bluuebunny/crossref_metadata_2025 huggingface dataset:
Iron deficiency and all-cause mortality after myocardial infarction
Authors: Jenca D , Melenovsky V , Mrazkova J , Sramko M , Kotrc M , Zelizko M , Adamkova V , Pitha J , Kautzner J , Wohlfahrt P
Published: October 2024

Introduction

Iron deficiency (ID) is commonly associated with cardiovascular diseases, including myocardial infarction (MI). However, the data on the clinical significance of ID in patients with MI are conflicting. This may be related to the use of various ID criteria.

Purpose

Our study aimed to compare the association of different ID criteria with all-cause mortality after MI.

Methods

Consecutive patients hospitalized at a large tertiary heart center for type 1 MI without previous history of coronary artery disease were included. We evaluated the association of different iron metabolism parameters measured on the first day after hospital admission with all-cause mortality during the follow-up.

Results

Of a cohort of 1,156 patients included (aged 64±12 years, 25% women), 194 (16.8%) died during the median follow-up of 3.4 years (IQR 626-1782 days). A total of 51,7% of post-MI patients had low iron levels (≤13 µmol/L), and 16,3% of them had iron level ≤12.8 µmol/L and soluble transferrin receptor (sTfR) ≥3 mg/L.

After multivariate adjustment, iron level ≤13 µmol/L (HR 1.67, 95% CI 1.19-2.34) and the combination of iron level ≤12.8 µmol/L and sTfR ≥3 mg/L (HR 2.56, 95% CI 1.64-3.99) were associated with an increased risk of mortality. This information provided additional predictive value to the GRACE score. No association between ferritin level and mortality was found.

Compared to the model which contains iron level, the addition of sTfR improved risk stratification (net reclassification improvement 0.61, 95% CI 0.52-0.69) by reclassifying patients into a higher-risk group.

Conclusion

ID is common among patients with the first MI. The criteria based on iron and soluble transferrin receptor levels provide the best prediction of mortality, and should be evaluated in future interventional studies with intravenous iron therapy.Kaplan-Meier survival for iron levelsK-M survival for combined ID parameters
Low density lipoprotein cholesterol and cardiovascular disease risk in patients with absence of coronary artery calcification: a multicenter cohort study
Authors: Andersen M H , Hansen M K , Thrane P G , Olesen K K W , Noergaard B L , Maeng M , Blaha M , Busk M , Jensen J M , Sand N P , Mortensen M B
Published: October 2024

Background

Low-density lipoprotein cholesterol (LDL-C) plays a central role in the development of coronary heart disease (CHD). Absence of coronary artery calcification (CAC 0), as assessed by coronary computed tomography angiography (CCTA), is associated with a favorable outcome as it indicates a low burden of atherosclerosis. However, questions remain regarding the risk of non-calcified plaque and CHD in younger patients with CAC zero, as atherosclerosis tends to be non-calcified in earlier stages.

Purpose

To assess if LDL-C is associated with presence of non-calcified plaque and future cardiovascular events in patients with CAC zero across the age spectrum.

Methods

This observational multicenter cohort study included patients aged 18 years or more who underwent CCTA between January 2008 and May 2021 with CAC zero. LDL-C was measured prior to CCTA. Patients were followed from date of CCTA to occurrence of cardiovascular event, death, or 1st of October 2022. No patients were lost to follow-up. We assessed the association between LDL-C and presence of non-calcified plaque on CCTA as adjusted odds ratios, and risk for myocardial infarction and CHD (myocardial infarction or coronary revascularization) as adjusted hazard ratios using Cox regression analyses, across different age groups.

Results

A total of 23,776 patients with CAC zero were included in the study. Median age was 54 years (IQR 47-61) and 14,605 (61%) were women. During median follow-up of 5.5 years, 165 (0.7%) and 427 (1.8%) experienced myocardial infarction and CHD, respectively. Overall, the prevalence of non-calcified plaque was 11.1% (n=2,650). Higher LDL-C was associated with presence of non-calcified plaque with an odds ratio of 1.21 (95% CI 1.16-1.27) per 1 mmol/L higher LDL-C. Individuals aged ≤45 years had a higher odds ratio for non-calcified plaque per 1 mmol/L higher LDL-C compared to individuals aged 46-60 and >60 years; 1.36 (95% CI 1.22-1.52), 1.22 (95% CI 1.15-1.30) and 1.13 (95% CI 1.04-1.22), respectively, p value for interaction between the youngest and oldest age group was <0.05. Overall, LDL-C was associated with higher risk for myocardial infarction and CHD with hazard ratios of 1.29 (95% CI 1.10-1.52) and 1.26 (95% CI 1.14-1.39) per 1 mmol/L higher LDL-C, despite CAC zero.

Conclusions

Particularly in younger patients with absence of CAC, elevated LDL-C is associated with presence of non-calcified plaque and increased risk for future cardiovascular events. These data are important for clinical practice, as they demonstrate the importance of managing LDL-C in younger individuals over the long-time horizon despite CAC zero.
Guideline-directed medical therapy implementation changes after acute coronary syndrome and their effect of prognosis: insights from Japanese real-world database using a storage system
Authors: Akashi N , Kabutoya T , Matoba T , Kohro T , Imai Y , Kario K , Kiyosue A , Nakayama M , Miyamoto Y , Ishii M , Nakamura T , Tsujita K , Sato H , Fujita H , Nagai R
Published: October 2024

Background

The implementation of guideline-directed medical therapy (GDMT) after acute coronary syndrome (ACS) was reported to improve prognosis. However, there have been limited number of real-world studies clarifying the association between the status of GDMT implementation and clinical prognosis in ACS patients based on recent multicenter database.

Purpose

The purpose of this study was to survey the extent to which GDMT was performed over time in patients after percutaneous coronary intervention (PCI) for ACS, as well as to investigate the prognostic impact of GDMT.

Methods

This study is a retrospective, multicenter, observational study. We developed the Clinical Deep Data Accumulation System (CLIDAS), which consists of 6 university hospitals and the national cardiovascular center in Japan, directly obtains clinical data including patients background, laboratory data, echocardiogram, electrocardiogram, cardiac catheterization report, prescription, and long-term outcome from electronic medical records. 4107 patients who underwent PCI for ACS and were prescribed one or more antiplatelet drugs at baseline from April 2013 to March 2019 were analyzed, and divided into GDMT group (n = 2514) and non-GDMT group (n = 1593). GDMT was defined as all prescriptions for angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, beta-blocker, and statin at baseline. The primary outcome was the major adverse cerebrocardiovascular event (MACCE) defined as being the composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke.

Results

The median follow-up duration was 2.36 years (interquartile range: 0.78-4.00 years). The study cohort consisted of 76% of men with a median age of 71 years. The incidence of MACCE was significantly lower in the GDMT group than in the non-GDMT group (8.8% vs. 13.0%, log rank P <0.001). Multivariable Cox regression analyses revealed that the GDMT group was a lower hazard ratio (HR) for MACCE after adjusting for confounding factors including the information about the first half and the second half (HR, 0.80; 95% confidence interval, 0.65-0.98; P = 0.035). The implementation rate of GDMT in the first half group (from April 2013 to March 2016) was lower than that in the second half group (from April 2016 to March 2019) (58.3% vs. 64.4%, P <0.001).

Conclusion

The real-world CLIDAS database revealed that GDMT was significantly associated with the reduction of MACCE in patients with ACS after PCI. In addition, an increase in the rate of GDMT implementation over time was observed.Kaplan-Meier curves for MACCE
Development and validation of a prognostic score integrating remote heart failure symptoms and clinical variables for mortality risk prediction after myocardial infarction. The PragueMi score
Authors: Wohlfahrt P , Jenca D , Melenovsky V , Stehlik J , Sramko M , Kotrc M , Mrazkova J , Zelizko M , Adamkova V , Pitha J , Kautzner J
Published: October 2024

Background

While heart failure (HF) symptoms are associated with adverse prognosis after myocardial infarction (MI), they are not routinely used for patients’ stratification.

Purpose

The primary objective of this study was to develop and validate a score to predict mortality risk after MI, combining remotely recorded HF symptoms and clinical risk factors, and to compare it against the guideline-recommended GRACE score.

Methods

A cohort study design using prospectively collected data from consecutive patients hospitalized for MI at a large tertiary heart centre between June 2017 and September 2022 was used.

Results

Data from 1,135 patients (aged 64±12 years, 26.7% women), were split into derivation (70%) and validation cohort (30%). Components of the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) questionnaire and clinical variables were used as possible predictors. The best model included the following variables – age, heart failure history, admission creatinine and heart rate, ejection fraction at hospital discharge, and HF symptoms 1 month after discharge including walking impairment, leg swelling, and change in HF symptoms. Based on these variables, the PragueMi score was developed. In the validation cohort, the PragueMi score showed superior discrimination to the GRACE score for 6 months (AUC 90.1, 95% CI 81.8-98.4 vs. 77.4, 95% CI 62.2-92.5, p=0.04) and 1-year risk prediction (AUC 89.7, 95% CI 83.5-96.0 vs. 76.2, 95% CI 64.7-87.7, p=0.004).

Conclusion

The PragueMi score combining heart failure symptoms and clinical variables performs better than the currently recommended GRACE score.
Adjustment of the SMART risk score by bioactive adrenomedullin enables a more accurate prediction of mortality in patients with ASCVD
Authors: Kurt B , Rau M , Hartmann O , Lobo De Sa F , Moellmann J , Spiesshoefer J , Milzi A , Schwarz M , Thiele K , Hartmann N , Van Der Vorst E , Dahl E , Marx N , Lehrke M , Kahles F
Published: October 2024

Background

Bioactive adrenomedullin 1-52 (bio-ADM) is a dynamic blood biomarker for real-time assessment of endothelial function. Bio-ADM was recently shown to be a prognostic marker in patients with acute heart failure and cardiogenic shock. The SMART (Second Manifestations of Arterial Disease) score is a validated tool for risk assessment in patients with established atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to assess whether measurement of bio-ADM adds incremental value to the SMART score in stable patients with ASCVD.

Methods

Circulating bio-ADM levels were assessed in n=695 stable patients with ASCVD in an all-comer cohort. Endpoints evaluated were all-cause mortality and cardiovascular mortality; follow up was 3 years.

Results

Bio-ADM was higher in non-survivors (all-cause death: n=54, median 33.1 pg/mL) compared to survivors (n=641, median 17.9 pg/mL; p<0.0001). Univariable Cox regression analyses showed bio-ADM to be associated with adverse outcome [standardized hazard ratio (HR) of bio-ADM values: All-cause death: 2.4, 95% confidence interval (CI): 2.0-2.9; p<0.001, cardiovascular death: 2.5, 95% CI: 1.9-3.3; p<0.001]. This association remained significant in various multivariable Cox regression models. Bio-ADM was found to be a strong marker for mortality (c-index: 0.80, Chi²: 54.1) and proved to be superior to other markers including hs-Troponin T (c-index: 0.61, Chi²: 2.0) and eGFR CKD-EPI 2021 (c-index: 0.687, Chi²: 33.5). Addition of bio-ADM to the SMART score significantly improved model performance in predicting mortality (SMART score: c-index: 0.717, Chi²: 24.73; SMART score + bio-ADM: c-index: 0.832, Chi²: 63.24; Delta c-index: 0.115; Delta Chi²: 38.51; all p<0.001) and showed net reclassification improvement in risk categorization with 11.6% in the group of survivors and 9.8% for non-survivors.

Conclusion

Bio-ADM provides incremental added value (improved discrimination, calibration and reclassification) on top of the SMART risk score in patients with ASCVD.
Correlation between LDL/HDL-cholesterol ratio and long term prognosis after acute coronary syndrome and severity of coronary artery disease
Authors: God M , Manola S , Jurin I , Novak A , Hadzibegovic I , Pavlovic N , Sipic T , Pavlov M , Blivajs A , Udovicic M , Lisicic A , Zeljkovic I
Published: October 2024

Introduction

Dyslipidaemia is an important correctable risk factor for coronary artery disease (CAD). Many studies have confirmed that the lower the low-density lipoprotein cholesterol (LDL-C) levels are, the lower is the CAD morbidity and mortality rates (1). However, many patients who achieved low levels of LDL-C still experience a major adverse cardiovascular event (MACE) because of the other residual risk factors. Therefore, there is a constant need for better stratification of patients who are at higher risk for novel MACE following their first acute coronary syndrome (ACS). Evidence increasingly suggests that the ratio of LDL-C/HDL-C might be a new and better marker of cardiovascular disease, as it simultaneously evaluates the levels of both LDL-C and HDL-C (2).

Purpose

The aim of this study was to investigate the prediction value of LDL-C/HDL-C ratio for long term prognosis after ACS as well as its correlation with CAD severity.

Methods

We included patients hospitalized at out centre with ACS from January 2017 to January 2024. Demographic data, data on LDL-C and HDL-C levels on admission and calculated Syntax score were used. Syntax score is a comprehensive angiographic scoring system which determines complexity by using coronary anatomy and lesion characteristics (3). Follow-up data were collected either by clinical follow-up visits or by telephone interviews. The MACE was defined as the composite of cardiovascular death, acute coronary syndrome and need for elective or urgent percutaneous or surgical revascularization.

Results

This registry-based study included 2471 patients with ACS, median age of 64 (interquartile range 56-73) years, 31% female. Total of 1099 patients (44%) had non-ST elevation ACS and 1372 (54%) had ST elevation myocardial infarction (STEMI). Median Syntax score was 13 (IQR 7-20.5), with 1494 (61%) patients having low Syntax score (≤16), 508 (21%) patients medium (16-22), and 448 (18%) high score (>22), respectively. Median follow up was 17 (3-27) months. LDL-C/HDL-C ratio correlated significantly with cardiovascular death, with weak coefficient (2.94 vs. 2.54 p<0.001; rho=0.102, p<.0001), however did not correlate with MACE (2.88 vs. 2.92, p=0.188, rho=0.06, p=0.77). This remained identical when tested for patients with STEMI and non-STE ACS. In addition, LDL-C/HDL-C ratio did not correlate with CAD severity as assessed with Syntax score (low 2.92 vs. medium 2.83 vs. high 2.86, p=0.597; rho=0.4, p=0.09).

Conclusion

Our data suggest that LDL-C/HDL-C ratio cannot be used as a relevant predictor of post-ACS long-term MACE or cardiovascular death, nor it can be correlated with CAD severity. Further studies are needed to establish the real value of LDL-C/HDL-C ratio as a post-ACS predictor.
Biochemical variables as predictors of in-hospital mortality in patients with acute coronary syndrome
Authors: Vavlukis M , Shehu E , Taravari H , Kostov J , Poposka L , Kostova N , Vrajnko E , Celikic A , Pocesta B , Kedev S
Published: October 2024

Background

There is a constant search of easily obtainable variables that can be put in relation with in-hospital mortality, enabling creation of prediction risk models in patients treated for acute coronary syndrome.

Purpose

The main goal of this study was to unravel what is the profile of the patients with acute coronary syndrome in risk of in-hospital mortality, based on simple biochemical variables acquired at the time of hospital admission.

Methods

This was a single-center cross-sectional cohort study on 3007 pts. treated for ACS (STEMI and NSTEMI). Venous blood sample at hospital admission was acquired for every patient. Patients were comparatively analyzed for their biochemical variables derived from venous blood sample, based on occurrence of in-hospital mortality.

Results

Out of 3007 pts, 988 (28.2%) were females, and 2519 (71.8%) males, at mean age 62.6 +/- 11.2 y. In-hospital mortality rate was 4.8% (145 out of 3007). We subjected to comparative analyzed hemogram, markers of renal function including sodium and potassium, glycemic profile, complete lipid panel (including ApoA1 and ApoB), and highly sensitive troponin. Significant association with in-hospital mortality was found for: hsTn, stress glycemia and glicated hemoglobin, BUN, creatinite, eGFR, sodium, potasium, full lipid panel [except for HDL-C and Lp(a)].

In the second step, markers proven to be significantly different were subjected to multivariate binary logistic regression (backward conditional). We designed two models, one that included ApoA1 and ApoB (including 1816 pts. for whom we had data), and the second without these two parameters (including 3007 pts.). With the first model we identified: Advanced age, stress glycemia, WBC, eGFR, HDL-C and ApoA1 as independent predictors. Surprisingly, HDL-C was found to be strong independent predictor in multivariate analyzis. While with second modeling we identified advanced age, hsTn, stress glycemia, RBC, WBC, BUN and eGFR as independent predictors.

Conclusion

Advanced age is a strong independent predictor in any modelling. When we have a possibility to obtain a complete lipid panel, beside stress glycemia and WBC as markers of the degree of neuro-hormonal activation and inflammation, and renal function, HDL-C and ApoA1 seems to be strong negative independent predictors. In the absence of this data beside aforementioned markers of neurohormonal activation and inflammation, and renal function, the degree of myocardial injury plays a significant role. According to our data it seems reasonable to obtain complete lipid panel at hospital admission.Multivariate logistic regression modelsAge distribution across genders
Enhancing computational fluid dynamics simulation for coronary artery disease analysis through spatial iterative modeling
Authors: Arya M , Tuzun U , Zoghi M
Published: October 2024

Background

Endothelial shear stress (ESS) critically influences the pathogenesis of coronary artery disease (CAD) by modulating the formation and progression of atherosclerotic lesions. Despite the use of 3D modeling in computational fluid dynamics (CFD) simulations to calculate ESS, the precision of these models significantly depends on the method of reconstruction. Spatial Iterative Method (SIM) extends the iterative approach in computer science to spatial data, using recurring algorithms to refine 3D models and analyses. Iterative approach executes a sequence of instructions repeatedly until a certain condition is met, enabling progressive problem-solving.

Purpose

In this study, we investigated the application of the SIM to estimate ESS in coronary arteries and explored Atherosclerotic Plaque Areas (APA) in patients with CAD.

Methods

We analyzed fifteen patients (9 males, mean age of 63 ± 10.56 years) with atherosclerotic plaque on coronary arteries.

The eighteen images captured from an anterior viewpoint in 10-degree increments of the coronary artery obtained from Coronary Computed Tomography Angiography at the best diastolic phase for each patient were used. We implemented the SIM for 3D model reconstruction, facilitating ninety comparisons across all iterations to evaluate ESS estimations accurately. (Figure 1.)

Results

In our study, we evaluated ESS contours from CFD simulations for a total of 282 APA (200 calcified and 82 soft plaques) across ninety spatial iterations. We categorized ESS into three groups: low (162 APA cases with ESS of less than 1 Pascal (Pa)), medium (67 APA cases with ESS between 1 and 2 Pa), and high (53 APA cases with ESS greater than 2 Pa). There was a significant association between ESS categories and plaque types (p < 0.0001, Figure 2.). The calcified plaques were formed in areas with low ESS (%80 of calcified plaques) and soft plaques in areas with medium and high ESS (%97 percent of soft plaques).

Conclusion

The significant association between ESS categories and plaque types shows the potential of SIM in hemodynamic analysis. This finding highlights the potential of SIM in enhancing the understanding of hemodynamic influences on plaque formation, offering a promising direction for future cardiovascular research.Figure 1.Sample Iteration of the SIMFigure 2.Heatmap of ESS vs. APA
The coronary angiography-derived index of microcirculatory resistance predicts perioperative myocardial injury in stable coronary artery disease patients undergoing PCI
Authors: Zhang B , Ma L
Published: October 2024

Background

Coronary microvascular dysfunction (CMD) assessed by the index of microcirculatory resistance (IMR) is associated with perioperative myocardial injury(PMI).The angiography-derived index of microcirculatory resistance (caIMR) is a novel and accurate alternative of IMR.

Objective

This study aims to evaluate the predictive value of caIMR on PMI in stable coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI).

Methods

Consecutive stable CAD patients undergoing elective PCI of a single lesion were recruited. caIMR were measured before and after revascularization.Total creatine kinase-MB (CK-MB) and high sensitivity Troponin T (hsTnT) levels were measured before and within 24 hours after PCI.

Results

A total of 65 patients were enrolled, twenty-six patients fulfilled the diagnostic criteria of PMI. Post-PCI caIMR values in the PMI group were significantly higher than those in the control group (27.02±3.70 vs. 15.91±3.43U, P<0.001). Pearson correlation analysis demonstrated that increased post-PCI caIMR values have a significant positive correlation with peak hsTnT (r = 0.803, P<0.001) and peak CK-MB (r = 0.512, P= 0.001). Multivariate logistic regression analysis showed the post-PCI caIMR was independent predictors of PMI(OR,1.731;95% CI:1.348-2.023; P<0.001).The ROC analysis suggested that the best cutoff value of post-PCI caIMR was 25.17U to diagnose PMI(AUC=0.951, sensitivity 88.5%, specificity 97.1%%).

Conclusions

The post-PCI caIMR can accurately predict PMI in stable CAD patients receiving elective PCI, supporting its use in clinical practice.
A comprehensive approach combining FFR, CFR, and IMR in order to predict adverse cardiovascular events in patients with non-obstructive coronary artery disease
Authors: Yoshikawa H , Murai T , Hikita H , Kanno Y , Cho S , Ito A , Yano H , Hishikari K , Takahashi A , Yonetsu T , Sasano T
Published: October 2024

Background

Abnormal coronary circulation is linked to poor patient outcomes. The predictive values of comprehensive physiological assessments in patients with non-obstructive coronary artery disease (NOCAD) have not been fully investigated.

Objectives

The study aimed to evaluate the predictive value of a comprehensive approach that combines fractional flow reserve (FFR), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) in patients with NOCAD.

Methods

FFR, CFR, and IMR were measured in the left anterior descending artery of 226 patients with NOCAD. The primary endpoint was defined as adverse cardiovascular events including cardiovascular death, heart failure, coronary revascularization, cerebral infarction, and peripheral vascular events.

Results

Optimal cutoffs predicting the endpoint were 0.89 for FFR, 2.3 for CFR and 18.0U for IMR. Among the patients, 53 were negative for all indices, 80 positive for one, and 93 positive for two or three. During a median follow-up period of two years, 29 adverse events occurred, with the distribution as follows: 1 (1.9%) in patients with all negative indices, 5 (6.2%) in those with one positive index, and 23 (24.7%) in those with two or three positive indices. Kaplan-Meier curve analysis demonstrated significantly worse event-free survival in patients with an increasing number of positive indices (χ2=18.5, P<0.001). The presence of two or three positive indices was an independent predictor of the endpoint (hazard ratio 7.280, p<0.001).

Conclusions

Combining FFR, CFR, and IMR is an effective method for predicting cardiovascular events in patients with NOCAD.
Diastolic hyperemia-free ratio for the assessment of intermediate coronary artery stenosis in patients with hemodialysis
Authors: Nohara H , Egami Y , Abe M , Osuga M , Kawanami S , Kawamura A , Ukita K , Yasumoto K , Tsuda M , Okamoto N , Matsunaga Y , Yano M , Nishino M
Published: October 2024

Background

Diastolic hyperemia-free Ratio (DFR) is new resting index and uses a pragmatic definition by including areas below the average aortic pressure with negative slope. Hemodialysis (HD) exhibits left ventricular hypertrophy and impaired microcirculation. The relationship between DFR and fractional flow reserve (FFR) in the patients with HD has not been yet investigated.

Purpose

We aimed to compare the rate of physiological discordance between HD patients and non-HD patients, and to elucidate the best DFR cut-off value predicting less than 0.80 of FFR in HD patients.

Methods

We enrolled 761 consecutive patients (1033 vessels) who underwent both DFR and FFR in the intermediate coronary artery stenosis between July 2020 and December 2023 in our hospital. The cutoff values of DFR 0.89 or less and FFR 0.80 or less were used for the study. We compared the DFR values with FFR values between HD group and Non-HD group.

Results

HD group consisted of 110 patients and Non-HD group consisted of 651 patients. A good correlation between DFR and FFR was observed in HD group (R=0.780 ; p < 0.0001) and Non-HD group (R=0.770 ; p < 0.0001). The rate of physiological discordance between HD group and non-HD group was each 31.3% and 20.5% (p < 0.01). Receiver operating characteristic curve showed that a suitable cut off value of DFR for equivalent FFR value of 0.80 was 0.84 in HD group and 0.89 in Non-HD group, respectively (Figure).

Conclusion

In the patients with HD, DFR may overestimate intermediate coronary artery stenosis and the suitable cut off value was 0.84.2024 ESC HD DFR Figure
Impact of fractional flow reserve measurement on angina frequency in the invasive arm of the ISCHEMIA trial
Authors: Singh A , Rodman J C S , Brown D L
Published: October 2024

Introduction

Fractional flow reserve (FFR) is an invasive, lesion-specific surrogate for myocardial ischemia. The use of FFR to guide lesion selection for revascularization is believed to improve outcomes compared to an angiographic approach because it allows categorization of lesions based on hemodynamic significance. Lesions that are not hemodynamically significant can be safely deferred while the revascularization of significant lesions has been reported to improve quality of life compared to medical therapy alone.

Purpose

To compare the outcomes of patients randomized to the invasive (INV) arm of the ISCHEMIA trial who underwent FFR during initial angiography with those whose treatment was guided by angiography alone.

Methods

The ISCHEMIA data set was obtained from the National Heart, Lung, and Blood Institute under a data use agreement. Subjects randomized to the INV arm who underwent FFR were compared to those who underwent angiography alone. Categorial variables were compared using the chi-squared or Fisher’s exact test. Continuous variables were compared using the student T-test or Wilcoxon rank sum test. Multivariable linear mixed effects regression was used to evaluate the association of FFR use on SAQ7 AF score as well as assess changes across five years of follow-up. Covariates included in the model were based on their univariate and clinical significance. All tests were two-sided and P<0.05 was considered statistically significant.

Results

Of the 5,179 patients with chronic coronary syndromes and at least moderate ischemia on stress testing, 2588 were assigned to the INV strategy and 2210 had data available for analysis. Of these individuals, 410 (19%) had FFR performed during their diagnostic angiogram. Females comprised 24% of FFR patients and 24% of non-FFR patients (P=0.85). FFR patients were older than non-FFR patients (65.7 [8.7] years vs. 64.3 [9.6] years, P=0.006). The incidence of hypertension, diabetes, smoking, or prior MI at baseline did not differ between groups. Mean ejection fraction did not differ between groups. Fewer FFR patients had severe ischemia at baseline (45% vs. 52%) and more had mild or moderate ischemia (54% vs. 48%) (P=0.009). FFR patients had fewer native vessels with >70% stenosis than non-FFR patients (1.0[0.9] vs. 1.5[1.0], P<0.001), and less complex disease as assessed by the Duke jeopardy score (P<0.001). On multivariable linear mixed effects regression, FFR was not associated with a significant change in the SAQ AF score (0.56 (-0.85 – 1.97; P=0.44)), after adjusting for other covariates. However, the SAQ7 AF score was 0.22 units less in those that underwent FFR compared to those that did not (95%CI=-0.44 – -0.01; P=0.043) when assessed over follow-up time.

Conclusion

ISCHEMIA patients randomized to an INV strategy who underwent physiologic assessment with FFR had no improvement in angina frequency compared to those who underwent angiography alone.
Coronary sinus reducer device for the treatment of refractory angina: a single center experience
Authors: Sobral Domingues M , Carvalho R , Certo Pereira J , Madeira S , Brito J , Raposo L , Teles R , Almeida M
Published: October 2024

Introduction

The coronary sinus Reducer emerged as a complementary therapy in patients with angina refractory to optimal medical therapy and not amenable to revascularization.

Aim

The aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina.

Methods and population

Twenty-six patients with refractory angina, objective evidence of myocardial ischemia attributable to the left coronary artery and deemed unsuitable for revascularization were treated with Reducer at a single center between April 2018 and January 2023. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month, were a reduction in Canadian Cardiovascular Society angina (CCS) class and a reduction in pharmacological antianginal therapy.

Results

Twenty-one (81%) patients had end-stage coronary artery disease without targets for further revascularization (13 had previous CABG ± PCI and 8 had only PCI) and 5 patients had microvascular disease without epicardial stenosis.

All procedures were performed via right jugular vein. The mean procedure and fluoroscopy duration were 66±29 and 19±8 minutes. Procedural success was achieved in all patients, with no device related complications. There was one cardiac tamponade, promptly treated with pericardiocentesis.

Regarding the efficacy endpoint, 21 patients (81%) had at least 1 grade reduction in CCS class, 13 patients (50%) had at least 2 class reductions, and 7 patients (28 %) became asymptomatic, with a mean reduction of CCS class of 1.4±0.9, from 2.6±0.5 to 1.2±0.9 (p=0.001) at 6-month follow-up. During this time frame, twelve patients (46%) withdrew or reduced the dose of at least one anti-anginal drug. The mean reduction of anti-anginal drugs was 0.54 ±0.86, from 3.5±1.02 to 2.9±1.07 (p=0.04).

Conclusion

In this real-world, single-center experience, implantation of Reducer was safe and associated with improvement of angina and reduction of anti-anginal drugs intake in patients with refractory angina unsuitable for revascularization.
The comparison of short-term dual antiplatelet therapy versus standard dual antiplatelet therapy in elderly patients with coronary artery disease who underwent percutaneous coronary intervention
Authors: Jin I
Published: October 2024

Introduction

Elderly patients are likely to have more underlying risk factors for bleeding and the bleeding risk increases with age although dual anti-platelet therapy (DAPT) is mandatory for patients who underwent percutaneous coronary intervention (PCI) for prevention of ischemic events. Therefore, elderly patients aged 75 or older are included as minor criteria for high bleeding risk, as defined by the Academic Research Consortium for High Bleeding Risk criteria. However, only limited data have been investigated of optimal duration of DAPT for patients aged 75 or older.

Purpose

The aim of this study is to evaluate optimal DAPT duration for elderly patients aged 75 and older.

Methods

We selected 1,571 patients aged 75 and older with coronary artery disease (CAD) from the pooled database among the 5 randomized controlled trials related to DAPT duration after PCI. DAPT was consisted of clopidogrel or ticagrelor in addition to aspirin. Short-term DAPT duration was defined as 1 to 3months, and standard DAPT duration was defined as 6 to 12months after PCI. Primary outcomes were net clinical adverse outcomes (NACE), composite of major cardiovascular and cerebrovascular adverse outcomes (MACCE) and TIMI major bleeding at 1 year. The inversed probability of treatment weighting (IPTW) analysis was performed to minimize selection bias effects of pooled database.

Results

The NACE was not significantly different between the short-term DAPT group (3.9%) and standard DAPT group (7.6%) (HR: 0.69, 95% CI: 0.46-1.04; p=0.076) (Figure A). Moreover, MACCE was not different in both groups. However, the significant reduction of bleeding risk was observed in short-term DAPT group (1.4%) than standard DAPT group (3.4%) (hazard ratio (HR): 0.40, 95% confidential interval (CI): 0.19-0.83; p=0.015) (Figure B). These results were consistent after multivariable Cox regression analysis and IPTW analysis.

Conclusions

Short-term DAPT duration (1 to 3months) was found to be superior to standard DAPT duration (6 to 12months) in terms of bleeding outcomes without the increased ischemic outcomes in patients aged 75 or older with CAD who underwent PCI.
Three decades of lipid-lowering therapy in type 2 diabetic patients with angiographically proven stable coronary artery disease
Authors: Vogel J , Ratz M , Elsner P , Plattner T , Vonbank A , Mader A , Larcher B , Leiherer A , Muendlein A , Frick M , Drexel H , Saely C H
Published: October 2024

Lipid-lowering therapy (LLT) is key to reducing the burden of macrovascular diabetes complications. Here, we aim to assess long-term trends in LLT and LDL-C levels among patients with type 2 diabetes (T2DM) with angiographically proven coronary artery disease (CAD).

We investigated T2DM patients (n=590), who were referred to elective coronary angiography and were diagnosed with CAD in one of three observational cohort studies (OS) spanning 25 years: OS1: 1999-2000 (n=190); OS2: 2005-2008 (n=241); OS3: 2022-2023 (n=159). These studies were conducted at the same cardiology unit of a tertiary care hospital in Central Europe.

The proportion of patients receiving statin therapy (C10AA and C10AB) increased significantly from 57.9% in OS1 to 64.3% in OS2 and 78.6% in OS3 (ptrend<0.001). Further, there was an increase in patients receiving high-intensity statin therapy, rising from none in OS1 to 8.5% in OS2 and 73.4% in OS3 (ptrend<0.001). The proportion of patients receiving more than one LLT compound also increased (OS1: 2.1%; OS2: 2.1%; OS3: 35.2%; ptrend<0.001). Use of ezetimibe (C10AX09) increased (OS1: 0.0%; OS2: 1.2%; OS3: 39.0%; ptrend<0.001) and fibrate use (C10AB) decreased (OS1: 5.3%; OS2: 3.3%; OS3: 0.6%; ptrend=0.015). Newly approved compounds (C10AX13 - C10AX16) were prescribed for 3.8% of patients in OS3. Among statin combination therapies, ezetimibe was predominantly used (93.5%). Mean LDL-C levels declined significantly from 123±38 mg/dL (OS1) to 115±39 mg/dL (OS2) and 77±38 mg/dL (OS3; ptrend<0.001). However, only 2.2% of patients in OS1, 2.5% in OS2 and 32.1% in OS3 reached an LDL-C target of <55 mg/dL (ptrend<0.001).

This analysis suggests an upward trend in treatment intensity and a substantial improvement in LDL-C levels among T2DM patients with CAD. However, the majority of these patients still does not reach their LDL-C target.
Comparison of the prognosis between complete and incomplete revascularization among moderate to severe chronic kidney disease patients with acute coronary syndrome
Authors: Phoksiri A , Kuanprasert S , Pota P , Thonghong T , Suwannasom P
Published: October 2024

Background

Complete revascularization (CR) in acute coronary syndrome patients with multivessel disease (MVD) is recommended in current clinical practice guidelines. However, the benefit of CR in moderate to severe chronic kidney disease (CKD) patients remains controversial. We aimed to compare the clinical outcomes between complete and incomplete revascularization among moderate to severe CKD patients who presented with ACS.

Methods

Of 1,924 ACS patients who underwent percutaneous coronary intervention (PCI) in our center, 127 patients were CKD. CR was defined as residual SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score ≤ 3. The primary outcome was the patient oriented clinical outcome (POCO) at 1 year, including all-cause death, any myocardial infarction, any revascularization, and heart failure requiring hospitalization.

Results

The mean age of the patients was 73.89±9.07 years. The median estimated glomerular filtration rate (eGFR) was 32.56±10.68 ml per minute per 1.73 m2. The rate of POCO at 1 year was significantly lower in the CR group (16.3% vs 39.3%; HR 0.36; 95%CI, 0.16-0.81; p=0.014). The primary outcome was mainly driven by 1-year all-cause death which was significantly lower in the CR group (14.0% vs 39.3%; HR 0.32; 95%CI 0.13-0.76; p=0.017). The rate of initiation of renal replacement therapy was comparable (4.7% vs 2.4%; p=0.55).

Conclusion

CR with a target SYNTAX score ≤ 3 improved 1-year prognosis of POCO and all-cause death in ACS patients with moderate to severe CKD without increasing the rates of renal replacement therapy.1-year POCOPrespecified Subgroup Analysis of POCO
Impact of symptom-to-balloon time on long-term prognosis: a 3-year follow-up study in non-st-segment elevation myocardial infarction patients with complex lesions
Authors: Kim Y H , Her A Y , Rha S W , Choi C U , Choi B G , Hyun S J , Park S , Kang D O , Cho J R , Kim M W , Park J Y , Park S H , Jeong M H
Published: October 2024

Background

Because no data are available, we compared clinical outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI), stratified based on the presence of complex lesions, according to symptom-to-balloon time (SBT, <48 h versus ≥48 h), undergoing newer-generation drug-eluting stents.

Methods

From the KAMIR (Korea Acute Myocardial Infarction Registry)-NIH dataset, a total of 4373 patients diagnosed with NSTEMI were enrolled and stratified into two groups: the complex group (2106 patients; SBT <48 h, 1365; SBT ≥48 h, 741) and the non-complex group (2267 patients, SBT <48 h, 1573; SBT ≥48 h, 694). The primary outcome was the 3-year all-cause death rate, and the secondary outcome was major adverse cardiac events (MACE), including cardiac death (CD), recurrent MI, and any repeat revascularization.

Results

The rates of all-cause death (adjusted hazard ratio [aHR], 0.656; p = 0.009) and cardiac death (aHR, 0.633; p = 0.037) in the complex group, and the rate of all-cause death (aHR, 0.773; p = 0.036) in the total study population, were significantly lower for patients with SBT <48 h than for those with SBT ≥48 h. In the non-complex group, all clinical outcomes were not significantly different between the SBT <48 h and SBT ≥48 h groups. In the SBT ≥48 h group, the complex group exhibits higher rates of all-cause death, any repeat revascularization, and MACE than those of the non-complex group

Conclusions

Reducing SBT was more effective in decreasing 3-year mortality in NSTEMI patients with a complex group compared to the non-complex group.
Incremental role of Cardio-Ankle Vascular Index in predicting ischemic threshold in patients with suspected coronary artery disease
Authors: Tunhasiriwet A , Krittanawong C , Hengrussamee K , Sukhum P , Yodwut C , Treesong M , Thiangtham S , Samut B , Wuttichaipradit C
Published: October 2024

Background

The Cardio-Ankle Vascular Index (CAVI) quantifies arterial stiffness and has emerged as a potential biomarker for cardiovascular disease and its associated risk factors. This study explores the prognostic utility of CAVI in predicting myocardial ischemia in patients with suspected coronary artery disease (CAD). Additionally, it examines the relationship between global longitudinal strain (GLS) and the wall motion score index (WMSI) during both rest and stress echocardiography.

Methods

We conducted a retrospective analysis of patients with suspected CAD who underwent CAVI measurement and stress echocardiography within a three-month window. Coronary angiography was utilized to evaluate anatomical stenosis (>50%). We used multivariate analysis to identify predictors of the ischemic threshold.

Results

In our cohort of 127 patients (average age 61.4 ± 9.1, 78% male), the prevalence of hypertension, dyslipidemia, and diabetes was 76%, 68% and 47% of patients, respectively. Prior coronary intervention and a history of myocardial infarction were showed significant prevalence at 33% and 9%, respectively. CAD distribution included absence in 15%, left main (LM) disease in 8%, proximal left anterior descending (LAD) artery disease in 38%, mid-to-distal LAD disease in 50%, left circumflex artery disease in 46%, and right coronary artery disease in 57%. A robust correlation between GLS and WMSI was observed both at rest and during peak stress (r=0.68 and r=0.57, p<0.001, respectively). High CAVI (≥8.5), resting GLS in the LAD(<-15.5%), and peak GLS during stress (<-15.3%) emerged as significant ischemic threshold predictors in multivariate analysis (AUC = 0.82, p<0.0001).

Conclusion

The correlation between WMSI and GLS provides valuable insights into cardiac mechanics. These findings underscore the clinical relevance of incorporating CAVI, GLS, and WMSI into routine assessments for patients with suspected CAD to enhance prognostic stratification.ROC for final predictive model
Extra cellular volume by computed tomography is useful for prediction of prognosis in cardiac sarcoidosis
Authors: Nishikawa Y , Takaoka H , Daimon M , Noguchi Y , Yoshida K , Ota J , Matsumoto M , Aoki S , Suzuki K , Yashima S , Kinoshita M , Suzuki-Eguchi N , Sasaki H , Kobayashi Y
Published: October 2024

Background

Extracellular volume (ECV) fraction on magnetic resonance imaging (MRI) has been useful in evaluating the degree of myocardial fibrosis and has been reported to help diagnose and evaluate the prognosis of cardiomyopathy. However, there are also several contraindications in the cardiac MRI, and the performance of it takes time. Computed tomography (CT) helps screen for coronary artery disease, is more versatile than cardiac MRI, and is also useful in screening for coronary artery disease. Myocardial extracellular volume (ECV) analysis on CT has been recently eligible and has shown a good correlation with ECV on MRI. We hypothesized that ECV on CT, a new fibrosis indicator, would be useful in predicting prognosis in patients with cardiac sarcoidosis (CS).

Purpose

The purpose of this study is to evaluate the utility of ECV analysis on CT for predicting major adverse cardiac events (MACEs) in cases with cardiac sarcoidosis (CS).

Methods

As a single-center study, 48 patients (18 males, 67 ± 11 years old) diagnosed with CS based on the 2016 Japanese Circulation Society criteria and who underwent cardiac CT using 320-row detector CT or 256-row detector CT, and including late-phase images from December 2008 to January 2024 were analyzed retrospectively. We evaluated the ECV of left ventricular myocardium (LVM) using commercially available software (Figure A). The primary endpoint was MACEs, a composite of all-cause death, heart failure hospitalization, and fatal ventricular arrhythmia.

Results

Among all 48 patients, 14 combined events (10 fatal ventricular arrhythmias, three heart failure hospitalizations, and one all-cause death) were observed during a follow-up of 56 ± 57 months. ECV of LVM on CT was significantly higher in patients with MACEs than the others (37 ± 5.6% vs 33 ± 4.6%, P = 0.0087). The best cut-off value of ECV of LVM on CT for prediction of MACEs was 34.97%, and the sensitivity and specificity of LV-ECV to predict MACEs were 71% and 76% at the best cut-off, and the area under the curve was 0.73 based on the receiver operating characteristics curve analysis (P = 0.009) (Figure B). The cases with ECV ≥ 34.97% (n = 18) had significantly higher MACEs than the cases with ECV < 34.97% based on the Kaplan-Meier analysis (P = 0.0031) (Figure C). In the multivariate Cox proportional hazard model, ECV on LVM (Hazard ratio 1.11, 95% confidence interval 1.00-1.21, p=0.0493) and history of VT ablation (Hazard ratio 27.7, 95% confidence interval 4.27-180, p=0.0011) were the significant predictors of MACEs.

Conclusion

Adverse events mainly caused by fatal ventricular arrhythmia are relatively common in CS. Evaluation of ECV by CT may be useful for the prediction of MACEs in cases with CS.
Endothelial dysfunction in acute coronary syndrome: a complex association with cardiovascular risk factors, sleep quality and cardiorespiratory capacity
Authors: Hbaieb M , Charfeddine S , Hammouda O , Bosquet L , Driss T , Abid L
Published: October 2024

Introduction

It is widely acknowledged that normal endothelial function plays a pivotal role in conferring cardioprotective effects against ischemia-reperfusion injury following acute myocardial infarction (AMI) treated by a primary percutaneous coronary intervention (PCI), thereby limiting infarct size (1). However, endothelial dysfunction (ED) has been extensively documented in patients with cardiovascular (CV) risk factors (2). This study proposes a novel perspective, positing that ED could be intricately linked not only with traditional CV risk factors, but also it can be associated with poor sleep quality. Consequently, this interplay might significantly contribute to the attenuation of exercise capacity.

Objective

The aim of this study was to assess endothelial function following AMI treated with a PCI and investigate the link between endothelial function, CV risk factors, sleep quality and exercise capacity. Furthermore, the study aimed to determine if endothelial function could serve as a predictive factor for future major adverse acute cardiac events (MAACE) following AMI.

Materials and methods

Sixty-three patients with AMI (56.21 ± 7.6 years) volunteered to participate in this study, . Endothelial function was assessed using the Endothelium Quality Index (EQI) . Sleep quality was evaluated using both actigraphy and the PSQI (Pittsburgh Sleep Quality Index) questionnaire. Exercise capacity was quantified through the 6-minute walking test (6mwt).

Results

ED was evident, as indicated by an EQI of 1.4 ± 0.7. Furthermore, ED was notably influenced by CV risk factors such as low physical activity level, age, and smoking. A significant correlation was found between EQI and both sleep efficiency (r = 0.340; p = 0.006) and PSQI score (r = -0.533; p < 0.001). Additionally, a strong association was observed between endothelial function and the results of the 6mwt (r = 0.291; p = 0.021). Furthermore, during a follow up period ( near 4 months) following PCI, MAACE were observed in patients with severe ED only.

Conclusion

In summary, findings of this study may emphasize the importance of enhancing sleep quality and advocating for an active lifestyle as modifiable elements to enhance endothelial function, which can be regarded as a prognostic tool subsequent to AMI, ultimately contributing to improved clinical outcomes. Moreover, this study concluded that AMI patients with severe endothelial dysfunction were more likely to develop MAACE.Endothelial Dysfunction after AMIED following AMI : Causes and effect