bluuebunny/crossref_metadata_2025_split huggingface dataset:
Diagnostic reliability of quantitative flow ratio for detection of myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices
Authors: Otsuka M , Satomi N , Kahata M , Kitagawa S , Kumagai A , Inoue K , Koganei H , Enta K , Ishii Y 
Published: November 2020

Abstract

Background
Quantitative flow ratio (QFR) is an image-based virtual fractional flow reserve (FFR) computed by three dimensional quantitative coronary angiography (3D-QCA) and estimated flow velocity. Several studies have reported that QFR had a good diagnostic performance as compared with wire-based FFR or instantaneous wave-free ratio (iFR).

Purpose
We compared the diagnostic reliability of QFR for detection of myocardial ischemia with other angiographic and visual predicted indices.

Methods
In 301 coronary lesions (263 patients) from our QFR database for previously-reported two studies, the diagnostic reliability of QFR, several angiographic and visual predicted indices were investigated using ROC analysis as reference of FFR≤0.8 or iFR≤0.89. Visual predicted FFR were estimated by 3 physicians (25-year experienced expert, 10-year experienced senior physician and 3-year experienced trainee) blinded to other indices.

Results
Area under the curve (AUC) of each index in ROC analysis is shown in Table.

Conclusion
QFR was reliable index detecting myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices.

Funding Acknowledgement
Type of funding source: None
Safety and efficacy of a hyperaemic agent, intracoronary nicorandil 4mg, for invasive physiological assessments during fractional flow reserve measurement
Authors: Nishikura T , Wakabayashi K , Aizawa N , Suzuki T , Shibata K , Furuya T , Kosaki R , Fukuoka H , Ikeda N , Kikuchi M , Miyoshi F , Tanno K 
Published: November 2020

Abstract

Background
Fractional flow reserve (FFR) is one of most reliable index for the determining the functional severity coronary artery stenosis. Adenosine is the most commonly used agent for maximal hyperaemia. However, adenosine can cause chest discomfort, bronchial hyper-reactivity, and atrioventricular block. The aim of this study is to evaluate the safety and efficacy of intracoronary nicorandil as an alternative hyperaemic agent for FFR.

Methods and results
We enrolled consecutive 82 patients (87 lesions) who underwent FFR measurement in our center from Nov. 2018. We compared three groups; intravenous infusion of adenosine (150 μg/kg/min); and adenosine added intracoronary nicorandil 2mg; and intracoronary nicorandil 4mg. Mean FFR value was 0.83±0.09, 0.82±0.09, 0.82±0.08, There was a strong correlation among three groups (R2&gt;0.9). Mean cyclic change in FFR was 0.026±0.023, 0.019±0.010, 0.016±0.014, respectively, cyclic change was smallest in intracoronary nicorandil 4mg group (vs ATP; p&lt;0.001, vs ATP + nicorandil 2mg; p&lt;0.001). By Wilcoxon test, mean FFR value of nicorandil 4mg was significant lower than ATP (p=0.0021), and equal to ATP + nicorandil 2mg (p=0.98).

Conclusions
Intracoronary nicorandil 4mg is a simple, safe, and effective way to induce steady-state hyperaemia for FFR.
Figure 1

Funding Acknowledgement
Type of funding source: None
Insufficient lipid lowering therapy could not bring favorable prognostic effect in high risk patients who were functionally deferred percutaneous coronary intervention
Authors: Abe T , Jujo K , Moriyama T , Iwanami Y , Shimazaki K , Hara M , Nakazawa G , Hagiwara N , Saito K 
Published: November 2020

Abstract

Introduction
Deferral of percutaneous coronary intervention (PCI) of a functionally insignificant stenosis is associated with favorable long-term prognoses. However, previous reports revealed that patients with fractional flow reserve (FFR) 0.81–0.85 had higher cardiovascular adverse event rates than those with FFR &gt;0.85. Numbers of large clinical trials established the lower, the better strategy for low-density lipoprotein cholesterol (LDL-C) management for patients after PCI. However, in the real clinical practice, the achievement rate of target LDL-C is often insufficient in patients with atherosclerotic risk factors who were functionally deferred PCI.

Purpose
We aimed to examine optimal LDL-C management for patients with intermediate coronary stenosis deferred PCI by FFR measurement.

Methods
This observational study included 293 consecutive patients with coronary stenosis deferred PCI due to greater FFR than 0.80. We separately analyzed 90 patients with 0.81–0.85 of FFR and 203 patients with &gt;0.85. Patients in each group were further classified into 2 groups based on LDL-C level at one year after FFR measurement; the Lower LDL-C group (&lt;100 mg/dL) and the Higher LDL-C group (&gt;100 mg/dL). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction, ischemic stroke, heart failure hospitalization and unplanned revascularization.

Results
Patients with FFR 0.81–0.85 had a significantly higher MACCE rate than those with FFR &gt;0.85 (hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.02–3.07, p=0.043). In patients with FFR 0.81–0.85, the Lower LDL-C group (n-=53) had a significantly lower rate of the primary endpoint than the Higher LDL-C group (HR: 0.41, 95% CI: 0.18–0.97, Log-rank p=0.036, Figure A). Whereas, there was no significant difference in the event rate between 2 groups in patients with FFR &gt;0.85 (Log-rank p=0.42, Figure B).

Conclusion
Uncontrolled LDL-C level was associated with higher MACCE rate in patients who were deferred PCI due to FFR 0.81–0.85. These results suggested that even in patients who were deferred PCI, those with coronary artery stenosis of lower FFR value should receive strict LDL-C lowering therapy with close monitoring.
Figure 1

Funding Acknowledgement
Type of funding source: None
Revascularization decisions in patients with stable angina and intermediate lesions: results of the second International Survey on Interventional Strategy (ISIS-2)
Authors: Toth G , Wijns W , Fournier S , Toth B , Johnson N , Barbato E 
Published: November 2020

Abstract

Background
ISIS-1 survey (conducted in 2012–2013) demonstrated a significant disconnect between guideline recommendations on invasive functional and imaging assessment of coronary stenosis severity and effective intention to adoption in patients with chronic coronary syndromes (CCS). Ever since, more evidences and new indexes/tools have become available, supposedly resulting into a simplified adoption. Therefore, six years later the second survey was repeated (ISIS-2) with the aim to evaluate a possible evolution in the intended adoption of invasive diagnostic tools.

Methods
ISIS-2 was conducted via a web-based platform from June to December 2019. Here, five complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography (QCA) values were known and kept concealed to the participants. Estimation of stenosis significance was asked for each lesion. In case of uncertainty, the most appropriate adjunctive invasive diagnostic method among QCA, intravascular ultrasound, optical coherence tomography, or invasive functional test (i.e. with FFR or a non-hyperemic index) was to be selected. Primary endpoint of the study was the rate of requested adjunctive functional or imaging assessment, as indicated by guideline recommendations. Secondary endpoint was the rate and accuracy of purely angiography-based decisions.

Results
A total of 411 participants performed 3749 lesion evaluations in ISIS-2: 2237 (60%) decisions were taken solely on angiogram and expressed no need for further evaluation with adjunctive tools. This rate of angiographic reliance was significantly reduced in ISIS-2 as compared with ISIS-1 (3139 [71%]; p&lt;0.001). Here the decision (significant or non-significant) was discordant with the known functional significance in 870 (39%) cases, markedly less as in ISIS-1 (1459, 46%; p&lt;0.001). In ISIS-2, participants expressed the need for either invasive functional assessment or intravascular imaging in 1110 (29%) and 379 (11%) cases, respectively. These rates were significantly higher as compared with ISIS-1 (928 [21%]; p&lt;0.001 and 354 [8%]; p&lt;0.001, respectively).

Conclusions
ISIS-2 survey suggests an evolving pattern over 6 years in the intention to integrate coronary angiography with invasive coronary physiology and imaging testing in patients with CCS.

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Unrestricted grant from Abbott Medical
Clinical outcomes of drug-eluting stent era according to chronic kidney disease and diabetes (IRIS-DES registry)
Authors: Kim D.W 
Published: November 2020

Abstract

Aims
Clinical outcomes in patients who underwent percutaneous coronary intervention (PCI) using various generation drug-eluting stent (DES) stratified by the degree of renal dysfunction and diabetes were not fully elucidated.

Methods and results
This study included 16,741 patients enrolled in the multicenter IRIS-DES registry. Renal insufficiency was graded according to the baseline renal function. The primary endpoint was major adverse cardiocerebrovascular event (MACCE), defined as a composite of all cause death, myocardial infarction, cerebrovascular events, and target vessel revascularization. Among 16,741 patients, 11,274 (67%) had eGFR ≥60 ml min–1 1.73m–2 at baseline, 4,280 (26%) had eGFR of ≥30 and &lt;60, and 1187 (7%) had eGFR &lt;30. At 3.6 years of follow-up (interquartile range, 2.97–4.87 yrs), the cumulative incidence of MACCE substantially increased according to the severity of renal insufficiency (11.3% in eGRF ≥60, 16.0% in eGFR of ≥30 and &lt;60, and 29.7% in eGRF &lt;30, respectively, P&lt;0.001). After multivariable adjustment of clinical covariates, as compared with patients with eGFR ≥60, the hazard ratios for MACCE was significantly higher in patients with eGFR of ≥30 and &lt;60 (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1–1.4) and in patients with eGFR &lt;30 (HR 2.0, 95% CI 1.7–2.4). This effect showed better consistent trends in non-diabetes and non- renal insufficiency in subgroup analysis of the primary endpoint (Figure 3).

Conclusions
Renal insufficiency is significantly associated with worse clinical outcomes in the DES era. Also, the effect on MACCE was consistent, being better in non-diabetes and non- renal insufficiency.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): CVRF
Multifactorial intervention and effect on morbidity, preventive medication and mortality in patients with type 2 diabetes within cardiac rehabilitation
Authors: Soja A.M.B , Carlson N , Rasmusen H.K , Sjoel A , Thygesen L.C , Zwisler A.D.O 
Published: November 2020

Abstract

Background
Although studies have reported beneficial impact of cardiac rehabili-ta-tion in the overall population, knowledge from clinical randomized trials of the effect of cardiac rehabilitation in patients with type 2 diabetes is still sparse.

Purpose
In the randomized DANSUK trial, we aimed to evaluate the short- and long-term effect on cardiovascular disease, hospital readmissions, mortality and use of preventive medication in patients with type 2 diabetes referred to comprehensive cardiac rehabilitation by comparing an intensified, targeted, multifactorial intervention with standard of care.

Methods
From 2000 to 2004 a total of 151 patients with type 2 diabetes and with ischemic heart disease (53%), heart failure (18%), or high-risk patients with at least three risk factors for ischemic heart disease (29%) were included in the DANSUK trial. The patients were allocated to standard of care (N=76) following current guidelines or comprehensive cardiac rehabilitation during a twelve weeks program with a stepwise implementation of behaviour modification and preventive medication to reach treatment goals (N=75). Clinical outcomes were compared after three and fourteen years of follow-up using national registries. Primary composite outcome measure included overall mortality, myocardial infarction or acute first-time readmission.

Results
Mean age was 66 years and more than one third of the population were women. After three years of follow-up, no difference in primary outcome was obtained (HR: 0,87; 95% CI: 0,58–1,32), but when hospitalized within the first three years, mean length of stay was significantly reduced by 25% in patients who had attended comprehensive cardiac rehabilitation compared to standard of care (5,8 vs. 7,7 days; p&lt;0.04). After fourteen years of follow-up there was still no difference in the combined endpoint between the two treatment groups.

Conclusions
Although the DANSUK trial earlier has demonstrated reductions in several risk factors and in the use of preventive medication in patients with abnormal glucose metabolism attending comprehensive cardiac rehabilitation compared to standard of care, these effects did not translate into the primary composite endpoint after three and fourteen years of follow-up in patients with known type 2 diabetes at enrolment. Nevertheless, there was a significant reduction in length of stay when admitted to hospital in the cardiac rehabilitation group compared to standard of care within the first three years of follow-up.

Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Danish Heart Foundation
Antiplatelet therapy prescription patterns for acute coronary syndrome: a decade analysed
Authors: Gupta S , Belley-Cote E , Basha A , McEwen C , Wu N , Mehta S , Schwalm J.-D , Whitlock R 
Published: November 2020

Abstract

Background/Introduction
Guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS) regardless of management strategy. Despite this, prescription practices lag and appropriate DAPT is not utilized.

Purpose
We aimed to trend differences in P2Y12 inhibitor prescriptions between ACS patients managed with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As well, we wanted to analyze the impact practice-changing trial publications, national guideline updates, and publicly funded drug coverage plans may have on prescription patterns.

Methods
From national databases, we obtained data for ACS patients in the province of Ontario, Canada between 2008 and 2018. Using an interrupted-time series with data aggregated monthly, we evaluated types of P2Y12 inhibitor prescribed at hospital discharge and changes to antiplatelet prescription patterns following publication of Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome (PLATO), Canadian Cardiovascular Society (CCS) antiplatelet therapy guidelines, and ticagrelor coverage by a publicly funded medication plan.

Results
We included 114,142 ACS patients; 49% underwent PCI and 8% required CABG. Between October 2008 and March 2018, the proportion of patients discharged on P2Y12 inhibitors increased from 73.4% to 87% (p&lt;0.0001) for PCI patients and 11.4% to 31.4% (p&lt;0.0001) for CABG patients. PLATO publication was associated with a 1.3% (p=0.002) monthly decline in clopidogrel prescriptions amongst PCI patients. The 2010 CCS antiplatelet therapy guidelines were associated with a 0.7% (p&lt;0.0001) monthly decline in clopidogrel prescriptions amongst PCI patients. The approval of ticagrelor by publicly funded medication plan was associated with an increase in ticagrelor prescriptions within the first month (24.5%; p&lt;0.0001) and a continued monthly increase (0.4%; p&lt;0.0001) in PCI patients. The approval was also associated with an increase in monthly ticagrelor prescriptions (0.2%; p&lt;0.0001) amongst CABG patients. The 2012 CCS antiplatelet therapy guidelines were associated with a decline in clopidogrel prescriptions within the first month (6.1%; p=0.003) and a monthly increase in ticagrelor prescriptions (0.3%; p=0.05) amongst PCI patients.

Conclusion
Drug coverage by a publicly funded medication plan and guideline updates had significant impact on P2Y12 inhibitor prescription practices. Despite improvements, P2Y12 inhibitor prescriptions for CABG patients are far behind PCI patients. Further research is necessary to address barriers to appropriate antiplatelet therapy in the ACS population.
Antiplatelet Prescription Patterns

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): New Investigator Fund - Hamilton Health Sciences Foundation, Hamilton, Canada
Role of smoking on body fat distribution and coronary artery disease
Authors: Sabet M , Elkaffas S , Bakhoum S.W.G , Kandil H 
Published: November 2020

Abstract

Introduction
Smoking and obesity are recognized as important modifiable risk factors for coronary artery disease (CAD). However, the general perception that smoking protects against obesity is a common reason for starting, and/or not quitting smoking.

Purpose
To detect the quantity, quality and relative distribution of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) estimated by abdominal computed tomography in smokers versus non- smokers.

Methods
The abdominal muscular wall was traced manually to calculate SAT and VAT areas (cm2) (outside and inside abdominal muscular wall respectively) as well as SAT density [Hounsfield units (HU)] at L4-L5 in 409 consecutive patients referred for evaluation of chest pain by multi-slice computed tomography coronary angiography (MSCT-CA).

Results
26% of the studied patients (n=107) were current smokers, while the remaining 74% (n=302) never smoked. Coronary artery atherosclerosis was more prevalent in smokers compared to non-smokers (64.5% vs 55.0%; p=0.09). Smokers had statistically significantly lower body mass index (BMI) (31.2±4.3 vs. 32.5±4.7 kg/m2; p=0.015), hip circumference (HC) (98.6±22.5 vs. 103.9±20.9 cm; p=0.031), total fat area (441.62±166.34 vs. 517.95±169.51cm2; p&lt;0.001), and SAT area (313.07±125.54 vs. 390.93±143.28 cm2; p&lt;0.001) as compared to non-smokers. However, smokers had statistically significantly greater waist-to-hip ratio (0.98±0.08 vs. 0.96±0.08; p=0.010), VAT/SAT area ratio (0.41±0.23 vs. 0.35±0.20; p=0.013), and denser SAT depot (−98.91±7.71 vs. −102.08±6.44 HU; p&lt;0.001).

Conclusion
Smoking contributes to CAD and to the pathogenic redistribution of body fat towards VAT, through limiting SAT potential to expand.

Funding Acknowledgement
Type of funding source: None
Apabetalone, a selective BET protein inhibitor, reduces ischemic cardiovascular events and hospitalization for heart failure in patients with acute coronary syndrome and type 2 diabetes
Authors: Ray K.K , Nicholls S.J , Buhr K.A , Ginsberg H.N , Kalantar-Zadeh K , Johansson J.O , Kulikowski E , Toth P.P , Wong N , Sweeney M , Schwartz G.G 
Published: November 2020

Abstract

Background
Despite established treatments, patients with type 2 diabetes mellitus (T2DM) and acute coronary syndrome (ACS) are at higher risk of ischemic cardiovascular (CV) events and hospitalization for heart failure (HHF) compared to those without T2DM. LDL-C lowering or use of GLP-1 agonists predominantly affects ischemic CV events, with little effect on HHF. Conversely, treatment with SGLT-2 inhibitors reduces HHF, with less effect on ischemic CV events. Preclinical studies indicate that bromodomain and extra-terminal (BET) proteins coordinate gene transcription for pathways that promote atherothrombotic events as well as heart failure. We assessed the clinical effect of apabetalone (APB), a novel BET protein inhibitor, on a composite of non-fatal ischemic CV events, HHF, and CV death in a post hoc analysis of the BETonMACE trial

Methods
BETonMACE was a double-blind, placebo-controlled phase 3 study in patients with T2DM and recent acute coronary syndrome receiving standard of care risk factor management. In 13 countries, 2425 patients were enrolled. We conducted a time-to-event analysis for first adjudicated CV death or non-fatal MI, stroke, or HHF using a log-rank test and Cox proportional hazards model.

Results
At baseline median age was 62 years, 25.6% were female, 87.6% white, and use of high intensity statin, ACE inhibitors/ angiotensin II blockers, dual antiplatelet therapy and beta blocker were 90, 88, 92 and 91% respectively. A total of 312 subjects had an endpoint event, with 139 (11.5%) patients in the ABP group and 173 (14.3%) among PBO (HR 0.78, 95% CI 0.63–0.98, p=0.03, Figure). At 26 months, the absolute risk reduction was 3.2% and number needed to treat was 31. Numerically favorable HRs were observed for each component endpoint except for stroke (Table).

Conclusion
This present analysis suggests that BET inhibition with APB may be a novel pathway through which to reduce both HHF and ischemic CV events in high risk patients with T2DM thus impacting broader clinical outcomes with potentially large benefits for patients and healthcare systems.

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Resverlogix Corp
Prognosis in patients with prior myocardial infarction and PEGASUS-TIMI 54 criteria in the CLARIFY registry
Authors: Biscaglia S , Campo G , Fox K , Tardif J.C , Tendera M , Greenlaw N , Ford I , Stanley B , Ferrari R , Steg P.G 
Published: November 2020

Abstract

Background/Introduction
The PEGASUS-TIMI 54 trial showed that prolonged treatment with ticagrelor reduces the cumulative occurrence of ischemic adverse events. CLARIFY is the biggest real life registry on chronic coronary syndrome.

Purpose
- To evaluate the percentage of patients eligible for long-term ticagrelor therapy in the CLARIFY registry.
– To compare the outcome of this subgroup of patients with those with PEGASUS exclusion criteria or without PEGASUS inclusion criteria.

Methods
Within the CLARIFY population, we selected post MI patients and we excluded those with missing info (post MI evaluable population). Then, we divided patients into 3 groups: excluded (meeting PEGASUS exclusion criteria, namely use of P2Y12 receptor antagonists or chronic oral anticoagulant, any stroke, coronary-artery bypass grafting in the past 5 years); eligible (meeting PEGASUS high-risk inclusion criteria, namely age≥65 years; diabetes; multivessel disease; creatinine clearance &lt;60 ml/min) and ineligible (not meeting PEGASUS high-risk inclusion criteria).
We therefore compared the ischemic (CV death, MI and stroke) and bleeding (major bleeding) outcome of the 3 groups adjusting for age, sex, smoking and geographical region.

Results
Among the 11811 post-MI evaluable patients, 4706 (39.8%) were included in the eligible group, 5715 (48.4%) in the excluded group, and 1390 in the ineligible group (11.8%). Both the ischemic and bleeding endpoints were significantly different among the 3 groups with the excluded patients with the worst and ineligible patients with the best outcome (see table). The same trend was shown for CV death, while the occurrence of MI was not significantly different among the 3 groups. In the eligible group, the ratio between ischemic and bleeding events was 6:1, whereas between CV death and major bleeding was 3.5:1.

Conclusions
Around 40% of CLARIFY post-MI patients could benefit from prolonged ticagrelor therapy. In this group of patients, ischemic risk seems to be higher than the bleeding one.
Ischemic & bleeding risk in the 3 groups

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): CLARIFY registry was funded by Servier