bluuebunny/crossref_metadata_2025_split huggingface dataset:
The CRP Troponin Test (CTT) stratifies mortality risk in patients with Non-ST Elevation Myocardial Infarction (NSTEMI)
Authors: Brzezinski R Y , Shacham Y , Banai S , Katz Shalhav M , Rogowski O , Shapira I , Zeltser D , Shenhar-Tsarfaty S , Berliner S , Mizrahi M 
Published: November 2023

Abstract

Introduction
The CRP-Troponin test (CTT) comprises serial measurements of both CRP and cardiac troponin and might reflect the systemic inflammatory response in patients with acute coronary syndrome. Here, we sought to test the ability of the CTT to stratify the short and long-term mortality risk in patients with non-ST elevation myocardial infarction (NSTEMI).

Materials and Methods
We examined 1,675 patients who were diagnosed with NSTEMI on discharge and had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 hours of admission. We used a tree classifier model to determine which measurements and cutoffs could be used to best predict mortality during a median follow-up period of 3 years [IQR 1.8–4.3] (Figure 1A).

Results
Patients with high CRP levels (above 90th percentile, &gt;54 mg/L) had a higher 30-day mortality rate regardless of their troponin test status (Figure 1B). However, among patients with "normal" CRP levels (&lt;54 mg/L), those who had high troponin levels (above the 80th percentile, 4,918 ng/L) had a higher 30-day mortality rate compared with patients with normal CRP and troponin concentrations; 7% vs. 2%, p&lt;0.01 (Figure 1B). A multivariate cox regression analysis showed that the CTT test result was an independent predictor for overall mortality even after adjusting for age, sex, and existing co-morbidities (Figure 1C).

Conclusion
Early serial CTT results may stratify mortality risk in patients with NSTEMI, especially in those presenting with "normal" CRP levels. The CTT is a simple diagnostic tool that could potentially assess the impact of inflammation during myocardial necrosis on the outcomes of patients with NSTEMI. The CTT might be used to identify patients who could benefit from novel anti-inflammatory therapies following myocardial infarction.Figure 1
Ten-year major clinical outcomes between first- and second-generation Drug-Eluting Stents in unstable angina patients underwent Percutaneous Coronary Intervention
Authors: Rha S W , Choi S Y , Choi B G , Byun J K , Cha J , Hyun S , Park S , Kim J B , Choi C U 
Published: November 2023

Abstract

Background
There are very limited long-term clinical outcome data comparing first-generation (1G) versus second-generation (2G) drug-eluting stents (DES) in unstable angina (UA) patients. The authors sought to compare the efficacy and safety 2G-DES with 1G-DES in dyslipidemia patients who underwent percutaneous coronary intervention (PCI) during ten-year clinical follow-up periods.

Methods
Finally, a total of 878 eligible UA patients who underwent PCI with 1G-DES (paclitaxel-, sirolimus-eluting stent, n = 333) or 2G-DES (zotarolimus [endeavor, endeavor resolute]- or everolimus-eluting stent [promus element, xience], n = 545) were enrolled. The study endpoints were individual and composite clinical outcomes up to ten-year.

Results
After PSM, two propensity-matched (PSM) groups (216 pairs) were generated. During the ten-year follow-up period, the 2G-DES group had a lower incidence of target lesion revascularization (TLR; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.22 – 0.84; p = 0.013), target vessel revascularization (TVR; HR, 0.40; 95% CI, 0.23 – 0.71; p = 0.002), any revascularization (HR, 0.48; 95% CI, 0.31 – 0.75; p &lt; 0.001), total major adverse cardiac events (MACE; HR, 0.54; 95% CI, 0.37 – 0.81; p = 0.003), TLR MACE (HR, 0.54; 95% CI, 0.30 – 0.97; p = 0.038), and MACCE (HR, 0.62; 95% CI, 0.42 – 0.90; p = 0.012, table).

Conclusion
In our single-center, all-comer registry, 2G-DES had better efficacy especially repeat revascularization compared with 1G-DES in UA patients during 10-year follow-up periods.
The BE-ALIVE score: predicting 30-day mortality in patients presenting with acute coronary syndromes and cardiogenic shock
Authors: Tindale A , Panoulas V 
Published: November 2023

Abstract

Aims
The aim of this study was to create and validate a simple scoring system for predicting 30-day mortality in patients presenting with acute coronary syndromes (ACS) and any sign of shock at their moment of admission.

Methods and results
2407 consecutive patients presenting to Harefield Hospital with clinical features of cardiogenic shock, from January 2011 to December 2020, were studied to build the training set. 30-day mortality was 17.2%. A scoring algorithm was built using binary logistic regression of variables available on admission and then converted to an additive risk score. The resultant scoring system is the BE-ALIVE score, which incorporates the following factors:
Base Excess (1 point for &lt; -2 mmols/L), Age (&lt;65 years: 0 points, 65-74: 1 point, 75-84: 2 points, ³85: 3 points), Lactate (&lt;2 mmols/L: 0 points, 2 - 4.9: 1 point, 5 - 9.9: 3 points, ³10: 6 points), Intubated (2 points), Left Ventricular function (mildly impaired or better: -1 point, moderately impaired: 1 point, severely impaired: 3 points) and External / out of hospital cardiac arrest (1 point).
The scoring system was validated using a testing set of 515 patients presenting to Harefield hospital. The validation metrics were excellent with an AUC of 0.9, Brier score of 0.06 versus a naïve classifier of 0.15, Spiegelhalter’s z-statistic probability of 0.267 and a calibration slope of 1.08.

Conclusion
The BE-ALIVE score is a simple and accurate scoring system to predict 30-day mortality in patients presenting with ACS and shock.
Validation of the BALLAR score for predicting 30-day mortality in patients requiring Impella monotherapy
Authors: Tindale A , Panoulas V 
Published: November 2023

Abstract

Background
The BALLAR score was published in 2021 with the aim of allowing clinicians to calculate 30-day mortality quickly and easily for patients requiring left-sided Impella monotherapy. The points are assigned as follows:
Base Excess (mmol/L): &lt; -2: 2 points, ≥ -2: 0 points
ALbumin (mmol/litre): &lt;25: 6 points, 25 - 34.9: 3 points, &gt;34.9: 0 points
LActate (mmol/litre): &lt;2: 0 points, 2 – 4.9: 1 Point, &gt;4.9: 4 Points
Renal function - Creatinine Clearance (ml/min): &lt;30: 6 points, 30 - 59.9: 4 points, 60 - 89.9: 1 point, &gt;89.9: 0 points
The scoring system performed well on its initial training cohort but had not previously been validated.

Purpose
To validate the BALLAR score using a predominantly external validation cohort requiring left-sided Impella therapy only, for any indication.

Methods
The data required to calculate the BALLAR score was retrospectively acquired for 89 patients. 39 patients were from our own UK tertiary centre, 7 from our sister hospital, and 43 from centres across the United States from the Impella Quality (IQ) assurance program.

Results
For the entire validation cohort of 89 patients, the BALLAR score showed both excellent discrimination and calibration statistics. The area under the receiver-operator characteristic (ROC) curve was 0.91 (0.84–0.98) (Figure 1), the Brier score was 0.11 versus a Naïve classifier of 0.23, the calibration slope was 0.92 calibration with Spiegelhalter’s Z-statistic of 0.98 (p=0.323, Figure 2).
For the external validation cohort of patients, the discrimination remained excellent with the area under the ROC curve of 0.88 (0.79-0.98). The Brier score remained better than a naïve classifier at 0.15, but the calibration slope was unsurprisingly worse at 0.73 with a Spiegelhalter’s Z statistic of 2.07 (p=0.04).
The negative predictive value of a BALLAR score ≤5 was 94%, and the positive predictive value was 100% of a BALLAR score &gt; 12, highlighting the rapid escalation of mortality risk in patients in the mid-zone of the shock spectrum.

Conclusions
The BALLAR score maintains high discriminatory ability when applied to a validation cohort of patients requiring left-sided Impella monotherapy for any indication. Further prospective work is underway, including app development, to assess the clinical utility of the BALLAR score as a means of categorising patient risk.Image 1Image 2
Low incidence of mechanical complications in patients with AMI
Authors: Kobo O , Toukan N , Hamuda N , Sanchez-Jimenez E , Abu- Fanne R , Levi Y , Saada M , Roguin A 
Published: November 2023

Abstract

Background
Despite early and currently effective epicardial coronary recanalization in patients with acute myocardial infarction (AMI), the mortality rate after mechanical complication (MC) remains high. Despite its impact on the prognosis of patients with AMI, up-to-date real life data regarding to epidemiology and management of patients with MC following AMI still scarce and most studies exclude patients with MC.

Methods
Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the epidemiology, predictors and outcomes of patients with MC following AMI in the US.

Results
We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582–12.855,p&lt; 0.001) in patients with MC compared to patients without MC (49.7% vs. 4.6 %,p&lt; 0.001) and all subtypes of MC showed a significant increase in mortality.

Conclusions
Nowadays, the incidence of MC after an AMI is lower than in the past, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and in those with fewer comorbidities. The subtype with the highest frequency and highest mortality rates was VSR.
Accuracy of the GRACE Score for mortality prediction in myocardial infarction with nonobstructive coronary arteries (MINOCA)
Authors: Lopes V , Moreira N , Fernandes R , Cunha G , Ferreira J , Costa G , Monteiro E , Fernandes D , Guimaraes J , Milner J , Marinho V , Monteiro S , Goncalves F , Goncalves L 
Published: November 2023

Abstract

Introduction
Myocardial infarction with nonobstructive coronary arteries (MINOCA) patients account for 3.5 to 15% of all myocardial infarctions. The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome, but the accuracy of the risk score for prognostic stratification in patients with MINOCA remains uncertain.

Purpose
We aimed to investigate whether the GRACE risk score can predict mortality in a real-world cohort of patients presenting with MINOCA.

Methods
We retrospectively analyzed patients admitted with MINOCA in a single center. Patients who were diagnosed with myocarditis and Takotsubo syndrome were excluded from the analysis. The GRACE risk score on admission was calculated. Patients were divided into a low-intermediate risk group (≤ 140 points, 71.5%) and a high-risk group (&gt;140 points, 28.5%) according to their GRACE risk scores. Receiver operating characteristic (ROC) analysis was used to quantify the accuracy of the GRACE risk score to estimate both in-hospital and one-year mortality in MINOCA patients.

Results
Of a total of 3721 myocardial infarction patients, MINOCA was identified in 11.6% (n=430). 313 patients had complete data for the calculation of the GRACE on admission and were included in the analysis. Mean age was 65±12 years, and 49% (n=154) of patients were male. Mean GRACE score was 125±31 points.
Patients in the high-risk group were older (74±9 vs. 61±11 years, p&lt;0.001), had a higher incidence of in-hospital mortality (0.4% vs. 5.6%, p=0.008), and had a higher rate of one-year mortality (2.7% vs. 19.5%, p&lt;0.001), compared with the low-intermediate risk group. There were no differences regarding sex and cardiovascular risk factors between the groups.
In-hospital mortality was 1.9% and one-year mortality was 7.3%. ROC curve analysis showed that the GRACE risk score has a high value in predicting in-hospital mortality (AUC ROC 0.892; 95% CI 0.798–0.986; p=0.001), and one-year mortality (AUC ROC 0.826; 95% CI 0.739–0.0.914; p&lt;0.001) in MINOCA patients. (Figure 1).
The overall c-statistics were similar compared with estimates obtained from patients with myocardial infarction and significant coronary artery disease: in-hospital mortality (AUC ROC 0.0.849; 95% CI, 0.807–0.891; p&lt;0.001); and one-year mortality (AUC ROC 0.776; 95% CI, 0.747–0.806; p&lt;0.001).

Conclusions
In conclusion, the GRACE risk score provides potentially valuable prognostic information on in-hospital and one-year mortality when applied to MINOCA patients.Figure 1
The role of cardiac magnetic resonance imaging in patients with MINOCA in daily clinical practice
Authors: Mata Caballero R , Olsen Rodriguez R , Abad Romero R , Fraile Sanz A , Perela Alvarez C , Nieto Ibanez D , Izquierdo Coronel B , Avarez Bello M , Martin Munoz M , Gil Mancebo N , Rodriguez Montes P , Espinosa Pascual M J , Alberca Vela M T , Perea Egido J , Alonso Martin J J 
Published: November 2023

Abstract

Background
In patients with ‘myocardial infarction with non-obstructive coronary arteries’ (MINOCA), the underlying cause is not always known. Cardiac magnetic resonance imaging (CMRI) is recommended as a key investigation in MINOCA because it can exclude myocarditis, takotsubo syndrome, and cardiomyopathies, as well as provide imaging confirmation of AMI. However, CMRI is not widely available. The aim of our study was to analyze the role of CMRI in patients with MINOCA in routine clinical practice in a non-tertiary hospital of the Spanish national health system.

Methods
We analyzed 62 consecutive MINOCA patients admitted to our University Hospital from 2019 to January 2023. The database were revised by a group of experts in order to adequate MINOCA to 2020 ESC Guidelines definition and the American Heart Association position paper. The tako-tsubo syndrome was excluded. According to these guidelines CMRI is recommended in the evaluation of MINOCA patients.

Results
Only in 32 patients, corresponding to 52% of the patients with MINOCA, the CMRI was performed because of the limited availability of this test in our health System. Of the CMRI performed, 46% provided the underlying mechanism of the MINOCA: myocarditis (21%) or confirmation of AMI (25%). The other CMRI were normal (54%) (figure). Although patients with normal CMRI had a significantly lower mean TropT hs (236.02 vs 794.02 ng/L, p=0.03), troponin levels were not able to discriminate patients with normal CMRI. Thus up to 33% of patients with pathological CMRI had a TropThs level less than 244 ng/L (which was the median of the series).
There were no significant differences in other biomarkers (PCR, CK) or clinical or analytical parameters. There were also no differences in prognosis at follow-up (death or readmissions) between patients with normal CMRI and patients with diagnostic CMRI.

Conclusions
1) In routine clinical practice, only 52% of patients with MINOCA underwent CMRI, 2) Of the patients who underwent CMRI, it provided the underlying mechanism of the MINOCA in 46% of them, 3) Although the TropThs level was lower in patients with normal CMRI, the troponin level was not useful to select the patients that would benefit most from such a test.CMRI in MINOCA patients
Prognostic role of late gadolinium enhancement and abnormal mapping values in myocardial infarction with non-obstructive coronary arteries
Authors: Armillotta M , Bergamaschi L , Amicone S , Fedele D , Impellizzeri A , Casuso M , Angeli F , Rinaldi A , Foa' A , Paolisso P , Casella G , Pavon A G , Lovato L , Galie' N , Pizzi C 
Published: November 2023

Abstract

Background
Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents an extremely heterogeneous clinical entity, as multiple pathophysiological mechanisms may result in variable outcomes. Cardiac magnetic resonance (CMR) plays a pivotal diagnostic role in MINOCA. However, to date, a prognostic stratification based on the CMR findings in ischemic MINOCA is still lacking.

Purpose
To assess the potential prognostic utility of early collected CMR parameters in a large cohort of selected MINOCA, in order to identify measurable parameters that may improve the risk stratification and management of this still not well-defined clinical entity.

Methods
We assessed 437 MINOCA from January 2017 to October 2021. We excluded patients with non-ischemic myocardial damage due both cardiac (i.e., myocarditis, cardiomyopathies, Takotsubo syndromes) and non-cardiac conditions. Patients were classified into 3 subgroups according to the CMR phenotype: i) presence of late gadolinium enhancement (LGE) and abnormal mapping (M) values (LGE+/M+), ii) regional ischemic injury with abnormal mapping and no LGE (LGE-/M+) and iii) non-pathological CMRs (LGE-/M-). The primary outcome was the presence of major acute cardiovascular events (MACE). The mean follow-up was 33.7±12.0 months and CMR was performed on average at 4.8±1.5 days from the acute presentation.

Results
The final cohort included 198 MINOCA: 116 (51.1%) comprised the LGE+/M+ group. The mean age of the study population was 60.2 years and more than 57% were females. During follow-up, MACE occurred significantly more frequently in MINOCA LGE+/M+ than in the LGE+/M- and normal-CMR (LGE-/M-) subgroups (20.7% vs. 6.7% and 2.7%, p=0.006). The extension of myocardial damage at CMR was significantly greater in patients who developed MACE. In multivariable Cox regression, %LGE was an independent predictor of MACE (HR=1.123, 95% CI 1.064 – 1.185, p&lt;0.001) together with T2 mapping values (HR=1.190, 95% CI 1.145 – 1.237, p=0.001).

Conclusions
In MINOCA with early CMR execution, the %LGE and abnormal T2 mapping values were identified as independent predictors of adverse cardiac events at ∼3.0 years follow-up. In the complex world of MINOCA, the non-invasive myocardial characterization provided by CMR represents a powerful tool to rapidly identify high-risk patients and guide appropriate clinical decision-making as well as therapeutic management.
Systemic inflammatory disease in patients with spontaneous coronary artery dissection
Authors: Kang M , Offen S , Reddavid C , Grewal T , Saw J 
Published: November 2023

Abstract

Background
Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of non-atherosclerotic myocardial infarction (MI). Systemic inflammatory diseases are commonly associated with SCAD patients, but the link between inflammatory diseases and SCAD remains unclear.

Purpose
To determine the prevalence of systemic inflammatory disease (SID) and elevated inflammatory markers (EIM) at SCAD presentation. To compare long-term outcomes between SCAD patients with and without SID, and with and without EIM at presentation.

Methods
We reviewed patients enrolled in the Canadian SCAD Study who had laboratory measurements of inflammatory markers at presentation with SCAD. We compared the baseline demographics, presence of SID, presentation characteristics, and long-term outcomes between patients with and without SID, and between patients presenting with and without EIM at time of SCAD. SID was determined using past medical history and patient self-identification. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were used as inflammatory biomarkers. Major adverse cardiovascular events (MACE) were defined as the composite of all-cause mortality, stroke or transient ischemic attack, MI, hospitalization for heart failure and unplanned revascularization.

Results
Of 1307 patients with SCAD, 360 had inflammatory markers measured at presentation. Of these 360 patients, 150 (43.1%) had EIM at presentation, and 13 (3.6%) reported a history of SID. Mean age was 52.9±9.8 years for patients with EIM, vs. 50.8±10.9years for patients without EIM (p=0.06). Patients with EIM had significantly higher body mass index compared to those without EIM (35.5% vs 17.6%, p=0.001). Of the patients with reported SID, there was higher prevalence of diabetes and hypertension. There was no significant difference in mean inflammatory marker levels, ESR (13.4±15.6mm/h vs 13.7±13.2mm/h, p=0.965) and CRP (15.6± 23.1mg/L vs 11.9± 26.8mg/L, p=0.644) among SID vs. no SID patients at SCAD presentation. Overall mean follow-up was 3.7±1.9 years. There was no difference in in-hospital MACE and overall MACE between patients with EIM vs. no EIM, and between SID and no SID cohorts. There were also no significant difference in angiographic findings, fibromuscular dysplasia prevalence, proportion treated conservatively vs. with revascularization in these cohorts.

Conclusion
There was no significant difference between presentation, laboratory values, treatment, or outcomes between SCAD patients with or without SID, and between patients who present with and without EIM. This suggests that both active inflammation and history of inflammatory diseases do not contribute to SCAD or outcomes.Table 1.SCAD cohort demographics & data
Termination-of-resuscitation rule in the emergency department for patients with initial pulseless electrical activity after out-of-hospital cardiac arrest
Authors: Funada A , Goto Y , Takamura M 
Published: November 2023

Abstract

Background/Introduction
In several Asian countries including Japan, emergency medical service (EMS) providers are prohibited from performing field termination-of-resuscitation (TOR) in patients with refractory out-of-hospital cardiac arrest (OHCA). In 2022, we developed a TOR rule in the emergency department for patients with initial asystole after refractory OHCA, which includes three criteria: unwitnessed arrest, EMS-initiated cardiopulmonary resuscitation (CPR) duration was more than 20 min, and there was no prehospital return of spontaneous circulation (ROSC). However, until now a TOR rule in the emergency department for patients with initial pulseless electrical activity (PEA) has not been developed.

Purpose
This study aimed to develop and validate a TOR rule in the emergency department for patients with initial PEA after refractory OHCA.

Methods
We analysed the records of 137,230 adult patients (≥18 years-old) with initial PEA from the nationwide all-Japan Utstein registry from 2016 to 2020. Patients were divided into two groups: development (n=109,642, 2016 to 2019) and validation (n=27,588, 2020). The primary outcome measures were specificity, false positive rate (FPR), and positive predictive value (PPV) of the TOR rule for patients with initial PEA in the emergency department for predicting 1-month mortality. Using recursive partitioning analysis, we developed a new TOR rule for patients with initial PEA after OHCA.

Results
The overall 1-month survival rate of the participants was 7.4% (95% confidence interval [CI], 7.2–7.5%). Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a TOR rule for patients with PEA could be defined if patients with OHCA met all the following four criteria immediately after hospital arrival: (1) unwitnessed arrest by any laypersons, (2) EMS-initiated CPR duration more than 20 min, (3) no prehospital ROSC, and (4) age greater than or equal to 80 years. The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.1% (95% CI, 98.9–99.3%), 0.87% (95% CI, 0.69–1.09%), and 99.2% (95% CI, 98.9–99.3%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 7.8% (95% CI, 7.7–8.0%), and 0.80 (95% CI, 0.79–0.80), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI, 98.5–99.4%), 0.93% (95% CI, 0.58–1.49%), 99.3% (95% CI, 98.8–99.5%), 8.3% (95% CI, 8.0–8.6%), and 0.789 (95% CI, 0.775–0.797), respectively.

Conclusions
We developed and validated a TOR rule in the emergency department for patients with initial PEA after OHCA. The rule includes four criteria (unwitnessed arrest, EMS-initiated CPR duration was more than 20 min, no prehospital ROSC, and age was greater than or equal to 80 years) with a more than 99% predictor of 1-month mortality.