bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between obstructive sleep apnea and heart failure in patients with and without obesity: a population-based cohort study
Authors: Kim K
Published: November 2023

Background

Obstructive sleep apnea (OSA) is a prevalent disorder characterized by partial or complete airway collapse during sleep, which often leads to sleep disruption and intermittent hypoxia. Previous research has suggested that patients with heart failure (HF) are more likely to have OSA. However, not enough evidence is available for association between new-onset OSA and HF. A recent Danish cohort study found that OSA, without continuous positive airway pressure therapy, is linked to a higher risk of HF across all age groups (1). In addition, the association between OSA and HF in patients with and without obesity has not been extensively studied in a large Asian cohort.

Purpose

To investigate the association between obstructive sleep apnea (OSA) and heart failure (HF) in a large Asian cohort stratified by obesity, as defined by World Health Organization (WHO) criteria for the Asian population, in both patients with and without obesity.

Methods

Using a nationally representative cohort of Korean adults over 40 years old who underwent national health screening between 2009 and 2010 with no prior history of HF or cardiovascular disease, we identified OSA using outpatient visit records (ICD-10: G47.3). Participants were tracked from January 1, 2011 to December 31, 2019 for new HF events, death from HF or other causes, or the end of follow-up, whichever occurred first. A Cox proportional hazards model adjusted for sociodemographic factors, health status, health behavior, and family history of heart disease was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Obesity was defined as a body mass index greater than 25.0 kg/m2 based on WHO criteria for the Asian population.

Results

The final study population included 326,662 participants (32.7% of them were with obesity). Among obese patients, those with OSA had a higher risk of developing HF (HR=1.52; 95% CI: 1.07-2.19) than those without OSA. The association between OSA and HF was less pronounced in non-obese patients (HR=1.07; 95% CI: 0.65-1.78 for HF in patients with OSA compared to those without OSA) with a significant interaction between obesity and OSA-HF association (P-value for interaction<0.001).

Conclusions

Our findings suggest that OSA is linked to an increased risk of HF, particularly in obese patients. Further research is necessary to examine important clinical subgroups regarding prevention of HF in patients with OSA.
Comparison of supine bicycle exercise versus treadmill exercise echocardiography in a cycling-naive population
Authors: Monteagudo Ruiz J M , Gonzalez Gomez A , Garcia Martin A , Hinojar Baydes R , Casas Rojo E , Jimenez Nacher J J , Martin Vives P , Zamorano J L , Fernandez-Golfin C
Published: November 2023

Introduction

Exercise echocardiography is a useful diagnostic test for the evaluation of coronary artery disease. Supine bicycle exercise echocardiography has the advantage of continuous monitoring of wall motion during exercise. On the contrary, the heart rate and workload is usually lower compared to treadmill exercise, especially between patients not used to cycling as is the case of many old adults. The aim of this study is to compare both exercise modalities.

Methods

A group of consecutive patients with chest pain underwent supine bicycle exercise echocardiography under a protocol adapted to the individual requirements. The operator chose between three protocols: light (5 watts every minute), medium (5 watts every 30 seconds) or intensive (10 watts every 30 seconds) according to age, sex and physical condition. The other group underwent treadmill exercise echocardiography using the Ball State University/Bruce Ramp protocol.

Results

A total of 902 patients were included. Of them, 258 patients underwent supine bicycle exercise echocardiography and 644 patients underwent treadmill exercise echocardiography. Mean age was 62.1 years (SD=13.4) and 48.5% of patients were women. Baseline characteristics were comparable in both groups, without significant differences regarding age, sex, body mass index, pre-test probability or image quality. There were no significant differences in the percentage of positive tests (5.0 vs. 5.3%, p = 0.883). However, the percentage of patients that achieved at least 85% of the predicted workload was significantly higher in the group of treadmill exercise echocardiography (91.3 vs. 45.0%, p < 0.001). The percentage of patients that achieved at least 85% of the age-predicted maximum heart rate was also significantly higher in the group of treadmill exercise echocardiography (76.7 vs. 44.2%, p < 0.001).

Conclusions

This study suggests that in a population not used to cycling, the use of supine bicycle exercise echocardiography, as opposed to the use of treadmill, hinders the achievement of an adequate maximum heart rate and workload, which can lead to inconclusive results. This should be considered while selecting the ischemic test to use.
Impact of systemic lupus erythematosus on outcomes in patients hospitalized with acute decompensated heart failure with reduced and preserved ejection fraction: a national inpatient sample study (2016)
Authors: Nomigolzar S , Nomigolzar R , El Sharu H , Subramanian L
Published: November 2023

Background

Systemic lupus erythematosus (SLE) is known to have an impact on cardiovascular outcomes, but its effect on patients with acute decompensated heart failure (ADHF) with reduced and preserved ejection fraction is not well understood. This study aims to investigate the impact of SLE on in-hospital outcomes in patients with ADHF.

Methods

This retrospective cohort study analyzed data from the United States National Inpatient Sample Database from 2016 to 2020. Patients hospitalized with ADHF with reduced and preserved ejection fraction were identified using ICD-10 codes and then categorized based on SLE diagnosis. Mortality and in-hospital complications were analyzed using multivariate logistic regression.

Results

Out of 10,700,000 ADHF hospitalizations, 0.61% (65,270) were associated with SLE. Compared to patients without SLE, those with SLE were younger (61 vs 72 years old, p<0.001), more likely to be female (85% vs 48%, p<0.001), had longer lengths of stay (coefficient: 0.23; p 0.005), and lower total hospital charges (coefficient: -$5,207; p<0.001). Patients with SLE had lower rates of cardiogenic shock, acute MI, and ischemic stroke (Figure 1). However, they had higher odds of in-hospital mortality, gastrointestinal bleeding, blood transfusion, pericardial complications, and AKI. No significant differences were found in respiratory failure and intracranial hemorrhage rates between the two cohorts.

Conclusions

This study suggests that the presence of SLE in patients hospitalized with ADHF is associated with worse in-hospital outcomes, including higher rates of all-cause mortality, gastrointestinal bleeding, blood transfusion, pericardial complications, and AKI. However, patients with SLE had lower rates of cardiogenic shock, acute MI, and ischemic stroke compared to those without SLE. These findings highlight the importance of early recognition and aggressive management of SLE in patients with ADHF to improve outcomes. Further research is needed to identify potential interventions that could improve the outcomes of this high-risk population.
Obesity and outcomes in cardiogenic shock due to acute myocardial infarction
Authors: Guglin M , Li B , Kanwar M , Abraham J , Kataria R , Bhimaraj A , Vallabhajosyula S , Kapur N
Published: November 2023

Background

Obesity paradox in heart failure (HF) is defined as better outcomes associated with higher body mass index (BMI).

Purpose

We explored the relationship between BMI and outcomes in cardiogenic shock (CS) due to acute myocardial infarction.

Methods

The Cardiogenic Shock Working Group (CSWG) registry includes patients with CS, regardless of etiology, from 17 clinical sites across the USA. In- hospital mortality, as a main outcome measure, was analyzed depending on BMI as a continuous variable, as well as BMI quartiles (BMI≤24.4 kg/m2, 24.433.1 kg/m2) for the subset of CS due to acute myocardial infarction (AMI-CS). We also explored mortality in categorized BMI subsets (underweight, normal weight, overweight, obese, and morbidly obese).

Results

A total of 969 patients with AMI-CS were included. The in-hospital mortality was 42.4%. When analyzed as a continuous variable, BMI had no association with survival to discharge. When the cohort was divided into quartiles according to BMI, mortality was consistent with 42.2%, 38.5%, 39.5%, and 49.3%, respectively, p=0.082. In categorized subsets, mortality was 30% in the underweight, 42.9% in the normal weight, 37.4% in the overweight, 44.5.% in the obese, and 47.9% in morbidly obese, p=0.15.

Conclusions

In acute myocardial infarction-related cardiogenic shock, obesity creates no survival advantage.
SCAI classification, the importance of its dynamic reclassification in the first 24 hours and the impact of risk modifiers in cardiogenic shock admissions
Authors: Presume J , Bello A R , Gomes D A , Brizido C , Strong C , Ferreira J , Tralhao A
Published: November 2023

Introduction

The Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification has been proposed as a simple, easily applied framework to stratify mortality risk across the spectrum of cardiogenic shock (CS) severity. This categorization has been recently refined (2022) to incorporate the continuum dynamic trajectory of the disease, as well as other risk modifiers.

The aims of this study were: 1) to validate the SCAI classification at admission in a cohort of patients admitted to the cardiac intensive care unit (CICU) due to CS; 2) evaluate the prognostic impact of SCAI stage variation during the first 24h of admission; 3) evaluate the prognostic impact of other risk modifiers.

Methods

We retrospectively analyzed patients consecutively admitted to the CICU with established CS (SCAI C and above) from all causes, from January 2017 to November 2022. SCAI staging was assessed at diagnosis and after 24 hours. The primary outcome was 30-day mortality.

Results

A total of 208 patients (66±16 years, 67% male) were included. Overall, 53% had an acute myocardial infarction, 34% were admitted due to decompensation of chronic heart failure, and 29.1% had a cardiac arrest. The proportion of patients in SCAI stage C to E at the time of diagnosis was 69% (n=143), 25% (n=52), and 6% (n=13), respectively. 30-day mortality increased across SCAI categories (p<0.001 – figure 1.1).

After the first 24 hours, 34 (%) of patients improved SCAI category, 113 (%) remained in the same class, and 45 (%) worsened, with a 30-day mortality of 18%, 34%, and 62%, respectively (p<0.001 – figure 1.2).

Risk modifiers also carried prognostic significance (figure 1.3). 30-day mortality was significantly higher in patients with acute myocardial infarction vs. other etiologies (52% vs. 32%; p=0.002), acute CS vs. acute-on-chronic CS (47% vs. 33%; p=0.034), and cardiac arrest (56% vs. 37%; p=0.005).

Conclusion

Early changes in SCAI classification reflect the dynamic nature of CS patients while retaining significant prognostic discrimination. 24h SCAI re-staging together with risk modifiers may be valuable in readjusting therapeutic strategies aiming at shock reversal.
Impact of high-profile transvalvular pumps in heasrt failure related cardiogenic shock
Authors: Kanwar M , Kataria R , Hernandez-Montfort J , Sinha S , Garan A R , Li B , Zhang Y , Burkhoff D , Kapur N K
Published: November 2023

Background

Heart failure-related cardiogenic shock (HF-CS) not related to acute MI is a leading cause of CS.(1) Congestion is a major predictor of mortality among patients with HF-CS, for whom in-hospital mortality remains between 25-40%.(2,3) Both low-profile (Impella CP) and high-profile (Impella 5.0/5.5) transvalvular pumps are used to manage these patients. In the last few years, use of Impella 5.0/5.5 pumps in these patients is increasing, although it is often used as an escalation strategy from other temporary mechanical circulatory support (tMCS) devices.

Purpose

To assess the impact of LV unloading using high profile transvalvular pump (Impella 5.0/5.5) compared to a low-profile pump (Impella CP) on outcomes in HF-CS.

Methods

The Cardiogenic Shock Working Group (CSWG) is a large, multi-center international prospective registry of CS patients.(1) For this analysis, we retrospectively reviewed patients with HF-CS who underwent Impella 5.0/5.5 therapy for HF-CS and compared them to patients who underwent an Impella CP. Patients who received an Impella device as part of their escalation strategy from another device (IABP) or concomitant or de-escalation strategy with ECMO were excluded.

Results

Of the 2,755 patients with HF-CS, 125 patients received an Impella 5.0/5.5 while 152 patients received an Impella CP alone; 13 patients were escalated from an Impella CP to 5.0/5.5 pump. Of these 292 patients who either received an Impella CP or 5.0/5.5 or a combination of the two, 228(78%) were male, 208(71%) were white with a mean LVEF at presentation of 19%. About a third (n=78, 27%) presented with de-novo HF-CS while 214(73%) were acute on chronic HF-CS. In-hospital mortality in the entire HF-CS cohort was 717(26%). Unadjusted mortality was higher in those who underwent Impella CP alone (n= 57; 38%) compared to patients with Impella 5.0/5.5 (n=27, 23%; p=0.01). This improvement in mortality was seen in acute on chronic HF-CS with Impella 5.5/5.0 vs CP (41% vs 26%, p=0.02), and as a trend in de-novo HF-CS (30% vs 14%, p=0.13). More patients on Impella 5.0/5.5 went on to receive heart replacement therapies (durable LVAD or heart transplantation) compared to Impella CP (56% vs 9%, p<0.001).

Conclusion(s)

Use of a high-profile transvalvular pump (Impella 5.0/5.5) was associated with improved mortality compared to a low-profile transvalvular pump (Impella CP) in HF-CS.
Characteristics and outcomes of combination VA-ECMO for cardiogenic shock
Authors: Hernandez-Montfort J , Kanwar M , Sinha S , Garan R A , Borui L , Zhang Y , Burkhoff D , Kapur N
Published: November 2023

Background

Use of VA-ECMO for cardiogenic shock is growing exponentially. The impact of VA-ECMO on in-hospital mortality among patients with CS due to heart failure or acute myocardial infarction remains poorly understood. Furthermore, the combination of VA-ECMO with IABP or Impella is also growing despite limited data supporting this approach. We sought to quantify in-hospital mortality among patients with CS due to HF or AMI in the presence or absence of concomitant IABP or Impella use.

Methods

We utilized the Cardiogenic Shock Working Group multi-center registry and focused on data obtained between 2021 and 2022. Patients managed with VA-ECMO alone, VA-ECMO and IABP or VA-ECMO and any left-sided transvalvular pump (Impella) were included in the analysis. Patients receiving IABP or Impella without VA-ECMO were excluded.

Results

Of the 1,634 CS subjects included in the analysis, 240 patients received VA-ECMO. 61.7% (n=148) were male. Mean age was 54.4±14.5. Baseline SCAI stage on admission for CS was Stage D (41.1%, n=76) and Stage E (46.0%, n=85). Among these patients, 5% (81), 4.5% (73), 5.9% (97) subjects received either VA-ECMO alone, VA-ECMO+IABP, or VA-ECMO+Impella respectively. In-hospital mortality among these groups for all cause CS, HF-CS, and MI-CS are shown in Figure 1A. In-hospital mortality among HF-CS stratified by acute on chronic HF (ACHF) or de novo HF are shown in Figure 1B. In-hospital mortality among HF-CS stratified by STEMI or Non-STEMI are shown in Figure 1C.

Conclusions

In-hospital mortality among VA-ECMO recipients for CS remains high and distinct among HF-CS and AMI-CS populations. Further research is needed in order to better understand the impact and trajectory of combined use of IABP or Impella with VA-ECMO among HF-CS and AMI-CS population.
Determinants of exercise-induced B-lines in asymptomatic severe aortic stenosis
Authors: D'Alfonso M G , Mori F , Ciampi Q , Saad A K , Zagatina A , Colonna P , Merli E , Van De Heyning C M , Agostini R , Russo M , Padang R , Pellikka P A , Picano E
Published: November 2023

Background

Guidelines recognize the role of exercise stress testing in evaluating functional capacity in patients with asymptomatic severe aortic stenosis (AS). Exercise stress echocardiography (ESE) allows the detection of pulmonary congestion with B-lines by lung ultrasound (LUS).

Aim

To identify the prevalence, determinants, and functional correlates of B-lines during ESE in asymptomatic severe AS.

Methods

We enrolled 35 asymptomatic patients (age= 69±16 years, 69% male) with severe AS, aortic valve area (AVA) <0.6 cm2/m2, mean aortic gradient (MAG) ≥ 40 mmHg, left ventricular ejection fraction ≥55%. All patients were referred for ESE (treadmill in 1, bicycle in 34 patients) in 7 experienced centers from 4 countries between 2021-2022. ESE assessment at rest and peak stress included global longitudinal strain (GLS), left atrial volume index (LAVI) and cardiac output (CO). B-lines were assessed by simplified LUS from 4 lung zones across the third intercostal space (2 on each side). Heart rate reserve (HRR) was measured as the peak/rest heart rate. CO reserve was calculated as the difference between peak stress CO and rest CO.

Results

B-lines (≥2) were present in 2 patients at rest and in 15 patients during ESE (6% vs 43%, p<0.001). When compared to patients without B-lines during ESE (Group 1, n=20), patients with B-lines during ESE (Group 2, n=15) were older (Group 1= 64±18 vs Group 2=75±8 years, p=0.030) had larger LAVI, higher logNT-pro-BNP and a trend to higher systolic pulmonary artery pressures (SPAP), see Table. The 2 groups showed similar values of resting AVA (Group 1= 0.52±0.11 vs Group 2=0.47±0.15 cm2/m2, p=0.311), stress AVA (Group 1= 0.45±0.09 vs Group 2=0.49±0.13 cm2/m2, p=0.663), resting MAG (Group 1= 45±15 vs Group 2=46±10 mm Hg, p=0.491), and stress MAG (Group 1= 59±19 vs Group 2=58±11 mm Hg, p=0.665). Patients with B-lines during ESE showed lower HRR and CO reserve, with a trend towards lower peak GLS, see Table.

Conclusions

Exercise-induced pulmonary congestion as evidenced by development of sonographic B- lines on LUS were present commonly (43%) among patients with "asymptomatic" severe AS undergoing ESE. Patients with exercise-induced B-lines have larger resting LAVI, higher NT-pro-BNP levels, lower CO reserve, and blunted HRR. Exercise-induced B-lines might provide an early sign of cardiac decompensation in "asymptomatic" patients with severe AS, which is an important factor to consider in the decision to intervene.TableFigure
Resting and stress coronary flow velocity for identification of different endotypes and risk classes in ANOCA patients beyond coronary flow velocity reserve
Authors: Gaibazzi N , Cortigiani L , Ciampi Q , Rigo F , Picano E
Published: November 2023

Background

Coronary microvasculature disease (CMD) affects a subset of patients with angina with no obstructive coronary arteries (ANOCA) and is diagnosed with transthoracic echocardiography (TTE) through a reduction (≤2.0) of coronary flow velocity reserve (CFVR), measured as the stress/rest coronary flow velocity (CFV) ratio.

Aim

To assess the dominant (functional vs structural, high-rest vs low-stress CFV) mechanism of CMD and the corresponding long-term risk.

Methods

In a prospective multicenter study design, we enrolled 1,033 patients (age 63±11 years, 533 women, 230 diabetics, ejection fraction 59±5%) with ANOCA. Recruitment (years 2004-2022) involved 4 accredited laboratories, with inter-observer variability <10% for CFV. CFV was obtained with TTE by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery at rest and after dipyridamole stress. All-cause death was the only end-point. A receiver operating characteristic analysis was used to obtain the best prognostic predictor, corresponding to >32 cm/s for resting and ≤53 cm/s for peak stress CFV.

Results

289 patients (28%) showed a reduction in CFVR. Four groups were identified: normal rest and peak CFV (Group 1, n=465), abnormal rest and normal peak CFV (Group 2, n=350), normal rest and abnormal peak CFV (Group 3, n=210), abnormal rest and peak CFV (Group 4, n=8).

During a mean follow-up of 4.8±4.1 years, 82 (8%) patients died. Eight-year mortality was 4% in Group 1, 11% in Group 2, 15% in Group 3, and 58% in Group 4 (p<0.0001). Yearly mortality was 2.3% in patients with isolated abnormal rest CFV as well as in those with isolated abnormal peak CFV (p=0.89) (Figure).

Conclusion

TTE allows phenotyping of the presence of CMD in the heterogeneous garden variety of ANOCA patients. High resting with reduced peak CFV is the less frequent, and by far more malignant, endotype.
The importance of vasodilator stress echocardiography in predicting all-cause mortality and acute heart failure in hypertrophic cardiomyopathy
Authors: Tesic M , Djordjevic-Dikic A , Aguiar Rosa S , Cortigiani L , Rigo F , Nemes A , Ciampi Q , Beleslin B , Viegas J , Palinkas E D , Olivotto I , Picano E
Published: November 2023

Background

Reduced coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD) during vasodilator stress echocardiography (VSE) is a marker of poor outcome and is associated with higher baseline coronary flow velocity (CFV) in hypertrophic cardiomyopathy (HCM). However, whether resting CFV has additive predictive value to CFVR during VSE in HCM is unknown.

Aim

To assess the prognostic value of baseline CFV and CFVR during VSE in HCM.

Methods

325 adult HCM patients (age=52+15 years, 147 [45%] females) with preserved left ventricular function and no known coronary artery disease who underwent VSE in 6 certified centers between 1999 and 2021 were prospectively analyzed. VSE modality was adenosine (0.14 mg/kg/min in 2', n=232) or dipyridamole (0.84 mg/kg in 6', n=93). CFVR in the LAD was assessed by transthoracic (n=306) or transoesophageal (n=19) echocardiography. Patients were followed for a median of 67 months (IQ range 31-103 months), the primary endpoint was a composite of all-cause mortality and acute heart failure (HF).

Results

Receiver operating characteristic analysis was used to determine the best cut-off value of CFV (>31 cm/s, elevated) and CFVR (≤2.0, reduced) to predict the primary endpoint. Patients with reduced CFVR had more frequently elevated baseline CFV (75% vs 49%, p<0.001). Elevated resting CFV was a predictor of composite endpoint at univariable (HR 2.04, 95% CI 11.05-3.97, p=0.035) but not at multivariable analysis. A reduced CFVR was an independent predictor of all-cause mortality (HR 5.50, 95% CI 1.94-15.59, p=0.001), acute HF (HR 5.80, 95% CI 1.60-21.00, p=0.007), and the composite end-point (HR 4.95, 95% CI 2.39-10.25, p<0.001). The 5-year event rate was 6-fold higher in patients with reduced CFVR compared to patients with preserved CFVR (19% vs 3%, p<0.001), with no additional impact of resting CFV (see Figure).

Conclusion

LAD CFVR ≤2.0 during VSE is a strong and independent predictor of all-cause mortality and acute HF in HCM. Elevated resting CFV is more frequent in patients with reduced CFVR, but has no independent prognostic value when CFVR is considered.Kaplan-Meier event-free survival curves
Mechanical LV support lowers diastolic LV pressure and prolongs diastolic coronary flow in the infarcted artery
Authors: Sakata T , Mavropoulos S , Mazurek R , Romeo F , Ravichandran A , Marx J , Kariya T , Watanabe S , Ishikawa K
Published: November 2023

Background

Percutaneous left ventricular (LV) assist device provides not only circulatory support but also LV unloading. However, impact of LV unloading on coronary flow and mechanisms by which it is regulated remain unclear. We aimed to elucidate potential effects of LV unloading on coronary physiology in a pig model of myocardial infarction (MI).

Methods

First, six Yorkshire pigs underwent mechanical LV unloading using Impella two weeks after percutaneous MI induction. Regional blood flow (RBF) in infarct, border and remote myocardium were measured by fluorescent microsphere injections before and 120 min after LV unloading (Study 1). Next, we investigated coronary flow patterns with detailed temporal information. Six Yorkshire pigs were subjected to 90-minute balloon occlusion of the middle left anterior descending artery followed by reperfusion. At 60 minutes after reperfusion, LV unloading was initiated and maintained at maximal support. LV pressure, coronary flow and pressure in the infarcted artery were simultaneously recorded. Measurements were repeated with and without LV mechanical support. Coronary wave intensity was calculated from the flow/pressure data (Study 2).

Results

In Study 1, RBF calculated using microsphere was significantly increased only in the infarct area, but not in the border or remote areas. In Study 2, LV unloading resulted in lower LV pressure during the whole diastolic phase and higher coronary pressure during the late diastolic phase in all animals. Coronary flow velocity was higher throughout the diastole under LV unloading. In addition, the proportion of diastole to the whole cardiac cycle was significantly prolonged with LV unloading. Accordingly, area under the curve of coronary flow was increased during diastole and also for the whole cardiac cycle. In the wave intensity analysis, the magnitude of forward wave intensity was reduced by LV unloading, suggesting that the impact of forces from the aortic side was less significant under continuous device support. The duration between backward suction and pushing waves was extended, implicating earlier relaxation and delayed contraction, further supporting prolonged diastole from the myocardial force perspective.

Conclusions

Mechanical LV unloading increases coronary flow by prolonging diastolic phase in the infarcted artery.
Sex differences in 82Rubidium PET-derived myocardial flow reserve and implications for long-term cardiac outcomes
Authors: Hojstrup S , Hansen K , Talleruphuus U , Marner L , Bjerking L , Bouchelouche K , Wiinberg N , Jakobsen L , Guldbrandsen K , Galatius S , Prescott E
Published: November 2023

Introduction

Coronary small vessel disease (CMD), defined by reduced myocardial flow reserve (MFR) in the absence of obstructive coronary artery disease, holds prognostic information on major cardiac events (MACE). We aimed to investigate if the prognostic value of MFR is independent of sex.

Method

A multicenter registry-based study of 7169 consecutive patients referred to clinically 82Rubidium PET myocardial perfusion imaging. We excluded patients with abnormal perfusion (defects >5% at rest or stress), previous revascularization, cardiomyopathy, or a diagnosis of heart failure. Global MFR≤2 was considered reduced. Patients were followed in registries for major adverse cardiac events (MACE) comprising all-cause mortality and admission for myocardial infarction, stroke, heart failure or unstable angina pectoris.

Results

A total of 2591 patients were included, 51% women, median age 69 [IQR 60-75] years. Women were older and men had a higher burden of cardiovascular risk factors. Overall, 31% had MFR≤2 (34% women vs 28% men, p<0.001). Mean MFR was lower in women compared with men (2.30 (SD 0.66) vs 2.44 (0.70), respectively) with higher myocardial blood flow both at rest and during stress among women (both p<0.001, Figure 1). In a linear regression model, sex remained associated with MFR after adjustments for age (p<0.001). At 3-year follow-up, MACE was less frequent in women than men (7.0% vs 9.4%, p=0.03). MFR≤2 was associated with MACE with an age-adjusted hazard ratio (HR) of 1.83 (95% CI: 1.20-2.77, p<0.01) in women and 1.75 (1.21-2.54, p<0.01) in men (p for interaction 0.82). The association remained significant after adjustments for left ventricular ejection fraction and charlson comorbidity index with a HR of 1.58 (1.07-2.31, p<0.05) in men and a HR of 1.68 (1.09-2.58, p<0.05) in women (p for interaction 0.69). On a continuous scale, MFR per every 0.1 unit decrease remained significantly associated to MACE (Figure 2).

Conclusions

Among patients suspected of obstructive CAD, CMD is more prevalent among women than men. The increased hazard of adverse outcomes with CMD did not differ by sex. This study provides new insight into the phenotype and prognosis of patients with CMD.Figure 1:Baseline distribution of MFRFigure 2:HR for MACE
Left atrial dysfunction during stress in patients with atrial fibrillation
Authors: Rivadeneira Ruiz M , Zagatina A , Kalinina E , Begidova I , Ciampi Q , Lowenstein J , Arbucci R , Boshchenko A , Manganelli F , Celutkiene J , Peteiro Vazquez J , Borguezan-Daros C , Merli E , Wierzbowska-Drabik K , Picano E
Published: November 2023

Background

Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS).

Objective

This study sought to assess LA function at rest and during stress across the spectrum of AF.

Methods

In a prospective, multicentric, observational study design, we studied a cohort of 2391 patients (age=67±12 years; 1459, 61% male): 2142 (89.6%) were in sinus rhythm (SR, Group 1), 165 (6.9%) had a history of paroxysmal AF (Group 2) and 84 (3.5%) were in permanent AF (Group 3). All patients were referred for CCS and underwent stress echocardiography (SE) with exercise (n=1092, 45.3%), dobutamine (n=320, 13.4%) or vasodilators (n= 989, 40.3%: dipyridamole n=963 and adenosine n=26). Left atrial volume index (LAVI) and LA reservoir strain (LASr) were assessed at rest and peak stress. Analysis with different vendors was performed offline on anonymized cine-loops by observers unaware of the study hypothesis.

Results

The progressive increase in LA dysfunction from Group 1 to 3 was accompanied by greater signs of pulmonary congestion and LV dysfunction (see Table 1). In particular, LASr progressively decreased from Group 1 to 3, both at rest and during stress, regardless of the stress employed (see Figure 1).

Conclusions

LA reservoir function can be easily assessed with deformation imaging at rest and during exercise or pharmacological stress echocardiography. LA dysfunction progressively increases from SR to paroxysmal to permanent AF and is associated with more important LV systolic dysfunction, LV filling pressure, and pulmonary congestion in CCS.Table 1.Echocardiographic parametersFigure 1.LAVI and LASr at rest and peak
Association between index of microcirculatory resistance and patients' characteristics, coronary computed tomography findings, and the sensor location
Authors: Hada M , Hoshino M , Usui E , Hanyu Y , Nagamine T , Ueno H , Nogami K , Matsuda K , Sakamoto T , Yonetsu T , Sasano T , Kakuta T
Published: November 2023

Background

The index of microcirculatory resistance (IMR) has been widely used for the assessment of microcirculatory function and the detection of the territory with microvascular dysfunction. For measuring coronary physiological indices including IMR, a pressure/temperature sensor-tipped guidewire is recommended to be located distally to the target lesion, however the determinants of IMR including wire location other than the hyperemic microvascular resistance itself are still undetermined.

Purpose

This study aimed to clarify the determining factors including coronary computed tomography angiography (CCTA) findings, wire position and vessel anatomy and its effect on IMR values.

Methods

We retrospectively investigated 121 intermediate left anterior descending artery lesions in chronic coronary syndrome patients in our institutional physiological registry (July 2020 to Aug 2022). All patients underwent preprocedural CCTA and coronary physiological assessment with pressure/temperature sensor-tipped guidewire during invasive coronary angiography or percutaneous coronary intervention (PCI). We placed the wire as far distal as practical for the assessment of physiological indices. Under adenosine-induced hyperemia, the wire was pulled manually to the guide catheter and its pullback length was recorded. CCTA assessment included qualitative lesion morphology assessment (spotty calcification, low attenuation plaque, napkin ring sign) and quantitative plaque analysis (remodeling index). Epicardial fat volume is also measured with the proprietary semi-automated software. The predicting factors for IMR was investigated.

Result

In a total cohort, IMR was 20.40 (14.07-29.92), and the prevalence of IMR>25 was 36 %. On linear regression analysis, patient characteristics including age and gender were not significant predictors for IMR. CCTA-based high risk plaque features (Spotty calcification, low attenuation plaque and napkin ring sign) were also not associated with IMR. In univariable and multivariable linear regression analysis, wire pullback length, remodeling index and epicardial fat volume were significant predictors for IMR (β 1.369 [0.223-2.515, p=0.020, β 6.651 [1.486-11.815], p=0.012, and β 0.055 [0.008-0.103], p=0.023, respectively).

Conclusion

Wire location (length form the coronary ostium), remodeling index and epicardial fat volume affects IMR values. Caution should be exercised for the interpretation of IMR values in consideration of these factors.
Endotypes of coronary microvascular dysfunction in patients with and without Diabetes Mellitus
Authors: Gallinoro E , Paolisso P , Bertolone D T , Belmonte M , Esposito G , Munhoz D , Sakai K , Bermpeis K , Ohashi H , Storozhenko T , Seki R , Sonck J , Collet C , De Bruyne B , Barbato E
Published: November 2023

Background

Coronary microvascular dysfunction (CMD) is an early feature of diabetic cardiomyopathy, which usually precedes the onset of ventricular dysfunction. Continuous intracoronary thermodilution allows an accurate and reproducible assessment of absolute coronary blood flow and microvascular resistance thus allowing the evaluation of coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR). Recently, two different endotypes of CMD, structural and functional were identified, based on CFR and minimal resistance (Rm-hyp) values.

Purpose

To compare the patterns of CMD among patients with and without diabetes mellitus by continuous intracoronary thermodilution.

Methods

Consecutive patients with angina and non-obstructive coronary artery disease undergoing absolute flow measurement with continuous intracoronary thermodilution between 2020 and 2022 were included. Considering a CFR threshold of 2.5, patients were divided into 4 groups, CMD with and without diabetes (DM-CMD and NDM-CMD respectively), and two control groups with and without diabetes (DM-Control and NDM-Control group, respectively). Rm-hyp threshold of 390 (median value) was used to divide structural and functional endotypes (Rm-hyp above or below the threshold respectively).

Results

204 patients were included (NDM-CMD=62 vs NDM-Control=77 and dm-CMD=38 vs dm-Control=27). The prevalence of CMD among diabetic patients was 58%. Both CFR and MRR were significantly reduced in both CMD groups compared to the control groups. DM-CMD and NDM-CMD patients had both lower Rm-hyp and higher Rm-rest as compared to the control groups. Among patients with CMD, DM-CMD had higher Rm-hyp compared to NDM-CM patients (480±163 vs 420±124 WU, respectively, p=0.04) and had a higher prevalence of structural endotype (78% vs 58%), p=0.03) which was higher among patients with insulin-dependent diabetes than in those without.

Conclusions

In patients with DM structural microvascular dysfunction is the most prevalent endotype. Functional endotype is more frequent among those with non-insuline dependent DM. Therefore, CMD in diabetic patients appears to be a continuum, evolving from a functional pattern to a structural one as the disease progresses.
Soluble urokinase Plasminogen Activator Receptor (suPAR) is associated with educational attainment in patients with coronary artery disease
Authors: Fueller D , Liu C , Ko Y A , Alkhoder A , Desai S R , Almuwaqqat Z , Patel S A , Ejaz K , Kauser T , Martini A , Alvi Z , Mehta P K , Sperling L S , Quyyumi A A
Published: November 2023

Background

Biological mediators of adverse social determinants of health may include chronic low-grade inflammation. Elevation of circulating soluble urokinase Plasminogen Activator Receptor (suPAR) levels indicates activation of inflammatory and immune pathways and is associated with cardiovascular outcomes, independent of C-reactive protein (CRP) levels.

Purpose

We investigated whether the adverse impact of lower educational attainment on all-cause and cardiovascular mortality is mediated by elevated suPAR levels in patients with coronary artery disease (CAD).

Methods

In 3,164 patients undergoing coronary angiography, we investigated multivariable associations, including demographic characteristics, behavioral and clinical risk factors, between suPAR levels collected at the time of angiography and self-reported educational attainment, and assessed the relationship between lower educational level (defined as high school degree or less as highest educational qualification) and outcomes using Cox proportional hazard and Fine and Gray’s sub-distribution competing risk models. Mediation analyses were performed to assess the total effect of education on mortality, and the indirect effects through hs-CRP and suPAR on survival stratified by education using accelerated failure time models under exponential distribution.

Results

Mean age of the cohort was 64.5±11.9 years, with 32% women and 8.1±3.8 years follow-up. SuPAR levels were 9.0% [95% CI 6.3–11.8, p <0.0001] higher in patients achieving a lower (≤high school) compared to a higher (≥college) education after full covariate adjustment including hs-CRP levels. Lower educational attainment was associated with a higher risk of cardiovascular death (HR 1.39 [95% CI 1.15–1.68, p=0.0008]). After adjustment for demographic, clinical and behavioral covariates, and hs-CRP levels, this effect remained significant (HR 1.29 [95% CI 1.06–1.57, p=0.01]). However, after adjustment for suPAR levels, the effect of a lower educational level on cardiovascular mortality became insignificant. Values were similar for all-cause death. SuPAR levels mediated 49% and hs-CRP levels 17% of the association between lower educational attainment and cardiovascular mortality.

Conclusion

SuPAR importantly mediates the effects of lower educational attainment on mortality, indicating the importance of systemic inflammation and immune dysregulation as biologic mediators of adverse social determinants of health.Figure 1Central Illustration
Prior COVID-19 infection is associated with persistent and higher thrombus burden in acute coronary syndromes
Authors: To-Dang B , Zuckerman M , Cannata S , Roy R , Dalton R , Cannata A , Webb I , Melikian N , Byrne J , Maccarthy P , Shah A J A Y , Dworakowski R , Pareek N
Published: November 2023

Background/Introduction

The COVID-19 pandemic challenged global healthcare systems by causing a multi-organ syndrome with a high mortality rate. COVID-19 infection is associated with a profound inflammatory response and hypercoagulability in the acute phase, however little is known on the persistence of endothelial dysfunction and hypercoagulability beyond this phase and its impact on acute coronary syndrome (ACS). 

Purpose

The purpose of this study was to investigate the effects of COVID-19 infection on the presentation and outcomes of coronary artery disease in patients with ACS.

Methods

A single centre prospective observational study was conducted from 10th of June 2020 to 6th of May 2021. Patients aged 18 or over presenting with ACS were included. Participants were excluded if they had active COVID-19 infection or if they did not undergo coronary angiography on admission.

Study participants were tested one presentation for SARS-CoV-2 nucleoprotein (N) antibody and SARS-CoV-2 spike protein receptor binding domain (RBD) antibody to determine whether the participants had prior COVID-19 infection, COVID-19 vaccination, or neither at the time of their presentation. Data was collected on their baseline demographics, angiographic findings, and treatments. Patients were followed up via telephone call and electronic case record review to assess outcomes at one year.

The primary end-point was all-cause mortality. Pre-specified secondary endpoints were cerebral infarction, repeat myocardial infarction or unplanned revascularisation and death (MACE) at one year, coronary artery ectasia, presence of thrombus, and thrombectomy requirement.

Results

280 patients were approached for the study. 5 refused participation, 8 were lost to follow-up, 2 did not undergo coronary angiography, and 98 had uninterpretable/insufficient blood samples for antibody analysis.

The remaining study population had 167 patients (median age 64 [43-85], 69.5% male). 22 (13.1%) had prior infection, 76 (45.5%) were antibody negative and 69 (41.3%) had a post COVID-19 immunisation response. 31.7% had diabetes mellitus, and 49.7% were smokers.

There was no difference in the primary endpoint between the groups. Patients with prior COVID-19 infection were more likely to have coronary ectasia/aneurysm compared to vaccinated and antibody negative patients (57.1% vs 27.5% and 30.3%, respectively p = 0.034). They were also more likely to have thrombosis (61.9% vs 33.3% and 52.6%, p = 0.019), and undergo thrombectomy (19.0% vs 4.3% and 3.9%, p=0.027).

Conclusions and Relevance

Our findings suggest that COVID-19 infection may lead to persistent endothelial dysfunction and hypercoagulability, portending increased severity of coronary artery ectasia and coronary thrombosis even after recovery from the initial infection.
Right ventricular dysfunction after coronary artery bypass grafting
Authors: Weiss T , Jensen J K , Vase H Ø , James S , Thelin S , Modrau I S
Published: November 2023

Background

Impaired right ventricular (RV) function is a frequent echocardiographic finding following coronary artery bypass grafting (CABG). It is subject of debate whether this finding reflects actual RV dysfunction with clinical impact, or rather limitations of the applied echocardiographic measurements.

Purpose

We aimed to investigate prevalence of RV dysfunction using currently available echocardiographic measurements, and self-reported physical capacity more than two years after CABG.

Materials and methods

This pre-specified cross-sectional substudy of the SWEDEGRAFT trial included patients scheduled for follow-up more than two years after elective CABG at our institution. The SWEDEGRAFT trial is an ongoing multicenter, randomized clinical trial comparing patency of saphenous vein grafts harvested with "no-touch" and open skeletonized technique. We prospectively assessed RV function with multivariable transthoracic echocardiography. Self-reported physical capacity was assessed using the three items for physical limitation of the Seattle Angina Questionnaire (SAQ-7) (3 denotes the worst and 15 the best possible physical capacity), as well as NYHA-class. Baseline and procedural data were retrieved from the SWEDEGRAFT trial. Preoperative echocardiographies were systematically reexamined.

Results

We enrolled 207 patients into our substudy at a median follow-up after CABG of 31.0 (range 24.2-39.9) months. RV function assessed by tricuspid annular plane systolic excursion (TAPSE) was significantly reduced compared to the preoperative assessment. In contrast, postoperative RV function as assessed by RV fractional area change (FAC) was preserved. Similarly, assessment of three-dimensional RV ejection fraction (3D-RVEF) indicated preserved RV function (mean 49.4 ± 6.3 %). Mean RV global longitudinal strain was -19.7 (±3.6), and mean RV free wall strain was -22.7 (±4.9). At follow-up, assessments of 3D-RVEF and strain modalities were obtainable in 51.7% and 72.4% of patients, respectively.

Patient-reported functional capacity was excellent (median score 15, interquartile range 1.5). NYHA-class improved significantly (NYHA-class I preoperative 49.4% vs. postoperative 61.4%, p=0.032). Postoperative median pro-Brain Natiuretic Peptide levels were 163 (interquartile range 195) ng/L.

Conclusion

RV systolic function was preserved more than two years after CABG when assessed by RV FAC and 3D-RVEF despite significant reduction in TAPSE. These findings likely reflect the increased sphericity of the RV following opening the pericardium during surgery. Our study supports that measurements of longitudinal systolic parameters likely underestimate RV systolic function after CABG.
Combined myocardial performance index as an echocardiographic predictor of prognosis in acute ST-elevation myocardial infarction
Authors: Hayrapetyan H G , Petrosyan H H , Tsaturyan A A , Torozyan S A , Hayrapetyan L H
Published: November 2023

Background

Myocardial infarction induces variable degrees of impairment in left ventricular (LV) systolic and diastolic functions. Right ventricular (RV) dysfunction can occasionally coexist with LV dysfunction. The most popular techniques for assessing systolic and diastolic function, respectively, the ejection fraction (EF) and transmitral flow, both have significant limitations. The myocardial performance index (MPI) is a single parameter that does not have these restrictions and can estimate both combined systolic and diastolic performance. We used the combined myocardial performance index (CMPI) (LV MPI + RV MPI) as a new predictor of prognosis in patients with ST-elevation myocardial infarction (STEMI).

Objectives

The purpose of this study was to evaluate the CMPI as an echocardiographic prognostic indicator in STEMI patients.

Methods

200 STEMI patients who underwent primary PCI were enrolled. Echocardiography was done within 24 h of clinical signs with measurement of LV MPI and RV MPI. The MPI was calculated as (isovolumic contraction time + relaxation time)/ejection time. The one-year cardiovascular mortality rate from the time of admission was selected as a prognostic indicator.

Results

The one-year cardiovascular mortality rate was 9% (18 patients). LV MPI was found to have a significant positive correlation with the development of 1-year death (p = 0.036), while CMPI was found to have a highly significant positive correlation (p = 0.0001). A cut-off point of MPI > 0.50 showed 65.9% specificity and 94.4% sensitivity for the prediction of one-year death (Area-0.659). On the other hand, a cut-off point of CMPI > 0.92 has shown 94.4% sensitivity and 95.1% specificity for identifying patients with a one-year death risk (Area - 0891).

Conclusions

The CMPI might be a strong prognostic predictor after acute STEMI.LVMPICMPI