bluuebunny/crossref_metadata_2025 huggingface dataset:
The gut hormone GLP-2 predicts cardiovascular risk in patients with acute myocardial infarction
Authors: Kahles F , Mertens R.W , Rueckbeil M.V , Arrivas M.C , Moellmann J , Lebherz C , Biener M , Giannitsis E , Katus H.A , Marx N , Lehrke M
Published: November 2020

Background

GLP-1 and GLP-2 (glucagon-like peptide-1/2) are gut derived hormones that are co-secreted from intestinal L-cells in response to food intake. While GLP-1 is known to induce postprandial insulin secretion, GLP-2 enhances intestinal nutrient absorption and is clinically used for the treatment of patients with short bowel syndrome. The relevance of the GLP-2 system for cardiovascular disease is unknown.

Purpose

The aim of this study was to assess the predictive capacity of GLP-2 for cardiovascular prognosis in patients with myocardial infarction.

Methods

Total GLP-2 levels, NT-proBNP concentrations and the Global Registry of Acute Coronary Events (GRACE) score were assessed at time of admission in 918 patients with myocardial infarction, among them 597 patients with NSTEMI and 321 with STEMI. The primary composite outcome of the study was the first occurrence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke (3-P-MACE) with a median follow-up of 311 days.

Results

Kaplan-Meier survival plots (separated by the median of GLP-2 with a cut-off value of 4.4 ng/mL) and univariable cox regression analyses found GLP-2 values to be associated with adverse outcome (logarithmized GLP-2 values HR: 2.87; 95% CI: 1.75–4.68; p<0.0001). Further adjustment for age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, family history of cardiovascular disease, hs-Troponin T, NT-proBNP and hs-CRP levels did not affect the association of GLP-2 with poor prognosis (logarithmized GLP-2 values HR: 2.96; 95% CI: 1.38–6.34; p=0.0053). Receiver operating characteristic curve (ROC) analyses illustrated that GLP-2 is a strong indicator for cardiovascular events and proved to be comparable to other established risk markers (area under the curve of the combined endpoint at 6 months; GLP-2: 0.72; hs-Troponin: 0.56; NT-proBNP: 0.70; hs-CRP: 0.62). Adjustment of the GRACE risk estimate by GLP-2 increased the area under the receiver-operating characteristic curve for the combined triple endpoint after 6 months from 0.70 (GRACE) to 0.75 (GRACE + GLP-2) in NSTEMI patients. Addition of GLP-2 to a model containing GRACE and NT-proBNP led to a further improvement in model performance (increase in AUC from 0.72 for GRACE + NT-proBNP to 0.77 for GRACE + NT-proBNP + GLP-2).

Conclusions

In patients admitted with acute myocardial infarction, GLP-2 levels are associated with adverse cardiovascular prognosis. This demonstrates a strong yet not appreciated crosstalk between the heart and the gut with relevance for cardiovascular outcome. Future studies are needed to further explore this crosstalk with the possibility of new treatment avenues for cardiovascular disease.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Society of Cardiology (DGK), German Research Foundation (DFG)
Long-term impact of the burden of new-onset atrial fibrillation in patients with acute myocardial infarction: data from the NOAFCAMI-SH registry
Authors: Xu S.L , Luo J , Li H.Q , Li Z.Q , Liu B.X , Qin X.M , Gong M.M , Shi B.B , Wei Y.D
Published: November 2020

Background

The prognostic implication of the burden of paroxysmal new-onset atrial fibrillation (NOAF) in patients with acute myocardial infarction (AMI) remains unclear. We aimed to determine the impact of NOAF burden on long-term cardiovascular outcomes in the setting of AMI.

Methods

This retrospective study was conducted to investigate the association of NOAF burden with the major adverse cardiac events (MACE, a composite of cardiovascular death, recurrent MI, worsening of heart failure, or ischemic stroke), using data from the New Onset Atrial Fibrillation Complicating Acute Myocardial Infarction in ShangHai registry. AF burden was defined as the percentage of time (%) spent in AF. Patients with paroxysmal NOAF were divided into three groups according to AF burden tertiles: low burden: 22.4%. A restricted cubic spline analysis was performed to illusrate the relationship between the burden of NOAF and MACE.

Results

Of 2399 participants, 278 developed NOAF during a median monitoring period of 194.9 hours. The mean age was 65.8±12.4 years, and the median burden of NOAF was 8.4% (IQR: 1.9%-38.1%). During up to 5-years follow-up, the incidence of MACE was 8.6, 17.4, 35.4, and 79.2 per 100 person-years in the sinus rhythm, low-, intermediate-, and high-burden groups, respectively. After adjustment, patients with high NOAF burden had the highest risk of MACE (hazard ratio [HR]: 3.10; 95% confidence interval [CI]: 2.36–4.07), cardiovascular death (HR: 2.26; 95% CI: 1.58–2.23), worsening of heart failure (HR: 4.90; 95% CI: 3.48–4.91), and ischemic stroke (HR: 4.42; 95% CI: 2.03–9.63). Our splines analyses uncovered a nonlinear dose-response pattern, as the HRs of MACEs increased with the progression of NOAF burden and appeared stable after approximately 15% of NOAF burden.

Conclusions

A greater burden of NOAF during AMI was strongly associated with a higher risk of adverse cardiovascular events.

Cumulative incidence of outcomes

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): 1. National Natural Science Foundation of China, 2. Natural Science Foundation of Shanghai
High levels of lipoprotein(a) are associated with the severity of coronary disease in patients with acute myocardial infarction. Data from the RICO survey
Authors: Farnier M , Yao H , Hounton N , Maza M , Chague F , Bichat F , Beer J.C , Lagrost L , Masson D , Cottin Y , Zeller M
Published: November 2020

Background

High level of Lipoprotein(a), Lp(a), is a well-recognised independent risk factor for atherosclerotic cardiovascular disease (ASCVD). However, limited data are available on the prevalence of high Lp(a) levels and on the threshold associated to coronary artery disease (CAD) burden in patients with acute myocardial infarction (MI).

Methods

We aim at assessing CAD burden in 651 consecutive patients hospitalized for an acute MI from January 2019 to September 2019 who underwent coronary angiography. Patients characteristics and angiographic features were compared for patients with Lp(a) <50 mg/dL (normal), ≥50 mg/dL (high) and >80 mg/dL (i.e >90th percentile) (very high).

Results

The prevalence of Lp(a) ≥50 mg/dL was elevated (19.0%) and 65 patients (10.0%) were in the >90th percentile. Median (IQR) age was similar across the 3 groups (normal: 68 (59–79)y; high: 74 (63–80)y; very high: 71 (57–82)y, p=0.239). When compared with patients with normal Lp(a), patients with very high levels (≥80 mg/dL) had higher prevalence of personal history of ASCVD (29 vs 16%, p=0.021) and family history of CAD (37 vs 19%, p=0.005), and were more frequently women (43 vs 29%, p=0.009). At coronary angiography, patients with very high Lp(a) levels had increased extent of CAD (Median SYNTAX score 17 (5–25) vs 10 (5–17), p=0.002) and more frequent multivessel disease (69 vs 54%, p=0.02).

Conclusion

Among real world patients hospitalized for an acute MI, Lp(a) levels >80 mg/dL are associated with an increased CAD burden and this threshold identifies a subset of patients with features of high ASCVD risk.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ARS Bourgogne Franche Comté; CHU Dijon Bourgogne
Definition of left ventricular remodelling following ST-elevation myocardial infarction: a systematic review of cardiac magnetic resonance studies
Authors: Legallois D , Hodzic A , Alexandre J , Dolladille C , Saloux E , Manrique A , Roule V , Labombarda F , Milliez P , Beygui F
Published: November 2020

Background/Introduction

An increase in left ventricular volumes between baseline and follow-up imaging is the main criteria for the quantification of left ventricular remodeling after ST-elevation myocardial infarction, but without consensual definition.

Purpose

We aimed to review the criterion used for the definition of left ventricular remodeling based on cardiac magnetic resonance imaging in studies including patients with ST-elevation myocardial infarction.

Methods

A systematic literature search was conducted using MEDLINE and the Cochrane Library from January 2010 to August 2019. Thirty-seven studies involving a total of 4209 patients were included.

Results

The median age of the patients was 59 years, 82% were male, and 93% underwent primary percutaneous coronary intervention. The median follow-up duration was 6 months (range, 3–12), and the second cardiac magnetic resonance session was performed at 6 months in 14 (38%) studies. Among these studies, 30 (81%) used a cut-off value for defining left ventricular remodeling, with a pooled left ventricular remodeling prevalence estimate of 22.8%, 95%-CI[19.4%-26.7%], and a major between-study heterogeneity (I2=82%). The seven remaining studies (19%) defined left ventricular remodeling as a continuous variable. A 20% increase in end-diastolic volumes or a 15% increase in end-systolic volumes between a baseline and a follow-up cardiac magnetic resonance imaging were the two most common criterion (13 [35%] and 9 [24%] studies, respectively). Seven studies used both end-diastolic and end-systolic vleft ventricular volumes.

Conclusion(s)

The definition of left ventricular remodeling using cardiac magnetic resonance following ST-elevation myocardial infarction is highly variable, among studies including highly selected patients. The most frequent left ventricular remodeling criterion were a 20% increase in end-diastolic volumes or a 15% increase in end-systolic volumes. A composite cut-off value of a 12% to 15% increase in end-systolic volume and a 12% to 20% increase in end-diastolic volume using a follow-up cardiac magnetic resonance imaging 1 to 3 months after myocardial infarction might be proposed as a consensual cut-off for defining adverse left ventricular remodeling for future large-sized, prospective studies with serial cardiac magnetic resonance imaging and long-term follow-up in unselected patients.

Funding Acknowledgement

Type of funding source: None
Intraventricular conduction defects in patients with st-segment elevation myocardial infarction – the paradox of right bundle branch block
Authors: Fernandes S , Montenegro F , Cabral M , Carvalho R , Santos L , Ruivo C , Pernencar S , Morais J
Published: November 2020

Intraventricular conduction defects (IVCD) in patients with acute myocardial infarct (AMI) are predictors of a worse prognosis. When acquired they can be the result of an extensive myocardial damage.

Purpose

To assess the impact of IVCD, regardless of being previously known or presumed new, on in-hospital outcomes of patients with AMI with ST segment elevation (STEMI) or undetermined location.

Methods

From a series of patients included in the National Registry of Acute Coronary Syndrome between 10/1/2010 and 9/1/2019, were selected patients with STEMI or undetermined AMI, undergoing coronary angiography.

Results

7805 patients were included: 461 (5.9%) presenting left bundle branch block (LBBB), 374 (4.8%) with right bundle branch block (RBBB) and 6970 (89.3%) with no IVCD. Clinical characteristics as well as in-hospital outcomes are described in the table 1. An unexpected worse prognosis in patients with RBBB has motivated a multivariate analysis. RBBB remained an independent predictor of in-hospital mortality (OR 1.91, 95% CI 1.04–3.50, p=0.038), along with female gender (OR 1.73, 95% CI 1.11–2.68, p=0.015), Killip Class>1 (OR 2.26, 95% CI 1.45–3.53, p<0.001), left ventricular ejection fraction <50% (OR 3.93, 95% CI 2.19–7.05, p<0.001) and left anterior descending artery as the culprit lesion (OR 1.85, 95% CI 1.16–2.91, p=0.009).

Conclusion

In spite of an apparent better clinical profile, in the current large series of unselected STEMI patients, the presence of RBBB is associated with the worst in-hospital outcome. RBBB doubles the risk of death, being an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding source: None
Usefulness of the PRECISE DAPT score as a predictor of ischaemic stroke after an acute coronary syndrome
Authors: Gonzalez Ferrero T , Alvarez Alvarez B.A.A , Cacho Antonio C.C.A , Perez Dominguez M.P.D , Antunez Muinos P.A.M , Abou Jokh Casas C.A.J.K , Rigueiro Veloso P.R.V , Agra Bermejo R.A.B , Garcia Acuna J.M.G.C , Gonzalez Juanatey J.R.G.J
Published: November 2020

Introduction

Ischaemic stroke (IS) risk after acute coronary syndrome is increasing. The aim of our study was to evaluate the stroke rate in a multicentre study and to determine the prediction ability of the PRECISE DAPT score, added to the prediction power of the GRACE score, already demonstrated.

Methods

This was a retrospective study, carried out in two centres with 5916 patients, with ACS discharged between 2011 and 2017 (median 66±13 years, 27.7% women). The primary endpoint was the occurrence of ischaemic stroke and its risk during follow up (median 5.5, IQR 2.6–7.0).

Results

A multivariable logistic regression analysis was made, where GRACE (HR 1.01, IC 95% 1.00–1.02) and PRECISE DAPT score (HR 1.03, IC 95% 1.01–1.05) were both an independent predictor of ischaemic stroke after ACS, in a model adjusted by age and AF, which was found to be the independent factor with highest risk (HR 1.67, IC 95% 1.09–2.55).

Conclusions

GRACE and PRECISE DAPT scores are ischaemic stroke predictors used during follow-up for patients after acute coronary syndrome. We should use both of them not only trying to predict ischaemic/haemorrhagic risk respectively but also as ischaemic stroke predictors.

Figure 1. AUC Curves

Funding Acknowledgement

Type of funding source: None
Over-representation of myocardial infarction with nonobstructive coronary arteries in oncological patients. The prevalence, clinical characteristics and long-term mortality
Authors: Stepien K , Nowak K , Szlosarczyk B , Stepien A , Nessler J , Zalewski J
Published: November 2020

Introduction

According to the current guidelines, myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined by general criteria of myocardial infarction (MI) with no hemodynamically significant lesions in coronary arteries (<50%). As shown in large MI registers, MINOCA is diagnosed in 1–13% of patients. The potential etiology of MINOCA is an intensively studied issue. To date, a number of potential mechanisms have been proposed. In our opinion, hypercoagulable states may be indicated as a direct trigger for such a sequence of events. Based on our previously published study, we found the presence of inherited thrombophilia in over 23.8% of MINOCA patients

Purpose

We suspect that oncological patients, the group with well-known prothrombotic state, are predisposed to MINOCA and have different clinical characteristics and long-term prognosis.

Methods

We analyzed a group of 1011 consecutive patients with MI who underwent coronary angiography in the years 2012–2017. A group of 134 patients with active cancer (13.3%) was separated. Working diagnosis of MINOCA was performed in accordance with current guidelines.

Results

MINOCA diagnosis was stated in 21 oncological patients (15.7%) and 51 others (5.8%) (P<0.001). Cancer patients were characterized by a higher incidence of anemia (47.6 vs 21.6%, P=0.027), lower hemoglobin levels (12.9 vs 14.1 g/dl, P=0.048) and higher troponin values (0.306 vs 0.076 ng/ml, P=0.003). Based on echocardiographic measurements, more frequent occurrence of takotsubo cardiomyopathy (19.1 vs 2.0%, P=0.010), higher values of right ventricular systolic pressure (44.5 vs 31.5 mmHg, P=0.016) and lower left atrial dimensions (36 vs 41.5 mm, P=0.020) were observed in the group of cancer patients. As expected, patients with active cancer had significantly higher all-cause mortality during long-term follow-up (66.7 vs 29.4%, P=0.003). In a multivariable analysis of oncological MINOCA was independently associated with a long-term mortality (P<0.001).

Conclusions

To our knowledge, our study is the first report concerning a high prevalence of MINOCA in oncological patients with MI. We observed a significant proportion of cancer-associated anemia in this group of patients. The high incidence of takotsubo cardiomyopathy and significant differences in individual echocardiographic parameters underline the important role of cardiac imaging in this group of patients with unfavorable long-term prognosis.

Figure 1

Funding Acknowledgement

Type of funding source: None
The impact of low diastolic blood pressure on 30-day mortality of patients with acute myocardial infarction
Authors: Asano T , Mitsuhashi Y , Sachi M , Wakabayashi K , Yahagi K , Shinke T , Mase T , Miyachi H , Tujiguchi S , Yamashita J , Yamazaki M , Miyauchi K , Yamamoto T , Nagao K , Takayama M
Published: November 2020

Background

It is known that low diastolic blood pressure (DBP) is associated with long-term cardiovascular events after acute myocardial infarction (AMI). However, the impact of low diastolic blood pressure on short-term outcome has not yet been well investigated.

Methods and results

We included 15,208 patients who were hospitalized for AMI and registered in the Tokyo CCU network registry between 2013 and 2016. Thirty-day in-hospital mortality rate was 4.8% (728/15,208). To assess the relationship between DBP at the time of admission and 30-day mortality non-linearly, spline regression model was applied with the stratification of the cohort according to tercile of systolic blood pressure (SBP, low:≤122 mmHg, intermediate:123–148 mmHg, high:≥149 mmHg) and J-curve phenomenon was observed in the low and high SBP groups. In multivariate logistic regression analysis, adjusted odds ratio of the lowest quintile of DBP (≤64 mmHg) was 1.65 (95% CI:1.02–2.66) in low SBP group and 4.55 (95% CI:1.72–12.00) in high SBP group.

Conclusion

Low DBP was associated with increased 30-day in-hospital mortality rate after AMI even in patients with high SBP.

Funding Acknowledgement

Type of funding source: None
Performance of the ESC 0/3-hour algorithm for rapid triage of myocardial infarction: systematic review and meta-analysis
Authors: Chiang C , Chiang C.H , Lee G.H , Lee C.C
Published: November 2020

Objective

The European Society of Cardiology (ESC) 0/3-hour algorithm is one of the most widely strategies used for rule-out or rule-in of acute myocardial infarction (AMI). However, a systematic evaluation of its performance has not been conducted. Furthermore, recent studies showed that the 0/3-hour algorithm is non-superior to the 0/1-hour algorithm.

Purpose

This study aims to summarize the safety and efficacy of the 0/3-hour algorithm and its comparative performance with the 0/1-hour algorithm.

Methods

We conducted literature search on PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials for studies published between 1 January 2008 and 31 May 2019. A bivariate random-effects meta-analysis was used to estimate the primary and secondary outcomes, defined as index myocardial infarction and triage efficacy, major adverse cardiac event (MACE) or mortality at 30 days, respectively.

Results

A total of 10,832 patients from 9 studies with a pooled AMI prevalence of 16% were analyzed. The 0/3-hour algorithm ruled out 69% of the patients with a pooled sensitivity of 94.2% [95% CI: 87.6%–97.4%] and negative predictive value of 98.6% [95% CI: 97.0%–99.4%]; 17% of the patients were ruled in with a pooled specificity of 94.9% [95% CI: 88.6%–97.8%] and positive predictive value of 72.9% [95% CI: 54.6%–85.7%]. The 30-day mortality and 30-day MACE for patients that were ruled out were 0.0% [95% CI: 0.0%–0.0%] and 1.4% [95% CI: 0.9%–2.0%], respectively. In a pooled analysis of 3 cohorts, the 0/3-hour algorithm had a non-superior sensitivity compared with the 0/1-hour algorithm (94.4% [95% CI: 87.0%–97.7%] vs. 98.4% [95% CI: 95.4%–99.7%]). The 0/3-hour algorithm also had a similar rule-out efficacy compared with the 0/1-hour algorithm (52% [95% CI: 39%–65%] vs. 53% [95% CI: 42%–64%]).

Conclusion

The widely used 0/3-hour algorithm has sensitivity substantially below the consensus goal of 99% and may not be sufficiently safe for triage of myocardial infarction. Furthermore, the 0/3-hour algorithm is not superior to the 0/1-hour algorithm despite the additional triage time.

Performance of ESC 0/3-hour algorithm

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Taiwan National Ministry of Science and Technology Grants
Association between variation of troponin and prognosis of acute myocardial infarction before and after primary percutaneous coronary intervention
Authors: Zhao Z.X.X , Wang W.Y , Liu L.C , Zhou Z.P , Sheng S.Z.X , Li L.J.N , Zhou Z.J.Y , Chen C.R.Z , Yan Y.H.B
Published: November 2020

Background

Circulating levels of cardiac troponin I (cTnI) after STEMI were considered prognostic factors for predicting MACE. ΔcTnI is the difference between peak cTnI post-primary PCI and cTnIon initial admission.

Purpose

Study aimed to assess the relationship between ΔcTnI, the ratio of ΔcTnI to cTnI on initial admission and MACE during the follow-up period.

Methods

A total of 2596 patients with cTnI measured upon admission and one-time measurement of cTnI during hospitalization were enrolled.

Results

In the adjusted models of the survival ROC curve, ΔcTnI and the ratio of ΔcTnI to cTnI on initial admission have stronger discrimination power of MACE [AUC 0.730 and 0.717] compared with peak cTnI post-PPCI and cTnI at admission (AUC 0.590, 0.546). Multivariate Cox regression analysis identified ΔcTnI [HR 1.018, 95% CI 1.001 to 1.035] as a relevant factor for MACE during follow-up. On the K-M survival curves,the incidence of MACE, mortality and angina pectoris were significantly higher in the group with maximum ΔcTnI (p=0.035, 0.049, 0.026).

Conclusion

ΔcTnI level and the ratio have stronger discrimination power of MACE. The group with maximum ΔcTnI has higher incidence of MACE, mortality and angina pectoris during the follow-up period.

Flow chart + survival ROC curve + K-M curve

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences
IL-10 / IL-6 serum ratio as a prognosis marker of STEMI
Authors: Leboube S , Bochaton T , Paccalet A , Crola Da Silva C , Jeantet P , Amaz C , De Bourguignon C , Varillon Y , Prieur C , Tomasevic D , Genot N , Rioufol G , Bonnefoy-Cudraz E , Mewton N , Ovize M
Published: November 2020

Introduction

IL-6 and IL-10 are two major cytokines secreted at the acute phase of myocardial infarction (MI). IL-6 has a pro-inflammatory effect whereas IL-10 has anti-inflammatory effect.

Objective

Our objective was to assess the prognosis value of IL-6, IL-10 and IL-10/IL-6 ratio serum level at the acute phase of ST elevation MI (STEMI).

Methods

We prospectively enrolled 247 patients admitted for acute STEMI from 2016 to 2019. Blood samples were collected at 5 time points: admission, 4, 24, 48 hours and 1 month (H4, H24, H48, M1). IL-6 and IL-10 were assessed using ELISA. Patients underwent cardiac magnetic resonance imaging at one month for infarct size (IS) and left ventricular ejection fraction (LVEF) assessment. Clinical outcomes were prospectively recorded over 18 months.

Results

Patient mean age was 59±12 years. IL-6 reached a peak at H24 at 5.4 pg/mL interquartile range (IQR) [2.1–11.0] and IL-10 peaked as early as admission at 5.6 pg/mL IQR [8.7–29.3] followed by a decrease within the first month. Median IL-10/IL-6 ratio at admission was 4.2 [1.4–8.6] with a strong decrease at H24 (0.5 [0.2–1.3]). IL-6 and IL-10 levels at H24 were correlated with IS (respectively r=0.44, p<0.0001, and r=0.29, p=0.0001) and inversely correlated with LVEF (respectively r=−0.42, p<0.0001 and r=−0.26, p=0.0003). Patients with IL-10/IL-6 ratio ≥1 had smaller IS compared to patients with IL-10/IL-6 ratio <1 (respectively 9.0% IQR [2.4–15.4] of LV versus 17% IQR [8.7–29.3] of LV, p<0.0001) and they had higher LVEF (58.0% IQR [52.0–62.3] versus 49.0% IQR [41.5–56.0], p<0.0001). Patients with IL-10/IL-6 ratio <1 were more likely to have an adverse clinical event (MI, stroke, hospitalization for heart failure and all-cause death) during the first 18 months after STEMI compared to patients with IL-10/IL-6 ratio ≥1 (HR=2.7, 95% CI [1.2–5.5], p=0.04).

Conclusion

Serum IL-10/IL-6 >1 was associated with a poor outcome after STEMI and might be a valuable prognostic marker.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospices Civils de Lyon, Fédération Française de Cardiologie
Usefulness of lung ultrasound in patients with acute coronary syndrome
Authors: Cristo Ropero M.J , Seoane Garcia T , Izquierdo Bajo A , Madrona Jimenez L , Rivera Rabanal F.J , Almendro Delia M , Hidalgo Urbano R , Vilches Arenas A , Garcia Rubira J.C
Published: November 2020

Background

The development of heart failure (HF) is a factor of poor prognosis in patients admitted due to acute coronary syndrome (ACS).

Research question

The aim of this study is to establish the usefulness of lung ultrasound (LU) to predict patients at risk of developing HF and the need for mechanical ventilation.

Methods

Prospective study with consecutive inclusion of patients with ACS type infarction without HF on admission and admitted to our centre between February 2017 and 2018. A lung ultrasound was performed in the first 24 hours, considering it positive when they presented 3 or more B lines in two or more quadrants of bilateral form. The result was related to the need for mechanical ventilation.

Results

We included 119 patients (65.1±12.8 years, 75.6% men), 12.6% presented a need for mechanical ventilation. Patients with a positive LU adjusted for a history of atrial fibrillation and the Killip-Kimball class have a risk 72.79 [95% CI: (9.21, 575.28)] times higher than needing mechanical ventilation at any time of the follow-up Adjusted for sex and heart rate, the result is 101.28 [95% CI: (12.83, 799.15); p=0.00005] times more risk of needing mechanical ventilation at any time of follow-up.

Conclusions

LU has a high positive predictive value for the development of severe HF and the need for mechanical ventilation, in patients admitted for ACS. Our findings suggest that LU should be incorporated in the initial stratification of patients with ACS.

Survival analysis mechanical ventilation

Funding Acknowledgement

Type of funding source: None
Invasive versus conservative management in spontaneous coronary artery dissection: a meta-analysis and meta-regression study
Authors: Bocchino P.P , Angelini F , Franchin L , D'Ascenzo F , Fortuni F , Conrotto F , Alfonso F , Saw J , Escaned J , De Ferrari G.M
Published: November 2020

Background

There is a paucity of data regarding the best treatment for spontaneous coronary artery dissection (SCAD).

Purpose

To compare the prognostic impact of conservative versus invasive treatment in patients with SCAD.

Methods

We systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2019. Random-effect meta-analysis was performed comparing clinical outcomes between the two groups.

Results

24 observational studies with 1720 patients were included. After 28±14 months, a conservative approach reduced target vessel revascularization rate compared with invasive treatment (OR=0.50; 95% CI 0.28–0.90; P=0.02). No difference was found regarding all-cause mortality (OR=0.81; 95% CI 0.31–2.08; P=0.66), cardiovascular mortality (OR=0.89; 95% CI 0.15–5.40; P=0.89), myocardial infarction (OR=0.95; 95% CI 0.50–1.81; P=0.87), heart failure (OR 0.96; 95% CI 0.41–2.22; P=0.92) and SCAD recurrence (OR=0.94; 95% CI 0.52–1.72; P=0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement and lower ejection fraction at admission are related with higher overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia.

Conclusion

A conservative approach provides similar clinical outcomes and lower target vessel revascularization rates compared to an invasive strategy in the setting of SCAD; therefore, when feasible, it should be preferred in this scenario.

Forest plots on the study outcomes

Funding Acknowledgement

Type of funding source: None
Bleeding risk prediction in elderly patients managed invasively for Acute Coronary Syndromes: external validation of the PRECISE-DAPT and PARIS risk scores
Authors: Montalto C , Crimi G , Morici N , Piatti L , Grosseto D , Sganzerla P , Tortorella G , De Rosa R , De Luca L , De Luca G , Palmerini T , Valgimigli M , Savonitto S , De Servi S
Published: November 2020

Background

Tailoring Dual Antiplatelet Therapy (DAPT) to each patient bleeding and ischemic risk profile is a majopr challenge in everyday clinical practice. As the elderlies were underrepresented in validation cohorts of bleeding risk scores, their generalizability in this context is uncertain.

Purpose

We sought to assess the clinical utility of the PRECISE-DAPT and PARIS bleeding risk scores to elderly patients suffering from ACS and undergoing invasive management.

Methods

Our external validation cohort included 1,883 patients older >74 years admitted for ACS and treated with PCI from 3 multicenter, randomized trials. Bleeding risk scores were calculated on a patient-level and subjects were stratified into risk categories according to each risk score definition.

Results

After a median follow-up of 365 days, patients in the high-risk categories according to the PRECISE-DAPT score experienced a higher rate of BARC 3–5 bleedings (log rank p=0.002) while this was not observed for those in the high-risk category according to the PARIS risk score (log rank p=0.3). Both scores had a moderate discriminative power (c-statistics 0.70 and 0.64, respectively) and calibration was accurate for both risk scores (all χ2>0.05), but PARIS risk score was associated to a greater overestimation of the risk (mean D observed-predicted probability = −0.65 for PRECISE DAPT and −4.62 for PARIS, p=0.02; Figure 1). Decision curve analysis was in favor of the PRECISE-DAPT score up to a risk threshold of 2%. A sensitivity showed that calibration and discrimination power was moderate for both risk scores also after including BARC 2 events.

Conclusion

In the setting of older adults managed invasively for ACS both the PARIS and the PRECISE-DAPT scores were moderately accurate in predicting bleeding risk. However, the use of the PRECISE-DAPT is associated with better performance and a higher net benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None
Ticagrelor pretreatment in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention
Authors: Graca Santos L , Ribeiro Carvalho R , Fernandes S , Montenegro Sa F , Ruivo C , Soares F , Correia J , Pernencar S , Morais J
Published: November 2020

Introduction

Dual antiplatelet therapy is recommended in non-ST elevation acute coronary syndrome (NSTACS), regardless of the treatment strategy (invasive vs. conservative). Although prasugrel pretreatment is not recommended due to safety concerns, the timing of ticagrelor administration is still debated.

Aim

To investigate the clinical effects of ticagrelor pretreatment in NSTACS patients (pts) undergoing percutaneous coronary intervention.

Methods

Retrospective multicentre study of 5213 NSTACS pts who underwent percutaneous coronary intervention (PCI) up to 72 hours following hospital admission, between January 2013 and December 2018. Patients with prior chronic exposure to oral antithrombotics (except acetylsalicylic acid), not acutely managed with ticagrelor, and those with missing data were excluded. A total of 415 pts were included for analysis, 256 (61.6%) received ticagrelor pretreatment (Group 1) and 159 (38.3%) were treated with ticagrelor only in the catheterization laboratory (Group 2). The primary safety endpoint was a composite of in-hospital major bleeding, need for red blood cell transfusion or haemoglobin drop ≥2g/dL and the secondary endpoint of periprocedural events was a composite of PCI failure, bailout use of GPIIb/IIIa inhibitors and in-hospital re-infarction. Multivariate analysis was performed to determine the correlates of ticagrelor pretreatment and each of the endpoints. One-year follow up was achieved in 103 pts (24.8%).

Results

Overall, mean age was 62±11 years and 20.7% were female. Crude event rates did not differ regarding primary endpoint (16.5 vs 11.5%; p=0.17), while secondary endpoint was more frequent among group 2 (2.1% vs 7.1%; p=0.01). Multivariate analysis showed no association between the timing of ticagrelor administration and the primary safety endpoint, while periprocedural events were less frequent in pretreated pts (Figure 1A). At the Kaplan-Meier analysis, one-year cumulative event-free (all-cause death, stroke or re-infarction) rates did not differ (Figure 1B).

Conclusion

In this cohort of NSTACS pts undergoing PCI in the first 72 hours after hospital admission, ticagrelor pretreatment was associated with less periprocedural events with no compromise regarding safety, compared to treatment in the catheterization laboratory. Additional data is still needed to clarify these findings.

Funding Acknowledgement

Type of funding source: None
Optimal antithrombotic strategy for patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention: updated meta-analysis of randomised controlled trials
Authors: Liao B , Wang T.K.M
Published: November 2020

Background

The optimal antithrombotic strategy for the growing proportion of patients with indications for both dual antiplatelet therapy and long-term anticoagulation remains controversial, with recent randomized trials published and mixed recommendations in guidelines. We meta-analysed bleeding and cardiovascular outcomes comparing dual versus triple and non-vitamin K oral anticoagulants (NOAC) versus vitamin K oral anticoagulants (VKA) antithrombotic regimens.

Methods

MEDLINE, Embase and Cochrane databases were searched for original randomised trials with relevant search terms from January 1980-December 2019. Two authors evaluated studies for inclusion and extracted data to pool efficacy and safety endpoints.

Results

The search yielded 331 articles, with 22 full-texts reviewed and six randomised trials totalling 12,146 patients included. Dual antithrombotic strategies had reduced TIMI major and minor bleeding (odds ratios 0.59, 95% confidence interval 0.44–0.80), as well as all, major, and minor bleeding (odds ratios 0.55–0.59, all P<0.05), with no differences in mortality, myocardial infarction, stroke, stent thrombosis or composite cardiovascular events (odds ratio 0.91–1.26, all P>0.05), compared with triple antithrombotic strategies in six trials. NOAC regimens had lower TIMI major and minor bleeding (odds ratio 0.64, 0.49–0.85), as well as major, minor and intracranial bleeding (odds ratios 0.36–0.66, all P<0.05), and similar no differences in mortality or all cardiovascular endpoints (odds ratios 0.85–1.13, all P>0.05), compared with VKA regimens in four trials.

Conclusion

Dual antithrombotic therapy with NOAC had significantly reduced bleeding without increase in cardiovascular events and mortality compared to their counterparts, and should generally be recommended in patients needing dual antiplatelet and long term anticoagulation therapy.

Funding Acknowledgement

Type of funding source: None
Impact of morphine treatment with and without metoclopramide co-administration on myocardial and microvascular injury in acute myocardial infarction: insights from a randomized trial
Authors: Stiermaier T , Schaefer P , Saad M , Meyer-Saraei R , De Waha-Thiele S , Fuernau G , Langer H , Barkhausen J , Desch S , Thiele H , Eitel I
Published: November 2020

Background

Intravenous morphine administration in patients with acute myocardial infarction (AMI) can adversely affect platelet inhibition induced by P2Y12 receptor antagonists, potentially resulting in an increased risk of adverse clinical events. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. Currently available data in this regard are, however, sparse, inconsistent, and methodologically limited.

Purpose

The aim of this study was to investigate the impact of morphine with or without metoclopramide (MCP) co-administration on myocardial and microvascular injury after AMI assessed by cardiac magnetic resonance (CMR).

Methods

This prospective, randomized, single-center study assigned 138 patients with AMI in a 1:1:1 ratio to (a) ticagrelor 180 mg plus intravenous morphine 5 mg (morphine group); (b) ticagrelor 180 mg plus intravenous morphine 5 mg and MCP 10 mg (morphine + MCP group); or (c) ticagrelor 180 mg plus intravenous placebo (control group). Study drugs were administered before primary percutaneous coronary intervention. CMR was performed in 101 patients on day 1–4 after the index event to assess infarct size, microvascular obstruction, and left ventricular ejection fraction.

Results

Infarct size was significantly smaller in the morphine only group as compared to controls (15.5%LV [IQR 5.0 to 21.4%LV] vs. 17.9%LV [IQR 12.3 to 32.9%LV]; p=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (10/36 [28%] versus 21/39 [54%]; p=0.022) and the extent of microvascular obstruction was smaller (0%LV [0 to 1.40%LV] versus 0.74%LV [0 to 3.10%LV]; p=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio 0.37; 95% confidence interval 0.14 to 0.93; p=0.035). Left ventricular ejection fraction did not differ significantly between the morphine and the control group (p=0.970) and there was no significant difference in left ventricular ejection fraction (p=0.790), infarct size (p=0.491), and extent (p=0.753) or presence (p=0.914) of microvascular obstruction when comparing the morphine + MCP group to the control group.

Conclusions

In this randomized study, intravenous administration of morphine prior to primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following AMI. This potential cardioprotective effect of morphine requires further evaluation in well-designed future trials with clinical endpoints.

Funding Acknowledgement

Type of funding source: None
2-year real-world outcomes of prasugrel, ticagrelor or clopidogrel therapy following percutaneous coronary intervention from a large multi-centre Australian registry
Authors: Pol D , Chowdhury E , Delacroix S , Worthley S , Eccleston D
Published: November 2020

Background

Real-world data comparing outcomes for prasugrel, ticagrelor or clopidogrel use in patients undergoing percutaneous coronary intervention (PCI) is limited, with only smaller cohorts or 12-month observations available.

Methods

Data was collected prospectively from a total of 14 sites around Australia, from November 2008 until March 2019. The cohort included consecutively enrolled patients presenting electively or following acute coronary syndromes who were prescribed dual antiplatelet therapy following PCI. There were no exclusion criteria. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year and 2 years after PCI. Secondary end points included safety, which was the incidence of major bleeding (BARC 3,4 or 5) at discharge.

Results

A total of 12,940 patients were included over a 11-year period. Patients receiving prasugrel were more likely to be male, younger (mean age 62.3+8.7 years), obese and present with STEMI than those receiving either ticagrelor or clopidogrel (all p<0.001). At 2 years the primary end point occurred in 120 of the 2968 patients (2.8 per 1000pyr) in the ticagrelor group, 446 of 9280 (2.7 per 1000pyr) patients in the clopidogrel group and 21 of 692 (1.8 per 1000pyr) prasugrel group (p=0.03). Major bleeding was observed in 0.2% in the ticagrelor group, 0.4% clopidogrel group and 0.1% in the prasugrel group (p=0.21).

Conclusion

For the first time we have shown in a large cohort of patients treated by PCI for ACS or CAD significantly lower 2-year rates of death, myocardial infarction and stroke amongst patients who received prasugrel than among those who received either clopidogrel or ticagrelor. The incidence of major bleeding did not differ between antiplatelet therapies.

Funding Acknowledgement

Type of funding source: None
Myocardial infarction triggered by exposure to air pollution – underestimated or overrated issue – 11 years study
Authors: Kuzma L , Struniawski K , Pogorzelski S , Zalewska-Adamiec M , Kralisz P , Bachorzewska-Gajewska H , Dobrzycki S
Published: November 2020

Introduction

Currently, the greatest threat to the health and life of people and the leading cause of death in Poland are cardiovascular diseases (CVD). Air quality is a well-known risk factor for the development of them.

Purpose

The aim of this study is to assess the impact of air pollution on the frequency of hospital admissions due to acute coronary syndrome (ACS).

Methods

The medical records of 30,695 patients hospitalized in the Department of Invasive Cardiology were analyzed. Patients treated for ACS and living within the borders of the analyzed city met inclusion criteria. Weather conditions such as temperature, humidity, atmospheric pressure, wind speed and the following components of air pollution were analyzed: carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2), trioxygen (O3), particulate matter with a diameter of 2.5 μm or less (PM2.5) and with a diameter of 10 μm or less (PM10). Poisson regression was used for statistical analysis.

Results

The study included 3,325 inhabitants of analyzed city (mean age 66.2 years, SD=12.2), male in majority (60.3%). The number of patients admitted for ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) was 1002, 1265, and 1058, respectively. An increase of CO concentration by 1 g/m3 was associated with a higher number of admissions due to NSTEMI (RR 1.74; 95% CI, 1.08–2.8; P=0.02), this effect was more noticeable in the female population (RR - 2.8; 95% CI, 1.39–5.65; P=0.004). In male subjects an increase in the concentration of PM2.5 by 10 μg/m3 was associated with a 0.5% increase in the number of admissions for NSTEMI (RR 1.05, 95% CI 1.02–1.22; P=0.02) and UA (OR 1.14, 95% CI 1.02–1.25; P=0.014). An increase in the concentration of SO2 by 1 μg/m3 affected the frequency of admissions in men due to NSTEMI (0.5% increase, RR 1.04, 95% CI 1.01–1.07; P=0.007) and UA (OR 1.17, 95% CI 1.02–1.36; P=0.031). The concentration of 03 and NO2 did not affect admissions rate due to ACS.

Conclusions

Air quality had an impact on the occurrence of ACS among residents of Bialystok. Increased exposure to air pollution, in particular, elevated PM2.5, SO2 and CO levels, was associated with a higher incidence of NSTEMI and UA. This effect was more noticeable in the male population.

Funding Acknowledgement

Type of funding source: None
Parenteral anticoagulation in non-ST segment elevation acute coronary syndromes: which option to pick?
Authors: Sousa J.P , Lopes P , Azevedo P , Baptista R , Gavina C , Monteiro S
Published: November 2020

Background

According to the 2015 European Society of Cardiology's non-ST segment elevation acute coronary syndrome (NSTE-ACS) clinical practice guideline, fondaparinux is the parenteral anticoagulant with the most favorable efficacy/safety profile. Thus, it is recommended over enoxaparin, for instance, in that setting. However, its use and performance in a contemporary portuguese cohort has not been fully described.

Purpose

To assess fondaparinux utilization degree and to compare its in-hospital efficacy and safety profiles with those of enoxaparin, in a contemporary portuguese cohort of NSTE-ACS patients.

Methods

Patients consecutively admitted with NSTE-ACS, between October 2010 and January 2019, were retrospectively identified from a national registry of acute coronary syndromes and were further divided in two groups, as per parenteral anticoagulation strategy (fondaparinux vs. enoxaparin). Key exclusion criteria were specific contraindications to both agents, recent hemorrhagic stroke and indications for anticoagulation other than ACS. The primary efficacy endpoint was a composite of in-hospital reinfarction and mortality, whereas the primary safety endpoint was moderate-to-severe bleeding, as defined by the GUSTO criteria.

Results

A total of 5843 NSTE-ACS patients (mean age 65±13 years, 72.4% males) were included. Of these, 89.2% had a myocardial infarction, while the remaining 10.8% were diagnosed with unstable angina. The most frequent cardiovascular comorbidities were hypertension (71.3%), dyslipidemia (63.0%) and diabetes mellitus (31.7%). Fondaparinux was the anticoagulant of choice in 27.5% of patients, whereas the remainder were treated with enoxaparin. Compared with patients receiving enoxaparin, those in the fondaparinux group were younger, had less hypertension or diabetes mellitus and exhibited a less severe presentation; nonetheless, they had more often a previous history of coronary artery disease or hemorrhagic events. An invasive approach in terms of revascularization was adopted in 87.7% of the cohort (79.1% in the fondaparinux group vs. 90.9% in the enoxaparin group, p<0.001). The primary efficacy and safety endpoints occurred in 2.4% and 4.7% of patients, respectively. After adjustment for relevant covariates, the use of fondaparinux was independently associated with a lower rate of both the primary efficacy (OR 0.56 [0.32–0.95], p=0.034) and the primary safety endpoints (OR 0.37 [0.23–0.59], p<0.001).

Conclusion

In a contemporary portuguese cohort of NSTE-ACS patients, fondaparinux was underused but still independently associated with a lower risk of both a composite of in-hospital reinfarction or mortality event and major hemorrhage.

Funding Acknowledgement

Type of funding source: None