bluuebunny/crossref_metadata_2025 huggingface dataset:
Longer symptom onset-to-door time persists despite reductions in STEMI door-to-balloon time: insights from the victorian cardiac outcomes registry
Authors: Vasudevan S , Dinh D , Brennan A , Bloom J E , Dawson L P , Nehme Z , Lefkovits J , Bray J , Nicholls S J , Stub D , Nelson A J
Published: November 2023

Background

Prompt revascularisation is central to achieving optimal outcomes for patients presenting with ST-segment elevation myocardial infarction (STEMI). To enable this, health systems have traditionally focused on the ‘door-to-balloon’ (DTB) component of total ischaemic time, while comparatively less attention has been given to symptom ‘onset-to-door’ (OTD) time.

Objective

To determine the temporal trends, predictors and outcomes among patients with increased OTD time.

Methods

Consecutive patients with STEMI treated with percutaneous coronary intervention (PCI) across 30 hospitals in the Victorian Cardiac Outcomes Registry were analyzed between 2014 and 2020. Linkage with data from Ambulance Victoria was performed for all patients transported via emergency medical services. Trends in OTD and DTB time were evaluated with Cochrane-Armitage test of trend. Characteristics and outcomes of patients with longer OTD time (>60 mins) were compared to those with shorter OTD time (<60 mins). Multivariable predictors of longer OTD were determined with logistic regression and presented as odds ratio and 95%CI in a forest plot.

Results

A total of 13,494 patients underwent PCI for STEMI with median OTD time of 150mins (86,328) and median DTB time of 66mins (43,107). DTB time progressively reduced over the study period (p=0.001) while the proportion of patients with longer OTD did not change (90.3%, p=0.91). Patients with longer OTD time were more likely to be older (>65yo = 41% vs. 35%, p<0.001), female (22 vs. 16%, p<0.001), live in a lower-socioeconomic area (36 vs. 28%, p<0.001), be treated for diabetes (17 vs. 13%, p<0.001), have developed their symptoms out-of-hours (65 vs. 60%, p=0.002) and present via ambulance [vs. self-present] (81 vs. 63%, p<0.001). Multivariable predictors of longer OTD time are presented in forest plot below. Higher rates of new renal impairment (6.7 vs. 5.0%, p=0.024) and 30-day MI (1.5 vs. 0.7%, p=0.017) were observed among patients with longer OTD, as were numerical trends in new 30-day heart failure (1.4 vs. 0.9%, p=0.22) and in-hospital shock (5.9 vs. 4.7%, p=0.081).

Conclusion

No change in the proportion of patients presenting with longer onset-to-door times was observed despite a parallel reduction in door-to-balloon time over the study period. Increased community awareness and education on the symptoms of myocardial infarction, particularly targeted at high risk demographic groups, are needed to further reduce ischaemic times.
External validation of the myocardial-ischemic-injury-index: a machine learning algorithm for the early diagnosis of myocardial infarction
Authors: Lopez Ayala P , Boeddinghaus J , Nestelberger T , Strebel I , Koechlin L , Rubini Gimenez M , Miro O , Martin-Sanchez F J , Keller D , Mueller C
Published: November 2023

Introduction

The myocardial-ischemic-injury-index (MI3) is a machine learning algorithm derived in 2019 for the early diagnosis of type 1 non-ST-elevation myocardial infarction (NSTEMI). MI3 incorporates age, sex, and two high-sensitivity cardiac troponin I (hs-cTnI) Architecht measurements. The performance of the MI3 algorithm is unknown in a setting where the time difference between the first and second troponin measurement is less than 3 hours. Thus, external validation seems mandatory before this algorithm could be considered for clinical use.

Purpose

To externally validate the performance of the MI3 algorithm and compare its performance with the ESC 0/1h-algorithm, the recommended algorithm by the European Society of Cardiology NSTEMI guidelines.

Methods

In a multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records, including cardiac imaging, serial hs-cTn and 90-days follow-up. Hs-cTnI (Architect) concentrations were measured in a blinded fashion at presentation and serially thereafter. The primary endpoint was type 1 NSTEMI during the index visit.

Results

Among 6487 patients with two available hs-cTnI concentrations, type 1 NSTEMI was the adjudicated final diagnosis in 882 (13.6%) patients. The median time difference between blood draws was 60 minutes (IQR: 57-70). Model performance was good, with a very high area under the receiver-operating-characteristic curve (0.961 [95% CI: 0.957-0.965]) and an optimal calibration overall (intercept -0.09 [-0.2-0.02]; slope 1.02 [0.97-1.08]), Figure 1. The originally defined low-probability MI3 score<1.6 and high-probability MI3 score≥49.7 triaged 4186 (64.5%) patients towards rule-out (sensitivity 99.1% [98.2-99.5]; negative predictive value [NPV] 99.8% [99.6-99.9]) and 915 (14.1%) patients towards rule-in (specificity 95.0% [94.3-95.5]; positive predictive value [PPV] 69.1% [66.0-72.0]), respectively (Figure 2). Both the sensitivity and the NPV of the ESC 0/1h-algorithm were greater than of the MI3 algorithm (difference for sensitivity: 0.84% [0.18-1.51], P=0.008; difference for NPV: 0.18% [0.05-0.33], P=0.016). In contrast, the specificity and PPV for the MI3 algorithm were higher (difference for specificity: 3.85% [3.29-4.40], P<0.001; difference for PPV: 7.82% [5.9-9.74], P<0.001).

Conclusion

In patients with two hs-cTnI (Architect) measurements with a median time difference of 60 minutes, the MI3 algorithm showed a very high discrimination and good calibration for type 1 NSTEMI.Diagnostic performance MI3 algorithmCutoff performance of the MI3 algorithm
Predictive value of d-dimer for plaque rupture, thrombus and worse clinical outcomes in acute coronary syndrome from TACTICS registry
Authors: Sato C , Wakabayashi K , Nishikura T , Kobayashi N , Kondo S , Sugiyama T , Kakuta T , Suwa S , Mori H , Kimura S , Higuma T , Yonetsu T , Mizukami T , Yamamoto M , Shinke T
Published: November 2023

Background

Acute coronary syndrome (ACS) mainly occurs by the rupture of lipid plaques with platelet aggregation. D-dimer (DD) is a primary degradation product and circulating marker of fibrinolysis. The use of DD helps to diagnose thrombosis. The serum DD level may indicate a thrombus within coronary artery in patients with ACS.

Purpose

The present study determined the association of serum DD level on admission with a thrombus within culprit lesion and ACS mechanism assessed by optical coherence tomography (OCT), and clinical outcomes.

Methods and Results

Tokyo/ Kanagawa/ Chiba/ Shizuoka/ Ibaraki active OCT applications for ACS (TACTICS) registry includes 695 consecutive ACS patients who underwent emergent PCI with OCT guidance. Of those, the information of serum DD level was available in 653 cases. Those patients were divided into two groups according to serum DD level on admission: high DD group(≧0.73 μg/ml, n= 328) and low DD group(＜0.73 μg/ml, n= 325). Comparison of type of plaque morphology and thrombus are shown in Figure. ACS patients with high DD level had poor long-term outcomes.

Conclusion

High serum DD level was associated with red-thrombus, plaque rupture, and worse prognosis in ACS. The simple test of DD may give us useful information in clinical practice for ACS.
Biological profiling in the spectrum of acute coronary syndrome: characterizing patients from MINOCA to NSTEMI with different features of the culprit plaque
Authors: D'aiello A , Pedicino D , Bonanni A , Vinci R , Severino A , Ponzo M , Conte C , Cribari F , Filomia S , Brecciaroli M , Grimaldi M C , Montone R A , Massetti M , Crea F , Liuzzo G
Published: November 2023

Background

In the last two decades, the development of procedures and tools such as coronary angiography and optical coherence tomography (OCT) have made it possible to highlight several aspects of acute coronary syndromes (ACS), identifying multiple subgroups such as patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and ruptured fibrous cap (RFC) or intact fibrous cap (IFC) culprit lesions. The aim of the study is to better characterize the ACS spectrum by evaluating the biological profile of non-characterized NTSEMI, RFC-NSTEMI, IFC-NSTEMI, and MINOCA patients.

Methods

We enrolled 56 consecutive patients presenting with ACS, specifically 16 patients with non-characterized NSTEMI, 12 patients with RFC-NSTEMI, 8 patients with IFC-NSTEMI, and 20 patients with MINOCA. Biological samples were collected and stored. We performed gene expression analysis through qRT-PCR technique for 21 genes.

Results

Our data displayed several differences in gene expression levels involved in inflammation, cellular adhesion, extracellular matrix turnover, and oxidative stress between the groups under examination. We observed no significant difference between non-characterized NSTEMI and MINOCA for all the studied genes. Alongside, MINOCA displayed significantly lower levels of the following genes than RFC and IFC patients: CD44, GPX1, ICAM1, PLA2G7, SOD1, and VEGFA. Furthermore, when compared with IFC patients, MINOCA showed lower levels of EDN1, LGALS8, MMP1, and TNF, and non-characterized NSTEMI showed a lower gene expression of CD31, ICAM1, and PI16. Finally, CD44, EDN1, GPX1, LGALS8, NOS3, SOD1, TFRC, and VEGFA were more expressed in RFC and IFC compared to non-characterized NSTEMI patients.

Conclusions

Our preliminary data, besides exploring new pathways in MINOCA patients, reflects the need for characterization and patients’ stratifications in the clinical management of ACS, since no differences were observed between non-characterized NSTEMI and MINOCA. This result may indicate that a one size fits all approach is not the most suitable since a plaque could be an innocent bystander and should be treated accordingly. A precision medicine approach that recognizes the presence of obstructive plaque and defines the type of culprit plaque (i.e., RFC or IFC) could identify better treatment, for a tailored therapy, allowing better prognosis and quality of life.Figure
Incremental value of physiological indices to predict high-risk plaque detected by NIRS-IVUS
Authors: Kakehi K , Yamada N , Onishi K , Sugimoto K , Funauchi Y , Takase T , Ueno M , Mathumura K , Nakazawa G
Published: November 2023

Background

The vulnerable plaque are called high-risk plaques (HRPs), and coronary computed tomography angiography (CCTA) studies have revealed the following characteristics: (1) lesion plaque density on CT≦30HU (2) positive remodeling, (3) The presence of spotty calcification, (4) ΔFractional Flow Reserve derived from CCTA (FFRCT) or Δ Quantitative Flow Reserve (QFR)≧0.06 has been cited as a feature of these lesions.

Therefore, identification of HRPs in non-culprit lesion is important to reduce future cardiovascular events.

Purpose

The purpose of the study was to determine whether HRP is predictable by incremental values of physiological indices in non-culprit lesions of ACS subjects.

Methods

A total of 137 non-culprit coronary lesions in 31 ACS subjects were retrospectively evaluated by CCTA, FFRCT, QFR and NIRS-IVUS imaging. Each coronary artery was divided into 30mm long segments beginning at the ostium to evaluate lesion vulnerability. By NIRS imaging, plaque with 4-mm maximum lipid-core burden index (maxLCBI4mm) ≥400 was defined as HRP. The relationship between HRP detected by NIRS and CCTA-derived plaque features, delta (Δ) FFRCT, and ΔQFR was evaluated.

Results

CT density, positive remodeling, diameter stenosis, ΔFFRCT, and ΔQFR were significantly associated with HRP, respectively (P<0.05). On multivariable analysis, CT density (OR; 0.95, 95%CI 0.91-0.99, P=0.0001), diameter stenosis (OR; 1.05, 95%CI 1.00-1.10, P=0.03) and ΔQFR (OR; 2119483 , 95%CI 1.75-2561856632475.6, P=0.03) independently predicted HRP, but not ΔFFRCT. ROC analysis for predicting HRP showed greater accuracy with incremental ΔQFR values in the model of CT density and diameter stenosis (AUC 0.93, P<0.0001).

Conclusion

HRP detected by NIRS may be predicted with greater accuracy by integrating QFR values with the assessment of CCTA-derived plaque features.figure1figure2
Impact of coronary physiological phenotypes on the immediate angiography-derived hemodynamic results of percutaneous coronary intervention
Authors: Wang B , Tsai T Y , Hery X Q , Kotoku N O Z O M I , Garg S C O T , Ninomiya K A I , Kageyama S H I G E , Masuda S H I N , Revaiah P C , Reiber J O H A N , Collet C A R L O S , Escaned J A V I E R , Biscaglia S I M O N E , Onuma Y O S H I , Serruys P W
Published: November 2023

Background

Angiography-based technologies can evaluate the physiological phenotypes of coronary artery disease (CAD) and the functional results of percutaneous coronary intervention (PCI), however, few studies have combined these to assess CAD pre- and post-PCI.

Purpose

We investigated the impact of physiological phenotypes of CAD on immediate post-PCI angiography-derived functional indices.

Methods

We analyzed 1004 vessels from three ongoing trials. Pre-PCI physiological phenotypes were characterized according to the angiography-derived pullback pressure gradient index (PPGi) as focal (≥0.66) or diffuse (<0.66). Local disease severity was assessed by instantaneous quantitative flow reserve (QFR) gradient per unit length (dQFR/ds) with a dQFR/ds≥0.025/mm, a "major" gradient. Post-PCI, epicardial and microvasculature functions were assessed using QFR and the index of microcirculatory resistance (angio-IMR), respectively.

Results

Pre-PCI, 327(35.81%) vessels had a PPGi<0.66, whilst 121 (13.25%) had a dQFR/ds<0.025 (Figure1, panel A). Post-PCI, a QFR<0.91 and IMR≥25 occurred in 247 (24.6%) and 310 (30.9%) vessels, respectively (Figure2, panel B). A post-PCI QFR<0.91 was associated with a lower PPGi (Odds ratio [OR]:1.31[1.17-1.47], p<0.001, Figure 1, panel C) but not a dQFR/ds (OR:0.99[0.96-1.02], p=0.453). A post-PCI IMR<25 was not associated with PPGi or dQFR/ds. Worsening in the IMR post-PCI was significantly associated with lower PPGi (1.31[1.16-1.48], p<0.001, Figure 1, panel D) and higher dQFR/ds (1.08[1.02-1.14], p=0.008, Figure 1, panel E) pre-PCI. Higher PPGi was associated with a higher odds ratio of achieving the optimal result (OR per 0.1 increase 1.25, [1.13-1.38], p<0.001, Figure 1, panel F). Multivariable analysis identified PPGi as an independent predictor of a post-PCI QFR≥0.91 and an optimal outcome (QFR≥0.91 and IMR<25, Figure2).

Conclusion

the phenotype of CAD pre-PCI can help predict functional outcome post-PCI, and therefore angiography-derived assessment has an important role in determining treatment strategy and outcome.Figure 1Figure 2
Differential outcomes in FFR-guided versus angiography-guided revascularization strategy according to target non-infarct related vessels: from FRAME-AMI trial
Authors: Jeon H S , Lee J H , Lee J W , Youn Y J , Lee J M , Hahn J Y , Ahn S G
Published: November 2023

Background

Incomplete revascularization of non-infarct related arteries (IRA) leads to worse outcomes in patients with acute myocardial infarction (AMI) and multivessel coronary artery disease (MVD). Outcomes of fractional flow reserve (FFR)- and angiography-guided percutaneous coronary intervention (PCI) for non-IRA may differ according to their location between the anterior descending artery (LAD) and non-LAD.

Aims

We investigated the impact of FFR- versus angiography-guided PCI on clinical outcomes according to the location of non-IRA (LAD versus non-LAD) in AMI patients with MVD.

Methods

This trial was a pre-specified post-hoc analysis of the FRAME-AMI study, an investigator-initiated, randomized, open-label, multicenter trial at 14 sites in Korea. In the FRAME-AMI trial, PCI was performed for non-IRA in 64.1% (FFR £0.80) and 97.1% (diameter stenosis of >50%) in FFR-guided PCI and angiography-guided PCI groups, respectively. We grouped the patients into four according to treatment strategy (FFR versus angiography) and location of non-IRA (LAD vs. non-LAD). The primary endpoint was a composite of time to death, MI, or repeat revascularization.

Results

Patients with non-IRA involving LAD and non-LAD were 55.0% and 45.0%, respectively. The proportion of performed PCI (82.2% vs. 78.3%, p=0.242) and the rate of the primary outcome (9.4% vs. 11.5%, p=0.421) were similar between LAD and non-LAD. Among patients with non-IRA involving LAD, the FFR-guided group had a fewer events rate of the primary outcome than the angiography-guided group (5.7% vs. 14.3%, p=0.010). Among those with non-IRA not involving LAD, the FFR-guided group tended to the lower incidence of the primary outcome compared to the angiography-guided group (7.4% vs. 14.5%, p=0.081). However, the effect of the interaction between LAD and non-LAD on the primary outcome was not found (p for interaction 0.667).

Conclusions

In AMI patients with MVD, FFR-directed PCI for non-IRA was superior to angiography-guided PCI regardless of the location of non-IRA. The benefit of an FFR-directed revascularization strategy for non-IRA is likely enhanced in LAD.
In-hospital prognosis of recreational drug use in patients with acute ST-elevation myocardial infarction: insights from the ADDICT-ICCU study
Authors: Clement A , Pezel T , Ramonatxo A , Roule V , Picard F , Swedsky F , Amri N , Maitre-Ballesteros L , Coppens A , Bouali N , Guiraud-Chaumeil P , Gall E , Lequipar A , Henry P , Dillinger J G
Published: November 2023

Background

Although recreational drug use may induce ST-elevated myocardial infarction (STEMI), its prevalence in patients hospitalized in intensive cardiac care units (ICCUs), as well as its short-term cardiovascular consequences, remains unknown.

Purpose

To assess the prevalence of recreational drug use and its prognosis for in-hospital major adverse cardiac events (MACEs) in patients with STEMI.

Methods

From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1575 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for STEMI. The following recreational drugs were detected within two hours after admission to the ICCU: i) tetrahydrocannabinol including cannabis and marijuana; ii) cocaine; iii) amphetamines; iv) MDMA; and v) heroin and other opioids. Administration of morphine for pain sedation during the initial management of patients was recorded, and their urine test for opioids was considered negative. The primary endpoint was MACEs defined by death, resuscitated cardiac arrest, or cardiogenic shock.

Results

Among the 325 patients with STEMI (age 62±13 years, 79% men), 41 (12.6%) had a positive test (cannabis: 88%, opioids: 37%, cocaine: 10%, MDMA: 5%). The prevalence of drug use increased to 34% in patients under 50 years of age. Recreational drug users were more frequently men (93% vs. 77%, p=0.02), younger (50±12 years vs. 63±13 years, p<0.001), and more active smokers (78% vs. 34%, p<0.001). Multiple drug use was reported in 16 cases (39%). Of the 41 patients with recreational drug use, 22 (54%) self-reported the use of recreational drugs on admission. During hospitalization, 17 MACEs occurred (5.2%), including 6 deaths (1.8%), 10 cardiogenic shocks (3.1%), and 7 cardiac arrest events (2.2%). Ventricular arrhythmia was more frequent in recreational drug users (9.8% vs. 1.4%, p=0.01). Use of recreational drugs was associated with more MACEs after adjustment for comorbidities (OR=13.6; 95%CI: 3.6-57.3).

Conclusion

In patients with STEMI, recreational drug use is prevalent, especially in patients under 50 years of age, and is independently associated with an increase of MACEs with more ventricular arrhythmia.Prevalence of recreational drug usePrognosis of recreational drug use
Adherence to guideline-directed medical therapy and 3-year clinical outcome following acute myocardial infarction
Authors: Hyun D , Lee S H , Choi J , Yoon C H , Cha K S , Oh S K , Seong I W , Jeong M H , Choi J H
Published: November 2023

Aims

Despite the well-established clinical benefits and strong recommendations in clinical guidelines, adherence to guideline-directed medical therapy (GDMT) is known to be insufficient. We investigated the adherence to GDMT and its impact on the 3-year clinical outcomes in patients with acute myocardial infarction (AMI).

Methods and results

Source data were obtained from KAMIR-NIH, a Korean multicenter observational registry. GDMT was defined according to the ACC/AHA class I recommendations. Adherence to GDMT was assessed at discharge and every year thereafter. The differences in clinical characteristics between patients receiving and those not receiving GDMT were adjusted using propensity score matching (PSM) or inverse probability of treatment weighting (IPTW). The primary endpoint was major adverse cardiovascular events (MACE), which was a composite of all-cause death and non-fatal MACE, including MI, revascularization, or stroke. Of 12,815 patients, GDMT adherence was 70.2% at discharge, and decreased gradually into 54.6% at 3-year. GDMT at discharge was associated with lower MACE risk in the unadjusted analysis (HR=0.51, 95%CI=0.47–0.55, p<0.001) and also in the PSM- or IPTW-adjusted analyses (HR=0.77, 95%CI=0.69–0.86; HR=0.79, 95%CI=0.72–0.86; p<0.001, all). These findings were replicated in the 1-year or 2-year landmark analyses (HR=0.58 to 0.82, p<0.01, all).

Conclusion

Adherence to GDMT was suboptimal among patients with AMI in Korea. As the adherence to GDMT was associated with a lower incidence of MACE during 3-year follow-up, the maintenance of long-term GDMT might be crucial for patients with AMI.Structured Graphical Abstract
Checkpoint nano-degrader to transiently promote efferocytosis in acute myocardial infarction
Authors: Gao J , Ge J U N B O
Published: November 2023

The efferocytosis of apoptotic cardiomyocytes (CMs) after acute myocardial infarction (AMI) is required for inflammation resolution and cardiac repair. However, this process would be impaired by the elevated CD47 presentation on apoptotic CMs. Herein, we developed CD47 density-controlled senescent RBC-mimetic liposome (RLP) as a nano-degrader to promote receptor signal-regulatory protein alpha (SIRPα) mediated internalization and transiently inhibit CD47-SIRPα axis. We demonstrated that RLP modified with Ly6G antibody hitchhiked neutrophiles and was released to macrophages in the border area of the infarct heart, which was subsequently internalized through SIRPα and degraded in lysosome. CD47-SIRPα axis blockade consequently promoted the efferocytosis of apoptotic CMs and lead to decreased infarct area and anti-inflammatory microenvironment for improved cardiac remodeling. This nano-degrader from senescent RBC-mimetic liposome presents a practical membrane protein degradation strategy to transiently inhibit CD47-SIRPα axis and boost apoptotic CMs efferocytosis.
One-month dual antiplatelet therapy following stent implantation in patients with acute coronary syndromes and high bleeding risk
Authors: Pivato C A , Musto C , Paolucci L , Testa L , Pacchioni A , Briguori C , Esposito G , Lucisano L , De Luca L , Latini A C , Regazzoli D , Sardella G , Indolfi C , Condorelli G , Stefanini G G
Published: November 2023

Background/introduction

There is a paucity of data regarding the safety of a one-month dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) presenting with acute coronary syndromes (ACS).

Purpose

We aimed to compare the clinical outcomes of patients at HBR with ACS or chronic coronary syndromes (CCS) treated with PCI using bioresorbable-polymer everolimus-eluting stent followed by one-month DAPT.

Methods

This is a pre-specified sub-analysis of the POEM trial, an interventional, prospective, multicenter, single-arm trial, that evaluated the safety of PCI with bioresorbable-polymer everolimus-eluting stent followed by one-month DAPT in patients with HBR against an objective performance criterion (OPC). The OPC was derived from the reported 1-year primary endpoint rate of 9.4% observed in the LEADERS FREE trial. According to the POEM protocol, patients were treated with one-month DAPT. In case of need for anticoagulation, patients received an oral anticoagulant in addition to a P2Y12 inhibitor for one month, followed by oral anticoagulation only after that. The primary endpoint was a composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis at 12 months.

Results

263 (59.4%) patients with CCS and 180 (40.6%) patients with ACS were included. Most of the HBR inclusion criteria were comparable between the two groups, Figure 1. At one year, the rates of the primary outcome were 4.3% (95% CI, 2.4-7.6%) and 5.7% (95% CI, 3.1-10.3%) among patients with CCS and ACS, respectively. Both 1-sided 97.5% upper confidence limits of the risk difference between the primary outcome and the prespecified OPC of 9.4% were below the non-inferiority margin of 3.85 % (CCS: -1.8 %; ACS: 0.9 %), Figure 2. No significant difference was evident between CCS and ACS patients for each isolated component of the primary endpoint (cardiac death: 1.7% vs. 2.0%, p= 0.857; myocardial infarction: 3.9% vs. 3.1%, p= 0.934; definite/probable stent thrombosis: 1.2% vs. 0.8%, p= 0.689). The risk for Bleeding Academic Research Consortium (BARC) type 1-5 or type 3-5 bleedings was also similar between CCS and ACS patients (4.3% vs. 5.2%, p=0.677, and 1.6% vs. 2.9%, p=0.351, respectively).

Conclusions

Among HBR patients with ACS who underwent PCI with BP-EES, a one-month DAPT strategy is associated with a similar risk of ischemic and bleeding events compared to those with CCS. These findings support the hypothesis that DAPT should be tailored to patients’ bleeding risk profiles and that a one-month strategy might be safely applied also in a particular setting of ACS.Figure 1.HBR inclusion criteria.Figure 2.Primary endpoint analysis.
Incremental value of a CCTA-derived AI-based ischemia algorithm over standard CCTA interpretation for coronary ischemia in patients with suspected coronary artery disease
Authors: Nabeta T , Bar S , Maaniitty T , Min J K , Earls J P , Bax J J , Saraste A , Knuuti J
Published: November 2023

Background

Coronary computed tomography angiography (CCTA) is a widely used non-invasive test to diagnose coronary artery stenosis in patients with suspected coronary artery disease (CAD). Positive predictive value for ischemia has been suboptimal using clinical reading. A novel AI-based ischemia algorithm applying machine learning that considers an array of atherosclerotic and vascular morphology features from CCTA images has been suggested to improve the diagnostic performance for ischemia.

Purpose

This study aims to evaluate the incremental diagnostic performance of CCTA derived AI-based ischemia algorithm in evaluating myocardial ischemia.

Methods

Patients with suspected CAD referred for CCTA at Turku University Hospital from February 2007 to December 2016 were analysed. The AI-based ischemia algorithm was calculated by analysts blinded for patient characteristics and clinical outcomes using typically-acquired CCTA images. In diagnostic reading significant stenosis defined by a stenosis > 50% on CCTA. The reference standard was ischemia detected by stress 15O-H2O positron emission tomography (PET).

Results

A total of 1445 patients (mean age 63 ± 9 years, 46% male) were included in this analysis. Myocardial ischemia by PET was detected in 384 (27%) patients while the other patients had either normal PET or had non-obstructive CAD by CCTA. A positive AI-based ischemia algorithm was found in 431 (30%) patients. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the AI-based ischemia algorithm for the assessment of myocardial ischemia were 83%, 74%, 86%, 66%, and 90%, respectively. Compared with diagnostic reading of CCTA (area under the receiver operating characteristic curve [AUC], 0.853; 95%CI 0.832-0.874), the model including clinical reading and AI-based ischemia algorithm demonstrated superior discrimination of myocardial ischemia (AUC 0.883; 95%CI 0.863-0.904, p-value <0.001). (Figure)

Conclusions

A novel AI-based ischemia algorithm derived from CCTA improves diagnostic accuracy compared with clinical reading of CCTA in assessing myocardial ischemia by PET perfusion imaging in patients with suspected CAD.Figure
Effect of symptoms recognition in patients with recurrent acute myocardial infarction: from KRAMI-RCC
Authors: Kim K , Kim H R , Koh J S , Kang M G , Park J R , Hwang J Y
Published: November 2023

Background

Clinical significance of self-recognition for myocardial infarction symptom in the general population has been well-known. However, evidence of self-recognition for ischemic symptoms in patients with recurrent myocardial infarction is limited. The study is aimed to verify the association between self-recognition and clinical characteristics, and clinical outcomes in patients with recurrent myocardial infarction.

Method

From 2016 to 2019, the Korean Registry of Acute Myocardial Infarction for Regional Cardiocerebrovascular Centers (KRAMI-RCC), a web-based registry for myocardial infarction in South Korea, was used. We divided into two groups based on self-recognition in questionnaire. Patient characteristics and clinical outcomes were analyzed.

Result

Among 11,894 MI patients, the rate of recurrent MI was 9.7%. The rate of self-recognition in subjects with first MI and recurrent MI was 14.4% and 52.0%, respectively (p<0.001). Patients without responses to the self-recognition questionnaire were excluded (n=86). Finally, enrolled subjects were 1,050. Males had a higher rate of self-recognition (79.3% vs. 69.0%). Younger patients, higher graduation levels, and living with a spouse were associated with the well-recognized symptoms. Chest pain, cold sweating, and radiating pain were related to being noticed as a symptom of MI. However, no difference of respiratory difficulties and stomachache in both groups was observed. The unrecognized group had more frequently occurred with cardiogenic shock and heart failure. A history of stroke and malignancy was associated with a low incidence of recognition. Patients with dyslipidemia had a high recognition rate. There was no difference of symptom recognition between ST elevation MI and non-ST elevation MI.

Interestingly, previously registered patients in KRAMI-RCC were significantly associated with higher recognition. The symptom recognition was related to prompt visit in regional cardiovascular centers (57% vs. 47%, p=0.002). The in-hospital mortality rate in the unrecognized group was higher at 6.7% compared to the recognized group (1.5%, p<0.000). Unrecognized MI symptoms and a presentation with cardiogenic shock were independent predictors in multivariate analysis to predict a model for in-hospital mortality.

Conclusion

The MI symptom recognition rate was still low in patients with recurrent MI. Self-recognition of MI symptoms was an independent predictor for in-hospital mortality. In this study, it is thought that rapid symptom recognition might help patients with myocardial infarction visit the hospital as soon as possible, thereby reducing cardiogenic shock and death.Multivariable analysisSelf-recognition and Outcomes
Consensus on the diagnosis and management of patients with type 2 myocardial infarction: an international Delphi study
Authors: Taggart C , Ferry A , Chapman A R , Bularga A , Wereski R J , Boeddinghaus J , Eggers K , Thygesen K , Lindahl B , Mills N L
Published: November 2023

Background

Type 2 myocardial infarction occurs due to a reduction in myocardial oxygen supply or an increase in demand without evidence of atherosclerotic plaque rupture. It is common representing around 20% of myocardial infarctions (1-4). Outcomes are poor with up to one third alive at five years, with cardiovascular outcomes comparable to type 1 myocardial infarction (1,5,6). Despite this, there are no evidence-based guidelines to guide assessment and management for clinicians.

Purpose

To gain consensus on the assessment and management of type 2 myocardial infarction from an international group of experts.

Methods

A systematic review of type 2 myocardial infarction was undertaken to identify the corresponding or senior author of all original research studies. We identified 73 experts from multiple clinical specialties. A three-round international eDelphi study was circulated, with round one consisting of open questioning to generate statements for deductive analysis. Consensus was defined a priori as >70% agreement on a 5-point Likert scale. Statements for which no consensus could be obtained were adapted and recirculated in round three (Figure 1).

Results

Of the 68 experts contacted there was a 56% (38/68), 54% (37/68) and 72% (49/68) response rate in round one, two and three, respectively. Consensus was achieved on 64% (43/67) of statements. Consensus varied across the following domains i) definition and diagnosis 42% (5/12), ii) risk stratification 75% (3/4), iii) assessment of coronary artery disease and cardiac function 50% (9/18), iv) specialty management 60% (6/10), v) treatment and secondary prevention 100% (9/9) and vi) communication and rehabilitation 79% (11/15). The panel agreed that all patients should undergo echocardiography (mean [SD] 2.08 [1.23]) and CT coronary imaging or a functional test should be performed on those with intermediate probability of future cardiovascular events (mean [SD] 1.81 [0.52]). Over 90% of the panel agreed that both patient and clinician understanding of type 2 myocardial infarction was poor and that further randomised controlled trials are need to direct care.

Conclusion

There remains uncertainty regarding the current definition of type 2 myocardial infarction and overall patient and clinician understanding was thought to be poor. However, it is generally accepted that the mainstay of management should be on the identification of coronary artery disease and left ventricular impairment with optimisation of therapies with proven benefit. Management should involve an individualised assessment and the multidisciplinary team.
LUV Score - a combination of bedside lung ultrasound and velocity-time integral (VTI) to predict mortality risk in STEMI patients
Authors: Pinheiro Machado G , Heiden Telo G , Barbato Da Rosa J P , Martins A , Azeredo W , Chies A , Nassif M , Da Silva J , Neves De Araujo G , Silveira A , Wainstein R , Wainstein M
Published: November 2023

Background

Early risk stratification is essential for in-hospital management of ST-segment–elevation myocardial infarction (STEMI). Development of acute heart failure and pulmonary edema is associated with poorer prognosis in this setting. Velocity–time integral (VTI) estimates stroke volume and cardiac output and has never been tested in acute coronary syndromes.

Purpose

Our aim was to evaluate the prognostic ability of a novel cardiothoracic ultrasound protocol for hemodynamic assessment with lung ultrasound (LUS) and VTI in patients with STEMI.

Methods

LUS and VTI were performed within 24h of admission for STEMI. LUS consisted of 8 scanning zones. A LUS combined with VTI (LUV) classification was developed. Receiver operating characteristic (ROC) analyses were performed to assess LUV score with in-hospital mortality, and it was compared with traditional Killip classification.

Results

From September 2022 and January 2023, 104 consecutive patients were admitted with ST-segment–elevation myocardial infarction. Fifteen patients were excluded from the analysis because were not assessed within 24h of admission. Therefore, 89 patients were included in the final analysis. Mean age was 62 years, 59% were male, 55% had hypertension, 32% had diabetes, 43% was anterior wall myocardial infarction and 16% had Killip 3 or 4 at admission. Overall in-hospital mortality was 7.9% and mortality across LUV categories were 0%, 0%, 8% and 50% for LUV A-D, respectively. A VTI ≥ 14 implied a negative predictive value for in-hospital mortality of 100%. The area under the ROC curve of LUV classification for in-hospital mortality was 0.92 (P=0.001), and Killip classification (0.85, P<0.001; P=0.48 for the difference between curves – Figure 1). Incidences of culprit vessel according to LUV categories are illustrated at Figure 2. There were no left main culprit vessel in our sample.

The distribution of Cardiac Output (CO) and Cardiac index (CI) and Cardiac Power Output (CPO) were the following: LUV A: CO = 4.5 (1.2), CI = 4.0 (1.1) CPO = 0.9 (0.3); LUV B CO = 3.8 (0.9) CI = 3.4 (0.8) CPO = 0.7 (0.2); LUV C CO = 3.3 (0.8) CI = 3.0 (0.8) CPO = 0.6 (0.1) ; LUV D CO = 2.9 (0.7) CI = 2.7(0.5) CPO = 0.5(0.1).

Conclusions

In a cohort of patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, LUV score provided an excellent AUC for prediction of in-hospital mortality. LUV score is an easy, noninvasive, rapidly acquired, and accurate method for risk stratification in STEMI patients.
Predictive values of age shock index and age modified shock index for in-hospital mortality in patients with ST-segment elevation myocardial infarction
Authors: Lyu S , Zhu J , Wang J , Wu S , Yang Y
Published: November 2023

Background and Purpose

This study aimed to evaluate the predictive values of admission age shock index (age SI) and age modified shock index (age MSI) for short-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

7324 patients with STEMI were included in the present study. Shock index (SI), modified shock index (MSI), age SI, age MSI and the TIMI score were calculated on admission. The primary outcome was all-cause mortality and the secondary outcomes were recurrent MI, cardiogenic shock and major adverse cardiovascular events (MACEs) during 30-day follow-up. Univariate and multivariate Cox regression were performed to evaluate the association between age SI, age MSI and outcomes. Predictive values of SI, MSI, age SI, age MSI and the TIMI score were evaluated and compared through analysis of the receiver operating characteristic (ROC) curves and integrated discrimination improvement (IDI).

Results

According to the ROC curve, the best cutoff of age SI for 30-day all-cause mortality were 50.0. Patients with elevated age SI had more comorbidities, received less evidence-based treatments and carried worse 30-day mortality. Multivariate Cox regressions demonstrated that age SI and age MSI were independent predictors of 30-day all-cause mortality and MACEs. The predictive values of age MSI for 30-day mortality were comparable to that of the TIMI score (c statistic: 0.743 vs. 0.758, z=1.740, p=0.082; IDI: 0.011, p=0.055) and better than that of SI (c statistic: 0.743 vs. 0.660, z=14.317, p<0.001; IDI: 0.046, p<0.001). The prognostic performance of age MSI was slightly inferior to that of the TIMI score (c statistic: 0.741 vs. 0.758, z=2.060, p=0.039; IDI: -0.001, p=0.846).

Conclusion

Age SI and age MSI were independent predictors for 30-day all-cause mortality and MACEs in patients with STEMI. The predictive value of age SI was comparable with the TIMI score but better than SI. Age SI and age MSI are practical risk stratification tools for STEMI.Figure.Receiver operating characterisTable.Discrimination and Calibration
Prognostic impact of ventricular tachycardia/fibrillation timing on cardio-vascular death in STEMI patients: 5 years of follow-up
Authors: Kozhukhov S , Parkhomenko A , Irkin O , Lutay Y A , Dovganych N
Published: November 2023

Objectives

Ventricular tachycardia (VT) and ventricular fibrillation (VF) are life-threatening arrhythmias that have negative impact on prognosis. This study investigated the relationship between the timing of VT or VF and long-term prognosis among ST-elevation myocardial infarction (STEMI) patients.

Background

It is unknown whether the timing of VT/VF occurrence affects the prognosis of patients with STEMI.

Methods

From 2001 to 2011 among 1621 STEMI patients (mean age 54,4±9,3 years) who participated in a prospective study, 221 (13.6%) had VT/VF during in-hospital stay. The mean time from STEMI symptoms onset was 4,5±0,1 h. 632 patients underwent TLT (39.0%), 267 (16.5%) - primary PCI. 772 (44,5%) patients did not undergo revascularization due to spontaneous recanalization or late admission. Patients with VT/VF were divided into two groups: early VT/VF - within 24 hour (h) of admission, 154 patients and late VT/VF - >24 h after admission, 67 patients. Patients have been monitored for 5 years of follow-up (FU). Cardiovascular (CV) death was the primary end-point.

Results

Patients with VT/VF were more likely to have cardiogenic shock, Killip Class II-III, AV block, and recurrent MI. Among STEMI patients the frequency of VT/VF occurrence was higher in patients with TLT – 19,0% and PTCA - 15,0% in compare to those without revascularization - 7,9%. However, the late VT/VF was 3.4 times less frequent among patients with TLT, 2.9 times - in PTCA, and twice less in patients without revascularization, compared to patients with early VT/VF. During FU long-term mortality has differed (Fig. 1). Kaplan-Mayer curves have significantly separated in late VT/VF group (p<0.01) during the first year (Fig. 2). Independent predictors of CV death in STEMI patients with late VT/VF were: higher Killip class (OR: 1.372, 95%CI 1.023-2.174, p<0.01), and higher peak CK-MB (OR: 1.031, 95% CI: 1.014-1.048, p<0.05).

Conclusions

VT and VF are frequent complications in STEMI and are powerful and independent predictors of 5-year survival. The timing of VT/VF occurrence had a peak during the first 24 h. However, patients with late VT/VF are at high risk of CV death in long-term FU and therefore require an individualized approach.
Adjunctive cilostazol in patients with acute ST-elevation myocardial infarction: a multicenter, randomized, open-label, phase 4 trial
Authors: Park S , Rha S W
Published: November 2023

Background/Aims

Previous studies showed that triple antiplatelet therapy (TAT), involving the addition of cilostazol to conventional dual antiplatelet therapy (DAT; aspirin + clopidogrel), has better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) than that with DAT; however, the optimal duration of TAT has not yet been determined.

Methods

Altogether, 985 patients who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DES) were prospectively enrolled in 14 medical centers in Korea. We randomly assigned patients into three groups: DAT (aspirin and clopidogrel for 12 months), TAT 1M (aspirin, clopidogrel, and cilostazol for 1 month), and TAT 6M (aspirin, clopidogrel, and cilostazol for six months). The primary endpoint was 1-year major adverse cardiovascular events (MACEs), defined as the composite of all-cause death, recurrent myocardial infarction (MI), stroke, or repeat revascularization.

Results

The primary endpoint was not different among the three groups (8.8% in the DAT, 11.0% in the TAT 1M, and 11.6% in the TAT 6M; hazard ratio for TAT 1M vs. DAT, 1.302; 95% confidence interval [CI], 0.792–2.141; p=0.297; hazard ratio for TAT 6M vs. DAT, 1.358; 95% CI, 0.829–2.225; p=0.225). With in-hospital outcomes, more bleeding events occurred in the TAT group than in the DAT group (1.3% vs. 4.7% vs. 2.6%, p=0.029) without significant differences in major bleeding. Besides, the TAT groups had higher incidence of headache (0% vs. 1.6% vs. 2.6%, p=0.020).

Conclusions

The addition of cilostazol to the DAT did not reduce the incidence of 1-year MACE compared to that with DAT alone. Instead, it may be associated with an increased risk of cumbersome side effects such as in-hospital bleeding and headaches.
Impact of the size-dependent difference of excimer laser coronary angioplasty in ST-elevation acute myocardial infarction; nuclear scintigraphy findings
Authors: Shibata N , Ohi T , Morita Y , Kanzaki Y , Watanabe N , Yoshioka N , Arao Y , Miyazawa H , Shimojo K , Goto H , Karasawa H , Nakagawa Y , Morishima I
Published: November 2023

Background

Excimer laser coronary angioplasty (ELCA) is reported to provide a good percutaneous coronary intervention (PCI) outcome. The current lineups of laser catheter sizes are 0.9-mm, 1.4-mm, and 1.7-mm catheter diameters. Although the cross ability and irradiation time is better in smaller catheter size, the available irradiation area is more significant in larger catheter size; however, it is unknown the difference in laser catheter size impacts good results in patients with ST-elevation myocardial infarction (STEMI).

Aim

To investigate the relationship between the laser catheter size and clinical outcome in patients with STEMI.

Methods and Results

We retrospectively enrolled 123 consecutive patients with STEMI who underwent primary PCI (median age: 67 [69-72] years, male: 102 [82.9%]). Patients were divided into 0.9-mm-catheter diameter group (small group, n = 47) and 1.4/1.7-mm-catheter diameter group (large group, n = 76). The patients’ characteristics, procedural results, peak creatine kinase/ creatinine kinase-myocardial band, final thrombolysis in myocardial infarction flow, and periprocedural complications were collected. Furthermore, from nuclear scintigraphy data based on a 17-segment model with a 5-point scoring system, which was calculated via the difference between 123I-BMIPP at 3-7 days and 99mTc-tetrofosmin at 3-6 months following PCI, the improvement of ejection fraction (EF) and myocardial salvage through summed rest score (SRS) were investigated.

There was no significant difference in patients’ characteristics, PCI procedure, and results between the two groups. The occurrence of coronary slow flow was similar between the two groups. On the other hand, nuclear scintigraphy data demonstrated that the improvement of EF and SRS were significantly better in the small group (EF; 13.3% vs. 7.6%, p=0.016, SRS; 18 vs. 5, p=0.012, respectively).

Conclusions

The nuclear scintigraphy findings showed that ELCA with small catheter size is feasible in patients with STEMI.Figure 1