bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome
Authors: Monteiro E , Pedro Barbosa J , Guimaraes J , Fernandes D , Costa G , Gomes A , Saleiro C , Campos D , Sousa J , Lopes J , Puga L , Teixeira R , Lourenco C , Madeira M , Goncalves L
Published: October 2021

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p<0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.
Predictors of patient and system delay for primary percutaneous coronary intervention
Authors: Candjondjo A , Ferreira J , Esteves A , Farinha J , Fonseca M , Coelho R , Gama L , Sa C , Lopes A , Fernandes A , Perdigao A , Seixo F , Fonseca N , Santos R , Caria R
Published: October 2021

Background

The delay times of the patient and the system for primary percutaneous coronary intervention (p-PCI) have a determining impact on the prognosis of patients with acute myocardial infarction with ST segment elevation (STEMI).

Purpose

To identify the predictors of patient and system delay for p-PCI in the period of 2020 at a reference hospital for p-PCI.

Methods

Patients submitted to p-PCI in the period from March to September 2020 were included and compared with the same period in 2019. We analyzed the differences between the two groups regarding the patient's delay times, time from the onset of symptoms to the first medical contact (FCM) and the system (time from the first contact with the health system to p-ICP). Data collection of the patient's previous history, coronary intervention performed and post-PCI follow-up was performed using the electronic patient record. Univariate analysis and logistic regression models from multivariate analysis were used to determine the predictors of “patient delay” and “system delay” and adjusted for confounding factors. The analysis was performed with a significance level of 5%.

Results

We included in the study 255 patients who underwent p-PCI, of which 122 in the period from 2020 and 133 in the period from 2019. Regarding the characteristics of the population, there were no significant differences between the two periods. Regarding the patient's delay time, there were no statistically significant differences. The variable first medical contact with a non p-PCI center was the only variable associated with system delay>90 minutes in the multivariate analysis, OR (6.18: 95% CI, 1.91–20), p=0.002. There was a statistically significant association between the period of 2020 (pandemic period) and total ischemia time, but with a negative effect, dependent variable adjusted for confounding factors [adjusted OR: −0.10; 95% CI: −107.61 to −5.57; p=0.03].

Conclusion

In this study, the patient's admission to a non p-PCI centers was identified as the only predictor of longer delay until p-PCI (system delay). However, these results should serve as a contribution to decision making in order to mitigate risks, regardless of any associated catastrophe and eventually alert the population not to neglect the symptoms suspected of acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: None.
Use of biomedical photonics for in vivo and in vitro assessment of haemostasis and microcirculation in patients on antithrombotic therapy
Authors: Matskeplishvili S , Gurfinkel Y U , Dyachuk L , Lugovtsov A , Ermolinskiy P , Pigurenko A , Priezzhev A , Matskeplishvili S
Published: October 2021

Background

Antithrombotic therapy in patients with cardiovascular disease requires rapid translation of laboratory assessment of haemorrheological parameters in clinical cardiology practice. Both antiplatelet and anticoagulant agents, especially when used in combination, can potentially increase the risk of severe bleeding. The precise balance between thrombosis and hemorrhage is therefore pivotal to ensure optimal treatment results.

Purpose

To develop simple and reliable methods to control the haemorheological properties of the blood and to assess the risk of potential bleeding.

Methods

We assessed platelet aggregation parameters measured in vitro by laser aggregometry and optical trapping techniques in blood samples of 131 patients with coronary artery disease. Additionally, blood rheology and microcirculation parameters were assessed in vivo in the nail-fold area using the digital capillaroscopy system.

Results

We found a statistically significant correlation between the number of aggregated blood cells in vitro and the presence of aggregates in the blood capillaries in vivo. A significant correlation was also observed between red blood cells (RBC) aggregation time in vitro and capillary flow velocity in vivo. The most severe deterioration of the rheological properties was found in patients with diffuse atherosclerotic disease receiving combined antithrombotic therapy.

Interestingly, optical examination of soft tissues surrounding the capillaries of the nail-fold area revealed the presence of micro-hemorrhages in patients with history of hemorrhagic complications on antithrombotic therapy (Fig. 1).

Conclusion

Novel methods of biomedical photonics applied for in vivo and in vitro assessment of the blood haemorrheological properties can provide important additional information on microcirculation parameters and optimize treatment in patients on antithrombotic therapy.

Funding Acknowledgement

Type of funding sources: None. In vivo nail-fold digital capillaroscopy
Post-procedure anticoagulation in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention
Authors: Yan Y , Gong W , Ma C , Wang X , Smith Jr S C , Fonarow G , Morgan L , Liu J , Vicaut E , Zhao D , Montalescot G , Nie S ,   the CCC-ACS Investigators
Published: October 2021

Background

Post-procedural anticoagulation (PPAC) after primary percutaneous coronary intervention (pPCI) in patient with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use.

Methods

Using data from the CCC-ACS registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting (IPTW) and Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality, and the primary safety endpoint was major bleeding.

Results

Of 34,826 evaluable patients 26,272 (75.4%) were treated with PPAC, and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After IPTW adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs. 1.8%; hazard ratio (HR): 0.62 [95% confidence interval 0.43, 0.89]; p<0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs. 2.2%; HR: 1.05 [0.83, 1.32]; p=0.14).

Conclusions

PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Improving Care for Cardiovascular Disease in China – Acute Coronary Syndrome (CCC-ACS) project is a collaborative study of the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC). The AHA has been funded by Pfizer and AstraZeneca for quality improvement initiatives through an independent grant. In-hospital clinical outcomes
Different inflammatory markers reflect different platelet reactivties in percutaneous coronary intervention patients treated with clopidogrel: a large sample study from China
Authors: Li J , Yuan D , Yang Y , Gao R , Xu B , Yuan J , Zhao X ,   State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases
Published: October 2021

Background

Platelet reactivity is closely associated with thrombosis and bleeding events in percutaneous coronary intervention (PCI) patients treated with clopidogrel. Inflammation also plays a crucial role in the development of coronary heart disease. How inflammation affects platelet reactivity needs furthrt study.

Aim

To investigate the association of inflammatory markers including leukocyte count and high-sensitivity C reactive proteins (hs-CRP) with platelet reactivity in PCI patients treated with clopidogrel.

Method

A total of 6772 PCI patients treated with clopidogrel who have the results of postoperative thromboelastogram (TEG) from January 2013 to December 2013 were enrolled. High on-treatment platelet reactivity (HTPR) was defined as adenosine diphosphate (ADP)-induced platelet maximum amplitude [MA(ADP)] of TEG >47 mm, and low on-treatment platelet reactivity (LTPR) was defined as MA(ADP) <31 mm.

Results

Among 6772 PCI patients, 2070 (30.57%) presented HTPR and 2568 (37.92%) presented LTPR. As for LTPR, multivariate logistic regression showed that increased leukocyte count (OR 1.153, 95% CI 1.117–1.191) and decreased hs-CRP (OR 0.920, 95% CI 0.905–0.936) were independent predictors, along with diabetes mellites (OR 0.868, 95% CI 0.759–0.993), hemoglobin (OR 1.023, 95% CI 1.019–1.028), platelet count (OR 0.997, 95% CI 0.996–0.998), and glucose (OR 0.962, 95% CI 0.931–0.994). As for HTPR, multivariate logistic regression showed that decreased leukocyte count (OR 0.885, 95% CI 0.854–0.917) and increased hs-CRP (OR 1.094, 95% CI 1.077–1.112) were independent predictors, along with sex (OR 0.636,95% CI 0.537–0.754), hemoglobin (OR 0.972, 95% CI 0.968–0.977), platelet count (OR 1.005, 95% CI 1.004–1.007), and glucose (OR 1.056, 95% CI 1.020–1.092).

Conclusions

This was the first large real-world study reporting that increased leukocyte count associated with more LTPR while increased hs-CRP associated with more HTPR in PCI populations treated with clopidogrel, which may contribute to understand the potential mechanism of the effect of inflammation on thrombosis and bleeding in patients with PCI.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Key Research and Development Program of China; Young and middle-aged talents in the XPCC Science and Technology Project
Role of inflammation in Myocardial Infarction with Non-Obstructive Coronary Arteries
Authors: Espinosa Pascual M J , Lopez Pais J , Izquierdo Coronel B , Nieto Ibanez D , Galan Gil D , Perela Alvarez C , Olsen Rodriguez R , Abad Romero R , Moreno Vinues C , Fraile Sanz A , Awamleh Garcia P , Mata Caballero R , Alonso Martin J J ,   IMACORN
Published: October 2021

Background

The characteristics of patients with Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) differ from those with Myocardial Infarction with Obstructive Coronary Artery Disease (MI-CAD). Thus, the mechanisms involved, such as inflammation, may be different. The objective of this study is to analyze the relationship between pro-inflammatory conditions and MINOCA, as well as the impact on their prognosis.

Methods

An analytical and observational study, including all patients admitted to our hospital with myocardial infarction and who underwent coronary angiography in the last four years (2016–2020; n=712). According to the definitions of the 2019 AHA Scientific Statement on Diagnosis and Management of MINOCA and ESC 2020 guidelines on Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation, we classified the patients into two groups: MI-CAD (n=643) and MINOCA (n=69). Besides general data, we recorded specific information about pro-inflammatory conditions (prevalence of autoimmune diseases, connective tissue disorders, and active infections and neoplasms). We also assessed C-reactive protein (C-RP) at admission, peak CK-MB and troponin levels. Follow-up analysis included death from any cause, major adverse cardiac events (MACE: cardiac death, MI, stroke), readmissions due to cardiovascular causes, and in-hospital mortality.

Results

The composite of pro-inflammatory conditions (autoimmune pathologies, connective tissue diseases and active cancer and infections) was significantly higher in the MINOCA group (30.4% vs 14.6%, p<0.001). Patients with MINOCA had higher rates of connective tissue disorders (5.8% vs 1.4%, p 0.01), and autoimmune diseases (14.5% vs 7.8%, p 0.058) tended to be more frequent in these patients. However, MINOCA patients had lower C-RP levels (180 vs 206mg/L, p<0.001), probably because they have smaller infarcts (peak CK-MB: 228 vs 325 U/L, p<0.001; high-sensitivity cardiac troponin T levels: 111 vs 176ng/L, p<0.001). In the follow-up of MINOCA patients, MACE did not occur more frequently in those patients with inflammatory conditions (4.8% vs 13%, p 0.3) than those without them. Moreover, pro-inflammatory disorders were not related to significantly higher mortality from any cause (8.7% vs 10%, p 0.86) nor readmissions due to cardiovascular causes (19.6% vs 23.8%, p 0.6). Our median follow-up was 29 months. There were no differences in in-hospital mortality.

Conclusion

This study suggests that pro-inflammatory disorders may be a risk factor for developing MINOCA without resulting in an unfavourable short- and long-term prognosis. Further research is needed to confirm this finding and identify its optimal management.

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of anemia in patients with ST-elevation myocardial infarction
Authors: Costa R , Frias A , Campinas A , Luz A , Santos M , Torres S
Published: October 2021

Introduction

Haemoglobin (Hb) levels are an important outcome predictor in several diseases.

Purpose

We aimed to evaluate Hb at hospital admission in patients with ST-segment elevation myocardial infarction (STEMI) as a predictor of in-hospital complications, mortality and heart failure (HF) during follow-up.

Methods

We retrospectively studied consecutive STEMI patients treated with primary percutaneous coronary intervention between January 2010 and December 2016. Clinical data was retrieved by review of patients' clinical records. Severity of anaemia was defined according World Health Organization cut-offs.

Results

Of 864 patients with mean age of 63±13 years, 646 (75%) were male. Mean Hb at hospital admission was 14±2g/dL, 682 (81%) with normal Hb, 118 (14%) with mild anaemia, 45 (5%) with moderate anaemia and 2 (0.2%) with severe anaemia. Female gender, smoking, diabetes, hypertension, previous myocardial infarction and peripheral artery disease were associated to higher incidence of anaemia at hospital admission. Anaemia was also associated to Killip-Kimball (KK) class ≥II at hospital admission. They also had higher incidence of in-hospital stroke, advanced atrioventricular block, gastrointestinal bleeding and blood transfusion. In-hospital mortality was 9%, higher patients with anaemia (13% vs 7%, p=0.022). Median follow-up was 43 (26–66) months. All-cause mortality was 14%, higher in patients with anaemia (27% vs 11%, p<0.001, Log rank test p<0.001). In multivariate analysis, age (HR 1.1, 95% CI 1.0–1.1), diabetes (HR 1.9, 95% CI 1.1–3.4), left ventricular ejection fraction (LVEF) at discharge (if <50%, HR 3.4, 95% CI 1.6–7.2), and anaemia at admission (HR 1.8, 95% CI 1.0–3.2) were independent predictors of all-cause death during follow-up. Incidence of de novo HF, clinical worsening or hospitalization was 18%, higher in patients with anaemia (27% vs 17%, p=0.007, Log rank test p=0.007). In multivariate analysis, age (HR 1.1, 95% CI 1.0–1.1), KK class (if II, HR 2.1, 95% CI 1.3–3.5; if III, HR 4.0, 95% CI 1.8–8.9; if IV, HR 2.1, 95% CI 1.2–3.9), body mass index (if obese, HR 2.5, 95 CI 1.4–4.4) and LVEF at discharge (if <50%, HR 4.2, 95% CI 2.2–7.7), but not anaemia at admission (p=0.633) were independent predictors HF.

Conclusion

In our contemporary cohort of STEMI patients, the presence of anaemia at hospital admission was not only associated to in-hospital complications, but also all-cause mortality during follow-up.

Funding Acknowledgement

Type of funding sources: None.
Location and impact of the infarct-related artery in acute coronary syndrome: insight from the Swiss SPUM- ACS cohort
Authors: Adjibodou B , Obeid S , Kraler S , Denegri A , Mach F , Matter C M , Nanchen D , Roffi M , Muller O , Raeber L , Luescher T
Published: October 2021

Background

Identifying the infarct-related artery (IRA) in patients with acute coronary syndromes (ACS) has prognostic and therapeutic implications.

Purpose

We aimed to evaluate the distribution, clinical presentation and impact of the culprit lesion location on long-term outcomes in ACS patients treated with primary percutaneous coronary intervention, medication and secondary prevention according to Guidelines.

Methods

Patients referred for ACS to one of the participating centres of the observational SPUM-ACS study between 2009 and 2017 with one year outcomes and independent events adjudication were included. The distribution of IRA, clinical presentation (STEMI/NSTEMI) and impact of IRA location on major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, target vessel revascularisation) at one year were investigated.

Results

4'546 patients were included with 55% presenting as STEMI (mean age 62-years; 20% women), 42% as NSTEMI and 3% as unstable angina. The left anterior descending (LAD) artery was involved in 44.3%, the right coronary artery (RCA) and left circumflex artery (LCX) in 32.9% and 20%, respectively. Proximal and middle segments of the 3 main vessels were more often the culprit location compared to distal segments and side branches (78% versus. 22%). Left main (LM) and bypass graft were rarely involved (1.6% and 1.2% respectively), but most often responsible to overall cardiac dysfunction (higher NT-proBNP and hs troponin levels). Patients with an occluded IRA at angiography usually presented as STEMI on ECG (100% for LM, 90.5% for LAD territory, 83.8% for RCA territory, 56.6% for LCX territory). However 43.1% of patients with occluded LCX presented as NSTEMI. These patients were prone to extensive cardiac damage and significantly higher hs troponin levels as compared to those with patent LCX or STEMI presentation (626 ng/l vs 310 ng/l and 626 ng/l vs 580 ng/l respectively, p<0.001). Overall, 1-year MACE occurred in 11.8%. In native coronaries, the location of IRA had no impact on outcomes (20% LM, 10.9% LAD, 11.8% RCA, 11.8% LCX, p=0.112). However, in NSTEMI-ACS there were twice as many events when the LM was the IRA (MACE 20%, p=0.023) and 3-times higher when a bypass-graft was the IRA (33.9%, p=0.0001).

Conclusions

ST elevations are highly suggestive of an occluded IRA. However more than 40% of patients presenting with ACS involving an occluded LCX did not demonstrate ST-elevation and were prone to extensive cardiac damage, urging the necessity for early invasive measures in these patients. In native coronaries the IRA location did not affect outcomes except in NSTEMI with LM involvement or ACS with bypass grafts as IRA that had much worse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): - Swiss National Research Foundation - Zurich Heart House
The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion
Authors: Calvao J , Braga M , Silva J C , Campinas A , Alexandre A , Brochado B , Amador A F , Costa C , Pinto R J , Proenca T , Carvalho M , Marques C , Cabrita A , Silveira J , Macedo F
Published: October 2021

Introduction

Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes.

Methods

In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)].

Results

Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68).

Conclusion

A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients.

Funding Acknowledgement

Type of funding sources: None.
High concentrations of plasma trimethylamine-n-oxide is associated with long-term cardiovascular mortality in patients with acute coronary syndrome
Authors: Eyileten C , Jarosz-Popek J , Jakubik D , Wolska M , Fitas A , Czajka P , Nowak A , Ufnal M , Postula M , Toma A , Lang I , Siller-Matula J M ,   I-COMET
Published: October 2021

Background

Acute coronary syndrome (ACS) remains a leading cause of mortality worldwide [1]. Patients who experienced ACS are at high risk of future cardiovascular events and death [2–4]. Identification of reliable predictive tools could potentially improve the risk stratification [5]. Numerous studies revealed that intestinal microbial organisms (microbiota) and its metabolites, as TMAO (trimethylamine-N-oxide) may play a pathogenic role in a cardiovascular disease (CVD) and ACS [6]. Elevated concentration of circulating TMAO has been associated with increased risk of CVD and major adverse cardiac events (MACE), including myocardial infarction (MI), stroke, major bleeding and all-cause mortality [7].

Purpose

To investigate the association of liver metabolite TMAO with cardiovascular disease (CV)-related and all-cause mortality in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention.

Methods

Our prospective observational study enrolled 292 patients with ACS. Plasma concentrations of TMAO were measured during the hospitalization for ACS. Observation period lasted 7 years in the median. Adjusted Cox-regression analysis was used for prediction of mortality.

Results

ROC curve analysis revealed that increasing concentrations of TMAO levels assessed at the time point of ACS significantly predicted the risk of CV mortality (c-index=0.78, p<0.001). The cut-off value of >4 μmol/L, labeled as high TMAO level (23% of study population), provided the greatest sum of sensitivity (85%) and specificity (80%) for the prediction of CV mortality and was associated with a positive predictive value of 16% and a negative predictive value of 99%. A multivariate Cox regression model revealed that high TMAO level was a strong and independent predictor of CV death (HR=11.62, 95% CI: 2.26–59.67; p=0.003). High TMAO levels as compared with low TMAO levels were associated with the highest risk of CV death in a subpopulation of patients with diabetes mellitus (27.3% vs 2.6%; p=0.004). Although increasing TMAO levels were also significantly associated with all-cause mortality, their estimates for diagnostic accuracy were low.

Conclusions

High TMAO level is a strong and independent predictor of long-term CV mortality among patients presenting with ACS. TMAO concentration of 4 μmol/L may be a cut-off value for prognosis of ACS patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier curvesTable 1
Circulating endothelial progenitor cells as predictors of long-term cardiovascular mortality after myocardial infarction: which definition should we use?
Authors: De Almeida Fernandes D , Leal V , Oliveiros B , Silva S , Goncalves L , Fontes Ribeiro C , Antonio N
Published: October 2021

Background

Endothelial progenitor cells (EPCs) are bone marrow-derived cells that play a crucial role in vascular repair after an acute myocardial infarction (AMI). Recent studies suggest that circulating EPCs levels may be useful as a surrogate biomarker for cardiovascular (CV) events. Nevertheless, the lack of a consensual definition and phenotypic characterization of EPCs hampers its use in clinical practice. CD34+KDR+, CD45dimCD34+KDR+ and CD34+CD133+KDR+ are among the most used antigenic phenotypes to define circulating EPCs but the best phenotype to predict CV outcomes remains to be determined.

Purpose

To determine the EPCs' surface phenotype that best predicts long-term CV death after an AMI, and to evaluate its optimal cut-off point.

Methods

One-hundred AMI patients were prospectively enrolled in the study. Circulating EPCs were quantified through high-performance flow cytometer within the first 24 hours of admission using different surface markers combinations allowing to simultaneously compare three EPCs definitions: 1) CD34+KDR+, 2) CD45dimCD34+KDR+, 3) CD34+CD133+KDR+. Mean follow-up time was 8.0±2.2 years.

Results

The mean age of our population was 59.7±11.0, the majority of patients were male (90%), 65% had ST-elevation myocardial infarction (STEMI) and 35% non-ST segment elevation myocardial infarction (NSTEMI). Diabetes mellitus was present in 38% and hypertension in 67% of the studied sample. During the long-term follow-up, 34 patients had re-admissions due to cardiovascular causes, 11 of them for AMI. Thirty-one patients had major adverse cardiovascular events (MACE) and 19 died.

Using ROC curves, the CD34+KDR+ phenotype showed the biggest area under the curve regarding prediction of CV mortality (0.722; p=0.010; confidence interval 95% (CI95%): 0.554 to 0.890). Patients with lower levels of EPCs according to this definition (≤0.022%) are 7 times more likely to die from CV causes at any time (hazard ratio = 7.55; p=0.008; CI95% 1.69 to 33.83).

Conclusion

The CD34+KDR+ phenotype appears to be the best definition of circulating EPCs for predicting long-term CV mortality after AMI. Further studies with larger samples are needed to clarify the optimal cut-off point for determining patients at risk and its role in everyday Cardiology.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Bolsa de Estudo João Porto da Sociedade Portuguesa de Cardiologia CD34+KDR+ as a predictor of CV death
Colchicine and quality of life in patients with acute coronary syndromes: results from the COPS randomized trial
Authors: Dawson L , Quinn S , Tong D , Boyle A , Hamilton-Craig C , Adams H , Layland J
Published: October 2021

Background

Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes.

Methods

Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo).

Results

Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p<0.001). No significant differences in adjusted mean score change among any of the EQ-5D-5L or SAQ dimensions were observed between treatment groups in either intention-to-treat or per-protocol analysis. There were borderline interactions in EQ-5D-5L scores for those with previous MI vs not, and in SAQ scores for those with obesity vs not. In categorical analysis using observed data, patients treated with colchicine were more likely to have clinically significant improvement in physical limitation score over the period (36% improved vs. 28%, P<0.05). Baseline health status scores were not associated with the primary endpoint at 12 months.

Conclusions

Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University
Clinical characteristics and outcomes of myocardial infarction with nonobstructive coronary arteries
Authors: Wong C J , Yap J , Gao F , Lau Y H , Huang W , Yeo K K ,   SingCLOUD
Published: October 2021

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is caused by a heterogenous group of conditions with clinically significant sequelae.

Purpose

This study aims to compare the clinical characteristics and prognosis of MINOCA with myocardial infarction with obstructive coronary artery disease (MICAD).

Methods

Data was obtained from the Singapore Cardiac Longitudinal Outcomes Database (SingCLOUD), a national multicenter registry of patients with cardiovascular disease. Patients with a first presentation of acute myocardial infarction who underwent coronary angiography between 1 January 2011 and 31 December 2014 were extracted from the database. Follow up was conducted until 31 December 2017. Subjects were classified as having either MICAD or MINOCA based on angiographic findings. The primary outcomes were all-cause mortality and major adverse cardiac events (MACE) defined as a composite of all-cause mortality, recurrent myocardial infarction, hospitalization for heart failure and ischemic stroke.

Results

All 4124 patients who met the inclusion criteria were included in this study, of which 159 (3.9%) were diagnosed with MINOCA. Patients with MINOCA were more likely to be female, present with a non-ST elevation myocardial infarction (NSTEMI), have a higher left ventricular ejection fraction and less likely to have diabetes mellitus, previous ischemic stroke or smoking history. Over a mean follow-up duration of 4.5 years, MINOCA patients had a lower incidence of all-cause mortality (10.1% vs. 16.5%, p=0.030) and MACE (20.8% vs. 35.5%, p<0.0001) compared to patients with MICAD. On multivariable analysis, patients with MINOCA had a significantly lower risk of all-cause mortality (HR 0.42; 95% CI 0.21–0.82; p=0.011), MACE (HR 0.42; 95% CI 0.26–0.69; p=0.001) and recurrent myocardial infarction (HR 0.35; 95% CI 0.15–0.85; p=0.021). Within the MINOCA group, older age, higher creatinine, a STEMI presentation and the absence of antiplatelet use predicted all-cause mortality and MACE.

Conclusions

While patients with MINOCA had better clinical outcomes compared to MICAD patients, MINOCA is not a benign entity with about one in five patients experiencing a major adverse cardiovascular event in the mid-term.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Project Grant
Differences between Takotsubo and the working diagnosis of myocardial infarction with non-obstructive coronary arteries
Authors: Lopez-Pais J , Izquierdo Coronel B , Raposeiras-Roubin S , Alvarez Rodriguez L , Uribarri A , Almendro-Delia M , Galan Gil D , Vedia O , Lopez Otero D , Espinosa Pascual M J , Garcia Acuna J M , Gonzalez-Juanatey J R , Alonso Martin J J , Perez De Juan Romero M A , Nunez-Gil I ,   Retako
Published: October 2021

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the XXXX1 registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centers (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p<0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p<0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p<0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p<0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in global mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

Compared to the rest of MINOCA, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding sources: None. Central Illustration
Dispatch of lay-responders is associated with bystander cardiopulmonary resuscitation, bystander defibrillation and 30-day survival following an out-of-hospital cardiac arrest
Authors: Jonsson M J , Berglund E B , Ringh M R ,   ESCAPE-NET
Published: October 2021

Background

Dispatch of lay-responders in out-of-hospital cardiac arrest (OHCA) is increasingly common and the recent European Resuscitation Council (ERC) guidelines has a strong recommendation in using these systems. Some previous studies with various study designs have shown associations with increased survival rates. We aim to investigate if the dispatch of lay-responders increases bystander cardiopulmonary resuscitation (CPR) rates, AED usage, and 30-day survival following an OHCA.

Methods

We included all OHCA in the two most populous regions in Sweden. OHCAs occurring during hours where the lay-responder system was not active were excluded as well as cases where the OHCA was witnessed by EMS. Risk ratios (RR) were calculated using modified Poisson regression adjusted for age, sex, location, witnessed status, EMS response time and hour of the day. Continuous variables were used as restricted cubic splines.

Results

We included 5217 OHCAs between January 2016 and December 2019. In 2327 cases the lay-responder system was activated and in 2890 the system was not activated. The proportion receiving bystander CPR was 71.4% where the system was activated compared to 59.9% when not. The corresponding number for AED attachment was 10.4% vs. 7.2% and for bystander defibrillation the number was 7.2% vs. 4.1%. The proportion of patients alive after 30 days was 10.6% when the system was activated and 8.3% when it was not activated.

The adjusted RR for bystander CPR was 1.37 (1.31–1.43). For AED attachment the RR was 1.48 (1.21–1.82) and for bystander defibrillation the RR was 1.92 (1.34–2.75). For 30-day survival the RR was 1.29 (1.04 – 1.60).

Conclusion

Dispatch of lay-responders in OHCA is associated with bystander CPR, AED attachment, bystander defibrillation, and 30-day survival. These results supports the ERC guidelines that recommends the introduction of similar lay-responder systems.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020
Who arrives first: EMS, fire-fighter or lay responder? The rally to the suspected out-of-hospital cardiac arrest
Authors: Berglund E , Ringh M , Claesson A , Svensson L , Jonsson M ,   Centre for Resuscitation Science, KI
Published: October 2021

Background

Time is the crucial factor for “the chain of survival” in Out-of-Hospital Cardiac Arrest (OHCA). We aimed to compare different response time intervals for dispatched lay responders, fire fighters and emergency medical services (EMS).

Methods

Mobile phone dispatched lay responders in two large Swedish regions (4 million inhabitants) were positioned and timed from alert until arrival to the place of the suspected OHCA. For each suspected OHCA the first arriving lay responder was compared to the first arriving EMS and first fire fighter unit. Time intervals, from witness call-to-dispatch and dispatch-to-arrival was measured.

Results

During 22 months a total of 2631 suspected OHCAs were included. The median time from call-to-dispatch was 1.8 (95% CI: 1.7–1.8) for EMS, 2.9 (95% CI: 2.8–3.0) for fire-fighter units and 3.0 (95% CI: 2.9–3.1) for lay responders. The median time from dispatch-to-arrival was 8.3 (95% CI: 8.1–8.5) for EMS, 6.8 (95% CI: 6.7–6.9) for fire fighters and 6.0 (95% CI: 5.7–6.2) for lay-responders who tried to fetch an AED and 4.6 (95% CI: 4.5–4.8) minutes for lay-responders who ran to perform bystander CPR.

Conclusion

First arriving lay responder have the shortest dispatch-to-arrival time when compared to both fire fighters and EMS. However, this advantage is diminished by a one-minute delay compared to EMS until they are alerted. New solutions are needed for the fully use of mobile dispatched lay responders.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020, For the ESCAPE-NET investigators
ADP-receptor antagonists in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis
Authors: Kleeberger J A , Ouarrak T , Freund A , Fuernau G , Geissler T , Huber K , Noc M , Montalescot G , Clemmensen P , Zeymer U , Desch S , Schneider S , Hausleiter J , Thiele H , Orban M
Published: October 2021

Purpose

The purpose of this pooled analysis is to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated with either clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Patients from the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial were included.

Methods and results

For the current analysis, the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. Eight hundred fifty-six patients were eligible for analysis. Of these, five hundred seven patients (59.2%) received clopidogrel, one hundred seventy-eight patients (20.8%) prasugrel and one hundred seventy-one patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj=0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj=0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20–0.69, padj=0.002) and not different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43–1.24, padj=0.24), see Table 1.

Conclusion

This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that an acute therapy with either clopidogrel, prasugrel or ticagrelor is no predictor of 1-year mortality. Treatment with ticagrelor seems to be associated with less in-hospital moderate and severe bleeding events in comparison to clopidogrel.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart FoundationEuropean Union 7th Framework Program
Clinical and echocardiographic trends in percutaneous balloon mitral valvuloplasty
Authors: Koren O , Israeli A , Rozner E , Darawshly N , Turgeman Y
Published: October 2021

Background

The prevalence of Rheumatic Mitral Stenosis (MS) has significantly changed over the last decades. We intend to examine patient demographics, Echocardiographic characteristics, procedural success rates, and complications throughout 30-years.

Methods

We conducted a single-center descriptive observational study. The study population consists of patients undergone percutaneous balloon mitral valvuloplasty (PBMV) at Emek Medical Center in Israel from January 1990 to May 2019.

Results

Four hundred seventeen patients underwent PBMV during the study period and were eligible for the study. Age did not change significantly over time (p=0.09). The prevalence of Male and patients who were smoking and had multiple comorbidities such as hypertension, dyslipidemia, ischemic heart disease, and chronic kidney disease became increases over time (p=0.02, p=0.02, p=0.001, p=0.01, p=0.02, and p=0.001, respectively). Wilkins score and all its components increased over time, and the total score was higher in females (p=0.01). Seventy-nine (18.9%) patients had complications. The rate of complications did not change over decades. Patients with Wilkins score >8, post-procedural MR of ≥2, and post-procedural MVA <1.5 had the highest risk for the need of Mitral valve replacement (MVR) surgery in 2 years following PBMV (3.64, 4.03, 2.44, respectively, CI 95%, p<.0001 for all). The median time in these patients was 630 days compared to 4–5 years in the entire population. Patients with Post-procedural MR of ≥2 and post-procedural MVA <1.5 had ten times risk for developing heart failure (HR 9.07 and 10.06, respectively, CI 95%, P<.0001)

Conclusion

Our research reveals trends over time in patients' characteristics and echocardiographic features. Our study population consists of more male patients with multiple comorbidities and more complex and calcified valvular structures in the last decade. Wilkins score >8, post-procedural MR of ≥2, and post-procedural MVA <1.5 cm2 were in-depended predictors for the time for surgery and heart failure hospitalization.

Funding Acknowledgement

Type of funding sources: None.