bluuebunny/crossref_metadata_2025_split huggingface dataset:
Validation and potential usefulness of the updated PROMISE minimal risk tool in patients with suspected coronary artery disease undergoing coronary CT angiography
Authors: Lima M R L , Lopes P L , Albuquerque F A , Presume J P , Freitas P F , Silva C S , Guerreiro S G , Abecasis J A , Saraiva C S , Coutinho Santos A C S , Goncalves P A G , Mendes M M , Ferreira A F , Marques H M 
Published: November 2023

Abstract

Introduction
The steady decline in test positivity among patients with suspected coronary artery disease (CAD) has raised interest in developing strategies to identify patients who may not require testing. The updated PROMISE minimal-risk tool (PMRT) was developed specifically for this purpose, but never tested in our population.
The aim of this study was to assess the diagnostic performance of this new tool, and to compare it with the guideline-recommended pre-test probability (PTP) and with the risk factor-weighted clinical likelihood (RF-CL) model in a Portuguese cohort of symptomatic patients undergoing coronary computed tomography angiography (CCTA).

Methods
We conducted a two-centre cross-sectional study of symptomatic patients undergoing CCTA for suspected CAD. Key exclusion criteria were age &lt;30 years, known CAD, suspected acute coronary syndrome or symptoms other than chest pain or dyspnoea. A simplified version of the updated PMRT (without HDL-C), the guideline PTP, and RF-CL score were calculated for each patient. Obstructive CAD was defined as any luminal stenosis ≥ 50% on CCTA. ‘Low risk’ was defined as absence of obstructive CAD and coronary artery calcium (CAC) score &lt; 100 (both conditions present, where CCTA results are unlikely to change patient management). The cut-off value of the PMRT with 95% positive predictive value for identifying patients with ‘Low risk’ was identified in ROC curve analysis.

Results
A total of 2162 patients (mean age 60±11years, 59% female) were included. Overall, 14.9% (N=323) of patients had obstructive CAD, and 73.5% (N=1589) fulfilled the criteria for ‘Low risk’. Patients with ‘Low risk’ were more frequently female, had higher prevalence of non-anginal chest pain and had fewer cardiovascular risk factors.
For obstructive CAD, the discriminative power of the updated PMRT was similar to the one provided by the guideline PTP and RF-CL models (Figure 1A). However, for identifying patients with ‘Low risk’, the updated PMRT showed greater discriminative power than the guideline PTP and RF-CL models (Figure1B).
The PMRT cut-off value with 95% positive predictive value for detecting patients at "Low risk" was identified as &gt;46%. A total of 458 patients (21.2%) had a PMRT &gt;46%.

Conclusion
In this cohort of symptomatic patients undergoing CCTA, the updated PMRT showed similar discriminative power for obstructive CAD, but greater discriminative power to identify "Low risk" than the guideline-recommended PTP and the RF-CL models. The criterion that identified "Low Risk" with 95% positive predictive value was present in roughly one fifth of patients undergoing CCTA, who would derive less benefit from testing.
Does prediabetes diagnosed by hemoglobinA1c or oral glucose tolerance test predict coronary artery disease in patients suspected of chronic coronary syndrome?
Authors: Overgaard K , Andersen T , Mohamed R , Heinsen L , Binderup H , Moller S , Auscher S , Lambrechtsen J , Egstrup K 
Published: November 2023

Abstract

Introduction
The presence of prediabetes worsens the prognosis of coronary artery disease, as patients with prediabetes are known to have an almost doubled cardiovascular mortality risk compared to normoglycemic patients. In clinical practice, HemoglobinA1c (HbA1c) has replaced the oral glucose tolerance test (OGTT) in the diagnosis of prediabetes. However, the background for the HbA1c threshold is based on the development of microvascular complications and progression to established diabetes. It remains unclear whether the substitution of OGTT with HbA1c results in an underestimation of prediabetics with a high risk of coronary artery disease, or if HbA1c is associated with macrovascular complications in prediabetic patients.

Purpose
We aimed to investigate whether HbA1c- or OGTT-diagnosed prediabetes could predict presence and severity of coronary artery disease in patients suspected of chronic coronary syndrome.

Methods
This was a descriptive cross-sectional study of 702 patients referred to a coronary CT angiography due to suspicion of chronic coronary syndrome. Coronary artery calcification (CAC)-score, presence of plaque and significant stenosis (&gt;50%), and plaque characteristics were evaluated. All patients had a fasting OGTT and blood samples performed. Patients were categorized according to glycemic status by HbA1c and OGTT, and compared to their test-specific range.

Results
Prediabetes was detected by HbA1c 167 (24%) or OGTT 272 (39%), and an overlap in classification by both tests was seen in 98 (22%) of participants. Both classifications of prediabetes showed increased presence of plaques, significant stenosis, calcified plaques, and correspondingly, a low frequency of a CAC-score=0 compared to their test-specific normal. Additionally, the HbA1c-prediabetics had an increased frequency of a high CAC score &gt;400 compared to normal HbA1c (23% vs. 10%, p&lt;0.0001). In the multiple logistic regression analysis the HbA1c-prediabetics had an odds ratio (OR) of 1.5 for plaque presence (confidence interval (CI) 1.0;2.4) and OR 2.1 for a CAC-score &gt;400 (CI 1.3;3.5). None of the associations for the OGTT-prediabetics were significant in the logistic regression analysis. Receiver operating characteristic curves were applied to the significant logistic associations. The HbA1c-prediabetics had an area under the curve (AUC)=0.77 for plaque presence and AUC=0.81 for CAC-score &gt;400.

Conclusion
Prediabetes defined by HbA1c can predict presence and severity of coronary artery disease. Although OGTT identified more patients as having prediabetes, their risk of coronary artery disease was not attributable to prediabetes. Thus, our results support the replacement of OGTT with HbA1c in clinical practice.
The prognostic role of left atrial strain in young patients after ST elevation myocardial infarction: a 3D echocardiographic study
Authors: Scarlatescu A I , Micheu M M , Popa-Fotea N M , Petre I G , Oprescu N , Mihail A M , Dorobantu M 
Published: November 2023

Abstract

Background
LA volume previously demonstrated its role as significant predictor of adverse events after AMI. The prognostic value of LA strain is less studied. Left atrial strain has been used as a more accurate alternative to assessing LA performance. 3D echocardiography compared with 2D measurements better reflect the entire atrial myocardium, leading to a more accurate estimation of LA function.

Purpose
In this study we aimed to assess the prognostic value of LA strain parameters determined by 3D echocardiography in young patients after STEMI.
Patients and methods: We enrolled 112 patients in this study - 84 young patients with a first STEMI treated by primary PCI and 28 healthy age and sex matched controls. All patients underwent standard transthoracic echocardiography. In addition to conventional echocardiographic parameters, 3D acquisitions of the left atrium were performed. 3D LA longitudinal strain parameters were determined using the automated function 4D Auto LAQ. Patients were followed up for one year after STEMI, the primary endpoint being the occurrence of MACE.

Results
Compared to the control group, patients with STEMI had lower values of all LA strain parameters. There were also significant differences between MACE and non-MACE groups. Patients with MACE at follow up had lower reservoir strain (15.16 ± 2.58 vs. 22.71 ± 5.25), lower conduction strain (-8.62 ± 1.77 vs. -10.97 ± 1.44) and lower pumps strain (-9.36 ± 1.51 vs. -12.73 ± 2.53), compared to those from the non-MACE group. All LA strain parameters proved to have very good predictive abilities for MACE in ROC analysis (AUC = 0.894, 95 %CI, P &lt; 0.0001 for LASr 3D, AUC = 0.854, 95 %CI, P &lt; 0.0001 for LASct 3D, and AUC = 0.883, 95%CI, P &lt; 0.0001 for LAScd 3D). For each variable we determined a cut off value as follows: 17.5 (Sb 91.7%, Sp 86.7%) for LASr 3D, -10.5 (Sb 75% Sp 86.7%) for LASct 3D, and -9.05 (Sb 75% Sp 91.7%) for LAScd 3D. LASr 3D under 17, and LASct 3D over -10.5 determined an approximately 2-fold increase in adverse events after STEMI. Univariate COX regression analysis showed that all parameters had a significant effect on MACE, while multivariate analysis identified only reservoir and pump functions as independent predictors for adverse events.
LASr 3D values showed a proportional decrease with worsening diastolic dysfunction, demonstrating significant differences between diastolic dysfunction grades. We determined LASr 3D cut-off values for discriminating between different degrees of diastolic dysfunction.

Conclusion
3D LA reservoir and pump strain proved to be independent predictors for MACE at one year follow up after STEMI in young patients. Beyond its prognostic role, LASr 3D may be helpful as a complementary method to evaluate diastolic dysfunction in young STEMI patients. Further larger scale studies are needed to validate these findings.
Diagnostic performance of machine learning on 12-lead electrocardiogram for predicting multi-vessel coronary vasospastic angina
Authors: Shimizu M , Misu Y , Tsunoda T , Miyazaki H , Tateishi R , Yamaguchi M , Yamakami Y , Kato N , Shimada H , Isshiki A , Kimura S , Fujii H , Suzuki M , Nishizaki M , Sasano T 
Published: November 2023

Abstract

Background
Multi-vessel coronary vasospastic angina (multi-VSA) is life-threatening disease. However, 12-leads electrocardiogram (ECG) in no chest symptom period was considered to have no predictive value for the multi-VSA. We tried to predict multi-VSA by machine learning (ML) on parameters of the 12-lead electrocardiogram.

Purpose
To predict multi-VSA by machine learning on ECG parameters in no chest pain period.

Methods
We recruited 227 consecutive sinus-rhythm patients (63.6±12.9years, 136men) who underwent acetylcholine-provocation test in coronary angiography (CAG). Multi-VSA was defined as spasm in at least 2 major branches which was provoked by ACh. ECG was recorded before CAG in no chest pain period. ML was performed on table data of ECG parameters (ex. ST level ant J point, R wave amplitude, and/or J wave in each lead) using several ensemble learning methods.

Results
79 patients (35%) showed multi-VSA, and the breakdown of the multi-VSA was as follows: double vessel 44, triple vessel 35, including LAD 73, LCx 47, RCA73. Univariate logistic regression analysis extracted 23 significant but weak predictors, the highest area under receiver operating characteristics curve (AUROC) was 0.673 of Q wave amplitude in lead aVL. Conversely, ML demonstrated high diagnostic performance (AUROC of extra trees classifier: 0.817). Shapley additive explanation method in the extra trees showed male, QTc, J wave in lead II, and low amplitude of Q wave in lead I/aVL played essential roles to build the ML model.

Conclusion
Several parameters of 12-lead ECG in multi-VSA patients contains potential features of VSA, and their aggregation and ensemble learning can predict VSA with high diagnostic performance.
A context-aware deep network for automated characterization of coronary artery plaque from coronary CT angiography
Authors: Leng S , Wang X H , Baskaran L , Teo L , Yew M S , Lu Z K , Huang S , Lee B H , Chan M Y Y , Ngiam K Y , Lee H K , Vaughan R , Tan S Y , Huang W M , Zhong L 
Published: November 2023

Abstract

Background
Identifying various types of plaque, including calcified, non-calcified, and mixed, can furnish crucial insights into a patient's susceptibility to cardiovascular disease and aid in making treatment decisions. Manual quantification of coronary artery plaque on coronary CT angiography (CCTA) poses several challenges, including subjectivity, time consumption, and potential measurement errors.

Purpose
Our objective was to develop a context-aware deep network (CADN) that could automatically evaluate coronary artery plaque in a sizable, multi-center prospective CCTA cohort.

Methods
The APOLLO study is a multi-center study involving CCTA scans of 5,000 Asian patients. At the present stage of this study, CCTA analysis was performed on a subset of 474 patients (138 females; mean age of 58 ± 11 years), of whom 76% were Chinese, 17% were Indian/Malay, and 7% were of other ethnicities. Additionally, 53% had hypertension, 20% had diabetes, 70% had hyperlipidemia, and 27% were obese. A total of 2,983 lesions in 1,422 arteries were analyzed, including 473 non-calcified, 1,612 mixed, and 898 calcified plaques. The CADN combines a 3D convolutional neural network with a Transformer and incorporates contextual information along with local features (Figure 1). The network was trained and tested in 379 and 95 patients, respectively.

Results
The CADN method showed a high level accuracy in detecting plaque, achieving a lesion-level area under the receiver operating characteristic curve of 0.87. Furthermore, the CADN method demonstrated a lesion-level diagnostic accuracy, F1 score, and intra-class correlation coefficient of 0.74, 0.71, and 0.90, respectively, in characterizing plaque into categories of no plaque, non-calcified, mixed, and calcified. When analyzing its performance in each coronary artery, the CADN method was able to accurately characterize the plaque into multiple categories in the LAD, LCX, and RCA with accuracies of 0.70, 0.73, and 0.77, respectively.

Conclusion
The context-aware deep network is a novel approach that demonstrates good diagnostic performance in detecting and characterizing coronary artery plaque.Figure 1.CADN for coronary plaque.
Direct comparison of the safety and efficacy of the ESC 0/1h-algorithm and the High-STEACS pathway for early rule-out of myocardial infarction
Authors: Glaeser J , Lopez-Ayala P , Nestelberger T , Boeddinghaus J , Koechlin L , Miro O , Martin-Sanchez F J , Christ M , Keller D , Mueller C 
Published: November 2023

Abstract

Background
The optimal approach for early rule out of myocardial infarction (MI) is still uncertain. The European Society of Cardiology (ESC) 0/1h-algorithm and the High-Sensitivity Troponin in the Evaluation of Patients with Acute Coronary Syndrome (High-STEACS) pathway, have both been validated individually in large studies. However, as a direct comparison of both strategies has not been performed until now, it is largely unknown whether one is preferable to the other.

Purpose
To directly compare the safety and efficacy of the ESC 0/1h-algorithm with the High-STEACS pathway.

Methods
Patients presenting with acute chest discomfort to the emergency department were prospectively enrolled into an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up, cardiac imaging and serial hs-cTnI. Hs-cTnI (Architect) concentrations were measured at presentation, after 1h and 3h. The primary diagnostic endpoint was safety, assessed as the sensitivity and negative predictive value of ruling out index NSTEMI. The primary diagnostic endpoint was evaluated in prespecified subgroups stratified by sex, age, coronary artery disease, time of chest pain onset and glomerular filtration rate. Co-primary prognostic endpoint was 30- and 730- days all-cause mortality. Findings were externally validated in a large single center study.

Results
Among 5377 eligible patients, 1088 (20.2%) were finally adjudicated with the diagnosis of NSTEMI. Application of the ESC 0/1h-hs-cTnI-algorithm provided higher sensitivity (99.7 % [95% CI, 99.4-100]) compared to the High-STEACS pathway (99.0% [95% CI, 98.4 – 99.6], difference in sensitivity 0.7 [1.3-0.2], P-value for difference &lt; 0.01), but left 846 patients (15.7%) without final triage towards rule-out or rule-in. Three patients with NSTEMI were missed by the ESC pathway compared to 11 patients missed by the High-STEACS algorithm (Figure). High safety and accuracy for the ESC pathway were confirmed in all subgroups and in the external validation cohort, whereas performance parameters for the High-STEACS pathway dropped considerably in the subgroup- and external validation analysis. Both strategies allowed reliable prediction of short and long-term mortality risk (log-rank test &lt;0.001).

Conclusion
While the High-STEACS pathway identifies more patients at low-risk, the ESC 0/1h-algorithm provides higher sensitivity and NPV for rule-out of index NSTEMI.Performance of the ESC 0/1-h algorithmPerformance of the High-STEACS pathway
Sex-Differences in Long-term Mortality in Patients with ST-Segment elevation myocardial infarction with and without obstructive coronary arteries
Authors: Quesada O , Pico M , Yildiz M , Henry T , Stanberry L , Chambers J , Palmer C , Garberich R , Murthy A , Aguirre F , Garcia S , Sharkey S 
Published: November 2023

Abstract

Background
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and understudied syndrome that disproportionally affects females. Studies to date evaluating sex-differences in ST-segment elevation MINOCA (STE-MINOCA) are limited; therefore, it remains uncertain whether the sex disparities observed in STEMI due to obstructive coronary arteries (STEMI-Obstruction) are also present in STE-MINOCA patients.

Objectives
Compare clinical characteristics and long-term mortality risk in male versus female patients presenting with STE-MINOCA and STEMI-Obstruction.

Methods
A multicenter registry-based cohort study enrolled consecutive STEMI patients at three regional, tertiary STEMI centers from 2003 to 2020. STE-MINOCA inluded patients with (1) coronary stenosis less than 60% as determined by coronary angiography, (2) evidence of ischemia with elevated troponin, and (3) no alternative diagnosis. Survival times between males and females with each diagnosis (STE-MINOCA & STEMI-Obstruction) were estimated using the Kaplan Meier method and compared using log-rank tests. The risk of 5-year mortality in patients surviving to discharge was estimated from a Cox regression model with the interaction term for sex and diagnosis STE-MINOCA or STEMI-Obstruction) and adjusted for age, hypertension, diabetes, dyslipidemia, year of event and clustered by the study site.

Results
Out of 8,566 STEMI patients, 420 (4.9%) had STE-MINOCA of whom 52.9% were female and 8146 (95.1%) had STEMI-Obstruction of whom 29.3% were female. Median follow-up was 7.1 years. Females had significantly higher 5-year mortality risk compared to male counterparts in both STE-MINOCA [HR 2.37 (1.37-4.11, p=0.002)] and STEMI-Obstruction [HR 1.81 (1.59-2.07, p&lt;0.001)] (Figure). After adjusting for confounding variables, the sex difference in mortality risk were not significant: HR 1.04 (0.60-1.81, p=0.89) in STE-MINOCA and HR 1.06 (0.92-1.21, p=0.45) in STEMI-Obstruction.

Conclusions
In this first study of consecutive STEMI patients examining sex differences by obstructive and non-obstructive mechanism, we report higher 5-year mortality risk in females presenting with STE-MINOCA and STEMI-Obstruction that was attenuated when accounting for age and baseline comorbidities. This study highlights the importance of standardized STEMI protocols to eliminate sex disparities.
Abbreviations and Acronyms:
Myocardial infarction with non-obstructive coronary arteries (MINOCA),
ST-segment elevation MINOCA (STE-MINOCA)
STEMI due to obstructive coronary arteries (STEMI-Obstruction)Figure
Impact of coronary artery calcium score level in prediction of major adverse cardiovascular events
Authors: Bjelobrk M B , Kovacevic M K , Cankovic M C , Ilic A I , Miljkovic T M , Preveden A P , Bjelic S B , Grkovic D G , Komazec N K , Milovancev A M , Dabovic D D , Stojsic S S 
Published: November 2023

Abstract

Background
Elevated coronary artery calcium (CAC) is associated with an increased risk of cardiovascular (CV) and total mortality, while the coronary artery calcium score (CACS) significantly increases the sensitivity and specificity of traditional risk factors and risk scores in asymptomatic patients with intermediate risk.

Purpose
The aim of the study was to determine an association between the CACS and risk of major adverse CV events (MACE), as well as which value of CACS could be added in a prediction model based on traditional cardiovascular risk factors (CVRFs) in patients without established coronary artery disease (CAD) to improve risk stratification.

Methods
The study was performed as retrospective study, included patients of both sexes, aged over 40 years, with at least one traditional CVRF who underwent MSCT coronarography with follow up of 3 years. All patients were monitored for the presence of CVRFs, use of antihypertensive, statin and antiplatelet therapy, atherosclerotic cardiovascular disease risk score (ASCVD), 10-Year Coronary Heart Disease Risk with Coronary Artery Calcification (MESA score) and CACS.

Results
Of the 100 included patients, 61 (61%) were male and the mean age was 57.1±10.7 years. Most of patients (47%) had an intermediate ASCVD risk, average CACS value of 65.0 (0.0 - 383.3), mean value of CACS of 327.8±653.2, mean MESA score of 13.4±10.1 and a total of 29% MACE, with hospitalization as a most common (24%). There was an association between MACE and ASCVD score (p = 0.037), as well as CACS (p = 0.022). Logistic regression showed that the occurrence of MACE is influenced by: glucose level ([OR] (95%CI) 1.330 (1.003-1.762), (p = 0.047)), ASCVD score (([OR] (95%CI) 1.881(1.161- 3.048, (p =0.010)), MESA score (([OR] (95%CI) 1.055(1.004-1.109) (p = 0.033) and CACS (([OR] (95%CI) 1.902(1.170-3.092) (p = 0.010), where an increase in CACS by one increases the risk of MACE by almost 2 times.

Conclusions
The occurrence of cardiovascular outcomes is influenced by CACS, MESA score, ASCVD score, glucose level and age. Additional research is needed, with larger number of patients, to develop a predictive model based on traditional CVRFs and CACS values, in asymptomatic patients, in order to improve risk stratification.