Polymer-free versus biodegradable-polymer drug-eluting stent in patients undergoing percutaneous coronary intervention: an assessor-blind, non-inferiority, randomised controlled trial

BACKGROUND

Few data are available on polymer-free drug-eluting stents in patients undergoing percutaneous coronary intervention (PCI).

AIMS

We aimed to determine the efficacy and safety of a polymer-free amphilimus-eluting stent (AES), using a reservoir-based technology for drug delivery, compared with a biodegradable-polymer everolimus-eluting stent (EES).

METHODS

This was a randomised, investigator-initiated, assessor-blind, non-inferiority trial conducted at 14 hospitals in Italy (ClinicalTrials.gov: NCT04135989). All-comer patients undergoing PCI were randomly assigned to either polymer-free AES or biodegradable-polymer EES. The primary endpoint was a device-oriented composite endpoint, including cardiovascular death, target vessel myocardial infarction, or target lesion revascularisation at 1-year follow-up.

RESULTS

Between January 2020 and June 2022, a total of 2,107 patients with 3,042 coronary lesions were randomised to polymer-free AES (1,051 patients) or biodegradable-polymer EES (1,056 patients). At 1-year follow-up, the primary endpoint occurred in 86 (8.2%) patients randomised to polymer-free AES and 76 (7.2%) patients randomised to biodegradable-polymer EES (risk difference 1%, upper limit of the 1-sided 95% confidence interval [CI] of 2.9%; p for non-inferiority=0.041). There were no significant differences in the incidence of the components of the primary endpoint between groups. However, definite or probable stent thrombosis occurred more frequently in patients randomised to polymer-free stents (1.0% vs 0.3%; hazard ratio 3.72, 95% CI: 1.04-13.33; p=0.044) due to an increased risk of early stent thrombosis within 30 day Conclusions: In all-comer patients undergoing PCI, polymer-free AES were non-inferior to biodegradable-polymer EES at 1-year follow-up in terms of a device-oriented composite endpoint despite being associated with an increased risk of early stent thrombosis.

Implementation of a value-based approach for older people who have suffered an acute myocardial infarction: study protocol

Introduction

Due to the rapid aging of the global population, new approaches are required to improve the quality of life of older people and to reduce healthcare system expenditures. One of the approaches that can be used is value-based healthcare. This article describes a value-based solution for older people who have suffered a myocardial infarction.

Methods

This solution combines the work of healthcare professionals and informal caregivers and the use of modern and user-friendly technologies to support the achievement of patients' values. Patients older than 65 years who have suffered a myocardial infarction will be divided into control and intervention groups within a pre-post-controlled design research study. Members of the intervention group will be provided with a personalized plan developed by healthcare professionals and based on the results from the baseline questionnaire.

Discussion

Two ValueCare digital solution components will be developed: a mobile application for the participants and a web platform for the professionals, researchers, and informal caregivers. Together with smartwatches, which will track important health aspects, and applications, this approach would enable older people to improve their health through correct lifestyle choices and their professional and informal caregivers to track their progress. With the use of the described technology and the multidisciplinary approach, the unmet needs and values of participants could be achieved. Using this approach, it could be possible to reduce overall healthcare expenses through the active involvement of both older people and their informal caregivers through a shared decision-making process with healthcare professionals.

Clinical trial registration

The ISRCTN registry number is 25089186. The date of trial registration is 16/11/2021.

Longitudinal changes in remnant cholesterol and the risk of cardiovascular disease

BACKGROUND AND AIM

The analyses of longitudinal changes in remnant cholesterol (RC) and cardiovascular disease (CVD) remains are limited. The objective of the study was to investigate the associations of longitudinal changes in RC with the risks of CVD and its subtypes (myocardial infarction [MI] and stroke).

METHODS AND RESULTS

The participants were enrolled in the Kailuan study. The RC short-term change pattern was defined by RC cutoff points according to equivalent percentiles for low-density lipoprotein cholesterol of 2.6 mmol/L at visits in 2006 and 2008. The RC long-term change pattern was defined as the RC trajectories from 2006 to 2010. Multivariate Cox proportion models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs). The cutoff values of RC were 0.52 mmol/L at the 2006 visit and 0.51 mmol/L at the 2008 visit. In the RC short-term change analysis, the participants in the high stable group had a 31% increased risk of CVD (HR 1.31; 95% CI 1.22-1.41), 73% increased risks of MI (HR 1.73; 95% CI 1.47-2.03), and 21% increased risks of stroke (HR 1.21; 95% CI 1.12-1.31) compared with participants in the low stable group. Three RC trajectories were employed in the RC long-term change analysis. Compared with the low stable group, the high stable group had a 1.34-fold risk of CVD (HR 1.34; 95% CI 1.17-1.53), 1.66-fold risk of MI (HR 1.66; 95% CI 1.24-2.21), and 1.22-fold risk of stroke (HR 1.22; 95% CI 1.05-1.42).

CONCLUSIONS

The stable high RC was associated with a higher risk of CVD. Maintaining optional RC levels could reduce the lifetime risk of CVD and prolong the year of life free from CVD.

Modification, validation and comparison of Naples prognostic score to determine in-hospital mortality in ST-segment elevation myocardial infarction

AIM

The relationship between inflammatory status and poor outcomes in acute coronary syndromes is a significant area of current research. This study investigates the association between in-hospital mortality and the modified Naples prognostic score (mNPS) as well as other inflammatory biomarkers in STEMI patients.

METHODS

This single-centre, cross-sectional study included 2576 consecutive STEMI patients who underwent primary percutaneous coronary intervention between January 2022 and November 2023. Participants were randomly divided into derivation and validation cohorts in a 6:4 ratio. The following inflammatory indices were calculated: pan-immune-inflammation value (PIV), systemic immune-inflammation-index (SII), systemic inflammation-response index (SIRI) and conventional NPS. The mNPS was derived by integrating hs-CRP into the conventional NPS. The performance of these indices in determining in-hospital mortality was assessed using regression, calibration, discrimination, reclassification and decision curve analyses.

RESULTS

Inflammatory biomarkers, including PIV, SII, SIRI, NPS and mNPS, were significantly higher in patients who died during in-hospital follow-up compared to those discharged alive in both the derivation and validation cohorts. Multivariable logistic regression analyses were performed separately for the derivation and validation cohorts. In the derivation cohort, mNPS was associated with in-hospital mortality (aOR = 1.490, p < .001). Similarly, in the validation cohort, mNPS was associated with in-hospital mortality (aOR = 2.023, p < .001). mNPS demonstrated better discriminative and reclassification power than other inflammatory markers (p < .05 for all). Additionally, regression models incorporating mNPS were well-calibrated and showed net clinical benefit in both cohorts.

CONCLUSION

mNPS may be a stronger predictor of in-hospital mortality in STEMI patients compared to the conventional scheme and other inflammatory indices.

Ex vivo imaging of subacute myocardial infarction with ultra-short echo time 3D quantitative T1- and T1ρ -mapping magnetic resonance imaging in mice

Aims

The aim of this study was to develop an ultra-short echo time 3D magnetic resonance imaging (MRI) method for imaging subacute myocardial infarction (MI) quantitatively and in an accelerated way. Here, we present novel 3D T1- and T1ρ -weighted Multi-Band SWeep Imaging with Fourier Transform and Compressed Sensing (MB-SWIFT-CS) imaging of subacute MI in mice hearts ex vivo.

Methods and results

Relaxation time-weighted and under-sampled 3D MB-SWIFT-CS MRI were tested with manganese chloride (MnCl2) phantom and mice MI model. MI was induced in C57BL mice, and the hearts were collected 7 days after MI and then fixated. The hearts were imaged with T1 and adiabatic T1ρ relaxation time-weighted 3D MB-SWIFT-CS MRI, and the contrast-weighted image series were estimated with a locally low-rank regularized subspace constrained reconstruction. The quantitative parameter maps, T1 and T1ρ , were then obtained by performing non-linear least squares signal fitting on the image estimates. For comparison, the hearts were also imaged using 2D fast spin echo-based T2 and T1ρ mapping methods. The relaxation rates varied linearly with the MnCl2 concentration, and the T1 and T1ρ relaxation time values were elevated in the damaged areas. The ischaemic areas could be observed visually in the 3D T1, 3D T1ρ , and 2D MRI maps. The scar tissue formation in the anterior wall of the left ventricle and inflammation in the septum were confirmed by histology, which is in line with the results of MRI.

Conclusion

MI with early fibrosis, increased inflammatory activity, and interstitial oedema were determined simultaneously with T1 and T1ρ relaxation time constants within the myocardium by using the 3D MB-SWIFT-CS method, allowing quantitative isotropic 3D assessment of the entire myocardium.

Downstream cangrelor versus upstream ticagrelor in patients with ST-segment elevation myocardial infarction: A propensity score-matched analysis

BACKGROUND

Pretreatment with a P2Y12 inhibitor may be considered in patients with ST-segment elevation myocardial infarction (STEMI) referred to percutaneous coronary intervention (PCI). Intravenous cangrelor is an alternative in this setting, where oral absorption can be hindered. The aim of this study was to compare cangrelor administered after coronary angiography (i.e., "downstream") and ticagrelor pretreatment (i.e., "upstream").

METHODS

STEMI patients undergoing PCI from October 2019 to June 2023 were included. The primary outcome was the composite of in-hospital major adverse cardiovascular events (MACE). Secondary outcomes included individual components of the primary outcome and in-hospital major bleeding. Univariable and multivariable regression analyses were performed in unmatched and propensity-matched cohorts.

RESULTS

Of 6086 patients enrolled in the prospective CAST registry, 761 were included: 383 (50.3 %) received downstream cangrelor and 378 (49.7 %) upstream ticagrelor. In the matched population, no between-group differences were observed in MACE (odds ratio [OR] 1.30; 95 % confidence interval [CI] 0.79-2.17; P 0.308), all-cause death (OR 1.91; 95 % CI 0.87-4.54; P 0.124), myocardial infarction (OR 2.64; 95 % CI 0.76-12.14; P 0.154), stent thrombosis (OR 0.38; 95 % CI 0.06-1.80; P 0.255), unplanned repeat revascularization (OR 1.22; 95 % CI 0.32-4.98; P 0.766) and major bleeding (OR 0.98; 95 % CI 0.50-1.93; P 0.955). Cardiogenic shock and bailout administration of glycoprotein IIb/IIIa inhibitors were independent predictors of MACE, while radial access showed an inverse association with the primary outc.

CONCLUSIONS

In P2Y12-naïve STEMI patients undergoing primary PCI, no significant differences were noted in the risk of in-hospital ischemic and bleeding events between downstream cangrelor and upstream ticagrelor.

Predictive models for cholesterol crystals and plaque vulnerability in acute myocardial infarction: Insights from an optical coherence tomography study

BACKGROUND

Cholesterol crystals (CCs) are recognized as a risk factor for vulnerable atherosclerotic plaque rupture (PR) and major adverse cardiovascular events. However, their predictive factors and association with plaque vulnerability in patients with acute myocardial infarction (AMI) remain insufficiently explored. Therefore, This study aims to investigate the association between CCs and plaque vulnerability in culprit lesions of AMI patients, identify the factors influencing CCs formation, and develop a predictive model for CCs.

METHODS

A total of 431 culprit lesions from AMI patients who underwent pre-intervention optical coherence tomography (OCT) imaging were analyzed. Patients were divided into groups based on the presence or absence of CCs and PR. The relationship between CCs and plaque vulnerability was evaluated. A risk nomogram for predicting CCs was developed using the least absolute shrinkage and selection operator and logistic regression analysis.

RESULTS

CCs were identified in 64.5 % of patients with AMI. The presence of CCs was associated with a higher prevalence of vulnerable plaque features, such as thin-cap fibroatheroma (TCFA), PR, macrophage infiltration, neovascularization, calcification, and thrombus, compared to patients without CCs. The CCs model demonstrated an area under the curve (AUC) of 0.676 for predicting PR. Incorporating CCs into the TCFA model (AUC = 0.656) significantly enhanced predictive accuracy, with a net reclassification improvement index of 0.462 (95 % confidence interval [CI]: 0.263-0.661, p < 0.001) and an integrated discrimination improvement index of 0.031 (95 % CI: 0.013-0.048, p = 0.001). Multivariate regression analysis identified the atherogenic index of plasma (odds ratio [OR] = 2.417), TCFA (OR = 1.759), macrophage infiltration (OR = 3.863), neovascularization (OR = 2.697), calcification (OR = 1.860), and thrombus (OR = 2.430) as independent risk factors for CCs formation. The comprehensive model incorporating these factors exhibited reasonable discriminatory ability, with an AUC of 0.766 (95 % CI: 0.717-0.815) in the training set and 0.753 (95 % CI: 0.704-0.802) in the internal validation set, reflecting good calibration. Decision curve analysis suggested that the model has potential clinical utility within a threshold probability range of approximately 18 % to 85 %.

CONCLUSIONS

CCs were associated with plaque vulnerability in the culprit lesions of AMI patients. Additionally, this study identified key factors influencing CCs formation and developed a predictive model with potential clinical applicability.

Peri-procedural outcome according to VARC-3 criteria and hemodynamic mid-term follow-up after Valve-in-valve transcatheter aortic valve replacement for failed aortic bioprosthesis

Despite the widespread adoption of valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) for patients with failed aortic bioprosthesis, the effectiveness of this treatment for Japanese patients frequently associated with small aortic annuli remains unclear. From December-2011 to October-2022, 41 consecutive patients undergoing VIV-TAVR were enrolled in this study. The endpoints were technical success, device success, early safety, and two-year mortality according to implanted surgical valve size (small valves: 19-mm and 21-mm, n = 23; large valves: 23-mm and 25-mm, n = 18). The patient population had a mean age of 80.5 years, 46.3% male. Technical success, device success, and early safety rates were 100%, 70.7%, and 87.8%, respectively. There was no significant increase in the transprosthetic gradient throughout the follow-up (mean pressure gradient pre-VIV, post-VIV, at one-year, and at two-year; 37.0 mmHg, 16.5 mmHg, 15.0 mmHg, and 12.0 mmHg, respectively). While technical success and two-year mortality were comparable (87.5% vs. 86.7%, log-rank p = 0.816), device success was significantly lower in the small valves than in the large valves (56.5% vs. 88.9%, p = 0.038). Early safety trended lower in the small valves. Valve hemodynamic performance improved in both groups, but severe prosthesis-patient mismatch was more common in the small valves. VIV-TAVR demonstrated acceptable technical performance and relatively low mid-term mortality in this Japanese population, irrespective of aortic annular size. However, device success and early safety were significantly worse in patients with small valves than in those with large valves.

Prognostic Impact of Insulin-Treated and Non-Insulin-Treated Diabetes in Patients with a Reduced Ejection Fraction After ST-Elevation Myocardial Infarction

Background

Insulin- and non-insulin treated diabetes (ITDM and NITDM) have different prognostic impact in patients with myocardial infarction and/or heart failure. The aim of this study was to analyze the prognostic impact of ITDM and NTIDM on the incidence of all-cause mortality and major adverse cardiovascular events (MACE- cardiovascular death, nonfatal infarction, nonfatal stroke, and target vessel revascularization) in the 8-year follow-up of patients with ST-segment elevation myocardial infarction (STEMI) with a reduced ejection fraction (EF).

Methods

We analyzed 2230 consecutive STEMI patients treated with primary percutaneous coronary intervention and with EF < 50%. Echocardiographic examination was performed after primary percutaneous coronary intervention . Patients were divided into 3three groups: those with ITDM, those with NITDM, and those with no DM. Patients presenting with cardiogenic shock were excluded.

Results

The incidence of DM was 20.7%; among the patients with DM, 103 (22.3%) had ITDM. Patients with ITDM and NITDM had a higher incidence of mortality and MACE, compared with patients without DM. Also, at 8-year follow-up, the incidences of all-cause mortality and MACE were significantly higher in patients with ITDM vs patients with NITDM (37.8% vs 13.1%, P < 0.001 and 40.8% vs 18.9%, P < 0.001, respectively). Multivariable analysis showed ITDM to be an independent predictor for long-term mortality (hazard ratio 1.76, 95% confidence interval 1.15-2.69), and MACE (hazard ratio 1.72, 95% confidence interval 1.15-2.62).

Conclusions

ITDM was an independent predictor of the occurrence of long-term mortality and MACE in patients with STEMI and reduced EF. NITDM was not an independent predictor for the occurrence of adverse events in analyzed patients.

Potential Correlation Between Hematological Parameters and Palpitation in Outpatients With COVID-19: A Retrospective Study

BACKGROUND

Research on heart injury caused by COVID-19 is limited to large observational and retrospective cohort studies using imaging or pathological data. Reported changes in the levels of myocardial markers in severe diseases have been limited, with few studies on mild infections. The effects of COVID-19 on cardiac function and changes in myocardial marker levels have not yet been reported.

METHODS

We analyzed data from outpatient blood samples collected at Beijing Anzhen Hospital during the 2022 COVID-19 outbreak and used the same periods in 2020 and 2021 as controls, focusing on changes in routine blood tests, coagulation, myocardial markers, and other blood indices in patients with palpitations.

RESULTS

The number of patients with palpitations increased by 4.87-fold during the COVID-19 mass outbreak in 2022. The indices of myocardial damage did not show any symptom-related increases but decreased within the normal range. The proportion of patients with palpitations whose D-dimer and fibrinogen/fibrin degradation product (FDP) values exceeded the reference ranges increased, as did the numbers of neutrophils, monocytes, and platelets. In this retrospective analysis, we found little change in the myocardial markers in patients with mild COVID-19.

CONCLUSIONS

In patients with mild COVID-19, attention should be diverted from detecting myocardial markers to changes in coagulation test results, focusing on the levels of coagulation indices to improve circulation and prevent thrombosis.

Efficacy and safety of bempedoic acid in acute coronary syndrome. Design of the clinical trial ES-BempeDACS

INTRODUCTION AND OBJECTIVES

Only about 1 out of every 3 patients with acute myocardial infarction (AMI) achieve low-density lipoprotein cholesterol (LDL-C) values <55mg/dL in the first year. The present study aims to evaluate the impact of early intensive therapy on lipid control after an AMI.

METHODS

An independent, prospective, pragmatic, controlled, randomized, open-label, evaluator-blinded clinical trial (PROBE design) will analyze the efficacy and safety of an oral lipid-lowering triple therapy: high-potency statin+bempedoic acid (BA) 180mg+ezetimibe (EZ) 10mg versus current European-based guidelines (high-potency statin±EZ 10mg), in AMI patients. LDL-C will be determined within the first 48hours. Patients with LDL-C ≥ 115mg/dL (without previous statin therapy), ≥ 100mg/dL (with previous low-potency or high-potency statin therapy at submaximal dose), or ≥ 70mg/dL (with previous high-potency statin therapy at high dose) will be randomly assigned 1:1 between 24 and 72hours post-AMI to the BA/EZ combination or to statin±EZ, without BA. The primary endpoint is the proportion of patients reaching LDL-C <55mg/dL at 8 weeks after treatment.

RESULTS

The results of this study will provide novel information for post-AMI LDL-C control by evaluating the usefulness of an early intensive lipid-lowering strategy based on triple oral therapy.

CONCLUSIONS

Early intensive lipid-lowering triple oral therapy vs the treatment recommended by current clinical practice guidelines could facilitate the achievement of optimal LDL-C levels in the first 2 months after AMI (a high-risk period).

IDENTIFICATION NUMBER

EudraCT 2021-006550-31.

The effect of standardization of insertion and removal of percutaneous left ventricular assist device

BACKGROUND

The effect of standardizing an insertion and removal protocol for pVAD devices has not been previously described.

OBJECTIVES

We sought to evaluate clinical outcomes in patients who underwent pVAD insertion pre- and post-protocol standardization.

METHODS

All patients who underwent pVAD insertion that remained in place at index procedure completion between January 2017 and September 2023 at a single academic center for both high-risk PCI and cardiogenic shock indications were included in the study. The primary outcome was the incidence of limb ischemia and major bleeding before and after the protocol initiation. Secondary outcomes included in-hospital and 30-day MACCE rate (death, myocardial infarction, stroke, emergent CABG), and how often the operators followed the protocol.

RESULTS

A total of 89 patients had pVAD left in place (29 pre-protocol initiation and 60 post-protocol initiation). There was a significant decrease in incidence of limb ischemia post-protocol initiation compared to pre (17.2 % vs 1.7 %, p = 0.01) but no difference in bleeding incidence (13.8 % vs 20.0 %, p = 0.47). Adherence increased in all components of the protocol except for right heart catheterization.

CONCLUSION

Standardization of an insertion and removal protocol for pVAD devices led to a statistically significant decrease in limb ischemia in a high-risk patient population.

The effectiveness of HALP score in predicting mortality in non-ST-elevation myocardial infarction patients

BACKGROUND

The HALP score, measured based on hemoglobin, albumin, lymphocyte, and platelet levels, is regarded as a novel scoring system that indicates the status of systemic inflammation and nutritional health. Our study aimed to evaluate the relationship between HALP score and prognosis in non-ST-elevation myocardial infarction (NSTEMI) patients.

METHODS

Between 1 January 2020 and 1 January 2022, 568 consecutive patients diagnosed with NSTEMI from a single center were included in the study retrospectively. The patients were divided into two equal groups according to the median HALP cutoff value of 44.05. Patients were followed for at least 1 year from the date of admission.

RESULTS

The average age of the patients was 62.3 ± 10.6 years and 43.7% were female. In-hospital and 1-year mortality were found to be significantly higher in the group with low HALP scores (6.0 vs. 2.1%, P  = 0.019 and 22.5 vs. 9.9%, P  < 0.001, respectively). In receiver operating characteristic curve analysis, a cutoff level of 34.6 of the HALP score predicted 1-year mortality with 71% sensitivity and 65% specificity (area under the curve: 0.707, 95% confidence interval: 0.651-0.762, P  < 0.001). In Kaplan-Meier analysis, higher mortality rates were observed over time in the group with lower HALP scores (log-rank test=16.767, P  < 0.001). In Cox regression analysis, the HALP score was found to be an independent predictor of 1-year mortality (odds ratio: 0.969, 95% confidence interval: 0.958-0.981, P  < 0.001).

CONCLUSION

We found that a low HALP score could predict in-hospital and 1-year mortality in patients admitted to the hospital with a diagnosis of NSTEMI.

Chest Pain at Rest With Unremarkable ECG and Cardiac Enzymes: Case Study Emphasising the Importance of Clinical Suspicion in the Diagnosis of Coronary Artery Disease

BACKGROUND

Coronary artery disease (CAD), primarily caused by atherosclerosis, is a leading cause of death, presenting as angina or myocardial infarction. Advances in cardiac imaging, angiography, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery have improved early detection and management of this condition. This report presents the case of a man who experienced worsening exertional chest pain and discomfort while at rest.

CASE REPORT

A 66-year-old man with a history of neurogenic syncope and asthma presented at the same-day emergency care (SDEC) unit with worsening exertional chest pain and discomfort whilst at rest. Despite normal ECG and cardiac enzyme results, further cardiac computed tomography angiography (CTCA) revealed significant CAD with moderate stenosis in the right coronary artery (RCA) and severe stenosis at the left anterior descending artery (LAD) bifurcation, leading to CABG surgery. Echocardiography showed a left ventricular ejection fraction of 50-54% with mid-inferior and basal to mid-inferoseptal hypokinesia. The cardiology-cardiothoracic multidisciplinary team concluded that CABG surgery would provide the most durable long-term outcome.

CONCLUSION

This case demonstrates the high importance of clinical suspicion of CAD despite normal initial investigations in the early identification and timely investigation as well as the role multidisciplinary teams and CABG can play in the timely management of complex CAD, ultimately leading to improved patient outcomes.

Newly Initiated Statin Treatment Is Associated with Decreased Plasma Coenzyme Q10 Level After Acute ST-Elevation Myocardial Infarction

Coenzyme Q10 (CoQ10) plays a crucial role in facilitating electron transport during oxidative phosphorylation, thus contributing to cellular energy production. Statin treatment causes a decrease in CoQ10 levels in muscle tissue as well as in serum, which may contribute to the musculoskeletal side effects. Therefore, we aimed to assess the effect of newly initiated statin treatment on serum CoQ10 levels after acute ST-elevation myocardial infarction (STEMI) and the correlation of CoQ10 levels with key biomarkers of subclinical or clinically overt myopathy. In this study, we enrolled 67 non-diabetic, statin-naïve early-onset STEMI patients with preserved renal function. Plasma CoQ10 level was determined by ultra-high-performance liquid chromatography-tandem mass spectrometry (UPLC/MS-MS), while the myopathy marker serum fatty acid-binding protein 3 (FABP3) level was measured with enzyme-linked immunosorbent assay (ELISA) at hospital admission and after 3 months of statin treatment. The treatment significantly decreased the plasma CoQ10 (by 43%) and FABP3 levels (by 79%) as well as total cholesterol, low-density lipoprotein cholesterol (LDL-C), apolipoprotein B100 (ApoB100), and oxidized LDL (oxLDL) levels. The change in CoQ10 level showed significant positive correlations with the changes in total cholesterol, LDL-C, ApoB100, and oxLDL levels, while it did not correlate with the change in FABP3 level. Our results prove the CoQ10-reducing effect of statin treatment and demonstrate its lipid-lowering efficacy but contradict the role of CoQ10 reduction in statin-induced myopathy.

Short- and long-term outcomes of patients with acute myocardial infarction complicated by cardiac arrest: a nationwide cohort study 2013-22

AIMS

To assess short- and long-term outcomes of acute myocardial infarction (AMI) complicated by out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA) in a nationwide cohort.

METHODS AND RESULTS

Cohort study of AMI patients admitted to hospitals in Norway 2013-22 registered in the Norwegian Myocardial Infarction Registry. Outcomes were in-hospital and long-term mortality. Cumulative mortality was assessed with the Kaplan-Meier and the life-table methods. Cox regression was used for risk comparisons. Among 105 439 AMI patients (35% women), we identified 3638 (3.5%) patients with OHCA and 2559 (2.4%) with IHCA. The mean age was 65.7 (13.2), 70.9 (12.6), and 70.7 (13.6) years for OHCA, IHCA, and AMI without cardiac arrest (CA), respectively. The median follow-up time was 3.3 (25th, 75th percentile: 1.1, 6.3) years. In-hospital mortality was 28, 49, and 5%, in OHCA, IHCA, and AMI without CA, and the estimated 5-year cumulative mortality was 48% [95% confidence interval (CI) 46-50%], 69% (95% CI 67-71%), and 35% (95% CI 34-35%), respectively. Among patients surviving to hospital discharge, no significant difference in mortality during follow-up was found between OHCA and AMI without CA [adjusted hazard ratio (HR) 1.04, 95% CI 0.96-1.13], while the long-term mortality of AMI patients with IHCA was higher (age-adjusted HR 1.31, 95% CI 1.19-1.45).

CONCLUSION

In this large, contemporary cohort of AMI patients, in-hospital mortality of patients with OHCA or IHCA was still high. Among patients surviving to hospital discharge, long-term mortality was comparable between OHCA and AMI without CA, while the outcome of patients with IHCA was significantly worse.

Emergency department use of a high-sensitivity point-of-care troponin assay reduces length of stay: an implementation study preliminary report

AIMS

Point-of-care (POC) high-sensitivity troponin (hs-cTn) assays within a clinical pathway may safely reduce length of stay (LoS) for patients presenting to the emergency department (ED) with possible acute myocardial infarction (AMI). In this early report, we present the first evaluation of a POC hs-cTn in real-life care.

METHODS AND RESULTS

In adult patients presenting to ED investigated for possible AMI, we compared the LoS in patients assessed with a troponin in the 8 weeks before (usual-care phase) and the 8 weeks following introduction of the Siemens Atellica VTLi POC hs-cTnI for decision-making (intervention phase). The VTLi replaced the laboratory (Beckman Coulter) assay as the default hs-cTn test within the clinical pathway. This was the only change to the pathway process. The safety outcome was first event AMI or cardiac death within 30 days. There were 2376 presentations in the usual-care phase with 188 individuals with AMI and 2392 in the intervention phase with 198 AMI. In the intervention phase, there was a mean (95% CI) reduction in LoS of 32 min (22-41 min) compared with the usual-care phase. This represents 21.4 fewer patient-hours in the ED each day (1196 in the 8-week period). In both phases, the pathway correctly identified all cases of AMI at index attendance. There were four follow-up events (two usual-care, two intervention) within 30 days.

CONCLUSION

The deployment of a hs-cTn POC analyser into a large ED safely reduced length of stay. If translatable to other EDs, this could represent an important advancement to patient care.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry, No. ACTRN12619001189112.

ECPR for cardiac arrest caused by abnormal uterine bleeding and coronary vasospasm: a case report

Introduction

Cardiac arrest during pregnancy is receiving increasing attention. However, there are few reports on cardiac arrest in nonpregnant women caused by abnormal uterine bleeding (AUB). We report a case in which extracorporeal cardiopulmonary resuscitation (ECPR) was used in a patient with cardiac arrest caused by AUB and coronary vasospasm.

Patient presentation

A 52-year-old female patient presented to the emergency department because of sudden chest pain, with a history of hypertension, coronary heart disease and AUB for more than half a month. At the initial stage of admission, cardiac arrest occurred after the ECG demonstrated ST-segment elevation in leads II, III and a VF. ECPR was started after traditional cardiopulmonary resuscitation, and coronary angiography was performed with the support of extracorporeal membrane oxygenation (ECMO). The left and right coronary arteries were slender and narrow, which was relieved after the injection of 100 µg nitroglycerine through the left coronary artery. After performing a coronary angiogram, the patient was given long-acting nitrates and calcium channel blockers orally, and her chest pain did not reoccur. The patient was weaned from ECMO support after 4 days.

Conclusion

This clinical case highlights the challenges that clinicians face in accurately diagnosing and possibly treating AUB and coronary vasospasm-induced acute myocardial infarction because of its rare occurrence and serious adverse events. ECPR can effectively improve the success rate of cardiopulmonary resuscitation.

Complete or incomplete revascularization in patients with left main culprit lesion acute myocardial infarction with multivessel disease: a retrospective observational study

BACKGROUND

Complete revascularization has demonstrated better outcomes in patients with acute myocardial infarction (AMI) and multivessel disease. However, in the case of left main (LM) culprit lesion AMI with multivessel disease, there is limited evidence to suggest that complete revascularization is better.

METHODS

We reviewed 16,831 patients in the Korea Acute Myocardial Infarction Registry who were treated from July 2016 to June 2020, and 399 patients were enrolled with LM culprit lesion AMI treated with percutaneous coronary intervention. We categorized the patients as those treated with complete revascularization (n=295) or incomplete revascularization (n=104). The study endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, ischemia-driven revascularization, stent thrombosis, and stroke. We performed propensity score matching (PSM) and analyzed the incidence of MACCE at 1 year.

RESULTS

After PSM, the two groups were well balanced. There was no significant difference between the two groups in MACCE at 1 year (12.1% vs. 15.2%; hazard ratio, 1.28; 95% confidence interval, 0.60-2.74; p=0.524) after PSM. The components of MACCE and major bleeding were also not significantly different.

CONCLUSION

There was no significant difference in clinical outcomes between the groups treated with complete or incomplete revascularization for LM culprit lesion AMI with multivessel disease.

Drug-Induced Myocardial Infarction: A Review of Pharmacological Triggers and Pathophysiological Mechanisms

Myocardial infarction (MI) is a significant cardiovascular event caused by the decrease in or complete cessation of blood flow to a portion of the myocardium. It can arise from a variety of etiological factors, including pharmacological triggers. This review aims to explore the diverse drugs and substances that might lead to drug-induced myocardial infarction, focusing on their mechanisms of action and the pathophysiological processes involved. Various established and emerging pharmacological agents that could elevate the risk of myocardial infarction, such as nonsteroidal anti-inflammatory drugs, hormonal therapies, anticoagulants, and antipsychotic medications, are discussed. The role of drug-induced endothelial dysfunction, coronary artery spasm, and thrombosis are presented in order to highlight the underlying mechanisms. This review emphasizes the need for increased awareness among healthcare professionals to mitigate the risks associated with different pharmacological therapies to improve patient outcomes.

Age Variation in Patients with Troponin Level Elevation Without Obstructive Culprit Lesion or Suspected Myocardial Infarction with Non-Obstructive Coronary Arteries-Long-Term Data Covering over Decade

Background/Objectives: Troponin level elevation without an obstructive culprit lesion is caused by heterogenous entities. The effect of aging on this condition has been poorly investigated. Methods: After screening 24,775 patients between 2010 and 2021, this study included a total of 373 patients with elevated troponin levels without an obstructive culprit lesion or suspected myocardial infarction with non-obstructive coronary arteries (MINOCAs) categorized into four age groups containing 78 patients (<51 years), 72 patients (51-60 years), 81 patients (61-70 years), and 142 patients (>70 years). This study analyzed the baseline characteristics, the in-hospital complications, in-hospital mortality, and the long-term outcomes. Results: The older patients exhibited a higher rate of major adverse cardiovascular in-hospital events than those of the other age groups (15.4% in the <51-year-old group vs. 36.1% in the 51-60-year-old group vs. 33.3% in the 61-70-year-old group vs. 47.2% in the >70-year-old group; p < 0.001). However, the rate of non-sustained ventricular tachycardia (nsVT) was higher in the 51-60-year-old patients than those of the other age groups (5.6% in the 51-60-year-old group vs. 1.3% in the 61-70-year-old group vs. 0.7% in the >70-year-old group; p = 0.027). At the 11-year follow-up, cardiovascular mortality was higher among the older patients compared to that of the younger patients (3.9% in the 61-70-year-old group vs. 4.2% in the >70-year-old group, p = 0.042), while non-cardiovascular mortality was comparable between the age groups. Conclusions: The older patients with troponin level elevation without an obstructive culprit lesion experienced a higher incidence of major adverse cardiovascular events during hospitalization compared to that of the younger groups. Additionally, higher cardiovascular mortality rates were revealed in the older patients at a long-term follow-up.

Myocardial infarction of the "forgotten chamber of the heart" — the right atrium: a clinical case

The incidence of atrial myocardial infarction (MI) varies widely, from 0.7 to 42%. This indicates that atrial MI is an overlooked rather than a rare pathology. Ischemic myocardial damage due to atherosclerotic lesions of the coronary vessels is characteristic of left atrial MI, which is often combined with left ventricular MI. In right atrial (RA) MI, the main pathogenesis link is RA overload, which occurs due to pulmonary hypertension. Isolated atrial MI is a poorly understood issue in modern cardiology; however, it may have independent clinical significance. However, there is no unified approach to pathogenesis, and there is no specific diagnostics or treatment. The article presents a clinical case of isolated RA MI (isolated necrosis of the right cardiac auricle) that developed as a result of a series of sequential events triggered by acute decompensation of chronic heart failure (CHF). The cause of this acute decompensation of CHF remains debatable. Probably, the leading contribution to CHF decompensation was made by a previous left ventricular MI with damage to the infarct-related right coronary artery basin, which causes RA involvement. Acute decompensation of CHF led to the development of deep vein thrombosis of the lower extremities. Pulmonary embolism developed as a result of deep vein thrombosis of the lower extremities and caused pulmonary hypertension, which in turn served as the basis for the development of RA MI. Due to the small thickness of the atrial wall, acute ischemic damage to the RA in this clinical case led to myomalacia and perforation of the RA wall. Due to the complexity of lifetime diagnosis of isolated atrial myocardial damage and scant clinical symptoms, this condition requires special attention and should be covered in order to develop generally accepted views on the management of patients with this pathology and to determine a list of effective treatment measures aimed at saving the patient’s life.

Cardiovascular Data Quality in the Danish National Patient Registry (1977-2024): A Systematic Review

Background

The increasing use of routinely collected health data for research puts great demands on data quality. The Danish National Patient Registry (DNPR) is renowned for its longitudinal data registration since 1977 and is a commonly used data source for cardiovascular epidemiology.

Objective

To provide an overview and examine determinants of the cardiovascular data quality in the DNPR.

Methods

We performed a systematic literature search of MEDLINE (PubMed) and the Danish Medical Journal, and identified papers validating cardiovascular variables in the DNPR during 1977-2024. We also included papers from reference lists, citations, journal e-mail notifications, and colleagues. Measures of data quality included the positive predictive value (PPV), negative predictive value, sensitivity, and specificity.

Results

We screened 2,049 papers to identify 63 relevant papers, including a total of 229 cardiovascular variables. Of these, 200 variables assessed diagnoses, 24 assessed treatments (10 surgeries and 14 other treatments), and 5 assessed examinations. The data quality varied substantially between variables. Overall, the PPV was ≥90% for 36% of variables, 80-89% for 26%, 70-79% for 16%, 60-69% for 7%, 50-59% for 4%, and <50% for 11% of variables. The predictive value was generally higher for treatments (PPV≥95% for 92%) and examinations (PPV≥95% for 100%) than for diagnoses (PPV≥80% for 71%). Moreover, the PPV varied for individual diagnoses depending on the algorithm used to identify them. Key determinants for validity were patient contact type (inpatient vs outpatient), diagnosis type (primary vs secondary), setting (university vs regional hospitals), and calendar year.

Conclusion

The validity of cardiovascular variables in the DNPR is high for treatments and examinations but varies considerably between individual diagnoses depending on the algorithm used to define them.

An Atypical Presentation of Acute Cholecystitis with Left Sided Chest Pain and ST Elevation - A Case Report

Background

ST elevation combined with typical chest pain is an indication for acute coronary vascularization and is usually associated with acute myocardial infarction. Herein, we present an unusual case of ST elevation.

Case Presentation

A 57-year-old male patient presented to the emergency department with chest pain radiating to both arms and the back. Typical clinical presentation and inferolateral ST elevations were suggestive of ST elevation myocardial infarction. Interestingly, coronary occlusion was excluded by coronary angiography. Despite extensive diagnostic workup, no underlying diagnosis was made. Four days later, the patient returned and reported pain in the right upper abdomen. Clinical presentation, laboratory analysis, and imaging features led to a diagnosis of calculous acute cholecystitis. Laparoscopic cholecystectomy was performed, and the diagnosis was confirmed. Electrocardiographic changes and pain resolved completely.

Conclusion

Acute calculous cholecystitis is initiated by gallbladder distension due to biliary duct occlusion caused by gallstones. ST elevations in response to gallbladder distension have been demonstrated in animal models. We hypothesize that the ST elevations observed in this patient with chest pain were linked to stone-mediated distension of the gallbladder, leading to reflex coronary vasoconstriction.

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

AIMS

Cardiogenic shock (CS) is a life-threatening disease burdened by a mortality up to 50%. The epidemiology has changed with non-ischaemic aetiologies being predominant, although data were mainly derived from patients admitted to dedicated acute cardiac care. We report the epidemiology and outcome of patients with CS admitted to general intensive care unit (ICU).

METHODS AND RESULTS

Prospective multicentric epidemiological study including 314 general ICU adhering to the GiViTI nationwide registry from 2011 to 2018, excluding cardiac arrest. The primary endpoint of the study was mortality. The association between clinical factors and mortality was evaluated using a logistic regression model. The odds ratios (ORs) of the covariates quantify their association with mortality during hospitalization. A total of 11 052 patients admitted to general ICU {incidence 2.17%; median age 72 [interquartile range (66-81)], 38.7% were women} with CS were included. Forty-seven per cent of patients had more than three organ insufficiency at the time of admission. The most common CS aetiologies were left heart failure (LHF, 5247-47.5%); acute myocardial infarction (3612-32.6%); right heart failure (RHF, 515-4.6%); and biventricular failure (532-4.8%). A total of 85.5% were mechanically ventilated during the ICU hospitalization. The overall ICU mortality was 44.8%, increasing to 53.4% during the hospitalization in the index hospital and to 54.3% at the latest hospital. Right heart failure-cardiogenic shock patients exhibited the highest mortality risk [OR: 1.19, 95% confidence interval (CI) (0.94-1.50); P < 0.001], followed by biventricular CS [OR 1.04, 95% CI (0.82-1.32)]. Respiratory failure [OR 1.13 (95% CI 1.08-1.19)], coagulation disorder [1.17 (95% CI 1.1-1.24)], renal dysfunction [OR 1.55 (95% CI 1.50-1.61)], and neurological alteration [OR 1.45 (95% CI 1.39-1.50)] were associated with worsen outcome along with severe hypotension [systolic blood pressure < 70 mmHg-OR 2.35, 95% CI (2.06-2.67)], increasing age [OR 2.21 95% CI (2.01-2.42)], and longer ICU stay prior to admission (two-fold increase for each 4.7 days).

CONCLUSION

In the general ICU, the aetiology of CS, excluding cardiac arrest, remains characterized mostly by LHF with RHF-CS burdened by higher mortality. Multiorgan failure at admission and longer hospital stay before ICU admission predispose to worsen outcome.

Prognostic utility of a multi-biomarker panel in patients with suspected myocardial infarction

BACKGROUND

The accurate identification of patients with high cardiovascular risk in suspected myocardial infarction (MI) is an unmet clinical need. Therefore, we sought to investigate the prognostic utility of a multi-biomarker panel with 29 different biomarkers in in 748 consecutive patients with symptoms indicative of MI using a machine learning-based approach.

METHODS

Incident major cardiovascular events (MACE) were documented within 1 year after the index admission. The selection of the best multi-biomarker model was performed using the least absolute shrinkage and selection operator (LASSO). The independent and additive utility of selected biomarkers was compared to a clinical reference model and the Global Registry of Acute Coronary Events (GRACE) Score, respectively. Findings were validated using internal cross-validation.

RESULTS

Median age of the study population was 64 years. At 1 year of follow-up, 160 cases of incident MACE were documented. 16 of the investigated 29 biomarkers were significantly associated with 1-year MACE. Three biomarkers including NT-proBNP (HR per SD 1.24), Apolipoprotein A-I (Apo A-I; HR per SD 0.98) and kidney injury molecule-1 (KIM-1; HR per SD 1.06) were identified as independent predictors of 1-year MACE. Although the discriminative ability of the selected multi-biomarker model was rather moderate, the addition of these biomarkers to the clinical reference model and the GRACE score improved model performances markedly (∆C-index 0.047 and 0.04, respectively).

CONCLUSION

NT-proBNP, Apo A-I and KIM-1 emerged as strongest independent predictors of 1-year MACE in patients with suspected MI. Their integration into clinical risk prediction models may improve personalized risk stratification.

The safety and efficacy of indobufen or aspirin combined with clopidogrel in patients with acute myocardial infarction after percutaneous coronary intervention

Currently, the standard treatment for patients who have undergone percutaneous coronary intervention (PCI) following acute myocardial infarction (MI) involves dual antiplatelet therapy (DAPT) with a combination of aspirin and a potent P2Y12 receptor inhibitor. However, the potential benefits of aspirin were partially constrained by the intolerance of some patients. The safety and efficacy of indobufen, an alternative antiplatelet agents to aspirin, in patients with AMI after PCI are yet to be thoroughly investigated.This retrospective study was conducted at a single center and utilized propensity score matching. The enrollment spanned from January 2019 to June 2022, incorporating patients with AMI after PCI. The participants were categorized into two groups based on discharged prescriptions: the aspirin DAPT group and the indobufen DAPT group. The primary endpoint focused on net adverse clinical event (NACE), defined as a composite outcome, including cardiac death, recurrence of MI, definite or probable stent thrombosis (ST), target lesion revascularization (TLR), ischemic stroke and Bleeding Academic Research Consortium (BARC) criteria type 2, 3, or 5. All the patients underwent a one-year follow-up period.A total of 1451 patients were enrolled in this study, with 258 assigned to the indobufen DAPT group and 1193 to the aspirin DAPT group. Following 1:1 propensity score matching, 224 patients were retained in each group. In the indobufen DAPT group, 58 individuals (25.9%) experienced the primary endpoint within one year, compared to 52 individuals (23.2%) in the aspirin DAPT group (HR 1.128, 95% CI 0.776-1.639, p = .527). Specifically, no significant differences were observed in either the efficacy endpoint (MACCE, 20.1% vs. 14.7%, HR 1.392, 95% CI 0.893-2.170, p = .146) or the safety endpoint (BARC 2,3 or 5, 8.04% vs. 10.30%, HR 0.779, p = .427). These findings remained consistent at 1, 3, or 6 months. Additionally, the incidence of gastrointestinal symptoms were significantly lower in indobufen DAPT group compared to the aspirin DAPT group (7.1% vs. 14.3%, p = .022).Our research reveals that the efficacy and safety of indobufen are comparable to aspirin in Chinese patients with AMI following PCI. Given the potential advantages of indobufen in alleviating gastrointestinal symptoms, we propose it as a viable alternative for individuals intolerant to aspirin.

Routine beta-blocker therapy after acute coronary syndromes: The end of an era?

BACKGROUND

Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.

METHODS

The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.

RESULTS

Recently, the REDUCE-AMI trial-the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)-showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%-49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1-12 months after ACS in patients with LVEF >40%.

CONCLUSION

We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.

Can FDG PET Serve as a Clinically Relevant Tool for Detecting Active Non-sarcoidotic Myocarditis?

The diagnostic work-up for myocarditis largely depends on non-invasive imaging because of the low yield of endomyocardial biopsy. In addition, differentiation among possible impressions is essential because of its non-specific clinical presentations. This ambiguity has led to the predominant use of cardiac magnetic resonance imaging techniques in the management of myocarditis, particularly during the global pandemic. Despite the unique ability of F-18 fluorodeoxyglucose positron emission tomography to visualize and quantify active myocardial inflammation, which has been well established in cardiac sarcoidosis, its diagnostic contribution in non-sarcoidotic myocarditis remains uncertain. This article reviews the current evidence on the non-invasive imaging diagnosis of non-sarcoidotic myocarditis and discusses the potential role of F-18 fluorodeoxyglucose positron emission tomography as a clinically relevant imaging tool.

Prognostic impact of new-onset atrial fibrillation in myocardial infarction with and without improved ejection fraction

AIMS

Improvement in left ventricular ejection fraction (impEF) often presents in contemporary acute myocardial infarction (AMI) patients. New-onset atrial fibrillation (NOAF) during AMI is an important predictor of subsequential heart failure (HF), while its impact on the trajectory of post-MI left ventricular ejection fraction (LVEF) and prognostic implication in patients with and without impEF remains undetermined. We aimed to investigate the prognostic impacts of NOAF in AMI patients with and without impEF.

METHODS AND RESULTS

Consecutive AMI patients without a prior history of AF between February 2014 and March 2018 with baseline LVEF ≤ 40% and had ≥1 LVEF measurement after baseline were included. ImpEF was defined as a baseline LVEF ≤ 40% and a re-evaluation showed both LVEF > 40% and an absolute increase of LVEF ≥ 10%. Persistently reduced EF (prEF) was defined as the second measurement of LVEF either ≤40% or an absolute increase of LVEF < 10%. The primary endpoint was a major adverse cardiac event (MACE) that was composed of cardiovascular death and HF hospitalization. Cox regression analysis and competing risk analysis were performed to assess the association of post-MI NOAF with MACE. Among 293 patients (mean age: 66.6 ± 11.3 years, 79.2% of males), 145 (49.5%) had impEF and 67 (22.9%) developed NOAF. Higher heart rate (odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.73-0.97; P = 0.015), prior MI (OR: 0.25, 95% CI: 0.09-0.69; P = 0.008), and STEMI (OR: 0.40, 95% CI: 0.21-0.77; P = 0.006) were independent predictors of post-MI impEF. Within up to 5 years of follow-up, there were 22 (15.2%) and 53 (35.8%) MACE in patients with impEF and prEF, respectively. NOAF was an independent predictor of MACE in patients with impEF (hazard ratio [HR]: 7.34, 95% CI: 2.49-21.59; P < 0.001) but not in those with prEF (HR: 0.78, 95% CI: 0.39-1.55; P = 0.483) after multivariable adjustment. Similar results were obtained when accounting for the competing risk of all-cause death (subdistribution HR and 95% CIs in impEF and prEF were 6.47 [2.32-18.09] and 0.79 [0.39-1.61], respectively).

CONCLUSIONS

The NOAF was associated with an increased risk of cardiovascular outcomes in AMI patients with impEF.

Long-term gender disparities in new-onset heart failure after acute coronary syndrome

AIMS

A paucity of studies addressed sex-related differences in clinical outcomes in the long term following acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). In these patients, it remains uncertain whether heart failure (HF) might exert a differential impact on the prognosis in the long term.

METHODS

We queried a large-scale database of ACS patients undergoing PCI. The primary endpoint was new-onset HF. Secondary endpoints included mortality, myocardial infarction, re-PCI and ischaemic stroke. Propensity score matching was generated to balance group characteristics. A total of 3334 patients after propensity score matching were analysed. Follow-up was assessed at the 5 year term.

RESULTS

At 5 year follow-up, HF risk increased significantly in males versus females {17.9% vs. 14.8%, hazard ratio [HR] [95% confidence interval (CI)] = 1.22 [1.03-1.44], P = 0.02}. At 5 year follow-up, mortality was significantly higher in the male cohort as compared with the female cohort [HR (95% CI) = 1.23 (1.02-1.47), P = 0.02]. On landmark analysis, differences in mortality emerged after the first year and were maintained thereafter. Ischaemic outcomes were comparable between cohorts.

CONCLUSIONS

Following ACS, males experienced a greater long-term risk of developing new-onset HF as compared with females. This difference remained consistent across all prespecified subgroups. Mortality was significantly higher in males. No differences were observed in ischaemic outcomes. New-onset HF emerges as a primary contributor to long-term gender disparities after ACS and a strong predictor of mortality in men with HF.

Prognostic impact of fibrinogen in patients with resistant hypertension

In this study, we investigated the long-term prognostic effects of fibrinogen levels in patients with resistant hypertension. A total of 266 patients with resistant hypertension who had serum fibrinogen measurements and 5 years of follow-up information were retrospectively included in the study. The patients were stratified according to their fibrinogen levels, which were then divided into tertiles. Clinical outcomes for major adverse cardiovascular events (MACE) were assessed at 5 years. MACE was defined as all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction (MI), non-fatal stroke, a new diagnosis of heart failure, or hospitalization for heart failure and peripheral arterial disease. The incidence of MACE at 5 years in patients with resistant hypertension was higher in the highest tertile of fibrinogen. Multivariate analysis identified fibrinogen as an independent predictor of MACE in patients with resistant hypertension (odds ratio = 1.002; 95% CI: 1.001-1.004; p = 0.009). Compared to the lowest tertile, MACE was approximately 2.5 times higher in tertile 2 and approximately 6.9 times higher in the highest tertile. Fibrinogen was able to predict MACE in patients with resistant hypertension (AUC for MACE 0.662 (95% CI 0.596-0.727; p < 0.001) based on receiver operating characteristic curve analysis. In the Kaplan-Meier curve showing follow-up without MACE (MACE-free) according to the fibrinogen cut-off value, the 5-year incidence of MACE was significantly higher in the high fibrinogen group (p < 0.001). Fibrinogen is a risk marker for MACE in patients with resistant hypertension. Antihypertensive therapy aimed at lowering fibrinogen levels may improve prognosis.

Integrating platelet reactivity in the age, creatinine and ejection fraction score to predict clinical outcomes following percutaneous coronary intervention in patients with chronic coronary syndrome: the PR-ACEF score

To evaluate if integrating platelet reactivity (PR) evaluation in the original age, creatinine and ejection fraction (ACEF) score could improve the diagnostic accuracy of the model in patients with stable coronary artery disease (CAD). We enrolled patients treated with percutaneous coronary intervention between 2010 and 2011. High PR was included in the model (PR-ACEF). Co-primary end points were a composite of death/myocardial infarction (MI) and major adverse cardiovascular events (MACE). Overall, 471 patients were enrolled. Compared to the ACEF score, the PR-ACEF showed an improved diagnostic accuracy for death/MI (AUC 0.610 vs 0.670, p < 0.001) and MACE (AUC 0.572 vs 0.634, p < 0.001). These findings were confirmed using internal validation with bootstrap resampling. At 5 years, the PR-ACEF value > 1.75 was independently associated with death/MI [HR 3.51, 95% CI (1.97-6.23)] and MACE [HR 2.77, 95% CI (1.69-4.53)]. The PR-ACEF score was effective in improving the diagnostic performance of the ACEF score at the long-term follow-up.

Efficacy and safety of levosimendan in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: The LEVOCEST trial

BACKGROUND

Primary angioplasty is the standard procedure for patients with ST-segment elevation myocardial infarction (STEMI). However, myocardial reperfusion results in additional cell damage. Levosimendan, due to its pleiotropic effects, may be a therapeutic alternative to prevent this damage. The objective of this study was to evaluate whether this drug can reduce infarct size in patients with STEMI.

METHODS

Patients were randomized to receive a 24-h infusion of either levosimendan (0.1 μg/kg/min) or placebo after the primary angioplasty. The main objective was to assess the size of the infarct by cardiac resonance at 30 days and 6 months after the event. Other variables such as left ventricular ejection fraction (LVEF) and adverse ventricular remodeling (AVR) were assessed by speckle-tracking echocardiography and magnetic resonance. Major adverse cardiovascular events (MACE) were also collected.

RESULTS

157 patients were analysed (levosimendan, n = 79; placebo, n = 78). We found that after 6 months, patients treated with levosimendan had a greater reduction in infarct size (13.19% ± 9.5% vs.11.79% ± 9%, p = 0.001), compared with those in the placebo group (13.35% ± 7.1% vs. 13.43% ± 7.8%, p = 0.38). There were no significant differences in MACE between both groups.

CONCLUSIONS

Levosimendan is a safe and effective therapeutic option for reducing infarct size in patients with STEMI.

Clinical Impact of Sarcopenia Screening on Long-Term Mortality in Patients Undergoing Coronary Bypass Grafting

BACKGROUND

Sarcopenia is an aging-related condition characterized by loss of skeletal muscle mass and is an indicator of subclinical atherosclerosis. The relationship between reduced muscle mass and long-term clinical outcomes in patients with advanced coronary artery disease who have undergone coronary artery bypass grafting (CABG) is not fully understood. This study is sought to evaluate the prognostic implications of sarcopenia screening in patients undergoing CABG.

METHODS

A total of 2810 patients who underwent CABG were analysed and classified according to presence of reduced muscle mass. The skeletal muscle index (SMI) was calculated as L3 muscle area (cm2)/height (m)2 on computed tomography. Reduced SMI was defined as SMI ≤ 45 cm2/m2 in male and ≤ 38 cm2/m2 in female. The primary outcome was all-cause mortality, and survival analysis was performed using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

The median follow-up was 8.7 years, and 924 patients (32.9%) had reduced SMI. Patients with reduced SMI were older (67.7 ± 8.8 vs. 62.2 ± 9.8 years; p < 0.001) and less frequently male (69.8% vs. 81.1%; p < 0.001). SMI was significantly associated with risk of death on a restricted cubic spline curve (HR = 1.04 per-1 decrease; 95% CI 1.03-1.05; p < 0.001). Patients with reduced SMI had a higher incidence of long-term mortality than those with preserved SMI (survival rate 41.4% vs. 62.8%; HRadj = 1.18, 95% CI 1.03-1.36, p = 0.020). Subgroup analysis showed that the prognostic implication of reduced SMI on long-term survival was more evident in male (HRadj = 2.01, 95% CI 1.72-2.35) than female (HRadj = 1.28, 95% CI 0.98-1.68) (interaction p = 0.006).

CONCLUSIONS

Reduced muscle mass, defined by SMI on computed tomography, was associated with long-term mortality after CABG. These results provide contemporary data to allow the evaluation of physical frailty in patients with advanced coronary artery disease before surgery.

TRIAL REGISTRATION

Long-Term Outcomes and Prognostic Factors in Patients Undergoing CABG or PCI: NCT03870815.

Clinical impact and predictors of periprocedural myocardial injury among patients undergoing left bundle branch area pacing

BACKGROUND

The clinical impact of Periprocedural myocardial injury (PMI) in patients undergoing permanent pacemaker implantation with Left Bundle Branch Area Pacing (LBBAP) is unknown.

METHODS

130 patients undergoing LBBAP from January 2020 to June 2021 and completing 12 months follow up were enrolled to assess the impact of PMI on composite clinical outcome (CCO) defined as any of the following: all-cause death, hospitalization for heart failure (HHF), hospitalization for acute coronary syndrome (ACS) and ventricular arrhythmias (VAs). High sensitivity Troponin T (HsTnT) was measured up to 24-h after intervention to identify the peak HsTnT values. PMI was defined as increased peak HsTnT values at least > 99th percentile of the upper reference limit (URL: 15 pg/ml) in patients with normal baseline values.

RESULTS

PMI occurred in 72 of 130 patients (55%). ROC analysis yielded a post-procedural peak HsTnT cutoff of fourfold the URL for predicting the CCO (AUC: 0.692; p = 0.023; sensitivity 73% and specificity 71%). Of the enrolled patients, 20% (n = 26) had peak HsTnT > fourfold the URL. Patients with peak HsTnT > fourfold the URL exhibited a higher incidence of the CCO than patients with peak HsTnT ≤ fourfold the URL (31% vs. 10%; p = 0.005), driven by more frequent hospitalizations for ACS (15% vs. 3%; p = 0.010). Multiple (> 2) lead repositions attempts, the use of septography and stylet-driven leads were independent predictors of higher risk of PMI with peak HsTnT > fourfold the URL.

CONCLUSIONS

PMI seems common among patients undergoing LBBAP and may be associated with an increased risk of clinical outcomes in case of more pronounced (peak HsTnT > fourfold the URL) myocardial damage occurring during the procedure.

Impact of sodium-glucose cotransporter inhibitors in acute coronary syndrome patients on endothelial function and atherosclerosis related-biomarkers: ATH-SGLT2i pilot study

Little is known about the effects of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on atherosclerosis. We aimed to determine if a 90-day intake of Dapagliflozin could improve atherosclerosis biomarkers (namely endothelial function assessed by flow-mediated dilatation [FMD] and carotid intima-media thickness [CIMT]) in diabetic and non-diabetic acute coronary syndrome (ACS) patients when initiated in the early in-hospital phase. ATH-SGLT2i was a prospective, single-center, observational trial that included 113 SGLT2i naive patients who were admitted for ACS and who were prescribed Dapagliflozin at a fixed dose of 10 mg during their hospital stay for either type 2 diabetes or for heart failure. After 90 days of follow-up, subjects who had a continuous intake of Dapagliflozin formed the SGLT2i group, while patients who did not take Dapagliflozin formed the non-SGLT2i group. In each of these main study groups, we considered diabetic and non-diabetic subgroups. The primary endpoint was the difference in between baseline and 90 days in FMD (∆FMD) and in FMD rate (∆FMD%). The secondary outcome was change in CIMT (∆CIMT). We enrolled 54 patients in the SGLT2i group aged 59 ± 9 years (70.4% males) which 30 were diabetics, and 59 in the non-SGLT2i group aged 63 ± 11 years (78% males) which 34 were diabetics. After 90 days, ∆FMD and ∆ FMD% were higher in the SGLT2i group in comparison with the non-SGLT2i group (0.05 ± 0.15 vs -0.05 ± 0.11, P < .001 and 1.78 ± 3.63 vs -0.88 ± 4, P < .001). Within the SGLT2i group, the improvement of FMD% was higher in non-diabetic patients (2.85 ± 3.46 vs 0.9 ± 3.59, P = .05). Multivariate analysis showed that Dapagliflozin intake was independently associated with FMD% improvement (HR = 2.24). After 90 days, CIMT showed no significant difference between the SGLT2i and the non-SGLT2i groups. In this pilot study, a 90-day intake of Dapagliflozin at the fixed dose of 10 mg started in the acute phase of an ACS, was associated with endothelial function improvement in diabetic and non-diabetic patients.

Self-adhesion conductive cardiac patch based on methoxytriethylene glycol-functionalized graphene effectively improves cardiac function after myocardial infarction

INTRODUCTION

Abnormal electrical activity of the heart following myocardial infarction (MI) may lead to heart failure or sudden cardiac death. Graphene-based conductive hydrogels can simulate the microenvironment of myocardial tissue and improve cardiac function post-MI. However, existing methods for preparing graphene and its derivatives suffer from drawbacks such as low purity, complex processes, and unclear structures, which limiting their biological applications.

OBJECTIVES

We propose an optimized synthetic route for synthesizing methoxytriethylene glycol-functionalized graphene (TEG-GR) with a defined structure. The aim of this study is to establish a novel self-adhesion conductive cardiac patch based on TEG-GR for protecting cardiac function after MI.

METHODS

We optimized π-extension polymerization (APEX) reaction to synthesize TEG-GR. TEG-GR was incorporated into dopamine-modified gelatin (GelDA) to construct conductive cardiac patch (TEG-GR/GelDA). We validated the function of TEG-GR/GelDA cardiac patch in rat models of MI, and explored the mechanism of TEG-GR/GelDA cardiac patch by RNA sequencing and molecular biology experiments.

RESULTS

Methoxytriethylene glycol side chain endowed graphene with low immunogenicity and superior biological properties without compromising conductivity. In rats, transplantation of TEG-GR/GelDA cardiac patch onto the infarcted area of heart could more effectively enhance ejection fraction, attenuate collagen deposition, shorten QRS interval and increase vessel density at 28 days post-treatment, compared to non-conductive cardiac patch. Transcriptome analysis indicated that TEG-GR/GelDA cardiac patch could improve cardiac function by maintaining gap junction, promoting angiogenesis, and suppressing cardiomyocytes apoptosis.

CONCLUSION

The precision synthesis of polymer with defined functional group expands the application of graphene in biomedical field, and the novel cardiac patch can be a promising candidate for treating MI.

Lipophilic index of serum phospholipids in patients with type 2 diabetes and atherosclerotic cardiovascular disease: links with metabolic control, vascular inflammation and platelet activation

BACKGROUND

Little is known about the mechanisms underlying the association of the serum phospholipid lipophilic index (LI) with atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes (T2D). Therefore, we investigated whether the LI is associated with glucometabolic control, meta-inflammation, thrombin generation, fibrin clot properties, endothelial function and platelet activation in T2D patients with angiographically documented ASCVD.

METHODS

We studied 74 T2D patients with ASCVD, aged 65.6 ± 6.8 years, with a median diabetes duration of 10 years and median HbA1c of 7.0%. Serum phospholipid fatty acids (FAs) were measured by gas chromatography. The serum phospholipid LI was calculated as the sum of the products of the proportion (% of total FAs) with the melting points (°C) of each individual FA, divided by the sum of the proportions of all FAs. Levels of HbA1c, insulin, leptin, adiponectin, lipid profiles, inflammatory markers (hsCRP, interleukin-6, TNF-α), Lp-PLA2 (a biomarker of vascular inflammation), endothelial function (sICAM-1, sVCAM-1, FMD, NMD), thrombin generation, fibrin clot properties and platelet activation, measured by light transmission aggregometry with arachidonic acid [AA] and adenosine diphosphate [ADP], were assessed.

RESULTS

Patients with LI > 16.9 °C (median) had higher HbA1c concentrations by 5.9% compared to the remaining subjects (p = 0.035). In this group, HbA1c levels ≥ 7.0% were found more often than in individuals with LI ≤ 16.9 °C (62.2 vs. 35.1%; p = 0.020). Subjects with LI > 16.9 °C had higher levels of TCh by 17.1% (p = 0.012), LDL-Ch by 29.4% (p = 0.003), interleukin-6 by 22.2% (p = 0.031) and Lp-PLA2 by 32.4% (p = 0.040), compared to the remaining patients. Moreover, they had increased maximal platelet aggregation induced by AA (p = 0.045), but not by ADP. Serum phospholipid LI correlated with HbA1c (r = 0.24; p = 0.037), TCh (r = 0.36; p = 0.002), LDL-Ch (r = 0.38; p < 0.001), interleukin-6 (r = 0.27; p = 0.020) and Lp-PLA2 (r = 0.26; p = 0.026). There were no intergroup differences in endothelial function, thrombin generation and fibrin clot properties. Regression analysis showed that HbA1c ≥ 7.0% and serum levels of LDL-Ch, interleukin-6 and Lp-PLA2 were predictors of LI > 16.9 °C in adjusted models.

CONCLUSIONS

In well-controlled T2D patients with ASCVD, the higher serum phospholipid LI is associated with worse glucometabolic control, enhanced vascular inflammation and higher platelet reactivity during aspirin treatment at cyclooxygenase-1-selective doses.

Drug-coated balloon angioplasty versus drug-eluting stent implantation in ACS patients with different angiographic patterns of in-stent restenosis

BACKGROUND

Drug-coated balloon (DCB) angioplasty and drug-eluting stents (DES) are two widely used treatments for in-stent restenosis (ISR). Focal and non-focal types of ISR affect the clinical outcomes. The present study aims to compare DES reimplantation versus DCB angioplasty in acute coronary syndrome (ACS) patients with focal ISR and non-focal ISR lesions.

METHODS

Patients with ISR lesions underwent percutaneous coronary intervention (PCI) were retrospectively evaluated and divided into DES group and DCB group. The primary endpoint was the incidence of target lesion failure (TLF) at 24 months follow up. Propensity score matching (PSM) was conducted to balance the baseline characteristics.

RESULTS

For focal ISR, TLF was comparable in the DES and DCB groups at 24 months of follow-up (Before PSM, hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.39-1.27; p = 0.244; After PSM, HR: 0.83; 95% CI: 0.40-1.73; p = 0.625). For non-focal ISR, TLF was significantly decreased in DES compared with DCB group (Before PSM, HR: 0.43; 95% CI: 0.29-0.63; p < 0.001; After PSM, HR: 0.33; 95% CI: 0.19-0.59; p < 0.001), which was mainly attributed to the lower incidence of clinically indicated target lesion revascularization (CD-TLR) (Before PSM, HR: 0.39; 95% CI: 0.26-0.59; p < 0.001; After PSM, HR: 0.28; 95% CI: 0.15-0.54; p < 0.001).

CONCLUSIONS

The clinical outcomes for DES and DCB treatment are similar in focal type of ISR lesions. For non-focal ISR, the treatment of DES showed a significant decrease in TLF which was mainly attributed to a lower incidence of CD-TLR.

Machine learning algorithms using the inflammatory prognostic index for contrast-induced nephropathy in NSTEMI patients

Aim: Inflammatory prognostic index (IPI), has been shown to be related with poor outcomes in cancer patients. We aimed to investigate the predictive role of IPI for contrast-induced nephropathy (CIN) development in non-ST segment elevation myocardial infarction patients using a nomogram and performing machine learning (ML) algorithms.Materials & methods: A total of 178 patients with CIN (+) and 1511 with CIN (-) were included.Results: CIN (+) patients had higher IPI levels, and IPI was independently associated with CIN. A risk prediction nomogram including IPI had a higher predictive ability and good calibration. Naive Bayes and k-nearest neighbors were the best ML algorithms for the prediction of CIN patients.Conclusion: IPI might be used as an easily obtainable marker for CIN prediction using ML algorithms.

Prognostic impact of high-intensity lipid-lowering therapy under-prescription after acute myocardial infarction in women

AIMS

Women are less likely to receive lipid-lowering therapy (LLT) after acute myocardial infarction (AMI). We analysed whether this under-prescription currently persists and has an impact on long-term outcomes.

METHODS AND RESULTS

The FAST-MI programme consists of nationwide registries including all patients admitted for AMI ≤ 48 h from onset over a 1 month period in 2005, 2010, and 2015, with long-term follow-up. This analysis focused on high-intensity LLT (atorvastatin ≥ 40 mg or equivalent, or any combination of statin and ezetimibe) in women and men. Women accounted for 28% (N = 3547) of the 12 659 patients. At discharge, high-intensity LLT was significantly less prescribed in women [54 vs. 68% in men, P < 0.001, adjusted odds ratio (OR) 0.78(95% confidence interval (CI) 0.71-0.87)], a trend that did not improve over time: 2005, 25 vs. 35% (P = 0.14); 2010, 66 vs. 79% (P < 0.001); 2015, 67 vs. 79.5% (P = 0.001). In contrast, female sex was not associated with a lack of other recommended treatments at discharge: beta-blockers [adjusted OR 0.98(95% CI 0.88-1.10), P = 0.78], or renin-angiotensin blockers [adjusted OR 0.94(95% CI 0.85-1.03), P = 0.18]. High-intensity LLT at discharge was significantly associated with improved 5 year survival and infarct- and stroke-free survival in women [adjusted hazard ratios (HR) 0.74(95% CI 0.64-0.86), P < 0.001 and adjusted HR: 0.81(95% CI: 0.74-0.89); P < 0.001, respectively]. Similar results were found using a propensity score-matched analysis [HR for 5 year survival in women with high-intensity LLT: 0.82(95% CI 0.70-0.98), P = 0.03].

CONCLUSION

Women suffer from a bias regarding the prescription of high-intensity LLT after AMI, which did not attenuate between 2005 and 2015, with potential consequences on both survival and risk of cardiovascular events.

Invasive Treatment Strategy for Older Patients with Myocardial Infarction

BACKGROUND

Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear.

METHODS

We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.

RESULTS

A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.

CONCLUSIONS

In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).

Prognostic Value of Systemic Inflammation Response Index and N-Terminal Pro-B-Type Natriuretic Peptide in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries- A Retrospective Study

Background

The Systemic Inflammation Response Index (SIRI) and N-terminal Pro-B-type natriuretic peptide (NT-proBNP) have been proposed as reliable predictors of poor prognosis in cardiovascular disease and all-cause mortality, However, their validity has not been extensively evaluated in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA).

Patients and Methods

259 patients diagnosed with MINOCA were enrolled in this study from January 2015 to December 2022, and serum levels of SIRI and NT-proBNP were detected. The primary endpoints were major adverse cardiovascular events (MACE). According to the occurrence of MACE during the follow-up period, patients were grouped into MACE and Non-MACE groups, and divided by the median values for SIRI and NT-proBNP into groups: low SIRI, high SIRI, low NT-proBNP, and high NT-proBNP.

Results

A statistically significant difference in the levels of SIRI and NT-proBNP was observed between the MACE group and the non-MACE group. Kaplan-Meier survival curve analysis revealed that patients with high SIRI and high NT-proBNP had a significantly higher risk of MACE (log-rank P < 0.001). Furthermore, even after adjusting for covariates, the high SIRI and high NT-proBNP were associated with an increased risk of MACE (P<0.001, HR: 3.188, 95% CI 1.940-5.241; P<0.001, HR: 2.245, 95% CI 1.432-3.519). Additionally, the combined prognosis prediction of SIRI and NT-proBNP was superior to a single prediction, and adding SIRI and NT-proBNP to the traditional risk factor model improved the model's predictive value.

Conclusion

High levels of SIRI and NT-proBNP exhibit a significant correlation with an increased risk of MACE, thereby suggesting that SIRI can be used as a reliable inflammatory indicator for predicting the risk in MINOCA patients, with significantly improved prognostic value when combined with NT-proBNP.

Effectiveness and Safety of the ESC-TROP (European Society of Cardiology 0h/1h Troponin Rule-Out Protocol) Trial

BACKGROUND

European guidelines recommend the use of a 0h/1h hs-cTn (high-sensitivity cardiac troponin) protocol in patients with acute chest pain. We aimed to determine the performance of this protocol in routine care when supplemented with patient history and ECG and a recommendation to refrain from noninvasive testing in low-risk patients.

METHODS AND RESULTS

This was a pre- and postimplementation study with concurrent controls. Patients with chest pain were enrolled at 5 Swedish emergency departments (EDs) during a 10-month period in both 2017 and 2018. All hospitals used a 0h/3h hs-cTnT protocol in 2017 and 3 EDs implemented a 0h/1h hs-cTnT protocol during 10 months in 2018. The 2 coprimary outcomes were the incidence of acute myocardial infarction and all-cause death within 30 days and ED length of stay. The study included 26 040 consecutive patients. In the intervention hospitals, 21 (0.40%) of the discharged patients had an acute myocardial infarction/death event during the control period (0h/3h testing) and 22 (0.45%) in the intervention period (0h/1h testing), which met the criteria for noninferiority. There was no significant difference in ED length of stay (ratio 0.99, P=0.48) or ED discharge rate between the periods in the intervention versus the control hospitals. A total of 3142 patients met low-risk 0h/1h hs-cTnT criteria and were discharged, of whom 2 had an acute myocardial infarction/death event.

CONCLUSIONS

A 0h/1h hs-cTnT protocol incorporating patient history and ECG was as safe as using a 0h/3h protocol but did not reduce ED length of stay or increase the discharge rate. Refraining from noninvasive testing in patients identified as low risk was safe.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03421873.

Interleukin-6 receptor antibodies (tocilizumab) in acute myocardial infarction with intermediate to high risk of cardiogenic shock development (DOBERMANN-T): study protocol for a double-blinded, placebo-controlled, single-center, randomized clinical trial

BACKGROUND

Inflammation and neurohormonal activation play a significant role in the adverse outcome seen in acute myocardial infarction (AMI) and the development of cardiogenic shock (CS), which is associated with a mortality rate up to 50%. Treatment with anti-inflammatory drugs such as tocilizumab, an interleukin-6 receptor antagonist, has been shown to reduce troponin release and reduce the myocardial infarct size in AMI patients and it may therefore have cardioprotective properties.

METHODS

This is a double-blind, placebo-controlled, single-center randomized clinical trial, including adult AMI patients without CS at hospital arrival, undergoing percutaneous coronary intervention (PCI) within 24 h from symptom onset, and at intermediate to high risk of developing CS (ORBI risk score ≥ 10). A total of 100 participants will be randomized to receive a single intravenous dose of tocilizumab (280 mg) or placebo (normal saline). The primary outcome is peak plasma pro-B-type natriuretic peptide (proBNP) within 48 h, assessed using serial measurements at intervals: before infusion, 12, 24, 36, and 48 h after infusion. Secondary endpoints include the following: (1) cardiac magnetic resonance imaging (CMR) during 24-48 h after admission and at follow-up after 3 months with assessment of left ventricular area at risk, final infarct size, and the derived salvage index and (2) biochemical markers of inflammation (C-reactive protein and leukocyte counts) and cardiac injury (troponin T and creatinine kinase MB).

DISCUSSION

Modulation of interleukin-6-mediated inflammation in patients with AMI, treated with acute PCI, and at intermediate to high risk of in-hospital CS may lead to increased hemodynamic stability and reduced left ventricular infarct size, which will be assessed using blood biomarkers with proBNP as the primary outcome and inflammatory markers, troponin T, and CMR with myocardial salvage index as the secondary endpoints.

TRIAL REGISTRATION

Registered with the Regional Ethics Committee (H-21045751), EudraCT (2021-002028-19), ClinicalTrials.gov (NCT05350592). Study registration date: 2022-03-08, Universal Trial Number U1111-1277-8523.

Sex and Population-Specific 99th Percentiles of Troponin for Myocardial Infarction in the Danish Population (DANSPOT)

BACKGROUND

Sex- and population-specific 99th percentiles of high-sensitivity cardiac troponin (hs-cTn) are recommended in guidelines although the evidence for a clinical utility is sparse. The DANSPOT trial will investigate the clinical effect of sex- and population-specific 99th percentiles of cTn. We report the 99th percentiles derived from this trial and their dependency on kidney function.

METHODS

We used samples from healthy Danish blood donors and measured hemoglobin A1c, N-terminal pro-brain natriuretic peptide and creatinine, and calculated an estimated glomerular filtration rate (eGFR). We compared 2 cutoffs for the eGFR of healthy participants (60 vs 90 mL/min/1.73 m2). The cTn assays investigated were Siemens Atellica and Dimension Vista hs-cTnI, Abbott hs-cTnI, and Roche hs-cTnT.

RESULTS

A total of 2287 participants were sampled, of which 71 (3.1%) were excluded due to a history of heart disease (n = 4), insufficient material (n = 7), or a screening biomarker (n = 60). Of the remaining 2216 participants, 1325 (59.8%) had an eGFR ≥90 mL/min/1.73 m2. Compared to a cutoff of 60 mL/min/1.73 m2 for eGFR, using 90 mL/min/1.73 m2 resulted in lower 99th percentiles for females; Siemens Vista (46 vs 70 ng/L), Abbott (14 vs 18 ng/L), and Roche cTnT (10 vs 13 ng/L), and decreased the number of measurements above the manufacturers' 99th percentiles for all assays.

CONCLUSIONS

We present reference values for 4 cTn assays for eGFR cutoffs of 60 and 90 mL/min/1.73 m2. These cutoffs differ based on the eGFR threshold for inclusion indicating that any chosen cutoff is also valuable with moderately reduced kidney function.

Renin-angiotensin system inhibition and mortality in patients undergoing dialysis with coronary artery disease: insights from a multi-center observational study

BACKGROUND

While the survival benefits of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are firmly established in the general population, their efficacy within patient undergoing dialysis with coronary artery disease (CAD) remains controversial.

METHODS

Between January 2015 and June 2021, 1168 patients undergoing dialysis with CAD were assessed from 30 tertiary medical centers. The primary outcome was all-cause death, and the secondary outcome was cardiovascular death. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were performed to account for between-group differences.

RESULTS

Overall, ACEI or ARB were prescribed to 518 patients (44.3%) upon discharge. After a median follow-up of 22.2 months, 361 (30.9%) patients died, including 243 cardiovascular deaths. The use of ACEI or ARB was associated with a significantly lower risk of all-cause (25.3% vs 35.4%, hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.52-0.82, p < 0.001) and cardiovascular death (17.0% vs 23.8%; HR 0.64, 95% CI 0.48-0.83, p = 0.001). These findings remained consistent across IPTW and PSM analyses. Sensitivity analyses for ACEI and ARB use separately yielded similar results.

CONCLUSIONS

Our findings suggested that among patients undergoing dialysis with CAD, ACEI or ARB use was associated with a lower risk of all-cause and cardiovascular death.

The de Winter electrocardiographic pattern: A systematic review of case reports

BACKGROUND

It has been established that concurrent ST-T alterations in limb leads can assist in identifying the location of left anterior descending (LAD) artery occlusion. The de Winter pattern is an atypical electrocardiographic manifestation characterized by ST-segment depression associated with LAD artery occlusion. We hypothesized that this atypical pattern could potentially interfere with the accurate localization of the LAD occlusion site on the electrocardiogram. We aimed to describe the distinctive characteristics of the de Winter pattern and to compare electrocardiographic variables in proximal and distal occlusions of the LAD artery.

METHODS

A systematic review was conducted using the PRISMA guidelines. PubMed, Scopus, and Web of Science were searched from their inception to June 2024. Continuous variables were compared using the Kruskal-Wallis test.

RESULTS

Sixty-six cases with LAD related lesions were included. The majority of cases involved young males with a low proportion of prior coronary artery disease. Most patients had sinus rhythm and normal QRS duration. ST-T changes in limb leads were common in the patients studied (91%), but our analysis showed that differentiating between proximal and distal occlusions based on these changes was challenging.

CONCLUSION

The de Winter pattern is primarily observed in young males with a low proportion of prior coronary artery disease. While ST-T changes in limb leads are frequent, localizing the LAD occlusion site based on these changes can be difficult. Further research is needed to understand the underlying mechanisms, prevalence, and improve diagnostic accuracy for this atypical pattern.