bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence of hypoxic hepatitis in patients with cardiogenic shock and association with mortality
Authors: Beer B N , Besch L , Weimann J , Surendra K , Sundermeyer J , Dettling A , Kluge S , Kirchhof P , Blankenberg S , Roedl K , Schrage B
Published: November 2023

Background

Shock of any cause leads to hypoxic and toxic organ damage, especially in perfusion-sensitive organs such as the liver. In septic shock, hypoxic hepatitis is defined as an increase of ASAT and ALAT to >700 U/l and is associated with increased mortality. However, pathophysiology, dynamics and treatment differ between septic and cardiogenic shock (CS). Thus, the definition of hypoxic hepatitis derived from patients with septic shock may not be suitable in CS.

Purpose

To evaluate incidence and impact of hypoxic hepatitis in patients with CS based on existing as well as on novel CS-specific cut-offs.

Methods

Unselected patients >18 years treated for cardiogenic shock at a tertiary care centre between 2009 and 2019 were analysed for presence and prognostic impact of hypoxic hepatitis. Receiver operating curve analyses/Youden Index Method were used to determine optimal ASAT/ALAT cut-off values for hypoxic hepatitis. Multivariable adjusted logistic regressions models were constructed to compare different ASAT/ALAT cut-offs for the prediction of in-hospital mortality.

Results

This analysis included 698 patients [mean age 69 years, 212 (29.9%) female]. A total of 386 (55.3%) patients died. Liver enzyme elevation >700 U/l was present in 135 (19.1%) patients and not associated with in-hospital mortality (OR 1.1, 95% CI: 0.69, 1.75, p-value 0.69). Mortality was best predicted by new cut-offs with a >34% increase for ASAT and a >51% increase for ALAT. Using these criteria, hypoxic hepatitis was found in 36% (254/698 patients), most commonly during early disease trajectory (74% within first 3 days, Figure 1). Hypoxic hepatitis using this definition was associated with in-hospital mortality (OR 2.46, 95% CI: 1.67, 3.64, p-value <0.001).

Conclusion

Using novel, CS-specific cut-offs, defines hypoxic hepatitis as a relevant marker of excess mortality in patients with CS. These findings identify hypoxic hepatitis as a relevant disease modifier in CS and emphasises the need for further investigation of therapies reducing its occurrence and impact.Figure 1
Risk of sepsis after extracorporeal cardiopulmonary resuscitation in patients with refractory cardiogenic shock from the RESCUE registry
Authors: Oh K , Bae D H , Kim M , Lee J H , Kim S M , Choi W G , Hwang K K , Kim D W , Cho M C , Yang J H , Gwon H C , Bae J W
Published: November 2023

Objectives

It is known that the incidence of sepsis is higher in patients receiving extracorporeal membranous oxygenation (ECMO). In particular, extracorporeal cardiopulmonary resuscitation (ECPR) is performed in emergency situations, which may increase the likelihood of non-aseptic management compared to routine procedures. So, we investigated the association of ECPR and incidence of sepsis in patients with refractory cardiogenic shock (CS).

Background

Pre- and post-ECPR sepsis are associated with increased mortality, and it is known that the occurrence of sepsis after ECPR is higher than in conventional cardiopulmonary resuscitation (CPR). However, it is not well known whether ECPR has a higher incidence of sepsis than ECMO insertion in non-CPR conditions.

Method

The SMART-RESCUE study is a multi-center, retrospective and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The incidence of sepsis was compared by dividing into two groups according to whether or not ECPR was performed. Patients with ECMO duration less than 48 hours were excluded.

Result

Total of 231 patients(mean age 59.46 years, men 67.70%, mead follow-up duration 136.5 days) were analyzed into ECPR group(n=95, 60.7 ± 13.0 years, men 75.8%) and non-ECPR group(n=136, 58.6 ± 15.5 years, men 65.4%) respectively.

ECPR group showed lower SBP, lower DBP, lower HR, more shock caused by ischemia, more smoking, lower LVEF, higher Hb, higher serum Na, lower AST, higher Peak troponin I, higher vasoactive inotropic score, higher ICMP portion.

After 1:1 propensity score matching corrected for height, SBP, DBP, Hb, initial pump flow, Na, ICMP, vasoactive inotropic score, difference remained in SBP, DBP, HR, cause of shock.

Sepsis incidence was 7.4%. The risk for sepsis incidence was not different between two groups(7.4% vs 6.3%, adjusted OR 1.18, 95% CI 0.38-3.65, p=0.774).

Conclusion

ECPR procedure does not increase sepsis compared to ECMO insertion not in CPR state in patients with cardiogenic shock.Adjusted Baseline CharacteristicsAdjusted Outcomes
Changes in cardiac electrical biomarker with hyperaemic stress: an experimental perspective
Authors: Chattopadhyay S , Adjei F , Kardos A
Published: November 2023

Background

"Cardiac electrical biomarker" (CEB) is a numerical index measured by the Vectraplex ECG (vECG) System with Vectraplex AMI software that measures changes in the cardiac electrical field vectors from dipolar to multipolar during myocardial ischemia. CEB performs well in detecting NSTEMI and STEMI against physician adjudicated diagnosis.

Purpose

To assess changes in CEB during adenosine stress induced ischaemia.

Method

Thirty-three patients, in the VECTRA-PCI trial, with normal surface ECG (sECG) had CEB measured before (CEB0), at maximal hyperaemia (CEBh)) and 1-(CEB1), 2-(CEB2) and 3-(CEB3) hours after standard fractional flow reserve (FFR) assessment using intravenous adenosine. vECGs were adjudicated for quality by 2 blinded observers. vECGs with artefacts and arrhythmias were discarded and CEBs from best traces were analysed. Forty-nine individuals with non-cardiac chest pain, without past medical history or risk factors for CAD, on no medications, normal ECGs, normal blood profile acted as controls. CEBs (median, IQR) were compared using appropriate tests.

Results

FFR was normal (>/=0.80) (nFFR) in 25 and ischaemic (<0.80) (iFFR) in 8 patients. CEB0 in nFFR and iFFR groups were similar to each other (p=0.785) (Fig 1) and to controls (30.0; IQR 17.0-44.0, vs nFFR: p=0.057, vs iFFR: p=0.241). Compared to CEB0, CEBh was higher in nFFR (p=0.014) (Fig 1A) and iFFR (p=0.016) groups (Fig 1B). CEBh in iFFR (126.0; 109.5-216.0) higher than nFFR (44.0; 27.8-104.8), (p=0.039). In nFFR group, CEB1, 2 and 3, though numerically lower, were statistically similar to CEBh and CEB0 (Fig 1A) suggesting quick recovery. In iFFR group CEB1 was similar to and CEB2 and 3 were lower than CEBh (Fig 1B) suggesting a slower recovery of CEB. Both CEBh and change from CEB0 to CEBh (δCEB0-h), but not CEB0, predicted ischaemic FFR with similar accuracy (p=0.570) (Fig 2). CEBh >96 and δCEB0-h >28 had similar sensitivity of 87.5% with specificity of 68% and 80% respectively.

Conclusion

Obstructive coronary atheroma is associated with higher CEB than non-obstructive atheroma under hyperaemic stress. Both CEBh and δCEB0-h accurately predict ischaemic FFR with higher specificity of δCEB0-h. This is the first study to measure CEB changes with hyperaemic stress in patients with coronary artery disease and could have potential for wider clinical application.

Figure 1. Changes in the CEB during and after hyperaemic stress in patients with normal (A) and ischaemic (B) FFR.

Figure 2. Area under the ROC curve to determine the diagnostic accuracy of pre-procedural CEB, hyperaemic CEB and change in CEB from baseline to hyperaemia in determining ischaemic FFR.Fig 1. Changes in CEB with stress.Fig 2. CEB for ischaemic FFR
Independent prognostic value of ejection fraction, resting coronary flow, coronary flow reserve, myocardial viability, and inducible ischemia in heart failure with a reduced ejection fraction
Authors: Ciampi Q , Cortigiani L , Rigo F , Gaibazzi N , Zagatina A , Wierzbowska-Drabik K , Kasprzak J , Djordjevic-Dikic A , Haberka M , Lorenzoni V , Barbieri A , Pepi M , Carerj S , Villari B , Picano E
Published: November 2023

Background and Aims

Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may complement established predictors based on wall motion.

Methods and results

In a prospective multicenter study design, we enrolled 1,408 HF patients (age 66±12 years, 1,035 men), with EF <50%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. Recruitment (years 2004-2022) involved 8 accredited laboratories, with inter-observer variability <10% for CFV measurement. Baseline CFV (abnormal value >31 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. Coronary flow velocity reserve (CFVR, abnormal value ≤2.0) was assessed with exercise (n=99), dobutamine (n=100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI) stress> rest (cut-off ∆≥0.12). LV contractile reserve (CR) was identified with WMSI stress< rest (cutoff ∆≥0.25). Test response ranged from score 0 (EF>30%, CFV ≤31 cm/s, CFVR >2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only end-point.

Results

During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, p<0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, p<0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, p<0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, p<0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, p=0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (n=61) and highest (31.9%) in patients with a score of 5 (n=15, p<0.001).

Conclusion

High resting CFV predicts worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.
Effect of alirocumab on quantitative flow ratio and diameter stenosis in non-infarct related arteries from patients with acute myocardial infarction: a PACMAN-AMI randomized clinical trial substudy
Authors: Baer S , Kavaliauskaite R , Otsuka T , Ueki Y , Haener J , Siontis G C M , Van Geuns R , Daemen J , Spirk D , Engstrom T , Lang I , Windecker S , Koskinas K C , Losdat S , Raeber L
Published: November 2023

Introduction

Treating hypercholesterolemia with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on top of statins leads to plaque regression and stabilization. The effects of PCSK9 inhibitors on coronary physiology and angiographic diameter stenosis (DS%) are unknown. Quantitative Flow Ratio (QFR) is a novel method to assess coronary hemodynamics.

Purpose

We aimed to investigate the effects of the PCSK9 inhibitor alirocumab on QFR and 3D-Quantitative Coronary Angiography (3D-QCA) DS% in non-infarct-related arteries (non-IRA) among acute myocardial infarction (AMI) patients.

Methods

This was a pre-specified substudy of the PACMAN trial, a randomized, double-blind, placebo-controlled trial comparing alirocumab vs. placebo on top of high-intensity rosuvastatin among AMI patients. QFR and 3D-QCA were assessed at baseline and 1-year follow-up in any non-infarct related artery (non-IRA) with ≥2.0mm diameter and >25% 3D-QCA DS%. The pre-specified primary endpoint was the number of patients with mean QFR increase from baseline to follow-up, and the secondary endpoint the change in 3D-QCA DS%.

Results

Of 300 enrolled patients, 265 had serial follow-up, of which 193 underwent serial QFR/3D-QCA analysis in 282 non-IRA. Baseline mean QFR was 0.96[IQR 0.91-0.98] and mean DS% 36.96±7.88% in the alirocumab group vs. 0.96[IQR 0.91-0.99] (p=0.593) and 36.63±8.46% (p=0.742) in the placebo group. At 1-year, QFR increased in 50/94 (53.2%) patients with alirocumab vs. 40/99 (40.4%) with placebo (Δ12.8%; OR=1.7, 95%CI 0.9-3.0; p=0.076). When excluding non-IRA with QFR >0.95, QFR increased in 37/57 (64.9%) patients with alirocumab vs. 22/50 (44.0%) with placebo (Δ20.9%; OR=2.4, 95%CI 1.1-5.2; p=0.031). DS% decreased by -1.03±7.28% with alirocumab and increased by +1.70±8.27% with placebo (Δ-2.54%, 95%CI -4.51 to -0.57; p=0.012).

Conclusions

Treatment of AMI patients with alirocumab vs. placebo for 1 year resulted in a significant regression in angiographic DS%. While no overall improvement of coronary hemodynamics was observed with alirocumab as compared to placebo, potential benefits were found in alirocumab treated patients with baseline QFR ≤0.95.Figure 1.Flowchart and primary endpointFigure 2.Secondary endpoint
Anonymous comparative assessment by an academic core laboratory of four angiography-derived fractional flow ratio software in patients with pressure derived iFR and FFR
Authors: Ninomiya K , Serruys P , Kotoku N , Kageyama S , Masuda S , Patel M , Escaned J , Akasaka T , Onuma Y
Published: November 2023

Background/Introduction

Functional assessment of coronary artery stenoses plays an important role in guiding the clinical management of patients with ischemic heart disease. Software to compute angiography-derived fractional flow ratio (angio-FFR) have been validated against pressure-wire-derived FFR (PW-FFR) with an area under the receiver operator characteristic curve (AUC) of 0.93-0.97. However, it is unknown whether commercially available angio-FFR software are equally reliable, and to what extent each might over- or under-estimate the true functional severity of a coronary artery lesion.

Purpose

The aim of this study was to investigate the diagnostic accuracies of five angio-FFR software/methods by an independent core-lab in a prospective cohort of 390 vessels with carefully documented sites of PW instantaneous-wave-free ratio (PW-iFR) and PW-FFR.

Methods

One "matcher investigator (MI)" colocalized on angiography the sites of PW measurement with angio-FFR measurements and provided the same two optimal angiographic views and frame selection to independent analysts, who were blinded to invasive physiological results and results from other software. Results are anonymized and randomly presented. The AUC of each angio-FFR was compared with 2D-quantative coronary angiography percent diameter stenosis (2D-QCA%DS) using a 2-tailed paired comparison of ROC (DeLong’s method).

Results

All 5 software/methods yielded a high proportion of analysable vessels (A:100%, B:100%, C:92.1%, D:99.5%, E:92.1%). The AUC’s for predicting an FFR≤0.8 for software A, B, C, D, E, and 2D-QCA%DS were 0.75, 0.74, 0.74, 0.73, 0.73, and 0.65, respectively (Figure A). The AUC for each angio-FFR was significantly greater than that for 2D-QCA%DS.

Furthermore, binary logistic regression analyses showed the predictors of false positives and false negative: severity of lesion stenosis, lesion location, microvascular resistance, and intermediate zone of angiography-derived FFR potentially reduce the diagnostic accuracy (Figure B).

Conclusions

This head-to-head comparison by an independent core-lab demonstrated that the diagnostic accuracy of various angio-FFR software for predicting a PW-FFR≤0.80 was useful, with a higher discrimination compared to 2D-QCA%DS, however it didn’t reach the diagnostic accuracy (AUC≥0.90) previously reported in validation studies of various vendors. The intrinsic clinical value of "angiography-derived FFR" therefore requires confirmation in large clinical trials.Figure AFigure B
Core laboratory comparative assessment of angiography-derived index of microvascular resistance (IMR) in patients with wire-based IMR
Authors: Tsai T , Gomez J , Wang B , He X C , Ninomia K , Kageyama S , Chenniganahosahalli Revaiah P , Kotoku N , Onuma Y , Serruys P
Published: November 2023

Background

Coronary microvascular disease (CMD) is responsible for nearly half of angina in the general population. The index of microvascular resistance (IMR) is the gold standard for the diagnosis of CMD. Abnormal IMR is independently associated with adverse outcomes and persistent angina after percutaneous coronary intervention (PCI) regardless of the achieved fractional flow reserve (FFR). However, the implementation of IMR in clinical practice is low due to cost and the need for hyperemia. Thus, multiple software and formulas have been developed to calculate wireless IMR via angiography analysis. However, these angiography-derived IMRs have never been compared head-to-head by an independent core laboratory.

Aim

In this study, we aim to investigate the diagnostic accuracies of five angiography-derived IMR software/formulas by an independent core lab in a retrospective cohort undergoing follow-up angiograms after successful PCI.

Methods

We analyzed 43 patients from the FUNCOMBO trial and 34 patients from the RETROFI II trial. All patients have received successful PCI for STEMI, and wire-based IMR was measured at six months (for FUNCOMBO) and three years follow-up (for RETROFI II). Angiography-derived IMR was calculated with the QFR®2.1 software, the Flashangio CaIMR® software, and the AngioPlus software. In addition, using QFR-derived data, we calculated the angio-IMR using the formula of Escaned et al. [angio-IMR = (Pa–[0.1*Pa])*QFR*e-Tmn (where e-Tmn is an estimation of hyperaemic mean transit time)] and Scarsini et al. [NH-IMRangio=Pa(resting)x QFR x N frame(resting)/frame per second]. The threshold of CMD diagnosis is 25 for all five angiography-derived IMR methods. The correlation and agreement of the five methods were evaluated against wire-based IMR measurement.

Results

The wire-based IMR was significantly correlated with Medis IMR (r= 0.396, p=0.001) and NH-IMRangio (r=0.378, p=0.001). The agreements between IMR and the angiography-derived IMRs are demonstrated in figure 1. The sensitivity, specificity, positive predicted value, negative predicted value, and accuracy were demonstrated in figure 2, which showed that using the published criteria, the accuracy of diagnosis was 52%, 68%, 67%, 68%, and 49% for Medis IMR, CaIMR, AngioPlus IMR, angio-IMR, and NH-IMRangio, respectively. Comparison of all angiography-derived IMR with wire-based IMR yielded the AUC’s of 0.648, 0.561, 0.606, 0.674, 0.688 for Medis IMR, CaIMR, AngioPlus IMR, angio-IMR, and NH-IMRangio respectively. (Figure 2.)

Conclusion

In this small validation cohort, we found that all five angiography-derived IMR calculation methods had either poor or very poor diagnostic accuracy. Among the five methods, the Medis IMR, Angio-IMR, and NH-IMRangio may be viable options for wireless CMD diagnosis.Figure 1Figure 2
Non-hyperaemic coronary flow velocity acceleration indices correlate with hyperaemic microvascular resistance in patients with INOCA
Authors: Tas A , Broyd C J , Alan Y , Atay Z , Kara I , Umman S , Sezer M
Published: November 2023

Background

Coronary microvascular dysfunction (CMD) is associated with an overall worse prognosis. While the diagnosis and endo-typing of CMD currently rely on hyperaemic physiological indices, the search for accurate non-hyperaemic techniques continues. Flow velocity acceleration pattern is mechanistically associated with changes in shear stress, endothelial function, arterial stiffness and pressure in pulsatile flow systems (1-3).

Purpose

We aim to interrogate whether resting flow velocity acceleration indices correlate with hyperaemic microvascular resistance (HMR) in patients with Ischemia and no obstructive coronary artery disease (INOCA).

Methods

In 21 Patients with INOCA (all of whom had presented with typical angina pectoris, had no significant epicardial stenoses but positive myocardial perfusion scan test for ischemia) invasive physiological assessment was performed by means of intracoronary Doppler. Hyperaemia was induced with intracoronary adenosine administration. Coronary flow reserve (CFR) and HMR were calculated per their definitions. Flow velocity acceleration indices were derived from the first derivative of the averaged resting flow velocity waveforms with respect to time. We have defined 6 wave peaks of interest in all patients (peak diastolic acceleration (initial prominent peak with ventricular relaxation, referred as A), early diastolic deceleration (B), early re-acceleration wave (C), peak presystolic deceleration (seen just before initial systolic acceleration peak, J), initial systolic acceleration peak (X) and pre-diastolic deceleration nadir (Z)) and calculated the ratios between them as well as adjusted them with respect to resting mean flow velocity (Figure 1).

Results

The mean age was 59 ± 8 years and the majority of the study group was female (%81). Cardiovascular risk factors were common amongst the study group.All patients had CFR < 2.5. Mean CFR and HMR were 2.05 ± 0.32 and 2.20 ± 0.60 mmHg.cm.sec-1 respectively. Raw C peak magnitude was significantly correlated with APVh (rho:-0.457 p:0.037) and HMR (rho:0.612 p:0.004). Adjusting the C magnitudes with APVb at patient level yielded better correlations (APVh rho:-0.496 p:0.022 ; HMR:0.642 p:0.002). The ratio between diastolic reacceleration peak (C) and presystolic peak deceleration (J), C/J , adjusted with the APVb ((C/J)/APVb) showed the most pronounced correlation with HMR (rho: 0.758 p < 0.001) (unadjusted C/J – HMR rho: 0.718 p<0.001)(Figure 2).

Conclusion(s)

Acceleration characteristics of resting coronary flow velocity correlate with hyperaemic microvascular resistance indicating structurally impaired coronary microcirculation, hence their utilisation may aid developing non-hyperaemic physiological markers for coronary microvascular dysfunction in patients with INOCA.Derived Acceleration WaveformsCorrelations between HMR and C/J Ratio
Diabetes mellitus and response to IL-1 blockade with Anakinra after ST-elevation myocardial infarction: a pooled analysis of the VCU-ART studies
Authors: Moroni F , Del Buono M G , Wohlford G , Markley R , Turlington J , Kadaryia D , Trankle C , Biondi-Zoccai G , Lipinski M J , Roberts C , Kontos M C , Carbone S , Arena R , Van Tassell B , Abbate A
Published: November 2023

Background

ST segment elevation myocardial infarction (STEMI) elicits an intense inflammatory response which is thought to contribute to subsequent maladaptive myocardial healing and remodeling, ultimately leading to heart failure (HF). The interleukin-1 (IL-1) blocker anakinra administered during the first 14 days after STEMI patients has been shown to effectively dampen the inflammatory response and reduce the incidence of HF events in pilot randomized controlled trials. Diabetes mellitus is a condition of enhanced systemic inflammation.

Purpose

To assess the role of diabetes mellitus as a modulating factor in respect to the efficacy of anakinra treatment during the first 14 days after STEMI.

Methods

We conducted a pooled analysis of three previous proof of principle trials on anakinra in STEMI. Diabetes mellitus was defined based on clinical history, use of glucose-lowering medications, or elevated hemoglobin A1c >6.5% at time of enrollment and further characterized as type I or type II based on the available clinical assessment. The area-under-the-curve for C reactive protein (AUC-CRP) at 14 days was used as a measure of the systemic inflammatory response during STEMI. The clinical endpoint was composite of death, hospitalizations for HF and urgent HF visits.

Results

The study population included 139 patients, of whom 39 (28%) had a diagnosis of diabetes mellitus at time of enrolment, all with type II. Median age was 56 [49-63] and 56 [49-63] years in patients with and without diabetes, respectively (p=0.652). There were 29 (21%) female and 52 (37%) Black-African American patients among those with diabetes compared to 29 (21%) female and 52 (37%) Black-African American patients in those without diabetes (p=0.69 and p=0.16, respectively). Treatment with anakinra (N=84) significantly dampened acute inflammation associated with STEMI in patients with diabetes (AUC-CRP 223 [117-399] vs 76 [42-148] mg•day/L, p<0.001) and in those without diabetes (AUC-CRP 223 [117-399] vs 76 [42-148] mg•day/L, p<0.001 – Figure 1). No statistically significant interaction between diabetes status and treatment with anakinra on outcomes was detected (pint=0.92): treatment with anakinra was associated with a hazard ratio [HR] 0.28 [0.09-0.84](p=0.02) in non-diabetic patients and HR 0.26 [0.11-1.32](p=0.10) in diabetic patients – Figure 2.

Conclusion

In this pooled analysis of the VCU-ART trials, the presence of type II diabetes mellitus showed no interaction with the efficacy of the treatment with anakinra early after STEMI in reducing the systemic inflammatory response or preventing new onset heart failure, hospitalization for HF or death.Figure 1.Figure 2
In-hospital and 1-year mortality associated with percutaneous coronary intervention use in patients with acute myocardial infarction older than 90 years
Authors: Trombara F , Cosentino N , Bonomi A , Milazzo V , Rubino M , De Metrio M , Resta M , Agostoni P G , Marenzi G
Published: November 2023

Background

Patients older than 90 years are less likely to receive percutaneous coronary intervention (PCI) for treatment of acute myocardial infarction (AMI). This is due to the lack of evidence derived from randomized trials, multimorbidity, and possible futility. We investigated the prognostic impact of PCI in a large population of patients hospitalized with AMI in the period 2003-2018, by using the Lombardy Health Database (Italy).

Methods

We analyzed data of all patients >90 years hospitalized with AMI (both STEMI and NSTEMI) in Lombardy. Patients were grouped according to whether they were treated or not with PCI during index hospitalization. The primary outcome was in-hospital mortality. One-year mortality and 1-year re-hospitalization for acute heart failure (AHF) or AMI were considered as secondary endpoints.

Results

During the study period, 15,954 patients (median age 92 [91-94] years); 50% STEMI) were hospitalized with a primary diagnosis of AMI. Twelve percent of them (n=1,954) were treated with PCI. The in-hospital mortality rate in the entire cohort was 22% (29% in STEMI and 15% in NSTEMI). It was significantly lower in patients treated with PCI than in those not treated with PCI (15% vs. 23%; P<0.0001). In the overall population, 1-year mortality was 56% and 1-year re-hospitalization for AHF/AMI was 19%. Both these endpoints were less frequent in PCI-treated (37% vs. 58% and 16% vs. 21%, respectively; P<0.0001). The adjusted risk of the study endpoints was significantly lower in patients treated with PCI: OR 0.61 (95% CI 0.54-0.69) for in-hospital mortality; HR 0.53 (95% CI 0.49-0.57) for 1-year mortality; HR 0.68 (95% CI 0.66-0.70) for 1-year re-hospitalization for AHF/AMI. The figure shows the 1-year survival curves of AMI patients treated or not treated with PCI. Similar results were found in STEMI and NSTEMI patients considered separately.

Conclusions

Our real-world data showed that in patients with AMI older than 90 years of age, PCI use is associated with a significant in-hospital and 1-year clinical benefit.
Exercise ECG and myocardial perfusion SPECT show high prognostic value up to four years after examination
Authors: Kraen M , Akil S , Heden B , Kjellstrom B , Berg J , Ostenfeld E , Arheden H , Carlsson M , Engblom H
Published: November 2023

Background

Abnormal results of myocardial perfusion SPECT (MPS) or exercise ECG (Ex-ECG) is known to be associated with increased risk of ischemic cardiac events. The predictive value of stress testing however, is influenced by underlying risk factors as well as follow up duration and may vary considerably over time. With traditional Cox proportional hazards analysis the time-varying effects are not sufficiently accounted for.

Purpose

To evaluate the prognostic longevity of MPS and Ex-ECG using statistical methods that allow hazard ratio changes over time.

Methods

908 patients (age 63 years, 49% male, 45% prior ischemic heart disease (IHD)) referred for MPS were prospectively included. Ex-ECG was performed in conjunction with MPS. Registry data were used for follow up. The outcome was a composite of acute myocardial infarction, unstable angina, unplanned revascularization, and cardiovascular death. Cox proportional hazard analysis and smoothed hazard functions with splines were used for risk assessment during follow up.

Results

Ex-ECG or MPS were abnormal in 198 (22%) or 148 (16%) of patients respectively. The mean follow up time was 8.2±2.6 years and the composite end point was reached in 189 patients (21%). The Kaplan-Meier curves suggest an interaction with time with the risk of event for subjects with abnormal test results being highest in the 2-3 of years after which the curves are approximately parallel (Figure 1). In multivariable models the best fit (lowest Akaike information criterion (AIC) value) was obtained with a logarithmic interaction term for time. With this approach and controlling for known risk factors the hazard ratio (HR) drops to 1 after approximately four years for both Ex-ECG and MPS (Figure 2). Age (HR=1.04, p<0.001), sex (HR=2.0, p<0.001), IHD (HR=1.7, p<0.001) and reduced exercise capacity (HR=0.99, p<0.001) were independent significant predictors of risk.

Conclusions

The high risk associated with abnormal MPS and Ex-ECG results decrease rapidly over time and after approximately 4 years the predictive value is lost. Thus, the long-term impact on prognosis of stress testing appear questionable. The time-varying effects on risk are substantial and warrant statistical considerations when designing clinical follow up studies of chronic coronary syndrome.
Left ventricular systolic dysfunction after acute myocardial infarction is associated with a high symptom burden and worse secondary prevention
Authors: Hamilton E , Alfredsson J A , Christersson C C , Erlinge D E , Lindmark K L , Omerovic E O , Desta L D , Jernberg T J , Reitan C H
Published: November 2023

Background

LV dysfunction and symptomatic heart failure are common complications after myocardial infarction and the mortality and morbidity burden remain high in this population. Published data are becoming dated, and mainly focus on mortality and hospitalization burden. There is a lack of contemporary data describing patients with post-MI LV dysfunction in terms of symptom burden and secondary prevention measures.

Purpose

The purpose of this study was to describe patients with different degree of LV dysfunction after MI, their symptom burden, quality of life and adherence to recommended secondary prevention measures in a nationwide patient material.

Methods

We included 49,564 adults ≥18 years, registered in the SWEDEHEART registry between 2011 and 2018, diagnosed with acute MI, discharged alive and with no previous heart failure. The population was stratified by degree of LV systolic function; EF >50%, EF 40-49%, EF 30-39% and <30%, assessed by echocardiography. Patients were assessed at 6-10 weeks and 10-14 months after MI. Descriptive analyses were used for demographics and characteristics at baseline, first and second follow up. Uni- and multivariable regression analyses was used to examine the associations between LV impairment and symptoms, occupation/working status, readmissions, quality of life (Eq5D), attending cardiac rehabilitation and physical training, smoking status and snuffing.

Results

Patients with impaired LVEF would more often experience shortness of breath (5.6% vs 32.3% for EF < 30 vs EF >50 at second follow up) (figure). Patients with EF <30% had a lower Eq5D mean at first follow up than patients with normal LVEF (0.77 vs 0.82), but that difference was smaller at second follow-up (0.80 vs 0.83). Subjects with EF <30% did participate in heart rehabilitation to a lesser extent than those with normal EF, both at the first (28.7% vs 37.4%) as well as the second follow up (44.9% vs 55.5%). In multivariate regression analyses (table), a lower EF was associated with shortness of breath (OR = 7.47, 95% CI = 6.24-8.94) and a lower probability of working or studying (OR = 0.25, 95% CI = 0.20 – 0.31) but not with chest pain. A lower EF was also associated with a lower probability of participating in heart school (OR = 0,67, 95% CI = 0.58-0.68) and physical training (OR = 0.54, 95% CI = 0.46-0.63).

Conclusion

Left ventricular systolic dysfunction after acute myocardial infarction is associated with a high symptom burden and worse secondary prevention. This may indicate heart rehabilitation programs should be better adapted to this large population with great needs.
High levels of high-density lipoprotein cholesterol (HDL-C) and major adverse cardiovascular events and 10-year all-cause mortality:results from Women's Ischemia Syndrome Evaluation (WISE) study
Authors: Ranasinghe S , Cui Y , Obrutu O , Wei J , Gulati M , Bittner V , Reis S , Handberg E , Pepine C , Bairey Merz C N
Published: November 2023

Background

High and low levels of high-density lipoprotein cholesterol (HDL-C) are associated with lower and higher cardiovascular risk, respectively. Emerging data in the general population and those with coronary artery disease have shown an increased risk of adverse outcomes with high (>1.8mmolL [70 mg/dL]) HDL-C levels. However, there are limited data on the risk of adverse of outcomes in women with suspected ischemic heart disease and high HDL-C levels.

Purpose

To investigate relationships between high (>1.8mmol/L [70 mg/dL]), average (1.3 - 1.8 mmol/L [ 50 - 70 mg/dL]), and low (<1.3 mmol/L [50 mg/dL]) HDL-C levels with major adverse cardiac events (MACE) (death, myocardial infarction, stroke, and heart failure hospitalization), and 10-year all-cause mortality in women referred for coronary angiography for suspected myocardial ischemia.

Methods

Participants (N= 935) enrolled in the Women’s Ischemia Syndrome Evaluation (WISE) study from 1997-2001 underwent baseline testing that included fasting lipids, detailed demographic, and clinical data. A total of 607 women with available HDL-C values were included in this analysis. The adjudicated MACE outcome median follow-up was 5.9 years (range, 0 - 9.3), and the all-cause mortality median follow-up was 8.4 years (range, 0 - 11.3). Associations between HDL-C level and outcomes were obtained via multivariate cox regression and adjusted for age, race, BMI, waist circumference, menopausal status, hypertension, diabetes, family history of CAD, history of stroke, smoking history, alcohol use, statin use, and CAD status. The U-shaped curve was obtained using continuous HDL-C with the cubic spline analysis before adjusting for covariates listed above.

Results

The mean age of the cohort was 59±12 years, 62% had 3 or more cardiac risk factors, and 66 (10.9%) had a high HDL-C. High and low HDL-C were both associated with increased MACE risk compared to average HDL-C (HR 1.80, CI 1.03 - 3.14, p = 0.038; HR 1.63, CI 1.09 - 2.42, p = 0.016, respectively. Similarly, high and low HDL-C were associated with increased risk of all-cause mortality (HR 3.64, CI 1.84 - 7.20, p <0.001; HR 2.81, CI 1.67 - 4.71, p <0.001, respectively, Figure).

Conclusions

High and low HDL-C levels are associated with an increased MACE and all-cause mortality in women presenting with suspected ischemia undergoing coronary angiography. Our results highlight the need for additional prospective studies to discern the mechanisms behind high HDL-C levels and elevated risk of adverse outcomes in women.
Identifying patients' cardiovascular vulnerability against atmospheric parameters and air pollution
Authors: Boussoussou N , Suveges P , Skoda R , Merkely B , Becker D , Sotonyi P
Published: November 2023

Background

Atmospheric parameters are direct environmental factors on the human body. There is a growing concern that atmospheric parameters might have a potential cardiovascular (CV) effect and increase morbidity and mortality. The health effects of climate change and air pollution are already major public health issues. In the future, the growing concern about unfavorable atmospheric situations and air pollution can further increase this problem. Despite the importance of different atmospheric parameters’ CV risks, there are few studies about identifying vulnerable populations against atmospheric parameters and air pollution.

Purpose

We aimed to explore vulnerable populations against atmospheric parameters.

Methods

The study comprised 7230 hospitalized patients with acute CV diseases (ACVDs). Demographic and individual CV risk factor data were collected for each patient. We examined the relationship between demographic characteristics (age, sex) and CV risk factors (hypertension, hyperlipidemia, diabetes, previous CV diseases) and meteorological and air pollution parameters on a day-to-day basis in a 5-year time period (2017-2021) using a General Additive Model with cubic splines of covariates, regularized by a ridge penalty, and employing generalized cross-validation.

Results

Patients with diabetes were detected as the most vulnerable group against atmospheric parameters. The interaction between temperature change (5°C≤) and elevated ozone concentration (90 µg/m³≤) showed a positive association with daily diabetic patients’ hospitalization counts (p<0.001). The relative strength of the association with demographic characteristics was the largest between daily temperature variation (5°C≤) and patients with age 55 or more (p=0.002). The effect of temperature change (5°C≤) and elevated ozone concentration (90 µg/m³≤) was positively associated with the daily hospitalization counts of male patients (p<0.001).

Conclusions

In our study, we can identify vulnerable subpopulations that have increased CV risk during specific atmospheric conditions. The importance of our findings is growing in the context that extreme atmospheric conditions and air pollution are likely to become more common in the future. In conclusion, a better understanding of vulnerability could help establish new CV prevention strategies.
Aggressive CTO PCI strategy improved the success rate but not clinical outcomes for coronary chronic total occlusion patients : Korean single center experience
Authors: Jung A H , Jin C D , Youk G S , Lee K M , Lim K H , Jo S Y , Cho Y R , Park K I , Park J S , Park T H , Kim M H
Published: November 2023

Background

Successful coronary chronic total occlusion (CTO) recanalization was well associated with lesion characteristics, technique and devices development. Indeed, the operators’ experience and new device usage are also associated with success rate. There is few data whether this technical advancement and/or new therapeutic strategy adoption influence the procedural success rate between Japan and Korea.

Purpose

This study sought to compare the success rate and its clinical outcome between aggressive strategy (joint PCI with Japanese CTO experts, never give up strategy) who adopted new devices and technology and conventional strategy in a Korean single center.

Methods

A total of 670 target lesions underwent PCI at a single center between September 1999 and February 2020, divided into conventional strategy (control group, n = 508) and aggressive strategy (Joint-PCI group, n = 162) before COVID pandemic period. Primary endpoint was procedural success rate, defined as <20% residual stenosis with TIMI flow grade ≥2 by visual estimation of the angiograms. We also observed the incidence of periprocedural complication, and MACCE (cardiac death, non-fatal MI, TLR/TVR, and stroke) during 3-year clinical follow-up period. To reduce the effect of potential confounding factors in an observational study, we used the propensity score matching (PSM).

Results

In comparison to conventional strategy, aggressive strategy group had no difference of male (76.2% vs 82.1%), but had a significantly difference of age (63.0 vs 60.9). For the primary endpoint, aggressive strategy group had a significantly difference in procedural success rate (79.5% vs. 92.5%)during 2015-2020, compared to conventional strategy. There was no difference in MACCE rate, 64 patients (12.6%) in conventional strategy group versus 21 (13.0%) in aggressive strategy group (p = 0.903) in Chi-square test. In PSM data, there was also no difference in MACCE rate (conventional strategy, 11.9% versus aggressive strategy, 11.0%).

Conclusions

Aggressive strategy with Japanese CTO experts, who adopted new devices and technology early, resulted in a higher success rate in CTO PCI. However, there were no differences in clinical outcomes during 3 year follow-up.

Figure 1. Success rate Table 1. Clinical outcomes
Imprecision and clinical performance of a whole blood high sensitivity point of care troponin I: the first prospective real-time study in suspected acute coronary syndrome
Authors: Dakshi A A , Hatherley J , Collinson P O , Phillips S , Bailey L , Hassan A , Shaw M , Miller G , Khand A
Published: November 2023

Introduction

Implementation of accelerated diagnostic protocols (ADP) for suspected ACS, with resultant improvement in patient flow, will be facilitated by the use of point of care (POC) testing. To date there has been no published data on the use of a whole blood POC high sensitive troponin (hstn) in real time in a clinical environment.

Methods

In a nested sub-study of a pragmatic randomised controlled trial consecutive patients with suspected ACS and CP<12 hours duration, underwent sampling for quidell triage true POC hstn I whole blood and plasma (as well as a central laboratory hstn I [Siemens Attellica]. Subjects were randomised to ESC 0/1 and 0/3 hour ADP and had repeat whole blood and plasma POC tn I and laboratory hstn I at these time points. (ClinicalTrials.gov Identifier: NCT05322395). Assay imprecision was assessed by duplicate analysis of whole blood samples at seven levels. Final diagnosis was adjudicated based on all relevant clinical and imaging data together with hstn T as the diagnostic biomarker in clinical use. (Roche diagnostics, 10% coefficient of variation (CV) 3-5 ng/L, 99th percentile 14 ng/L) using the 4th universal definition of myocardial infarction (MI)

Results

1157 patients consented and had both investigational POC whole blood and plasma (taken and analysed in real time) and central lab hstn I available. The mean age was 58, 48% were female and 15.4% patients had suffered a previous MI. Assay imprecision of whole blood POC quidel triage true revealed 10% CV at 8.6 ng/L, (>50% lower level than 99th percentile [20.4ng/l]) and a 20% CV at 1.2 ng/l). There was excellent overall agreement between laboratory hsTnI method and whole blood poc cTnI [Quidell triage true = 1.28cTnI Attelica +1.3]. ROC (receiver operator characteristics) curves were computed for each assay against adjudicated index MI to study clinical performance. At all time points there were excellent performance for whole blood POC: AUC 0.97 [95% CI 0.94-098]), 0.98 [95% CI 0.97-1.00] and 0.95 [95% CI0.92-0.98] at time 0 (presentation, figure), 1 and 3 hours respectively. There was statistical equivalence for performance of whole blood POC and plasma POC hstn I and laboratory hstn I

Conclusion

The POC whole blood quidell triage true demonstrates imprecision levels consistent with high sensitivity characteristics and has a clinical performance equivalent to an established and well validated laboratory hstn I. This is the first clinical validation of Whole blood POC hstn assay studied real-time in a clinical environment.
Simple patient and lesion characteristics on coronary angiography can accurately predict FFR-proven ischemia
Authors: Yang S , Leng S , Wang C , Fam J M , Low A F H , Tan R S , Chai P , Teo L , Chin C Y , Chan M , Yeo K K , Wong A S L , Lim S T , Zhong L
Published: November 2023

Aims

Fractional flow reserve (FFR) measured during invasive coronary angiography (ICA), the reference standard for diagnosing coronary ischemia, potentially risks pressure wire-induced arterial wall injury. We aimed to develop a model for diagnosing coronary ischemia based on simple patient and lesion characteristics without invasive intracoronary pressure measurement.

Methods

We performed quantitative coronary angiography (QCA) analyses on subjects who had undergone FFR measurements during clinically indicated ICA. Clinical, ICA and QCA variables were input into a prediction model for coronary ischemia, defined as FFR ≤0.8. Least absolute shrinkage and selection operator (LASSO) regression with internal ten-fold cross-validation was implemented using R software to minimize multicollinearity and select final model variables, i.e., those corresponding to the nadir of the binomial deviation plot. Per-vessel and per-subject results were reported.

Results

Among 103 subjects (mean age 61 ±10 years; 74 male, 29 female) recruited from hospitals in Singapore (participants in a prospective study NCT03054324) and China, we analyzed 148 stenotic vessels visually assessed diameter (DS) ≥30%. From a dataset comprising 37 variables including baseline clinical characteristics, coronary artery morphological parameters and plaque characteristics, LASSO selected six final model variables: lesion length, minimal lumen diameter, stenosis flow reserve, DS, systolic blood pressure and diabetes, negating serious multicollinearity. The first three variables were measured on QCA, the third using ICA images acquired at rest. Our model outperformed DS ≥70% for discriminating coronary ischemia at both per-vessel (area-under-curve [AUC] 0.907 vs 0.770, p<0.001) and per-subject levels (AUC 0.882 vs 0.759, p<0.001). Per-vessel model accuracy, sensitivity, specificity, positive and negative predictive values were 85.1%, 82.4%, 93.2%, 87.1% and 83.3%, respectively; and per-subject, 83.4%, 82.0%, 85.7%, 89.3% and 76.6%, respectively.

Conclusion

Compared with visual diameter assessment, our LASSO-based model attained superior prediction of FFR-defined coronary ischemia using an array of variables without the need for invasive pressure measurement.