Increased Risk of Heart Failure in Elderly Patients Treated with Beta-Blockers After AV Node Ablation

INTRODUCTION

Controversy exists regarding the indication of beta-blockers (BB) in different scenarios in patients with cardiovascular disease. We sought to evaluate the effect of BB on survival and heart failure (HF) hospitalizations in a sample of pacemaker-dependent patients after AV node ablation to control ventricular rate for atrial tachyarrhythmias.

METHODS

A retrospective study including consecutive patients that underwent AV node ablation was conducted in a single center between 2011 and 2019. The study's primary endpoints were the incidence of all-cause mortality, first HF hospitalization and the cumulative incidence of subsequent hospitalizations for HF. Competing risk analyses were employed.

RESULTS

A total of 111 patients with a mean age of 73.9 years were included in the study. After a median follow-up of 45.5 months, 43 patients had died (38.7%) and 31 had been hospitalized for HF (27.9%). The recurrent HF hospitalization rate was 74/1000 patients/year. Patients treated with BB had a non-significant trend to higher mortality rates and a higher risk of recurrent HF hospitalizations (incidence rate ratio 2.23, 95% confidence interval 1.12-4.44; p = 0.023).

CONCLUSION

After an AV node ablation, the use of BB is associated with an increased risk of HF hospitalizations in a cohort of elderly patients.

Remnant cholesterol in patients admitted for acute coronary syndromes

BACKGROUND

Remnant cholesterol has been identified as one of leading lipid values associated with the incidence of coronary heart disease. There is scarce evidence on its distribution and prognostic value in acute coronary syndrome (ACS) patients.

METHODS AND RESULTS

We included all consecutive patients admitted for ACS in two different centres. Remnant cholesterol was calculated by the equation: total cholesterol minus LDL cholesterol minus HDL cholesterol, and values ≥30 were considered high. Among the 7479 patients, median remnant cholesterol level was 28 mg/dL (21-39), and 3429 (45.85%) patients had levels ≥30 mg/dL. Age (r: -0.29) and body mass index (r: 0.44) were the variables more strongly correlated. At any given age, patients with overweigh or obesity had higher levels. In-hospital mortality was 3.75% (280 patients). Remnant cholesterol was not associated to higher in-hospital mortality risk (odds ratio: 0.89; P = 0.21). After discharge (median follow-up of 57 months), an independent and linear risk of all-cause mortality and heart failure (HF) associated to cholesterol remnant levels was observed. Remnant cholesterol levels >60 mg/dL were associated to higher risk of mortality [hazard ratio (HR): 1.49 95% CI 1.08-2.06; P = 0.016], cardiovascular mortality (HR: 1.49 95% CI 1.08-2.06; P = 0.016), and HF re-admission (sub-HR: 1.55 95% CI 1.14-2.11; P = 0.005).

CONCLUSIONS

Elevated remnant cholesterol is highly prevalent in patients admitted for ACS and is inversely correlated with age and positively with body mass index. Remnant cholesterol levels were not associated to higher in-hospital mortality risk, but they were associated with higher long-term risk of mortality and HF.

Prognostic value of liver fibrosis assessed by the FIB-4 index in patients with acute coronary syndrome

INTRODUCTION AND OBJECTIVES

Liver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS).

METHODS

Retrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as <1.30, 1.30-2.67 or> 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR).

RESULTS

We included 3106 patients and 6.66% had a FIB-4 index ≥ 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P=.016). Patients with a FIB-4 index> 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P=.038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index ≥ 1.3 had a higher risk of first (sHR, 1.61; P=.04) or recurrent (IRR, 1.70; P=.001) HF readmission. Similarly, FIB-4 index ≥ 1.30 was associated with a higher MB risk (sHR, 1.62; P=.030).

CONCLUSIONS

The assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.

Most Recent Trials and Advances in Hypertension

Hypertension is one of the most prevalent cardiovascular risk factors and blood pressure control remains a clinical challenge, especially for patients with established cardiovascular disease. Late-breaking clinical trials and other evidence in hypertension have evolved to assess the most accurate ways to measure blood pressure, the use of combination therapies, considerations in special populations and evaluation of new techniques. Recent evidence supports the superiority of ambulatory or 24-hour blood pressure measurements, rather than office blood pressure measurements, for the assessment of cardiovascular risk. The use of fixed-dose combinations and polypills has been demonstrated to be valid and to provide clinical benefits beyond blood pressure control. There have also been advances in new approaches such as telemedicine, devices and the use of algorithms. Clinical trials have provided valuable data on blood pressure control in primary prevention, during pregnancy and in the elderly. The role of renal denervation remains unsolved but innovative techniques using ultrasound or alcohol injections are being explored. Current evidence and results of latest trials are summarised in this review.

Effect of PCSK9 inhibitors on remnant cholesterol and lipid residual risk: The LIPID-REAL registry

BACKGROUND

Monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 55%, regardless of baseline treatments. Nonetheless, the effect of other lipid parameters, such as cholesterol remnants or, the so-called lipid residual risk, is unknown.

METHODS

Multicenter and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals in Spain. Before and on-treatment lipid parameters were recorded. Residual lipid risk was estimated by (1) cholesterol remnants, (2) triglycerides/HDLc ratio (TG/HDL), (3) total cholesterol/HDLc (TC/HDL) and (4) the triglycerides-to-glucose index (TGGi).

RESULTS

Six hundred fifty-two patients were analysed, mean age of 60.2 (9.63) years, 24.69% women and mean LDLc before treatment 149.24 (49.86) mg/dl. Median time to second blood determination was 187.5 days. On-treatment LDLc was 67.46 (45.78) mg/dl, which represented a 55% reduction. Significant reductions were observed for TG/HDL ratio, cholesterol remnants, TC/HDL ratio and TGGi. As consequence, 34.61% patients had LDLc <55 mg/dl and cholesterol remnants <30 mg/dl; additionally, 31.95% had cholesterol remnants <30 mg/dl but LDLc >55 mg/dl. Patients who had levels of cholesterol remnants >30 mg/dl before initiating the treatment with PCSK9 had higher reductions in cholesterol remnants, TG/HDL ratio, TC/HDL and TGGi. By contrast, no reduction differences were observed according to baseline LDLc (< or > the mean), age, gender or obesity.

CONCLUSIONS

This multicenter and retrospective registry of real-world patients treated with PCSK9 inhibitors demonstrates a positive effect on cholesterol remnants and lipid residual risk beyond LDLc reductions.

Cholesterol remnants distribution in patients admitted for acute coronary syndrome

Background

Cholesterol remnants have been identified as one of leading lipid measurements associated with the incidence of coronary heart diseases. Nonetheless, there is scarce evidence on cholesterol remnants distribution in patients with acute coronary syndrome (ACS).

Methods

We included all consecutive patients admitted for ACS in two different centers. Cholesterol remnants were calculated by the equation: total cholesterol minus low-density lipoprotein cholesterol (LDLc) minus high-density lipoprotein cholesterol (HDLc) and values ≥30 were considered high. Premature ACS was defined in patients presenting with age &lt;55 for men or &lt;65 for women. Correlation weres assessed by linear regression and predictive models were obtained after logistic binary regression.

Results

We included 7,479 patients, mean age 66.68 (13.02), 2,062 (27.57%) women, mean body mass index (BMI) 28.60 (4.64) kg/m2, 2088 (27,92%) with diabetes and 2,726 (36.45%) admitted for ST-elevation ACS. Median (interquartile range) remnants level was 28 mg/dl (21–39) and 3,429 (45.85%) patients had levels ≥30 mg/dl. Significantly higher levels of remnants were observed in patients with diabetes, current smokers, BMI &gt;30 kg/m2, absence of previous cardiovascular disease or premature ACS. No gender differences were observed in remnants level. Age (r: −0.29) and BMI (r: 0.44) were the variables more strongly correlated. As shown in the figures, at any given age, the risk of having cholesterol remnants ≥30 increased with higher BMI.

In-hospital mortality was 3.75% (280 patients). After adjustment by age, gender, previous cardiovascular disease and GRACE score, cholesterol remnants were not associated to higher mortality risk (OR: 0.89 95% CI 0.64–1.10; p=0.21)

Conclusions

Elevated cholesterol remnants is highly prevalent in patients admitted for ACS and their levels inversely correlate with age and positively with body mass index. We propose a risk matrix for estimating the probability of having cholesterol remnants ≥30. Elevated cholesterol remnants were not associated to higher in-hospital mortality risk.

Funding Acknowledgement

Type of funding sources: None.

Differential prognosis of patients candidates for standard, short or prolonged dual antiplatelet treatment discharged after an acute coronary syndrome

Background

Current evidence supports the efficacy of prolonged dual antiplatelet treatment prolonged (DAPT) patients at high-ischemic risk and low bleeding risk. In contrast, several trials have demonstrated the efficacy and safety of short DAPT (1,3 o6 months) in high-bleeding risk (HBR) patients. Nonetheless, 12 months of DAPT is the most commonly strategy recommended in patients discharged after an ACS.

Methods

We evaluated patterns of DAPT candidates in all patients discharged in single center between 2009 and 2019 after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. We evaluated all-cause and cardiovascular mortality, mayor bleeding (MB), and major cardiovascular events (MACE) after discharge.

Results

We assessed 3,155 patients discharged after an ACS, mean age was 68.4 (13.0), 25.9% were women, 32.5% had diabetes, 13.2% received complex percutaneous coronary interventions and 40.5% were categorized as HBR. After categorization, 1,277 (40.48%) were candidates for short DAPT, 1,203 (38.1%) for standard 12m DAPT and 675 (21.39%) for prolonged DAPT.

After a median follow-up was 1032 days (interquartile range 555–1950), all-cause mortality was 15.8%, cardiovascular mortality 10.5%, 35.9% had a first MACE and 6.2% had at least one MB. As shown in figure 1, patients candidates for short or prolonged DAPT had significantly higher rates of all-cause and cardiovascular mortality as well as MACE. In contrast, higher rate of MB was only increased in patients candidates for short-DAPT (figure 2). Multivariate analysis demonstrated higher risk of MB (sHR: 1.60 95% CI 1.10–2.60; p=0.030) only in patients candidates for short-DAPT. In contrast, candidates for short-DAPT has higher risk of all-cause mortality (HR: 2.92 95% CI 1.95–4.37; p&lt;0.01) and cardiovascular mortality (HR: 3.01 95% CI 1.78–5.32; p&lt;0.01) and MACE (HR: 2.22, 95% CI 1.82–2.70; p&lt;0.01). Similarly, patients candidates for prolonged DAPT had higher risk of all-cause mortality (HR: 1.72 95% CI 1.10–2.69; p=0.002), cardiovascular mortality (HR: 2.47 95% CI 1.39–4.40; p=0.017) and MACE (HR: 1.58 95% CI 1.28–1.95; p&lt;0.001).

Conclusions

Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality. Patients candidates for short-DAPT had higher risk of MB through the follow-up. These results might reinforce the need of individual assessment of most optimal DAPT duration in all patients discharged after an ACS.

Funding Acknowledgement

Type of funding sources: None.

Predictors of no-reflow in patients with myocardial infarction and ST-segment elevation treated with primary angioplasty

Introduction

The no-reflow phenomenon is a serious complication of coronary intervention, especially in primary angioplasty and effective preventive measures are unknown.

Methods

Retrospective study of all patients treated by primary angioplasty in a single center through 4 years. We define no-reflow as the absence of flow immediately after stent angioplasty. The variables associated with this phenomenon were analyzed using binary logistic regression. The delay to primary angioplasty was calculated as the sum of the time to the first medical contact, activation, transfer until arterial puncture.

Results

We included 1453 patients, mean age 64.1 years, 21% women, 16.1% Killip &gt;1. The mean delay to primary angioplasty was 180 minutes (interquartile range 125–323). No-reflow was recorded in 81 (5.57%) patients and these patients had a higher mean age (69.37±12.51 vs. 63.76±13.52; p&lt;0.001), higher delay to primary angioplasty (770.93±2056.91 vs. 348.80±749.73; p&lt;0.001), presentation with Killip grade &gt;1 (29.0% 15.36%; p=0.002), in addition to lower systolic blood pressure (121.18±28.63 vs. 113.37±28.22; p=0.021). Regarding coronary angiography, patients who developed no-reflow presented more frequently TIMI-0 (88.89% vs. 70.32%; p&lt;0.001) and a tendency to being the left anterior descending the culprit vessel (46.91% vs. 36.88, p=0.07). In 59.3% of the patients who presented no-reflow, a final TIMI 3 was achieved, with the measurements carried out, compared to (94.9%) of the patients who did not have no-reflow (p&lt;0.001).

Multivariate analysis identified the following variables associated with no-reflow: age (OR: 1.03 95% CI 1.01–1.05; p=0.008), delay to primary angioplasty &gt;120 min (OR: 2.70, 95% CI 1.21–6.00; p=0.015), initial TIMI-0 (OR: 3.22, 95% CI 1.57–6.58; p=0.001). In fact, patients aged &gt;40 had a very low incidence of no-reflow (1.72%), regardless of delay to primary angioplasty; however, in patients &gt;70 years of age, the incidence was much higher (figure)

Hospital mortality was 9.25% (125 patients) and was almost 4 times higher in patients who presented no-reflow (23.68% vs. 8.39%; p&lt;0.001). Adjusted for age, sex, delay to primary angioplasty diabetes and final TIMI flow, the no-reflow phenomenon was associated with higher hospital mortality (OR: 2.34 95% CI 1.02 4.25; p=0.030)

Conclusions

The no-reflow phenomenon has a low incidence but high mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty. Age, delay to primary angioplasty and initial TIMI 0 flow are the main predictors of no-reflow.

Funding Acknowledgement

Type of funding sources: None.

Age as a prognostic modifier in anemic patients discharged after acute coronary syndrome

Introduction

The presence of anemia on admission is a poor long-term prognostic factor in patients diagnosed with acute coronary syndrome (ACS). However, it is unknown whether age is a factor modifying the effect of anemia on mortality.

Objective

To determine the effect of age on anemia in terms of long-term mortality in patients admitted for ACS.

Methods

This is an observational study in which we included all patients discharged from cardiology for ACS in two centers from 2003 to 2020. Patients with anemia were classified by hemoglobin values &lt;13 g/dL in men and &lt;12 g/dL in women in the first blood count performed during hospitalization. The interaction between age and anemia was analyzed using the Cox regression model and the chunk test. We analyzed the effect of anemia on mortality using the Cox regression model adjusted for several confounding variables and the interaction with age.

Results

We included 8872 patients diagnosed with ACS, with a mean age of 66.38 (SD ±12.76) years, 27.1% female and 34.3% diagnosed with ST-segment elevation ACS. The mean hemoglobin value was 13.88 (SD ±1.85) g/dL and 20.5% of patients were anemic on admission.

During follow-up (median 1764 days, IQR 694–2439 days) there was an increased risk of all-cause mortality in patients with anemia adjusted for age and other risk factors (sex, renal function, GRACE score, atrial fibrillation, LVEF and previous revascularization), HR 15.5 (CI 5.77–41.75; p&gt;0.005). We found a significant interaction between age and anemia (p&lt;0.01). As represented in the figure, the adjusted risk of mortality decreased at older ages; in patients whose age was &gt;80 anemia was not associated to higher mortality risk. Similar results were observed for cardiovascular mortality, HR 21.36 (CI 6.13–74.43, p&gt;0.005).

Conclusion

Age modifies the risk of mortality in patients discharged after an ACS being the risk of mortality higher in youngest ages and disappearing in octogenearians. There results should be taken under consideration for the treatment and management of ACS patients.

Funding Acknowledgement

Type of funding sources: None.

Effect on cholesterol remnants and residual lipid risk with PCSK9 inhibitors: the LIPID-REAL Registry

Background

Monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 55%, regardless of baseline treatments. Nonetheless, the effect of other lipid parameters, as cholesterol remnants or, the so-called residual lipid risk, are unknown.

Methods

Multicenter and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals from Spain. Before and on-treatment lipid parameters were recorded. Cholesterol remnants were calculated by the equation: total cholesterol minus LDLc minus HDLc and values ≥30 were considered high. Residual lipid risk was estimated by 1) the estimation of LDL particle size, by the triglycerides/HDLc ratio (TG/HDL) and values &lt;2 were assumed as low and dense LDL particles; 2) total cholesterol/HDLc (TC/HDL) and values &gt;3 were considered high; and; 3) the triglycerides-to-glucose (TG/Gluc) index, obtained as the natural logarithm of (triglycerides * glucose/2)

Results

A total of 652 patients were analyzed, mean age 60.0 (10.5) years and 161 (24.69%) women. Baseline LDLc was 149.2 (49.9) mg/dl, cholesterol remnants 29.9 (20.3) mg/dl, TG/HDL 3.9 (4.1), TC/HDL 4.9 (1.9) and TG/Gluc index 8.9 (0.7). Most patients (92.3%) were on statins; 54.8% with ezetimibe, 8.5% with fibrates.

Evolocumab was initiated in 318 (56.6%) patients; 229 (40.7%) alirocumab 75 mg and 15 (2.7%) alirocumab 150 mg. Median time to second blood determination were 187.5 (IQR 101–242) days. Mean on-treatment LDLc was 67.46 (45.78) mg/dl what represented a 55% reduction. As shown in the figure, significant reduction in cholesterol remnants (p=0.017), TG/HDL ratio (p=0.020), TC/HDL ratio (p&lt;0.001) and TG/Gluc index (p&lt;0.001). The percentage of patients with remnants &gt;30 mg/dl decreased: 34.62% to 30.07 (p&lt;0.01). Significant reductions were also observed in the percentage of patients with TG/HDL &gt;2 (71.25% to 61.98%; p&lt;0.01) or TC/HDL &gt;3 (94.28% to 38.97%; p&lt;0.01)

Conclusions

This multicenter and retrospective registry of real-world patients treated with PCSK9 inhibitors demonstrates a positive effect on cholesterol remnants and lipid-residual risk beyond LDLc reductions.

Funding Acknowledgement

Type of funding sources: None.

Polypill Strategy in Secondary Cardiovascular Prevention

BACKGROUND

A polypill that includes key medications associated with improved outcomes (aspirin, angiotensin-converting-enzyme [ACE] inhibitor, and statin) has been proposed as a simple approach to the secondary prevention of cardiovascular death and complications after myocardial infarction.

METHODS

In this phase 3, randomized, controlled clinical trial, we assigned patients with myocardial infarction within the previous 6 months to a polypill-based strategy or usual care. The polypill treatment consisted of aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and atorvastatin (20 or 40 mg). The primary composite outcome was cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization. The key secondary end point was a composite of cardiovascular death, nonfatal type 1 myocardial infarction, or nonfatal ischemic stroke.

RESULTS

A total of 2499 patients underwent randomization and were followed for a median of 36 months. A primary-outcome event occurred in 118 of 1237 patients (9.5%) in the polypill group and in 156 of 1229 (12.7%) in the usual-care group (hazard ratio, 0.76; 95% confidence interval [CI], 0.60 to 0.96; P = 0.02). A key secondary-outcome event occurred in 101 patients (8.2%) in the polypill group and in 144 (11.7%) in the usual-care group (hazard ratio, 0.70; 95% CI, 0.54 to 0.90; P = 0.005). The results were consistent across prespecified subgroups. Medication adherence as reported by the patients was higher in the polypill group than in the usual-care group. Adverse events were similar between groups.

CONCLUSIONS

Treatment with a polypill containing aspirin, ramipril, and atorvastatin within 6 months after myocardial infarction resulted in a significantly lower risk of major adverse cardiovascular events than usual care. (Funded by the European Union Horizon 2020; SECURE ClinicalTrials.gov number, NCT02596126; EudraCT number, 2015-002868-17.).

Sex Differences in Low-Density Lipoprotein Cholesterol Reduction With PCSK9 Inhibitors in Real-world Patients: The LIPID-REAL Registry

BACKGROUND

Previous evidence supports that monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 50%-65%, regardless of baseline treatments. We tested possible sex differences in a multicentre registry of real-world patients treated with PCSK9 inhibitors.

METHODS

This is a multicentre and retrospective study of 652 patients initiating treatment with any PCSK9 inhibitor in 18 different hospitals. Before-treatment and on-treatment LDLc and medical treatments, clinical indication, and clinical features were recorded.

RESULTS

Women represented 24.69% of the cohort. The use of statins was similar in both sexes, but women were receiving most frequently ezetimibe. Before-treatment median LDLc was 135 (interquartile range 115-166) mg, and it was higher in women. The median on-treatment LDLc was 57 (interquartile range 38-84) mg/dL, which represented a mean 54.5% reduction. On-treatment LDLc was higher in women, and the mean LDLc reduction was lower in women (47.4% vs. 56.9%; P = 0.0002) receiving evolocumab or alirocumab. The percentage of patients who achieved ≥50% LDLc reduction was higher in men (71.36% vs. 57.62%; P = 0.002). According to LDLc before-treatment quartiles, LDLc reduction was statistically lower in women in the 2 highest and a significant interaction of women and baseline LDLc >135 mg/dL was observed. Women were negatively associated with lower rates of LDLc treatment target achievement (odds ratio: 0.31). Differences were also observed in women with body mas index >25 kg/m2. Only 14 patients (2.14%) presented side effects.

CONCLUSIONS

This multicentre and retrospective registry of real-world patients treated with PCSK9 inhibitors highlights significant gender differences in LDLc reduction.

Should PRECISE-DAPT be included for long-term prognostic stratification of diabetic patients with NSTEACS?

AIMS

There are insufficient data regarding risk scores validation in patients with diabetes mellitus and non-ST elevation acute coronary syndrome (NSTEACS). We performed a diabetes mellitus-specific analysis of cardiovascular outcomes after NSTEACS. We tested the predictive power of the Global Registry of Acute Coronary Events (GRACE) and PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy (PRECISE-DAPT) scores.

METHODS

This work is a retrospective analysis that included 7,415 consecutive NSTEACS patients from two Spanish Universitarian hospitals between the years 2003 and 2017. The area under the ROC curve among with and without diabetes mellitus patients was calculated, to evaluate the predictive power of both scores.  RESULTS: Among the study participants, 2124 patients (28.0%) were diabetic. The median follow-up was 54,3 months (IQR 24,7-80,0 months). Diabetic patients were more women (30.5% vs. 25.7%) and older (70.0 ± 10.8 vs. 65.3 ± 13.2 years old); they had higher GRACE (146 ± 36 vs. 137 ± 36), PRECISE-DAPT (15 ± 7 vs. 18 ± 9) at admission. Early invasive coronary angiography (≤ 24 h after admission) was performed more frequently in non-diabetic. We tested the predictive power of the GRACE and PRECISE-DAPT risk scores among diabetic and non-diabetic. PRECISE-DAPT risk score showed a good predictive power for all-cause mortality, cardiovascular mortality and MACE in diabetic admitted with NSTEACS, without differences compared to non-diabetic.

CONCLUSIONS

PRECISE-DAPT risk score has an appropriate predictive power in diabetic patients admitted with NSTEACS compared to non-diabetic NSTEACS. However, GRACE would be predictive worse in diabetic during long-term follow-up in a large contemporary registry.

Myocarditis after RNA-based vaccines for coronavirus

Background

The incidence of myocarditis after RNA-based vaccines for coronavirus has gained social and medical interest.

Methods

We performed an intention-to-treat meta-analysis, following the PRISMA statement. After a systematic search, without language restriction, 9 publications were selected. Two were excluded (one was only in subjects with age 12–17 and other might had included subjects from a larger publication). We followed the PRISMA guidelines for abstracting data and assessing data quality and validity. Data was verified by 2 investigators.

Results

We analyzed 17,704,413 subjects, from 7 studies, that included 627 cases of confirmed myocarditis). The incidence of myocarditis was 0.0035% (95% CI 0.0034–0.0035). Mean incidence rate was 10.69 per 100.000 persons-year. Cases reported from Israel represented 45.14% from total (283 out of the 627). Only 1 case of fatal myocarditis or death was reported. There was significant heterogeneity between results. The meta-regression analysis excluded mean age, region, number of cases or number of people included as sources of heterogeneity. No small-study effect was observed (p = 0.19).

Conclusions and relevance

Myocarditis incidence after RNA vaccines is very rare (0.0035%) and has a very favorable clinical course.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry

BACKGROUND

In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure.

METHODS

This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS.

RESULTS

Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)].

CONCUSIONS

In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up.

BRIEF SUMMARY

In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

Direct Oral Anticoagulants versus Warfarin in Octogenarians with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis

Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63-0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70-0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69-1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76-1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36-0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF.

Reduction of cardiovascular events in patients with cardiovascular disease with the CV-polypill: a retrospective and propensity score matching study

Background

Previous clinical trials suggested that a strategy based on a cardiovascular (CV) polypill improves risk factor control and reduces the incidence of CV events. The CNIC-Polyill (aspirin (ASA) 100mg, atorvastatin 20/40mg (or simvastatin 40mg) and ramipril 2,5–10mg) has shown to improve adherence and risk factors control.

Methods

The NEPTUNO study is a retrospective, non-interventional analysis of an anonymized medical history dataset in the BIG-PAC administrative database in the years 2015–2018. Patients at age ≥18 years with previous CV disease were allocated in four different cohorts according to their therapy: CNIC-polypill containing ASA 100mg, R 2.5/5/10mg and A 20/40mg (1:case cohort), identical mono-components (ASA,R,A) (C2), equipotent medication (ASA 100mg, simvastatin 40/80mg or rosuvastatin 5/10mg, enalapril 5–20mg or valsartan 40–160mg) (C3) and usual care (C4) (control cohorts) and were followed for 2 years. To ensure comparability of the study cohorts, a propensity score matching (PSM) was performed. The primary endpoint was the incidence first major cardiovascular event (MACE) including: myocardial infarction, angina, ischemic stroke, transitory ischemic attack, peripheral artery disease and CV mortality.

Results

8,946 patients were recruited. After the PSM, 4 well-balanced cohorts of 1,614 patients were obtained. The mean age was 63.3 years and 60.4% were men. Cohort 1 (Case cohort, CNIC-polypill) compared with cohorts 2, 3 and 4 showed a significant reduction in MACEs (19.8% vs. 23.3%, 25.5% and 26.8%; p&lt;0.001), respectively although the CV death rate (8.1% vs. 8.1%, 8.9% and 9.2%; p=0.357) did not show differences. The hazard ratio (HR) for a MACE in the CV polypill cohort vs cohort 2 was 0.761 (IC95%; 0.657–0.881), p=0.001; vs Cohort 3 was 0.821 (IC95%; 0.714–0.944), p=0.006 and vs. Cohort 4 was 0.834 (IC95%; 0.716–0,950), p=0.008. Time to the event was also longer in the CV-polypill cohort compared the other 3 cohorts (274.8 days vs 249.2 days; 226.4 days and 217 days; p&lt;0.001). There was a significant greater reduction in the case cohort vs the 3 control cohorts in the absolute levels of all the analyzed lipidic variables (LDL (−19.6 vs. −12.9, −12.3 and −9.1 mg/dL; p&lt;0.001), triglycerides (−67.5 vs. −59.9, −56.1 and −54.4 mg/dL; p&lt;0.001)) and in reduction of blood pressure (PAS (−14.1 vs. −11.7, −10.4 and −10.4 mmHg; p&lt;0.001) and PAD (−4.5 vs −2.5, −2.1, −1.2 mmHg; p&lt;0.001)). Higher persistence to treatment in the CNIC- polypill cohort (72.1% vs. 62. 2%, 60.0% and 54.2%; p&lt;0.001) was also found.

Conclusion

This study shows the reduction of clinical events by the CNIC-polypill in a large population of real-life patients. In spite of the retrospective design of this study, the results of our analysis support the use of a CV-polypill in secondary prevention of cardiovascular events. These results need to be confirmed by prospective randomized clinical trials with major clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Ferrer International Figure 1

LDLc reduction with fixed-dose combination rosuvastatin-ezetimibe in patients with coronary heart disease that are not candidates for PCSK9 inhibitors treatment

Background

Statin plus ezetimibe combination has a recommendation class IIa, level of evidence B, for low-density lipoprotein cholesterol (LDLc) reduction. Since LDLc treatment target for patients with coronary heart disease (CHD) has been recently reduced to &lt;55 mg/dl most patients might need lipid-lowering drugs combinations and fixed-dose combinations are known to increase adherence. Current indications for PCSK9 inhibitors accepted for reimbursement in Spain in patients with CHD are LDL &gt;100 mg/dl despite maximal dose tolerated of statins or any of previous patients with statin intolerance and LDL &gt;100 mg/dl.

Methods

Investigator-initiated retrospective analysis of patients with coronary heart disease that received fixed-dose combination with rosuvastatin-ezetimibe between 2019 and 2020 in a specialized unit for patients with CHD. Inclusion criteria were: CHD and LDLc &lt;100 mg/dl despite statin treatment or &gt;100 mg/dl without previous lipid-lowering treatments. We also analysed patients in whom treatment was initiated at discharge from and acute coronary syndrome (ACS) or with chronic coronary syndrome (CCS)

Results

We analyzed 137 patients, 79.4% males, mean age 62. (12.3) and 24.1% with ACS. Statin treatment before initiation fixed-dose combination was higher in patients with CCS (71.2% vs. 8.2%; p&lt;0.01). Mean LDLc before treatment was 103.0 (30.5) mg/dl and it was higher in patients with ACS (121.3 (40.2) vs. 97.4 (24.4); p&lt;0.001). Median time to second blood test was 203 days (IQR 122–300); mean post-treatment LDLc was 60.8 (21.2) mg/dl and no difference (p=0.18) was found in patients with ACS vs CCS: 56.0 (26.1) vs. 62.4 (19.2) mg/dl. Mean LDLc reduction was 38.5% and it was higher in was higher in ACS patients (49.9% vs. 34.7%) (figure). LDLc &lt;55 mg/dl was achieved in 42.1% of the patients, more frequently in patients with ACS: 59.3% vs. 36.3% (p=0.036). No increase in transaminases was detected and a reduction in triglycerides was found (149.1 (100.4) to 124.7 (82.3) mg/dl; p=0.041).

Conclusions

Treatment with a fixed-dose combination with rosuvastatin-ezetimibe in patients with CHD not candidate for PCSK9 inhibitors is effective and safe for LDLc reduction especially in patients discharged after an ACS.

Funding Acknowledgement

Type of funding sources: None.

The value of GRACE risk score for predicting mortality in heart failure patients admitted with non-ST elevation acute coronary syndrome

Background

Acute coronary syndrome (ACS) in heart failure (HF) patients has not been well studied yet.

Purpose

The main aims of this study were to compare the characteristics and outcomes of Non-ST elevation ACS (NSTACS) in patients with and without prior HF, and to assess the GRACE risk score performance for risk stratification in both groups.

Methods

All consecutive patients (n=5661) admitted due to a NSTACS from November'2003 to November'2017 in two Spanish hospitals were retrospectively analysed. Patients were divided according to prior HF. As GRACE score predicts mortality in 6 months, logistic regression models were used to predict mortality in both groups. The different aspects of model performance were studied, including calibration and discrimination.

Results

Killip class, GRACE and CRUSADE scores were higher in HF-patients compared to patients without prior HF. Also, HF-patients had more complications (major bleeding, worsening HF, acute kidney injury) and higher mortality. Discrimination capacity of GRACE score to predict mortality at 6 months was slightly higher in non-HF patients (AUC 83.9% [81.6–86.2]) than in HF-patients [AUC 77.0% [70.1–83.8]) (Figure 1). The risk score calibration was acceptable for both groups [Brier scores were 0.139 (c-AUC 0,77) for HF-patients, and 0.046 (c-AUC 0.839) for non-HF patients]. Finally, HF-patients with lower GRACE scores had a higher predicted mortality than non-HF patients (Table 1).

Conclusions

We showed the potential utility of GRACE risk score in HF-patients admitted with NSTACS, expanding the indication of GRACE risk score for HF-patients as well. In fact, GRACE risk score not only keeps its accuracy, but it is even more robust in HF-patients than in non-HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Trends in major bleeding events in patients with acute coronary syndrome

Background

Bleeding events incidence has gained a crucial role in acute coronary patients (ACS) due to its independent effect prognostic value.

Methods

We assessed the trend of in-hospital and first-year-after-discharge major bleeding events (MB) in all ACS admitted in a single center between January 2009 and Agoust 2019. MB was defined as those fitting definitions 3 or 5 of the BARC consortium. Patients were categorized as high-bleeding risk (HBR) if according to the 2019 Academic Research Consortium HBR consensus if they met at least one major or two minor criteria. Inclusion period was divided in 3 groups: 2009–2012 (n=884; 27.4%), 2013–2015 (n=1,047; 32.5%); 2016–2019 (n=1,294; 40.1%). Post-discharge MB was assessed by competing events regression models, taking all-cause mortality as a competing event, and results are presented as sub-hazard ratio (sHR).

Results

We included 3225 patients, mean age was 68.4 (29.7), 25.7% females, 1,108 32.1% had diabetes and 44.0% STEMI. Radial access was perfume in 92% of the angiographies in the 3 time-periods. A significant decrease in dual antiplatelet treatment (DAPT) before angiography was noted (69.0%; 56.3%; 53.6%; p=0.001) with a decreasing pattern in clopidogrel and increase in ticagrelor and prasugrel. A total of 1,591 (46.2%) were categorized as HBR patients. A non-significant trend to higher incidence of in-hospital MB was noted through the 3 time periods: 1.39%; 1.43%; 2.55% (p=0.056) and it was mainly driven by the significant increase only in HBR patients: 2.21%; 3.55%; 6.26% (p=0.003). Multivariate analysis identified age (OR: 1.06 95% CI 1.03–1.08, p&lt;0.001) and the time period 2016–2019 (OR: 1.96 95% CI 1.01–3.84; p=0.031) as main variables associated to higher in-hospital MB.

In contrast, postdischarge MB did not change overtime (p=0.155) and trends were the same in HBR and non-HBR patients (figure). The competing risk regression analysis, adjusted by age, gender, previous cardiovascular disease, revascularization and medical treatments, identified that the leading factors for postdischarge MB were diabetes (sHR: 1.37; 95% CI 1.01–2.92), time-period 2016–2019 (sHR: 1.52; 95% CI 1.01–2.30), HBR patient (sHR: 1.91; 95% CI 1.28- 2.87) and and previous heart failure (sHR: 2.26; 95% CI 1.264.40)

Conclusions

This continuous 10-year registry highlights the increasing trend of in-hospital mainly driven by the incidence in HBR patients. In contrast, postdischarge MB increased in all patients.

Funding Acknowledgement

Type of funding sources: None. Post-discharge MB incidence