bluuebunny/crossref_metadata_2025_split huggingface dataset:
Atlas of the immune cell repertoire in human atherosclerotic plaques characterized by single cell RNA-sequencing and multi-color flow cytometry
Authors: Horstmann H , Lindau A , Hansen S , Stachon P , Hilgendorf I , Bode C , Zirlik A , Wolf D 
Published: November 2020

Abstract

Rationale
Atherosclerosis is a chronic inflammatory disease that is driven by the accumulation of pro- and anti-inflammatory leukocytes in the intima of affected arteries. Yet, the cellular composition of human atherosclerotic plaques is only poorly understood. Here, we characterized immune cells to human carotid atherosclerotic plaques by multi-color flow cytometry and scRNAseq.

Methods and results
First, we compared a set of previously reported digestion protocols to liberate leukocytes from human carotid plaques after surgical thrombendarteriectomy. One digestion cocktail, containing Collagenase IV and DNase I, was superior regarding cell survival and cell surface marker preservation. Second, leukocytes from 56 surgical specimen were characterized by flow cytometry with a set of 16 parameters and cell surface markers capable of identifying principal hematopoietic leukocyte lineages. This protocol allowed to extract and analyze on average 4x103 viable CD45+ leukocytes from a mean of 988 mg plaque tissue. Surprisingly, we found that atherosclerotic plaques were dominated by T cells with 33.7±2.2% CD4+ T-helper cells and 25.6±2.5% CD8+ cytotoxic T cells. CD11b+ myeloid cells, including monocytes and macrophages, represented only 20.2±4.0% of all CD45+ leukocytes. CD19+B cells and CD56+ NK-cells accounted for 3.9±1.2 and 3.3±0.5%, respectively. TCR-g/d+ T cells and neutrophils were undetectable in atherosclerotic plaques. This cellular composition differed significantly from peripheral blood, but was not relevantly changed between different plaque locations, indicating that macrophage-rich necrotic cores mostly contain dead cells. We confirmed the principal composition of human plaques by single-cell RNA-sequencing from six patients. To allow an estimation of cellular heterogeneity independent of classical cell surface marker assignment, we performed an unsupervised cluster detection algorithm by t-distributed stochastic neighbor embedding (tSNE) and found more than 16 leukocyte clusters with unique cell surface marker expression, suggesting an unexpected high diversity of plaque leukocytes.

Conclusion
We developed an immune cell phenotyping protocol optimized for human carotid plaques. The definition of phenotypes and frequencies in atherosclerotic plaques will allow to build clinical associations between the immune cell composition and clinical outcomes in future.

Funding Acknowledgement
Type of funding source: None
Microvascular disease, peripheral artery disease, and the risk of lower limb amputation
Authors: Olesen K.K.W , Anand S.S , Gyldenkerne C , Thim T , Maeng M 
Published: November 2020

Abstract

Background
Peripheral artery disease (PAD) is the leading cause of non-traumatic lower limb amputation. Microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) increases the risk of lower limb amputation in patients with established PAD.

Purpose
We estimated risk of lower limb amputation associated with microvascular disease and PAD in a Danish cohort.

Methods
We conducted a population-based cohort study of every person living in Western Denmark aged 50–75 years on January 1, 2012 and followed them for 7 years. People with previous lower limb amputation were excluded. People were stratified by the presence of microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) and PAD (peripheral atherosclerosis including intermittent claudication, or previous lower limb revascularization). We estimated the 7-year cumulative incidence and hazard ratio (HR) of lower limb amputation using individuals with neither microvascular disease nor PAD as reference. We also provide a sex-specific analyses and estimated the population attributable fraction of amputation associated with male sex.

Results
We included 933,597 individuals, of whom 16,007 had microvascular disease, 18,400 had PAD, and 1,789 had both microvascular disease and PAD. Patients with either microvascular disease (3.7%) or PAD (3.9%) had similar unadjusted 7-year risks of lower limb amputation (Figure). Microvascular disease (adjusted HR 3.21, 95% CI 2.86–3.59) and PAD (adjusted HR 7.37, 95% CI 6.68–8.14) increased the risk of lower limb amputation separately in adjusted analysis. Individuals with both microvascular disease and PAD had the highest risk of amputation (adjusted HR 11.82, 95% CI 10.11–13.80). While the relative impact of microvascular disease and PAD were similar in men and women, men had increased risk of amputation compared to women, in absolute terms. The population attributable fraction of amputations associated with male sex was 31%.

Conclusion
Microvascular disease and PAD are independently associated with a 3-fold and 7-fold increase of amputation rate, respectively. Combined, microvascular disease and PAD had an additive effect constituting a 12-fold amputation risk. Amputation risk was higher in men than in women, with 3 in 10 lower limb amputations in Western Denmark attributable to male sex.
Figure 1

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital
Clinical impact of peripheral artery disease on acute coronary syndrome
Authors: Fonseca Goncalves F , Borges S.C , Monteiro J.J , Mateus P.S , Moreira J.I 
Published: November 2020

Abstract

Introduction
Peripheral artery disease (PAD) and acute coronary syndrome (ACS) are two diseases with high morbidity and mortality and, sometimes, may be present simultaneously, making patient management more complex.

Purpose
This study sought to characterize and evaluate the prognostic impact of PAD in patients with an ACS.

Methods
This was a retrospective study of patients admitted with an ACS, periodically included in a national multicenter registry, between October 2010 and September 2019.

Results
Of a total of 26036 patients, 1429 had previous history of PAD. This group had a higher predominance of men (79,5% vs 72,0%, p&lt;0,001) and was older (71±11 years vs 66±14 years, p&lt;0,001). Besides having a higher burden of cardiovascular risk factors, they also had more past history of myocardial infarction (MI), stroke and chronic kidney disease.
In patients with PAD, non-ST segment elevation MI was the most frequent type of MI (58,6% vs 45,0%, p&lt;0,001) and left ventricular ejection fraction assessed during hospitalization was lower (49±13% vs 51±12%, p&lt;0,001). These patients were submitted less frequently to a coronary angiography (74,0% vs 85,2%, p&lt;0,001) and, when performed, more cases of multivessel coronary artery disease were found (70,6% vs 50,4%, p&lt;0,001). Nevertheless, they were less likely to undergo revascularization, with fewer angioplasties performed (47,8% vs 64,7%, p&lt;0,001), despite the greater number of coronary artery bypass grafting (9,0% vs 6,0%, p&lt;0,001). Both during hospitalization and at discharge, ticagrelor, beta-blockers and ACE inhibitors were less prescribed in the PAD group. Statins prescription was also lower, but only at discharge.
In a multivariate regression analysis, we found that, during hospitalization, the presence of PAD was associated with a significant higher risk of myocardial reinfarction (OR 1,90 (CI 1,18–3,06)) and death (OR 1,43 (CI 1,03–2,00)). In addition, there was a tendency for more strokes (OR 1,88 (CI 0,98–3,61)). During a 1-year follow-up, PAD was also independently associated with a significant increase in mortality (HR 1,50 (CI 1,16–1,95)).

Conclusions
PAD is a disease present in patients with a higher number of comorbidities and is associated with more severe coronary events. Nevertheless, these patients seem to receive less evidence-based therapy. In this study, PAD was independently associated with a significant increase in short and medium-term major adverse events.
Kaplan-Meier curves of 1-year follow-up

Funding Acknowledgement
Type of funding source: None
History of stroke is a major factor to affect prognosis of elderly chronic limb-threatening ischemia patients with frailty after endovascular therapy
Authors: Kanda D , Ikeda Y , Sonoda T , Anzaki K , Arikawa R , Tokushige A , Ohishi M 
Published: November 2020

Abstract

Background
Chronic limb-threatening ischemia (CLTI) is the most advanced form of severe arteriosclerosis, and CLTI patients are known to have poor prognosis due to complication of polyvascular diseases, including cerebrovascular disease. Stroke often causes disability of exercise, leading to develop frailty and sarcopenia, and frailty and sarcopenia are known to important factors affecting the prognosis of cardiovascular disease. However, the effect of history of stroke for clinical outcomes in elderly CLTI patients with frailty has not been well evaluated.

Purpose
The aim of the present study was to investigate whether a history of stroke affects prognosis of elderly CLTI patients with frailty after endovascular therapy (EVT).

Methods
The subject was 228 consecutive elderly (≥65 year) CLTI patients underwent EVT. These patients had frailty with clinical frailty scale 5 or 6 or 7 which was defined by Geriatric Medicine Research. Clinical frailty was assessed on admission before procedure of EVT by physicians or other health professionals. The study patients were divided into two groups based on patients with or without history of stroke group (Group A and B). We investigated the association between history of stroke on admission and outcome after EVT.

Results
All-cause death ≤6 month and ≤12 month after EVT were 10 cases (4%) and 19 cases (8%). Group A had higher rate of all-cause death ≤6month and ≤12 month (14 vs. 3%, p=0.012, 19 vs. 6%, p=0.019) than those of Group B. Kaplan Meier analysis elucidated that survival rate was significantly lower in Group A compared to that in Group B (p=0.031). As a result of cox proportional hazards analysis, all-cause death ≤6 month was associated with history of stroke [hazard ratio (HR): 5.07, 95% confidence interval (CI): 1.47–17.52, p=0.010)], hs-CRP (HR: 1.09, 95% CI: 1.01–1.16, p=0.010) in the univariate analysis. Similarly, cox proportional hazards analysis for revealed that history of stroke (HR: 3.02, 95% CI: 1.19–7.68, p=0.020), hs-CRP (HR: 1.09, 95% CI: 1.03–1.14, p&lt;0.001), hemodialysis (HR: 2.53, 95% CI: 1.03–6.24, p=0.043), use of clopidogrel (HR: 0.22, 95% CI: 0.07–0.78, p=0.019) and serum albumin level (HR: 0.40, 95% CI: 0.21–0.80, p=0.008) were significantly associated with all-cause death ≤12 month. Multivariate analysis models after adjusted for the demographic characteristics of patients and clinically relevant factors for all-cause death ≤6 month and ≤12 month after EVT revealed that history of stroke was an independent risk factor (HR: 5.18, 95% CI: 1.44–17.43, p=0.011, HR: 2.98, 95% CI: 1.71–7.61, p=0.022).

Conclusions
These data suggested that history of stroke was a crucial independent predictor for incidence of all-cause death in elderly CLTI patients with frailty.

Funding Acknowledgement
Type of funding source: None
Can left atrial mechanics predict anticoagulation in cryptogenic stroke?
Authors: Azul Freitas A , Milner J , Ferreira J , Ferreira C , Martinho S , Almeida J , Goncalves V , Jorge E , Goncalves L 
Published: November 2020

Abstract

Introduction
Ischemic stroke is a leading cause of death and disability in the Western world, frequently due to cardioembolism and atherothromboembolism. Cryptogenic strokes occur without a well-defined aetiology after a standard vascular and cardiac evaluation, and secondary prevention may include antiplatelet therapy while awaiting results of long-term cardiac monitoring. In this study, we aimed to identify echocardiographic predictors of paroxysmal atrial fibrillation (AF) latter identified in follow-up of patients with cryptogenic stroke.

Methods
We retrospectively assessed all patients with cryptogenic stroke admitted in our hospital in the last 2 years. Only patients in normal sinus rhythm with a minimum of 24 hours of cardiac monitoring at admission and 24 hours Holter monitor within 6 months after discharge were included. Echocardiographic measures included left ventricle ejection fraction, left atrium (LA) volume, left and right atrium longitudinal strain, left and right ventricle longitudinal strain, E/A ratio, E/e' ratio, isovolumetric relaxation time (IVRT) and E wave deacceleration time. Echocardiographic data was assessed to determine its accuracy to identify AF.

Results
The study included 32 patients with a mean age of 72±10 years and a male preponderance (87.5%). AF was identified in 12 (37.5%) patients. This group of patients had a larger indexed LA volume (44.3 vs 29.1 mL/m2, p=0.043), a lower IVRT (87 vs 116 ms, p=0.028), and a lower LA longitudinal strain in contractile (6.7 vs 13.6%, p&lt;0.001) and in reservoir phase (17.1 vs 23.6%, p=0.042). All other variables were not significantly different among groups, including LA longitudinal strain in conduit phase. LA longitudinal strain in contractile phase showed the best predictive power with an area under the ROC curve of 0.925 (95% CI 0.82–1 p=0.001). The cut-off value that best predicted AF was 8.17% with a sensitivity of 1 and specificity of 0.9.

Conclusion
LA longitudinal strain in contractile phase is a powerful method to identify AF in cryptogenic stroke. When reduced, anticoagulation may be considered in order to prevent recurrence. Further studies are warranted to reproduce these results in larger cohorts.

Funding Acknowledgement
Type of funding source: None
Different clinical features between left atrial and left atrial appendage thrombus: an insight into more than 16,000 transesophageal echography database
Authors: Fukunaga M , Masuda H , Isotani A , Morinaga T , Yano M , Miura S , Ando K 
Published: November 2020

Abstract

Background
Thrombosis localization inside the left atrium (LA) is very frequently in the left atrial appendage (LAA). Some cases show atrial thrombus outside LAA, whose characteristics have not well elucidated.

Purpose
To reveal the different clinical background between thrombus inside LAA and outside LAA in a large transesophageal echo (TEE) database.

Methods
We searched the TEE database over 8 years of our center to identify patients in whom LA thrombus was pointed out. After initial TEE imaging, LA thrombus was confirmed with repeated TEE by echocardiography specialist or other modality, such as CT images.

Results
In a consecutive 16,142 TEE cases, LA thrombus was suspected in 162 cases (1%), finally 38 cases were identified as LA thrombus. They were divided into two groups; LAA only group and outside LAA group. Atrial fibrillation was concomitant in 34 patients (89%). History of stroke was significantly higher in LAA group (46.2% vs 8.3%, p=0.03) and malignant tumor was significantly higher in outside LAA group (23.1% vs 58.3%, p=0.035). LA thrombus was the first symptom in 3 cases of outside LAA group, following by malignant tumor was newly detected. Oral anticoagulation was prescribed in 23 cases (61%) at TEE study, mostly treated with warfarin, and median 123 days later thrombus dissolution was confirmed in 21 cases (55%). During mean follow up of 893 days, 4 patients experienced ischemic stroke, but two of them were due to self-interruption.

Conclusion
Outside LAA thrombus is minor but more concomitant with malignant tumor. Physician must be aware that screening of cancer is important if outside LAA thrombus is detected.

Funding Acknowledgement
Type of funding source: None
Statin use associated with lower mortality in very elderly patients with peripheral arterial disease
Authors: Tseng A , Girardo M , Liedl D , Bhatt S , Wennberg P , Shamoun F 
Published: November 2020

Abstract

Introduction
Given the potential side effects and the lack of data on its efficacy, the role of statins in the very elderly (age 75+) with peripheral arterial disease (PAD) is uncertain. Previous studies have shown significant mortality benefit in very elderly patients with coronary artery disease, but the effect in PAD has not been evaluated.

Methods
Very elderly patients aged 75 to 80 with at least five years of follow-up who underwent ankle-brachial index (ABI) measurement were included. PAD was defined as either low ABI &lt;0.90 or high ABI &gt;1.40. Demographic, medication use, comorbidity and mortality data was obtained using the electronic medical record. Univariate and multivariate Cox proportional hazard analyses were performed.

Results
In total, 4,560 very elderly subjects with PAD were included in the analysis. The median age was 77 (interquartile range 76–79) and 39% were female. 3,462 (76%) had low ABI while 1098 (24%) had high ABI. Univariate analysis showed that patients on statins were more likely to be male, have diabetes, have coronary artery disease, and have hyperlipidemia. Overall, 1,355 (30%) patients died in the five-year period. Unadjusted all-cause mortality hazard ratios for patients with low or high ABI with statin use was 0.66 (95% confidence interval [CI]: 0.57–0.75) and 0.80 (95% CI: 0.66–0.97), respectively. After adjusting for age, sex, coronary artery disease and diabetes, statin use in low and high ABI was still associated with significant reductions in risk of all-cause mortality of 0.59 (95% CI: 0.51–0.67) and 0.66 (95% CI: 0.54–0.80), respectively. The survival curve for very elderly patients with PAD by statin use is shown in Figure 1.

Conclusion
Statin use in the very elderly was associated with lower risk of all-cause mortality in the five-year period after diagnosis of PAD. There appears to be a mortality benefit with statin use in the very elderly with PAD, though careful consideration of benefits and side effects should be individualized in this age group.
Figure 1

Funding Acknowledgement
Type of funding source: None
Clinical benefits of the orthogonal tri-axial technique in the left atrial appendage closure procedures
Authors: Du X.F , Chu H.M , Fu G.H , Wang B.H 
Published: November 2020

Abstract

Background
Intracardiac echocardiography (ICE) has been an alternative imaging guidance of transesophageal echocardiography (TEE) in the left atrial appendage closure (LAAC) procedures. However, its application experience is limited.

Objective
We aimed to analyze the clinical benefits of an orthogonal tri-axial (OTA) technique using ICE and electroanatomic mapping system (EAMS) in the LAAC procedures.

Methods
This retrospective study enrolled 52 atrial fibrillation (AF) patients with high risks of stroke and/or bleeding (CHA2DS2-VASc score 4.67±1.48; HAS-BLED score 2.87±0.94) who underwent the LAAC procedures following the OTA technique (ICE group). ICE probe was advanced into left atrium (LA) navigated by the EAMS. Evaluation of sizing and device implantation were performed from three orthogonal axes including axis-X: from left pulmonary veins (PVs) to LAA; axis-Y: from right PV ostium to LAA; axis-Z: from lower LA to LAA. Procedure-related parameters and clinical outcomes were compared to those from another 52 patients with comparable baseline characteristics who underwent LAAC following the TEE guidance (TEE group). All procedures were achieved under local anesthesia.

Results
The fluoroscopic exposure (99.5±113.6 vs 229.0±135.4mGy, P&lt;0.001) and time (5.9±4.7 vs 8.1±3.9min, P=0.011) and contrast consumption (66.5±54.9 vs 124.1±69.6ml, P&lt;0.001) in the ICE group were significantly lower than those in the TEE group, respectively, without increasing the procedural time (79.6±24.4 vs 82.3±39.5min, P=0.674). Similar proportions of Watchman (26 vs 32, P=0.236) and ACP (10 vs 13, P=0.478) devices were recorded between groups while more LAmbre devices were applied in the ICE group (16 vs 7, P=0.033). All procedures were accomplished successfully. The fluoroscopic exposure (22.9±32.7 vs 228.9±148.6mGy, P&lt;0.001) and time (1.9±2.9 vs 9.9±5.0min, P&lt;0.001), the contrast consumption (17.7±21.7 vs 124.6±62.8ml, P&lt;0.001) and the procedural duration (74.6±19.7 vs 88.1±20.6min, P=0.107) were lower in the last 25% cases in the ICE group compared to the first 25% cases. Both acute and long-term (during the 45-day and 6-month follow-ups) peri-device leaks (PDLs) were similar between groups. No procedure-related complications or thromboembolism events were observed.

Conclusions
The advantage of the ICE- plus EAMS-guided LAAC in fluoroscopic exposure and contrast consumption minimizing could be expected following the OTA technique. Procedural efficiency improves after the learning curve.

Funding Acknowledgement
Type of funding source: None
Biomarkers in patients with cryptogenic stroke/TIA and subclinical atrial fibrillation
Authors: Kjekshus H , Skrebelyte-Strom L , Bakkelund V , Arnesen H , Ronning O.M , Steine K , Seljeflot I 
Published: November 2020

Abstract

Background
A large proportion of patients with cryptogenic stroke or transitory ischemic attack (TIA) have underlying subclinical atrial fibrillation (SCAF) detected on follow up. It is not clear whether SCAF is the underlying primary entity in the pathogenesis of stroke in these patients, or merely a marker of atrial myopathy associated with left atrial remodeling, fibrosis and inflammation.

Purpose
As a hypothesis generating study, we investigated a panel of selected biomarkers involved in fibrosis, inflammation, and thrombosis: growth differentiation factor 15 (GDF-15), transforming growth factor b (TGFb), galectin-3, soluble suppressor of tumorgenicity2 (sST2), von Willebrand factor (vWF), Tissue metalloprotease1 (TIMP1), Matrix metalloprotease9 (MMP9), Emmprin, Interleukin6 (IL6), C-reactive protein (CRP), Tissue factor (TF), Plasminogen activator inhibitor (PAI1), and their relation to the occurrence of SCAF during follow-up in patients after cryptogenic stroke or TIA. We hypothized that biomarker levels were increased in patients with subclinical AF.

Methods
236 patients, median age 71 years (range 21–94) of which 38% were women, with their first cryptogenic stroke or TIA were included 2–4 days after the index event and followed with an Implantable Cardiac Rhythm Monitor for &gt;1 year. Echocardiography and blood sampling were performed at inclusion. ELISA methods were used.

Results
SCAF occurred in 84 patients (36%). Only GDF-15 was significantly increased in AF- vs no-AF patients: 1010 pg/mL (inter quartile range: 814–1416) vs 860 pg/mL (inter quartile range: 622–1197) (p=0.018), and correlated with the number of premature atrial contractions (PAC)/24h (by Holter ECG during index hospitalization) (rs=0.314, p&lt;0.001) and AF-burden during follow-up (rs=0.149, p=0.022). Furthermore, there was a significant trend across quartiles of GDF-15 for having AF, and patients in the three highest quartiles (Q2–4) compared with Q1 had an odd ratio of having AF of 2.16 (95% CI 1.10–4.25), adjusted for sex and body mass index. The significance, however, was lost when adjusting for age, which correlated significantly to GDF-15 (rs=0.283; p&lt;0.001). ROC curve analyses showed an AUC of 0.593 (0.52–0.68) for GDF-15 compared to 0.617 (0.54–0.69) for age. GDF-15 was also associated with co-morbidities such as hypertension (p&lt;0.001), diabetes (p&lt;0.001), and vascular disease (p&lt;0.001).

Conclusion
In patients with a cryptogenic stroke or TIA experiencing SCAF during follow up, only levels of GDF-15 were elevated and correlated with PAC/24h and AF-burden. However, GDF-15 was highly related to age and co-morbidities and did not add significantly to the prediction of AF in a multivariate analysis.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Stiftelsen Dam, Norwegian Atrial Fibrillation Research Network