bluuebunny/crossref_metadata_2025_split huggingface dataset:
Time from ECG Diagnosis to sheath insertion is a strong predictor for mortality in patients with ST elevation myocardial infarction admitted for primary percutaneous coronary intervention
Authors: Larsen A.I , Loland K , Hovland S , Bleie O , Trovik T , Hegbom K , Larsen T , Fossum E , Eek C , Moer R , Juliebo V , Uchto M , Rotevatn S 
Published: November 2020

Abstract

Introduction
If reperfusion can be performed within 120 minutes, pPCI is the ESC guideline recommended treatment in patients with ST-elevation myocardial infarction (STEMI).

Aims
Historically, prognosis is dependent on time from diagnosis to reperfusion in patients with STEMI. We sought to investigate this in a contemporary patient population by assessing mortality as function of time from ECG diagnosis to sheath insertion in the Norwegian registry for invasive cardiology (NORIC).

Methods
NORIC, which is a part of the Norwegian Cardiovascular Disease Registry, is a national, mandatory and non-consensual person-identifiable health registry. Data from NORIC were linked with the National Population Register. Data were registered from 1st of January 2013 to 31st of June 2019.

Results
During this period complete data were available for n=5754 patients with 526 events. ECG diagnosis to sheath insertion was a predictor of mortality with the 4th (&gt;106 min) vs 1st quartile (&lt;54 min) with a HR of 1.74 (95% CI 1.36–2.22), p-value &lt;0.00001. The HR increased by 1.20 (95% CI 1.11–1.30) per quartile (p-value for trend &lt;0.00001).
Nationally 62% percent of the patients received pPCI within the ESC recommended 90 minutes from ECG-diagnosis with large geographical variation (range 38–89%). Nationally 80% received pPCI within 115 minutes (range 75–202 minutes).

Conclusion
In a contemporary STEMI population, time from ECG diagnosis to sheath insertion is a strong predictor for mortality in patients admitted for pPCI for STEMI. However, the data also demonstrate large variations between different geographical health regions in Norway that should be addressed.

Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Haukeland University Hospital
Spontaneous coronary artery dissection – contemporary management and outcome of a national cohort
Authors: Wilander H , Swahn E , Johnston N , Jonasson L , Pagonis C , Tornvall P , Venetsanos D , Sederholm Lawesson S 
Published: November 2020

Abstract

Background
Spontaneous coronary artery dissection (SCAD) is proposed to cause 1–4% of all acute myocardial infarctions (AMI).
The aim of this study was to conduct a first description of Swedish SCAD patients regarding the prevalence of risk factors, treatment and prognosis.

Method
All patients with AMI registered in the Swedish Coronary Angiography and Angioplasty Register (SCAAR) December 2015 until December 2017 were included. The index angiographies of the SCAD patients were reevaluated by an independent angiographer at each center. Patients with non-SCAD AMI (n=31670) were used for comparison.

Results
SCAD was identified in 137 patients with AMI (100 women, 37 men). The SCAD population was younger than the non-SCAD population 53.9 (51.7–56.1) vs 68.5 (68.3–68.6) years, more often women (73.0 vs 30.7%) and presented with less risk factors: diabetes 2.9 vs 20.8%; hypertension 27.0 vs 57.6%; smoking 41.2 vs 58.1%; statin therapy 12.4 vs 36.9% and previous AMI 7.3 vs 19.6% (p&lt;0.001 for all comparisons).
SCAD patients less frequently underwent percutaneous coronary intervention (PCI) 43.1 vs 70.8% (p&lt;0.001) and received less statin treatment, 78.9 vs 91.5% (p&lt;0.001).
There was no significant difference regarding treatment with aspirin or double antiplatelet therapy at discharge: 93 vs 89.7% (p=0.45) and 86.7 vs 84.2%, respectively (p=0,43).
There was no significant difference in one-year mortality 6.6 vs 8.2% (p=0.57).

Conclusions
With a current prevalence of 0.43% of all Swedish AMIs, data supports SCAD being an underdiagnosed condition with a prognosis resembling that of non-SCAD AMI. Furthermore, SCAD patients are younger and harbor less cardiovascular risk factors. While significant differences in management are present, current therapeutic strategies of the two groups are similar, indicating overtreatment of SCAD.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung foundation, ALF funding
Novel low-delta value troponin algorithms have good precision for rule-out of NSTE-ACS
Authors: Tjora H , Steiro O.T , Langorgen J , Omland T , Collinson P , Bjorneklett R.O , Nygard O.K , Skadberg Ø , Bonarjee V.V.S , Vikenes K , Aakre K.M 
Published: November 2020

Abstract

Background
Rapid rule-out algorithms for non-ST-elevation infarction (NSTEMI) may be beneficial for logistics in the emergency room. Current algorithms are designed to rule-out NSTEMI, but do not differentiate between unstable angina (UAP) in need of revascularization and non-cardiac chest pain patients (NCCP) who could be discharged. Recent improvements in analytical precision of high sensitivity troponin (cTn) assays allow for trialing algorithms with very small delta values.

Purpose
Could the use of lower delta values produce rule-out algorithms for NSTE-ACS with a false negative rate of ≤5%, and a sufficient high rule-out rate of patients with NCCP.

Method
927 patients with suspected NSTE-ACS were consecutively included. Serum samples were collected at 0, 3 and 8–12 hours. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT. The 0- and 3-hour samples were additionally measured for cTnIand cTnI from Singulex Clarity System (cTnI(sgx)). The diagnostic performance to rule-out NSTE-ACS was compared between one low-delta value algorithm from each assay (cTnT, cTnI and cTnT).

Results
The prevalence of NSTEMI was 13.4%, UAP 11.4% and NCCP 60%. Median age was 63 years, 60% males. Fig. 1 shows baseline and 3-hour delta cTn values for the UAP and NCCP patients for the three different assays. The baseline cTn value differed significantly between UAP and NCCP for all assays, p value &lt;0.001. The novel low-delta cTnT algorithm (Table 1) ruled out 8 NSTE-ACS patients (3.5%), the cTnI algorithm and cTnI (sgx) algorithm ruled out 11 (4.8%) and 12 (5.2%) patients with NSTE-ACS, respectively. Moreover, the cTnT algorithm allocated 35.3% of the NCCP patients to discharge. Respective numbers for the cTnI(sgx) and cTnI algorithm were 30.6% and 33.5%. Comparing the ROC curves, the cTnT algorithm had significantly higher AUC compared to the cTnI(sgx) algorithm (p value =0.005, DeLong test).

Conclusion
The low-delta value algorithms correctly ruled in ≥95% of the NSTE-ACS patients whilst &gt;30% of NCCP patients were ruled out. The cTnT algorithm had the best performance with a significant higher AUC compared to the cTnI(sgx) algorithm.
Figure 1

Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority, Haukeland and Stavanger University hospital
Sex-based differences of copeptin for early rule-out of non-ST-elevation myocardial infarction
Authors: Vargas K.G , Tajsic M , Latsuzbaia A , Andric T , Kassem M , Jaeger B , Huber K 
Published: November 2020

Abstract

Objective
There is paucity of data on the role of sex in the dual biomarker strategy using copeptin and conventional troponin for the early rule-out of non-ST-elevation myocardial infarction (NSTEMI). We aimed to evaluate sex-based differences on copeptin levels, combined negative predictive value (NPV) and predictors of copeptin elevation at admission.

Methods
Biomarkers were measured in 852 adult patients presenting to the emergency department with chest pain and suspected NSTEMI. Logistic regression analyses on predictors of copeptin elevation were evaluated by sex.

Results
Overall, 362 women (42.5%) and 490 men (57.5%) were included. Copeptin levels were higher in men (median 7.36 pmol/L vs. 4.8 pmol/L; P&lt;0.001). Men had a similar NPV (100%) as women (99.6%, CI: 98.8–100) using the dual biomarker rule-out strategy and when compared to troponin alone (men, NPV=98.7%, CI: 97.5–99.8; and women, NPV=98.7%, CI: 97.5–100). Multivariate logistic regression showed positive association of male sex with copeptin elevation (OR=2.37; CI: 1.61–3.49; P&lt;0.001). In men, diastolic blood pressure was a negative predictor of copeptin elevation (OR=0.98, 95% CI: 0.96–0.99), while positive predictors were current MI (OR=2.16, 95% CI: 1.19–3.91), chronic renal insufficiency (OR=3.58, 95% CI: 1.33–9.62), and atrial fibrillation (OR=2.56, 95% CI: 1.23–5.32), respectively (all P&lt;0.05). In women, current MI (OR=2.98, CI: 1.23–7.24), atrial fibrillation (OR=2.90, CI: 1.26–6.70) and syncope (OR=7.56, CI: 2.26–25.30) were significant predictors of copeptin elevation.

Conclusions
Men with suspected NSTEMI have higher copeptin levels. The dual biomarker rule-out strategy has a similar performance in both male and female patients. Certain predictors of copeptin elevation are sex-specific.
Copeptin levels at presentation

Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI
Authors: Restan I , Steiro O.T , Tjora H.L , Langoergen J , Omland T , Collinson P , Bjoerneklett R , Vikenes K , Strand H , Skadberg O , Mjelva O.R , Larsen A.I , Bonarjee V.V.S , Aakre K.M 
Published: November 2020

Abstract

Background
NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients.

Purpose
To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI.

Method
971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose

Results
Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value &lt;0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value &lt;0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value &lt;0.001).

Conclusion
Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain.
Figure 1

Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals
Plaque erosion is associated with less systemic atherosclerosis than other plaque types of acute coronary syndrome
Authors: Kato A , Minami Y , Asakura K , Katamine M , Katsura A , Muramatsu Y , Sato T , Kakizaki R , Hashimoto T , Meguro K , Shimohama T , Ako J 
Published: November 2020

Abstract

Background
Previous studies have demonstrated that plaque erosion is associated with less atheromatous plaque at both culprit and non-culprit lesion than other plaque types of acute coronary syndrome (ACS). However, the status of systemic atherosclerosis in patients with plaque erosion remains to be elucidated.

Purpose
To clarify if plaque erosion is associated with less systemic atherosclerosis than other plaque types of ACS.

Methods
A total of 239 consecutive patients with ACS who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. Patients were classified into either plaque erosion (PE, n=45) or non-plaque erosion (non-PE, n=194) including plaque rupture and calcified nodule based on OCT findings of the culprit lesions. The status of systemic atherosclerosis was assessed by the findings of carotid echography, the severity of aortic arch calcification (AAC; grade 0–3) on chest X-ray, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABPI).

Results
The maximum intima media thickness (IMT) was significantly thinner in the PE group than in the non-PE group (1.9±0.8 vs. 2.3±0.9 mm, p=0.023) (Panel A). The prevalence of heterogeneous plaque and calcified plaque was significantly lower in the PE group than in the non-PE group (25.0 vs. 50.4%, p=0.010, 18.8 vs. 38.5%, p=0.037, respectively). The prevalence of AAC grade was significantly different between the two groups with a tendency toward lower AAC grade in the PE group than the non-PE group (Panel B). The mean baPWV (1588.1±420.6 vs. 1686.5±363.5 cm/sec, p=0.186) and ABPI (1.1±0.1 vs. 1.1±0.1, p=0.270) was comparable between the two groups.

Conclusion
Plaque erosion was associated with less atherosclerosis in carotid artery and aortic arch than non-plaque erosion. These findings may help further clarify the distinct pathophysiology of plaque erosion.

Funding Acknowledgement
Type of funding source: None
Central apneas and Ticagrelor related dyspnea in patients with acute coronary syndrome
Authors: Giannoni A , Borrelli C , Gentile F , Mirizzi G , Coceani M , Paradossi U , Passino C , Emdin M 
Published: November 2020

Abstract

Background
Patients treated with ticagrelor often develop dyspnea of unknown origin. We aim to explore the contribution of central apneas to ticagrelor-related dyspnea in patients with acute coronary syndrome (ACS).

Methods
We consecutively enrolled patients with ACS, preserved left ventricular ejection fraction and no history of obstructive sleep apnea, treated either with ticagrelor 90 mg bid (n=30) or prasugrel 10 mg od (n=24). One week after ACS onset, all patients underwent, beyond thorough cardiovascular and respiratory assessment, 24-hour cardiorespiratory monitoring and assessment of chemosensitivity to hypercapnia.

Results
Patients treated with ticagrelor reported more frequently dyspnea than patients treated with prasugrel (43% versus 4%, p=0.001), despite no difference in demographic, clinical, echocardiographic and pulmonary data. Patients with dyspnea induced by ticagrelor showed higher apnea-hypopnea and central apnea index both at daytime and at nighttime compared to patients treated with ticagrelor but without dyspnea and patients treated with prasugrel (daytime AHI: 26 [7–34] vs 6 [4–14] and 6 [0–11] events/hour; nighttime AHI: 65 [17–72] vs 22 [8–37] and vs 11 [4–23] events/hour; daytime CAI: 5 [1–15] vs 1 [0–6] and 0 [0–1) events/hour; nighttime CAI 34 [2–55] vs 3 [0–9] and 0 [0–1], all p&lt;0.05). Likewise, they also presented with higher hypercapnic ventilatory response (2.4 [1.9–2.7] vs 1.3 [1.1–1.9] and 0.9 [0.5–2.1] L/min/mmHg, all p&lt;0.05).

Conclusions
Central apneas should be considered a likely mechanism of dyspnea in ACS patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability in this setting.

Funding Acknowledgement
Type of funding source: None
Effect of body mass index on ischemic and bleeding events in patients presenting with acute coronary syndromes: insights from the START-ANTIPLATELET registry
Authors: Moscarella E , Calabro P , Gragnano F , Cesaro A , Pafundi P.C , Patti G , Cavallari I , Antonucci E , Cirillo P , Pignatelli P , Palareti G , Sasso F.C , Pengo V , Gresele P , Marcucci R 
Published: November 2020

Abstract

Background
The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding events as possible explanations to the obesity paradox in ACS patients.

Methods
For the purpose of this sub-study, patients enrolled in the START-ANTIPLATELET registry were stratified according to Body Mass Index (BMI) into three groups: normal, BMI &lt;25kg/m2; overweight, BMI: 25–29.9kg/m2; obese, BMI ≥30kg/m2. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, and major bleeding.

Results
Patients were classified as follows: 410 (33.9%) normal, 538 (44.5%) overweight, 261 (21.6%) obese. Compared to the normal weight group, obese and overweight patients had a higher prevalence of cardiovascular risk factors, but were younger, with a better left ventricular ejection fraction (LVEF) and lower PRECISE-DAPT score. At one-year follow-up NACE was more frequently observed in normal than in overweight and obese patients (15.1%,8.6%,and9.6%, respectively; p=0.004), driven by a significantly higher rate of all-cause death (6.3%,2.6%, and 3.8%, respectively; p=0.008), while no significant differences were noted in terms of MI, stroke, and major bleeding. When correcting for confounding variables, BMI loses its power in independently predicting outcomes, failing to confirm the obesity paradox in a real-world ACS population.

Conclusions
Our study conflicts the obesity paradox in real-world ACS population, and suggest that the reduced mortality rate may be explained by a lower bleeding risk in obese patients allowing a more aggressive medical treatment, and by a better LVEF translating into a higher survival rate.

Funding Acknowledgement
Type of funding source: None
De-escalation strategy with half-dose prasugrel or ticagrelor on pharmacodynamics and outcome in East Asians patients with acute coronary syndrome
Authors: Kim M.H , Jin C.D , Song K , Lee K.M , Moon H.Y , Jo Y.S , Yoon C.H , Cho Y.R , Park J.S , Lim K.H 
Published: November 2020

Abstract

Background
East Asians treated with potent P2Y12 inhibitors (prasugrel or ticagrelor) are exposed to more potent platelet inhibitory response. Whether half-dose de-escalation strategy would be benefit for chronic antiplatelet strategy in East Asian patients with acute coronary syndrome (ACS) remain uncertain.

Method
In half-dose de-escalation strategy, 129 Korean ACS patients were assigned to receive standard-dose potent P2Y12 inhibitors (n=86, prasugrel [n=38], ticagrelor [n=48]), followed by half-dose reduction at 1 month for maintenance, and was compared to clopidogrel (n=43) as control. The primary safety outcome was any clinically significant bleeding according to BARC (Bleeding Academic Research Consortium) criteria at 12 months. The pharmacodynamic response is accessed by VerifyNow P2Y12 reaction unit (PRU) at 1 month and 3 months post PCI.

Results
Ticagrelor achieved significantly lower PRU (7 [4–32] vs. 11 [5–76] vs. 167 [97–212]) than prasugrel and clopidogrel, resulting OPR rate 0% vs. 21.6% vs. 58.5%, respectively at 1 month post PCI. Similar results were observed at 3 months (PRU 12 [6–43] in ticagrelor vs. 88 [58–148] in prasugrel vs. 169 [107–199] in clopidogrel), with OPR rate 7.1% vs. 51.5% vs. 65.9%, respectively. At 12 months, the incidence of BARC type-1 or -2 bleeding was significantly higher in potent P2Y12 inhibitors (37.5% in ticagrelor, 34.2% in prasugrel) than in clopidogrel (36.0 vs. 14.0%; HR, 2.86; 95% CI, 1.19–6.87; p=0.018).

Conclusion
In Korean ACS patients, pharmacodynamic response (OPR rate) with half-dose prasugrel appears comparable to that with clopidogrel, whereas ticagrelor still exhibit potent platelet inhibition either standard or half doses. De-escalation strategy with half-dose potent P2Y12 inhibitor was associated with higher incidence of clinically insignificant bleeding compared with clopidogrel. Optimal dose reduction strategies in potent P2Y12 inhibitors to balance safety and effectiveness remain uncertain, and require further studies.
Pharmcodynamics to oral P2Y12 inhibitors

Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): National Research Foundation of Korea
Ticagrelor versus Clopidogrel in high bleeding risk patients presenting with Acute Coronary Syndromes: insights from the multicenter START-ANTIPLATELET registry
Authors: Gragnano F , Moscarella E , Calabro' P , Cesaro A , Pafundi P.C , Patti G , Antonucci E , Cirillo P , Pignatelli P , Palareti G , Pelliccia F , Sasso F.C , Pengo V , Gresele P , Marcucci R 
Published: November 2020

Abstract

Background
Optimal dual antiplatelet therapy in high bleeding risk (HBR) patients with acute coronary syndromes (ACS) remains debated. Although current guidelines recommend the use of potent P2Y12 inhibitors in these patients (according to the labeled indications), clopidogrel is frequently used in clinical practice based on a perceived advantage in terms of safety in the HBR population.

Purpose
We sought to investigate the use of clopidogrel versus ticagrelor in consecutive HBR ACS patients and their impact on ischemic and bleeding events at 1 year.

Methods
ACS patients enrolled in the START-ANTIPLATELET registry with at least 1 HBR criterion were included in the present analysis and stratified according to DAPT type (clopidogrel versus ticagrelor). The primary endpoint was net adverse clinical endpoint (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. The secondary endpoints were major adverse cardiac and cerebral events (MACE), defined as a composite of all-cause death, myocardial infarction and stroke, each individual component of NACE and MACE, and target vessel revascularization.

Results
Among a total of 1,209 patients with 1-year follow-up in the registry, 383 patients were considered at HBR, of whom 174 (45.4%) were on clopidogrel and 209 (54.6%) on ticagrelor. Clopidogrel was more likely to be administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group than in the clopidogrel group (10.40±4.29 versus 9.35±5.4; p-value=0.03). At 1-year follow-up, the risk of NACE and MACE events was significantly higher in the clopidogrel than in the ticagrelor group (NACE: HR 1.82; 95% CI 1.07–3.09; p-value=0.02; MACE: HR 1.83; 95% CI 1.04–3.24; p-value=0.03) (Figure). After multivariate adjustment for clinical and procedural characteristics, no difference in NACEs nor MACEs was observed between patients on clopidogrel versus ticagrelor (NACE: adjusted HR 1.27; 95% CI 0.71–2.27; p-value=0.42; MACE: adjusted HR 1.19; 95% CI 0.63–2.24; p-value=0.59) (Figure). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs.

Conclusions
In a real-world ACS registry, approximately 50% of patients are at HBR and frequently treated with clopidogrel. In HBR ACS patients, no difference was observed in ischemic and bleeding events between clopidogrel and ticagrelor after adjustment for potential confounders.
Kaplan-Meier curves at 1-year follow-up.

Funding Acknowledgement
Type of funding source: None