Fourth Universal Definition of Myocardial Infarction (2018)

Study on the Synergistic Effect of Klotho and KRAS on Reducing Ferroptosis After Myocardial Infarction by Regulating RAP1/ERK Signaling Pathway

Myocardial infarction (MI) is a coronary artery-related disease that seriously threatens human life and is the leading cause of sudden death worldwide, where a lack of nutrients and oxygen leads to an inflammatory response and death of cardiomyocytes. Ferroptosis is a form of non-apoptotic cell death associated with metabolic dysfunction, resulting in abnormal breakdown of glutamine and iron-dependent accumulation of reactive oxygen species (ROS) during metabolism. However, the molecular mechanism of ferroptosis in the pathogenesis of MI and the function of Klotho and KRAS on ferroptosis during MI remain unclear. The MI rat model was established by LAD ligation with a 6-0 suture. H9c2 cells were placed in glucose-deficient DMEM (Thermo) and cultured in an anaerobic environment (1% CO2 and 5% CO) to establish an in vitro OGD cell model. The damage to rat heart tissue was detected by HE staining, and Klotho and KRAS were determined by RT-qPCR, Western Blot, and IHC. TUNEL staining was used to determine apoptosis in rat heart tissue samples. The interaction between Klotho and KRAS was verified by co-immunoprecipitation and Western Blot. The cardiomyocyte activity was measured by CCK-8 assay. LDH, CK-MB, cTnT, and Fe2+ markers were detected by the kits. For the assessment of ferroptosis, GSH and ROS in cardiomyocytes and serum were detected by kits, and PTSG was detected by Western Blot. IL-1β and IL-6 in cardiomyocytes and serum were determined by ELISA. Klotho was downregulated in MI. Downregulation of Klotho promoted myocardial injury; increased apoptosis of cardiomyocytes; promoted LDH, CK-MB, and cTnT concentrations; inhibited GSH; and promoted ROS levels, PTGS2 expression, and ferroptosis in rats. The same results were obtained in vitro. Klotho and KRAS had endogenous interactions. KRAS knockdown can reverse Klotho knockdown-mediated MI and ferroptosis. RAP1/ERK pathway was highly expressed in MI, and inhibiting RAP1/ERK pathway activation can reverse the promoting effect of overexpressed KRAS on MI progression and ferroptosis. Klotho interacts with KRAS and inhibits ferroptosis after MI by regulating the RAP1/ERK pathway.

Traditional Versus Dual Lumen Microcatheter-Assisted Parallel Wiring in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry

BACKGROUND

The effectiveness and safety of traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

AIMS

To compare traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring.

METHODS

We compared the clinical and angiographic characteristics and outcomes of traditional versus DLMC-assisted parallel wiring after failed antegrade wiring (AW) in a large, multicenter CTO PCI registry.

RESULTS

Among 1353 CTO PCIs with failed AW with a single wire, traditional parallel wiring (n = 1081) or DLMC-assisted parallel wiring (n = 272) were utilized at the operator's discretion. The baseline characteristics of patients were similar in both groups except for higher prevalence of diabetes mellitus, and lower prevalence of hypertension, prior heart failure, prior MI and cerebrovascular disease in DLMC patients. Lesions in the DLMC group were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate/severe calcification, and had higher J-CTO score (2.6 ± 1.0 vs. 2.1 ± 1.3, p < 0.001). Technical (87.1% vs. 74.3%, p < 0.001) and procedural (83.8% vs. 75.5%, p = 0.001) success and the incidence of in-hospital major cardiac adverse events (MACE) (4.8% vs. 2.0%, p = 0.020) were higher in the DLMC group. In propensity score matching analysis, DLMC-assisted wiring was associated with higher technical success (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.54, p = 0.002) and no significant difference in MACE (OR 2.00, 95% CI 0.89-4.50, p = 0.093).

CONCLUSIONS

In lesions that could not be crossed with AW, DLMC-assisted parallel wiring was associated with a higher likelihood of technical success, without an increased risk of MACE, compared with traditional parallel wiring.

Angiography-Derived Microcirculatory Resistance in Detecting Microvascular Obstruction and Predicting Heart Failure After STEMI

BACKGROUND

Microvascular obstruction (MVO) is associated with heart failure (HF) following ST-segment-elevation myocardial infarction. Angiography-derived microcirculatory resistance (AMR), a wire- and adenosine-free measure, may facilitate early assessment of microvascular function post-primary percutaneous coronary intervention. This study aimed to evaluate the ability of AMR to detect MVO and its prognostic value for predicting HF in patients with ST-segment-elevation myocardial infarction post-primary percutaneous coronary intervention.

METHODS

Patients with consecutive ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention with a cardiac magnetic resonance examination 2 to 7 days post-procedure between April 2016 and February 2023 were retrospectively reviewed. AMR was computed from coronary angiography. MVO was identified and quantified via cardiac magnetic resonance. The end point was new-onset HF during follow-up.

RESULTS

Overall, 475 patients (aged 56.8±11.7 years; 399 men) were included. The area under the curve for AMR to detect MVO was 0.821 (95% CI, 0.782-0.859), with an optimal cutoff value of 2.7 mm Hg*s/cm. During a median follow-up of 37.3 months, 121 (25.5%) patients developed HF. AMR, whether as a continuous (per 0.5-mm Hg*s/cm increase; hazard ratio, 1.29 [95% CI, 1.10-1.52]; P=0.002) or categorical (AMR >2.7 mm Hg*s/cm; hazard ratio, 2.15 [95% CI, 1.43-3.22]; P<0.001) variable, was independently associated with HF after adjusting for traditional risk factors (age, symptom-to-balloon time, left anterior descending coronary artery, and ejection fraction) and late gadolinium enhancement-cardiac magnetic resonance parameters. AMR improved prognostication over traditional risk factors and late gadolinium enhancement-cardiac magnetic resonance parameters (net reclassification improvement, 0.533; P<0.001; integrative discrimination index, 0.023; P=0.005).

CONCLUSIONS

AMR showed good diagnostic performance in detecting MVO and was an independent and incremental predictor of HF in patients with ST-segment-elevation myocardial infarction post-primary percutaneous coronary intervention.

Periprocedural Myocardial Injury Using CKMB Following Elective PCI: Incidence and Associations With Long-Term Mortality

BACKGROUND

Myocardial injury detected after percutaneous coronary intervention (PCI) is associated with increased mortality. Predictors of post-PCI myocardial injury are not well established. The long-term prognostic relevance of post-PCI myocardial injury remains uncertain.

METHODS

Consecutive adults aged ≥18 years with stable ischemic heart disease who underwent elective PCI at NYU Langone Health between 2011 and 2020 were included in a retrospective, observational study. Patients with acute myocardial infarction or creatinine kinase myocardial band (CKMB) or troponin concentrations >99% of the upper reference limit before PCI were excluded. All patients had routine measurement of CKMB concentrations at 1 and 3 hours post-PCI. Post-PCI myocardial injury was defined as a peak CKMB concentration >99% upper reference limit. Linear regression models were used to identify clinical factors associated with post-PCI myocardial injury. Cox proportional hazard models were generated to evaluate relationships between post-PCI myocardial injury and all-cause mortality at long-term follow-up.

RESULTS

Among 10 807 patients undergoing elective PCI, the median age was 67 years (interquartile range, 15.6), and 24.9% were of female sex. Post-PCI myocardial injury occurred in 1813 (16.8%) patients. Myocardial injury was less common among female than male patients (14.1% versus 17.7%, P<0.001). Older age, longer lesion lengths, multivessel PCI, severe coronary calcification, and thrombectomy device use were independently associated with post-PCI myocardial injury with CKMB levels ≥99% upper reference limit. Over 46 071 patient-years of follow-up (mean 4.3 years), 472 patients died (4.4%). A greater proportion of patients with versus without post-PCI myocardial injury died during follow-up (7.9% versus 3.6%, P<0.001). After adjustment for demographics and clinical covariates, post-PCI myocardial injury was associated with an excess hazard for long-term mortality (hazard ratio, 1.46 [95% CI, 1.20-1.78]).

CONCLUSIONS

Myocardial injury defined by elevated CKMB early after PCI is common and associated with all-cause, long-term mortality. More complex coronary anatomy is predictive of post-PCI myocardial injury.

Targeting Investigation and Treatment in Type 2 Myocardial Infarction: A Pilot Randomized Controlled Trial

BACKGROUND

Type 2 myocardial infarction occurs in the absence of atherothrombosis, due to myocardial oxygen supply or demand imbalance, often during another acute illness. It is common and associated with poor clinical outcomes. No randomized controlled trials are available to guide investigation or treatment.

OBJECTIVES

The authors assessed the feasibility of implementing a complex intervention of investigation and treatment for coronary and structural heart disease in patients with type 2 myocardial infarction.

METHODS

A pilot phase of a prospective randomized controlled trial was conducted. Process outcomes included the proportion of eligible patients approached, consented, and randomized. Adherence was defined as the number of recommended investigations and treatments administered at 90 days. Qualitative interviews explored reasons for participation and patient experience.

RESULTS

Between November 2022 and November 2023, 4,127 patients with increased cardiac troponin concentrations were screened across 3 sites, and 403 patients (10%) met inclusion criteria. One hundred and forty-three patients (35%) were eligible, 119 patients (83%) were approached, and 60 patients (42%, age 70 ± 10 years, 38% women) consented and randomized to the intervention (n = 28) or standard care (n = 32). Follow-up was complete in all participants. Adherence to recommendations was 90.7% (95% CI: 85.3%-96.1%). Patients highlighted variation in communication of the diagnosis and in trial investigation and management recommendations were potential barriers to participation.

CONCLUSIONS

It is feasible to recruit and randomize patients with type 2 myocardial infarction to a complex intervention targeting coronary or structural heart disease. A multicenter trial with an optimized intervention is now required to inform practice.

Comparing the Efficacy of Sirolimus and Paclitaxel-Eluting Balloon Catheters in the Treatment of Coronary In-Stent Restenosis: A Prospective Randomized Study (TIS 2 Study)

BACKGROUND

Current therapy for in-stent restenosis (ISR) is based on drug-eluting stents (DES) or drug-eluting balloon catheters. This prospective randomized study compared the efficacy of a novel sirolimus-eluting balloon (SEB) catheter to that of a paclitaxel-eluting balloon (PEB) catheter for the treatment of bare-metal stent (BMS-ISR) or DES-ISR.

METHODS

A total of 145 patients with 158 BMS or DES-ISR lesions were randomly assigned to the treatment with either SEB or PEB. The in-segment late lumen loss at 12 months, the 12-month incidence of binary ISR, and major adverse cardiac events (cardiac death, nonfatal acute myocardial infarction, or target lesion revascularization) were compared between groups.

RESULTS

The noninferiority of SEB compared with PEB in the treatment of BMS/DES-ISR with respect to late lumen loss was not demonstrated (Δlate lumen loss, -0.024 mm [95% CI, -0.277 to 0.229]; for a noninferiority margin of 0.20 mm), except in the post hoc subanalysis for the BMS-ISR group (-0.203 mm [95% CI, -0.584 to 0.178]). No significant differences in the incidence of repeated binary ISR (31.6% versus 30.4%, P=0.906) or 12-month major adverse cardiac events (31% for both; P>0.999) between the SEB and PEB groups were observed.

CONCLUSIONS

The noninferiority of SEB relative to PEB in the treatment of BMS/DES-ISR with respect to late lumen loss was not confirmed.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03667313.

IGFBP5 mediates the therapeutic effect of isoliquiritigenin in myocardial ischemia-reperfusion injury via AKT/GLUT4 regulated insulin resistance

Background

Myocardial ischemia/reperfusion injury (MIRI) is a critical problem in cardiovascular medicine, often occurring after coronary revascularization procedures or cardiopulmonary bypass. The characters of MIRI are both energy metabolism disturbances and severe myocardium insulin resistance (IR), which exacerbated myocardial damage and cell death. Isoliquiritigenin (ISL), a flavonoid derived from licorice roots (Glycyrrhiza spp.), has demonstrated protective effects on MIRI. However, the potential cardio-protective effects and mechanism of ISL in MIRI remain unclear.

Propose

In this study, we aimed to investigate ISL's therapeutic effects on MIRI. Moreover, we elucidate the underlying mechanisms of ISL regulated myocardium insulin resistance in vivo and in vitro.

Methods

In vivo, SD rats underwent left anterior descending coronary artery ligation/reperfusion to induce MIRI. Chest echocardiography was performed to monitor cardiac function post-reperfusion, followed by measurement of myocardial injury and IR markers. In vitro, H9C2 cardiomyocytes subjected to oxygen-glucose deprivation/reperfusion (OGD/R). Markers associated with myocardial injury and IR were assessed. Then, we identified potential therapeutic targets IGFBP5 for MIRI by network pharmacology and molecular docking analysis. Finally, lentivirus were used to silence or over-express IGFBP5 to elucidate the role of IGFBP5 in regulating the therapeutic effects of ISL on IR in MIRI.

Results

In the present study, In vivo experiments demonstrated that ISL attenuated myocardial infarct size, decreased serum markers of myocardial injury, improved left ventricular systolic function, and enhanced insulin sensitivity. In vitro data revealed that ISL ameliorated glucose uptake and cell survival rate. Furthermore, ISL increased AKT phosphorylation and upregulated membrane-bound GLUT4 (M-GLUT4) protein expression levels. These effects of ISL are mediated by the induction of IGFBP5, as demonstrated using gene-specific shRNA or overexpression for IGFBP5.

Conclusion

Our results reveal that ISL protects against myocardial damage caused by MIRI through the regulation of IR via the IGFBP5/AKT/GLUT4 pathway.

Biological variation of cardiac biomarkers in athletes during an entire sport season

OBJECTIVES

Cardiac biomarkers are useful for the diagnostic and prognostic assessment of myocardial injury (MI) and heart failure. By measuring specific proteins released into the bloodstream during heart stress or damage, these biomarkers help clinicians detect the presence and extent of heart injury and tailor appropriate treatment plans. This study aims to provide robust biological variation (BV) data for cardiac biomarkers in athletes, specifically focusing on those applied to detect or exclude MI, such as myoglobin, creatine kinase-myocardial band (CK-MB) and cardiac troponins (cTn), and those related to heart failure and cardiac dysfunction, brain natriuretic peptide (BNP) and N-terminal brain natriuretic pro-peptide (NT-proBNP).

METHODS

Thirty athletes participated, providing monthly fasting blood samples over 11 months. Samples were analyzed using chemiluminescent immunoassays and statistical analyses were conducted using the classical ANOVA method, a linear mixed model and a Bayesian approach.

RESULTS

The study observed significant gender differences in biomarker concentrations, with higher BNP and NT-proBNP in females and higher myoglobin and CK-MB in males. Physical activity within 24 h before sampling notably affected CK-MB, myoglobin, and hs-cTnI variability. The BV estimates demonstrated high individuality for most biomarkers, suggesting their potential for personalized monitoring. The study also revealed substantial heterogeneity for NT-proBNP and BNP within the population.

CONCLUSIONS

These findings underscore the importance of considering gender-specific reference intervals and the impact of recent physical activity when interpreting cardiac biomarkers in athletes. The study delivers new BV estimates for CK-MB and myoglobin while emphasizing the need for tailored clinical assessments in athlete populations.

Clinical performance validation and four diagnostic strategy assessments of high-sensitivity troponin I assays

Acute coronary syndrome (ACS) includes conditions such as unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). High-sensitivity cardiac troponin I (hs-cTnI) assays have been recommended as primary biomarkers for NSTEMI diagnosis due to their high sensitivity and specificity. However, there is no consensus on the optimal diagnostic strategy for early NSTEMI detection. This study aims to evaluate the diagnostic performance of four hs-cTnI-based strategies for suspected NSTEMI: Limit of Detection (LoB), Single Cut-off, hs-cTnI 0/1 h Algorithm, and hs-cTnI 0/2 h Algorithm, in a Chinese cohort and compare the performance of assays from different manufacturers. Performance verification was conducted, including LoB, LoD, LoQ, and precision analysis. Clinical samples from 267 ACS patients were analyzed using Hybiome hs-cTnI assays. Diagnostic accuracy was assessed based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1-score. The LoB strategy demonstrated 100% sensitivity but low PPV (14.0%). Both the hs-cTnI 0/1 h Algorithm and hs-cTnI 0/2 h Algorithm showed high diagnostic performance, with the 0/2 h algorithm providing the best overall. 89.0% accuracy, 93.3% sensitivity, and 73.68% F1-score. The hs-cTnI 0/2 h Algorithm offers the most reliable diagnostic performance for early NSTEMI diagnosis.

Validation of the Prognostic Ability of Eight Risk Scores for Cardiovascular Events in NSTEMI Patients with Multi-Vessel Disease

This study compared eight risk scores regarding their predictive ability in non-ST-elevation myocardial infarction (NSTEMI) patients (n = 862) with multi-vessel disease (MVD) after percutaneous coronary intervention (PCI). The primary outcome was cardiac death. The secondary outcomes included major adverse cardiovascular event (MACE) [a composite of all-cause death, myocardial infarction (MI), and unplanned repeat revascularization], all-cause death, and MI. During a median follow-up of 4.8 years, 47 (5.5%) cardiac death, 218 (25.3%) MACE, 79 (9.2%) all-cause death, and 40 (4.6%) MI were recorded. The Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score II was the most accurate for cardiac death with the highest area under the receiver operating characteristic curve (AUC) (0.814, 95% CI: 0.758-0.869). The logistic SYNTAX score extended model (LSSextended) exhibited the most powerful ability in predicting MACE (AUC: 0.624, 95% CI: 0.580-0.667) and MI (AUC: 0.657, 95% CI: 0.567-0.747). The modified Age, Creatinine, and Ejection Fraction score (MAS) was the most accurate score in predicting all-cause death (AUC: 0.798, 95% CI: 0.752-0.844). The scores involving clinical variables showed better ability to predict adverse cardiovascular events among NSTEMI patients with MVD after PCI.

The effect of inflammatory markers on mortality in patients with acute myocardial infarction

Consider that inflammatory factors are associated with short-term mortality in patients with acute myocardial infarction (AMI). In this retrospective analysis of 2,784 AMI patients from the Medical Information Mart for Intensive Care-IV database, we evaluated the impact of inflammatory markers on in-hospital mortality and predicted 30-day and 90-day outcomes. Patients were divided into groups based on in-hospital survival (n = 2,364) and mortality (n = 420). Analysis of initial hospital admission laboratory data, including inflammatory factors, revealed these factors as independent predictors of in-hospital mortality (Q4 of RDW: OR 1.96, NLR: OR 1.63, SII: OR 1.85, and SIRI: OR 2.23, all P < 0.05). Cox proportional hazards models confirmed their significance for predicting 30-day (Q4 of NLR: OR 1.83, SII: OR 1.86, and SIRI: OR 2.01, all P < 0.05) and 90-day mortality (Q4 of RDW: OR 1.46, NLR: OR 1.69, SII: OR 1.73, and SIRI: OR 1.72, all P < 0.05). Increasing levels of inflammatory markers correlated with higher odds and hazard ratios, as illustrated by Restricted Cubic Spline curves. Kaplan-Meier survival analysis showed better survival rates with lower inflammatory marker levels. Receiver operating characteristic curves demonstrated good predictive performance of individual inflammatory factors, with a new composite marker showing the highest predictive ability (AUC = 0.720). This study underscores the association of inflammatory factors with both hospital and short-term mortality in AMI patients.

Cardiac arrhythmia following acute myocardial infarction: a retrospective analysis of 27,648 hospitalized patients in a tertiary heart hospital

Arrhythmia frequently complicates acute myocardial infarction (AMI) and contributes to high morbidity and mortality. We aimed to investigate the prevalence, risk factors, and impact of cardiac arrhythmias in AMI patients at a tertiary heart hospital. This retrospective observational study included AMI patients who were admitted between January 1991 and May 2022. Patients' data were analyzed and compared according to the absence or presence of cardiac arrhythmias post-AMI. We hypothesized that arrhythmias are associated with higher mortality following AMI. During the study, 27,648 patients were hospitalized with AMI, of whom 2118 (7.7%) developed arrhythmia. Patients who developed arrhythmia had a higher average age compared to those without arrhythmia (57.2 vs. 54.8 years, p=0.001), and a larger proportion were male compared to female patients (85.2% vs. 14.8%, p=0.001). Atrial fibrillation was observed in 383 patients (18.1%). Ventricular tachycardia was found in 461 (21.8%), and ventricular fibrillation occurred in 526 patients (24.8%). Complete heart block was developed in 286 (13.5%) patients, 1st-degree atrioventricular (AV) block in 36 (1.7%), 2nd-degree AV block in 138 (6.5%), left bundle branch block in 81 (3.8%), and right bundle branch block in 118 (5.6%). The rate of β-blocker use has increased in the arrhythmias group at discharge compared to the on-admission rate (55.7% vs. 32.5%). However, it remained sub-optimal. Arrhythmias were associated with longer hospital stays and five times higher hospital mortality than the non-arrhythmia group. Multivariable logistic regression analysis indicated that arrhythmia was associated with increased mortality risk three times following AMI (adjusted odds ratio 3.01; 95% confidence interval 2.42-3.75, p=0.001). Almost one-tenth of patients hospitalized with AMI in Qatar developed arrhythmia with variable outcomes; however, the in-hospital mortality remained high. Addressing the risk factors and optimizing the prevention and treatment of AMI and arrhythmias is crucial to improving clinical outcomes. This study may underestimate the incidence of arrhythmias post-AMI as it did not report all types.

Machine learning to risk stratify chest pain patients with non-diagnostic electrocardiogram in an Asian emergency department

Introduction

Elevated troponin, while essential for diagnosing myocardial infarction, can also be present in non-myocardial infarction conditions. The myocardial-ischaemic-injury-index (MI3) algorithm is a machine learning algorithm that considers age, sex and cardiac troponin I (TnI) results to risk-stratify patients for type 1 myocardial infarction.

Method

Patients aged ≥25 years who presented to the emergency department (ED) of Singapore General Hospital with symptoms suggestive of acute coronary syndrome with no diagnostic 12-lead electrocardiogram (ECG) changes were included. Participants had serial ECGs and high-sensitivity troponin assays performed at 0, 2 and 7 hours. The primary outcome was the adjudicated diagnosis of type 1 myocardial infarction at 30 days. We compared the performance of MI3 in predicting the primary outcome with the European Society of Cardiology (ESC) 0/2-hour algorithm as well as the 99th percentile upper reference limit (URL) for TnI.

Results

There were 1351 patients included (66.7% male, mean age 56 years), 902 (66.8%) of whom had only 0-hour troponin results and 449 (33.2%) with serial (both 0 and 2-hour) troponin results available. MI3 ruled out type 1 myocardial infarction with a higher sensitivity (98.9, 95% confidence interval [CI] 93.4-99.9%) and similar negative predictive value (NPV) 99.8% (95% CI 98.6-100%) as compared to the ESC strategy. The 99th percentile cut-off strategy had the lowest sensitivity, specificity, positive predictive value and NPV.

Conclusion

The MI3 algorithm was accurate in risk stratifying ED patients for myocardial infarction. The 99th percentile URL cut-off was the least accurate in ruling in and out myocardial infarction compared to the other strategies.

Cardioprotection exerted by intravenous statin at index myocardial infarction event attenuates cardiac damage upon recurrent infarction

AIMS

Recurrent acute myocardial infarction (RE-AMI) is a frequent complication after STEMI, and its association with stent thrombosis can be life-threatening. Intravenous atorvastatin (IV-atorva) administration during AMI has been shown to limit infarct size and adverse cardiac remodelling. We determined by cardiac magnetic resonance (CMR) whether the cardioprotection exerted by IV-atorva at the index AMI event translates into a better prognosis upon RE-AMI in dyslipidemic pigs.

METHODS AND RESULTS

Hypercholesterolemic pigs underwent a first AMI (90-min coronary balloon occlusion). During ongoing ischaemia, animals received IV-atorva or vehicle. Forty days later, animals underwent RE-AMI and were sacrificed on Day 43. All animals remained on p.o. atorvastatin and a high-cholesterol diet from the first AMI until sacrifice. Serial CMR analysis was performed on Day 3 post-AMI, prior- (Day 40) and post-RE-AMI (Day 43). No differences were detected in oedema formation in both animal groups during AMI and RE-AMI. Gadolinium DE-CMR revealed smaller infarcts in IV-atorva-treated animals at index event at 3 and 40 days post-AMI compared to vehicle-administered pigs (P < 0.05). CMR analyses post-RE-AMI revealed smaller infarcts in the animals treated with IV-atorva at index event than in the vehicle-administered pigs. These IV-atorva at index event benefits were associated with higher left ventricular (LV) ejection fraction and normal LV wall motion in the jeopardized myocardium at RE-AMI (P < 0.05 vs. vehicle). The scar region of RE-AMI of animals treated with IV-atorva at index event showed reduced cardiac inflammatory infiltrate, apoptosis and senescence activation, and increased reparative fibrosis and neovessel formation vs. vehicle-administered pigs. Animals treated with IV-atorva at index event also showed lower C-reactive protein and higher interleukin-10 plasma levels in the setting of RE-AMI.

CONCLUSION

The cardioprotection afforded by IV-atorva administration during an index-AMI event shows a legacy effect attenuating myocardial damage and preserving cardiac contractile function upon RE-AMI. The potential benefits of this intravenous approach should be tested in the clinical setting.

Performance Evaluation of the New High-Sensitivity Cardiac Troponin I Immunoassay on CL-2600i Mindray Analyzer

Background: International guidelines recommend the use of high-sensitivity cardiac troponin (hs-cTn) I and T methods for the detection of myocardial injury as a pre-requisite for the diagnosis of acute myocardial infarction (AMI) in patients admitted to the emergency department. Recently, Mindray (Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China) has introduced a new chemiluminescence immunoassay (CLIA) for the detection of the cTn complex. The present study aims to verify and validate the hs-cTnI Mindray assay on the new automated CL2600i analyzer compared to the routine Alinity-i series instrument by Abbott (Abbott, Chicago, IL, USA). Methods: This study evaluated linearity, precision through the 5 × 5 protocol, methodological comparison on plasma and serum matrices, hs-cTnI 99th percentile imprecision, and the hs-cTnI detection rate in a healthy population. Results: The results obtained proved that the performance of the Mindray hs-cTnI test on the CL2600i platform was closely comparable to the Abbott Alinity-i system (plasma R2: 0.974; serum R2: 0.995). The CVs were consistently low, and no significant differences were reported. Excellent analytical performance, with high sensitivity, was also observed in the healthy population (overall detection rate: 79%), as well as good linearity within the measuring range (R2: 0.994). Conclusions: The Mindray hs-cTnI test confirms its robustness and utility in routine practice as an advanced assay. The new technology, with more sensitive detection methods, may improve the accuracy and reliability of cardiac biomarker testing, ultimately leading to better outcomes in the management of patients with AMI and other cardiac conditions.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

Factors Associated with Mortality Risk in Patients with Cardiogenic Shock Post-ST-Elevation Myocardial Infarction: Insights from a Regional Centre in Northwest Romania

Background and Objectives: ST elevation myocardial infarction (STEMI), particularly when complicated by cardiogenic shock (CS), is a critical condition associated with high mortality rates. Identifying predictors of in-hospital mortality can enhance patient management and outcomes. Materials and Methods: This observational, retrospective case-control study included STEMI patients, both complicated and uncomplicated by CS. Additionally, demographics, clinical characteristics, laboratory data and in-hospital mortality rates were analysed for STEMI patients with CS and those without CS. Results: This study included a total of 101 patients with STEMI, of whom 51 (50.5%) had STEMI without CS and 50 (49.5%) had STEMI with CS. No significant differences were observed in demographic characteristics or STEMI risk factors between the two groups. Emergency coronarography was performed in 90.1% of the patients, with successful thrombolysis achieved in 24.5%. Patients with CS exhibited a significantly higher mortality (52%) than those without CS (11.76%). Univariate analysis identified white blood cell counts, CK-MB, CK levels, elevated creatinine and uric acid levels and a reduced left ventricular ejection fraction (LVEF) as predictors of mortality. Logistic regression analysis revealed that LVEF and CK-MB were independent predictors of in-hospital mortality in patients with STEMI and CS. Each 1% increase in LVEF was associated with a reduced mortality risk (HR = 0.89; 95% CI 0.81-0.98; p = 0.018), while elevated CK-MB levels were linked to an increased mortality risk (HR = 1; 95% CI 1-1.01; p = 0.014). Conclusions: Reduced systolic function and elevated CK-MB levels are key predictors of in-hospital mortality and outcomes in STEMI patients with CS. These findings underscore the importance of early identification and support the development of targeted management strategies aimed at improving outcomes in this high-risk population.

Association Between Myocardial Infarction and Quality Of Life in the ISCHEMIA Trial

BACKGROUND

The association between myocardial infarction (MI) subtypes (procedural MI [PMI] and spontaneous MI [SMI]) and subsequent quality of life (QoL) is incompletely understood.

OBJECTIVES

The authors analyzed the association between PMI and SMI and generic and disease-specific QoL in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.

METHODS

QoL was assessed before randomization and at 1.5, 3, and 6 months, and every 6 months thereafter. European Quality of Life-5 dimensions visual analog scale (EQ-5D VAS) (generic) and Seattle Angina Questionnaire (SAQ-7) summary score (disease-specific) were used. The primary analysis was a linear, repeated-measures, multivariable-adjusted, mixed-effects model, with a random intercept for patient. QoL assessments occurring <3 months after MI were defined as early QoL and those occurring >3 months after MI were defined as late QoL.

RESULTS

4,375 randomized patients were included in the primary analysis population. The median duration of follow-up was 36.2 months (Q1-Q3: 23.8-49.5 months). In the primary analysis population, a total of 84 PMIs and 352 SMIs occurred. SMI was associated with significant decreases in both early (adjusted difference -5.7; 95% CI: -7.3 to -4.1 points) and late EQ-5D VAS (-3.1 points; 95% CI: -4.3 to -1.9 points) and in early (-7.7 points; 95% CI: -9.4 to -6.1 points) and late SAQ-7 (-1.9 points; 95% CI: -3.2 to -0.7 points). PMI was not associated with early (adjusted difference -0.8 points; 95% CI: -3.3 to 1.8 points) or late (-0.7 points; 95% CI: -2.7 to 1.2 points) changes in EQ-5D VAS, and was associated with a reduction in early (-3.0 points; 95% CI: -5.7 to -0.4) but not late SAQ-7 (-0.2 points; 95% CI -2.2 to 1.8 points).

CONCLUSIONS

In ISCHEMIA, SMI was associated with reductions in both early and late generic and disease-specific QoL, whereas PMI was only associated with a transient reduction in disease-specific QoL.

Poor Mental Health Status as a Risk Factor and Prognosticator in SMuRF-Less Acute Myocardial Infarction

Background: The etiology of acute myocardial infarction (AMI) in patients without history of standard modifiable risk factors (SMuRFs) remains unclear. Simultaneously, evidence suggests that mental health status (MHS) contributes to the pathogenesis of AMI and worsens its outcomes. Methods: This analysis of the prospective "Beyond-SMuRFs" (NCT05535582) study included 650 consecutive patients with AMI who had available data on self-reported MHS before AMI, calculated by the SF36-Questionnaire mental component summary (MCS). Poor MHS was defined as MCS ≤ 50. Multivariable logistic-regression and Cox-regression analyses were implemented to investigate poor MHS as a potential predictor of SMuRF-less AMIs and compare all-cause mortality based on SMuRF-less and MH status, respectively. Results: Of 650 patients with AMI (mean age 62.6 ± 12.1 years), 288 (44.3%) had MCS ≤ 50 and 128 (19.7%) were SMuRF-less patients. Three out of four SMuRF-less patients reported an MCS ≤ 50 (n = 96, 75%), a significantly higher percentage than the corresponding percentage in patients with SMuRFs (n = 192, 36.8%; p < 0.01). The multivariable logistic regression model showed that MCS ≤ 50 was an independent predictor of SMuRF-less AMI [aOR = 0.95; 95% CI (0.94-0.96)]. Time-to-event analysis for all-cause mortality showed that patients with MCS > 50 had lower mortality rates than those with poor MHS (aHR, 3.61 [95% CI, 2.02 to 6.43], p < 0.01). Higher risk for all-cause mortality was also observed in SMuRF-less patients with poor MHS compared to patients with at least one SMuRF and good MHS [aHR, 4.52 (95% CI, 0.94-21.73)]. Conclusions: Poor MHS was an independent predictor of the occurrence of SMuRF-less AMI and predictive of higher mortality in patients with and without SMuRFs.

Pharmacologic agents for perioperative cardioprotection in noncardiac surgery

PURPOSE OF THE REVIEW

This review will discuss the current pharmacologic strategies for mitigation of perioperative myocardial. State-of-the-art benefits and harms of pharmacologic interventions to delineate knowledge gaps in current guidelines and clinical practice will be presented.

RECENT FINDINGS

Beta-blockers are known to reduce major adverse cardiac events but inappropriate preoperative initiation results in adverse outcomes. Renin-Angiotensin-Aldosteron System (RAAS) inhibitors once universally discontinued before surgery are now under reconsideration as continuation seems not to be associated with increased risk. Statins continue to be the cornerstone due to their pleiotropic effect. Continuation of aspirin is supported perioperatively if the bleeding risk due to surgery is low to moderate. A few studies have investigated a strategy of strict intraoperative blood pressure control but failed to observe a meaningful effect on outcome. Whether prompt intensification of treatment in case of diagnosis of myocardial injury after noncardiac surgery improves outcome remains to be established. Since the MANAGE trial, no new studies have prospectively addressed this question.

SUMMARY

New data have questioned previous ideas and suggest a more nuanced, personalized approach to perioperative management. Accordingly, future studies should address refinement in risk stratification, optimization of pharmacologic strategies, and the development of novel therapies in attempting to enhance outcomes in high-risk surgical populations.

Social Support and 10-Year Mortality Following Acute Myocardial Infarction

This study investigates social support type and long-term mortality following AMI. Demographic and clinical data were collected retrospectively from a tertiary hospital for all patients with AMI (2011-2017). Study groups based on support type were defined: (1) employed partner (served as the reference group); (2) unemployed partner; (3) no partner, family support; (4) institutional or benefit-dependent; and (5) non-kin support (caregiver). Ten-year all-cause mortality risk was assessed and compared between the groups. We identified 2652 AMI patients with recorded support type: mean age 67.6 (SD = 14) years, 66% male; 40% had no partner, followed by those with an unemployed partner (31%). Over the follow-up of (median) 7.6 years, 1471 patients died; significantly higher mortality rates were observed in patients without family support (67.9%) or receiving non-kin support (94.9%). Those with non-kin support were at the highest mortality risk, AdjHR = 2.20, 95% CI: 1.67-2.91, p < 0.001, as compared with the reference group. Subgroup analyses found women below age 75 years, Arab women, and those with higher functional status to be most vulnerable to mortality in the absence of family support. Lack of family support was associated with increased long-term mortality among AMI patients. Assessment of support status among AMI patients is integral for secondary prevention.

Subacute Cardiomyopathy Due to Statin Treatment: Can It Be True?-Case Report and Literature Review

Background and Clinical Significance: Statins are a widely used drug class associated with a plethora of muscular side effects ranging from the subclinical elevation of creatine kinase to fulminant rhabdomyolysis. Cardiac myopathy secondary to statin treatment is rare and was recently reported as a part of statin-induced necrotizing autoimmune myopathy (SINAM). Its occurrence outside of this context is still debated. Case Presentation: We present the case of a 60-year-old male who developed atorvastatin-induced rhabdomyolysis, without associated hydroxymethyl glutaryl coenzyme A reductase (HMGCR) antibodies, with clinical findings of cardiac failure and severe ECG anomalies. The symptoms slowly regressed with statin withdrawal, and the patient made a full recovery. We discuss the recently proposed statin-associated cardiomyopathy (SACM) and the possible mechanisms. We compare our case to the three other cases of statin-induced cardiac myositis found in the literature. Conclusions: We believe that in vulnerable patients, as was our case, statins can determine significant subacute cardiac toxicity. This would seem to occur in the context of severe skeletal muscle injury, probably due to higher metabolic resistance on the part of the myocardium. Also, the available evidence suggests myocardial involvement should be actively investigated in SINAM patients, preferably by cardiac MRI.

Copeptin in Acute Myocardial Infarction: Is There a Role in the Era of High-Sensitivity Troponins?

The quest for prompt and effective diagnosis of acute myocardial infarction (AMI) has been in the spotlight for decades. Ongoing research focuses on refined biomarker strategies for the early identification and disposition of patients with symptoms suggestive of AMI. Copeptin, a surrogate of the hormone arginine vasopressin, has emerged as a novel biomarker that could potentially aid in the diagnostic approach of patients with chest pain presenting to the emergency department. Observational studies have demonstrated that copeptin is upregulated in patients with AMI, although the exact pathophysiological mechanisms implicated in its release during myocardial ischemia remain unclear. Following these observations, copeptin was proposed as an adjunct to troponin in an effort to augment the diagnostic accuracy of conventional troponin assays. However, after the introduction of high-sensitivity troponin assays, the diagnostic utility of copeptin has been debated. This narrative review aims to elucidate plausible pathophysiological mechanisms involved in copeptin release during myocardial ischemia and to summarize the most recent evidence regarding its diagnostic potential in combination with high-sensitivity troponin assays.

Emerging Biomarkers and Electrochemical Biosensors for Early Detection of Premature Coronary Artery Disease

Coronary artery disease (CAD) is one of the primary causes of morbidity and death worldwide. Premature CAD (pCAD) is the term used to describe the 3-10% of CAD occurrences that occur in people under 45 worldwide. Diagnostic difficulties arise from the different risk factor profiles of pCAD and late-onset CAD. Better cardiovascular risk prediction in younger populations has been made possible by the development of biomarker detection tools. This can be applied to a diagnostic tool, including electrochemical biosensors, which have been predicted to be instrumental because of their adaptability for point-of-care applications for quicker diagnoses. These biosensors provide efficient, scalable, and reasonably priced solutions for the quick identification and tracking of CAD. Multiplex biomarker detection has been adopted as a viable approach for early diagnosis and risk assessment due to the constraints of using a single biomarker for pCAD diagnosis. Thus, this study looks at current developments in biosensing technology and discusses established and new cardiac biomarker panels for pCAD identification.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Current Insights into Pathophysiology, Diagnosis, and Management

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an increasingly recognized clinical entity characterized by myocardial injury in the absence of a significant coronary artery obstruction. MINOCA encompasses a diverse range of pathophysiological mechanisms, including coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, thromboembolism, and spontaneous coronary artery dissection. A systematic diagnostic approach is essential to identify the underlying etiology and guide appropriate management strategies. Advanced imaging techniques, particularly cardiac magnetic resonance, play a pivotal role in distinguishing ischemic from non-ischemic myocardial injury and refining prognosis. Despite growing awareness, standardized treatment protocols remain limited, with current management largely extrapolated from strategies used in obstructive coronary artery disease. Notably, MINOCA is significantly more prevalent in women, emphasizing the need to understand sex-related differences in its pathophysiology, presentation, and clinical outcomes. This narrative review offers a comprehensive and up-to-date overview of MINOCA, including a dedicated chapter on sex-related considerations. It integrates recent advancements and highlights the importance of personalized management strategies.

Motion-unrestricted dynamic electrocardiogram system utilizing imperceptible electronics

Electrocardiogram (ECG) plays a vital role in the prevention, diagnosis, and prognosis of cardiovascular diseases (CVDs). However, the lack of a user-friendly and accurate long-term dynamic electrocardiogram (DCG) device in motion has made it challenging to perform many daily cardiovascular risk screenings and assessments, such as sudden cardiac arrest, resulting in additional economic burdens on society. Here, we present a motion-unrestricted dynamic electrocardiogram (MU-DCG) system, which employs skin-conformal, imperceptible electronics for long-term, comfortable, and accurate 12-lead DCG monitoring. To facilitate assembly for use on the skin, the MU-DCG system features a pressure-activated flexible skin socket for stably soft-connecting the on-skin soft module and the off-skin stiff module during dynamic movements. Crucially, blinded cardiologist evaluations confirm minimal motion artifacts in MU-DCG-acquired ECG signals. Our results demonstrate that the MU-DCG system, with large-area, ultra-thin on-skin electrodes/leads, and an off-skin module, accomplishes anti-motion interference acquisition and in-situ analysis while retaining wearing imperceptibility.

Effectiveness of a Simplified Checklist to Overcome the Inertia of Treatment Implementation in ACS Patients with High Comorbidity Burden

Background/Objective: High-risk subsets of patients with acute coronary syndrome (ACS) experience decreased access to optimal care and have poor clinical outcomes, reflecting an inertia to the delivery of guideline-directed and evidence-based therapy and implementation of critical care pathways. We aim to investigate the clinical effectiveness of a simplified implementation checklist to counter treatment inertia in patients with high comorbidity burden. Methods: An ACS critical care pathway was simplified and reduced to a minimalistic checklist including only items on GDMT and invasive strategy. A total of 2005 consecutive patients with ACS were evaluated including 1499 patients receiving standard care and 506 patients managed with the checklist. Patients with STEMI undergoing primary percutaneous coronary interventions and patients receiving upfront cardiovascular intensive care were excluded. Multivariate regression spline models were used to study the relationship between comorbidity, expressed as the Charlson Comorbidity Index (CCI) and a management strategy including guideline-directed medical therapy (GDMT) and an early invasive approach. Inverse probability of treatment weighting (IPTW) was used to address confounding factors. The use of GDMT and early invasive therapy were compared in patients receiving standard care and checklists. The 90-day composite outcome of all-cause mortality, recurrent ACS and stroke were compared between patients receiving standard care and those receiving checklists. Results: High CCI was associated with decreased GDMT, invasive strategy and the utilization of critical care pathway. Checklist utilization was unaffected by high CCI and led to sustained and higher use of GDMT and invasive approach in patients despite high CCI. Checklist managed patients have >10% higher rates of prescription of each class of GDMT (p < 0.0001) and more than twice the rate of early invasive approach (51.0% vs. 20.7%, (p < 0.0001) compared to patients receiving standard care. The 90-day composite outcome was lower in checklist management patients compared to patients receiving standard care, adjusted hazard ratio 0.61 (95% CI 0.46-0.81), log-rank p = 0.0006, especially in patients with high CCI, adjusted hazard ratio 0.60 (95% CI 0.38-0.97), log-rank p = 0.035 for CCI 5-6; adjusted hazard ratio 0.53 (95% CI 0.35-0.84), log-rank p = 0.0057 for CCI 7 or more. Conclusions: The use of a simplified checklist is associated with better implementation of GDMT and invasive strategy as well as better 90-day clinical outcomes in ACS patients with high comorbidity burden.

Lipoprotein(a) Levels and Adverse Outcomes in Heart Failure

BACKGROUND

Although lipoprotein(a) [Lp(a)] level elevation is associated with new-onset heart failure (HF), it is unclear if elevated Lp(a) levels predict cardiovascular events in patients with chronic HF. Thus, we examined the association between Lp(a) levels and adverse cardiovascular outcomes in patients with HF.

METHODS AND RESULTS

A total of 1088 patients with HF undergoing cardiac catheterization at Emory-affiliated hospitals from 2004 to 2022 were divided into low (<30 mg/dL), intermediate (30-49 mg/dL), and high (≥50 mg/dL) Lp(a) groups. The primary outcome was the composite of cardiovascular death and HF hospitalization. Outcomes were assessed by Lp(a) group with competing risk modeling accounting for noncardiovascular death after adjustment for demographics, traditional cardiovascular risk factors, ejection fraction, ischemic HF etiology, and N-terminal prohormone of brain natriuretic peptide. Sensitivity analyses were performed to explore for heterogeneity of effect. The median age was 67 years, 34% were women, 18% were Black, 74% had ischemic HF, and 60% had an ejection fraction of ≤40%. During a median follow-up time of 4.3 years, 474 composite events (44%) occurred. When compared with participants with Lp(a) <30 mg/dL after multivariable adjustment, those with Lp(a) 30-49 mg/dL (subdistribution hazard ratio [sHR] 1.35, 95% confidence interval 1.04-1.76, P = .025) and Lp(a) ≥50 mg/dL (sHR 1.38, 95% confidence interval 1.11-1.72, P = .004) had a significantly higher risk of cardiovascular death or HF hospitalization. This relationship seemed to diminish over time and was nominally stronger in those with ischemic versus nonischemic HF (Pinteraction = .06), but did not meet significance after adjustment for multiple hypothesis testing.

CONCLUSIONS

In patients with HF, Lp(a) ≥30 mg/dL independently predicts the risk of cardiovascular death or HF hospitalization.

ST-Segment Elevation Myocardial Infarction Following Left Internal Thoracic Artery-to-Coronary Bypass Secondary to Arterial Steal Phenomenon

BACKGROUND

In the post-left internal thoracic artery (LITA)-to-coronary artery bypass graft (CABG) setting, anginal symptoms are associated with the presence of large, unligated LITA side branches. These symptoms are mediated by a variable arterial steal phenomenon.

CASE SUMMARY

This report describes an atypical case of ST-segment elevation myocardial infarction (STEMI) following LITA-CABG secondary to a variable arterial steal phenomenon induced by both a branch variant of the LITA and an intercostal artery. Angiography-guided embolization of the branch vessels successfully resolved the patient's ischemia.

DISCUSSION

STEMI secondary to LITA branch-mediated steal has not been previously reported. This case demonstrates that large LITA side branches can lead to myocardial infarction and that embolization of the relevant side branches is an effective treatment strategy.

TAKE-HOME MESSAGES

Providers should be aware that LITA side branches, if not ligated during surgery, may lead to threatening coronary ischemia. If such side branches cannot be ligated intraoperatively, then intravascular embolization is an effective treatment strategy.

Association between mild renal insufficiency, inflammatory status on initial admission, and 1-year mortality following ST-segment elevation myocardial infarction

The systemic inflammation tends to increase progressively as kidney function deteriorates. However, it remains unknown whether mild renal insufficiency affects inflammatory response at admission and subsequent clinical outcomes following ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate the joint, interactive, and mediating effects of estimated glomerular filtration rate (eGFR) and neutrophil-lymphocyte ratio (NLR) at admission on 1-year mortality in STEMI patients. Data were collected from 5,594 consecutive STEMI patients at seven centers (NCT04996901). Mildly reduced eGFR (60-89 mL/min/1.73m2) was associated with both elevated NLR and increased 1-year mortality (β 0.55, 95%CI [0.07-1.02], P = 0.024; HR 2.18, 95%CI [1.55-3.08], P < 0.001; respectively). Inflammation at admission mediated a small but significant proportion of the association between mildly reduced eGFR and mortality risk (1.7%, P = 0.030). Incorporating eGFR and NLR into a predictive model significantly improved mortality prediction following STEMI compared with clinical risk factors alone (C-index, 0.799 vs. 0.730, P < 0.001; net reclassification index 0.334, P < 0.001). These findings support the identification of patients at risk who may benefit from intensive kidney function monitoring and early adjuvant intervention, while also highlighting the need for developing anti-inflammatory therapies for STEMI patients with renal insufficiency.

ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review

The traditional management of acute coronary syndrome has relied on the identification of ST-segment elevation myocardial infarction (STEMI) as a proxy of acute coronary occlusion. This conflation of STEMI with acute coronary occlusion has historically overshadowed non-ST-segment elevation myocardial infarction (NSTEMI), despite evidence suggesting 25% to 34% of NSTEMI cases may also include acute coronary occlusion. Current limitations in the STEMI/NSTEMI binary framework underscore the need for a revised approach to chest pain and acute coronary syndrome management. The emerging paradigm distinguishing occlusion myocardial infarction from nonocclusion myocardial infarction (NOMI) seeks to enhance diagnostic accuracy and prognostic effect in acute coronary syndrome care. This approach not only emphasizes the urgency of reperfusion therapy for high-risk ECG patterns not covered by current STEMI criteria, but also emphasizes the broader transition from viewing acute coronary syndrome as a disease defined by the ECG to a disease defined by its underlying pathology, for which the ECG is an important but insufficient surrogate test. This report outlines the emerging occlusion myocardial infarction paradigm, detailing specific ECG patterns linked to acute coronary occlusion, and proposes a new framework that could enhance triage accuracy and treatment strategies for acute coronary syndrome. Although further validation is required, the occlusion myocardial infarction pathway holds promise for earlier acute coronary occlusion detection, timely cath lab activation, and improved myocardial salvage-offering potentially significant implications for both clinical practice and future research in acute coronary syndrome management.

Effect of Disclosing a Polygenic Risk Score for Coronary Heart Disease on Adverse Cardiovascular Events

BACKGROUND

In the Myocardial Infarction Genes clinical trial (URL: https://www.clinicaltrials.gov; Unique identifier: NCT01936675), participants at intermediate risk of coronary heart disease (CHD) were randomized to receive a Framingham risk score (Framingham risk score group, n=103) or an integrated risk score (integrated risk score group [IRSg], n=104) that additionally included a polygenic risk score. After 6 months, IRSg participants had higher statin initiation and lower low-density lipoprotein cholesterol. We conducted a post hoc 10-year follow-up analysis to investigate whether disclosure of a polygenic risk score for CHD was associated with a reduction in major adverse cardiovascular events (MACE).

METHODS

Participants were followed from randomization in October 2013 to September 2023 to ascertain MACE, testing for CHD, and changes in risk factors. The primary outcome was time to first MACE, defined as cardiovascular death, nonfatal myocardial infarction, coronary revascularization, and nonfatal stroke. Statistical analyses included Cox proportional hazards regression and linear mixed-effects models.

RESULTS

We followed all participants who completed the trial, 100 in Framingham risk score group and 103 in IRSg (mean age at the end of follow-up, 68.2±5.2; 48% male). During a median follow-up of 9.5 years, 9 MACEs occurred in Framingham risk score group and 2 in IRSg (hazard ratio, 0.20 [95% CI, 0.04-0.94]; P=0.042). In Framingham risk score group, 47 (47%) underwent at least 1 diagnostic test for CHD, compared with 30 (29%) in IRSg (hazard ratio, 0.51 [95% CI, 0.32-0.81]; P=0.004). A higher proportion of IRSg participants were on statin therapy during the first 4 years postrandomization and had a greater reduction in low-density lipoprotein cholesterol for up to 3 years postrandomization. No significant differences were observed between 2 groups in other traditional cardiovascular risk factors during follow-up.

CONCLUSIONS

Disclosure of an integrated risk score that included a polygenic risk score to individuals at intermediate risk for CHD was associated with lower MACE incidence after 10 years, likely due to higher statin initiation, leading to lower low-density lipoprotein cholesterol levels.

Cardiac fibroblast-derived mitochondria-enriched sEVs regulate tissue inflammation and ventricular remodeling post-myocardial infarction through NLRP3 pathway

Resident cardiac fibroblasts (CFs) play crucial roles in sensing injury signals and regulating inflammatory responses post-myocardial infarction (MI). Damaged mitochondria can be transferred extracellularly via various mechanisms, including extracellular vesicles (EVs). In this study, we aimed to investigate whether CFs could transfer damaged mitochondrial components via small EVs (sEVs) and elucidate their role in regulating inflammatory responses post-MI. Left anterior descending coronary artery ligation was performed in mice. Mitochondrial components in sEVs were detected using nanoflow cytometry. Differential protein expression in sEVs from normoxia and normoglycemia CFs (CFs-Nor-sEVs) and CFs post oxygen-glucose deprivation (CFs-OGD-sEVs) was identified using label-free proteomics. CFs-sEVs were co-cultured with mouse bone marrow-derived macrophages (BMDMs) to assess macrophage inflammatory responses. Effects of intramyocardial injection of CFs-sEVs were assessed in MI mice in the absence or presence of NLRP3 inhibitor CY-09. Results demonstrated that mitochondrial components were detected in CFs-derived sEVs post-MI. Damaged mitochondrial components were enriched in CFs-OGD-sEVs (CFs-mt-sEVs), which promoted pro-inflammatory phenotype activation of BMDMs in vitro. Myocardial injection of CFs-mt-sEVs enhanced tissue inflammation, aggravated cardiac dysfunction, and exacerbated maladaptive ventricular remodeling post-MI in vivo. Mechanistically, above effects were achieved via activation of NLRP3 and above effects could be reversed by NLRP3 inhibitor CY-09. This study indicates that CFs could transfer damaged mitochondrial components via the sEVs post-MI, promote macrophage inflammatory activation and exacerbate maladaptive ventricular remodeling post MI by activating NLRP3. Our findings highlight the potential therapeutic effects of inhibiting CFs-mt-sEVs and NLRP3 to improve cardiac function and attenuate ventricular remodeling post-MI.

Potential length of stay reductions from emergency department use of a point-of-care high-sensitivity cardiac troponin assay: Pilot findings from Australia's first cardiac emergency department

OBJECTIVE

To compare actual ED length of stay (LOS) using laboratory-based high-sensitivity cardiac troponin I (hs-cTnI) testing with the potential LOS that could result from using point-of-care (POC) hs-cTnI tests.

METHODS

Baseline hs-cTnI tests were performed on the same blood sample in the laboratory (Access hsTnI assay) and in the ED (Atellica VTLi POC assay). Actual and potential LOS were compared for patients who were discharged after having a baseline laboratory hs-cTnI test only. Total LOS incorporated time from arrival to blood sample collection, blood sampling to result availability and result availability to discharge. For potential LOS, the blood sampling to result availability time with POC use was fixed at 10 min (2-min preparation and 8-min test-processing). The laboratory blood sampling to result availability time was from blood sample collection to result uploading on the pathology computer system. For the study, it was assumed that this was the only LOS component that would differ with POC use. Invalid POC result rates were monitored.

RESULTS

For 152 patients discharged after having a single baseline laboratory hs-cTnI test, the median actual LOS was 195 (interquartile range [IQR]: 152-319) min, which included a median laboratory blood-sampling-to-result-availability time of 48 (IQR: 41-59) min. The potential LOS from POC use was 157 (IQR: 103-282) min, which included the fixed 10-min blood-sampling-to-result-availability time. The mean actual-potential LOS difference was 43 (95% confidence interval [CI]: 40-46) min. The POC invalid result rate was 11%.

CONCLUSION

The Atellica VTLi could deliver a mean ED LOS reduction of 43-min per patient for those discharged after a single baseline hs-cTnI test. Use in actual practice and the invalid result rate require further evaluation.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Prevalence and prognostic relevance of electrocardiographic abnormalities among patients with ANCA-associated vasculitis

OBJECTIVES

Current guidelines provide limited evidence for cardiovascular screening in ANCA-associated vasculitis (AAV). This study aimed to investigate the prevalence of ECG abnormalities and associations between no, minor or major ECG abnormalities with cardiovascular mortality in AAV patients compared with matched controls.

METHODS

Using a risk-set matched cohort design, patients diagnosed with granulomatosis with polyangiitis or microscopic polyangiitis with digital ECGs were identified from Danish registers from 2000 to 2021. Patients were matched 1:3 to controls without AAV on age, sex and year of ECG measurement. Associated hazards of cardiovascular mortality according to ECG abnormalities were assessed in Cox regression models adjusted for age, sex and comorbidities, with subsequent computation of 5-year risk of cardiovascular mortality standardized to the age- and sex-distribution of the sample.

RESULTS

A total of 1431 AAV patients were included (median age: 69 years, 52.3% male). Median follow-up was 4.8 years. AAV was associated with a higher prevalence of left ventricular hypertrophy (17.5% vs 12.5%), ST-T deviations (10.1% vs 7.1%), atrial fibrillation (9.6% vs 7.5%) and QTc prolongation (5.9% vs 3.6%). Only AAV patients with major ECG abnormalities demonstrated a significantly elevated risk of cardiovascular mortality [HR 1.99 (1.49-2.65)] compared with controls. This corresponded to a 5-year risk of cardiovascular mortality of 19.14% (16-22%) vs 9.41% (8-11%).

CONCLUSION

Patients with AAV demonstrated a higher prevalence of major ECG abnormalities than controls. Notably, major ECG abnormalities were associated with a significantly increased risk of cardiovascular mortality. These results advocate for the inclusion of ECG assessment into routine clinical care for AAV patients.

Multimorbidity Patterns and In-Hospital Outcomes in Chinese Young Women (Aged <55 Years) Presenting with ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Recent evidence highlights an increasing incidence of myocardial infarction in young women. Identifying clinical multimorbidity patterns in this population may improve therapeutic strategies and clinical care.

METHODS AND RESULTS

We identified multimorbidity patterns in 9570 young women with ST-segment-elevation myocardial infarction (median age, 50 years [range, 47.0-53.0 years]) admitted to the China Chest Pain Center Database between 2016 and 2021. Hierarchical clustering of 15 medical conditions was performed to derive multimorbidity patterns. The primary outcome was a composite of in-hospital adverse events. Associations between multimorbidity patterns and outcomes were evaluated using multivariable-adjusted logistic regression models. Among 9570 patients, 50% (n=4789) had multimorbidity. Six multimorbidity patterns were identified, including 4 specific patterns: (1) pattern 1, cerebrovascular cluster (histories of cerebrovascular disease and hypertension); (2) pattern 2, traditional cardiovascular disease risk factors cluster (histories of hyperlipidemia, obesity, and diabetes, and family history of cardiovascular disease and smoking); (3) pattern 3, coronary-heart failure cluster (histories of heart failure, coronary artery disease, peripheral arterial disease, and thyroid dysfunction); and (4) pattern 4, anemia-renal dysfunction cluster (histories of atrial fibrillation, anemia, chronic kidney disease, and peptic ulcer). Compared with patients without multimorbidity, those with pattern 1 (odds ratio [OR], 2.29 [95% CI, 1.49-3.52]), pattern 2 (OR, 1.52 [95% CI, 1.24-1.86]), and pattern 4 (OR, 2.25 [95% CI, 1.10-4.61]) exhibited higher risks for composite outcomes.

CONCLUSIONS

Specific multimorbidity patterns in young women with ST-segment-elevation myocardial infarction were associated with distinct in-hospital outcomes in a nationwide registry, providing proof-of-concept evidence to guide future therapeutic approaches.

Neutrophil to platelet ratio predicts in-hospital mortality in patients with acute myocardial infarction

Acute myocardial infarction (AMI) is a critical medical emergency worldwide and a leading cause of mortality. This study aims to investigate the predictive utility of the neutrophil-to-platelet ratio (NPR) in identifying AMI patients at an increased risk of in-hospital mortality. We enrolled 664 patients, including 421 with ST-elevation myocardial infarction (STEMI) and 243 with non-ST-elevation myocardial infarction (NSTEMI), at Zhongshan Hospital, Fudan University, from January 2020 to September 2023. NPR was calculated as the neutrophil count divided by the platelet count. The primary outcome was defined as in-hospital mortality. The overall in-hospital mortality among AMI patients was 6.78%. Mortality was notably higher in the high NPR group compared to the low NPR group. Univariate analysis identified several variables significantly associated with in-hospital mortality, including age, left ventricular ejection fraction (LVEF), neutrophil-to-lymphocyte ratio (NLR), and NPR. NPR demonstrated a strong independent association with in-hospital mortality following adjustment for potential confounders. Receiver operating characteristic (ROC) curve analyses were performed to assess the discriminative power of NPR and NLR in predicting in-hospital mortality. NPR exhibited an area under the curve (AUC) of 0.755 (95% CI, 0.682-0.829, p < 0.001), indicating good discriminative ability. Similarly, NLR showed a discriminative AUC of 0.674 (95% CI, 0.586-0.762, p < 0.001). The optimal cutoff values for predicting mortality were determined as 0.042 for NPR (sensitivity 80%, specificity 62.2%) and 8.02 for NLR (sensitivity 62.2%, specificity 67.5%). Bootstrap validation with 1000 iterations confirmed the robustness of these findings, with validated AUCs of 0.755 (95% CI, 0.681-0.826) for NPR and 0.674 (95% CI, 0.587-0.766) for NLR. This study identifies NPR as an independent and valuable predictor of in-hospital mortality among AMI patients, The findings underscore NPR's potential utility in clinical practice for risk stratification and early intervention strategies aimed at reducing mortality rates in this high-risk patient population.

Altered fibrin clot properties and elevated von Willebrand factor are associated with progression to permanent atrial fibrillation: A cohort study

BACKGROUND

The role of a prothrombotic state in atrial fibrillation (AF) progression to permanent arrythmia (PerAF) is unclear. Formation of denser and poorly lysable fibrin clots has been observed in AF patients also with sinus rhythm in association with higher stroke risk. We investigated whether altered fibrin clot properties and other prothrombotic state markers may contribute to AF transition to PerAF.

METHODS

In the cohort study, in 226 anticoagulated patients (median age 69 years, median CHA2DS2-VASc of 3) with paroxysmal (n = 83, 36.7%) or persistent (n = 143, 63.3%) AF, we assessed at baseline plasma clot permeability (Ks), clot lysis time (CLT), proteins involved in fibrinolysis and von Willebrand factor (vWF) antigen. We recorded patients with PerAF during a median follow-up of 58 months.

RESULTS

During follow-up, PerAF was documented in 62 (27.4%, 5.7%/year) subjects, who had higher prevalence of heart failure, higher body mass index and longer history of arrhythmia. AF transition to PerAF was associated with 25.7% longer CLT in relation to 21.3% higher plasminogen activator inhibitor type 1, and 29% higher vWF compared to the remainder, with no differences in Ks, plasminogen or α2-antiplasmin. By multivariable analysis, CLT (per 10 min, odds ratio [OR] 2.734, 95% confidence interval [CI] 1.788-4.180, p < .001), vWF (per 10%, OR 1.352, 95% CI 1.145-1.596, p < .001) and heart failure (OR 2.637, 95% CI 1.008-6.900, p = .048) were associated with progression to PerAF.

CONCLUSION

Suppressed fibrin clot susceptibility to lysis and elevated vWF could contribute to progression to PerAF despite anticoagulation, which suggests links between blood coagulation and AF progression.

Comparison of Pulmonary Outcome in Minimally Invasive (TCRAT) and Full Sternotomy CABG

BACKGROUND

 Pulmonary complications are among the main causes of increased mortality, and morbidity, as well as prolonged intensive care unit (ICU) and hospital stay after cardiac surgery. Recently, a sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced. A higher risk of pulmonary injury could be anticipated due to the thoracic incision and the longer duration of surgery. Pulmonary complications in TCRAT were compared to standard coronary artery bypass grafting (CABG) via full median sternotomy (FS).

METHODS

 Records of 151 consecutive TCRAT (from September 2021 to November 2022) and 229 consecutive FS patients (from January 2017 to December 2018) patients, who underwent elective or urgent CABG, were analyzed. Preoperative baseline characteristics (age, sex, body mass index, diabetes, hypertension, chronic obstructive pulmonary disease, smoking status, left ventricular ejection fraction, pulmonary hypertonus, and EuroScore II) were comparable between groups.

RESULTS

 Differences between examined groups examined were found for the pulmonary parameters: Horowitz index 6 hours after operation (TCRAT 270 ± 72 vs. FS 293 ± 73, p < 0.05), pneumothorax (TCRAT 0% vs. FS 2.6%, p < 0.05), bronchoscopies (TCRAT 5.9% vs. FS 1.7%, p < 0.05), and pleural effusion (TCRAT 8.6% vs. FS 3.5%, p < 0.05). Moreover, there were differences between groups with regard to mean ICU stay (TCRAT 2.4 ± 3.0 days vs. FS 1.8 ± 1.8 days, p < 0.05), stroke (TCRAT 0% vs. FS 1.3%, p < 0.05), and hospital stay (TCRAT 10.9 ± 8.5 days vs. FS 13.2 ± 9.3 days, p < 0.05). There were no differences regarding atelectasis, reintubations, tracheostomies, ventilation time, and mortality.

CONCLUSION

 Pulmonary complications in terms of pleural effusions were more common with TCRAT, however, without substantial impact on clinical outcome.

Temporal trends and outcomes of rotational atherectomy: A single-centre experience

INTRODUCTION AND OBJECTIVES

Rotational atherectomy (RA) is widely used for the management of calcified coronary stenoses. However, there is limited data on its use, trends, and outcomes. We sought to report our twelve-year experience with RA and explore the trends and outcomes of percutaneous coronary intervention (PCI) with this device.

METHODS

Our institutional PCI database was queried to identify all cases of RA-PCI performed between January 2009 and December 2020. We analysed peri-procedural outcomes and major adverse cardiovascular events (MACE) during follow-up: cardiovascular death, myocardial infarction, and target lesion revascularization.

RESULTS

Four hundred ten procedures (2.8% of total PCI volume) in 388 patients were included. Mean age was 72.3±9.3 years, 74.0% were male, 53.6% had diabetes, and 33.8% presented with acute coronary syndrome. There was a significant increase in median SYNTAX score (ptrend=0.003) and the proportion of type B2/C lesions (ptrend=0.003). Transradial access was preferred (60.0% overall) with a growing trend over time (ptrend=0.003). Maximum burr size was <1.75 mm in 88.0% of cases (burr-to-artery ratio of 0.49±0.07). Angiographic success rate was consistently high (96.6% overall). Complications were recorded in 9.0% of procedures, with a temporal decline (ptrend=0.029). Clinical follow-up was available for 357 patients (median time of 40 months). At one year, MACE rate was 12.1% with no significant temporal changes.

CONCLUSIONS

RA-PCI was a safe and effective procedure with a high rate of angiographic success and few complications, particularly in recent years, in line with significant technical improvements. The MACE incidence is acceptable considering the clinical risk and angiographic complexity.

The Role of IVUS in Coronary Complications

Intravascular ultrasound (IVUS) is an essential tool in the diagnostic and therapeutic management of coronary artery disease. In daily practice, IVUS is particularly useful for plaque characterization, optimizing stent implantation, and identifying the cause of in-stent restenosis. In acute coronary syndromes, it helps to detect culprit lesions that are not clearly visible on angiography and plays a key role in the diagnostic algorithm for myocardial infarction with non-obstructive coronary arteries (MINOCA). Additionally, IVUS is frequently used in complex and calcified lesions to guide optimal plaque modification strategies and improve procedural and long term outcomes. Beyond these common applications, IVUS is crucial in managing coronary complications, such as coronary dissection, perforation, intramural hematoma, and side-branch occlusion. In these challenging cases, IVUS allows us to overcome some of the limitations of angiography. This review explores the role of IVUS in bail out situations, offering practical tips and techniques for navigating coronary complications and improving procedural success in a safer and more refined manner.

Intracoronary stenting and additional results achieved by shockWAVE coronary lithotripsy: design and rationale of ISAR-WAVE trial

BACKGROUND

Percutaneous coronary intervention of severely calcified lesions is limited by inadequate stent expansion and poor clinical outcomes. Over the past decade, several devices and techniques have been developed for calcium modification and lesion preparation. Intravascular lithotripsy (IVL) is a novel tool in this context. Although numerous observational studies have been reported on this technique, randomized trials powered for clinical outcomes on the relative merits of IVL in patients with severely calcified lesions are lacking.

STUDY DESIGN AND OBJECTIVES

The ISAR-WAVE trial is a multicenter, prospective, randomized, single-blind controlled trial. The aim is to test whether IVL is superior to other calcium-modifying techniques (modified or super high-pressure balloon and atheroablative devices) in de novo severely calcified coronary lesions. The study is planned to enroll 666 patients. The primary endpoint is the composite of major cardiac and cerebrovascular adverse events defined as death, nonfatal myocardial infarction, nonfatal stroke and clinically indicated target vessel revascularization at 12 months. In addition to the individual components of the primary endpoint, secondary endpoints include also safety, quality of life and cost-effectiveness measures.

CONCLUSIONS

ISAR-WAVE is a multicenter, randomized trial designed to test the hypothesis that a strategy of IVL confers superior clinical performance compared to other calcium-modifying techniques in patients undergoing percutaneous intervention for a de novo severely calcified coronary artery lesion.

TRIAL REGISTRATION

ClilicalTrial.gov, NCT06369142.

PATCH (Preferred Attachment Strategy for Optimal Electrocardiograms)-1 Study

12-Lead electrocardiography (ECG) is among the most frequently performed tests in medical practice. Despite its pivotal role in diagnostic and treatment decisions, baseline artifacts and errors in lead placement are common. The PATCH (Preferred Attachment Strategy for Optimal Electrocardiograms)-1 study enrolled patients with stable cardiovascular disease and a clinical indication for an ECG. Each participant underwent both a standard (S) 12-lead ECG and a patch (P) ECG (EKG-Patch™) during one routine ambulatory clinic visit. The P-ECG has an all-in-one design with built-in lead wires attached to pre-positioned electrodes. An experienced clinical research coordinator performed all ECGs. Each was interpreted by an experienced cardiologist blinded to the method of ECG. A total of 200 participants (67.4 ± 14.9 years; range: 21-95 years) (women 44%) had P- and S-ECGs. Common clinical indications included coronary artery disease (40.5%), essential hypertension (14.0%), heart failure (10.5%), atrial fibrillation (10.0%) and valvular heart disease (6.5%). Many participants had more than one indication. The P-ECG provided a tracing in 1.4 ± 0.5 min compared to 2.4 ± 0.5 min with the S-ECG (p < 0.001). Most participants either preferred the P-ECG (47%) or did not have a preference (52%). Baseline artifacts that impacted interpretability were detected in 13 (6.5%) P-ECGs and 30 (15.0%) S-ECGs (p = 0.006). Heart rhythm, rate, conduction, axis, intervals (PR, QRS, QT, and QTc) and ST-T wave findings did not differ between P-and S-ECGs. In conclusion, the P-ECG was preferred among participants, had fewer baseline artifacts than the S-ECG, and provided a rapid and reproducible ECG in patients with stable cardiovascular disease in an ambulatory clinic setting.

Spatial FAP Expression as Detected by 68 Ga-FAPI-46 Identifies Myofibroblasts Beyond the Infarct Scar After Reperfusion

PURPOSE

Myocardial infarction (MI) triggers complex cellular responses essential for tissue repair and remodeling, including myofibroblast activation. Fibroblast activation protein alpha (FAP) identifies activated myofibroblasts post-MI, however its spatial distribution relative to the scar and area at risk (AAR) is unclear. Non-invasive FAP-imaging with PET radiotracer 68 Ga-FAPI-46 shows uptake beyond the infarct scar. We therefore aimed to characterize FAP expression in the AAR using a myocardial ischemia-reperfusion (MI/R) model in mice.

PROCEDURES

We induced MI/R in male C57BL/6N mice. The AAR was identified by in vivo lectin staining, and expression of FAP, CD68, and hypoxic tissues were measured using immunohistochemistry. Spatial FAP was further interrogated by 68 Ga-FAPI-46 in mice by autoradiography and humans by PET. Additionally, human cardiac tissues from acute MI patients were examined for fibroblasts and inflammatory cells by expression of FAP, CD13, and α-smooth muscle actin.

RESULTS

FAP expression peaked three days post-MI/R predominantly within the AAR (p < 0.05 vs. d0). Consistent between murine models and human tissues, FAP+ myofibroblasts accumulated within the infarct scar and borderzone, occasionally extending into non-ischemic myocardium. CD68+ macrophages peaked similarly at three days post-MI/R (p < 0.05 vs. d0). FAP expression weakly correlated with CD68 but not with extent of ischemic or hypoxic territory post-MI/R. FAP imaging in mice and humans revealed aligned non-uniform 68 Ga-FAPI-46 uptake extending from the infarct scar into surviving myocardium after MI.

CONCLUSIONS

Our findings demonstrate a distinct FAP expression pattern post-MI/R. The alignment of ex vivo 68 Ga-FAPI-46 signal with myofibroblasts in the AAR supports its identification of a unique substrate in myocardial injury complementing other non-invasive imaging measurements of perfusion, viability and fibrosis.

Long-term cardiovascular outcomes after percutaneous coronary intervention in patients with systemic sclerosis

Background

Recent data have shown that systemic sclerosis (SSc) is a significant risk factor for coronary artery disease (CAD) and poorer cardiovascular outcomes in the setting of acute coronary syndrome. However, the morphological characteristics of CAD and the long-term cardiovascular outcomes in patients with concurrent SSc and CAD remain unclear.

Methods

We retrospectively investigated 3,300 patients with CAD who underwent percutaneous coronary intervention (PCI) without prior myocardial infarction or coronary artery revascularization. Laboratory, echocardiographic and angiographic characteristics, and clinical outcomes were compared between patients with and without SSc according to a 1:3 propensity score-matching analysis adjusted for patient demographics and comorbidities. The primary outcome was a composite of cardiac death, myocardial infarction, and stroke, and the secondary outcome was a composite of the primary outcome and heart failure hospitalization.

Results

Among all 3,300 patients, 17 (0.5 %) had SSc. The patients were classified into an SSc group (n = 17) and non-SSc group (n = 51) by propensity score matching. There were no significant differences in laboratory or echocardiographic parameters between the two groups. However, CAD tended to be more complex in the SSc group because of the higher proportion of left main trunk lesions (p = 0.100) and higher SYNergy between PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score (p = 0.030). During a median follow-up of 3.1 years, patients with SSc more frequently experienced primary and secondary outcomes than those without SSc (both log-rank p < 0.02).

Conclusions

Among patients with CAD, long-term cardiovascular outcomes after PCI were poorer in those with than without SSc.

Polygenic Risk Scores in Myocardial Injury After Noncardiac Surgery: A VISION Substudy

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) is the most prevalent vascular complication following surgical procedures. Although the revised cardiac risk index (RCRI) is widely used to predict postoperative cardiovascular complications, its predictive accuracy is suboptimal.

OBJECTIVES

Considering genetic influences may improve risk prediction. The authors propose integrating polygenic risk scores (PRS) with the RCRI to enhance MINS prediction. Identification of PRS associated with MINS could provide pathophysiological insights.

METHODS

This is a case-control study nested within the Vascular Events in Noncardiac Surgery Participants Cohort Evaluation cohort, including patients aged 45 and above who underwent noncardiac surgery. Daily troponin levels were measured preoperatively and on days 1, 2, and 3 postoperatively. PRS was computed for MINS risk factors using publicly available summary statistics. Logistic regression models were used to assess the association between each PRS and MINS. PRS discrimination was assessed independently and in combination with RCRI.

RESULTS

A total of 253 MINS cases were matched with 253 controls, adjusted for age, sex, and limited to individuals of European ancestry (ntotal = 506). The type II diabetes (T2D) PRS (OR: 1.26; 95% CI: 1.00-1.58; P = 0.047) and the HbA1c PRS (OR: 1.26; 95% CI: 1.03-1.54; P = 0.026) were associated with MINS. No other PRS, including those for coronary artery disease, stroke, and lipid biomarkers, showed significant associations.

CONCLUSIONS

The T2D PRS and the HbA1c PRS were associated with an increased risk of MINS. The findings may reflect the multifactorial pathophysiology of MINS. Larger genetic studies and trials evaluating perioperative glucose management warrant consideration.