2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Do We Still Need Aspirin in Coronary Artery Disease?

Aspirin has for some time been used as a first-line treatment for acute coronary syndromes, including ST-elevation myocardial infarction, for secondary prevention of established coronary disease, and for primary prevention in patients at risk of coronary artery disease. Although aspirin has been in use for decades, the available evidence for its efficacy largely predates the introduction of other drugs, such as statins and P2Y12 inhibitors. Based on recent trials, the recommendation for aspirin use as primary prevention has been downgraded. In addition, P2Y12 inhibitors given as a single antiplatelet therapy have been associated with a lower incidence of bleeding than dual antiplatelet therapy in combination with aspirin in patients with stable and unstable coronary artery disease. The aim of this review is to discuss the role of aspirin considering the available evidence for primary prevention, secondary prevention for stable coronary artery disease or acute coronary syndromes, and after percutaneous coronary intervention or coronary artery bypass revascularization.

β1-adrenergic receptor polymorphisms: a possible genetic predictor of bisoprolol response in acute coronary syndrome

Aim

To investigate the association between beta1-adrenergic receptor (ADRB1) polymorphisms and response to bisoprolol treatment in beta-blocker naive patients with acute coronary syndrome (ACS).

Patients & methods

Seventy-seven patients received bisoprolol for four weeks. Blood pressure and heart rate were measured at baseline and during treatment. TaqMan allelic discrimination method was utilized for ADRB1 Ser49Gly and Arg389Gly genotyping.

Results

Arg389Arg carriers showed greater reductions in systolic and diastolic blood pressure (-8.5% ± 7.8% vs -0.76% ± 8.7%, p = 0.000218), and (-9.5% ± 9.7% vs -0.80% ± 11.5%, p = 0.000149), respectively, compared with Gly389 carriers. No statistical difference was found for study's outcomes based on codon 49.

Conclusion

Arg389Gly polymorphism is a promising bisoprolol response predictor in ACS patients.

The prediction value of platelet-derived growth factor for major adverse cardiovascular events in patients with acute non-ST-segment elevation myocardial infarction

BACKGROUND

The value of plasma Platelet-Derived Growth Factor (PDGF) as a biomarker in predicting major adverse cardiovascular events (MACEs) in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear.

METHODS

A total of 242 patients with NSTEMI were enrolled in this observational cohort study. The correlation between PDGF and MACEs was evaluated during a five-year follow-up. Kaplan-Meier survival analysis with Cox proportional-hazards regression was used to identify predictive values of PDGF.

RESULTS

The mean follow-up of NSTEMI patients was 1334 days. It was found that as the PDGF level increased, a significant uptrend in the incidence of MACEs and all-cause death, including the MACEs of 30 days, 180 days, 1 year, 5 years and the death of 1 year and 5 years (All Log-rank p < .05). Subgroup analysis further showed that PDGF had better predictive value for patients with age >65 years, GRACE score ≥140 and platelet count (PLT) >200 × 109/L.

CONCLUSION

PDGF levels can predict short-term and long-term MACEs in NSTEMI patients after discharge, especially for patients with older age, higher GRACE score and baseline PLT > 200 × 109/L.Key messagesPDGF is a risk factor for short- and long-term MACEs in patients with STEMI.PDGF has a better prognostic value in patients with older age and PLT > 200 × 109/L.Baseline plasma PDGF levels were positively correlated with GRACE score.

Iodixanol-associated acute kidney injury and prognosis in patients undergoing elective percutaneous coronary intervention: a prospective, multi-center study

OBJECTIVE

To evaluate iodixanol-associated acute kidney injury (AKI) and prognosis in patients undergoing elective percutaneous coronary intervention (PCI).

METHODS

Patients undergoing elective PCI and iodixanol administration were prospectively enrolled in 8 centers between May 2020 and November 2021. The primary endpoint was AKI, defined as an increase in SCr of ≥ 0.3 mg/dL (26.4 μmol/L) or relative elevation ≥ 50% from baseline in the 48-72 h after PCI. Prognosis evaluations included the major adverse renal and cardiovascular events (MARCE): all-cause mortality, new-onset renal replacement therapy (NRRT), non-fatal myocardial infarction, and non-fatal stroke. AKI predictors were identified using multivariable logistic regression and associations between AKI and outcomes were examined using Cox regression.

RESULTS

A total of 3630 patients were included in the final analysis and 2.9% of patients (107/3,630) suffered AKI. Among them, 95.3% (102/107) of AKI were stage 1, and 4.6% (5/107) of stage 2. The multivariable analysis indicated that age over 75-year-old, diabetes, NT-pro-BNP > 300 pg/mL, hemoglobin < 110 g/L, eGFR < 60 mL/min/1.73m2, and diuretics were independently associated with AKI (p < 0.05). After a median follow-up of 13 months, MARCE occurred in 3.6% (131/3630) of the study population, and their incidence was higher in AKI (9.4%, 10/107) vs. non-AKI patients (3.4%, 121/3,523). However, after multivariable adjustment, there was no statistically significant association between AKI and MARCE (p = 0.382).

CONCLUSIONS

In patients undergoing elective PCI, cases of iodixanol-associated AKI were mostly mild and, after multivariable adjustment, held no statistically significant association with MARCE on mid-term follow-up.

CLINICAL RELEVANCE STATEMENT

The incidence of iodixanol-associated AKI was low and mainly limited to mild renal impairment in patients undergoing elective PCI. Physicians should provide adequate contrast for coronary artery evaluation and, at the same time, minimize the contrast volume.

KEY POINTS

• The incidence of iodixanol-associated acute kidney injury was low and mostly limited to mild renal impairment. • Iodixanol administration had no statistically significant impact on the major adverse renal and cardiovascular events in patients undergoing elective percutaneous coronary intervention.

Usefulness of post-systolic index in facilitating stratification of risk in patients with intermediate- or low-risk non-ST-segment elevation acute coronary syndrome

BACKGROUND

Although there is reportedly a usefulness of left ventricular global longitudinal strain (LV GLS) on 2D speckle-tracking echocardiography in excluding significant coronary artery disease (CAD) in suspected intermediate- or low-risk non-ST-segment elevation-acute coronary syndrome (NSTE-ACS), the efficacy of post-systolic index (PSI) in this context is yet unknown. Therefore, we explored the usefulness of PSI in facilitating stratification of risk in patients with intermediate- or low-risk NSTE-ACS.

METHODS AND RESULTS

We assessed 50 consecutive patients suspected of intermediate- or low-risk NSTE-ACS, and finally analyzed 43 patients whose echocardiographic images were suitable for strain analysis. All patients underwent CAG. Among the 43 analyzed patients, 26 had CAD, and 21 underwent percutaneous coronary intervention (PCI). Patients with CAD had higher PSI (25% [20.8-40.3%] vs 15% [8.0-27.5%], P = 0.007). Receiver-operator characteristic curve analysis identified that a PSI of > 20% detected performance of PCI (sensitivity 80.7%, specificity 70.6%, area under curve [AUC] 0.72, 95% confidence interval [CI] 0.57-0.88). Moreover, the AUC obtained using the GRACE risk score was 0.57 (95% CI 0.39-0.75), and increased to 0.75 (95% CI 0.60-0.90) when PSI and LV GLS were added. Thus, the addition of PSI and LV GLS improved the classification of performance of PCI (net reclassification improvement [95%CI] 0.09 [0.0024-0.18], P = 0.04).

CONCLUSIONS

Post-systolic index is a useful parameter that can facilitate stratification of risk in patients with intermediate- or low-risk NSTE-ACS. We recommend measuring PSI in routine clinical practice.

Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department

PURPOSE OF THE REVIEW

To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations.

RECENT FINDINGS

Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

Diabetes Mellitus in Acute Coronary Syndrome

The global prevalence of diabetes mellitus (DM) has led to a pandemic, with significant microvascular and macrovascular complications including coronary artery disease (CAD), which worsen clinical outcomes and cardiovascular prognosis. Patients with both acute coronary syndrome (ACS) and DM have worse prognosis and several pathophysiologic mechanisms have been implicated including, insulin resistance, hyperglycemia, endothelial dysfunction, platelet activation and aggregations as well as plaque characteristics and extent of coronary lesions. Therefore, regarding reperfusion strategies in the more complex anatomies coronary artery bypass surgery may be the preferred therapeutic strategy over percutaneous coronary intervention while both hyperglycemia and hypoglycemia should be avoided with closed monitoring of glycemic status during the acute phase of myocardial infraction. However, the best treatment strategy remains undefined. Non-insulin therapies, due to the low risk of hypoglycemia concurrently with the multifactorial CV protective effects, may be proved to be the best treatment option in the future. Nevertheless, evidence for the beneficial effects of glucagon like peptide-1 receptor agonists, dipeptidyl-peptidase 4 inhibitors and sodium glycose cotransporter 2 inhibitors, despite accumulating, is not robust and future randomized control trials may provide more definitive data.

Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study

AIMS

Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0- and 1-h algorithms are accepted as a rule-in/rule-out strategy, but there is a lack of validation in specific populations.

METHODS AND RESULTS

The IN-HOspital Program to systematizE Chest Pain Protocol (IN-HOPE study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0 h/3 h protocol, but, in addition, blood samples were also collected at 0 and 1 h and sent to a central laboratory (core lab) to measure high-sensitivity cardiac troponin T (hs-cTnT). To assess the theoretical performance of 0 h/1 h algorithm, troponin < 12 ng/L with a delta < 3 was considered rule-out while a value ≥ 52 or a delta ≥ 5 was considered a rule-in criterion (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0 h/3 h protocol, the accuracy of 0 h/1 h algorithm overall and in groups with a higher probability of AMI. All patients were followed up for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless of the indication of the test. A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of them with a HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless of clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3 h algorithms while 52.4% of the patients in the rule-in group (0 h/1 h) were considered as AMI by adjudication. In the observation group (grey zone) of 0 h/1 h algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value of <5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L, and 7.7% in the level ≥ 90 ng/L.

CONCLUSION

In this large multicentre study, a 0 h/1 h algorithm had the potential to classify as rule-in or rule-out in almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with value < 5 ng/L.

CLINICALTRIALS.GOV

NCT04756362.

Harmful effect of repetitive intravenous iodinated contrast media administration on the long-term renal function of patients with early gastric cancer

This retrospective study investigated whether repetitive exposure to intravenous iodinated contrast media (ICM) affects long-term renal function in patients who undergo curative surgery for early gastric cancer (EGC) collected from the Korean Health Insurance and Review Assessment (HIRA) database. Patients diagnosed with gastric cancer between January 2010 and December 2013 underwent regular computed tomography (CT) scans to monitor for extragastric recurrence. Patients who already had chronic kidney disease (CKD) before cancer diagnosis or had undergone chemotherapy or repeated surgery were excluded. A nested case-control study design was chosen to analyze the effect of repetitive ICM exposure to long-term renal function by comparing patients who developed CKD 2 years after cancer diagnosis and patients who did not. Among 59,971 patients collected according to inclusion and exclusion criteria, 1021 were diagnosed with CKD 2 years after cancer diagnosis. Using 1:5 matching after adjusting for age, sex and date of cancer diagnosis, 5097 control patients were matched to 1021 CKD patients. Conditional logistic regression showed that the number of CTs taken using ICM slightly increased the odds of CKD (odds ratio, 1.080; 95% confidence interval (CI): 1.059, 1.100; P < 0.0001). Thus, the administration of ICM might contribute to chronic renal function impairment.

Relationship between vitamin D and coronary artery disease in Egyptian patients

BACKGROUND

Previous studies have reported conflicting results about the association of vitamin D (VD) level with coronary artery disease (CAD). We aimed to study the association of VD with atherosclerotic CAD in Egyptian individuals.

RESULTS

We prospectively enrolled 188 consecutive CAD patients with a median age of 55(50-62) years; 151(80.3%) were male. All patients were diagnosed by cardiac catheterization and were compared with 131 healthy controls. VD levels were measured in serum samples of all participants. Compared to controls, CAD patients had a significantly lower median VD level, 14.65 (9.25-21.45) versus 42.0 (32.0-53.0) ng/mL, p < 0.001. VD was correlated with the number of diseased coronary arteries and lipid profile (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides, p < 0.001 for each). By multivariate analyses, VD was an independent predictor of CAD [OR 1.22 (95% CI 1.07-1.4), p = 0.003, optimal cut-off value 30 ng/mL (AUC 0.92, sensitivity 81% and specificity 81.4%), p < 0.001], and the number of diseased coronary arteries, p < 0.001, especially three-vessel disease [OR 0.83 (95% CI 0.72-0.95), p = 0.008].

CONCLUSIONS

We have shown that low VD should be considered a non-traditional risk factor for CAD in Egyptian individuals. Low VD was correlated with coronary atherosclerosis, especially in patients with multivessel effects.

Methods of the PivotaL triAl of the Atellica VTLi point of care emergencY dePartment high sensitivity troponin evalUationS

BACKGROUND

The Atellica® VTLi point-of-care (POC) High Sensitivity Cardiac Troponin-I (hs-cTnI) assay is intended for use as an aid in the diagnosis of myocardial infarction (MI). Our primary objective is to assess its diagnostic performance in patients presenting with suspected acute coronary syndrome (ACS).

METHODS

This prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance.

RESULTS

We expect study completion within 114 weeks of enrollment of the first patient.

CONCLUSIONS

It is anticipated that the Atellica VTLi hs-cTnI assay validation study will define a performance equivalent to lab-based hs-cTnI, with results within ∼8 min at the point of care.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review

AIMS

The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail.

DATA SOURCES

Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty.

STUDY SELECTION

We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status.

RESULTS

Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers.

CONCLUSION

People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

MINOCA: A Working Diagnosis

Cases of patients presenting with myocardial infarction (MI) without angiographic obstructive CAD are not trivial and have significant prevalence. "The Fourth Universal Definition of MI" (4UDMI) published in 2018 introduced MI with non-obstructive coronary arteries (MINOCA). The new section was of great importance as it validated the diagnosis by defining its criteria and recognizing its presence in the community and the need for further investigation. Given the nature of the diagnosis of MINOCA, coronary angiography provides limited information about prognosis and risk stratification for future major adverse cardiovascular events (MACE). Thus, additional imaging to understand the underlying etiology of MINOCA in conjunction with a better understanding of prognostic factors is necessary to expand on the current guidelines and aid in screening for possible complications, risk of MACE, and all-cause mortality. Discerning the etiology of the presentation is crucial, and physiologic studies, as well as additional imaging, are an important part of this evaluation. These modalities include intravascular studies such as optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), and imaging in the form of cardiac CT (CCT) and cardiac MRI (CMR). This step is essential to target treatment regimens more efficiently. The purpose of promoting multiple imaging modalities beyond traditional angiography is to address the working MINOCA diagnosis, with the finality of identifying the specific ischemic pathophysiology. MINOCA has multiple causative mechanisms, making it a heterogeneous collection of etiologies, resulting in acute MI: atherosclerotic, and non-atherosclerotic. This literature revision demonstrates that MINOCA prevalence and mortality are not trivial, and the diagnosis affects quality of life. MINOCA presents a definitive risk of MACE without proper stratification and targeted medical therapy. Several prognostic factors of morbidity and mortality in MI-CAD patients have been identified to correlate with MINOCA patients, especially inflammatory markers. MINOCA is not an exclusion diagnosis but a working diagnosis for which further imaging studies should be performed.

Sex differences in the management of atherosclerotic cardiovascular disease

Disparities between women and men persist in the diagnosis, treatment, and prognosis of atherosclerotic cardiovascular disease (ASCVD). Despite growing attention to sex-based differences in cardiovascular care, there are continued disparities in short- and long-term outcomes. Such disparities highlight the need to identify pathophysiologic differences in treatment patterns for stable ischemic heart disease, non-ST elevation myocardial infarction (NSTE-ACS), ST-elevation myocardial infarction (STEMI), and myocardial infarction with non-obstructive coronary arteries (MINOCA). The role of age as an effect modifier should also be considered given that young women diagnosed with ACS continue to experience increased rates of in-hospital mortality and major adverse cardiovascular events. Both patient-directed and systems-based approaches remain integral to improve outcomes in cardiovascular care. While inadequate representation of women in clinical trials remains a barrier to the implementation of evidence-based therapies, a growing body of data has established the efficacy and safety of medications in women across acute coronary syndromes. This review seeks to feature existing data on the differential treatment guidelines, care implementation, and cardiovascular outcomes between women and men, highlighting next directions for clinical investigation.

Electrocardiographic R wave amplitude in V6 lead as a predictive marker of cardiac dysfunction in Duchenne muscular dystrophy

PURPOSE

Duchenne muscular dystrophy (DMD) is an inherited muscular disease characterized by progressive and fatal muscle weakness. Electrocardiographic (ECG) abnormalities, including abnormal R wave amplitudes are frequently observed in DMD. However, clinical implications of abnormal R wave amplitudes remain unclear. Hence, DMD patients were examined for changes in R wave amplitude over time using synthesized 18-lead ECG and the relationship between R wave amplitude and cardiac function.

METHODS

The results of 969 ECG examinations of 193 patients with DMD who underwent electrocardiography and echocardiography on the same day were retrospectively reviewed.

RESULTS

A negative correlation was observed between R wave amplitude and age. Positive correlations between R wave amplitude and left ventricular ejection fraction were observed in leads V4, V5, V6, syn-V7, syn-V8, and syn-V9, with V6 showing the strongest correlation (r = 0.52). Mean R wave amplitude during cardiac dysfunction was lower than that observed with preserved cardiac function in leads V6 to syn-V9. Patients had preserved R wave amplitude up to three years before the onset of cardiac dysfunction, with a sharp decrease two years before cardiac dysfunction in leads V6 to syn-V9.

CONCLUSIONS

In DMD patients, the R wave amplitude decreases with age. The sharp decline in R amplitude two years before cardiac dysfunction indicates that electrophysiological damage to the myocardium of the left ventricle lateral to the posterior wall precedes the finding of cardiac dysfunction. The R amplitude in V6 of the standard 12-lead ECG is a convenient predictive marker of cardiac dysfunction, similar to that of the 18-lead ECG.

Efficacy and safety of cilostazol-based triple antiplatelet therapy compared with clopidogrel-based dual antiplatelet therapy in patients with acute ST-elevation myocardial infarction undergoing percutaneous coronary intervention: A multicenter, randomized, open-label, phase 4 trial

BACKGROUND

Previous studies reported that compared to conventional dual antiplatelet therapy (DAT; aspirin + clopidogrel), triple antiplatelet therapy (TAT), involving the addition of cilostazol to DAT, had better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). However, the optimal duration of TAT is yet to be determined.

METHODS

In total, 985 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) were prospectively enrolled in 15 PCI centers in South Korea and China. We randomly assigned patients into 3 groups: DAT (aspirin and clopidogrel for 12 months), TAT 1M (aspirin, clopidogrel, and cilostazol for 1 month), and TAT 6M (aspirin, clopidogrel, and cilostazol for 6 months). The primary endpoint was 1-year major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, recurrent myocardial infarction, stroke, or repeat revascularization.

RESULTS

The primary endpoint did not differ among the 3 groups (8.8% in DAT, 11.0% in TAT 1M, and 11.6% in TAT 6M; hazard ratio for TAT 1M vs DAT, 1.302; 95% confidence interval [CI], 0.792-2.141; P = .297; hazard ratio for TAT 6M vs DAT, 1.358; 95% CI, 0.829-2.225; P = .225). With respect to in-hospital outcomes, more bleeding events occurred in the TAT group than in the DAT group (1.3% vs 4.7% vs 2.6%, P = .029), with no significant differences in major bleeding events. Additionally, the TAT group had a higher incidence of headaches (0% vs 1.6% vs 2.6%, P = .020).

CONCLUSIONS

The addition of cilostazol to DAT did not reduce the incidence of 1-year MACEs compared with DAT alone. Instead, it may be associated with an increased risk of drug intolerance and side effects, including in-hospital bleeding and headaches.

Relationship of maximum walking speed with peak oxygen uptake and anaerobic threshold in male patients with heart failure

This retrospective observational study aimed to examine the relationships of maximum walking speed (MWS) with peak oxygen uptake (peak VO2) and anaerobic threshold (AT) obtained by cardiopulmonary exercise testing (CPX) in patients with heart failure. The study participants were 104 consecutive men aged ≥ 20 years who had been hospitalized or had undergone outpatient care at our hospital for heart failure between February 2019 and January 2023. MWS was measured in a 5-m section with a 1-m run-up before and after the course. Multivariable analysis was used to examine the association between MWS and peak VO2 and AT by CPX. The Pearson correlation coefficient showed that MWS was positively correlated with percent-predicted peak VO2 and percent-predicted AT (r = 0.463, p < 0.001; and r = 0.485, p < 0.001, respectively). In the multiple linear regression analysis employing percent-predicted peak VO2 and percent-predicted AT as the objective variables, only MWS demonstrated a significant positive correlation (standardized β: 0.471, p < 0.001 and 0.362, p < 0.001, respectively). Multiple logistic regression analyses, using an 80% cutoff in percent-predicted peak VO2 and AT, revealed that only MWS was identified as a significant factor in both cases (odds ratio [OR]: 1.239, 95% confidence interval [CI]: 1.071-1.432, p = 0.004 and OR: 1.469, 95% CI: 1.194-1.807, p < 0.001, respectively). MWS was correlated with peak VO2 and AT in male patients with heart failure. The MWS measurement as a screening test for exercise tolerance may provide a simple means of estimating peak VO2 and AT in heart failure patients.

Presumed Takotsubo syndrome is associated with high in-hospital mortality in very elderly frail females: a case series

Given the aging of general population, very elderly females with Takotsubo syndrome (TTS) are not rarely encountered in clinical practice. Although coronary angiography with left ventriculography is the gold standard diagnostic tool to exclude or confirm TTS, currently, this invasive procedure is less frequently performed in older patients with several comorbidities, such as renal failure, anemia, infections, neurological disorders, malignancy, and severe frailty. In these patients, a "presumed" TTS is diagnosed on the basis of clinical presentation, electrocardiogram, cardiac biomarkers, and echocardiographic findings without coronary angiography. While, in younger patients, TTS is generally a benign condition, in very elderly females, it is associated with higher in-hospital mortality and poor prognosis. Herein, we present four cases of ultra-octogenarian females diagnosed with "presumed TTS", who did not undergo coronary angiography due to severe frailty and multiple comorbidities and who exhibited poor outcome. This could arise the question if an early more aggressive approach could have changed final results. Probably, the solution could only be a personalized decision deriving from a profound and detailed discussion of each case through a multidisciplinary team approach.

[Heart rate disorders in patients with Tako-tsubo syndrome]

OBJECTIVES

This study sought to evaluate the incidence, prognosis and treatment of heart rhythm disorders (HRD) in Tako-tsubo syndrome (TTS).

BACKGROUND

TTS is associated with HRD. The HRD prognostic value is not well characterized in TTS yet.

METHODS

The HRD of patients included in the National Registry of Tako-tsubo syndrome, admitted between 2002 and 2018 and coming from 38 hospitals throughout the country, was analyzed. We analyzed any heart rhythm disorder in patients presented before admission, at admission and in long-term follow-up.

RESULTS

All types of HRD were described in 259 (23.5%) cases, from a cohort of 1,097 consecutive patients with TTS. HRD was more associated with diabetes mellitus, smoking, hyperuricemia, sleep apnea, anemia with a worse LVEF on admission. The most frequent HRD was a new onset of atrial fibrillation. During hospitalization, patients with HRD showed more complications such as shock on admission, major bleeding, acute renal failure, and combined infections. At follow-up, they presented higher mortality and more major adverse cardiac events, but with a non-significant correlation.

CONCLUSIONS

The incidence of HRD in patients with TTS is not infrequent. TTS, when associated with HRD, presents more complications and a worse prognosis both in hospital and in the long term.

Higher troponin T serum concentrations in hospital patients without diagnosed cardiac diseases compared to a population-based cohort

OBJECTIVES

Upper reference limits of high-sensitivity cardiac troponin T (hs-cTnT) are derived from healthy, population-based cohorts, and are frequently exceeded in hospitalized patients. In this study we aim to systematically examine the differences between in-hospital patients with no diagnosed cardiac diseases and a population-based cohort.

METHODS

Retrospective analyses were performed in two independent cohorts. We included 5,652 participants of the prospective population-based LIFE cohort as well as 9,300 patients having been treated at our hospital between 2014 and 2021. In both cohorts, subjects with diagnosed or suspected cardiac diseases were excluded. We used Spearman's rank correlation for correlation analyses of hs-cTnT serum concentrations and age. Sex- and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained in both cohorts.

RESULTS

In both cohorts, hs-cTnT serum concentrations positively correlated with age. Male sex was associated with higher hs-cTnT serum concentrations. Persons treated in hospital showed significantly higher hs-cTnT concentrations in females and males aged above 50. While in the population-based cohort only 99th percentile hs-cTnT results of females aged above 70 and males aged above 60 years exceeded the assay's upper reference limit, the 99th percentiles of in-hospital females over 40 years and males of all age groups exceeded this threshold.

CONCLUSIONS

Besides age and sex, hospitalization per se is correlated with higher serum concentrations of hs-cTnT in most age groups. Our results indicate, that unconditionally applying current hs-cTnT cut-offs to inpatients might overestimate myocardial infarction and potentially lead to overdiagnosis.

Theoretical analysis of immunochromatographic assay and consideration of its operating parameters for efficient designing of high-sensitivity cardiac troponin I (hs-cTnI) detection

Troponin is the American College of Cardiology and American Heart Association preferred biomarker for diagnosing acute myocardial infarction (MI). We provide a modeling framework for high sensitivity cardiac Troponin I (hs-cTnI) detection in chromatographic immunoassays (flow displacement mode) with an analytical limit of detection, i.e., LOD < 10 ng/L. We show that each of the various control parameters exert a significant influence over the design requirements to reach the desired LOD. Additionally, the design implications in a multiplexed fluidic network, as in the case of Simple Plex™ Ella instrument, are significantly affected by the choice of the number of channels or partitions in the network. We also provide an upgrade on the existing LOD equation to evaluate the necessary minimum volume to detect a particular concentration by considering the effects of stochastics and directly incorporating the target number of copies in each of the partitions in case of multiplexed networks. Even though a special case of cTnI has been considered in this study, the model and analysis are analyte agnostic and may be applied to a wide class of chromatographic immunoassays. We believe that this contribution will lead to more efficient designing of the immunochromatographic assays.

Coronary Computed Tomographic Angiography With Fractional Flow Reserve in Patients With Type 2 Myocardial Infarction

BACKGROUND

Type 2 myocardial infarction (T2MI) related to a supply/demand imbalance of coronary blood flow is common and associated with poor prognosis. Coronary artery disease (CAD) may predispose some individuals to T2MI and contribute to its high rate of recurrent cardiovascular events. Little is known about the presence and extent of CAD in this population.

OBJECTIVES

The goal of this study was to evaluate the presence and characteristics of CAD among patients with T2MI.

METHODS

In this prospective study, consecutive eligible individuals with Fourth Universal Definition of Myocardial Infarction criteria for T2MI were enrolled. Participants underwent coronary computed tomography angiography (CTA), fractional flow reserve derived with coronary CTA (FFRCT), and plaque volume analyses.

RESULTS

Among 50 participants, 25 (50%) were female, and the mean age was 68.0 ± 11.4 years. Atherosclerotic risk factors were common. Coronary CTA revealed coronary plaque in 46 participants (92%). A moderate or greater stenosis (≥50%) was identified in 42% of participants, and obstructive disease (≥50% left main stenosis or ≥70% stenosis in any other epicardial coronary artery) was present in 26%. Prevalence of obstructive CAD did not differ according to T2MI cause (P = 0.54). A hemodynamically significant focal stenosis identified by FFRCT was present in 13 participants (26%). Among participants with a stenosis ≥50% (n = 21), FFRCT excluded lesion-specific hemodynamically significant stenosis in 8 cases (38%).

CONCLUSIONS

Among individuals with adjudicated T2MI, CAD was prevalent, but the majority of patients had nonobstructive CAD. Mediators of ischemia are likely multifactorial in this population. (Defining the Prevalence and Characteristics of Coronary Artery Disease Among Patients with Type 2 Myocardial Infarction using CT-FFR [DEFINE TYPE 2 MI]; NCT04864119).

Dyspnea-Related Ticagrelor Discontinuation After Percutaneous Coronary Intervention

BACKGROUND

Nearly 20% of patients on ticagrelor experience dyspnea, which may lead to treatment discontinuation in up to one-third of cases.

OBJECTIVES

The authors sought to evaluate the incidence, predictors, and outcomes of dyspnea-related ticagrelor discontinuation after percutaneous coronary intervention (PCI).

METHODS

In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, patients were maintained on ticagrelor and randomized to aspirin or placebo for 1 year. The occurrence of dyspnea associated with ticagrelor discontinuation was evaluated among all patients enrolled in the trial. A landmark analysis was performed at 3 months after PCI, that is, the time of randomization. Predictors of dyspnea-related ticagrelor discontinuation were obtained from multivariable Cox regression with stepwise selection of candidate variables.

RESULTS

The incidence of dyspnea-related ticagrelor discontinuation was 6.4% and 9.1% at 3 and 15 months after PCI, respectively. Independent predictors included Asian race (lower risk), smoking, prior PCI, hypercholesterolemia, prior coronary artery bypass, peripheral artery disease, obesity, and older age. Among 179 patients who discontinued ticagrelor because of dyspnea after randomization, ticagrelor monotherapy was not associated with a higher risk of subsequent ischemic events (composite of all-cause death, myocardial infarction, or stroke) compared with ticagrelor plus aspirin (5.0% vs 7.1%; P = 0.566).

CONCLUSIONS

In the TWILIGHT trial, dyspnea-related ticagrelor discontinuation occurred in almost 1 in 10 patients and tended to occur earlier rather than late after PCI. Several demographic and clinical conditions predicted its occurrence, and their assessment may help identify subjects at risk for therapy nonadherence.

Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials

BACKGROUND

The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI.

METHODS

We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding.

RESULTS

A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up.

CONCLUSIONS

In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.

Comparison of heart, grace and TIMI scores to predict major adverse cardiac events from chest pain in a Spanish health care region

Acute non-traumatic chest pain (ANTCP) is the second cause of consultation in the Emergency department (ED). About 70% of all Acute Myocardial Infarctions present as non persistent ST-elevation acute coronary syndrome (NSTE-ACS) in the electrocardiogram. Our aim was to compare whether the HEART risk score is more effective than the GRACE and TIMI scores for the diagnosis and prognosis of Major Adverse Cardiac Events (MACE) at six weeks in patients with ANTCP and NSTE-ACS. A prospective cohort study was conducted with patients with ANTCP that attended an ED and a Primary Care Emergency Center (PCEC) from April 2018 to December 2020. The primary outcome was MACE at six weeks. Diagnostic performance was calculated for each scale as the Area under the Receiver Operating Characteristic (ROC) curve (AUC), sensitivity (SE), specificity (SP), and predictive values (PV). Qualitative variables were compared using the Chi-square test, and continuous variables were compared using the nonparametric Kruskal-Wallis test. We adjusted a logistic regression for risk groups, age, and gender to determine the effect of the HEART, GRACE, and TIMI scores on MACE. The degree of agreement (kappa index) was calculated in the categorical classification of patients according to the three risk scales. Cox proportional hazards regressions were performed for each scale and were compared using partial likelihood ratio tests for non-nested models. From a sample of 317 patients with ANTCP, 14.82% had MACE at six weeks. The AUC was 0.743 (95% CI 0.67-0.81) for the HEART score, 0.717 (95% CI 0.64-0.79) for the TIMI score, and 0.649 (95% CI 0.561-0.738) for the GRACE score. The HEART scale identified low-risk patients with a higher SE and negative PV than the GRACE and TIMI scores. The HEART scale was better than the GRACE and TIMI scores at diagnosing and predicting MACE at six weeks in patients with ANTCP and probable NSTE-ACS. It was also a reliable tool for risk stratification in low-risk patients. Its application is feasible in EDs and PCECs, avoiding the need for complementary tests and their associated costs without compromising patient health.

Association between post-stroke smoking and stroke recurrence in first-ever ischemic stroke survivors: based on a 10-year prospective cohort

BACKGROUND

Whether smoking is a risk factor for ischemic stroke (IS) recurrence in IS survivors is still uncovered, and evidences are sparse. Meanwhile, an add-on effect of clopidogrel was observed in myocardial infarction patients who smoked, but whether the paradox exists in IS patients is still unsolved. The objectives of this study are to explore the association between smoking behavior after index stroke and IS recurrence and to explore whether the paradox exists.

METHODS

A prospective cohort of first-ever IS patients was conducted between 2010 and 2019. The prognosis and smoking features of enrolled patients were obtained via telephone follow-up every 3 months. Fine-gray model with interaction terms was applied to measure the relationships between stroke recurrence and smoking behaviors after index stroke and to explore the add-on effect of clopidogrel in smoking patients.

RESULTS

There were 171 (24.26%) recurrences and 129 (18.30%) deaths during follow-up in 705 enrolled IS patients. One hundred forty-six (20.71%) patients smoked after index stroke. The hazard ratios (HRs) and 95% confidence intervals (CIs) of interaction terms between antiplatelet drug and follow-up smoking (smoking status and daily smoking amount) were 1.092 (95% CI: 0.524, 2.276) and 0.985 (95% CI: 0.941, 1.031), respectively. A significantly higher risk of recurrence was observed in patients with a higher daily smoking amount during follow-up (per cigarette), with HR being 1.027 (95% CI: 1.003, 1.052).

CONCLUSIONS

Smoking could elevate the risk of IS recurrence, and IS survivor should be advised to quit or smoke less. Add-on effect of clopidogrel may not exist in smoking strokers taking clopidogrel.

Hiccups: Nerve Irritation or Masquerading as Acute Coronary Syndrome

The typical clinical presentation of acute coronary syndrome (ACS) includes chest pain that may radiate to the left arm, shoulder, jaw, and neck, accompanied by diaphoresis, dyspnea, nausea, vomiting, and hiccups, which have been observed as the sole symptom of presentation. The mechanism of hiccups involves the activation of the vagus and phrenic nerves, leading to the activation of the diaphragm and intercostal muscles. Several hypotheses link hiccups to ACS, associating irritation of the left anterior descending artery with activation of sympathetic phrenic and vagal nerves. This case report highlights the occurrence of hiccups in patients with inferior and right ventricular myocardial infarction (MI), indicating possible nerve synapse involvement. Timely recognition of hiccups as a possible atypical symptom of ACS can facilitate early evaluation and management, preventing delays in patient care and ensuring better outcomes.

Comparison of HEAR and HEART Scores for Major Adverse Cardiovascular Events

BACKGROUND

Early identification of patients with low and high risk for acute coronary syndrome in the emergency department (ED) is important for process management and proper resource use. The aim of this study was to compare the HEAR and HEART scores to determine the risk for major adverse cardiovascular events (MACE) over 30 days.

METHODS

Demographic data and clinical evaluations of the patients who presented to the ED with chest pain were recorded. ECGs were evaluated without knowing the clinical status of the patients. The HEART (including history, ECG, age, coronary risk factors, and troponin level) and HEAR (including four items with no troponin) risk scores were calculated. MACE was defined as all MI, all coronary revascularization procedures (PCI and CABG), all-cause death, cardiac arrest, cardiogenic shock, or life-threatening cardiac arrhythmias within 30 days. Patients with MACE were evaluated as Group 1, and patients without MACE were considered as Group 2, and the data from the two groups were compared.

RESULTS

A total of 230 patients were included in the study. There were 56 (24.3%) patients with MACEs. According to the ROC analysis, the threshold value was determined as ≤3 for both scoring systems. According to this threshold value, sensitivity and specificity were found to be 0.77 and 0.78 for the HEAR score and 0.82 and 0.77 for the HEART score.

CONCLUSIONS

Although the HEAR and HEART scoring systems are useful for the management of patients with chest pain in the ED, the HEART score was evaluated to be more effective.

Prognostic Value of Endothelial Progenitor Cells in Acute Myocardial Infarction Patients

Objective

To determine prognostic role of endothelial progenitor cells (EPCs) in intensive care patients with acute myocardial infarction (AMI).

Materials and Methods

From December 2018 to July 2021, a total of 91 eligible patients with AMI were consecutively examined in a single intensive care unit (ICU) in China. Patients with a history of acute coronary artery disease were excluded from the study. Samples were collected within 24 hr of onset of symptoms. EPCs, defined as coexpression of CD34+/CD133+ cells or CD133+/CD34+/KDR+, were studied using flow cytometry and categorized by quartiles. Based on the 28-days mortality outcome, the patients were further divided into two groups: death and survival. The study incorporated various variables, including cardiovascular risk factors such as body mass index, hypertension, diabetes, hypercholesterolemia, atherosclerotic burden, and medication history, as well as clinical characteristics such as APACHEⅡscore, central venous-arterial carbon dioxide difference (GAP), homocysteine, creatinine, C-reactive protein, HbAlc, and cardiac index. Cox regression analysis was employed to conduct a multivariate analysis.

Results

A total of 91 patients with AMI who were admitted to the ICU were deemed eligible for inclusion in the study. Among these patients, 23 (25.3%) died from various causes during the follow-up period. The counts of EPCs were found to be significantly higher in the survival group compared to the death group (P < 0.05). In the univariate analysis, it was observed that the 28-days mortality rate was associated with the several factors, including the APACHEⅡscore (P=0.00), vasoactive inotropic score (P=0.03), GAP (P=0.00), HCY (P=0.00), creatinine (P=0.00), C-reactive protein (P=0.00), HbAlc (P=0.00), CI (P=0.01), quartiles of CD34+/CD133+ cells (P=0.00), and quartiles of CD34+/CD133+/KDR+ cells (P=0.00). CD34+/CD133+/KDR+ cells retained statistical significance in Cox regression models even after controlling for clinical variables (HR: 6.258 × 10-10 and P=0.001). Nevertheless, no significant correlation was observed between CD34+/CD133+ cells and all-cause mortality.

Conclusions

The decreased EPCs levels, especially for CD34+/CD133+/KDR+ cells subsets, were an independent risk factor for 28-days mortality in AMI patients.

Diagnostic Puzzles and Cause-Targeted Treatment Strategies in Myocardial Infarction with Non-Obstructive Coronary Arteries: An Updated Review

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a distinct subtype of myocardial infarction (MI), occurring in about 8-10% of spontaneous MI cases referred for coronary angiography. Unlike MI with obstructive coronary artery disease, MINOCA's pathogenesis is more intricate and heterogeneous, involving mechanisms such as coronary thromboembolism, coronary vasospasm, microvascular dysfunction, dissection, or plaque rupture. Diagnosing MINOCA presents challenges and includes invasive and non-invasive strategies aiming to differentiate it from alternative diagnoses and confirm the criteria of elevated cardiac biomarkers, non-obstructive coronary arteries, and the absence of alternate explanations for the acute presentation. Tailored management strategies for MINOCA hinge on identifying the underlying cause of the infarction, necessitating systematic diagnostic approaches. Furthermore, determining the optimal post-MINOCA medication regimen remains uncertain. This review aims to comprehensively address the current state of knowledge, encompassing diagnostic and therapeutic approaches, in the context of MINOCA while also highlighting the evolving landscape and future directions for advancing our understanding and management of this intricate myocardial infarction subtype.

Suboptimal Knowledge and Care of Patients with Acute Coronary Syndrome Among Nurses Working in Selected Hospitals in Addis Ababa, Ethiopia 2021

Background

Acute Coronary Syndrome is the leading cause of morbidity and mortality in developing nations including Ethiopia. As frontline healthcare providers, nurses need to be prudent in handling cases of acute coronary syndrome. However, nurses' knowledge and practice of acute coronary syndrome are not well-known across Ethiopia. Thus, this study aimed to assess knowledge, practice, and associated factors regarding the care of acute coronary syndrome among acute care nurses working at selected hospitals in Addis Ababa, Ethiopia.

Methods

Institution-based descriptive cross-sectional study design was conducted from February to March among 252 purposively selected nurses working in tertiary hospitals of Addis Ababa, Ethiopia. A pretested and structured questionnaire was used for data collection. Data were entered into Epi-Data 4.6 and exported to SPSS version 25. Both descriptive and inferential statistics were used to describe and test the association between selected variables. P-values < 0.05 were declared as significant factors for the outcome variable.

Results

Out of 252 nurses, (52%) had good knowledge, and (44.4%) had good practice towards care of Acute Coronary Syndrome. Being a master's degree [AOR=3.801, (95% CI:1.314-10.996), P =0.014] and having guidelines [AOR= 10.998, (95% CI:2.478-48.805), P =0.002] were significantly associated with nurse's good knowledge of ACS. While having a master's degree [AOR=4.258, (95% CI:1.676-10.820), P=0.002] and getting in-service training [AOR= 1.902, (95% CI:1.022-3.539), P = 0.042] were significantly associated with nurse's good level of practice.

Conclusion

In this study, nurses had inadequate knowledge and practice regarding the care of Acute Coronary Syndrome. Nurses' educational level, presence of clinical practice guidelines, and getting training were determinant factors associated with good knowledge and practice. Therefore, organizational and nursing educational support are needed to improve this gap by providing short- and long-term training, and updated evidence-based clinical practice guidelines should be available for all acute care nurses.

The effect of discontinuing beta-blockers after different treatment durations following acute myocardial infarction in optimally treated, stable patients without heart failure: a Danish, nationwide cohort study

AIMS

We studied the effect of discontinuing beta-blockers following myocardial infarction in comparison to continuous beta-blocker use in optimally treated, stable patients without heart failure.

METHODS AND RESULTS

Using nationwide registers, we identified first-time myocardial infarction patients treated with beta-blockers following percutaneous coronary intervention or coronary angiography. The analysis was based on landmarks selected as 1, 2, 3, 4, and 5 years after the first redeemed beta-blocker prescription date. The outcomes included all-cause death, cardiovascular death, recurrent myocardial infarction, and a composite outcome of cardiovascular events and procedures. We used logistic regression and reported standardized absolute 5-year risks and risk differences at each landmark year. Among 21 220 first-time myocardial infarction patients, beta-blocker discontinuation was not associated with an increased risk of all-cause death, cardiovascular death, or recurrent myocardial infarction compared with patients continuing beta-blockers (landmark year 5; absolute risk difference [95% confidence interval]), correspondingly; -4.19% [-8.95%; 0.57%], -1.18% [-4.11%; 1.75%], and -0.37% [-4.56%; 3.82%]). Further, beta-blocker discontinuation within 2 years after myocardial infarction was associated with an increased risk of the composite outcome (landmark year 2; absolute risk [95% confidence interval] 19.87% [17.29%; 22.46%]) compared with continued beta-blocker use (landmark year 2; absolute risk [95% confidence interval] 17.10% [16.34%; 17.87%]), which yielded an absolute risk difference [95% confidence interval] at -2.8% [-5.4%; -0.1%], however, there was no risk difference associated with discontinuation hereafter.

CONCLUSION

Discontinuation of beta-blockers 1 year or later after a myocardial infarction without heart failure was not associated with increased serious adverse events.

A knowledge graph-based analytical model for mining clinical value of drug stress echocardiography for diagnosis, risk stratification and prognostic evaluation of coronary artery disease

The three major techniques for clinically diagnosing coronary heart disease, including angina associated with myocardial ischemia, are coronary angiography, myocardial perfusion imaging, and drug stress echocardiography. Compared to the first two methods, which are invasive or involve the use of radionuclides, drug stress echocardiography is increasingly used in clinical practice due to its non-invasive, low-risk, and controllable nature, and wide applicability. We developed a novel methodology to demonstrate knowledge graph-based efficacy analysis of drug stress echocardiography as a complement to traditional meta-analysis. By measuring coronary flow reserve (CFR), we discovered that regional ventricular wall abnormalities (RVWA) and drug-loaded cardiac ultrasound can be used to detect coronary artery disease. Additionally, drug-loaded cardiac ultrasound can be used to identify areas of cardiac ischemia, stratify risks, and determine prognosis. Furthermore, adenosine stress echocardiography(ASE) can determine atypical symptoms of coronary heart disease with associated cardiac events through CFR and related quantitative indices for risk stratification. Using a knowledge graph-based approach, we investigated the positive and negative effects of three drugs - Dipyridamole, Dobutamine, and Adenosine - for coronary artery disease analysis. Our findings show that Adenosine has the highest positive effect and the lowest negative effect among the three drugs. Due to its minimal and controlled side effects, and high sensitivity for diagnosing coronary microcirculation disorders and multiple lesions, adenosine is frequently used in clinical practice.

Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials

Background

Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes.

Methods

The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used.

Results

This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies.

Conclusions

An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.

Incorporation of Shared Decision-Making in International Cardiovascular Guidelines, 2012-2022

Importance

Shared decision-making (SDM) is a key component of the provision of ethical care, but prior reviews have indicated that clinical practice guidelines seldom promote or facilitate SDM. It is currently unknown whether these findings extend to contemporary cardiovascular guidelines.

Objective

To identify and characterize integration of SDM in contemporary cardiovascular guideline recommendations using a systematic classification system.

Design, Setting, and Participants

This cross-sectional study assessed the latest guidelines or subsequent updates that included pharmacotherapy recommendations and were published between January 2012 and December 2022 by the American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC). Data were analyzed from February 21 to July 21, 2023.

Main Outcomes and Measures

All pharmacotherapy recommendations were identified within each guideline. Recommendations that incorporated SDM were rated according to a systematic rating framework to evaluate the quality of SDM incorporation based on directness (range, 1-3; assessing whether SDM was incorporated directly and impartially into the recommendation's text, with 1 indicating direct and impartial incorporation of SDM into the recommendation's text) and facilitation (range, A-D; assessing whether decision aids or quantified benefits and harms were provided, with A indicating that a decision aid quantifying benefits and harms was provided). The proportion of recommendations incorporating SDM was also analyzed according to guideline society and category (eg, general cardiology, heart failure).

Results

Analyses included 65 guideline documents, and 33 documents (51%) incorporated SDM either in a general statement or within specific recommendations. Of 7499 recommendations, 2655 (35%) recommendations addressed pharmacotherapy, and of these, 170 (6%) incorporated SDM. By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating SDM (86 of 865 recommendations [10%]), whereas heart failure and myocardial disease contained the least (9 of 315 recommendations [3%]). The proportion of pharmacotherapy recommendations incorporating SDM was comparable across societies (ACC: 75 of 978 recommendations [8%]; CCS: 29 of 333 recommendations [9%]; ESC: 67 of 1344 recommendations [5%]), with no trend for change over time. Only 5 of 170 SDM recommendations (3%) were classified as grade 1A (impartial recommendations for SDM supported by a decision aid), whereas 114 of 170 recommendations (67%) were grade 3D (SDM mentioned only in supporting text and without any tools or information to facilitate SDM).

Conclusions and Relevance

In this cross-sectional study across guidelines published by 3 major cardiovascular societies over the last decade, 51% of guidelines mentioned the importance of SDM, yet only 6% of recommendations incorporated SDM in any form, and fewer adequately facilitated SDM.

Challenges and solutions of echocardiography generalization for deep learning: a study in patients with constrictive pericarditis

Purpose

The inherent characteristics of transthoracic echocardiography (TTE) images such as low signal-to-noise ratio and acquisition variations can limit the direct use of TTE images in the development and generalization of deep learning models. As such, we propose an innovative automated framework to address the common challenges in the process of echocardiography deep learning model generalization on the challenging task of constrictive pericarditis (CP) and cardiac amyloidosis (CA) differentiation.

Approach

Patients with a confirmed diagnosis of CP or CA and normal cases from Mayo Clinic Rochester and Arizona were identified to extract baseline demographics and the apical 4 chamber view from TTE studies. We proposed an innovative preprocessing and image generalization framework to process the images for training the ResNet50, ResNeXt101, and EfficientNetB2 models. Ablation studies were conducted to justify the effect of each proposed processing step in the final classification performance.

Results

The models were initially trained and validated on 720 unique TTE studies from Mayo Rochester and further validated on 225 studies from Mayo Arizona. With our proposed generalization framework, EfficientNetB2 generalized the best with an average area under the curve (AUC) of 0.96 (± 0.01 ) and 0.83 (± 0.03 ) on the Rochester and Arizona test sets, respectively.

Conclusions

Leveraging the proposed generalization techniques, we successfully developed an echocardiography-based deep learning model that can accurately differentiate CP from CA and normal cases and applied the model to images from two sites. The proposed framework can be further extended for the development of echocardiography-based deep learning models.

Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients

BACKGROUND

The 2021 American College of Cardiology/American Heart Association chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk factors) for short-term risk stratification, yet limited data exist integrating them with high-sensitivity cardiac troponin T (hs-cTnT).

METHODS

Retrospective, multicenter (n = 2), observational, US cohort study of consecutive emergency department patients without ST-elevation myocardial infarction who had at least one hs-cTnT (limit of quantitation [LoQ] <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular event (MACE) outcome was 30-day prognosis.

RESULTS

Among 1979 emergency department patients undergoing hs-cTnT measurement, 1045 (53%) were low risk (0-3), 914 (46%) intermediate risk (4-6), and 20 (1%) high risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT <99th percentile remained at low risk (range 0%-1.2%) across all HEAR score strata. Higher scores were not associated with long-term (2-year) events.

CONCLUSIONS

HEAR scores are of limited value in those with baseline hs-cTnT 99th percentile to define short-term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.

Circulating IGF-1 and IGFBP-2 may be biomarkers for risk stratification in patients with acute coronary syndrome: A prospective cohort study

BACKGROUND AND AIM

The involvement of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-2 (IGFBP-2) following acute coronary syndrome (ACS) is rarely studied in clinical practice. Therefore, we sought to evaluate the relationship between IGF-1 and IGFBP-2 concentrations at admission and risk stratification based on the Thrombolysis in Myocardial Infarction (TIMI) risk score in patients with ACS.

METHODS AND RESULTS

In all, 304 patients diagnosed with ACS were included in this study. Plasma IGF-1 and IGFBP-2 were measured using commercially available ELISA kits. The TIMI risk score was calculated and the study population was stratified into high (n = 65), medium (n = 138), and low (n = 101) risk groups. Levels of IGF-1 and IGFBP-2 were analyzed for their predictive ability of risk stratification based on the TIMI risk scores. Correlation analysis showed that IGF-1 levels were negatively correlated with TIMI risk levels (r = -0.144, p = 0.012), while IGFBP-2 levels were significantly and positively correlated with TIMI risk levels (r = 0.309, p < 0.001). In multivariate logistic regression analysis, IGF-1 (odds ratio [OR]: 0.995; 95% confidence interval [CI]: 0.990-1.000; p = 0.043) and IGFBP-2 (OR: 1.002; 95%CI: 1.001-1.003; p < 0.001) were independent predictors of high TIMI risk levels. In receiver operating characteristic curves, the area under the curve values for IGF-1 and IGFBP-2 in the prediction of high TIMI risk levels were 0.605 and 0.723, respectively.

CONCLUSIONS

IGF-1 and IGFBP-2 levels are excellent biomarkers for risk stratification in patients with ACS, which provides further guidance for clinicians to identify patients at high risk and to lower their risk.

Cardiovascular Toxicity Associated With Immune Checkpoint Inhibitor Therapy: A Comprehensive Review

Immune checkpoint inhibitors (ICIs), a significant breakthrough treatment of cancer, exert their function through enhancing the immune system's ability to recognize and attack cancer cells. However, these revolutionary cancer treatments have been associated with a range of immune-related adverse effects, including cardiovascular toxicity. The most commonly reported cardiovascular toxicities associated with ICIs are myocarditis, pericarditis, arrhythmias, and vasculitis. These cardiovascular manifestations are often severe and can lead to life-threatening complications. Therefore, prompt identification and management of these toxicities is critical, and a multidisciplinary teamwork by cardiologists and oncologists are required to ensure optimal patient outcomes. In this review, we summarize the current knowledge on the mechanisms underlying ICI-associated cardiovascular toxicity, clinical presentations of these toxicities, potential risk factors, diagnosis, management, and surveillance strategies during ICI therapy. While ICIs have already transformed cancer treatment, further research is needed to better understand and manage their immune-related cardiovascular effects, and possibly, to identify biomarkers which can predict the occurrence of these cardiovascular complications.

Baseline characteristics of patients enrolled in the EMPACT-MI trial

AIMS

Empagliflozin has been shown to reduce the risk of adverse cardiovascular outcomes in patients with type 2 diabetes and in those with heart failure. The impact of empagliflozin in post-acute myocardial infarction (AMI) patients is unknown.

METHODS AND RESULTS

The Study to Test the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction (EMPACT-MI) trial screened 6610 participants with AMI and randomized 6522 to empagliflozin or placebo in addition to standard of care. The median (interquartile) age was 64 (56-71) years and 75.1% of patients were male. Major comorbidities included hypertension (69.1%), type 2 diabetes (31.7%), prior myocardial infarction (13.0%), and atrial fibrillation (10.9%). The majority (74.3%) of patients presented with an ST-elevation myocardial infarction. Overall, 56.9% of patients had acute signs or symptoms of congestion requiring treatment and 78.3% had left ventricular systolic dysfunction with ejection fraction <45%. Clinical characteristics, including baseline demographics, rates of revascularization, and cardiovascular medications at discharge were largely comparable to recent trials of the post-AMI population.

CONCLUSION

The EMPACT-MI trial will establish the benefit and risks of empagliflozin treatment in patients with AMI.

Vascular Inflammation, Cancer, and Cardiovascular Diseases

PURPOSE OF REVIEW

Cancer and cardiovascular disease are among the leading causes of morbidity and mortality in the USA. Cancer and cardiovascular disease have inflammatory underpinnings that have been associated with both the development and progression of these disease states.

RECENT FINDINGS

Inflammatory signaling has been found to be a critical event in both cardiovascular disease and cancer formation and progression. Further, many chemotherapeutic agents potentiate inflammation exacerbating existing cardiovascular disease or leading to its presence. The exact mechanisms of these interactions remain poorly understood. The proinflammatory milieu observed in both cancer and cardiovascular disease likely plays an important role in the development and potentiation of both conditions. Further evaluation of this relationship will be critical in the development of new diagnostic and therapeutic modalities.

The bidirectional association between atrial fibrillation and myocardial infarction

Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI) and vice versa. This bidirectional association relies on shared risk factors as well as on several direct and indirect mechanisms, including inflammation, atrial ischaemia, left ventricular remodelling, myocardial oxygen supply-demand mismatch and coronary artery embolism, through which one condition can predispose to the other. Patients with both AF and MI are at greater risk of stroke, heart failure and death than patients with only one of the conditions. In this Review, we describe the bidirectional association between AF and MI. We discuss the pathogenic basis of this bidirectional relationship, describe the risk of adverse outcomes when the two conditions coexist, and review current data and guidelines on the prevention and management of both conditions. We also identify important gaps in the literature and propose directions for future research on the bidirectional association between AF and MI. The Review also features a summary of methodological approaches for the study of bidirectional associations in population-based studies.

Sex Differences in the Diagnosis, Management, and Outcomes of Suspected Non-ST-Elevation Acute Coronary Syndromes Meeting Rapid Rule-Out Criteria

(1) Background: patients who meet current rapid rule-out criteria for myocardial infarction (MI) are considered low risk, yet their management remains nebulous, especially among women. We aimed to examine sex differences in the diagnosis, management, and outcomes of patients meeting the rapid rule-out criteria. (2) Methods: by simulating application of the rapid rule-out MI criteria, we analyzed consecutively triaged men and women with suspected NSTE-ACS who had high-sensitivity cardiac troponin T (hs-cTnT) values that met criteria (n = 11,477), in particular, those who were admitted (n = 3775). (3) Results: men constituted ~55% of triaged patients who met the rule-out criteria, whether admitted or discharged. Men were more likely to be admitted (33.7% vs. 31.9%, p = 0.04), more commonly with hs-cTnT values between level of detection (LOD, 5 ng/ml) and the 99th percentile (59.4% of all admissions vs. 40.5% for women), whereas women were more likely to be admitted with values < level of blank (LOB, 3 ng/mL; 22.9% vs. 9.2% for men). Thirty-day mortality (1 man and 1 woman) and in-hospital MI (9 men vs. 1 woman) were uncommon among admitted patients, yet resource utilization during 3-4 hospitalization days was substantial for both sexes, with men undergoing coronary angiography (6.8% vs. 2.9%) and revascularization (3.4% vs. 1.1%) more commonly. Long-term survival for both men and women, whether admitted or discharged, was significantly worse for hs-cTnT values between LOD and the 99th percentile, even after adjusting for age and cardiovascular comorbidities. (4) Conclusions: reporting actual hs-cTnT values < 99th percentile allows for better risk stratification, especially for women, possibly closing the sex gap.

Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry

This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.