bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrocardiographic predictors of ventricular fibrillation in ST-segment elevation acute myocardial infarction
Authors: Martinez Gomez E , Nunez Sanchez I , Ramos Lopez N , Jeronimo Baza A , Ferrandez Escarabajal M , McInerney A , Ferrera Duran C , Noriega Sanz F J , Fernandez Ortiz A , Viana Tejedor A
Published: October 2021

Introduction

Ventricular fibrillation (VF) during ST-segment elevation myocardial infarction (STEMI) is a critical emergency that requires immediate action to recover sinus rhythm and prevent sudden death. The surface electrocardiogram (ECG) is an essential diagnostic tool performed during STEMI. Our objective was to identify markers on the ECG that might be useful as potential predictors of peri-infarct VF.

Methods

Data was obtained prospectively from consecutive patients with a STEMI diagnosis admitted to the Cardiology Acute Care Unit at a tertiary hospital from July-2019 to May-2020. In all cases, primary angioplasty was performed. Clinical and laboratory data and in-hospital complications were collected. Surface ECG parameters were evaluated at the time of diagnosis.

Results

Of a total of 93 patients included, 11 patients had peri-infarct VF (11.8%). No differences in age, sex or cardiovascular risk factors between groups were found.

The ECG at admission showed notable differences: the degree of maximum elevation of the ST segment in mm (STmax) and the sum of such elevation (STsum) in all leads were significantly higher in the VF group (Table). A receiver operating characteristics analysis was performed in order to evaluate the diagnostic capacity of STmax for VF (Figure). A cut off of 4 mm (4mV) in STmax demonstrated the highest sensitivity and specificity for predicting VF. Patients with ST elevation >4mm in any lead had a 16 times greater probability of developing peri-infarct VF (OR 16.4, 95% CI 1.98–136.4; p=0.01). After adjusting for age, STsum also showed a significant association with peri-infarct VF. An STsum of >12mm resulted in a 4 times greater risk of VF.

Conclusions

The surface ECG remains an essential tool in the evaluation of patients with STEMI. The maximum ST elevation and the sum of the ST elevation demonstrates a strong association with the development of peri-infarct VF. A ST elevation >4mm in any lead is associated with a 16 times higher risk of developing VF.

Funding Acknowledgement

Type of funding sources: None. Table 1. Baseline demographics, electrocardiographic (ECG) and laboratory data in patients with and without ventricular fibrillation. CKD: chronic kidney disease. STmax: maximum elevation of the ST segment in the ECG measured in millivolts (mV). STsum: sum of all ST elevation on the 12 lead ECG. LVEF: left ventricular ejection fraction.Figure 1. Receiver operating characteristics (ROC) curve analysis to evaluate the diagnostic capacity of maximum ST elevation for the development of ventricular fibrillation in patients with infarction.
Ticagrelor or clopidogrel after acute coronary syndrome in the elderly: a propensity score matching analysis from 16 653 patients included in two large multinational registries
Authors: Bianco M , Careggio A , Biole' C , Quadri G , Quiros A , Raposeiras-Roubin S , Abu-Assi E , Kinnaird K , Spirito A , Templin C , Nunez-Gil I , De Ferrari G M , Varbella F , D'Ascenzo F , Cerrato E
Published: October 2021

Background

Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) has been suggested.

Purpose

We assessed the incidence of major bleeding (MB), reinfarction (REAMI), and all-cause death in elderly patients to evaluate the safety and efficacy of ticagrelor versus clopidogrel in a population at high risk of bleeding and ischemia treated with percutaneous coronary intervention (PCI).

Methods

RENAMI and BleeMACS, real-world registries of patients with ACS who underwent PCI and received dual antiplatelet therapy, were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor and propensity score matching (PSM) analysis performed. Statistical analysis considered two age groups (<75 versus ≥75 years).

Endpoints were BARC 3–5 MB, REAMI and all-cause death at 1 year. Independent risk factors of MB were identified.

Results

The study included 16,653 patients (13,153 <75 and 3,500 ≥75 years). Ticagrelor was underused in elderly patients (16.3% versus 20.8%, P<0.001). Using PSM, two treatment groups of 1,566 patients were included in the final analysis. Ticagrelor appeared to prevent REAMI (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.2–0.6; P<0.001) and all-cause death (HR, 0.60; 95% CI, 0.4–0.9; P=0.026) irrespective of age. In patients ≥75 years, ticagrelor increased the incidence of MB compared with clopidogrel (HR, 1.49; 95% CI, 0.70–3.0; P=0.257) without statistical significance; ticagrelor was found to significantly reduce all-cause death (HR, 0.32; 95% CI, 0.1–0.8; P=0.012) and REAMI (HR, 0.25; 95% CI, 0.1–1.1, P=0.072) without statistical significance. Multiple Cox regression revealed that age (HR, 1.03; 95% CI, 1.02–1.05; P<0.001) was an independent risk factor for bleeding, whereas hemoglobin level was inversely proportional to bleeding (HR, 0.80; 95% CI, 0.72–0.88; P<0.001).

Conclusions

Ticagrelor did not significantly increase MB compared with clopidogrel in elderly patients hospitalized for ACS and treated with PCI, significantly improving 1-year survival. Further studies on elderly patients are required.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Astra Zeneca
Shockwave intravascular lithotripsy facilitated percutaneous coronary intervention in patients with calcified coronary artery disease: a systematic review and meta-analysis of observational studies
Authors: Kassimis G , Patoulias D , Theodoropoulos K , Papadopoulos C E , Davlouros P , Alexopoulos D , Sianos G , Ziakas A , Kanonidis I , Banning A
Published: October 2021

Background

Percutaneous coronary intervention (PCI) outcomes for patients with significant coronary artery calcification (CAC) have been consistently inferior compared to patients without significant CAC. Shockwave Intravascular Lithotripsy (S-IVL) system offers a novel option for lesion modification of severely calcified plaques but supporting evidence on safety and efficacy of this technology is narrow. The aim of this study is to assess S-IVL safety and efficacy in patients with severe CAC undergoing PCI.

Methods

We systematically searched MEDLINE, ClinicalTrials.gov and the Cochrane Library to identify studies assessing the efficacy and safety of S-IVL in adult patients with calcified coronary artery disease undergoing PCI. We excluded those studies assessing the effect of S-IVL in patients with under-expanded coronary stents and/or in-stent restenosis.

Results

The largest meta-analysis to date was performed. All studies were observational since no relevant randomized controlled trials have been published so far. Nine studies were included in our qualitative synthesis, while 7 of them, in a total of 794 enrolled patients, were used in the quantitative synthesis. Frequency of peri-procedural outcomes of interest was low: a) coronary dissection: 2.52%, b) coronary perforation: 3.0%, c) MI: 3.51%. Relative frequency of 1-month MACE was 5.59% and cardiovascular death 1.01%. S-IVL resulted in a significant increase in the in-stent post-IVL minimum lumen diameter by 1.67 mm, a significant decrease in the in-stent post-IVL vessel diameter stenosis by 53.60%, and a significant increase in the in-stent post-IVL acute gain by 1.68 mm. OCT analysis confirmed a significant decrease in area stenosis post-IVL by 19.71% and calcium angle by 22.14o and a significant increase in lumen area by 1.62 mm2, without however affecting maximum calcium thickness. When we compared post-stent post-IVL vs. pre-stent post-IVL OCT results, we demonstrated a further significant decrease in area stenosis by 35.89% and in calcium angle by 20.33o, a significant increase in lumen area by 2.74 mm2 and a neutral effect on maximum calcium thickness.

Conclusion

Shockwave Intravascular lithotripsy offers a significant improvement in coronary lumen to facilitate stent delivery and deployment in severely calcified coronary arteries. Although S-IVL appears to be associated with a low incidence of complications and MACE based on our present findings, further evidence from RCTs and longer-term follow-up is required to advocate its routine use in patients with severe CAC.

Funding Acknowledgement

Type of funding sources: None.
Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting
Authors: Vassilev D , Mileva N , Collet C , Sokolova K , Nikolov P , Karamfiloff K , Rigatelli G , Gil R
Published: October 2021

Introduction

Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes.

Methods

Patients with significant angiographically bifurcation lesions defined as diameter stenosis >50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR >0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry.

Results

For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation >1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p<0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score <10% – HR=1.715 (CI 1.049–2.804, p-0.031).

Conclusion

Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital
Mid-term mortality after stenting of distal left main stenosis with regular, third generation drug eluting stent or dedicated bifurcation stent or surgery-registry based,all-comers data
Authors: Vassilev D , Zlatancheva G , Shumkova M , Nikolov P , Gil R
Published: October 2021

Background

Distal left main (LM) bifurcation lesions remain a challenge for interventional cardiologists and they are associated with significant morbidity and mortality. The aim of the current study was to identify predictors of cardiac mortality at mid-term follow up after PCI (DES vs. dedicated bifurcation stent) or CABG.

Methods

All patients with distal LM stenosis ≥50% were included in prospective registry starting from 01.2015. The exclusion criteria for registry are cardiogenic shock, a priory life expectancy duration <1 year, lack of inform consent. All patients were prospectively followed about the alive status through the national security number data base. All deaths were deemed cardiac if proof otherwise (the data patient families or family's physicians were contacted through phone call about the reason of death)

Results

For three year follow up period (median 35 months, IQR 18–50) 303 patients were included. 220 patients were stented with 3rd generation DES, 43 with dedicated bifurcation stent BiOSS (Balton, Poland), and rest were sent for CABG. The mean age was 67±10 years, 72% were males, 37% diabetics, all with hypertension, 97% dyslipidemia, 15% PAD, 9% COPD, 16% carotid artery disease, previous MI 28%, previous PCI 50% - without significant difference between three groups. The frequency of acute coronary syndrome during admission was 11% - without difference in frequency between groups. The patient referred to CABG had significantly lower left ventricular EDV and ESV, more severe mitral regurgitation and kinetic disturbances, higher SYNTAX score and longer lesion length. On univariate COX regression analysis, the following factors were associated with mortality: age, NYHA class, GFR, baseline troponin, hemoglobin, LV EF, mitral regurgitation, kinetics disturbances, treatment with beta blockers, ACE inhibitors, statin, atrial fibrillation, SYNTAX score, lesion length. The type of treatment was not associated with differences in mortality (figure). On COX multiple regression survival analysis independent predictors of survival were: age (HR=1.036, CI 1.005–1.068, p=0.023); COPD (HR=2.313, CI 1.170–4.572, p=0.016); GFR (HR=0.988, CI 0.978–1.000, p=0.048); hemoglobin (HR=0.970, CI 0.955–0.986, p=0.000); left ventricular EF (HR=0.958, CI 0.832–0.985, p=0.003).

Conclusions

The type of treatment was not associated with mid-term mortality. Our data demonstrate that dedicated bifurcation stent could be used safely for distal LM stenosis treatment with similar safety as 3rd generation DES.

Funding Acknowledgement

Type of funding sources: None.
Software supported robotic PCI in coronary arteries – comparison from the ROBO.pci trial
Authors: Hofmann F J , Doerr O , Blachutzik F , Keranov S , Koehne A , Widmann L , Boeder N F , Elsaesser A , Hamm C , Nef H
Published: October 2021

Background

Robotic percutaneous coronary interventions (rPCI) have proven to be efficient and safe. The robotics software has recently been updated and now allows precise and fully controlled navigation of devices and wires to fit the various morphologic conditions of coronary arteries and calcified segments.

Objectives

In the present study we aimed to compare the different robotic wiring modalities supported by the new software.

Study design

rPCI performed using the updated robotics software was compared with rPCI using the manually executed wire positioning. Lesion crossing was performed with each method under identical circumstances, crossing the same lesion and measuring the wire times. Measurements were started at the ostium of the guiding catheter and were stopped at a pre-defined individual coronary anatomical landmark.

Results

Eleven consecutive patients with 11 lesions were enrolled in this trial. The mean age of patients was 63±6 years with typical cardiovascular comorbidities and 54% (6/11) presented with three-vessel disease. All patients underwent PCI in an elective setting with stable chronic coronary syndrome. The majority of lesions were located in the LCX (45%, 5/11) followed by the LAD (27%, 3/11) and the RCA (27%, 3/11). All lesions were de novo ACC/AHA grade B2/C lesions, and the procedure was performed by experienced (high-volume) interventional cardiologists. The lesion crossing times were not significantly different (manual crossing 15.00 [IQR: 40] sec vs. rPCI without software support 18.00 [IQR: 18] sec vs. rPCI with software support 13.00 [IQR: 47] sec; p=n.s.).

rPCI without software support tends to be slower than rPCI with software support. There was no statistical significance. rPCI was found to be safe and feasible and the new software tends to reduced procedural time, which could reduce operators' health risks and improve patients' outcomes. Further randomized controlled trials are needed to evaluate the long-term benefits.

Funding Acknowledgement

Type of funding sources: None.
Impact of nodular calcification on the outcomes of patients with acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PCI)
Authors: Demuyakor A , Hu S , Koniaeva E , Liu M , Weng Z , Zhao C , Feng X , He L , Xu Y , Zeng M , Meng W , Yi B , Qin Y , Jia H , Bo Y
Published: October 2021

Background

Calcified plaque is thought to adversely impact clinical outcomes but the impact of nodular calcification after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) remains unclear.

Purpose

This study sought to explore the impact of nodular calcification on the outcomes of patients undergoing percutaneous coronary intervention for acute coronary syndromes.

Methods

Five-hundred culprit plaque with calcification were analysed from 495 ACS patients in whom PCI was performed. Plaques were divided into nodular calcification group (n=238) and non-nodular calcification group (n=262). Calcification is defined as an area with low back-scattering signal and a sharp border. Nodular calcification was defined as a protruding mass with an irregular surface, high backscattering, and signal attenuation on optical coherence tomography (OCT).

Results

Patients with nodular calcification were older (p<0.001) and had lower left ventricular ejection fraction (p=0.006) compared to patients with non-nodular calcification. Lesion length (31 (25.2, 38.5) vs. 29 (22.8, 34.1), p<0.001) was longer in plaques with nodular calcification. A higher prevalence of superficial calcium (p<0.001) was observed in plaques with nodular calcification compared with non-nodular calcification group. Minimum stent area (MSA) (5.0 (3.9, 6.3) vs. 5.4 (4.2, 6.7), p=0.011) and stent expansion (70 (62.7, 81.8) vs. 75 (65.2, 86.6), p=0.004) were significantly smaller in the nodular calcification group than in the non-nodular calcification group. Independent predictors of nodular calcification were age (p<0.001) lesion length (p=0.002) and calcium depth (p<0.001).

Conclusion

This study demonstrated that the presence of nodular calcification is associated with unfavourable outcomes with smaller minimum stent area and higher incidence of stent under expansion in patients with ACS treated with primary PCI.

Funding Acknowledgement

Type of funding sources: None.
A meta-analysis of randomized controlled studies comparing off-pump vs on-pump CABG in the elderly
Authors: Machado R J , Saraiva F A , Mancio J , Sousa P , Cerqueira R J , Barros A S , Lourenco A P , Leite-Moreira A F
Published: October 2021

Background

The increasing demand for coronary revascularization in the elderly has raised the interest in off-pump coronary artery bypass graft (CABG) as an option in these high-risk patients.

Purpose

We sought to investigate the differences between off-pump CABG (OPCAB) and on-pump CABG (ONCAB), among patients older than 60, in short and mid-term results throughout a meta-analysis of randomized clinical trials (RCTs).

Methods

A literature search was conducted using MEDLINE, ISI Web of Science and Cochrane Library (1960–2020). RCTs reporting mortality outcomes of OPCAB vs ONCAB within elderly patients (as prespecified or secondary analysis) were included. Data on myocardial infarction, stroke, repeat revascularization, renal failure and composite endpoints after CABG were also collected. Hazard ratio (HR) and variance for follow-up outcomes and frequencies or odds ratio (OR) for early endpoints were collected. Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI).

Results

Seven RCTs encompassing a total of 6,609 patients were included (3,303 OPCAB and 3,306 ONCAB, 50% were men). Five trials reported mortality during follow-up (6 months (2 studies) to 5 years). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95% CI: 0.88–1.17, p=0.82) and composite endpoint incidence (4 studies pooled HR: 0.98, 95% CI: 0.88–1.09, p=0.73) between OPCAB and ONCAB. At 30-days, no differences between groups were noted in mortality (5 studies pooled OR: 0.90, 95% CI: 0.62–1.31, p=0.59), early myocardial infarction (5 studies pooled OR: 0.95, 95% CI: 0.60–1.51, p=0.82) and renal complications (3 studies pooled OR: 0.74, 95% CI: 0.50–1.11, p=0.14). The need for early repeat revascularization was significantly higher in OPCAB (2 studies pooled OR: 2.58, 95% CI: 1.16–5.75, p=0.02), with higher percentage of incomplete revascularization among OPCAB in both trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01). However, OPCAB showed a tendency for lower risk of early stroke (6 studies pooled OR: 0.70, 95% CI: 0.48–1.03, p=0.07).

Conclusions

Pooling data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. However, OPCAB was associated with a higher risk of early repeat revascularization and there was a trend for reduced early stroke risk. Further randomized studies, specifically designed to include elderly patients, are needed to establish the better CABG strategy.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Universidade do Porto/FMUP and FSE-Social European Fund; Fundação para a Ciência e Tecnologia Early and Mid-term Results
Thrombosis and major bleeding risk after primary percutaneous coronary intervention among patients with multi-vessels coronary artery disease
Authors: Zhao X , Liu L C , Zhou Z P , Sheng S Z X , Li L J N , Zhou Z J Y , Chen C R Z , Wang W Y , Chen C Y , Song S L , Zhao Z H J , Yan Y H B
Published: October 2021

Background and aims

The present study aimed to develop and validate separate risk prediction models for thrombosis events (TEs) and major bleeding (MB) in patients with multi-vessel coronary artery lesions who had undergone primary percutaneous coronary intervention (PCI).

Methods and results

TEs were defined as the composite of myocardial infarction recurrence or ischemic cerebrovascular events, whereas MB was defined as the occurrence of bleeding academic research consortium (BARC) 3 or 5 bleeding. The derivation and validation cohorts comprised 2976 patients who underwent primary PCI between January 2010 and June 2017. At a median follow-up of 3.07 years (1122 days), TEs and MB occurred in 167 and 98 patients, respectively. Independent predictors of TEs were older age, prior PCI, non-ST elevated MI (NSTEMI), and stent thrombosis (ST). Independent predictors of MB were triple therapy at discharge, coronary artery bifurcation lesions, lesion restenosis, target lesion of the left main coronary artery, and PTCA. In the derivation and validation cohorts, the areas under the curve were 0.817 and 0.820 for thrombosis and 0.886 and 0.976 for bleeding, respectively. In the derivation cohort, high thrombotic risk (n=755) was associated with a higher 3-year incidence of TEs, major adverse cardiovascular events (MACEs), and all-cause death, compared to low risk (n=1275) (p=0.0022, 0.019, 0.012, respectively). High bleeding risk (n=1675) was associated with a higher incidence of bleeding, MACEs, cardiac death, compared to low risk (n=355) (p<0.0001).

Conclusion

Simple risk scores can be useful in predicting the risks of ischemic and bleeding events after primary PCI, thereby stratifying thrombotic or MB risks and facilitating clinical decisions.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2016-I2M-1–009), National Natural Science Funds (number: 81970308) and the Fund of “Sanming” Project of Medicine in Shenzhen (number: SZSM201911017). Figure 2Figure 3
Colchicine in patients with acute myocardial infarction: an updated meta-analysis of randomized controlled trials
Authors: Mendoza R , Bailon D , Bernardo J , Jimenez R , Te-Rosano A , Tiongco R
Published: October 2021

Background

Improvement in cardiovascular outcomes and treatment with anti-inflammatory agents have been the subject of many research. Colchicine inhibits tubulin polymerization and is used in treating pericarditis. Recent studies have shown its benefit when used for coronary events. The objective of this meta-analysis is to reexamine the role of colchicine in reducing cardiovascular events in acute coronary syndromes in light of more recent trials.

Methods

A systematic search for randomized controlled trials which involves use of colchicine and acute coronary syndrome was done using PubMed, Google Scholar, MEDLINE and Clinicaltrials.gov. Studies done in the last decade and those involving human subjects were included in the study.

Results

Seven RCT's (n: 11,282) were included in this meta-analysis comparing colchicine vs. placebo. Dose ranged from 0.5mg/day to 1mg/day. Among patients being treated for ACS, colchicine was associated with a significant reduction in composite cardiovascular outcomes (RR 0.69, 95% CI 0.60 – 0.79, P<0.ehab724.12731), unstable angina (RR 0.67, 95% CI 0.55 – 0.82, P<0.0001), and myocardial infarction (RR 0.75, 95% CI 0.62 – 0.92, P<0.005,). Gastrointestinal events were evident in the colchicine group with no statistical difference between the two (RR 1.28, 95% CI 0.98 – 1.67, P 0.07).

Conclusion

Use of colchicine reduces composite cardiovascular outcomes, recurrence of unstable angina and MI among patient who had ACS. There was no statistically significant difference between colchicine and placebo in terms of gastrointestinal events. It is possible that colchicine be part of the standard treatment in patients with acute coronary syndrome.

Funding Acknowledgement

Type of funding sources: None. Myocardial infarction forest plot
Prognostic implications of cholesterol chrystals at ACS causing culprit lesions, insights from the translational OPTICO-ACS study program
Authors: Nelles G , Abdelwahed Y , Seppelt C , Meteva D , Staehli B , Kraenkel N , Steiner J , Skurk C , Riedel M , Sieronski L , Haghikia A , Sinning D , Landmesser U , Joner M , Leistner D ,   OPTICO-ACS
Published: October 2021

Aims

Cholesterol chrystals (CC) represent a feature of advanced plaque remodeling. Optical coherence tomography (OCT) allows for detailed morphological assessment of the culprit lesion, including the presence of CCs, in vivo. Since CCs have been identified as prognostically relevant plaque feature in coronary artery disease (CAD), the present analysis aims to further characterize their impact on adverse cardiovascular outcome in a large cohort of patients, presenting with acute coronary syndrome (ACS).

Methods

Within the translational OPTICO-ACS study program, 371 consecutive ACS-patients were included into the final analysis. OCT-characteristics, including the presence of CCs, were assessed by a standardized CoreLab analysis following universal consensus standards for OCT-derived plaque features. All patients were followed up for 12 months after the index event and major adverse cardiac events (MACE) consisting of death, myocardial infarction, target vessel revascularization plus re-hospitalization due to unstable or progressive angina pectoris were documented.

Results

215 patients (58.1%) presented with cholesterol chrystals (CCs) at the culprit lesion. Plaque rupture (RFC-ACS) represented the primary ACS-causing pathophysiology (75.3%) in those patients. Further, the presence of CCs was associated with other high-risk features within the culprit lesion, i.e. the presence of thin cap fibroatheroma (77.7% vs. 63.2%; p<0.05), plaque calcification (80.5% vs. 67.1; p<0.01) and microchannels (80.1% vs. 70.1; p<0.05) as well as an increased area stenosis (0.77 vs. 0.73 mm2; p<0.01) and a greater maximum lipid arc (282.8 vs. 242.6°; p<0.01) as compared to culprit lesions free of CCs. Of note, there was a strong association among the occurrence of macrophages within the plaque and cholesterol crystals. Finally, and most importantly MACE during 12 months follow-up, consisting of cardiac death, myocardial infarction, target vessel revascularization and re-hospitalization due to progressive or unstable angina pectoris, occurred with nearly twice the frequency in CC-patients (20.3% vs. 10.6%; p<0.01) as compared to patients without CCs at the culprit site.

Conclusion

The present analysis introduces cholesterol chrystals as a novel prognostically relevant high-risk plaque feature allowing individual risk stratification for patients after ACS.

Funding Acknowledgement

Type of funding sources: None.
Clinical outcomes by angiographic type of spontaneous coronary artery dissection
Authors: Mori Junco R , Macaya F M , Cerrato E C , Escaned J E ,   DISCO
Published: October 2021

Background

Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of myocardial infarction. Although different SCAD angiographic classifications exist, their clinical impact remains unknown.

Purpose

To evaluate the relationship between an angiographic classification and the development of adverse clinical events during the follow-up of a large, unselected cohort of patients with SCAD.

Methods

We conducted an observational study of consecutive SCAD patients from 26 centers across Italy and Spain. Cases were classified into 5 different angiotypes according to the latest classification endorsed by the European Society of Cardiology. The main composite endpoint included all-cause death, non-fatal myocardial infarction (MI), and any unplanned revascularisation.

Results

In total, 302 SCAD patients (mean age 51.8±19 years) were followed up for a median of 22 months (IQR 12–48). At 28 days, the composite outcome was higher for the angiotypes with a circumscribed contained intramural hematoma (2A and 3): 20.0% vs. 5.4%, p<0.001 (non-fatal MI: 11.0% vs. 3.5%, p=0.009; unplanned revascularisation: 11.0% vs. 2.5%, p<0.001), which was sustained during follow-up (24.5% vs. 9.9%, p=0.001). There were no differences in mortality (0,3% overall). The presence of an angiotype 2A or 3 was an independent predictor of a higher incidence of the composite outcome (adjusted HR: 2.44, CI 1.24–4.80, p=0.010).

Conclusions

The SCAD angiographic classification correlates with outcome. Those presenting with an angiographically circumscribed contained intramural hematoma (angiotypes 2A and 3) showed an increased risk of short-term adverse clinical events that was maintained during follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Society of Cardiology KM curves for angiotypes 2A & 3 vs otherKM curves for angiotypes 2A & 3 vs other
Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers
Authors: Oliveira L , Campante Teles R , Machado C , Madeira S , Vale N , Almeida C , Brito J , Leal S , Raposo L , Araujo Goncalves P , Pacheco A , Mesquita Gabriel H , Almeida M , Martins D , Mendes M
Published: October 2021

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.
ACE Insertion/Deletion gene polymorphism aassociations in STEMI Patients
Authors: Kozhukhov S , Parkhomenko A , Dovganych N , Lutay Y A
Published: October 2021

Objective

ACE Insertion/deletion (I/D) polymorphism has been reported to be associated with various cardiovascular conditions, however its impact in patients with AHF remains controversial.

This study aimed to analyze ACE I/D distribution, rate of acute heart failure (AHF) and survival in ST segment elevation myocardial infarction (STEMI) patients.

Methods

Genomic DNA from 245 STEMI patients and 87 healthy control subjects were analyzed by single polymerase chain reaction method. Based on the ACE I/D genotype STEMI patients were divided with AHF/no AHF, and then - for preserved/reduced ≤40% left ventricle (LV) ejection fraction (EF) to investigate the frequency of the mutant allele D.

Results

ACE gene polymorphism analyses revealed that D allele had been found more often in STEMI patients than in controls (84.1 vs. 72.4%). The frequency of II, ID, and DD genotypes in STEMI patients was 27.6%, 52.9% and 19.5% compared to 15.9%, 54.3% and 29.8%, respectively in controls with a significant difference in mutant homozygous genotype. Distribution of I/D ACE gene variants among AHF cases vs no AHF, showed similar frequency of II allele (15.8 vs 13.5%), ID allele (54.9 vs 52.8%) and DD allele (29.3 vs 33.7% respectively). In patients with preserved EF there was not statistical significance among different alleles with and without AHF. However, ACE DD polymorphism has been found in AHF patients with reduced EF significantly more often (50.0 vs 30.5%; p<0.05) in compare to AHF patients with preserved EF. Finally, cardiovascular death among all STEMI patients during 3-year follow up was more frequent in patients with DD allele (17.7% vs 5.7% with II and vs 9.9% with ID allele).

Conclusion

Presented results confirmed ACE DD polymorphism to be associated with higher rate of cardiovascular death and presence of AHF with reduced LV EF in STEMI patients. Future studies are needed to evaluate importance of ACE DD polymorphism in order to find optimal treatment strategies and to prevent negative outcomes in those patients.

Funding Acknowledgement

Type of funding sources: None.
Incremental prognostic value of worsening renal function parameters in addition to the GRACE score in patients with acute coronary syndrome
Authors: Presume J , Gomes D , Albuquerque F , Strong C , Trabulo M , De Araujo Goncalves P , Campante Teles R , Almeida M , Mendes M , Ferreira J
Published: October 2021

Background

Baseline renal function, one of the parameters included in the GRACE score, has prognostic relevance in patients admitted for acute coronary syndrome (ACS).

Purpose

The aim of this study was to compare different worsening renal function (WRF) parameters during hospitalization for ACS and their impact on all-cause mortality. Furthermore, we aimed to assess if these parameters had any incremental prognostic value in addition to the GRACE score.

Methods

We conducted a single-center retrospective study enrolling consecutive patients admitted for ACS from January 2016 to December 2018. Estimation of glomerular filtration rate (eGFR) for each patient was calculated based on the CKD-EPI formula. WRF during hospitalization was assessed by means of: serum creatinine (sCr) elevation ≥0,3mg/dL, duplication of the sCr value or maximum sCr value ≥2,0mg/dL.

Results

A total of 555 patients were included (65±13 years old, 72% male). Overall, 402 (72%) had hypertension, 167 (30%) were diabetic, 88 (16%) had left ventricular ejection fraction <40%. Mean GRACE score was 102.7±29.1 and median sCr at baseline was 0.83 mg/dL [0.70; 0.97]. Median length of hospitalization was 4 days [2; 10] and the mean follow-up of 963 days.

Baseline eGFR showed significant correlation with mortality during follow-up (HR 0.742 [95% CI 0.691–0.797] per 10 mL/min/1.73m2 increase in eGRF). Moreover, all WRF parameters showed significant association with all-cause mortality during follow-up on a univariate analysis - p<0,001 (Table 1). Elevation of sCr ≥0,3 mg/dL during hospitalization was the most frequent WRF parameter (210 patients - 38%) and the most sensitive parameter to predict our endpoint, occurring in 56 patients who died during follow-up (sensitivity 66.7%). Both duplication of sCr and absolute sCr ≥2,0mg/dL during hospitalization showed a lower prevalence; however, the majority of patients with one of these findings died during follow-up (51,4% and 68,5%, respectively).

On a multivariate Cox regression analysis, adjusted for the GRACE score, all individual WRF parameters remained independently associated with all-cause mortality during follow up (Table 2).

Conclusion

Worsening renal function has significant prognostic impact in patients admitted for ACS. Identification of these parameters during hospitalization adds significant value to the prognostic stratification of the GRACE score.

Funding Acknowledgement

Type of funding sources: None.
Acute heart failure: a mechanism underscoring sex differences in outcomes following acute coronary syndromes
Authors: Cenko E , Yoon J , Van Der Schaar M , Bergami M , Manfrini O , Vasiljevic Z , Zdravkovic M , Stankovic G , Vavlukis M , Kedev S , Milicic D , Badimon L , Bugiardini R
Published: October 2021

Background

It remains uncertain whether female sex is itself a strong risk factor for worse outcomes in acute coronary syndromes (ACS).

Purpose

We hypothesized that sex differences in vulnerability to heart failure after ACS may modify the association between sex and outcomes.

Methods

Data were drawn from the ISACS-Archives network of registries. The study population consisted of 87,812 patients with known time from symptom onset to hospital presentation. Participants were stratified by ACS subtypes: STEMI and NSTE-ACS Data on presenting heart failure symptoms were collected from medical record abstraction. Heart failure was categorized as Killip class >2. Time from symptom onset to hospital presentation was categorized as early (≤120 minutes) or late (>120 minutes). Primary outcome measure was 30-day mortality. Estimates were performed using a parametric balancing strategy by weighting and compared by test of interaction on the log scale.

Results

Among the study sample, 30922 (35.2%) patients were women. Patient outcomes varied according to subtype of ACS. The mortality rates at 30-days were significantly higher among women vs men in STEMI (RR:1.65; 95% CI: 1.56–1.73) compared with NSTE-ACS (RR:1.18; 95% CI: 1.09–1.28; P interaction <0.0001). Similarly, the women vs men RR of heart failure was higher in STEMI (RR: 1.24; 95% CI: 1.20–1.29) compared with NSTE-ACS (RR:1.02; 95% CI: 0.97–1.08; P interaction <0.0001). Sex difference in heart failure rates with STEMI presentation were independent (P<0.0001) of early (34.3% in women vs 24.2% in men) or late (35.5% in women vs 30.7% in men) hospital presentation. The same finding was not seen in NSTE-ACS patients. Overall, women presenting with heart failure was had higher 30-day mortality than did their male counterparts with heart failure (29.8% vs 25.5%; RR: 1.24; 95% CI: 1.17–1.31).

Conclusions

Women exhibit substantially more vulnerability to heart failure in STEMI than men: a greater percentage of women have heart failure, and women with heart failure have higher 30-day mortality than men with heart failure. This finding was not seen in NSTE-ACS. heart failure on initial assessment is a key feature to explain the sex gap in mortality after ACS.

Funding Acknowledgement

Type of funding sources: None.
Mean platelet volume-to-lymphocyte ratio as a predictor of no-reflow phenomenon and in-hospital mortality following primary percutaneous coronary intervention in patients with STEMI
Authors: Willim H A , Sari K R , Cipta H
Published: October 2021

Background

ST-segment elevation myocardial infarction (STEMI) is the most severe form of acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is currently the treatment of choice for STEMI. However, many factors can influence the outcomes of primary PCI. Inflammation and platelet activation play a vital role in the development of complications following primary PCI. Recently, the mean platelet volume-to-lymphocyte ratio (MPVLR) has emerged as a novel biomarker of worse outcomes linking inflammation and thrombosis.

Purpose

The aim of this study was to conduct a systematic review and meta-analysis to investigate the prognostic value of MPVLR as a predictor of no-reflow phenomenon and in-hospital mortality following primary PCI in patients with STEMI.

Methods

A systematic literature search was performed in the databases of PubMed, ScienceDirect, ProQuest, and Google Scholar. The primary outcomes were no-reflow phenomenon and in-hospital mortality following primary PCI for STEMI. The outcomes were compared between patients with high and low MPVLR at admission. The Newcastle-Ottawa Scale was used to assess the quality of the included studies. The Review Manager 5.3 was used to perform the meta-analysis.

Results

Four cohort studies involving 3038 patients with STEMI undergoing primary PCI were included in this meta-analysis. The pooled analysis showed that a high MPVLR at admission was associated with higher no-reflow phenomenon (odds ratio [OR] = 4.54, 95% confidence interval [CI]: 2.45–8.41, P<0.ehab724.13681, I2=86%) and higher in-hospital mortality (OR=2.69, 95% CI: 1.96–3.68, P<0.ehab724.13681, I2=0%) following primary PCI.

Conclusions

This systematic review and meta-analysis showed that a high MPVLR predicts no-reflow phenomenon and in-hospital mortality following primary PCI in patients with STEMI.

Funding Acknowledgement

Type of funding sources: None. MPVLR and no-reflow phenomenonMPVLR and in-hospital mortality
Diagnostic value of circulating microRNAs compared to high-sensitivity troponin T for the detection of non-ST-segment elevation myocardial infarction
Authors: Biener M , Giannitsis E G , Thum T , Baer C , Costa A , Andrzejewski T , Stoyanov K M , Vafaie M , Meder B , Katus H A , De Gonzalo Calvo D , Mueller-Hennessen M
Published: October 2021

Background/Introduction

MicroRNAs (miRNAs) are promising biomarkers due to their high specificity and may facilitate differential diagnosis of patients presenting with suspected acute coronary syndrome (ACS) to the emergency department (ED).

Purpose

To assess the diagnostic value of eleven miRNAs for the detection of non-ST-segment elevation myocardial infarction (NSTEMI).

Methods

1,042 patients presenting between August 2014 and April 2017 to the ED with suspected ACS were included. NSTEMI was diagnosed per criteria of the 4th Universal definition of myocardial infarction (UDMI) using high-sensitivity troponin T (hs-cTnT). Expression levels of eleven microRNAs (miR-21, miR-22, miR-29a, miR-92a, miR-122, miR-126, miR-132, miR-133, miR-134, miR-191, miR-423) were determined using RT-qPCR. Discrimination of NSTEMI was assessed for individual and a panel of miRNAs compared to the hs-cTnT reference using C-statistics and reclassification analysis.

Results

NSTEMI was diagnosed in 137 (13.1%) patients. The AUC of the hs-cTnT based reference was 0.937. In a multivariate model three miRNAs (miR-122, miR-133 and miR-134) were found to be associated with NSTEMI with AUCs between 0.506 and 0.656. A panel consisting of these miRNAs revealed an AUC of 0.662 for the diagnosis of NSTEMI. The AUC of the combination of the miRNA panel and troponin reference was significantly lower than the reference standard (AUC: 0.897 vs. 0.937, p=0.006). Despite a significant improvement of NSTEMI reclassification measured by IDI and NRI, miRNAs did not improve specificity of hs-cTnT kinetic changes for the diagnosis of NSTEMI (ΔAUC: 0.04).

Conclusion

Although single miRNAs are significantly associated with the diagnosis of NSTEMI a miRNA panel does not add diagnostic accuracy to the hs-cTnT reference considering baseline values and kinetic changes as recommended by 4th version of UDMI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart Foundation/German Foundation of Heart Research.CIBERES (CB07/06/2008 to DdGC) is a project from Carlos III Health Institute. Central illustration
Predicting acute kidney injury and future cardiac events using urinary liver-type fatty acid-binding protein in patients with acute myocardial infarction
Authors: Kojima K , Ohgaku A , Fujito H , Koyama Y , Arai R , Ebuchi Y , Monden M , Takei N , Tamaki T , Murata N , Fukamachi D , Okumura Y
Published: October 2021

Background

Urinary liver-type fatty acid-binding protein (L-FABP) has been known as a candidate biomarker for early detection of acute kidney injury (AKI). It has also been suggested to have an effective predictive value for cardiovascular mortality in patients. Therefore, this study aimed to examine the ability of urinary L-FABP in predicting AKI and future cardiovascular events in patients with acute myocardial infarction (AMI).

Methods

We evaluated consecutive 258 patients with AMI. Urinary L-FABP was measured at admission and a 2-year follow-up was performed. AKI was defined as an increase of >0.3 mg/dl in serum creatinine level within 2 days after emergency percutaneous coronary intervention. The composite endpoint was cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure.

Results

AKI was detected in 20 patients (7.8%). Patients with AKI had significantly higher urinary L-FABP levels (68.0 μg/gCr vs 3.1 μg/gCr, p<0.001) compared to those with non-AKI. Receiver operating characteristic analysis showed urinary L-FABP levels exhibited 85.7% sensitivity and 96.0% specificity, at a cutoff value of 29.7 μg/gCr. We used propensity score analyses to balance measurable confounders between patients with and without AKI, including age, left ventricular ejection fraction, an inflammation marker, renal function, and albuminuria. In logistic regression adjustment with the propensity score, urinary L-FABP level of >29.7 μg/gCr was an independent predictor of AKI (p=0.001). Furthermore, high urinary L-FABP (>29.7 μg/gCr) on admission correlated with an increased risk of the composite endpoints during 2-year follow-up in the Kaplan–Meier analysis (p<0.001).

Conclusions

Urinary L-FABP level may be a useful biomarker for predicting not only the onset of AKI but also adverse cardiovascular events in patients with AMI.

Funding Acknowledgement

Type of funding sources: None.