocal atherosclerosis (p=0.003), class acute cardiac failure III-IV according to Killip (p=0.007), the presence of ST segment elevation (p=0.001), decreased LVEF (S) <42% (p=0.01), the development of acute kidney damage (p=0.006), and an electric storm (p=0.0005). In long-livers, these parameters also, regardless of management tactics, included Killip class acute cardiac failure III-IV (p=0.03), the presence of ST segment elevation (p=0.004), the development of acute kidney damage (p=0.001), and an electric storm (p=0.003), grade 3 atrioventricular block (p=0.02), acute erosive-ulcerative gastropathy with a decrease in hemoglobin level of more than 20 g / l (p=0.04).

Conclusions

Patients of older age groups are characterized by high rates of daily mortality. The level of hospital mortality in senile patients and long-livers is determined by a number of clinical and medical history, laboratory and instrumental parameters, the significance of which does not depend on patient management tactics. The choice of treatment strategy has a significant effect on hospital mortality in elderly people, while the development of complications of ACS played a large role in thanatogenesis in long-livers.

Funding Acknowledgement

Type of funding source: None
Prognostic implications of previously known or newly diagnosed diabetes and hypovitaminosis D in patients with myocardial infarction
Authors: Aleksova A , Santon D , Stenner E , Gagno G , Francescut C , Padoan L , Saro R , Beltrami A.P , Sinagra G
Published: November 2020

Background

Vitamin D deficiency and diabetes mellitus are frequent among patients with acute myocardial infarction. Independently, both were associated with a worse prognosis after myocardial infarction (MI). However, it is unclear whether the risk of worse outcome, associated with diabetes mellitus, may be accentuated in presence of hypovitaminosis D.

Purpose

We assessed if previously known or newly diagnosed diabetes is associated with worse outcome (major cardiovascular events) in combination with hypovitaminosis D in patients with acute MI.

Methods and results

Were enrolled 1004 patients with acute MI; 64.7% of them, had hypovitaminosis D and 37% were diabetic.

We grouped our population by diabetic status: previously known diabetes (diagnosis of diabetes before MI, n=330; 32.9%); newly diagnosed diabetes (during hospitalization for MI, but no known diabetes at presentation, n=47; 4.7%); or no diabetes (n=627; 62.5%).

Hypovitaminosis D was more frequent among patients with previously known (70.2%) and newly diagnosed diabetes (73.3%), when compared to non diabetic patients (61.2%).

During median follow-up of 15.6 months, patients with previously known and newly diagnosed diabetes had increased risks of major cardiovascular events (HR 1.72; 95% CI, 1.26 to 2.36. The risk of major events during the follow-up among diabetic patients, was further increased in presence of hypovitaminosis D (Figure 1).

Conclusions

The presence of both, previously known or newly diagnosed diabetes and hypovitaminosis D, in patients with MI is synergistically associated with a worse outcome.

Funding Acknowledgement

Type of funding source: None
Low-density lipoprotein cholesterol levels on admission and long-term outcomes in statin-naive patients with acute coronary syndrome
Authors: Satou R , Matsuzawa Y , Akiyama E , Konishi M , Yoshii T , Okada K , Maejima N , Iwahashi N , Hibi K , Kosuge M , Ebina T , Tamura K , Kimura K
Published: November 2020

Introduction

Dyslipidemia, especially an increase in the low-density lipoprotein cholesterol (LDL-C) has been established as one of the most important risk factors for atherosclerotic cardiovascular diseases. In contrast, some recent studies have shown that the low LDL-C level was associated with short-term poor prognosis in patients with cardiovascular disease, and this is so-called “cholesterol paradox”. However, there is few data evaluating the effects on long-term outcome of “cholesterol paradox” in patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study was to examine whether the low LDL-C level on admission affect long-term prognosis in patients with ACS.

Methods

A total of 434 ACS patients who survived to hospital discharge were enrolled in this study. All patients were statin-naïve on admission, and were received statin therapy after hospitalization. Patients were divided into the low LDL-C (≤114 mg/dl) and high LDL-C (>114 mg/dl) groups using the first tertile of the LDL-C level on admission. The primary endpoint was composite outcomes of all-cause death, myocardial infarction, ischemic stroke, hospitalization for congestive heart failure and unplanned revascularization.

Results

During a median follow-up period of 5.5 years, primary endpoint occurred in 117 patients. Overall, event-free rates differed significantly between the low and high LDL-C groups, demonstrating the lower event-free rate in patients with the low LDL-C group (38.9% in low LDL-C group versus 20.7% in high LDL-C group, p=0.0002; Figure). Even after adjustment for age, sex, body mass index, and various classical risk factors, the low LDL-C group was significantly at higher risk for primary composite outcomes compared to the high LDL-C group (adjusted hazard ratio 1.65, 95%-confidence interval 1.10–2.49, p=0.02).

Conclusion

In patients with ACS, the low LDL-C level on admission was significantly associated with long-term worse prognosis, regardless of statin therapy at discharge. In ACS patients with low LDL-C level, it might be necessary for elucidating the residual risk for secondary adverse event to improve their prognosis.

Funding Acknowledgement

Type of funding source: None
Usefulness of troponin in selecting patients for invasive coronary angiography after cardiac surgery
Authors: Omran H , Deutsch M.A , Groezinger E , Renner A , Neumann J , Westermann D , Scholtz W , Rudolph T , Gummert J , Rudolph V , Hakim-Meibodi K
Published: November 2020

Background

Great uncertainty exists about the indication for invasive coronary angiography (ICA) in patients with suspected acute coronary syndrome following cardiac surgery.

Aim

The aim of this study was to define clinical criteria that best identify patients who benefit from ICA after cardiac surgery.

Methods

We performed a retrospective analysis of all patients who underwent cardiac surgery between January 2009 and May 2019 at our center. Exclusion criteria included pediatric patients as well as pacemaker, TAVR and LVAD implantation and heart transplantation procedures. The primary outcome was usefulness of ICA as defined by consequent PCI or re-operation due to ICA findings. ECG changes (ST-elevations) and high-sensitivity Troponin I (hsTrop I) were analyzed.

Results

48,136 patients were screened and after applying exclusion criteria 29,359 patients were finally included in the analysis (mean age 67.8±11.0 years, 31.1% females, Euroscore II 5.14±8.9%). A total of 1,171 patients (4%) underwent post-op ICA. The primary outcome occurred in 440 patients (1.5%) of which 290 underwent consequent PCI and 214 underwent consequent re-operation. Baseline characteristics are shown in table 1. Unadjusted analyses did not identify significant differences in the level of cardiac biomarkers between useful-ICA and unuseful-ICA groups.

In multivariate regression analysis, only ST-elevation on ECG predicted the primary outcome (OR 1.33, 95% CI 1.003–1.76).

Dichotomizing hsTrop I concentrations by applying the guideline-specified cut-off (>70x URL) resulted in correct classification of useful-ICA patients in 95.7%. However, the false-positive rate was also extremely high (83.6%) with a positive predictive value (PPV) of 1.6% and a negative predictive value (NPV) of 99.6% (accuracy 17.5%).

Using area under the curve (ROC) analysis following optimal cut-off values for hsTrop I were identified: in CABG patients a cut-off value of >650x URL (corresponding absolute value 17000 ng/L) was defined with a corresponding sensitivity of 83.3%, specificity of 83.6%, PPV of 8.9% and NPV of 99.6% (accuracy 83.6%). In non-CABG patients (i.e. valve or aortic procedures), the cut-off was about twice as high as that for CABG patients (1,350x URL or 35,000 ng/L) with a corresponding sensitivity of 84.1%, specificity of 89.2%, PPV of 5.9% and NPV of 99.9% (accuracy 89.1%).

Conclusion

Our study demonstrates that currently recommended cut-off concentrations of high-sensitivity troponin are not useful for guiding clinical decision-making in patients with suspected acute coronary syndrome following cardiac surgery, while substantially higher cut-off values might be useful. Those cut-off values critically depend on the type of cardiac surgery performed (CABG vs. non-CABG).

Troponin_Curves post-op

Funding Acknowledgement

Type of funding source: None
A single high-sensitivity cardiac troponin T compared to the HEART score for a rapid rule-out of acute myocardial infarction at a prehospital emergency clinic
Authors: Johannessen T.R , Atar D , Vallersnes O.M , Larstorp A.C.K , Mdala I , Halvorsen S
Published: November 2020

Background

Patients presenting with acute chest pain outside of hospitals represent a diagnostic challenge.

Purpose

We aimed to validate whether a single high-sensitivity cardiac troponin T (hs-cTnT) safely can rule out acute myocardial infarction (AMI) in a primary care emergency setting. In addition, we aimed to investigate if the hs-HEART (History, Electrocardiogram (ECG), Age, Risk factors, and hs-Troponin) score would add valuable diagnostic information.

Methods

This is a secondary analysis from a prospective diagnostic study, including 1711 patients with acute non-specific chest pain presenting to a primary care emergency clinic from November 2016 to October 2018. The European Society of Cardiology (ESC) 0/1-hour algorithm triages patients towards direct rule-out if the 0-hour hs-cTnT is below 5 ng/L, combined with a normal ECG and a 3-hour symptom duration. The hs-HEART score (0–10 points) was calculated retrospectively, and a score ≤3 points was considered low-risk. In addition, a modified hs-HEART score, with more comparable hs-cTnT cut-off values, was applied. The primary endpoint was AMI during the index episode; the secondary the 90-day incidence of AMI (including index) and all-cause death.

Results

Among 1711 patients, 61 (3.6%) had an AMI, and 525 (30.7%) were assigned towards direct rule-out. With no AMIs in this group, the rule-out safety was high (negative predictive value (NPV) and sensitivity 100%). The hs-HEART score triaged more patients (n=966) as low-risk, but missed six AMIs (NPV 99.4% and sensitivity 90.2%). The modified hs-HEART score (n=707, AMI=3) increased the low-risk sensitivity to 95.1%. The 90-day incidence of AMI and all-cause death in the direct rule-out, low-risk hs-HEART, and modified hs-HEART group, were 0.0%, 0.7%, and 0.4%, respectively.

Conclusions

The ESC direct rule-out approach, with a single hs-cTnT below 5 ng/L, combined with a normal ECG, and a 3-hour symptom duration, is superior to the two hs-HEART scores in ruling out AMI in a primary care emergency setting.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Norwegian Research Fund for General Practice