bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between cholesterol crystals and 6-month prognosis in patients with acute coronary syndrome: an optical coherence tomography study
Authors: Chen J , Luo D , Xu J Y , Xu C W , Huang B , Jiang H
Published: November 2023

Background

Optical coherence tomography (OCT) guided percutaneous coronary intervention (PCI) has been demonstrated to improve short and long-term outcomes compared with standard angiography-guided PCI. However, little is known about the impact of cholesterol crystals on the prognosis of patients with acute coronary syndrome (ACS) in the setting of receiving OCT-guided PCI.

Purpose

This study aims to investigate the association between cholesterol crystals and 6-month outcomes in ACS patients who underwent OCT-guided PCI.

Methods

Patients with ACS who underwent OCT-guided PCI in a high-volume PCI center between July 2020 and June 2022 were retrospectively enrolled and were further divided into two groups according to the presence or absence of cholesterol crystals. OCT imaging characteristics including plaque morphology before the PCI procedure in target lesions were assessed. The primary outcome was a composite of all-cause death, ischemia-driven revascularization, or readmission for heart failure in a 6-month follow-up period. The association between cholesterol crystals and 6-month outcomes was evaluated using Kaplan-Meier curves. Independent predictors for cholesterol crystals and 6-month outcomes were evaluated by the logistic regression and Cox proportional hazards regression analyses, respectively.

Results

403 patients were enrolled in this study. The mean age was 61 years old and 79.4% were men. Cholesterol crystals were presented in 224 (55.6%) target lesions in patients with ACS. Baseline characteristics were not statistically different between the two groups in age, sex, smoke, previous hyperlipidemia, and other clinical features, except for diabetes, multivessel disease, and ACS classification (p <0.05). In the multivariable logistic regression analysis, cholesterol crystals were associated with diabetes, plaque rupture, lipid length, calcification, macrophage infiltration, and thin-capped fibroatheroma (all p <0.05). Patients with cholesterol crystals had higher risks of poor 6-month composite outcomes when compared to those without cholesterol crystals (13.4% vs. 6.7%, HR 2.09, 95%CI 1.07-4.09, p = 0.031), even after confounders adjustment for age, sex, diabetes, multivessel disease and ACS classification using inverse probability of treatment weighting (p = 0.027). Subgroup analysis showed significant interactions between cholesterol crystals and 6-month outcomes with respect to the male (HR 2.82, 95%CI 1.22-6.51, p = 0.015), target lesions in LAD (HR 4.47, 95%CI 1.29-15.44, p = 0.018), and incomplete revascularization (HR 3.08, 95%CI 1.04-8.98, p = 0.042). The Cox regression analysis identified cholesterol crystal as an independent predictor for 6-month composite outcomes (HR 2.12, 95%CI 1.08-4.19, p = 0.030).

Conclusions

The presence of cholesterol crystals was associated with a poor 6-month prognosis in patients with ACS, even in the setting of receiving OCT-guided PCI.
Minimum stent area, stent expansion and ultrasonic flow ratio post pci: insights from multivessel talent trial
Authors: Chenniganahosahalli Revaiah P , Kageyama S , Kotoku N , Masuda S , Wang B , Xingqiang H , Tsung-Ying T , Wlodarczak A , Moellmann H , Sharif F , Silvestri M , Tu S , Onuma Y , Serruys P W
Published: November 2023

Background

Ultrasonic flow ratio (UFR) is a novel method for fast computation of fractional flow reserve (FFR) from intravascular ultrasound. Recently studies have shown the feasibility of morphofunctional computational methods to reliably estimate coronary physiology from intravascular ultrasound images.

Purpose

To assess minimum stent area and stent expansion and its relation to ultrasonic flow ratio post percutaneous coronary intervention.

Methods

The study population consisted of 150 consecutive patients (280 vessels) who underwent intravascular ultrasound for optimization of PCI for three vessel disease as mandated in the ongoing MULTIVESSEL TALENT trial (NCT04390672). The UFR analysis was performed at the CORRIB Core Lab by an analyst who was blinded to the clinical data using a prototype software package (IvusPlus prototype, Pulse Medical Imaging Technology, Shanghai, China). The stent expansion and minimum stent area was automatically detected by the software.

Results

The median and mean UFR of 280 vessels post-PCI was 0.94 (0.91-0.97).and 0.93±0.04, respectively. Twenty three percent (n=115) of the 280 vessels had a UFR less than 0.91.The average minimum stent area (MSA) among the population was 5.82 ± 1.95 mm2. The mean stent expansion among the population was 97% ± 22%. We compared the site reported MSA with the software derived MSA which showed strong correlation (r=0.859; P<0.001). There was no correlation between MSA and UFR (r= -0.13, P=0.81). The stent expansion among patients who had UFR <0.91 when compared to ≥0.91 was significantly lower (82% vs 98%, P<0.001). The delta UFR within the stent was significantly higher in patients who had a UFR<0.94 vs ≥0.94 (0.06 vs 0.02; P<0.01). Delta UFR within the stent was higher when the stent expansion was <80% and <90% when compared to >80% and >90% (0.07 vs 0.03; P<0.01) and (0.06 vs 0.02; P<0.01) respectively.

Conclusion

Combination of IVUS and FFR enables the operator to conform to highest standards in PCI. This study demonstrates that UFR is not related to the minimum stent area, and patients who have UFR <0.94 have sub-optimal stent expansion.MSA and UFRUFR and Stent expansion
Adjunct remote ischemic conditioning to PCI in ST-segment elevation myocardial infraction patients: Systematic review and meta-analysis
Authors: Desouki Mariam Tarek M D , Elzankaly Osama O Z , Helmi Ahmed A H , Ramadan Shrouk S R , Hakim Diaa D H
Published: November 2023

Introduction

ST-segment elevation myocardial infarction (STEMI) is the most dangerous presentation of the acute coronary syndrome (ACS). Throughout the last three decades, clinicians have been attempting to reduce the short and long-term major adverse cardiac events (MACE) associated with STEMI. Remote ischemic conditioning (RIC) is one of the new adjunctive modalities to PCI in treating STEMI patients whereby brief reversible episodes of ischemia and reperfusion are applied to the tissue (by alternative cycles of inflation and deflation of a blood pressure cuff on the upper or lower limb) confers global protection and renders remote tissues resistant to ischemia/reperfusion injury.

This review aims to provide reliable evidence from published randomized controlled trials (RCTs) regarding whether RIC is beneficial for STEMI patients or not.

Methods

We followed the PRISMA guidelines during the preparation of this systematic review and meta-analysis. A computer literature search for (PubMed, Web of Science, Scopes, and Google Scholar) was carried out. We included RCT, comparing the remote ischemic conditioning, regardless of its timing of application to PCI, with either placebo or sham procedure, in terms of both short-term and long-term cardio protection. Outcomes of myocardial salvage index, myocardial infarction size, and left ventricular ejection fraction were pooled as the standardized mean difference between the two groups from baseline to endpoint.

Results

11 RCTs (7151 patients), were included in this analysis. The overall effect on short-term outcomes, was in favor of PCI only in terms of myocardial salvage index(P value=0.04, 95% CI [0.00-0.08]), and left ventricular ejection fraction(P value=0.05, 95% CI [0.02,2.16]), while the adjunctive application of remote ischemic conditioning was beneficial in terms of: myocardial infarct size ( P value=0.004, 95% CI [-3.22,-0.62]).

Regarding the long-term outcomes, the overall effect did not show any benefit in either of the two groups in terms of: major adverse cardiac and cerebrovascular events (MACCE) (P value=0.13, 95% CI [0.48,1.10]), hospitalization for heart failure (P value=1.00, 95% CI [0.83,1.20]), and cardiac death (P value=0.91, 95% CI [0.73,1.32]).

Conclusion

The adjunctive application of RIC to PCI during treatment of STEMI patients showed a beneficial effect only on short-term reduction of myocardial infarct size, nevertheless, it was not of benefit regarding the other short and long-term metrics of myocardial salvage and left ventricular function.
Eicosapentaenoic acid, arachidonic acid, and triglyceride levels mediate most of the benefit of icosapent ethyl in REDUCE-IT
Authors: Szarek M , Bhatt D , Miller M , Steg P G , Brinton E A , Jacobson T A , Tardif J C , Ballantyne C M , Ketchum S B , Pineda A L , Dunbar R L , Siri-Tarino P W , Mason R P
Published: November 2023

Background

In REDUCE-IT, icosapent ethyl (IPE) reduced major adverse cardiovascular (CV) events (MACE) relative to placebo (PBO) in 8179 statin-treated patients with residual hypertriglyceridemia and high CV risk. Questions have been raised about the mechanisms of benefit of IPE and the potential effects of the pharmaceutical grade mineral oil PBO on the results.

Purpose

The contributions of eicosapentaenoic acid (EPA), arachidonic acid (AA), triglycerides (TG), and other biomarkers (listed in Table 1) to MACE reduction by IPE relative to PBO were quantified via mediation analyses to illustrate the mechanisms of IPE.

Methods

Patients were randomised 1:1 to IPE 4 g/day or PBO and followed for a median 4.9 years. For a biomarker to be a mediator, there had to be both a treatment group difference on the biomarker and an association between the biomarker and risk of MACE. For the first condition, treatment group differences in change from baseline in each biomarker were analysed by mixed effects repeated measures models. For the second condition, time-varying values of each biomarker were related to the risk of MACE by calculating the time-weighted moving average (TWMA) for each variable, using all values for a given patient. Each was analysed in a Cox regression model with time to MACE as the outcome and TWMA values as time-varying covariates. The individual and joint mediation of those biomarkers determined to be mediators were assessed in Cox models that included treatment assignment. Biomarkers individually found to be ³10% mediators in absolute terms were included in the multivariable models. If biomarkers that would otherwise be included in multivariable models were strongly correlated (baseline values R2>0.5), the marker with the greatest univariate mediation was included. All analyses were intention-to-treat.

Results

IPE reduced MACE by 25% (HR (95% CI) = 0.75 (0.68, 0.83), p<0.0001). Treatment group differences on all potential mediators had p<0.05, and all but oxLDL were significantly related to MACE (p<0.05). Analyses of individual biomarkers showed EPA to be the strongest single mediator (Table 1). EPA, AA, and TG jointly mediated 78.9% of the IPE treatment effect, with EPA driving most of the mediation (57% as a single mediator). The marginal mediation by the remaining 3 biomarkers was 4.5% of the treatment effect, for total joint mediation of 83.4% (Figure 1).

Conclusion

In this mediation analysis of REDUCE-IT, most of the IPE benefit on MACE reduction was attributable to the two major mechanisms of the drug: (1) increasing EPA while reducing AA and, to a lesser extent, (2) reducing TG. The remainder of measured biomarker changes accounted for a minority of the benefit.Table 1Figure 1
Interplay among proton pump inhibitors, platelet reactivity and CYP2C19 genotyping in clopidogrel-treated patients after drug-eluting stent implantation
Authors: Kim J H , Hong S J , Cha J J , Lim S , Joo H J , Park J H , Yu C W , Jeong Y H , Ahn T H , Lim D S
Published: November 2023

Background

Several published data suggested that concomitant use of clopidogrel and proton pump inhibitors (PPIs) is associated with reduced antiplatelet efficacy of clopidogrel and increased adverse clinical outcomes. We sought to evaluate the interplay between PPI and clopidogrel on platelet reactivity and long-term clinical outcomes in patients after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation.

Methods

The PTRG-DES (Platelet function and genoType-Related long-term proGnosis in DES-treated patients) registry is a multi-center, real-world registry of patients who underwent PCI with DES and received dual antiplatelet therapy of aspirin and clopidogrel in South Korea. Patients prescribed with PPI were compared to those without the use of PPI (the control group). The primary outcome was a composite of all-cause death, myocardial infarction, stent thrombosis, and stroke at 5 years. Secondary outcomes included cardiac death, major bleeding, and gastrointestinal bleeding. Adjusted outcomes were compared after 1:2 propensity score (PS) matching analysis.

Results

Among 13,160 patients, 2235 (17.0%) were prescribed with concomitant PPI at the time of clopidogrel loading. Average age was 64.4 years, 67.2% were men, and 35.1% had diabetes. The PPI group demonstrated a higher on-treatment P2Y12 reaction unit than the control group (p<0.001). The 5-year cumulative incidence of the composite primary outcome was higher in the PPI group (12.1% vs. 9.8%, log-rank p<0.001). After PS matching, the primary outcome was similar between the two groups (12.9% vs. 12.1%, log-rank p=0.24). However, the PPI group with CYP2C19 poor metabolizers showed an increased adjusted risk of the primary outcome (hazard ratio 2.69, p<0.001).

Conclusions

PPI use in patients with clopidogrel administration after DES implantation was associated with increased platelet reactivity, but similar cardiovascular outcomes in real-world practice. Physicians should be careful when administering PPI with clopidogrel in patients with CYP2C19 poor metabolizers.Distribution of P2Y12 reaction unitCumulative Incidence of outcomes
A meta-analysis on the efficacy of ticagrelor monotherapy after 3 months of dual antiplatelet therapy vs ticagrelor plus aspirin dual therapy on patients with ACS who underwent PCI
Authors: Galera L , Pestano N , Tumanan-Mendoza B , Punzalan F , Flores J , Europa M
Published: November 2023

Background

Major adverse cardiovascular events remain the major cause of mortality and morbidity after acute coronary syndrome, including patients who underwent percutaneous coronary intervention. Several studies have shown increased incidence of re-infarction, cardiac death, stroke, stent thrombosis, and all-cause mortality among these patients. The use of dual antiplatelet therapy has been recommended for post-procedural patients, according to guidelines. However, prolonged exposure to dual antiplatelets raised concerns on risk of bleeding. Our study aims to determine whether short term dual antiplatelet therapy followed with Ticagrelor monotherapy will benefit patients who are at higher risk of bleeding.

Objective

To determine the efficacy of Ticagrelor monotherapy after three months of Dual Antiplatelet Therapy versus 12 months of Ticagrelor plus Aspirin dual therapy in the prevention of MACE and bleeding among patients who had ACS and have undergone PCI.

METHODOLOGY

Randomized controlled trials on Ticagrelor monotherapy vs Ticagrelor + Aspirin Dual Therapy with outcomes on myocardial infarction, cardiac death, stroke, stent thrombosis, bleeding, all-cause mortality, were searched through PubMed.

Results

A total of 10,175 participants who had Acute Coronary Syndrome who have undergone Percutaneous Coronary Intervention were included in this analysis. Our results showed that discontinuing Aspirin after 3 months of Dual antiplatelet was not associated with significant increase in the risk of Major Adverse Cardiovascular Events: Myocardial Infarction (RR 0.96 95% CI 0.73-1.25), Cardiac Death (RR 0.92 95% CI 0.74-1.14), Stroke (RR 1.27 95% CI 0.69 -2.31), Stent Thrombosis (RR 0.87, 95% CI 0.48-1.59), Bleeding (RR 0.58 , 95% CI 0.49- 0.69) and All Cause Death (RR 0.77, 95% CI 0.52 – 1.14). Discontinuing Aspirin 3 months was associated with lower risk of bleeding (RR 0.58, 95% CI 0.49 - 0.69).

Conclusion

Minimizing the duration of exposure to antiplatelet agents with the use of Ticagrelor monotherapy after three months of DAPT among ACS patients who underwent PCI significantly reduced the incidence of bleeding, particularly among those who are at higher risk of bleeding. There is no significant difference in the risk for myocardial infarction, cardiac-related deaths, stroke, stent thrombosis, and all-cause mortality between the two groups.
Improvement of symptoms and quality of life in patients with coronary vasomotion disorders by endotype-based drug therapy
Authors: Kroll C , Hubert A , Seitz A , Bekeredjian R , Sechtem U , Ong P
Published: November 2023

Introduction

In patients with angina pectoris and/or signs of ischemia but no obstructive coronary artery disease (ANOCA) coronary vasomotion disorders are a frequent cause for their symptoms. However, the heterogeneous clinical presentation resulting from a wide spectrum of subtypes (so-called endotypes) poses a major therapeutic challenge. Many patients suffer from long-term refractory symptoms and severely reduced quality of life.

Purpose

The purpose of this study was to demonstrate that the quality of life of these patients can be improved by an endotype-based drug therapy.

Methods

A total of 50 patients (56% women, mean age 63±14 years) with a confirmed diagnosis of coronary vasomotion disorder were enrolled between April 2021 and February 2022. The endotypes were classified according to the diagnostically distinguishable subtypes (coronary spasm: n=30; vasodilatation disorder: n=3; combined vasomotion disorder: n=17). Based on the guideline recommendations of the European Society of Cardiology, an individual endotype-adapted medication was prescribed. The efficacy and tolerability of the medications were monitored over a period of 3 months. In addition, the quality of life was assessed quantitatively (score 0-100) using the Seattle Angina Questionnaire-7 (SAQ-7) at baseline and after 1, 2 and 3 months. The symptoms at home were documented weekly using a patient diary (PROM).

Results

Within the study population, arterial hypertension (74%) and dyslipidemia (80%) were among the most frequent concomitant cardiovascular risk factors. After 3 months of endotype-based antianginal therapy, a clinically relevant and significant improvement of 15 points on average in the SAQ7-score was achieved in 70% of the patients within the entire cohort (p<0.001), while no change (<5 points) was recorded in 14% of the study participants and 16% experienced an aggravation in the clinically relevant range (≥5 points). Accordingly, the PROM mood score (scale 1-5) also showed a significant improvement of 0.5 points (2.7±0.8 vs. 3.2±0.8; p<0.001) as well as a significant decrease in monthly number of chest pain attacks by 38% (11.7±13.6 vs. 7.3±15.4; p=0.041) and nitroglycerin intake by 67% (2.7±5.9 vs. 0.9±2.6; p=0.004). When comparing the initial and final medication, a significant increase (33%) in the intake of calcium channel antagonists (non-DHP) was recorded in patients with coronary spasm (p=0.004). Within the patient group with combined vasomotion disorders, statins, ezetimibe and ranolazine were taken significantly more often by 35% respectively at the end of the observation period (p=0.031).

Conclusion

Targeted endotype-based drug therapy can contribute decisively to a clinically relevant improvement of symptoms and quality of life in ANOCA patients.Outcome of the whole patient cohortSAQ improvement during follow-up
Bailout inclisiran-based triple lipid-lowering therapy reduces plaque lipid content in stable coronary artery disease patients
Authors: Trusinskis K , Lapsovs M , Kokina B , Karantajere M , Knoka E , Caunite L , Jegere S , Narbute I , Sondore D , Grave A , Kumsars I , Erglis A
Published: November 2023

Background

Low-density lipoprotein cholesterol (LDL-C) has a causal role in atherosclerotic cardiovascular disease. Genetic studies and variability in individual response to lipid-lowering therapies suggest combining hypolipidaemic medications with different mechanisms of action.

Purpose

The aim of this study was to evaluate the effect of triple inclisiran-based hypolipidaemic therapy in patients not reaching LDL-C target on maximum statin/ezetimibe treatment.

Methods

This prospective study enrolled 37 stable coronary artery disease patients admitted for elective percutaneous coronary intervention after 4-6 weeks on maximum tolerated statin and/or ezetimibe therapy during run-in period. Afterwards, patients with LDL-C level >1.8 mmol/l at the time of inclusion were assigned to receive add-on inclisiran (triple therapy group). In all participants near-infrared spectroscopy (NIRS) was performed at baseline and after 15 months for atherosclerotic plaque evaluation in the segment of interest, defined as 20-50% lesion in the proximal or middle third of a coronary artery. Statistical analysis was carried out with SPSS Statistics software.

Results

Average LDL-C level among screened patients was 2.81 (±1.17) mmol/l. In 19 patients LDL-C level remained >1.8 mmol/l on maximally tolerated statin and/or ezetimibe treatment, and after 15 months of triple therapy mean LDL-C reached 1.81 (±1.02) mmol/l with a significant LDL-C percentage change of 35.59% (95%CI -47.31 to -9.18, P=0.006) in this group. 17 patients continued statin/ezetimibe as mono or dual treatment and at 15-month follow-up mean LDL-C level comprised 1.67 (±0.61) mmol/l among these participants. According to NIRS data, maximum lipid-core burden index within 4 mm (maxLCBI4 mm) was significantly reduced by 28.85 (95%CI -189.39 to 17.64, P=0.041) in triple therapy group and by 114.72 in mono or dual therapy group (-194.76 to 23.01, P=0.004), with no statistically significant difference established between both groups (P=0.494).

Conclusions

Triple therapy demonstrated significant atherosclerotic plaque lipid content reduction along with LDL-C level lowering in patients with insufficient effectiveness of statin/ezetimibe treatment.
Preprocedural computed tomography angiography for prediction of transcatheter aortic valve implantation outcomes. A machine learning study
Authors: Kwiecinski J , Grodecki K , Pieszko K , Dabrowski M , Chmielak Z , Slomka P , Wojakowski W , Witkowski A , Dey D
Published: November 2023

Background

Prediction of outcomes following transcatheter aortic valve implantation (TAVI) is challenging. While over the past decades multiple scores for risk stratification in TAVI patients have been proposed due to their limited accuracy none of them have been adopted clinically. Recently machine learning was leveraged for this purpose yet again, while new approaches showed promise in prediction of outcomes following TAVI this was only the case for models which included peri-procedural data.

Purpose

Considering that in aortic stenosis outcomes are governed by both valve degeneration and myocardial adverse remodelling which ensues, we aimed to employ the pre-procedural computed tomography (CT) to develop a machine-learning model for prediction of 1-year outcomes following TAVI.

The model was developed on data of consecutive patients who underwent TAVI at a high-volume center between January 2016 and January 2022. Machine learning by extreme gradient boosting was trained and tested with repeated 10-fold hold-out testing using CT-derived volumetric measurements including myocardial mass and quantitative fibrocalcific valve volume and attenuation measured using standardized software. We compared our CT model based on 21 imaging variables, age and gender with the EuroSCORE II for prediction of 12-month all-cause mortality. External validation was performed on unseen data of consecutive patients who underwent TAVI in 2019-2020 at an independent high volume TAVI center.

Results

The derivation cohort included 631 consecutive patients (48% men, 80±8 years old, EuroSCORE II 6.5 [4.6-10.3] %). Our model was externally tested on data of 226 patients (46% men, 78±8 years old, EuroSCORE II 7.4 [4.9-10.8] %). Over the 12 months of follow-up 86 (13%) and 29 (13%) subjects died in the derivation and validation cohort respectively. In external validation the CT-based machine learning model had an area under the receiver operator curve (AUC) of 0.70 [0.63-0.76] which was superior to the EuroSCORE 0.59 [0.53-0.66] and age 0.58 [0.52-0.65], p<0.001 for a difference. The feature importance for the machine learning model are presented in Figure 1; the highest-ranked features included LV ejection fraction and mass, the noncalcific valve volume and the mean aortic valve calcification attenuation.

Conclusions

Machine-learning facilitates leveraging preprocedural CT angiography for prediction of TAVI outcomes. By combining CT derived cardiac assessment machine-learning provides superior prediction to EuroSCORE II.
Long-term outcomes of patients with late presentation STEMI undergoing percutaneous coronary revascularization
Authors: Neef P A , Loy O , Brennan A L , Ajani A E , Reid C , Dinh D , Clark D J , Freeman M , Stub D , Hiew C , Oqueli E
Published: November 2023

Background/Introduction

Patients with late-presentation ST-segment myocardial infarction (STEMI) (12-48hr of symptom onset) tend to have worse clinical outcomes compared to early presenters (<12hr of symptom onset). The optimal management and decision for primary percutaneous coronary intervention (PCI) is limited by the current evidence, particularly in the modern revascularisation era.

Purpose

The aim of this study was to assess the short- and long-term clinical outcomes of primary PCI in patients with STEMI who present late following symptom onset (12-48hr) compared to those who present early (<12hr).

Methods

Data from 4265 consecutive patients undergoing PCI for STEMI within 48hr of presentation were analysed from the Melbourne Interventional Group registry between 2014 and 2020. Patients were categorised based upon symptom-to-door time (early <12hr vs late 12-48hr).. The primary endpoints were in-hospital, 30-day and long-term mortality. Secondary outcomes were major adverse cardiovascular events (MACE; composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke or repeat revascularisation), procedural outcomes and medications at 30-day.

Results

4044 patients were early presentation and 221 patients were late presentation. The median symptom-to-door time was 1.73hr (interquartile range (IQR) 1.2, 2.8) for early presenters and 14.8hr (IQR 13.2, 18.1) for late presenters. Late presenters were less likely to have out-of-hospital cardiac arrest and require inotropic support (all p<0.01). There was no significant difference in in-hospital mortality (6.5% vs 5.4%, p=0.53) and MACE (9.0% vs 7.7%, p=0.52), nor 30-day mortality (7.4% vs 7.3%, p=0.94) and MACE (11.1% vs 10.5%, p=0.77). Long-term mortality did not differ between early and late presenters with hazard ratio 1.17 (95% confidence interval 0.71-1.95, p=0.54). There was no difference in major bleeding at 30-days (p=0.42).

Conclusions

Primary PCI in patients following late presentation STEMI is not associated with worse short- or long-term clinical outcomes compared to those who present early . Further, randomised controlled trials in the modern revascularisation era are needed to guide clinical practice.
Can machine learning improve risk prediction and individualise decision making between percutaneous and surgical revascularisation?
Authors: Ninomiya K , Kageyama S , Shiomi H , Masuda S , Kotoku N , Revaiah P , Kimura T , Onuma Y , Serruys P
Published: November 2023

Background/Introduction

In patients with three-vessel coronary artery disease (CAD) and/or left main (LM) CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).

Purpose

The aim of this study was to assess whether these individualised revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors.

Methods

The present study consisted of patients enrolled in the SYNTAX study, which is a randomized trial comparing PCI and CABG in patients with complex coronary artery disease. ML algorithms were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG), and pre-specified effect-modifiers: disease type (3-vessel or LMCAD) and anatomical SYNTAX score. The model’s discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1800 patients) and externally validated in the CREDO-KYOTO registry (n=7362), and then compared to the original SYNTAX score II 2020 (SS2020).

Results

The gradient boosting ML model identified the top 10 prognostic factors at the time of decision making as: age, creatinine clearance, left ventricular ejection fraction, peripheral vascular disease, C-reactive protein, hemoglobin, HbA1c, glucose, systolic and diastolic pressure.

The ML model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95% CI 0.75-0.81) in cross-validation and 0.77 (95% CI 0.76-0.79) in external validation. The ML model discriminated 5-year mortality better than the SS2020 in the external validation cohort (vs C-index 0.72 for SS2020, p <0.001) and identified heterogeneity in the treatment benefit of CABG versus PCI (Figure).

Conclusions

An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems—trained to collect large numbers of parameters—may harmonize decision making.Figure
The impact of ticagrelor therapy on CABG-related bleeding in patients with STEMI managed with pPCI
Authors: Gulfidan A , Durmaz E , Cimci M , Karadag B , Incesu G , Soysal A U , Yalman H , Aygun A A , Miroglu M , Ceviker A , Dogramaci E , Karpuz M H
Published: November 2023

Background

Patients on double antiplatelet treatment who need early in-hospital coronary artery bypass grafting (CABG) are at high risk of major bleeding. However, recent studies have demonstrated that early CABG surgery within 7 days of discontinuation of p2Y12 inhibitors are safe with respect to bleeding events in patients with acute coronary syndrome.

Purpose

In this study, we aimed to investigate the impact of ticagrelor preloading on CABG related bleeding in patients with ST-segment elevation myocardial infarction (STEMI) initially managed with primary percutaneous coronary intervention (pPCI).

Methods

Patients with the diagnosis of STEMI who were managed with pPCI and underwent subsequent early (4-7 days following pPCI) or delayed (> 7 days following pPCI) CABG surgery were included. All study patients were preloaded with ticagrelor 180 mg prior to pPCI procedure. Patients’ demographics, clinical variables and short-term cardiovascular outcomes were recorded.

Results

The study cohort included 98 patients. Fifty-four (54%) patients underwent early and 44(45%) patients underwent delayed CABG surgery. Left main coronary artery involvement and presence of chronic total occlusion in the non-infarct related artery were 26.5% and 25.5%. CABG-related bleeding occurred in 22 (22.4%) patients. There was no significant difference with respect to total ticagrelor dose and timing of the surgery between patients with or without CABG-related bleeding (p: 0.165 and p:0.142). Multivariate analyses demonstrated that only preoperative hemoglobin level was an independent predictor of CABG-related bleeding (OR:0.720, p: 0.034).There were three deaths within the 30 days of surgery, all occurring in patients with CABG-related bleeding. However, CABG-related bleeding was not associated with long-term cardiovascular events during the follow-up.

Conclusion

Our results indicated that discontinuation of ticagrelor therapy 3 days prior to surgery is sufficient to avoid CABG-related bleeding. Moreover, early CABG following STEMI does not increase the risk of long-term cardiovascular events.
Fibroblast growth factor 23 is a strong independent marker of poor outcome after an acute coronary syndrome
Authors: Kallmeyer A , Pello A , Canovas E , Acena A , Gonzalez-Casaus M L , Tarin N , Cristobal C , Gutierrez-Landaluce C , Huelmos A , Rodriguez-Valer A , Gonzalez Lorenzo O , Alonso J , Mahillo I , Lorenzo O , Tunon J
Published: November 2023

Our study aimed to assess the role of fibroblast growth factor 23 (FGF-23) as a prognostic marker after an acute coronary syndrome (ACS).

It was a prospective and multicentric study, performed at five tertiary hospitals in our city, which included 1,190 patients with ACS. FGF-23 plasma levels and other components of mineral metabolism (calcidiol, parathormone [PTH], klotho, and phosphate), lipids, troponin, high-sensitivity C-reactive protein, and N-terminal-pro-brain natriuretic peptide were measured at discharge. The primary outcome was a combination of acute ischemic events, heart failure (HF) and death. Secondary outcomes were the separate components of the primary outcome.

Median follow-up was 5.44 (3.03-7.46) years. 294 patients developed the primary outcome. Patients with FGF-23 less than median (which was settled in 110 RU/mL) were less frequently females, and were younger and had a lower load of cardiovascular risk factors. Besides, calcidiol and PTH levels were lower in patients with FGF-23 below the median.

Multivariable analysis showed that FGF-23 (HR 1.18 [1.08-1.29], p<0.001), calcidiol (HR 0.86 [0.74-1.00], p=0.046), previous CAD or cerebrovascular accident, and hypertension were independent predictors of the primary outcome. The predictive power of FGF-23 was homogeneous across different subgroups of population. FGF-23 resulted an independent predictor of HF (HR 1.38 [1.22-1.57], p<0.001), and death (HR 1.21 [1.07-1.37], p=0.002), but not of acute ischemic events. According to renal function, FGF-23 was an independent predictor for the primary outcome in patients with estimated glomerular filtration rate (eGFR) above 60 ml/min/1.73m2,, showing that the potential prognostic role of FGF-23 was not exclusively related to chronic kidney disease patients. Moreover, regarding the secondary outcomes, FGF-23 resulted an independent predictor of HF and death.

To sum up, FGF-23 seems to be a strong, independent, predictor of HF and death among patients with ACS. This effect is homogeneous across different subgroups of population and not limited to patients with CKD.
Effect of acute strenuous exercise on platelet aggregation, thrombin generation and fibrinolysis in patients with coronary artery disease
Authors: Kristiansen J , Grove E L , Sjurdarson T , Mohr M , Kristensen S D , Hvas A M
Published: November 2023

Introduction

Acute strenuous exercise may cause coronary thrombosis and sudden cardiac death.

Purpose

To investigate the effect of acute strenuous exercise on platelet aggregation, thrombin generation and fibrinolysis in patients with stable coronary artery disease (CAD) and healthy individuals.

Method

Patients with stable CAD (n=164) and healthy individuals (n=25) performed acute strenuous exercise on a cycle ergometer until exhaustion. Blood samples were taken at baseline (before exercise), immediately after and 2 hours after acute strenuous exercise.

Results

From baseline to immediately after strenuous exercise, TRAP-induced platelet aggregation increased significantly in CAD patients (Δ77 AU×min, 95% confidence interval (CI): 55;98, p<0.001) and also in healthy individuals (Δ153 AU×min, 95%CI: 103;225, p<0.001), and remained slightly elevated 2 hours after strenuous exercise in both groups (CAD patients: Δ53 AU×min, 95%CI: 27;80, p<0.001; healthy individuals: Δ140 AU×min, 95%CI: 56;225, p=0.002). Thrombin generation was not affected immediately after exercise, but decreased after 2 hours in patients with CAD (endogenous thrombin potential: Δ-5%, 95%CI: -9;-2, p=0.004). Fibrin clot lysis time increased immediately after exercise (CAD patients: Δ10%, 95%CI: 3-16, p=0.003; healthy individuals: Δ30%, 95%CI: 16;46, p<0.001), whilst plasminogen activator inhibitor-1 (PAI-1) decreased (CAD patients: Δ-17%, 95%CI: -33;-10, p<0.001; healthy individuals: Δ-40%, 95%CI: -53;-25, p<0.001). After 2 hours, an increased fibrinolysis was seen in both groups, expressed as a decrease in PAI-1 in both groups (CAD patients: Δ-41%, 95%CI: -46;-35 p<0.001; healthy individuals: Δ-64%, 95%CI: -75;-46, p<0.001) and a reduced fibrin clot lysis time in patients with CAD (Δ-18%, 95%CI: -24;-11, p<0.001).

Conclusions

Acute strenuous exercise induced an immediate increase in platelet aggregation. Platelet aggregation remained slightly elevated after 2 hours while fibrinolysis was increased and thrombin generation slightly decreased indicating a more favourable haemostatic profile after 2 hours.
Premature coronary artery disease in all-comers undergoing first PCI
Authors: Pinxterhuis T H , Ploumen E H , Zocca P , Schotborgh C E , Anthonio R L , Roguin A , Danse P W , Benit E , Aminian A , Von Birgelen C
Published: November 2023

Background

The prevalence of coronary artery disease (CAD) increases with age, yet some individuals develop obstructive CAD at younger age.

Purpose

The present analysis aimed to assess differences in baseline risk profile and 3-year adverse event risk between patients undergoing percutaneous coronary intervention (PCI) for premature or non-premature CAD.

Methods

We pooled patient-level data of four randomized PCI trials in all-comers (TWENTE (clinicaltrials.gov: NCT01066650); DUTCH PEERS (NCT01331707); BIO-RESORT (NCT01674803); and BIONYX (NCT02508714)), who had no previous coronary revascularization (by PCI or coronary artery bypass surgery) or myocardial infarction (MI). Premature CAD was defined as CAD in men <50 years and in women <55 years, while non-premature CAD was classified as CAD in older patients. Main clinical endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality, any MI, emergent coronary bypass surgery, or clinically indicated target lesion revascularization.

Results

Of all 6,171 PCI patients with first revascularizations, one out of seven (n=887, 14.4%) had premature CAD. These patients had lower rates of diabetes (10.6% vs. 16.6%, p<0.001), hypertension (32.7% vs. 50.7%, p<0.001), hypercholesterolemia (35.9% vs. 40.3%, p=0.012), and peripheral arterial disease (2.0% vs. 6.6%, p<0.001). Yet, they were more often overweight (76.2% vs. 69.8%, p<0.001), smoker (60.7% vs. 26.4%, p<0.001), and had more often a family history of CAD (59.8% vs. 44.5%, p<0.001). Patients with premature CAD suffered more often from acute ST-segment elevation MI and underwent less often treatment of calcified or bifurcated lesions (Table 1).

At 3-year follow-up, the main endpoint MACE did not differ significantly between patients with premature and non-premature CAD (6.6% vs. 9.4%; adj.HR:0.86, 95%-CI:0.65-1.16, p=0.33; Figure 1). All-cause mortality was lower in patients with premature CAD (0.8% vs. 4.4%; adj.HR:0.23, 95%-CI:0.10-0.52, p<0.001). Yet, in patients with premature CAD the rate of repeated target vessel revascularization was higher than in patients with non-premature CAD (6.1% vs. 4.3%; adj.HR: 1.63, 95%-CI:1.18-2.26, p=0.003). In addition, their definite stent thrombosis risk was higher (1.0% vs. 0.5%; adj.HR:3.20, 95%-CI:1.39-7.38; p=0.006) than in patients with non-premature CAD.

Conclusions

One out of seven patients who were treated with PCI had premature CAD, and these patients had less complex risk profiles. Patients with premature CAD had higher risks for repeated revascularization and stent thrombosis, but the 3-year all-cause mortality risk was lower. In patients with premature CAD, long-term outcome after PCI might be improved by addressing modifiable risk factors such as smoking and overweight.Figure 1:Kaplan-Meier cumulative event
Impact of DM on clinical outcomes in patients with CAD diagnosed by CCTA
Authors: Kwon S U , Cho S W , Kwak J J , Doh J H , Namgung J
Published: November 2023

Background/Introduction

Diabetes mellitus (DM) is the most important risk factor for coronary artery disease (CAD) progression and prognosis. The DM patients with normal coronary artery on coronary CT angiography had good prognosis, however the prognosis of mild and moderate CAD was not fully elucidated.

Purpose

The aim of this study was to investigate the impact of DM on clinical outcomes in patients with mild and moderate CAD diagnosed by coronary CT angiography.

Methods

A total of 6014 patients underwent CCTA were prospectively enrolled and the 1126 patients with minimal and intermediate CAD were analyzed. Patients were categorized according to maximal severity of coronary artery stenosis: minimal CAD (31 to 50%) and intermediate CAD (51 to 70%). The primary outcome was major adverse cardiac events (MACE) including all-cause death, non-fatal myocardial infarction, coronary revascularization, or cardiac hospitalization.

Results

Nine hundred eighty-five patients had minimal CAD and 141 patients had intermediate CAD. The DM patients were 307 (31.2%) in the minimal CAD group and 52 (36.9%) in the intermediate CAD group. During the follow-up period (median 18.9 months [interquartile range: 7.8 to 34.6 months]), there is no significant difference of the risk of MACE between the non-DM and DM patients in the minimal CAD group (26.9% vs. 32.8%; adjusted hazard ratio [HR], 1.05; 95% confidence interval [CI], 0.74-1.49; p=0.79). However, compared with the non-DM patients, the DM patients significantly increased the risk of MACE in the intermediate CAD group (36.5% vs. 63.2%; adjusted HR, 2.37; 95% CI, 1.18-4.77; p=0.02).

Conclusion

The prognosis of the DM patients was similar with the non-DM patients in the minimal CAD group. However, the DM patients had worse clinical outcomes compared with the non-DM patients in the intermediate CAD group.Study design and clinical outcomeKaplan-Meier curves of event rate for MA
No difference on angiographic features between women and men in patients with acute coronary syndrome: insights from the ADDICT-ICCU study
Authors: Guiraud-Chaumeil P , Lequipar A , Delmas C , Millischer D , Merat B , Grentzinger A , Lafont A , Gall E , Singh M , Clement A , El Beze N , Andrieu S , Pezel T , Henry P , Dillinger J G
Published: November 2023

Background

Previous studies have observed poorer outcomes in women with acute coronary syndrome (ACS). Angiographic features and angioplasty techniques to explain this difference between women and men have rarely been analyzed in recent studies.

Purpose

To analyze by a core laboratory angiographic finding, coronary artery disease (CAD) complexity and percutaneous intervention outcomes in women and men in patients with ACS.

Methods

From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1575 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for ACS (n=379) with an independent angiographic core laboratory evaluation. The prevalence, location, and severity of CAD (lesion≥50%), the Syntax score, the residual Syntax score and the characteristics of percutaneous coronary intervention (PCI) were compared between women and men. The primary endpoint was Major Adverse Cardiac Events (MACE) defined by death, resuscitated cardiac arrest, or cardiogenic shock.

Results

Among the 379 patients with ACS (mean age: 63±13 years), 23% were women (n= 86) and 77% were men (n=286). Cardiovascular risk factors and CAD history were well balanced between women and men except for active smoking with less smokers in women (59% vs 81%, p<0.001).

Regarding location of CAD (stenosis ≥50%), there was no significant difference between women and men: left anterior descending artery (56% vs 57%; p=0.90), circumflex (28% vs 39%; p=0.12) and right coronary artery (50% vs 48%; p=0.81). No difference was found for baseline Syntax score (7.98 vs 9.64; p=0.13). Women and men have a similar rate of multivessels disease (44% vs 50%; p=0.46) and 3 vessels disease (16% vs 20%; p=0.57).

Concerning PCI, Syntax score of the culprit lesion was significantly lower in women (4.5 vs 5.5, p=0.02). Women and men received a similar number of stents (2.3 vs 2.4; p=0.33). Stent length (28.9 vs. 30.3, p=0.43) or stent diameter (3.1 vs 3.2; p= 0.11) were not significantly different. Final TIMI 3 flow was found in 92.9% of women and 88.1% of men (p=0.23). The rate of procedural complications was low in both groups. At the end of the procedure, the residual Syntax score was similar in women and men (4.4 vs 5.4; p= 0.34).

The rate of in-hospital MACE was not different between women and men (4.7% vs 4.4%; p=0.91).

Conclusion

In this study with an independent angiographic core laboratory analysis of ACS patients, no difference between women and men regarding CAD severity or PCI outcomes was observed. Other reasons should be considered if a difference in prognosis exists between women and men.Angiographic features in Women and menAngiographic analysis by Core Laboratory
Uncertain meaning of early Q-wave in STEMI. Can we still rely on its relevance?
Authors: Pupiales Davila K , Gopar-Nieto R , Gonzalez-Pacheco H , Briseno-De La Cruz J L , Sierra-Lara Martinez J D , Araiza-Garaygordobil D , Patino-Gomez T A , Luna-Hernandez A , Baltazar-Cordero E , Arias-Mendoza A
Published: November 2023

Background

In patients with a first STEMI treated with invasive reperfusion strategy, early Q-waves do not predict a poor prognosis. The presence of a Q wave, although the common clinical misconception of its association with irreversible myocardial necrosis, should not necessarily change the reperfusion strategy, but hasten it.

Purpose

We aimed to examine if early Q-waves in patients in the emergency department of a tertiary center in the first 6 hours of chest pain, were associated with base demographics, in-hospital mortality, major adverse cardiovascular events, cardiac biomarkers, and cardiac imaging.

Methods

Retrospective cohort study of 1012 patients of which 251 had early Q-waves on their 12-lead ECG during the first 6 hours of chest pain. Q-waves were defined by the criteria of the Fourth Universal Definition of Myocardial Infarction. The cohort were the patients with Q-waves in ECG and compared each variable with its due statistical test.

Results

We found that age (54 vs 54, p=0.393), BMI (27.3 vs 27.4, p=0.683), diabetes (63 vs 196, p=0.266), smoking (118 vs 278, p=0.09), dyslipidemia (84 vs 195, p=0.152), hypertension (98 vs 258, p=0,747) and previous stroke (2 vs 10, p=0.42) were not associated with the presence of early Q-waves in our population.

There were no statistically significant differences within groups in global mortality (6% vs 14%, p=0.754), neither in cardiogenic shock (7% vs 15%, p =0.754), acute heart failure (8% vs 15%, p=0.390), acute pulmonary edema (2% vs 7%, p=0.749), stroke (0% vs 3%, p=0.292), atrial fibrillation and flutter (8% vs 12%, p=0.183), high degree AV block (15% vs 29%, p=0.273), ventricular tachycardia and fibrillation (18% vs 41%, p=0.522) and mayor bleeding (2% vs 3%, p=0.509).

Heart rate at admission was higher (p<0.05) as well as the first determination of CK-MB (11.84 vs 8.48, p<0.05). Interestingly, Q-waves were associated with greater likelihood of coronary occlusions, with a TIMI grade 0 before intervention (184 vs 458, p=0.044). There were no differences in reduced left ventricle ejection fraction (60.21 vs 60.96, p=0.06) or microvascular disease (76.38 vs 76.53, p=0.96) in cardiac magnetic resonance.

Conclusions

The presence of Q-wave at 6 first hours of chest pain was associated with higher cardiac biomarker expression and a greater incidence of coronary artery occlusion on cardiac catheterization. Early PCI should be directed as a first option to this group of patients, and this evidence might aim to perform it beyond the established 12-hour cutoff time.