Fourth Universal Definition of Myocardial Infarction (2018)

Myocardial Infarction-Associated Shock: A Comprehensive Analysis of Phenotypes, SCAI Classification, and Outcome Assessment

Background and Objectives: In-hospital mortality associated with myocardial infarction complicated by cardiogenic shock (MI-CS) remains critically high. A particularly challenging form, mixed shock (MS), combines features of cardiogenic shock (CS) with distributive elements such as vasodilation and reduced vascular resistance. MS is associated with elevated mortality rates and presents unique diagnostic and therapeutic challenges. This study aimed to analyze the clinical, historical, instrumental, and laboratory characteristics of the primary phenotypes of MI-CS, stratified according to the Society for Cardiovascular Angiography and Interventions (SCAI) shock severity scale. Materials and Methods: In this single-center, retrospective observational study, we reviewed the medical records of 1289 patients admitted to the emergency cardiology department from 1 January to 12 December 2020. Among them, 117 patients were identified as having MI-CS and were divided into two groups: MS (n = 48) and isolated CS (n = 69). The data were analyzed using the SCAI shock classification. Logistic regression analysis was employed to identify predictors of mortality and improved survival outcomes. Results: Patients with MS were older (80 years [71.0; 83.0] vs. 73 years [64.0; 81.0], p = 0.035). The overall mortality rate was significantly higher in the MS group (68% vs. 53%, RR = 1.438, 95% CI: 1.041-1.986, p = 0.03). Logistic regression identified mechanical ventilation (OR = 8.33, 95% CI: 2.54-22.80, p = 0.012), elevated lactate levels (OR = 1.20, 95% CI: 1.02-1.41, p = 0.026), and cardiopulmonary resuscitation (CPR) (OR = 7.97, 95% CI: 2.51-24.40, p < 0.0001) as independent predictors of mortality. Conversely, the use of an intra-aortic balloon pump (IABP) (OR = 0.22, 95% CI: 0.06-0.80, p = 0.021) and a higher body mass index (BMI) (OR = 0.91, 95% CI: 0.84-0.99, p = 0.038) were associated with reduced mortality risk. Conclusions: MS in the context of MI-CS represents a distinct clinical phenotype with specific hemodynamic features and significantly worsened outcomes. The identification of mortality predictors, such as mechanical ventilation, elevated lactate levels, and CPR, alongside protective factors like IABP use and a higher BMI, underscores the importance of early and tailored therapeutic interventions. These findings highlight the need for further studies to refine treatment protocols and improve outcomes in this high-risk population.

Triglyceride-glucose index: carotid intima-media thickness and cardiovascular risk in a European population

BACKGROUND

The triglyceride-glucose (TyG) index is now widely recognized as a marker of insulin resistance and has been linked to the development and prognosis of atherosclerotic cardiovascular diseases (ASCVD) in numerous populations, particularly in the Eastern world. Although there are fewer reports from the Western world, and they are sometimes contradictory, the absence of definitive data on the relationship between a raised TyG index and cardiovascular risk suggested the opportunity of testing this biochemical marker against a well-established vascular marker such as the carotid intima media thickness (c-IMT).

METHODS

Primary prevention patients were selected from a cohort of individuals who underwent c-IMT measurement between 1984 and 2018 at the Dyslipidemia Center at the ASST Grande Ospedale Metropolitano Niguarda in Milan, Italy. The TyG index was calculated as the Ln [fasting TG (mg/dL)×fasting glucose (mg/dL)/2]. Carotid ultrasonography was performed using echographic measurements of the far walls of the left and right common, internal carotids, and bifurcations. Patients were followed for up to 20 years with periodic evaluation of biochemical parameters. ASCVD events were monitored through hospital records, where all patients were regularly examined.

RESULTS

The analysis included 3108 individuals with a mean age of 54.9 ± 13.1 years. Participants were generally non-obese, with an average BMI of 24.6 ± 3.5 Kg/m2. Among the women, 83.1% were postmenopausal. The mean TyG index was 8.65 ± 0.59. There was a significant association between the TyG index and all c-IMT measurements. Those in the highest TyG index quartiles had significantly higher IMTmean and IMTmax compared to those in the lower quartiles. These associations were consistent across all vascular sites examined and remained significant after adjusting for all potential confounders. Kaplan-Meier survival analysis revealed an increased incidence of ASCVD events in the two highest TyG index quartiles.

CONCLUSIONS

TyG index is a sensitive marker of risk in a European population with moderate ASCVD risk, as assessed by c-IMT measurements, in a large cohort of Lipid Clinic patients.

Exposure to specific polyfluoroalkyl chemicals is associated with cardiovascular disease in US adults: a population-based study

Background

Polyfluoroalkyl chemicals (PFCs) present potential health risks due to their persistence and bioaccumulation. However, there is currently insufficient evidence regarding their impact on cardiovascular disease (CVD). Consequently, it is imperative to investigate the correlation between PFCs and CVD.

Methods

The data was collected from National Health and Nutrition Examination Survey in 2005-2012. Logistic regression models were employed to assess the association between single PFC and CVD. Generalized additive model (GAM) was used for evaluating nonlinear relationships. Subgroup analyses were conducted to explore interaction effects. Bayesian kernel machine regression (BKMR) and weighted quantile sum (WQS) models were used to evaluate the joint effect of PFC exposures on CVD.

Results

In logistic regression, PFDE, MPAH, and PFUA were positively associated with CVD. In the GAM, there was a significant nonlinear relationship between MPAH and CVD. Subgroup analysis revealed the interaction of gender and race in the effects of PFCs and CVD. PFUA was positively correlated with CVD in males but show no significant difference in females. PFDE was positively associated with CVD among non-Hispanic white individual. The results of BKMR indicated that the impact of mixed PFCs on CVD increased initially and then weakened, showing an overall positive trend. The results of WQS suggested that PFDO contributed most to the effect.

Conclusion

Our study showed that serum PFDE, MPAH, and PFUA levels were positively correlated with CVD. PUFA was found to interact with gender and race in relation to CVD. A general positive correlation exists between mixed exposure to PFCs and CVD, with PFDO being the most contributory PFC. Our study provided important evidence for probing the impact of PFCs on CVD and laid a foundation for further mechanism research.

Prognostic Implication of Computational Angiography-Derived Fractional Flow Reserve in Patients With Nonobstructive Coronary Artery Disease

BACKGROUND

Risk stratification of patients with symptomatic nonobstructive coronary artery disease remains uncertain. Our study assessed the clinical value of single-vessel, multivessel, and 3-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in patients with nonobstructive coronary artery disease.

METHODS AND RESULTS

We enrolled patients with ≤50% stenosis with a caFFR value ≥0.8 in all 3 coronary arteries on coronary angiography. The sum of caFFR values in the 3 vessels was computed for each patient. Patient stratification was based on the median value of the following criteria: single-vessel analysis, multivessel analysis, and 3-vessel analysis. The primary end point of this study was major adverse cardiac events at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. A total of 490 patients were included. The 5-year major adverse cardiac event rates in single-vessel analysis were statistically insignificant between low- and high-caFFR groups (left anterior descending artery [P=0.163]; left circumflex artery [P=0.797]; right coronary artery [P=0.127]). In multivessel analysis, patients in the multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) showed an increased risk of 5-year major adverse cardiac events compared with patients in the single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR], 2.648 [95% CI, 1.141-6.145]; P=0.023). In 3-vessel analysis, patients in the low 3-vessel caFFR group demonstrated a greater 5-year major adverse cardiac event risk than the high 3-vessel caFFR group (HR, 2.43 [95% CI, 1.087-5.433]; P=0.031).

CONCLUSIONS

We demonstrated that both multiple-vessel and 3-vessel caFFR measurements serve as valuable prognostic indicators for risk assessment in patients with nonobstructive coronary artery disease.

Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials

BACKGROUND

The role of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT) after ST-elevation myocardial infarction (STEMI) remains uncertain.

AIMS

We aimed to compare the effect of rivaroxaban versus warfarin in patients with STEMI complicated by LVT.

METHODS

Adult patients with STEMI and two-dimensional transthoracic echocardiography showing LVT were assigned to rivaroxaban (15 mg once daily) or warfarin (international normalised ratio goal of 2.0-2.5) in an open-label, randomised clinical trial (RCT). A prospective pooled analysis was planned comparing DOAC- versus warfarin-based anticoagulation for the same indication. The main outcome of the RCT was complete LVT resolution at 3 months, determined by a blinded imaging core laboratory. Complete LVT resolution and bleeding were investigated in the pooled analysis.

RESULTS

A total of 50 patients (median age: 55 years, 18% females) were enrolled from June 2020 to November 2022. Three-month complete LVT resolution occurred in 19/25 (76.0%) patients assigned to rivaroxaban and 13/24 (54.2%) assigned to warfarin (relative risk [RR] 1.40, 95% confidence interval [CI]: 0.91-2.15; p=0.12) with no thrombotic or major bleeding events. Pooled analysis showed numerically better complete LVT resolution with DOACs (rivaroxaban and apixaban; 93/115 [80.8%] vs 79/112 [70.5%], RR 1.14, 95% CI: 0.98-1.32; p=0.08) and less major bleeding (2/116 [1.7%] and 9/112 [8.0%], risk difference -0.06, 95% CI: -0.12 to 0.00; p=0.05) than with warfarin.

CONCLUSIONS

Although the findings are limited by a small sample size, the results suggest that DOACs are safe with at least similar outcomes concerning LVT resolution and major bleeding compared with warfarin. (ClinicalTrials.gov: NCT05705089).

FTO rs1121980 polymorphism contributes to coronary artery disease susceptibility in a Chinese Han population

BACKGROUND

The fat mass and obesity-associated protein (FTO) has been showed to be involved in the pathogenesis and progression of coronary artery disease (CAD). However, the effects of FTO variants on CAD risk remain poorly understood. We herein genotyped three SNPs (rs1121980, rs72803657, and rs4783818) in FTO to investigate the influence of FTO polymorphisms on individual susceptibility to CAD.

METHODS

Genotyping for the three SNPs (rs1121980, rs72803657, and rs4783818) was conducted in a cohort of 712 CAD cases with 349 myocardial infarction (MI) cases and 701 control participants, utilizing the polymerase chain reaction-ligation detection reaction (PCR-LDR) technique. The associations of these SNPs with CAD were analyzed using multivariate logistic regression, and the associations with lipid profiles were assessed by the Kruskal-Wallis or Wilcoxon-Mann-Whitney tests.

RESULTS

The A allele (OR = 1.26, 95% CI = 1.01-1.57, and P = 0.044) and the AA genotype (OR = 3.13, 95% CI = 1.53-6.38, and P = 0.002) of FTO rs1121980 were significantly associated with an elevated risk of CAD. Similarly, the A allele (OR = 1.54, 95% CI = 1.18-2.02, and P = 0.002) and the AA genotype (OR = 5.61, 95% CI = 2.57-12.27, and P < 0.001) of rs1121980 exhibited increased MI risk. This SNP also showed significant associations under recessive genetic models for both CAD and MI (OR = 3.09, 95% CI = 1.52-6.27, P = 0.002 for CAD; OR = 5.40, 95% CI = 2.49-11.71, P < 0.001 for MI). However, the other two SNPs did not show significant associations with CAD or MI risks under any genetic model tested. Stratified analyses indicated a more pronounced association of the A allele with increased CAD/MI risk among younger participants, non-smokers, and non-drinkers. Interestingly, A allele carriers in younger subjects exhibited higher triglyceride (TG) levels and lower high-density lipoprotein cholesterol (HDL-C) levels compared to non-carriers (P < 0.05).

CONCLUSIONS

Our data provides the first evidence that the FTO rs1121980 polymorphism is associated with an increased risk of CAD in the Chinese population. This association is more significant in younger subjects, likely due to the elevated TG levels and reduced HDL-C levels.

Personalized perioperative blood pressure management in patients having major non-cardiac surgery: A bicentric pilot randomized trial

STUDY OBJECTIVE

We hypothesize that personalized perioperative blood pressure management maintaining intraoperative mean arterial pressure (MAP) above the preoperative mean nighttime MAP reduces perfusion-related organ injury compared to maintaining intraoperative MAP above 65 mmHg in patients having major non-cardiac surgery. Before testing this hypothesis in a large-scale trial, we performed this bicentric pilot trial to determine a) if performing preoperative automated nighttime blood pressure monitoring to calculate personalized intraoperative MAP targets is feasible; b) in what proportion of patients the preoperative mean nighttime MAP clinically meaningfully differs from a MAP of 65 mmHg; and c) if maintaining intraoperative MAP above the preoperative mean nighttime MAP is feasible in patients having major non-cardiac surgery.

DESIGN

Bicentric pilot randomized trial.

SETTING

University Medical Center Hamburg-Eppendorf, Hamburg, Germany, and RWTH Aachen University Hospital, Aachen, Germany.

PATIENTS

Patients ≥ 45 years old having major non-cardiac surgery.

INTERVENTIONS

Personalized blood pressure management.

MEASUREMENTS

Proportion of patients in whom preoperative automated nighttime blood pressure monitoring was possible; proportion of patients in whom the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg (difference > ±10 mmHg); intraoperative time-weighted average MAP below the preoperative mean nighttime MAP.

MAIN RESULTS

We enrolled 105 patients and randomized 98 patients. In 98 patients (93 %), preoperative automated nighttime blood pressure monitoring was possible. In 83 patients (85 %), the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg. The median time-weighted average MAP below the preoperative mean nighttime MAP was 3.29 (1.64, 6.82) mmHg in patients assigned to personalized blood pressure management.

CONCLUSIONS

It seems feasible to determine the effect of personalized perioperative blood pressure management maintaining intraoperative MAP above the preoperative mean nighttime MAP on postoperative complications in a large multicenter trial.

Sex and race disparities in emergency department patients with chest pain and a detectable or mildly elevated troponin

Background

Identifying and eliminating health disparities is a public health priority. The goal of this analysis is to determine whether cardiac testing or outcome disparities exist by race or sex in patients with detectable to mildly elevated serum troponin.

Methods

We conducted a secondary analysis of the CMR-IMPACT trial that randomized patients with symptoms suggestive of acute coronary syndrome and a detectable or mildly elevated troponin measure from 4 US hospitals to an early invasive angiography or cardiac MRI strategy. The primary endpoint was the composite of all-cause mortality, myocardial infarction, cardiac hospital readmission, and repeat cardiac ED. Secondary outcomes were components of the composite and revascularization.

Results

Participants (n = 312, mean age 61 ± 11 years) were 36.2 % non-white and 40.1 % female. The composite outcome occurred in 63.7 % of non-white vs. 49.8 % of white patients (aHR 1.50, 95 % CI 1.08-2.09) and 53.6 % of female vs. 55.6 % of male patients (aHR 0.93, 95 % CI 0.68-1.28). Non-white (aHR 0.57, 95 % CI 0.35-0.92) patients had lower rates of revascularization also less median stenosis (p < 0.001) and stenosis >70 % (p < 0.001) during index cardiac testing. Despite these findings, ACS after discharge was higher among non-white patients (aHR 1.84, 95 % CI 1.11-3.05). Females had lower rates of revascularization (aHR 0.52, 95 % CI 0.33-0.82), but no increase in ACS after discharge (aHR 0.90, 95 % CI 0.55-1.49).

Conclusion

Non-white patients had higher rates of ACS following discharge despite lower rates of obstructive CAD following standardization of index cardiac testing. Future disparity works should explore care following the index encounter.

Accuracy of dynamic stress CT myocardial perfusion in patients with suspected non-ST elevation myocardial infarction

Coronary CT angiography (CCTA) and dynamic stress CT myocardial perfusion (CT-MPI) are established modalities in the analysis of patients with chronic coronary syndromes. Their role in patients with suspected non-ST elevation myocardial infarction (NSTEMI) is unknown. CCTA with CT-MPI might assist in the triage of NSTEMI patients to the Cath lab. We investigated the correlation of significant epicardial lesions by CT-MPI in addition to CCTA compared to invasive coronary angiography (ICA) with fractional flow reserve (FFR) in patients with NSTEMI. Twenty NSTEMI patients scheduled for ICA were enrolled in this study with planned ICA. CCTA and CT-MPI was performed pre-ICA. For each coronary artery, the presence or absence of significant lesions was interpreted by CCTA with CT-MPI, using an FFR of ≤ 0.8 or angiographic culprit (stenosis > 90%, suspected plaque rupture) as reference. The main outcome was the per-vessel correlation. Sixteen out of 20 patients had a culprit lesion that required immediate revascularization. CCTA with ≥ 50% stenosis demonstrated a per vessel sensitivity and specificity for the detection of significant stenosis of respectively 100% (95% CI: 86-100%) and 75% (95% CI: 58-88%). CCTA with CT-MPI showed a lower sensitivity 90% (95% CI: 70-99%) but higher specificity of 100% (95% CI: 90-100%). CCTA with CT-MPI exhibits a strong correlation for identifying significant CAD in patients with NSTEMI. Thereby, it might assist in the triage of ICA in NSTEMI patients.

Advanced Machine Learning to Predict Coronary Artery Disease Severity in Patients with Premature Myocardial Infarction

Background

Studies using machine learning to identify the target characteristics and develop predictive models for coronary artery disease severity in patients with premature myocardial infarction (PMI) are limited.

Methods

In this observational study, 1111 PMI patients (≤55 years) at Tianjin Chest Hospital from 2017 to 2022 were selected and divided according to their SYNTAX scores into a low-risk group (≤22) and medium-high-risk group (>22). These groups were further randomly assigned to a training or test set in a ratio of 7:3. Lasso-logistic was initially used to screen out target factors. Subsequently, Lasso-logistic, random forest (RF), k-nearest neighbor (KNN), support vector machine (SVM), and eXtreme Gradient Boosting (XGBoost) were used to establish prediction models based on the training set. After comparing prediction performance, the best model was chosen to build a prediction system for coronary artery severity in PMI patients.

Results

Glycosylated hemoglobin (HbA1c), angina, apolipoprotein B (ApoB), total bile acid (TBA), B-type natriuretic peptide (BNP), D-dimer, and fibrinogen (Fg) were associated with the severity of lesions. In the test set, the area under the curve (AUC) of Lasso-logistic, RF, KNN, SVM, and XGBoost were 0.792, 0.775, 0.739, 0.656, and 0.800, respectively. XGBoost showed the best prediction performance according to the AUC, accuracy, F1 score, and Brier score. In addition, we used decision curve analysis (DCA) to assess the clinical validity of the XGBoost prediction model. Finally, an online calculator based on the XGBoost was established to measure the severity of coronary artery lesions in PMI patients.

Conclusions

In summary, we established a novel and convenient prediction system for the severity of lesions in PMI patients. This system can swiftly identify PMI patients who also have severe coronary artery lesions before the coronary intervention, thus offering valuable guidance for clinical decision-making.

Predictive Value of High-Sensitivity Troponin I for Left Ventricular Ejection Fraction in Patients with Non-ST-Elevation Myocardial Infarction

Background

According to the World Health Organization's 2021 statistics, cardiovascular diseases (CVDs), particularly coronary artery disease (CAD), remain among the leading causes of global morbidity and mortality, affecting both high-income and low-income countries like Vietnam.

Objective

Acute myocardial infarction (AMI) remains a major cause of mortality and cardiovascular complications, with a poor prognosis in patients with left ventricular systolic dysfunction (LVSD). High-sensitivity cardiac troponin I (hs-cTnI) is a specific biomarker of myocardial injury linked to infarct size and LVSD. However, its role in predicting left ventricular ejection fraction (LVEF) in non-ST-elevation myocardial infarction (NSTEMI) is underexplored. This study investigates the correlation between hs-cTnI and LVSD in NSTEMI patients.

Methods

A descriptive, cross-sectional study was conducted on 117 patients with first-time NSTEMI treated at Cho Ray Hospital from February 2024 to April 2024. Admission hs-cTnI levels were measured and correlated with LVEF, assessed via echocardiography. The predictive value and optimal cut-off points of hs-cTnI for LVSD (LVEF < 50% and ≤ 40%) were determined using receiver operating characteristic (ROC) curve analysis.

Results

Hs-cTnI levels showed a significant inverse correlation with LVEF (r = - 0.569, p < 0.001). Patients with moderate-to-severe LVSD (LVEF ≤ 40%) had the highest median hs-cTnI levels (25,000 pg/mL, p < 0.001). The area under the ROC curve (AUC) for predicting LVEF < 50% was 0.78, with a cut-off of 12,344 pg/mL (sensitivity 68.5%, specificity 82.5%). For LVEF ≤ 40%, the AUC was 0.82, with a cut-off of 20,979 pg/mL (sensitivity 73.3%, specificity 88.5%, accuracy 84.6%). These findings underscore hs-cTnI's utility in identifying LVSD.

Conclusion

Hs-cTnI is inversely correlated with LVEF and serves as a reliable biomarker for predicting LVSD in NSTEMI patients, facilitating risk stratification and early management decisions.

Association of Serum Gamma-Glutamyltransferase with In-hospital Heart Failure in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background

To explore the association between gamma-glutamyltransferase (GGT) and in-hospital heart failure (HF) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 412 patients diagnosed with STEMI and treated with primary PCI were included in our study. Univariate and multivariate logistic regression models were used to evaluate the association between GGT and the risk of in-hospital HF in STEMI patients. The receiver operating characteristic (ROC) curve was used to assess the accuracy of GGT in predicting in-hospital HF.

Results

The incidence of HF after STEMI increased significantly with increasing GGT tertiles (the first, second, and third tertile groups were 7.97%, 14.49%, and 18.38%, respectively; p = 0.039). Multivariate logistic regression analysis revealed that the risk of HF in the second and third GGT tertile groups was 2.51 times greater (95% CI, 1.06-5.96) and 2.77 times greater (95% CI, 1.13-6.81), respectively, than that in the first GGT tertile group. Each 1-unit increase in the lnGGT level was related to a 1.88-fold increased risk of HF (odds ratio, OR, 1.88; 95% CI, 1.19-2.96; p = 0.007). Restricted cubic splines suggested a linear relationship between GGT and in-hospital HF (p for nonlinearity = 0.158). The area under the curve was 0.607 (95% CI, 0.558-0.654; p = 0.007) when GGT was used to predict in-hospital HF, with a sensitivity of 57.14% and a specificity of 64.04%. Moreover, the incidence of HF significantly increased in-hospital death risk (OR, 7.75; 95% CI, 1.87-32.12; p = 0.005).

Conclusions

GGT is positively associated with in-hospital HF and is an independent risk factor for in-hospital HF in STEMI patients.

[Detrimental impact of acute coronary syndrome on the independence of the elderly]

Objectives

To evaluate the prognostic role of functional status in older adults hospitalized for acute coronary syndrome (ACS) and the implications of the coronary event on functional decline during follow-up.

Materials and Methods

This was a single-center, prospective cohort study including patients aged ≥65 years hospitalized for ACS with (STEMI) or without ST-segment elevation in 2022. Patients with total dependence or lacking a care network were excluded. Functional status was assessed using the Barthel Index and the Lawton and Brody scales at admission, 30 days, and one year post-discharge. The association between initial functional status and major adverse cardiovascular events (MACE) was analyzed, as well as the impact of ACS on functional status over the short and long term.

Results

A total of 110 patients older than 65 years were included (mean age 78.8±4.6 years; 61.8% male). At admission, 94.3% presented mild functional dependence according to the Barthel Index, with similar findings on the Lawton and Brody scales. At 30 days, a significant functional decline was observed (Barthel: 71.2±11.3, p<0.001; Lawton: 4.8±2.5, p=0.02), which persisted at one year. Initial functional status was not associated with MACE. ST-segment elevation ACS (STEMI) was an independent predictor of short-term functional decline (adjusted OR 1.75; p=0.04).

Conclusions

In older adults with ACS, initial functional status did not predict adverse events; however, significant functional decline was observed, particularly after STEMI. This underscores the importance of personalized strategies for managing this vulnerable population.

A Machine Learning Model Using Cardiac CT and MRI Data Predicts Cardiovascular Events in Obstructive Coronary Artery Disease

Background Multimodality imaging is essential for personalized prognostic stratification in suspected coronary artery disease (CAD). Machine learning (ML) methods can help address this complexity by incorporating a broader spectrum of variables. Purpose To investigate the performance of an ML model that uses both stress cardiac MRI and coronary CT angiography (CCTA) data to predict major adverse cardiovascular events (MACE) in patients with newly diagnosed CAD. Materials and Methods This retrospective study included consecutive symptomatic patients without known CAD referred for CCTA between December 2008 and January 2020. Patients with obstructive CAD (at least one ≥50% stenosis at CCTA) underwent stress cardiac MRI for functional assessment. Eighteen clinical, two electrocardiogram, nine CCTA, and 12 cardiac MRI parameters were evaluated as inputs for the ML model, which involved automated feature selection with the least absolute shrinkage and selection operator algorithm and model building with an XGBoost algorithm. The primary outcome was MACE, defined as a composite of cardiovascular death and nonfatal myocardial infarction. External testing was performed using two independent datasets. Performance was compared between the ML model and existing scores and other approaches using the area under the receiver operating characteristic curve (AUC). Results Of 2210 patients who completed cardiac MRI, 2038 (mean age, 70 years ± 12 [SD]; 1091 [53.5%] female participants) completed follow-up (median duration, 7 years [IQR, 6-9 years]); 281 experienced MACE (13.8%). The ML model exhibited a higher AUC (0.86) for MACE prediction than the European Society of Cardiology score (0.55), QRISK3 score (0.60), Framingham Risk Score (0.50), segment involvement score (0.71), CCTA data alone (0.76), or stress cardiac MRI data alone (0.83) (P value range, <.001 to .004). The ML model also exhibited good performance in the two external validation datasets (AUC, 0.84 and 0.92). Conclusion An ML model including both CCTA and stress cardiac MRI data demonstrated better performance in predicting MACE than traditional methods and existing scores in patients with newly diagnosed CAD. © RSNA, 2025 Supplemental material is available for this article.

Prognostic Value of Cardiac MRI Late Gadolinium Enhancement Granularity in Participants with Ischemic Cardiomyopathy

Background Ischemic late gadolinium enhancement (LGE) assessed with cardiac MRI is a well-established prognosticator in ischemic cardiomyopathy. However, the prognostic value of additional LGE parameters, such as extent, transmurality, location, and associated midwall LGE, remains unclear. Purpose To assess the prognostic value of ischemic LGE features to predict all-cause mortality in ischemic cardiomyopathy. Materials and Methods This study is a secondary analysis of a prospective dual-center trial of participants with ischemic cardiomyopathy and left ventricular ejection fraction (LVEF) under 50% referred for viability assessment using cardiac MRI between 2008 and 2022. The LGE granularity parameters (extent of ischemic LGE, transmurality, location, and associated midwall LGE) assessed by cardiac MRI experts were compared with traditional prognosticators of adverse events in ischemic cardiomyopathy (age, sex, body mass index, diabetes, smoking, dyslipidemia, heart failure hospitalization, atrial fibrillation, renal failure, known myocardial infarction, and LVEF). The primary outcome was all-cause mortality. Predictive value was evaluated using Cox regression analysis and assessed using time-dependent receiver operating characteristic curves at 10 years. The cardiac MRI LGE score was developed using LGE granularity parameters. Results Among 6082 participants (mean age, 64.5 years ± 11.8 [SD]; 4419 men), 3591 had ischemic LGE. During a median follow-up of 9.0 years (IQR, 6.6-11.5 years), 652 participants died. The presence of ischemic LGE was strongly associated with mortality (hazard ratio, 3.45 [99.5% CI: 2.55, 4.67]; P < .001). In the group with ischemic LGE, the LGE granularity model combining these LGE features showed the best predictive value above traditional prognosticators and ischemic LGE extent to predict all-cause mortality (area under the receiving operating characteristic curve [AUC] at 10 years, 0.89 [99.5% CI: 0.89, 0.90] vs 0.83 [99.5% CI: 0.83, 0.84]; P < .001). The cardiac MRI LGE score performed well in participants with ischemic LGE (AUC at 10 years, 0.87 [99.5% CI: 0.85, 0.90]). Conclusion In a large cohort of participants with ischemic cardiomyopathy, an LGE granularity model had a higher prognostic value over traditional prognosticators to predict mortality. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Lima and Ebrahimihoor in this issue.

Feasibility of fractal dimension analysis for left ventricular trabecular complexity using cardiac computed tomography

AIMS

To evaluate the consistency between fractal dimensions (FD) derived from cardiac computed tomography (CT-FD) and cardiac magnetic resonance (MR-FD) in assessing left ventricular trabecular complexity.

METHODS

This retrospective study included 170 patients who underwent CCT and CMR scans within two weeks. Five short-axis cine images were selected at end-diastole: one basal, three mid, and one apical slice. Short-axis CCT views were reconstructed and aligned with the cine images. CT-FD and MR-FD values were calculated for each slice, with mean values determined for each patient. Severe left ventricular hypertrophy (LVH) was defined as a maximum wall thickness > 15 mm in end-diastolic cine images.

RESULTS

The diastolic CT-FD and MR-FD values exhibited high consistency, with values of 1.253 ± 0.091 and 1.250 ± 0.102, respectively (n = 535, ICC = 0.882, 95 % CI: 0.861-0.899, P < 0.001). Similarly, the systolic CT-FD and MR-FD values demonstrated good consistency, with values of 1.268 ± 0.072 and 1.286 ± 0.093, respectively (n = 390, ICC = 0.720, 95 % CI: 0.669-0.765, P < 0.001). For subgroups of systolic NLVH and LVH, the ICCs were 0.773 (n = 305, CI: 0.723-0.814, P < 0.001) and 0.565 (n = 85, 95 % CI: 0.402-0.694, P < 0.001), respectively. The diagnostic efficacy of mean CT-FD aligned with that of mean MR-FD in distinguishing abnormal cardiac conditions from the CMR-negative group.

CONCLUSIONS

CCT is a feasible method for assessing left ventricular trabecular complexity, with good agreement with CMR, except in cases of severe left ventricular hypertrophy during systole.

The kinetics of cardiac troponin T release during and after 1- and 6-h maximal cycling trials

OBJECTIVES

In this study, the effects of short-duration high-intensity exercise and long-duration exercise on high-sensitivity cardiac troponin T (hs-cTnT) levels were compared.

METHODS

Twelve male amateur cyclists performed 1- and 6-h cycling trials. In both exercise trials, hs-cTnT was assessed at rest, immediately postexercise and at 1, 3, 6, 12, and 24 h postexercise. Additionally, hs-cTnT levels were assessed every hour during the 6-h trial.

RESULTS

Exercise resulted in an increase in hs-cTnT levels in all subjects. Circulating hs-cTnT levels increased in both exercise trials (p < 0.001), with higher peak values occurring after the 1-h trial compared with those of the 6-h trial (p = 0.023). The upper reference limit (URL) exceeded 83 % of the participants in the 1-h trial and 42 % of the participants in the 6-h trial. There was substantial individual variability in peak hs-cTnT in both trials. Values of hs-cTnT were greater after exercise than during exercise for the 6-h trial. For both exercise trials, the maximum postexercise hs-cTnT values correlated with the %HRMAX (r = 0.906 for the 1-h trial, r = 0.735 for the 6-h trial). For the 1-h trial, the maximum postexercise hs-cTnT values were observed at 3 h in all subjects. No significant difference in the hs-cTnT values was observed for the 6-h trial during the first 12 h postexercise.

CONCLUSIONS

Our results demonstrated greater hs-cTnT levels in young male participants after a 1-h cycling trial than after a 6-h cycling trial, despite a substantially greater energy expenditure and total external work completed in the 6-h trial. Postexercise hs-cTnT values are associated with relative exercise intensity.

Long-term outcomes and operators' experience in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) is typically performed by experienced operators. Therefore, the safety of pPCI for STEMI performed by less experienced operators with the support of experienced operators remains unknown. We aimed to investigate the long-term outcomes of pPCI for STEMI performed by less experienced operators with the support of experienced operators. In total, 775 STEMI patients were enrolled and divided into groups according to operator experience in PCI: less experienced (n = 384) and experienced (n = 391) operator groups. Experienced operators were defined as those who had performed > 50 elective PCI procedures per year as the first operator or instructional assistant, whereas less experienced operators were defined as others. When less experienced operators performed the pPCI, experienced operators supported them. The primary endpoint was any cardiovascular event, defined as a composite of cardiovascular death, nonfatal myocardial infarction, and unplanned hospitalization for heart failure. In the propensity score-matched analysis, 324 patients were included in each group. The cumulative incidence of the primary endpoint over a median of 5 years in the less experienced operator group was similar to that in the experienced operator group (15% vs. 18%, P = 0.209). In the multivariate Cox proportional hazards model, there was no excess risk for patients operated upon by less experienced operators for the primary endpoint (adjusted hazard ratio, 0.85; 95% confidence interval, 0.58-1.25; P = 0.417). pPCI for STEMI by less experienced operators did not increase the risk of in-hospital mortality or 5-year long-term cardiovascular events if supported by experienced operators.

Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery

BACKGROUND

The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality.

METHODS

A consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined.

RESULTS

Lower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002).

CONCLUSIONS

We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

Biomarkers to Predict Abnormal Technetium-99m Pyrophosphate Scans in Patients With Suspected Transthyretin Amyloidosis

Background

Technetium Tc 99m pyrophosphate scintigraphy (99mTc PYP imaging) is a diagnostic tool for transthyretin amyloid cardiomyopathy (ATTR-CM). Cardiac biomarkers, particularly high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), may help identify patients at low or high risk for ATTR-CM.

Objectives

The authors sought to evaluate the predictive value of hs-cTnT and NT-proBNP in patients undergoing 99mTc PYP imaging for suspected ATTR-CM in a large U.S. cohort.

Methods

This was a retrospective study of patients who underwent 99mTc PYP imaging between May 2013 and September 2022, including those with at least 1 hs-cTnT measurement within 6 months of the scan.

Results

ATTR-CM was diagnosed in 427 of 1,442 patients (29.6%). A hs-cTnT level <6 ng/L (n = 50, 3.5%) showed a negative predictive value of 100% (95% CI: 93%-100%) and sensitivity of 100% (95% CI: 99%-100%) for ruling out ATTR-CM. As the hs-cTnT threshold increased, the number of patients who could be ruled out also increased, but false negatives emerged. The positive predictive value for ruling in ATTR-CM remained low. NT-proBNP showed similar results (n = 1,378). The combination of hs-cTnT <14 ng/L and NT-proBNP <60 ng/L identified 45 patients (3.3%) without ATTR-CM.

Conclusions

In patients undergoing 99mTc PYP imaging for suspected ATTR-CM, very low hs-cTnT levels can effectively rule out the diagnosis, although in a small subset of patients. Higher thresholds increase the risk of false negatives. NT-proBNP and combined biomarker strategies showed similar trends, the utility of hs-cTnT and NT-proBNP for ruling in the disease is limited.

4-Factor prothrombin complex concentrates and factor VIII inhibitor bypass activity use in cardiac surgery

OBJECTIVES

The objective of this study was to compare total thromboembolic complications between 4-factor prothrombin complex concentrate (4F-PCC) with factor VIII inhibitor bypassing activity (FEIBA) when utilized during cardiac surgery.

DESIGN

A quasi-experimental analysis of retrospective data from consecutive patients.

SETTING

A tertiary care university hospital.

PARTICIPANTS

Patients undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

Patients received either 4F-PCC or FEIBA after discontinuation of cardiopulmonary bypass and reversal of heparin with protamine.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed for thromboembolic events (stroke, arterial or venous thrombosis, pulmonary embolism, myocardial infarction), acute kidney injury, ischemic bowel, death, duration of intensive care unit and hospital stay, clinical and surgical characteristics and blood product utilization. A comparison of the clinical and surgical variables demonstrated a mean effect size of 0.33 imbalance between groups that was reduced to 0.18 after propensity score weighting. The propensity scores weighted analysis found an incidence of composite thromboembolic events of 39% in the 4F-PCC ( n  = 90) and 47% in the FEIBA ( n  = 50) group, difference -8 (-24% to 12%), P  = 0.13. Individual thromboembolic events, acute kidney injury, ischemic bowel, mortality, and length of intensive care unit or hospital stay was not different among groups. Patients who received FEIBA had greater chest tube drainage and received more cryoprecipitate intraoperatively. Patients who received 4F-PCC received more fresh frozen plasma transfusions postoperatively.

CONCLUSIONS

Among cardiac surgery patients, there was no difference in thromboembolic events between patients who received 4F-PCC or FEIBA when used as an adjunct to blood product administration.

Knockdown of KLF6 ameliorates myocardial infarction by regulating autophagy via transcriptional regulation of PTTG1

Krüppel-like factor 6 (KLF6) knockdown provides protection against kidney ischemia/reperfusion injury and ischemic stroke. However, it is unclear whether it plays a role in myocardial infarction (MI). Here, the expression of KLF6 was analyzed using the Gene Expression Omnibus (GEO) database and determined in patients with MI. The impact of KLF6 knockdown was further confirmed in in vivo and in vitro models of MI. The interaction between KLF6 and pituitary tumor-transforming gene 1 (PTTG1) was also evaluated. According to the GEO database, KLF6 expression was found to be upregulated in mouse hearts after MI compared to sham-operated mice. The upregulation of KLF6 in hearts from mice post-MI and in patients with MI was confirmed. KLF6 knockdown was found to alleviate myocardial injury, diminish infarct size, and suppress apoptosis and autophagy in mice with MI. In addition, inactivation of the AMP-activated protein kinase (AMPK)/mammalian target of rapamycin (mTOR) signaling was observed after KLF6 knockdown in mice with MI. In an in vitro model of MI, the knockdown of KLF6 increased cell survival and inhibited autophagy through the AMPK/mTOR pathway. In addition, KLF6 interacted with the promoter of PTTG1 and negatively regulated its expression. Knockdown of PTTG1 abolished the function of KLF6 knockdown in vitro. This study demonstrates the protective effect of KLF6 knockdown against MI, which is attributed to the elevation of PTTG1 expression and inhibition of the AMPK/mTOR pathway. These findings provide a novel insight into MI treatment.NEW & NOTEWORTHY Our study demonstrates for the first time the role of Krüppel-like factor 6 (KLF6)/PTTG1 axis in myocardial infarction (MI). This study demonstrates the protective effect of KLF6 knockdown against MI, which is attributed to the elevation of PTTG1 expression and inhibition of the AMPK/mTOR pathway. These findings provide a novel insight into MI treatment.

Serial secretoneurin measurement and risk of ventricular arrhythmias and death in patients with left ventricular systolic dysfunction

BACKGROUND

Secretoneurin, a member of the granin protein family, is associated with the risk of mortality in patients with acute and chronic heart failure. Secretoneurin may play an important role in cardiomyocyte calcium handling, suggesting that it may influence cardiac arrhythmia risk. We hypothesized that baseline and serial measurements of circulating secretoneurin are associated with the risk of incident ventricular tachyarrhythmias (VA) and death, and that serial measurement would provide prognostic information beyond baseline values.

METHODS

We measured circulating secretoneurin concentrations in blood samples obtained at 3-month intervals for one year in a prospectively enrolled cohort of ambulatory patients with left ventricular ejection fraction (LVEF) ≤ 35 % and a primary-prevention implanted cardioverter defibrillator (ICD). Associations between secretoneurin modeled as a time-dependent variable and the incidences of VA and death were assessed.

RESULTS

154 patients (66 ± 14 years, LVEF 23 ± 8 %) were included in the analysis. During one-year follow-up, 26 (17 %) patients experienced VA, and 16 (10 %) died. Adjusting for age, sex, eGFR, and LVEF, baseline secretoneurin concentration was associated with the risk of death (hazard ratio (HR) per 10 pmol/L increase: 1.14 (95 % CI: 1.02-1.27), p = 0.020) but not VA (HR: 0.98 (0.81-1.19), p = 0.856). Using serial measurements at 3-month intervals, time-varying secretoneurin was associated with a similarly higher risk of death (HR: 1.14 (1.02-1.27), p = 0.017) but not of VA (HR: 0.97 (0.81-1.17), p = 0.776).

CONCLUSION

In stable ambulatory patients with reduced LV systolic function and a primary prevention indication for ICD, secretoneurin concentration was associated with the risk of death but not ventricular tachyarrhythmia.

Characteristics of Atherosclerotic Plaques Left after Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome. Assessment According to Computed Tomographic Angiography of the Coronary Arteries

AIM

To evaluate characteristics of atherosclerotic plaques (ASP) remaining after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) by coronary computed tomography angiography (CCTA).

MATERIAL AND METHODS

Among 249 patients (193 men) with ACS aged 58±10 years, 183 (73.5%) had myocardial infarction, 66 (26.5%) had unstable angina. CCTA was performed after PCI at 3-7 days after the onset of ACS according to the standard protocol: in 41 patients, on a 64-slice tomograph (Aquilion 64, Toshiba, Japan) and in 208 patients, on a 640-slice tomograph with 320 rows of detectors (Aquilion ONE Vision Edition, Toshiba, Japan). CCTA of all patients was performed on a Vitrea workstation. Patients with at least one non-calcified ASP were included.

RESULTS

Among all ASPs, non-calcified ASPs predominated, 609 of 785 (77.6%), including 400 soft and 209 combined ones. Signs of obstruction (stenosis ≥50%) were noted in 72.2% of non-calcified ASPs. ASPs were characterized by a pronounced burden, 69 [61.4; 74.2]%, and a low minimum density, 31 [23; 37] HU, which was consistent with mature plaques with a lipid core. Various signs of ASP instability were observed in 6-35.3% of cases. There were 2 [2;3] (1 to 6) affected coronary arteries (CAs) and 3 [2;4] (1 to 7) ASPs, including calcified ones, per patient. 77.7% of ASPs were located in the CA proximal and middle segments. Obstructive stenosis was detected in 92% of patients. The number of ASPs with obstructive stenosis ranged from 0 to 7 per patient, with a median of 2 [1;3]. In 44% of patients, stenosis was 70% or more. The maximum burden of non-calcified ASPs was high, 74.3±12.1%; their maximum and total length were 13.8±10.4 mm and 26.5±19.7 mm, respectively; and the ASP minimum density was low, 25 [17;32] HU. ASPs with a low-density area of ≤46 HU and ≤30 HU were detected in 24.9% and 14.8% of patients, respectively. Other CCTA signs of instability were quite common: punctate calcifications in 52.2% of patients, coronary positive remodeling in 37%, the presence of "ring-like enhancement" in 16.1%, an uneven plaque contour in 26.7%, and at least one sign of ASP instability in 73% of patients.

CONCLUSION

After PCI, patients with ACS still have rather many ASPs, including those with CCTA signs of instability, with stenosis >50%; more than a third of the plaques had stenosis >70%; the plaques were extended and localized mainly in the proximal and middle sections of the main CAs.

Prognostic potential of inflammatory markers in chronic kidney disease patients combined with acute myocardial infarction

Background

Inflammation significantly impacts chronic kidney disease (CKD) and acute myocardial infarction (AMI). This study investigates the prognostic value of inflammatory markers in predicting outcomes for CKD patients with AMI.

Methods

We enrolled patients diagnosed with CKD concomitant with AMI, choosing five inflammatory markers related to both diseases. Patients were categorized into elevated inflammatory markers group and control group based on inflammatory markers cut-off values for predicting in-hospital major adverse cardiac and cerebrovascular events (MACCE). Using univariate and multivariate logistic regression, we identified inflammation-related risk factors for MACCE. We adjusted covariates stepwise to explore the relationship between independent risk factors and adverse outcomes. We also evaluated the predictive value of these markers for MACCE by receiver operating characteristic (ROC) curves.

Results

In the multivariate logistic regression analysis, higher levels of neutrophil-to-lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) significantly increased risk of MACCE (all P < 0.05). After adjusting above two indicators, NLR was independently associated with in-hospital MACCE in CKD patients with AMI (OR = 10.764, 95% CI: 1.887-61.406, P = 0.007). Furthermore, compared to other inflammatory markers, NLR had the highest predictive value for MACCE in patients with AMI and CKD [Area Under the Curve (AUC): 0.748, 95% Confidence Interval (CI): 0.634-0.861, P < 0.001].

Conclusion

In CKD patients combined with AMI, elevated levels of inflammation markers could increase the risk of MACCE. NLR may provide superior predictive value compared to other markers.

Adjustment of the ACEF score by the triglyceride glucose index improves the prediction of clinical outcomes in patients undergoing percutaneous coronary intervention

BACKGROUND

The ACEF score (age, creatinine, and left ventricular ejection fraction) and the triglyceride-glucose (TyG) index have been identified as robust risk prediction models for adverse outcomes post-percutaneous coronary intervention (PCI) in coronary atherosclerotic heart disease (CHD) patients. This study aimed to assess whether incorporating the TyG index enhances the predictive ability of the ACEF score and enhances risk stratification for CHD patients undergoing PCI.

METHODS

This observational cohort study enrolled 1248 patients diagnosed with CHD who underwent PCI at the Third People's Hospital of Chengdu, China, between May 2018 and December 2022. Receiver operating characteristic (ROC) curves were employed to establish the optimal cutoff values for the TyG index and ACEF score. The primary endpoint event was defined as major adverse cardiac and cerebrovascular events (MACCEs). Cumulative survival curves were plotted using the Kaplan-Meier method. Univariable and multivariable Cox regression analyses were conducted to identify predictors of MACCEs. The predictive ability of the ACEF score and the TyG index was assessed using the area under the ROC curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

Over a median follow-up period of 30.60 months, 214 patients experienced MACCEs. Kaplan-Meier survival analysis demonstrated a significant association between elevated ACEF score (> 1.27) and TyG index levels (> 8.82) with a heightened incidence of MACCEs (HR = 2.018, 95%CI 1.593-2.789; HR = 2.057, 95%CI 1.572-2.691; Log-Rank test, both P < 0.001). Multivariable Cox regression analysis revealed that even after adjusting for multiple confounders, both the ACEF score and TyG index remained as predictors of MACCEs (HR = 1.702, 95%CI 1.210-2.394, P = 0.002; HR = 1.575, 95%CI 1.296-1.916, P < 0.001). Additionally, the addition of the ACEF score and TyG index into the conventional risk model significantly improved the ability to predict MACCEs, as evidenced by the increase in the C-statistic value from 0.664 to 0.703, along with notable improvements in continuous NRI (0.391), categorical NRI (0.107), and IDI (0.033) (all P < 0.001).

CONCLUSION

The combination of the TyG index and the ACEF score enhances the predictive ability for long-term MACCEs in patients with CHD undergoing PCI.

Metabonomic Biomarkers of Plaque Burden and Instability in Patients With Coronary Atherosclerotic Disease After Moderate Lipid-Lowering Therapy

BACKGROUND

Contemporary risk assessment in patients with coronary atherosclerotic disease (CAD) often relies on invasive angiography. However, we aimed to explore the potential of metabolomic biomarkers in reflecting residual risk in patients with CAD after moderate lipid-lowering therapy.

METHODS AND RESULTS

We analyzed serum metabolomic profile among 2560 patients with newly diagnosed CAD undergoing moderate lipid-lowering therapy, through nuclear magnetic resonance spectroscopy and quantified 175 metabolites, predominantly lipoproteins and their components. CAD severity was evaluated using Gensini score for plaque burden and circulating cardiac troponin T levels for plaque instability. The association of metabolites with CAD severity was examined using multivariate linear regression, and the underlying potential causality was explored using a 2-sample Mendelian randomization approach. Two composite metabolomic indices were constructed to reflect CAD severity using least absolute shrinkage and selection operator linear regression, and their associations with risk of major adverse cardiac events during a median follow-up of 3.8 years were evaluated using Cox models. Our investigation revealed that triglycerides and apolipoprotein B in low-density lipoprotein particles displayed stronger associations with CAD severity compared with the clinically used low-density lipoprotein cholesterol marker. In large high-density lipoprotein, components like cholesterol, cholesterol esters, triglyceride, apolipoprotein A1/A2 showed inverse associations with CAD severity. Certain metabolites, including apolipoprotein B and dihydrothymine, showed a putative causal link with Gensini score. Notably, per standard deviation increase in Gensini score-based metabolomic index was associated with 14.8% higher major adverse cardiac event risk (hazard ratio, 1.148 [95% CI, 1.018-1.295]) independent of demographic factors, medication use, and disease status.

CONCLUSIONS

Our findings highlight the potential of nuclear magnetic resonance-based metabolomics in identifying novel biomarkers of plaque burden and instability. Metabolites related to plaque burden may facilitate noninvasive assessment of CAD prognosis.

Phaeochromocytoma mimicking acute ST-elevation myocardial infarction

Phaeochromocytomas are rare catecholamine-secreting tumours, usually benign, originating from chromaffin cells of the adrenal glands. Their typical presentation includes the triad of headaches, sweating and tachycardia due to excessive catecholamine release. However, many patients do not exhibit all three symptoms, making diagnosis challenging. A significant proportion of cases (around 40%) are linked to genetic disorders. Cardiac complications, including life-threatening events, are common.This report details the case of a 43-year-old woman presenting with chest pain, headaches and diaphoresis. Initial ECG showed an anterolateral ST-elevation myocardial infarction pattern, but coronary angiography revealed no arterial disease. The left ventricular angiogram indicated apical ballooning. Elevated blood pressure prompted suspicion of phaeochromocytoma, which was confirmed through positive metanephrine tests.The tumour, located in the right adrenal gland, was successfully removed laparoscopically, and pathological examination confirmed the diagnosis.Phaeochromocytoma should be suspected in patients with unexplained myocardial infarction, labile hypertension and normal coronary arteries, as beta-blockers can be harmful if used in untreated cases.

Early coronary revascularization among 'stable' patients with non-ST-segment elevation acute coronary syndromes: the role of diabetes and age

AIMS

To investigate the impact of an early coronary revascularization (<24 h) compared with initial conservative strategy on clinical outcomes in diabetic patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) who are in stable condition at hospital admission.

METHODS AND RESULTS

The International Survey of Acute Coronary Syndromes database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, haemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all-cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% confidence intervals (CIs) were employed. Of the 7589 NSTE-ACS patients identified, 2343 were diabetics. The data show a notable reduction in mortality for the elderly (>65 years) undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% vs. 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% vs. 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients (OR: 1.04; 95% CI: 0.53-2.06).

CONCLUSION

Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS.

CLINICAL TRIAL NUMBER

ClinicalTrials.gov: NCT01218776.

Prognostic Value of Human Epididymis Protein 4 in Acute Myocardial Infarction

Purpose

To investigate the prognostic value of human epididymis protein 4 (HE4) in patients with acute myocardial infarction (AMI).

Patients and Methods

A total of 212 consecutive patients diagnosed with AMI in the Department of Cardiovascular Medicine of Hunan Provincial People's Hospital from June 2020 to May 2021 were enrolled. We determined plasma HE4 levels at baseline. The patients were followed up regularly and the occurrence of major adverse cardiac events (MACE) was recorded after discharge.

Results

After a mean follow-up period of 242 (159-427) days, 67 patients had MACE. Multivariate Cox regression analysis showed that HE4 was an independent predictor of MACE in patients with AMI [HR = 1.004 (1.002-1.007), P = 0.002]. Kaplan-Meier survival curves showed that patients with HE4 levels > 532.9 pmol/L had higher MACE compared with patients with ≤ 532.9 pmol/L HE4 levels (HR=4.044, 95% CI 2.373-6.890, P <0.001). Receiver operating characteristic (ROC) curve analysis showed that the area under the curve (AUC) of HE4 for predicting MACE was 0.734 (95% CI: 0.669-0.792, P < 0.001).

Conclusion

Human epididymis protein 4 (HE4) might be a novel biomarker for predicting the prognosis of patients with AMI.

Prediction of Major Adverse Cardiovascular Events in Patients with Peripheral Artery Disease Using Circulating Immunomodulatory Proteins

Background/Objectives: The leading cause of death for people with peripheral artery disease (PAD) is major adverse cardiovascular events (MACE), including heart attacks and strokes. However, research into biomarkers that could help predict MACE in patients with PAD has been limited. Immunomodulatory proteins are known to significantly influence systemic atherosclerosis, suggesting they could be useful prognostic indicators for MACE in patients with PAD. In this study, we evaluated a broad panel of immunomodulatory proteins to identify those linked to MACE in individuals with PAD. Methods: We conducted a prognostic study involving a prospectively recruited cohort of 406 patients consisting of 254 with PAD and 152 without PAD. At the baseline, we measured the plasma concentrations of 17 circulating immunomodulatory proteins and followed the cohort for two years. The primary outcome was 2-year MACE, a composite of myocardial infarction, stroke, or death. Plasma protein concentrations were compared between patients with PAD with and without 2-year MACE using Mann-Whitney U tests. We further examined the prognostic potential of differentially expressed proteins through a Cox proportional hazards analysis, determining their independent associations with 2-year MACE while controlling for all the baseline demographic and clinical characteristics, including the existing coronary artery and cerebrovascular diseases. Additionally, A Kaplan-Meier analysis was performed to evaluate the 2-year freedom from MACE in patients with low versus high levels of the differentially expressed proteins based on the median plasma concentrations. Results: The mean age of the cohort was 68.8 years (SD 11.1), with 134 patients (33%) being female. During the two-year follow-up, 63 individuals (16%) developed MACE. The following proteins were significantly elevated in patients with PAD who experienced 2-year MACE compared to those who did not: galectin-1 (0.17 [SD 0.06] vs. 0.10 [SD 0.07] pg/mL, p = 0.012), alpha-1-microglobulin (16.68 [SD 7.48] vs. 14.74 [SD 6.71] pg/mL, p = 0.019), and galectin-9 (0.14 [SD 0.09] vs. 0.09 [SD 0.05] pg/mL, p = 0.033). The Cox proportional hazards analysis indicated that these three proteins were independently associated with 2-year MACE after adjusting for all the baseline demographic and clinical factors: galectin-1 (HR 1.45 [95% CI 1.09-1.92], p = 0.019), alpha-1-microglobulin (HR 1.31 [95% CI 1.06-1.63], p = 0.013), and galectin-9 (HR 1.35 [95% CI 1.02-1.78], p = 0.028). Over the two-year follow-up, patients with higher levels of galectin-1, galectin-9, and alpha-1-microglobulin had a lower freedom from MACE. Additional analysis showed that these three proteins were not significantly associated with 2-year MACE in patients without PAD. Conclusions: Among the 17 immunomodulatory proteins evaluated, galectin-1, galectin-9, and alpha-1-microglobulin were found to be independently and specifically associated with 2-year MACE in patients with PAD. Assessing the plasma concentrations of these proteins can aid in risk stratification for MACE in patients with PAD, helping to inform clinical decisions regarding multidisciplinary referrals to cardiologists, neurologists, and vascular medicine specialists. This information can also guide the aggressiveness of medical management, ultimately improving cardiovascular outcomes for patients with PAD.

How Close Are We to Patient-Side Troponin Testing?

Laboratory-based high-sensitivity cardiac troponin testing has been the pillar for emergency stratification of suspected acute coronary syndrome for well over a decade. Point-of-care troponin assays achieving the requisite analytical sensitivity have recently been developed and could accelerate such assessment. This review summarises the latest assays and describes their potential diverse clinical utility in the emergency department, community healthcare, pre-hospital, and other hospital settings. It outlines the current clinical data but also highlights the evidence gap, particularly the need for clinical trials using whole blood, that must be addressed for safe and successful implementation of point-of-care troponin analysis into daily practice. Additionally, how point-of-care troponin testing can be coupled with advances in biosensor technology, cardiovascular screening, and triage algorithms is discussed.

Identification of transcription factor-lipid droplet-related gene biomarkers for the prognosis of post-acute myocardial infarction-induced heart failure

Introduction

Patients with acute myocardial infarction (AMI) are at high risk of progressing to heart failure (HF). Recent research has shown that lipid droplet-related genes (LDRGs) play a crucial role in myocardial metabolism following MI, thereby influencing the progression to HF.

Methods

Weighted gene co-expression network analysis (WGCNA) and differential expression gene analysis were used to screen a transcriptome dataset of whole blood cells from AMI patients with (AMI HF, n = 16) and without progression (AMI no-HF, n = 16). Functional enrichment analysis were performed to observe the involved function. Machine learning methods were used to screen the genes related to prognosis. Transcriptional factors (TF) were predicted by using relevant databases. ROC curves were drawn to evaluate the TF-LDRG pair in predicting HF in the validation dataset (n = 16) and the clinical trial (n = 13).

Results

The 235 identified genes were primarily involved in pathways related to fatty acid and energy metabolism. 22 genes were screened out that they were strongly associated with prognosis. 35 corresponding transcription factors were predicted. The TF-LDRG pair, ABHD5-ARID3a, was demonstrated good predictive accuracy.

Discussion

Our findings suggest that ABHD5-ARID3a have significant potential as predictive biomarkers for heart failure post-AMI which also provides a foundation for further exploration into the molecular mechanisms underlying the progression from AMI to HF.

An exploration into the diagnostic capabilities of microRNAs for myocardial infarction using machine learning

BACKGROUND

MicroRNAs (miRNAs) have shown potential as diagnostic biomarkers for myocardial infarction (MI) due to their early dysregulation and stability in circulation after MI. Moreover, they play a crucial role in regulating adaptive and maladaptive responses in cardiovascular diseases, making them attractive targets for potential biomarkers. However, their potential as novel biomarkers for diagnosing cardiovascular diseases requires systematic evaluation.

METHODS

This study aimed to identify a miRNA biomarker panel for early-stage MI detection using bioinformatics and machine learning (ML) methods. miRNA expression data were obtained for early-stage MI patients and healthy controls from the Gene Expression Omnibus. Separate datasets were allocated for training and independent testing. Differential expression analysis was performed to identify dysregulated miRNAs in the training set. The least absolute shrinkage and selection operator (LASSO) was applied for feature selection to prioritize relevant miRNAs associated with MI. The selected miRNAs were used to develop ML models including support vector machine, Gradient Boosted, XGBoost, and a hard voting ensemble (HVE).

RESULTS

Differential expression analysis discovered 99 dysregulated miRNAs in the training set. LASSO feature selection prioritized 21 miRNAs. Ten miRNAs were identified in both the LASSO subset and independent test set. The HVE model trained with the selected miRNAs achieved an accuracy of 0.86 and AUC of 0.83 on the independent test set.

CONCLUSIONS

An integrated framework for robust miRNA selection from omics data shows promise for developing accurate diagnostic models for early-stage MI detection. The HVE model demonstrated good performance despite differences between training and test datasets.

Effect of stellate ganglion block on perioperative myocardial injury following thoracoscopic surgery for lung cancer (SGBMI): protocol for a single-centre, randomised controlled trial

INTRODUCTION

Myocardial injury is a common complication of thoracoscopic surgery. The stellate ganglion block is believed to affect myocardial oxygen consumption. The Stellate Ganglion Block and Myocardial Injury (SGBMI) trial aims to test the hypothesis that stellate ganglion block can reduce the incidence of perioperative myocardial injury in patients undergoing thoracoscopic surgery for lung cancer.

METHODS AND ANALYSIS

The SGBMI trial is a double-blind, randomised trial comparing the effects of a stellate ganglion block and a sham procedure in patients with cardiovascular risk factors undergoing thoracoscopic surgery. The exclusion criteria include procedure-related contraindications and severe heart failure. The stellate ganglion block or sham procedures will be performed preoperatively. The primary outcome is myocardial injury within 30 days of the follow-up. The main safety outcomes are sepsis, infection and procedure-related complications. We will enrol 248 patients to ensure at least 80% power for the evaluation of the primary outcome. The primary results of the SGBMI trial are expected to be announced by the year 2027.

ETHICS AND DISSEMINATION

Ethical approval for the study is obtained from the Ethics Committee of the Shanghai Pulmonary Hospital (approval number: L22-394). Written informed consent will be obtained from all participating patients. The publication of results in a peer-reviewed journal and presentations at conferences are anticipated.

TRIAL REGISTRATION NUMBER

ChiCTR2300071469 (registered on 16 May 2023).

Cardiooncology in the ICU - Cardiac Urgencies in Cancer Care

Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.

Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

BACKGROUND

The MINT trial (Myocardial Ischemia and Transfusion) raised concern for harm from a restrictive versus liberal transfusion strategy in patients with acute myocardial infarction (MI) and anemia. Type 1 and type 2 MI are distinct pathophysiologic entities that may respond differently to blood transfusion. This analysis sought to determine whether the effects of transfusion varied among patients with a type 1 or a type 2 MI and anemia. The authors hypothesized that the liberal transfusion strategy would be of greater benefit in type 2 than in type 1 MI.

METHODS

The authors compared rates of death or MI at 30 days in patients with type 1 (n=1460) and type 2 (n=1955) MI and anemia who were randomly allocated to a restrictive (threshold, 7-8 g/dL) or a liberal (threshold, 10 g/dL) transfusion strategy.

RESULTS

The primary outcome of death or MI was observed in 16% of type 1 MI and 15.4% of type 2 MI patients. The rate of death or MI was higher in patients with type 1 MI randomized to a restrictive (18.2%) versus liberal (13.8%) transfusion strategy (relative risk [RR], 1.32 [95% CI, 1.04-1.67]) with no difference observed between the restrictive (15.8%) and liberal (15.1%) transfusion strategies in patients with type 2 MI (RR, 1.05 [95% CI, 0.85-1.29]). The test for a differential effect of transfusion strategy by MI type was not statistically significant (Pinteraction = 0.16).

CONCLUSIONS

The concern for harm with a restrictive transfusion strategy in patients with acute MI and anemia raised in the MINT primary outcome manuscript may be more apparent in patients with type 1 than type 2 MI.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02981407.

Diagnostic performance of a point-of-care high-sensitivity cardiac troponin I assay among Chinese patients with chest pain

BACKGROUND

A novel handheld point-of-care high-sensitivity cardiac troponin I analyser has recently been introduced to the market. Evaluating its diagnostic performance against laboratory standards is imperative, given the variations in cardiac troponin levels across populations. This study compared the diagnostic performance between the point-of-care high-sensitivity cardiac troponin I assay (Siemens Healthineers Atellica VTLi) and a laboratory high-sensitivity cardiac troponin I assay (Abbott ARCHITECT STAT High Sensitive Troponin-I) performed using blood samples from various populations (overall, male, female, younger and older) of Chinese patients with chest pain.

METHODS

This cross-sectional study included 585 consecutive Chinese patients (age ≥18 year) who presented to an emergency department with chest pain (lasting >5 min) and were managed following the chest pain protocol between 1 August 2023 and 12 June 2024. For both assays, blood samples were collected at two time points (0 hour (initial) and 3 hour (subsequent)). The primary outcome was the diagnostic performance of the two assays, evaluated with their 99th percentile upper reference limits used as the cut-off values for diagnosing myocardial infarction. The gold standard for comparison was the final diagnoses made by attending physicians.

RESULTS

The point-of-care and laboratory assays exhibited equivalent sensitivity and negative predictive values (both 100%) for blood samples collected at both time points. However, the point-of-care assay outperformed the laboratory assay in terms of specificity (initial: 90.5% to 96.3% vs 79.8% to 94.7%; subsequent: 87.8% to 94.8% vs 77.7% to 92.4%) and positive predictive value (initial: 24.4% to 30.8% vs 11.6% to 23.5%; subsequent: 12.5% to 25.0% vs 5.9% to 18.8%), particularly in older patients.

CONCLUSION

The point-of-care assay is recommended for rapid clinical decision-making. Future studies should explore the effects of its integration into clinical practice and the feasibility of using sex-race-age-specific 99th percentile upper reference limits to enhance its diagnostic performance.

Hydrogel encapsulating gold nanoparticles for targeted delivery of nitroglycerin to reduce post-cardiac dysfunction inflammation by inhibiting the Wnt/β-catenin signaling pathway

The discovery of nitric oxide's role in biological processes like platelet function, vasodilation, cell permeability, and inflammation has advanced our understanding of organic nitrate therapy's hemodynamic and nonhemodynamic effects. Short-term use of organic nitrates prevents left ventricular enlargement and infarct expansion. However, information on their long-term impact on LV remodeling in post-acute cardiac dysfunction patients is limited. In this study, we utilized an innovative active hydrogel with gelatin (Gel)/polyethylene glycol (PEG)/polylactic acid (PLA) encapsulating gold nanoparticles (AuNPs)-based drug delivery system for the sustained release of nitroglycerin (NTG). Gel/PEG/PLA/NTG/AuNPs hydrogel-based system is a non-transplant surgical method that can adhere to the surface of the heart and deliver the drug directly to the epicardium. Cardiac dysfunction was induced by ligating the left anterior descending coronary artery. Echocardiograms were used to study the pre- and post-operative hemodynamics. Hematoxylin and eosin (H&E) and Masson's trichrome stain (MTS) staining revealed that the acute myocardial infarction (AMI) rats' group had irregularly shaped fibers and a lack of transverse striations, whereas Gel/PEG/PLA/NTG/AuNPs hydrogel group showed significant improvement. Rats in the Gel/PEG/PLA hydrogel group demonstrated marked vasodilation, compared to the AMI group. Mechanistically, we determined that hydrogel disrupts the initiation of post-cardiac dysfunction via inhibiting Wnt/β-catenin transcriptional activation. Hence, the Gel/PEG/PLA/NTG/AuNPs hydrogel group effectively protected against ischemic injury and inflammation in AMI, demonstrating a novel method for treating acute cardiac dysfunction.

Cardiac troponin elevation and mortality in takotsubo syndrome: New insights from the international takotsubo registry

BACKGROUND

The clinical relevance of cardiac troponin (cTn) elevation in takotsubo syndrome (TTS) remains uncertain. The present study sought to investigate the role of cardiac troponin (cTn) elevations in mortality prediction of patients with Takotsubo syndrome (TTS).

METHODS

Patients enrolled in the International Takotsubo (InterTAK) Registry from January 2011 to February 2020 with available data on peak cTn levels were included in the analysis. Peak cTn levels during the index hospitalization were used to define clinically relevant myocardial injury. The threshold at which clinically relevant myocardial injury drives mortality at 1 year was identified using restricted cubic spline analysis.

RESULTS

Out of 2'938 patients, 222 (7.6%) patients died during 1-year follow-up. A more than 28.8-fold increase of cTn above the upper reference limit was identified as threshold for clinically relevant myocardial injury. The presence of clinically relevant myocardial injury was significantly associated with an increased risk of mortality at 5 years (adjusted HR 1.58, 95% CI 1.18-2.12, p =.002). Clinically relevant myocardial injury was related to an increased 5-year mortality risk in patients with apical TTS (adjusted HR 1.57, 95% CI 1.21-2.03, p =.001), in presence of physical stressors (adjusted HR 1.60, 95% CI 1.22-2.11, p =.001), and in absence of emotional stressors (adjusted HR 1.49, 95% CI, 1.17-1.89, p =.001).

CONCLUSION

This study for the first time determined a troponin threshold for the identification of TTS patients at excess risk of mortality. These findings advance risk stratification in TTS and assist in identifying patients in need for close monitoring and follow-up.

Clinical outcomes during and after wearable cardioverter defibrillator use in Japanese patients with heart failure: A single-center experience

Background

A wearable cardioverter defibrillator (WCD) is indicated for a limited period in patients at high risk of sudden cardiac death (SCD). Nonischemic heart failure (HF) is common among Japanese patients with HF. The aim of this study was to evaluate the incidence of fatal arrhythmias during WCD use and the clinical outcomes after WCD withdrawal in Japanese patients with HF.

Methods

We retrospectively studied 105 hospitalized HF patients who were discharged with a WCD. The main outcome was SCD/ventricular arrhythmias during WCD use and the other outcomes were implantation of an implantable cardioverter-defibrillator (ICD), SCD/ventricular arrhythmias after WCD withdrawal, and changes in left ventricular ejection fraction (LVEF).

Results

Eighty-seven (83%) patients received a WCD for primary prevention of SCD, of whom 60 (69%) were new-onset HF patients with an LVEF ≤35%. The median daily wear time was 22.1 h. Two patients experienced sustained ventricular tachycardia and one patient experienced atrioventricular block with asystole while on WCD. After WCD withdrawal, 81 (77%) patients decided not to receive ICD implantation. The percentage of patients with an LVEF ≥35% increased from 20% at baseline to 70% at 1 year after discharge. During the median follow-up of 50 months, 78 (96%) of the 81 patients who did not have an ICD were free of SCD/ventricular arrhythmias.

Conclusions

The use of a WCD is useful for determining the appropriate indication for ICD implantation in Japanese patients with new-onset HF, a low LVEF, and a risk of SCD.

Coronary microvascular dysfunction is a hallmark of all subtypes of MINOCA

INTRODUCTION

Myocardial infarction without obstructive coronary artery disease (MINOCA) is a heterogeneous clinical condition presenting with myocardial necrosis not due to an obstruction of a major coronary artery. Recently, a relevant role of coronary microvascular dysfunction (CMD) in the pathogenesis of MINOCA has been suggested; however, data on this are scarce. Particularly, it is unclear if CMD is equally present in all subtypes of MINOCA or differentially identifies one or more of these conditions. Therefore, the aim of this study was to assess CMD in all three coronary vessels of MINOCA patients, relating it with the clinical subtype.

METHODS

We retrospectively assessed coronary microvascular function in all three coronary territories by means of angiography-based index of microvascular resistance (aIMR) in 92 patients (64 with working diagnosis of MINOCA, 28 control patients). To further assess the association of CMD with MINOCA subtypes, MINOCA patients were subdivided according to clinical data in coronary cause (n = 13), takotsubo (n = 13), infiltrative or inflammatory cardiomyopathy (n = 9) or unclear (n = 29).

RESULTS

Patients with working diagnosis of MINOCA showed a significantly elevated average aIMR compared to control patients (30.5 ± 7.6 vs. 22.1 ± 5.9, p < 0.001) as a marker of a relevant CMD; these data were consistent in all vessels. Among MINOCA subtypes, no significant difference in average aIMR could be detected between patients with coronary cause (33.2 ± 6.6), takotsubo cardiomyopathy (29.2 ± 6.9), infiltrative or inflammatory cardiomyopathy (28.1 ± 6.8) or unclear cause (30.6 ± 8.5; p = 0.412). Interestingly, aIMR was significantly elevated in the coronary vessel supplying the diseased myocardium compared with other vessels (31.9 ± 11.4 vs. 27.8 ± 8.2, p = 0.049).

CONCLUSION

Coronary microvascular dysfunction is a hallmark of all MINOCA subtypes. This study adds to the pathophysiological understanding of MINOCA and sheds light into the role of CMD in MINOCA.

Association Between Patient and System Delays and In-Hospital Mortality in Primary PCI for STEMI: Findings from a Large, Nationwide Inpatients Sample

PURPOSE

System delay is associated with mortality in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). However, the influence of patient delay has been relatively overlooked. We aimed to evaluate the influence of patient and system delays on STEMI patients undergoing primary PCI in China.

METHODS

STEMI patients registered at the Nationwide Chinese Cardiovascular Association Database-Chest Pain Center from January 2017 to September 2021 were screened. The exposures were total ischemic time (TIT), system delay and patient delay. The primary outcome was in-hospital mortality.

RESULTS

Among 458,260 patients from 2529 centers, median TIT, system delay and patient delay were 4.1, 1.5 and 2.1 hours, respectively. The adjusted odds ratio of in-hospital mortality increased by 2.2% (odds ratio [OR], 1.022, 95% confidence interval [CI], 1.017-1.027), 2.3% (1.023, 1.006-1.040) and 2.2% (1.022, 1.017-1.027) for every one-hour increase in TIT, system delay and patient delay, respectively.

CONCLUSIONS

Patient delay demonstrated a comparable impact to system delay on in-hospital mortality among STEMI patients undergoing primary PCI. Widespread primary PCI-capable center, improved awareness about myocardial infarction and regional transfer system are essential to shorten patient delay.

Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism

BACKGROUND

 High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined.

STUDY HYPOTHESIS

 We hypothesized that different HS-TnT cutoff values may be optimal for identifying (1) low-risk patients who may be eligible for outpatient management and (2) patients at increased risk of clinical deterioration who might benefit from advanced PE therapies.

METHODS

 Retrospective analysis of hemodynamically stable patients in the University of Michigan acute ED-PE registry with available HS-TnT values. Primary and secondary outcomes were 30-day mortality and need for intensive care unit-level care. Receiver operating characteristic curves were used to determine optimal HS-TnT cutoffs in the entire cohort, and for those at higher risk based on the simplified Pulmonary Embolism Severity Index (PESI) or imaging findings.

RESULTS

 The optimal HS-TnT cutoff in the full cohort, 12 pg/mL, was significantly associated with 30-day mortality (odds ratio [OR]: 3.94, 95% confidence interval [CI]: 1.48-10.50) and remained a significant predictor after adjusting for the simplified PESI (sPESI) score and serum creatinine (adjusted OR: 3.05, 95% CI: 1.11-8.38). A HS-TnT cutoff of 87 pg/mL was associated with 30-day mortality (OR: 5.01, 95% CI: 2.08-12.06) in patients with sPESI ≥1 or right ventricular dysfunction.

CONCLUSION

 In this retrospective, single-center study of acute PE patients, we identified distinct optimal HS-TnT values for different clinical uses-a lower cutoff, which identified low-risk patients even in the absence of other risk-stratification methods, and a higher cutoff, which was strongly associated with adverse outcomes in patients at increased risk.

Initial experience with orbital atherectomy in a non-surgical center in Portugal

INTRODUCTION AND OBJECTIVES

Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with a higher risk of procedural complications, suboptimal stent expansion, and in-stent restenosis. Lesion preparation with orbital atherectomy (OA) in severely calcified lesions has been shown to increase procedural success and decrease reintervention rates. In this study, we sought to report the procedural safety and efficacy of our initial experience with OA in a non-surgical center in Portugal.

METHODS

Patients with severely calcified coronary lesions who were treated with intended intravascular ultrasound (IVUS) guided OA were included in a prospective single-center registry. We evaluated several endpoints, including: debulking success, defined <50% residual stenosis severity after OA; procedural success, defined as stent implantation according to Optimal-IVUS PCI criteria; use of additional calcium debulking strategies; and procedural complications, including coronary no-reflow, dissection, perforation or side branch occlusion. Patients were followed up for 30 days to assess early cardiovascular or procedure-related death, myocardial infarction, myocardial injury and reintervention.

RESULTS

Between January 2023 and September 2023, 37 patients and 53 coronary arteries underwent OA. IVUS imaging was used in all cases. Debulking and procedural success were achieved in 90.5% and 97.3% of cases, respectively. In 26 (49.1%) lesions, additional calcium debulking techniques were needed. Procedural complications occurred in three cases and one patient died during hospitalization.

CONCLUSION

Our initial experience with OA for heavily calcified coronary lesions demonstrated high procedural success and overall favorable clinical outcomes.

Systematic Review of Sex-specific High Sensitivity Cardiac Troponin I and T Thresholds

PURPOSE

High-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) have been demonstrated to have lower sex-specific 99th percentiles in healthy females. However, these sex-specific thresholds are not widely adopted in clinical practice which could lead to underdiagnosis of acute myocardial infarction in females. We conducted a systematic review to explore sex-specific 99th percentiles for hs-cTnI and hs-cTnT from healthy reference populations.

METHODS

The principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to complete this systematic review. We used PubMed and OVID EMBASE to search for original studies published between November 2017 and November 2021 that included reference populations used to establish the 99th percentiles of hs-cTnI and hs-cTnT with the following inclusion criteria: adults; English language; samples taken as part of a healthy, reference population; studies using high-sensitivity troponin assay; and sample size > 300. Studies were excluded if the reference population sample size was < 300, if a conventional troponin assay was used, or if they did not include independently derived, sex-specific 99th percentiles. Data was extracted from the studies through Covidence to perform a qualitative data synthesis. Female-specific, male-specific, and overall 99th percentiles for hs-cTn were compared.

FINDINGS

We reviewed 131 articles of which 19 met inclusion criteria. These 19 studies derived sex-specific 99th percentiles for 11 different hs-cTnI assays and 9 different hs-cTnT assays. More than 90% (13 of 14 studies) of hs-cTnI assays found lower female 99th percentiles compared to male and to overall 99th percentiles. One study included nine different hs-cTnI assays, of which only one assay resulted in a higher female 99th percentile compared to male and to overall 99th percentiles. Eight of nine hs-cTnT studies (88.9%) found lower female 99th percentiles compared to male and to overall 99th percentiles.

IMPLICATIONS

The data shows significantly lower 99th percentiles in females compared to 99th percentiles in males and overall. Incorporating these sex-specific 99th percentile cut-offs into clinical practice could lead to increased diagnosis and potentially better outcomes for females presenting with acute myocardial infarction.

MINOCA as the result of coronary artery aneurysm thrombosis

Myocardial infarction (MI) can be caused by many factors. In addition to the typical obstruction or stenosis of the coronary arteries, there is heterogenic MI with non-obstructive coronary arteries (MINOCA). A rare cause of MINOCA is the thrombosis of a coronary artery aneurysm (CAA). This current case report describes a male patient with CAA thrombosis as the cause of MINOCA following surgery for a mucoepidermoid carcinoma. The patient underwent angiography that identified three CAAs that were located as follows: (i) in the proximal part of the left anterior descending artery (5.55 mm); (ii) in the distal part of the circumflex artery (8.05 mm); and (iii) in the distal part of the right coronary artery (6.61 mm). Thrombotic masses were identified within all three structures. The patient received balloon angioplasties without stent implanting and recovered well. The patient was also notable for the presence of two brain artery aneurysms that were the cause of the previous strokes that he had experienced. This case report also reviews the literature in order to: (i) summarize the aetiological factors and clinical manifestations of CAA; (ii) discuss the diagnostic methods for CAA; (iii) describe the medical and surgical management of CAA; and (iv) assess the prognosis of this rare clinical event.

Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months

OBJECTIVE

To profile the initial 6-month experience at the Victorian Heart Hospital (VHH) cardiac emergency (CE). The primary objective was to describe VHH CE patient characteristics, including presenting complaint, final diagnosis and disposition. Secondary objectives were to report on patient numbers, patient source and quality indicator performance including ambulance off-load by 40 min, waiting time and length of stay (LOS).

METHODS

A retrospective review included all patients who presented to the VHH CE from 9 March 2023 to 8 September 2023. Patient reports containing the relevant clinical information were generated from the CE electronic medical record system. Diagnoses of MI were checked for accuracy by full record review.

RESULTS

There were 3303 CE presentations in the first 6 months of operation, of which 6% were transferred from other sites. Median age was 65 years (interquartile range [IQR]: 53-77), 56% were males; the most common presenting complaints were presumed cardiac chest pain (67%) and arrhythmia (17%). The admission, discharge and transfer rates were 38%, 54% and 8%, respectively. In total, 15% were diagnosed with MI. The most common diagnoses for discharged and admitted patients were non-specific chest pain (57%) and ST-elevation MI (22%), respectively. Ambulance off-load by 40 min was met for 96%. Median waiting time was 6 min (IQR: 3-10). Median CE LOS for discharged and admitted patients was 3.2 h (IQR: 2.5-4.0) and 3.7 h (IQR: 1.8-6.0), with 75% and 56% being <4 h, respectively.

CONCLUSIONS

The population predominantly had cardiovascular disease as expected. Some performance indicators, including ED LOS, were identified as requiring intervention.