bluuebunny/crossref_metadata_2025 huggingface dataset:
Machine learning analysis of factors influencing ischemic stroke after coronary artery bypass grafting
Authors: Gelsomino S , Bonacchi M , Del Pace S , Caciolli S , Parise O , Prifti E.P , La Meir M , Maessen J.G
Published: November 2020

Aims

Ischemic Stroke (IS) is a devastating complication of coronary bypass (CABG) surgery, significantly increasing mortality, morbidity, cost, and the need for long-term care, and reducing the quality of life. With the aim of a learning-machine method, we investigated factors influencing the occurrence of IS after CABG.

Methods and results

We employed a statistical learning method – random forests – to examine which of various variables had the greatest impact on postoperative IS. A dataset including 16,255 consecutive patients undergoing isolated CABG between 1997 and 2017 In one Institution was examined.

Along with demographic and clinical variables technical-related factors were included, encompassing surgical technique, number of touches on the aorta, cardiopulmonary bypass, total aortic clamping, use of the side-biting clamp, or number of proximal anastomoses. A ranking score based on the average percent increase in mean squared error and obtained for all variables was employed to quantify the importance of any variable in predicting IS.

A total of 641 strokes occurred (3.9%). Total aortic clamp showed the highest incidence of stroke (n=570, 88.95% of total). Total aortic clamp had the highest score among all variables followed by previous stroke and carotid artery disease >50%. In contrast, other variables related to surgical technique showed low ranking scores in predicting IS. In patients undergoing CABG with the use of total aortic, a previous brain ischemic insult as well as age >75 years increase the risk of IS (fIGURE)

Conclusions

The use of total aortic clamp is the strongest predictor of stroke. A clamp-less technique is recommended whenever possible especially in older patients and those who experienced preoperative stroke or who had significant carotid stenosis.

Importance of variables in predicting IS

Funding Acknowledgement

Type of funding source: None
Treatment of de novo coronary artery lesions with paclitaxel drug coated balloons (DCB) in diabetic and non-diabetic patients
Authors: Mohd Saad Jalaluddin K.M.Z
Published: November 2020

Background

Drug-coated balloon has been widely used to treat In-Stent Restenosis as recommended by ESC/EACT coronary intervention guideline. However, trials of effectiveness of DCB in treating de novo lesions in diabetic patients are limited. This study will highlight the impact of DCB in diabetic patients with only de novo lesions against non-diabetic patients.

Aim

To compare the outcomes of Paclitaxel Drug Coated Balloon (DCB) in Diabetic and non-diabetic patients with only de novo coronary artery disease.

Methods

A retrospective, single center study was conducted from January 2016 till December 2018. All diabetic and non-diabetic patients underwent angioplasty to only de novo coronary artery lesions were included in the study. Patients' baseline characteristic, angiographic data, post procedural and 12 months follow-up outcomes including major adverse coronary artery event (MACE), target lesion revascularization (TLR) and myocardial infarction (MI) are compared.

Results

A total of 1257 patients (726 diabetic and 531 non-diabetic patients) with total 1385 de novo coronary artery lesions (791 lesions in diabetic group and 594 lesions in non-diabetic group) were included in this study. Mean age for non-diabetic group was 57.6±10.6 years and diabetic group was 59.6±9.6 years with male predominance (91.1% in non-diabetic group, n=484 and 79.2% in diabetic group, n=575). Majority of diabetic group has hypertension (83.7%, n=608 vs 58.6%, n+311), chronic renal failure (10.3%, n=75 vs 1.9%, n=10), documented coronary artery disease (55.6%, n=404 vs 47.5%, n=252) and previous coronary angioplasty 39.5%, n=287 vs 28.8%, n=153).

Adequate pre-dilatation was done in both groups (98.5%, n=585 in non-diabetic group and 99.4%, n=786 in diabetic group; p=0.000). Mean DCB diameter and length were almost similar in both groups. Mean residual stenosis after DCB was 11.15±16.9% in non-diabetic group and 13.13±13.4% in the diabetic group (p=0.008). 74.6% of non-diabetic group (n=396) and 77.1% of diabetic group (n=560) were on double antiplatelet therapy for 12 months.

86.8% (n=461) of non-diabetic and 88.4% (n=642) of diabetic patients were available for follow up. MACE events were significantly higher (p=0.000) in diabetic group (4.3%, n=31) as compare to non-diabetic group (0.6%, n=3). Target lesion revascularization (TLR) and myocardial infarction (MI) was also significantly higher in diabetic group (TLR 1.4%, N=10 vs 0.6%, n=3, p=0.049; MI 2.6%, n=19 vs 0.4%, n=2, p=0.002).

Conclusion

Treating de novo coronary lesions in diabetic patients with DCB associated with significantly higher MACE events, target lesion revascularization and myocardial infarction. Diabetic patients appear to have a greater volume of atherosclerotic plaque and increased propensity for atherosclerotic plaque rupture.

Funding Acknowledgement

Type of funding source: None
Associations between psychosocial burden and prognostic biomarkers in patients with stable coronary heart disease – a STABILITY substudy
Authors: Wassberg C , Batra G , Hadziosmanovic N , Hagstrom E , White H , Stewart R , Siegbahn A , Wallentin L , Held C
Published: November 2020

Background

Psychosocial burden is associated with increased risk of cardiovascular (CV) events in patients with stable coronary heart disease (CHD). The underlying mechanisms linking psychosocial burden and CHD are unclear and might be explained by studying biomarkers known to be associated with CV risk.

Methods

15,608 patients in the STABILITY trial completed a questionnaire on to what extent they were feeling down, had loss of interest, experienced financial stress and if they were living alone. Levels of high-sensitivity (hs) C-reactive protein (hs-CRP), interleukin-6 (IL-6), hs-troponin T (hs-TnT) and N-terminal pro-B type natriuretic peptide (NT-proBNP) were assessed at baseline. Associations between levels of psychosocial burden (sometimes, often/always vs. never/rarely) and biomarkers were evaluated in a linear model where geometric mean ratio of the log-transformed biomarker were calculated.

Results

Adjusted associations (age, gender and established CV risk factors) are presented in the table.

Conclusion

Psychosocial burden in patients with stable CHD was independently associated with elevated biomarkers. The underlying association is likely to be complex and involve multiple pathways.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The STABILITY study was funded by GlaxoSmithKline. Roche Diagnostics, Rotkreuz, Switzerland, supported the research by providing the GDF-15 assay free of charge.
Diabetes, coronary artery disease, and risk of dementia – a cohort study from Western Denmark
Authors: Olesen K.K.W , Thrane P.G , Gyldenkerne C , Thim T , Maeng M
Published: November 2020

Background

Diabetes patients have a higher risk of both ischemic stroke and dementia compared to non-diabetes patients. Coronary artery disease (CAD) is associated with an increased risk of ischemic stroke. We hypothesized that diabetes and CAD are independent, and additive, risk factors for ischemic stroke and dementia.

Purpose

We examined the risk of dementia and ischemic stroke in diabetes and non-diabetes patients with and without CAD by coronary angiography.

Methods

We conducted a cohort study of all patients ≥65 years, who underwent coronary angiography between 2003–2016 in Western Denmark. Patients diagnosed with dementia or early cognitive decline at the time of CAG were excluded. Patients were stratified by diabetes and CAD. Outcomes were dementia and ischemic stroke. We estimated the cumulative incidence of a combined endpoint of dementia and ischemic stroke accounting for the competing risk of death. Follow-up was capped at the 75th percentile of overall follow-up (9.2 years). We estimated adjusted hazard ratios (aHRs) using patients without diabetes and CAD as reference. We also examined the association between extent of CAD and dementia in subgroup analysis of diabetes patients.

Results

A total of 62,372 patients were included, of whom 10,417 (16.7%) had diabetes and 43,023 (69.0%) had obstructive CAD. Median follow-up was 5.8 years. Patients with both diabetes and CAD had the highest risk of dementia (aHR 1.47, 95% CI 1.27–1.71), including Alzheimer's dementia (aHR 1.26, 95% CI 1.01–1.56) and vascular dementia (aHR 2.60, 95% CI 1.78–3.80), as well as ischemic stroke (aHR 2.02, 95% CI 1.77–2.32). Patients with either diabetes or CAD were at intermediate risk of dementia and ischemic stroke (Figure). We did not find a significant trend between the extent of CAD and risk of dementia in diabetes patients (p for trend=0.0687).

Conclusions

Both diabetes and CAD were independent risk factors of dementia and ischemic stroke in patients ≥65 years after angiography. Patients with combined diabetes and CAD had a particularly high risk of cognitive impairment and ischemic stroke.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital
Evaluation of two classical contrast-induced nephropathy definitions for predicting long-term mortality in patients undergoing elective percutaneous coronary intervention
Authors: Lin K , You Z , Chen H , He C , Chen X , Guo Y , Zhu P
Published: November 2020

Background

Contrast-induced nephropathy (CIN) is a frequent complication after percutaneous coronary intervention (PCI), and is associated with poor outcome. However, the optimal definition of CIN has been debated because of its different incidence and influence on prognosis. At present, there are limited data regarding th impact of different CIN definitions on long-term mortality in patients undergoing elective PCI.

Purpose

To explore the influence of two classical CIN definitions on long-term mortality and identify which definition was more suitable for predicting long-term mortality in patients undergoing elective PCI..

Methods

We prospectively observed 5600 consenting patients undergoing PCI from January 2012 to December 2018. Two classical CIN definitions include those defined by ESUR[Contrast-media-induced nephrotoxicity (CMN)] and AKIN[contrast induced acute kidney injury (CI-AKI)]. CMN was defined as an increase in serum creatinine (SCr) ≥25% or 0.5 mg/dLabove thebaseline level within 3 days,while CI-AKI wasdefined as an increase in SCr ≥50% or 0.3 mg/dL within 48hs after contrast medium exposure.The association of CIN with long-term mortality was investigated by Cox regression analysis.Interaction analyses were performed for long-term mortality across subgroups.

Results

The incidence of CIN according to ESUR (CMN) and AKIN (CI-AKI) definition were18.3% (n=1023) and 6.1% (n=342), respectively. During a median follow-up of 2 years, after adjusting other potential risk factors, multivariable cox regression analysis revealed CIN was a risk factor for long-term mortality [hazard ratio (HR): 2.021, 95% confidence interval (CI): 1.389–2.938, P<0.0001] according to AKIN definition, but not for ESUR definition (HR: 1.344, 95% CI: 0.982–1.838, P>0.05). Further interaction analysis showed that there was a significant interaction between age >75ys and CMN for long-term mortality (P=0.042) while no such association was observed between age >75ys and CI-AKI (P=0.806).

Conclusions

CIN defined by AKIN may be more suitable for predicting long-term mortality in patients undergoing elective PCI. However, in elderly patients, CIN defined by ESUR could also be used for predicting long-term mortality.

Association Between CIN and mortality

Funding Acknowledgement

Type of funding source: None
Beta-amyloid and mitochondrial-derived peptide-c are additive predictors of adverse outcome to high-on-treatment platelet reactivity in type 2 diabetics with revascularized coronary artery disease
Authors: Ikonomidis I , Katogiannis K , Kyriakou E , Taichert M , Katsimaglis G , Tsoumani M , Andreadou I , Lambadiari V , Maratou I , Kousathana F , Varlamos C , Plotas P , Alexopoulos D , Dimitriadis G , Tsantes A.E
Published: November 2020

Background and aims

Increased b-amyloid and decreased Mitochondrial-derived peptide (MOTS-c), are reported in diabetes. We investigated their additive value to high on-clopidogrel platelet reactivity (HPR) for adverse outcome in type 2 diabetics after recent revascularization.

Patients and methods

In 121 type II diabetics, treated with clopidogrel and aspirin, (93 males, mean age 67.2 years) we measured: a). maximum platelet aggregation to adenosine diphosphate (ADP) by Light Transmission Aggregometry (LTAmax), b) Malondialdehyde (MDA), as oxidative stress marker, c) MOTS-c, d) b-amyloid blood levels. Cardiac death and acute coronary syndromes (MACE) were recorded during 2 years of follow-up.

Results

Out of 121 patients, 32 showed HPR (LTAmax >48%,). At baseline, HPR was associated with b-amyloid >51 pg/ml (p=0.006) after adjusting clinical variables, HbA1c, MOTS-c, MDA and medication. During follow-up, 22 patients suffered a MACE. HPR, b-amyloid >51 pg/ml and MOTS-c<167 ng/ml were predictors of MACE (relative risk 3.1, 3.5 and 3.8 respectively, p<0.05) after adjusting for confounders and medication. There was significant interaction between HPR and b-amyloid or MOTS-c for the prediction of MACE (p<0.05). Patients with HPR and b-amyloid>51mg/dl or HPR and MOTS-c concentration<167 ng/ml had a 4-fold higher risk for MACE than patients without these predictors (relative risk 4.694 and 4.447 respectively p<0.01). The above results were confirmed in an external validation cohort of 90 patients with diabetes and CAD.

Conclusions

Increased b-amyloid or low MOTS-c are additive predictors to high on-clopidogrel platelet reactivity for adverse outcome in diabetics with CAD during 2-years follow- up.

Funding Acknowledgement

Type of funding source: None
Spontaneous coronary artery dissection (SCAD) in men: an observational study
Authors: Wood A , Adlam D
Published: November 2020

Background/Introduction

SCAD is a rare cause of acute coronary syndrome. Approximately 90% of SCAD patients are women, and factors such as the hormonal changes of the menstrual cycle are thought to be relevant. It is therefore interesting to consider why patients without such hormonal exposure may be affected. SCAD in men remains poorly understood.

Purpose

To study the clinical features and natural history of SCAD in men and to see how it differs from SCAD in women.

Methods

Patients with SCAD were recruited by self-referral and clinician referral from across the UK. Angiograms are reviewed by two experienced cardiologists and other data is obtained from patient questionnaires and from medical records.

Results

53 male SCAD patients were identified from the registry. Mean age at SCAD was 47±5.4 (SD). 1 presented with cardiac arrest, 2 as chronic dissections without a clear acute event, 15 as STEMI and 32 as NSTEMI; admission ECGs were not available for 3 patients. The vessel affected was the circumflex in 15 patients, RCA in 4, LAD in 27 and multi vessel in 7. SCAD type was 1 in seven patients, 2a in 21, 2b in 16, 3 in 7 and 4 in 2. LV function post SCAD was normal in 37 out of 50 patients with data available and mean EF was 52.4%. Of 37 with cardiac MRI data, 11 had no visible late gadolinium enhancement. 23 patients had been screened for fibromuscular dysplasia and only 1/23 had this diagnosis. 2 other patients had a non-FMD aortopathy (dilated ascending aorta) and 1 had a very small cerebral aneurysm that was not thought to represent FMD. Mean follow up from the first SCAD event was 3 years (SD 2 years); over this time period 10/51 patients had recurrent SCAD (2 patients presented as chronic dissections on elective angiography and it was not possible to date the index event).

Conclusions

This is the largest study so far reported of SCAD in men. The mean age was similar to that seen in women, though with a narrower age range, and the proportions of STEMI and NSTEMI are also similar. The most frequently affected vessel was the LAD. Type 2 SCAD was by far the commonest angiographic appearance. The majority of patients had preserved LV systolic function and a significant proportion had no measurable scar. These findings suggest that the presenting features of SCAD in men are very similar to those in women. The incidence of FMD appears to be far lower than in women, however; studies in female SCAD patients suggest that FMD is present in 11–86% (depending on methods used for screening). Finally, rate of recurrent SCAD in men appears significant. The largest series so far reported in SCAD (327 patients, 90.5% women, followed prospectively) showed a recurrence rate of 10.4% over 3 years. We saw a recurrence rate of 19.6%. This may simply represent the play of chance in a small population, or recruitment bias as our study is primarily retrospective, however it is an intriguing observation worthy of further investigation.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): BeatSCAD
Higher level of high sensitivity C-reactive protein is associated with more fibrocalcific plaque and longer lesion in patients with acute coronary syndrome
Authors: Katamine M , Minami Y , Asakura K , Kato A , Katsura A , Sato T , Muramatsu Y , Hashimoto T , Kameda R , Meguro K , Shimohama T , Ako J
Published: November 2020

Background

The association between the level of high sensitivity C-reactive protein (hsCRP) and coronary plaque characteristics in patients with acute coronary syndrome (ACS) remains to be elucidated.

Purpose

To clarify the morphological characteristics of culprit lesion in patients with ACS according to the hsCRP levels using optical coherence tomography (OCT).

Methods

A total of 215 consecutive patients with ACS, who underwent OCT imaging of culprit lesions were included. The patients were classified into either the higher hsCRP group (hsCRP ≥0.14 mg/dL, n=108) or the lower hsCRP group (hsCRP <0.14 mg/dL, n=107) according to the median preprocedural hsCRP level. The morphological characteristics of culprit lesion assessed by OCT were compared between the two groups.

Results

The higher hsCRP group had higher prevalence of insulin therapy (14 vs. 6%, p=0.037) and current smoker than the lower hsCRP group (37 vs. 18%, p=0.002). The prevalence of long lesion (≥25 mm, 67 vs. 53%, p=0.041) and fibrocalcific plaque (53 vs. 33%, p=0.003) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Figure). On the other hand, the prevalence of plaque rupture (36 vs. 46%, p=0.174) and lipid-rich plaque (47 vs. 64%, p=0.011) was rather lower in the higher hsCRP group than in the lower hsCRP group (Figure). In a multivariate analysis, fibrocalcific plaque (odds ratio [OR]: 2.098, 95% confidence interval [CI]: 1.125–3.913, p=0.019), lesion length (mm, OR: 1.036, 95% CI: 1.010–1.061, p=0.004) and current smoker (OR: 2.757, 95% CI: 1.388–5.476, p=0.003) was independently associated with higher hsCRP level.

Conclusions

ACS patients with high hsCRP levels had more fibrocalcific plaque and longer lesion than those with low hsCRP levels. The association between high hsCRP levels and vulnerable characteristics of culprit plaque was not demonstrated.

Funding Acknowledgement

Type of funding source: None
Prognostic impact of elevated baseline CRP levels in primary PCI-treated patients with residual cholesterol risk
Authors: Zobenica V , Milasinovic D , Jelic D , Mehmedbegovic Z , Zaharijev S , Radomirovic M , Djurosev I , Pavlovic A , Dudic J , Dedovic V , Asanin M , Vukcevic V , Stankovic G
Published: November 2020

Background

Recent large randomized studies have indicated the potential of anti-inflammatory therapies to reduce adverse cardiovascular events in patients with myocardial infarction, with the most pronounced benefit in patients with baseline elevated C-reactive protein (CRP).

Purpose

Our aim was to assess the association of CRP levels with 30-day and 1-year mortality in patients with acute myocardial infarction treated with primary PCI and with residual cholesterol risk.

Methods

The study included 1531 patients admitted for primary PCI, with the residual cholesterol risk, i.e. low-density lipoprotein cholesterol (LDL-C) levels of >1.80 mmol/l (70 mg/dl), from a prospectively kept electronic registry of a high-volume tertiary center, for whom in-hospital CRP measurements were available. Elevated CRP was defined as ≥5 mg/l (local laboratory cut off value), measured during index hospitalization. Cox regression models were constructed to assess the impact of elevated CRP on 30-day and 1-year mortality.

Results

72% of the included patients with LDL-C >1.80 mmol/l had elevated in-hospital CRP (n=1107). Compared with patients with CRP levels within reference limit, elevated CRP was associated with older age (62 vs. 60, p<0.001), higher rates of diabetes (25.8% vs. 18.5%, p=0.002), renal failure (6.4% vs. 2.1%, p<0.001) and Killip class >1 at presentation (22.5% vs. 12.3%, p<0.001), as well as lower EF (44% vs. 48%, p<0.001) and lower haemoglobin on admission (13.9 g/dl vs. 14.2 g/dl, p<0.001). Crude mortality rates were increased in patients with CRP ≥5mg/l at both 30 days (6.0% vs. 2.4%, p=0.003) and 1 year (13.2% vs. 6.3%, p<0.001) (Figure). After adjusting for the observed baseline differences, CRP ≥5mg/l remained an independent predictor of mortality at 1 year (HR 1.691, 95% CI: 1.050–2.724, p=0.03), but not at 30 days (HR 1.690, 95% CI: 0.859–3.324, p=0.13).

Conclusion

In primary PCI-treated patients with residual cholesterol risk, elevated in-hospital CRP was independently associated with 1-year mortality. Our findings may thus suggest a potential window of opportunity, for anti-inflammatory therapies to improve outcomes beyond the acute phase.

Figure 1

Funding Acknowledgement

Type of funding source: None
Iron deficiency is associated with larger infarcts and with adverse remodeling in STEMI patients and reduces myocardial tolerance to ischemia/reperfusion by inhibiting the eNOS/sGC/PKG pathway in mice
Authors: Barrabes J.A , Aluja D , Castellote L , Rodriguez A , Otaegi I , Pineda V , Mila A , Baneras J , Lidon R.M , Sambola A , Rodriguez-Palomares J , Valente F , Beneitez D , Ferreira-Gonzalez I , Inserte J
Published: November 2020

Background

Iron deficiency (ID) interferes with the cardioprotective pathway endothelial nitric oxide synthase/soluble guanylate cyclase/protein kinase G (eNOS/sGC/PKG), but its role in acute myocardial infarction remains unclear.

Methods

Patients (n=125) with a first anterior STEMI treated with PCI underwent magnetic resonance imaging in the acute phase and at 6 months. We assessed whether ID (ferritin level <100 μg/L or <300 μg/L if transferrin saturation was <20%) was associated with infarct size acutely or with adverse left ventricular (LV) remodeling (LV end-diastolic volume increase at 6 months >20%, n=105). C57BL6/N mice were fed with standard diet or iron-deficient diet for 4 weeks before undergoing 45-min coronary occlusion/24-h reperfusion.

Results

Patients with ID (43.2%) had larger infarcts (22.8±10.2 vs 16.8±9.8% of LV mass, P=0.002) and more frequent microvascular obstruction (70.0 vs 43.3%, P=0.004) in the initial exam than the rest. They also developed adverse LV remodeling more often (38.6 vs 14.8%, P=0.005), even after adjusting by infarct size and final TIMI flow grade (OR 3.1, 95% CI 1.1–8.6, P=0.027). In mice, ID diet reduced myocardial iron content, serum ferritin and hemoglobin levels without reaching anemic values and without inducing echocardiographic alterations. ID diet reduced myocardial eNOS protein content, its dimeric form, and nitrites/nitrates and cGMP levels. eNOS decrease was associated with reduced HSP90 levels and increased eNOS ubiquitination in correlation with oxidative and nitrosative stress. Weekly iv administration of iron sucrose effectively reverted the ID-diet effects. Infarct size was larger in the ID group than in controls (58.8±3.0 vs. 40.3±3.6%, P=0.03) but was not increased in ID-diet animals treated with iron sucrose (36.3±4.0%) or receiving the sGC activator ataciguat before ischemia (31.0±2.5%).

Conclusions

ID is associated with larger infarcts and with more frequent adverse LV remodeling in patients with STEMI and reduces myocardial tolerance to ischemia/reperfusion in mice by attenuating eNOS/sGC/PKG pathway activity. Iron sucrose treatment and sGC activation reverted these deleterious effects of ID in mice. Iron supplementation might be beneficial in STEMI patients with ID.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIBER-CV. Instituto de Salud Carlos III (PI16/00232), co-financed by the ERDF
Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome
Authors: Campos I , Oliveira C , Pires C , Medeiros P , Flores R , Mane F , Braga C , Gaspar A
Published: November 2020

Introduction

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients.

Aim

To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI.

Methods

From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year.

Results

The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029].

Conclusion

We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts.

Funding Acknowledgement

Type of funding source: None
Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention
Authors: Hromadka M , Motovska Z , Hlinomaz O , Kala P , Varvarovsky I , Dusek J , Svoboda M , Jarkovsky J , Tousek F , Majtan B , Simek S , Branny M , Mrozek J , Cervinka P , Widimsky P
Published: November 2020

Background

Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI).

Purpose

Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI.

Method

The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year.

Results

Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow <2 before PCI (p=0.029), TIMI flow <3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B <30 min was achieved in 70% of patients, only 5.3% had interval >90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age >70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP <100 mmHG and HR >100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. >6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028).

Conclusion

The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow <3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction.

Funding Acknowledgement

Type of funding source: None
The predictive value of CHA2DS2-VASc score on adverse in-hospital outcomes among patients with the acute coronary syndrome and atrial fibrillation who undergo PCI
Authors: Borovac J.A , Kwok C.S , Mohamed M.O , Fischman D.L , Savage M , Alraies C , Kalra A , Nolan J , Zaman A , Ahmed J , Bagur R , Mamas M.A
Published: November 2020

Background

Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and having concomitant atrial fibrillation (AF) have a greater risk of adverse short- and long-term outcomes and death compared with patients in the same setting but without AF. On the other hand, the predictive value of CHA2DS2-VASc score in terms of in-hospital mortality and periprocedural adverse events following PCI among patients with ACS and AF is unknown.

Purpose

We retrospectively analyzed data of patients with the main admission diagnosis of ACS that underwent PCI and had AF during the 2004–2014 period from the large nationwide US National Inpatient Sample (NIS) database.

Methods

A CHA2DS2-VASc score was calculated for each patient and incorporated into a multivariable-adjusted logistic regression to determine its independent impact on in-hospital outcomes consisting of death, acute kidney injury (AKI), bleeding, vascular injury, and stroke/transient ischemic attack (TIA).

Results

A total of 283,890 patients with AF who underwent PCI following ACS were included in the analysis. The average reported prevalence of the AF in the whole cohort was 10.0% with a significant trend (p<0.001) of increase during the observed 10-year period. The average age of the cohort was 72.1±11 years, 63.4% were male while the median CHA2DS2-VASc score was 3 (IQR 2–4). Crude rates of adverse in-hospital outcomes were significantly higher among patient groups with higher CHA2DS2-VASc score (Table 1). Following adjustment for baseline covariates, incremental increase in CHA2DS2-VASc score was independently associated with an increased odds of in-hospital death (OR 1.20, CI 95% 1.18–1.22), periprocedural vascular injury (OR 1.18, 95% CI 1.17–1.20), bleeding (OR 1.17, 95% CI 1.16–1.18), stroke/TIA (OR 1.17, 95% CI 1.15–1.19), and AKI (OR 1.05, 95% CI 1.04–1.06) (Figure 1).

Conclusions

The CHA2DS2-VASc score provides important prognostic information in ACS patients with AF undergoing PCI and is independently associated with in-hospital death and periprocedural adverse events. Therefore, CHA2DS2-VASc score could be used as a practical and inexpensive tool for risk stratification in this population.

Figure 1

Funding Acknowledgement

Type of funding source: None
The association between osteoarthritis and invasive treatment and clinical outcomes in 6.5 million patients presenting with acute myocardial infarction
Authors: Parmar S , Mohamed M , Wilkie R , Mamas M
Published: November 2020

Background

People with osteoarthritis (OA) have an increased risk of cardiovascular disease, including acute myocardial infarction (AMI). Despite OA being the most common joint condition and the fastest increasing major health condition, there is limited information on the management strategies and subsequent outcomes of OA patients presenting with AMI.

Purpose

To describe the association between OA and invasive management strategies (including coronary angiography (CA), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG)) and clinical outcomes.

Methods

We analysed all hospitalisations for AMI between 2004 and 2015 recorded in the National Inpatient Sample (NIS), the largest inpatient electronic health record database in the United States. The proportion of patients receiving CA, PCI, and CABG were compared between patients with and without OA, as were the proportions of in-hospital adverse events including major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, cardiac complications and acute stroke), in-hospital mortality, stroke, and major bleeding. Multivariate logistic regression modelling with adjustment for potential confounders (demographics, medical history, and comorbidities) was performed to examine associations between OA and in-hospital clinical outcomes; results are expressed as adjusted odds ratios (AdjOR) with 95% confidence intervals (95% CI).

Results

A total of 6,561,940 people were hospitalised for AMI between January 2004 and September 2015, of which 444,217 (6.8%) had a concurrent diagnosis of OA. On average, those with OA were older (median: 77 vs. 67 years), more likely to be female (55.7% vs. 38.6%), and less likely to receive CA (55.3% vs. 65.2%), PCI (33.3% vs. 43.6%), and CABG (7.4% vs. 8.5%) (Figure 1A, p<0.001 for all). After adjustment for confounders, OA was associated with a lower likelihood of receiving CA (AdjOR 0.89; 95% CI 0.87, 0.90), PCI (0.85; 0.84, 0.87), and CABG (0.92; 0.90, 0.94). With reference to outcomes, OA was associated with lower likelihood of in-hospital adverse events (MACCE: AdjOR 0.71; 95% CI 0.69, 0.72; in-hospital mortality: 0.69; 0.67, 0.71; stroke: 0.81; 0.77, 0.85; and major bleeding: 0.73; 0.70, 0.75) (Figure 1B, p<0.001 for all).

Conclusion

In a national cohort of AMI hospitalisations, patients with OA were less likely to receive invasive management compared to those without OA. However, they were also less likely to experience adverse events. Further work is required to investigate treatment disparities in this increasingly prevalent patient group when presenting with AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None
Compared presentation, management and long-term outcomes after acute myocardial infraction in men and women <50 years of age. The FAST-MI programme
Authors: Danchin N , Puymirat E , Eltchaninoff H , Manzo-Silberman S , Marchand S , Bataille V , Drouet E , Naccache N , Ferrieres J , Schiele F , Simon T
Published: November 2020

The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme.

Methods

FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%).

Results

Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08).

All in-hospital complications except reinfarction (1.8 vs 0.6%, p<0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P<0.001); PCI was less often used (74% vs 85.5%, P<0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P<0.001), even in patients with significant CAD (46% vs 55%, P=0.004).

Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke.

Conclusion

There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender.

Five-year mortality

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca
Creatine kinase is associated with bleeding after thrombolytic therapy for myocardial infarction
Authors: Brewster L , Fernand J
Published: November 2020

Background

The ADP-scavenging enzyme creatine kinase (CK) is reported to reduce ADP-dependent platelet activation. Therefore, we studied whether highly elevated CK after myocardial infarction (MI) is associated with bleeding.

Method

Data of the Thrombolysis In Myocardial Infarction Study Group phase II trial on the efficacy of angioplasty following intravenous recombinant tissue-type plasminogen activator (rt-PA), are used to assess whether peak plasma CK (CKmax) is independently associated with adjudicated fatal or non-fatal bleeding (primary) and combined bleeding/all-cause mortality (secondary) in multivariable binomial logistic regression analysis, adjusting for baseline and treatment allocation covariates.

Results

The included patients (N=3339, 82% men, 88% white, mean age 57 y, SE 0.2), had a history of angina pectoris (55%), hypertension (38%), and/or diabetes mellitus (13%). CKmax ranged between 16 and 55 890 IU/L (mean 2389 IU/L; SE 41), reached within 8 h in 51% of the patients (93% within 24 h). Adjudicated fatal/non-fatal bleeding occurred in 30% of the patients (respectively 26% in the low vs 34% in the high CK tertile), and bleeding/all-cause mortality in 35% (29% in the low, vs 40% in the high CK tertile). In multivariable regression analysis, the adjusted odds ratio for fatal/non-fatal bleeding (vs not bleeding and survival) was 2.6 [95% CI, 1.8 to 3.7]/log CKmax increase, and 3.1 [2.2 to 4.4] for bleeding/all-cause mortality).

Conclusion

Highly elevated plasma CK after MI is a hitherto overlooked independent predictor of bleeding and hemorrhagic death. This biologically plausible association warrants further prospective study of the potential role of extracellular CK in ADP-dependent platelet activation and bleeding.

Funding Acknowledgement

Type of funding source: None
Soluble urokinase plasminogen activator receptor (suPAR) can predict long-term mortality in patients with acute chest pain
Authors: Chew-Harris J , Appleby S , Troughton R.W , Richards A.M , Pemberton C.J
Published: November 2020

Background

Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory protein associated with plaque instability. Its modulation may reflect on immune dysfunction related to cardiovascular disease burden. We describe the prognostic performance of suPAR in patients presenting with chest pain suspicious of acute myocardial infarction (AMI).

Methods

suPAR concentrations were measured at presentation using the ViroGates CE-marked ELISA in 812 patients with the primary complaint of acute chest pain. Standard cardiac markers including hsTnT and NT-proBNP (both Roche) were also measured. Data for all biomarkers were treated as continuous and expressed as median [interquartile range (IQR)]. Statistical assessment was made using SPSS v25 (IBM). Groups were compared by Mann-Whitney U test/Spearman's rho. Prognostic performance of suPAR was assessed using receiver operator curve (ROC) area under the curve (AUC), Cox-proportional hazards regression and Kaplan-Meier analyses.

Results

In this chest pain cohort [median age: 63 yrs (IQR: 54–74), 34% female], 156/812 of patients had adjudicated AMI [STEMI (n=22)/NSTEMI (n=134)]. Total all-cause mortality was 18% within 10 yrs. Although median suPAR concentrations were elevated in AMI patients versus all other diagnoses [3.2 ng/mL (IQR:2.4–4.3) vs 2.7 ng/mL (IQR:2.2–3.6) (P<0.0001)], it did not assist in AMI diagnosis (ROC-AUC=0.60). In the entire chest pain cohort, suPAR (AUC≥0.82) had comparable discrimination to that of NT-proBNP (AUC≥0.84) for the prediction of mortality within 2 yrs (n=52), 4 yrs (n=77) and 10 yrs (n=149), and was better than hsTnT (AUC≤0.70). Addition of suPAR improved the mortality ROC curve of NT-proBNP (0.84 to 0.87) and for hsTnT (0.70 to 0.81) for 2-yr death prediction (Figure). Alone, suPAR was the strongest predictor (AUC=0.77) of new unstable angina at 2-yrs (n=52). The fully adjusted hazard ratio (HR) using Cox models showed suPAR (HR: 1.2) and NT-proBNP (HR: 1.3) to be the only independent biomarkers associated with death at 4 and 10-yrs (P<0.0001). Stratification of baseline suPAR by Kaplan-Meier plots for all-cause mortality showed the highest tertile of suPAR, compared to the lowest, was associated with a HR of 5.7 and 5.1 for 4-yr and 10-yr death, respectively.

Conclusion

suPAR is a strong prognostic indicator of long-term mortality and its usage alongside current cardiac biomarkers may assist in the risk stratification of AMI patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Health Research Council of New Zealand, National Heart Foundation of New Zealand
Epicardial fat tissue: a new tool for identification of coronary artery disease patients?
Authors: Ferreira J , Martins R , Goncalves V , Freitas A , Almeida J , Monteiro S , Goncalves L
Published: November 2020

Introduction

Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD.

Purpose

To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD.

Methods

We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis >50%.

Results

One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p<0.001), PLAXM (r=0.372, p<0.001), PSAXB (r=0.445, p<0.001) and PSAXM (r=0.372, p<0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p<0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p<0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p<0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p<0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p<0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%.

Conclusions

In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction.

Figure 1

Funding Acknowledgement

Type of funding source: None