Incorporating glomerular filtration rate or creatinine clearance by the modification of diet in renal disease equation or the Cockcroft-Gault equations to improve the global accuracy of the Age, Creatinine, Ejection Fraction [ACEF] score in patients undergoing percutaneous coronary intervention

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

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

Predictive modeling for acute kidney injury after percutaneous coronary intervention in patients with acute coronary syndrome: a machine learning approach

BACKGROUND

Acute kidney injury (AKI) is one of the preventable complications of percutaneous coronary intervention (PCI). This study aimed to develop machine learning (ML) models to predict AKI after PCI in patients with acute coronary syndrome (ACS).

METHODS

This study was conducted at Tehran Heart Center from 2015 to 2020. Several variables were used to design five ML models: Naïve Bayes (NB), Logistic Regression (LR), CatBoost (CB), Multi-layer Perception (MLP), and Random Forest (RF). Feature importance was evaluated with the RF model, CB model, and LR coefficients while SHAP beeswarm plots based on the CB model were also used for deriving the importance of variables in the population using pre-procedural variables and all variables. Sensitivity, specificity, and the area under the receiver operating characteristics curve (ROC-AUC) were used as the evaluation measures.

RESULTS

A total of 4592 patients were included, and 646 (14.1%) experienced AKI. The train data consisted of 3672 and the test data included 920 cases. The patient population had a mean age of 65.6 ± 11.2 years and 73.1% male predominance. Notably, left ventricular ejection fraction (LVEF) and fasting plasma glucose (FPG) had the highest feature importance when training the RF model on only pre-procedural features. SHAP plots for all features demonstrated LVEF and age as the top features. With pre-procedural variables only, CB had the highest AUC for the prediction of AKI (AUC 0.755, 95% CI 0.713 to 0.797), while RF had the highest sensitivity (75.9%) and MLP had the highest specificity (64.35%). However, when considering pre-procedural, procedural, and post-procedural features, RF outperformed other models (AUC: 0.775). In this analysis, CB achieved the highest sensitivity (82.95%) and NB had the highest specificity (82.93%).

CONCLUSION

Our analyses showed that ML models can predict AKI with acceptable performance. This has potential clinical utility for assessing the individualized risk of AKI in ACS patients undergoing PCI. Additionally, the identified features in the models may aid in mitigating these risk factors.

Prognostic value of age, creatinine, and left ventricular ejection fraction risk score in patients evaluated with fractional flow reserve: a cross-sectional study

OBJECTIVE

In this study, we investigated the relationship between age, creatinine, and left ventricular ejection fraction risk score and the severity of coronary lesions detected by applying fractional flow reserve in the patient group presenting with chronic coronary syndrome. Also, we presented long-term follow-up results in patients whose age, creatinine, and left ventricular ejection fraction score was evaluated by the fractional flow reserve procedure.

METHODS

This study was planned retrospectively and in two centers. For this purpose, 114 patients who met the study criteria and who underwent elective fractional flow reserve between January 2014 and January 2019 were included in the study. Age, creatinine, and left ventricular ejection fraction was calculated as age/left ventricular ejection fraction +1 (if estimated glomerular filtration rate<30 mL/min).

RESULTS

They were divided into two groups according to the cutoff value of the age, creatinine, and left ventricular ejection fraction score. A total of 76 patients had an age, creatinine, and left ventricular ejection fraction score of ≤1.17 (Group I) and 38 patients had an age, creatinine, and left ventricular ejection fraction score of >1.17 (Group II). The number of patients with severe lesions in fractional flow reserve was significantly higher in Group II compared with Group I (60.5 vs. 32.9%, p=0.005). According to the Kaplan-Meier analysis, a significant increase was observed in major adverse cardiac events and mortality during the follow-up period in the group with a high-risk score (Log Rank: 15.01, p<0.001 and Log Rank: 8.51, p=0.004, respectively).

CONCLUSION

In light of the data we obtained from our study, we found a correlation between the severity of the lesion detected in fractional flow reserve and the age, creatinine, and left ventricular ejection fraction scores. In addition, we found that patients with high age, creatinine, and left ventricular ejection fraction scores had higher mortality and major adverse cardiac events rates during follow-up.

Contemporary risk models for infective endocarditis surgery: a narrative review

Infective endocarditis is a complex heterogeneous condition involving the infection of the endocardium and heart valves, leading to severe complications, including death. Surgery is often indicated in patients with infective endocarditis but is associated with elevated risk compared with other forms of cardiac surgery. Risk models play an important role in many cardiac surgeries as they can help inform clinicians and patients regarding procedural risk, decision-making to proceed or not, and influence perioperative management; however, they remain under-utilized in the infective endocarditis settings. Another crucial role of such risk models is to assess predicted versus found mortality, thereby allowing an assessment of institutional performance in infective endocarditis surgery. Traditionally, general cardiac surgery risk models such as European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, and Society of Thoracic Surgeon's score have been applied to endocarditis surgery. However, there has been the development of many endocarditis surgery-specific scores over the last decade. This review aims to discuss clinical characteristics and applications of all contemporary risk scores in the setting of surgical treatment of infective endocarditis.

Age, creatinine clearance, and ejection fraction (mACEF) score predicts long-term cardiac mortality in patients with hypertrophic obstructive cardiomyopathy treated non-invasively

OBJECTIVE

Presently, an effective model to predict long-term cardiac mortality in patients with hypertrophic obstructive cardiomyopathy (HOCM) is lacking. Therefore, the objective of this study was to evaluate the predictive value of the modified Age, Creatinine clearance, and Ejection Fraction (mACEF) score for long-term cardiac mortality in patients with HOCM.

METHODS

Two hundred and ninety two patients with HOCM treated non-invasively were enrolled in this study, all of whom had intact medical information.

RESULTS

Over a median follow-up period of 41.9 months, 28 cardiac deaths occurred. In univariate Cox regression analysis, the mACEF score was associated with long-term cardiac death [hazard ratio (HR)=1.795, 95% confidence interval (CI) 1.518-2.124, p<0.001]. Multiple Cox regression analysis identified the mACEF score as an independent risk factor for long-term cardiac death (adjusted HR=1.372, 95% CI 1.076-1.749, p=0.011). Analysis of the receiver operating characteristic (ROC) for long-term cardiac death showed that the mACEF score had a considerable predictive value (area under ROC 0.844, sensitivity 89.29%, specificity 75.00%) with an optimum cut-off value of 0.96. The study population was divided into high-risk (mACEF score ≥0.96, n=91) and low-risk (mACEF score <0.96, n=201) groups according to the optimum cut-off value. Kaplan-Meier survival analysis was performed and showed a dramatic higher rate of long-term cardiac mortality in the high-risk group than in the low-risk group (27.4% vs. 1.7%, p<0.001 by log-rank test).

CONCLUSION

The mACEF score has a considerable predictive value for long-term cardiac mortality in patients with HOCM treated non-invasively. A mACEF score ≥0.96 could be considered as a sign of poor prognosis in patients with HOCM.

Age, Serum Creatinine, and Left Ventricular Ejection Fraction Improved the Performance of the CatLet Angiographic Scoring System in Terms of Outcome Predictions for Patients with Acute Myocardial Infarction: A Median 4.3-Year Follow-Up Study

BACKGROUND

We recently developed the Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system. Our preliminary study demonstrated that the CatLet score better predicted clinical outcomes than the SYNTAX score. The current study aimed at assessing whether 3 clinical variables (CVs) - age, serum creatinine, and left ventricular ejection fraction (LVEF) - improved the performance of the CatLet score in outcome predictions in patients with acute myocardial infarction (AMI).

METHODS

This study was a post hoc study of the CatLet score validation trial. Primary endpoint was major adverse cardiac or cerebrovascular events (MACCEs), and secondary endpoints were all-cause deaths and cardiac deaths.

RESULTS

Over 1,185 person-years (median [interquartile range], 4.3 [3.8-4.9] years), there were 64 MACCEs (20.8%), 56 all-cause deaths (18.2%), and 47 cardiac deaths (15.2%). The addition of the 3 CVs to the stand-alone CatLet score significantly increased the Harrell's C-index by 0.0967 (p = 0.002) in MACCEs, by 0.1354 (p < 0.001) in all-cause deaths, and by 0.1187 (p = 0.001) in cardiac deaths. When compared with the stand-alone CatLet score, improved discrimination and better calibration led to a significantly refined risk stratification, particularly at the intermediate-risk category.

CONCLUSIONS

CatLet score had a predicting value for clinical outcome in AMI patients. This predicting value can be improved through a combination with age, serum creatinine, and LVEF (http://www.chictr.org.cn; unique identifier: ChiCTR-POC-17013536).

Narrative Review of Carotid disease and the kidney

Patients with chronic kidney disease (CKD) have an increased cardiovascular (CV) risk that is only in part explained by established risk factors. Carotid arteriosclerosis and atherosclerosis are increased in CKD, play a role in the causation of CV disease in these patients and can affect the progression of renal disease. The arterial stiffening process is evident even in CKD patients with a very mild reduction of glomerular filtration rate (GFR) whereas arterial thickening is evident in more advanced stages. Possible mechanisms include functional and structural alterations of the arterial wall. Arterial stiffness can mediate the effect of CKD on target organs (i.e., brain, kidney and heart). In this review we discuss the arterial phenotype of patients with CKD. This is characterized by increased common carotid artery stiffness and outward remodeling (enlargement and thickening of the arterial wall) and a normal/reduced stiffness paired with an inward remodeling (narrowing of the arterial wall) of muscular arteries. We also discuss the consequences of carotid dysfunction, including the involvement of large elastic arteries stiffness on ventricular-vascular coupling, the mechanisms linking carotid stiffening and increased cardio- and cerebrovascular risk in CKD patients, and the therapeutic options to improve carotid function.

Prediction of 5-Year Mortality in Patients with Chronic Coronary Syndrome Treated with Elective Percutaneous Coronary Intervention: Role of the ACEF Score

We evaluated the predictive power of age, creatinine, and ejection fraction (ACEF) score on mortality at 5-year follow-up in a population of 471 patients with chronic coronary syndrome (CCS) treated with percutaneous coronary intervention (PCI). Patients in the ACEF-High tertile showed the highest incidence of death at 5 years (15.7% vs. 2.6% in ACEF-Low and 4.3% in ACEF-Mid; log rank p<0.001). The ACEF score could significantly discriminate between patients who died and those who were still alive at 5 years (AUC 0.741, 95% CI 0.654-0.828), and an ACEF score >1.32 was identified as the optimal cutoff point to predict 5-year mortality (sensitivity 74%, specificity 68%). An ACEF score >1.32 was an independent predictor of 5-year mortality (HR 5.77, 95% CI 2.70-12.31; p<0.001). Our study shows that the ACEF score can predict mortality at 5-year follow-up in patients with CCS treated with PCI.

Comparison of Prognostic Value Among 4 Risk Scores in Patients with Acute Coronary Syndrome: Findings from the Improving Care for Cardiovascular Disease in China-ACS (CCC-ACS) Project

Background

Accurate risk assessment and prospective stratification are of great importance for treatment of acute coronary syndrome (ACS). However, the optimal risk evaluation systems for predicting different type of ACS adverse events in Chinese population have not been established.

Material/Methods

Our data were derived from the Improving Care for Cardiovascular Disease in China-ACS (CCC-ACS) Project, a multicenter registry program. We incorporated data on 44 750 patients in the study. We compared the performance of the following 4 different risk score systems with regard to prediction of in-hospital adverse events: the Global Registry for Acute Coronary Events (GRACE) risk score system; the age, creatinine and ejection fraction (ACEF) risk score system, and its modified version (AGEF), and the Canada Acute Coronary Syndrome (C-ACS) risk assessment system.

Results

Admission AGEF risk score was a better prognosis index of potential for in-hospital mortality for patients with ST segment elevation myocardial infarction (STEMI) than GRACE risk score (AUC: 0.845 vs 0.819, P=0.012), ACEF (AUC: 0.845 vs 0.827, P=0.014), C-ACS (AUC: 0.845 vs 0.767, P<0.001). In patients with non-ST segment-elevation acute coronary syndrome (NSTE-ACS), there was no statistically significant difference between the GRACE risk scale and AGEF (AUC: 0.853 vs 0.832, P=0.140) for in-hospital death.

Conclusions

AGEF risk score showed a non-inferior utility compared with the other 3 scoring systems in estimating in-hospital mortality in ACS patients.

Association of Side-Branch Treatment and Patient Factors in Left Anterior Descending Artery True Bifurcation Lesions: Analysis from the GRAND-DES Pooled Registry

Methods

Patients undergoing PCI to left anterior descending (LAD) bifurcation lesions with contemporary DES were analyzed from a nationwide registry. Baseline risk was assessed using the Age, Creatinine, and Ejection Fraction (ACEF) score. Target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization, was assessed at 3 years.

Results

Among 1,089 patients with LAD bifurcation lesions, 548 (50.3%) patients underwent SB treatment. The SB treatment group showed a nonsignificant, but numerically lower rate of 3-year TLF (6.6% vs. 9.2%, HR 0.75, 95%CI 0.44–1.28, p = 0.29). In patients with low pretreatment risk (ACEF<1.22), SB treatment was associated with a lower rate of 3-year TLF (HR 0.43, 95%CI 0.19–0.96, p = 0.04), while no significant difference was observed in patients with high risk (ACEF≥1.22). The difference in the low risk group was mostly driven by target lesion revascularization (HR 0.24, 95%CI 0.08–0.75, p = 0.01).

Conclusions

SB treatment for LAD bifurcation lesions showed favorable long-term outcomes compared with main-branch-only intervention, especially in patients with low pretreatment risk.

Utility of age, creatinine, and ejection fraction score in patients with type B aortic dissection undergoing thoracic endovascular aortic repair

BACKGROUND

Older age, renal and cardiac dysfunction are predictors of poor outcome in aortic dissection. The aim of this study was to evaluate the association of the age, creatinine and ejection fraction (ACEF) score with adverse events in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

The study enrolled 605 patients from January 2010 to July 2015, who were classified into three groups according to the tertiles of ACEF score: Tertile 1 (≤0.77, n = 204), Tertile 2 (0.77-0.96, n = 205) and Tertile 3 (>0.96, n = 196). The association between ACEF, AGEF (age, glomerular filtration rate and ejection fraction) and the updated version of the ACEF (ACEF II) score with adverse events was analyzed.

RESULTS

After a median 3.4 years follow-up, 63 (10.4%) patients died. Multivariable analysis revealed that ACEF score was independently associated with long-term mortality (adjusted hazard ratio = 3.54; 95% confidence interval, 2.09-6.01; p < 0.001). ACEF, AGEF and ACEF II score had similar predictive ability for both in-hospital and long-term death. The in-hospital mortality (1.5% vs. 1.0% vs. 6.6%, p = 0.001) were significantly higher in Tertile 3. In addition, cumulative long-term mortality in Tertile 3 was significantly higher than that in Tertile 1 and 2 (Log-Rank = 23.74; p < 0.001).

CONCLUSION

ACEF score could be served as an useful and relatively simple tool for pre-TEVAR risk stratification in TBAD patients.

Age, creatinine and ejection fraction (ACEF) score: a simple risk-stratified method for infective endocarditis

BACKGROUND

Older age, renal dysfunction and low left ventricular ejection fraction are accepted predictors of poor outcome in patients with infective endocarditis (IE). This study aimed to investigate the prognostic significance of the age, creatinine and ejection fraction (ACEF) score in IE.

METHODS

The study involved 1019 IE patients, who were classified into three groups according to the tertiles of ACEF score: low ACEF (<0.6, n = 379), medium ACEF (0.6-0.8, n = 259) and high ACEF (>0.8, n = 381). The ACEF score was calculated as follows: age (years)/ejection fraction (%)+1 (if serum creatinine value was >2 mg/dL). The relationship between ACEF score and adverse events was analyzed.

RESULTS

In-hospital mortality was 8.2%, which increased with the increase of ACEF score (4.2% vs. 5.0% vs. 14.4% for the low-, medium- and high-ACEF groups, respectively; P < 0.001). ACEF score had a good discriminative ability for predicting in-hospital death [areas under the curve (AUC), 0.706, P < 0.001]. The predictive value of ACEF score in surgical treatment was significantly higher than in conservative treatment for predicting in-hospital death (AUC, 0.812 vs. 0.625; P = 0.001). Multivariable analysis revealed that ACEF score was independently associated with in-hospital mortality (adjusted odds ratio, 2.82; P < 0.001) and long-term mortality (adjusted hazard ratio, 2.51; P < 0.001).

CONCLUSION

ACEF was an independent predictor for in-hospital and long-term mortality in IE patients, and it could be considered as a useful tool for risk stratification. ACEF score was more suitable for surgical patients in terms of assessing the risk of in-hospital mortality.

Arterial Stiffness in the Heart Disease of CKD

CKD frequently leads to chronic cardiac dysfunction. This complex relationship has been termed as cardiorenal syndrome type 4 or cardio-renal link. Despite numerous studies and reviews focused on the pathophysiology and therapy of this syndrome, the role of arterial stiffness has been frequently overlooked. In this regard, several pathogenic factors, including uremic toxins (i.e., uric acid, phosphates, endothelin-1, advanced glycation end-products, and asymmetric dimethylarginine), can be involved. Their effect on the arterial wall, direct or mediated by chronic inflammation and oxidative stress, results in arterial stiffening and decreased vascular compliance. The increase in aortic stiffness results in increased cardiac workload and reduced coronary artery perfusion pressure that, in turn, may lead to microvascular cardiac ischemia. Conversely, reduced arterial stiffness has been associated with increased survival. Several approaches can be considered to reduce vascular stiffness and improve vascular function in patients with CKD. This review primarily discusses current understanding of the mechanisms concerning uremic toxins, arterial stiffening, and impaired cardiac function, and the therapeutic options to reduce arterial stiffness in patients with CKD.

Renal haemodynamics and coronary atherosclerotic burden are associated in patients with hypertension and mild coronary artery disease

Intrarenal hemodynamic alterations are independent predictors of cardiovascular events in different populations. It has been hypothesized that there is an association between renal hemodynamics and coronary atherosclerotic burden in patients with hypertension. Therefore, the present study examined the associations between renal hemodynamics, coronary atherosclerotic burden and carotid atherosclerotic disease. A total of 130 patients with hypertension aged between 30-80 years who had been referred for an elective coronary angiography were enrolled in the present study. A duplex ultrasound of the intrarenal vasculature was performed to evaluate the resistive index (RI), pulsatility index (PI) and acceleration time (AT). The carotid intima-media thickness was additionally assessed. A coronary angiography was performed to detect the atherosclerotic burden using the Gensini Score (GS). Based on the GS values, subjects were divided into quintiles (I: ≤9; II: 9-17; III: 17-30; IV: 30-44; and V: GS >44) as well as in subjects with mild (GS ≤30) or severe coronary disease (GS >30). A weak significant difference in PI was identified among quintiles (P=0.041), whereas, RI and AT did not differ significantly. PI was associated with GS in the group with low coronary atherosclerotic burden (GS ≤30; P=0.047), whereas, no association was detected in subjects with GS >30. This association remained following adjustment for age and left ventricular ejection fraction (P=0.025). In conclusion, renal vascular alterations were associated with coronary atherosclerotic burden in patients with hypertension with mild coronary disease.

Risk of de novo dialysis after elective cardiac surgery according to preoperative renal dysfunction

OBJECTIVES

The aim was to estimate the risk of dialysis postoperative de novo dialysis in patients undergoing elective cardiac surgery, according to varying degrees of pre-existing renal dysfunction, and to compare the outcomes with the expected prevalence of dialysis based on several risk scores.

METHODS

A retrospective analysis was performed over a 5-year period (2012-16) from a series of 1332 adult patients who underwent elective cardiac surgery. Patients were divided into 3 estimated creatinine clearance (eCrCl) groups: eCrCl >60 ml/min, eCrCl from 50 ml/min to 60 ml/min and eCrCl ≤49 ml/min. The primary outcome was any renal failure requiring first-time dialysis during the postoperative hospital stay. The expected risk for postoperative dialysis was calculated with 3 predictive scores: the Society of Thoracic Surgeons Bedside Risk Tool, the Cleveland Clinic Score and the Simplified Renal Index. The global accuracy of eCrCl and the different scores was evaluated in terms of calibration and discrimination.

RESULTS

In the overall population, 26.6% of patients presented moderate or severe pre-existing renal dysfunction, and the need for de novo dialysis varied from 0.6% to 5.0% depending on the degree of preoperative eCrCl (P < 0.0001). Preoperative renal dysfunction with eCrCl <50 ml/min was associated with nearly 8-fold increase of risk for postoperative dialysis; eCrCl between 50 ml/min and 60 ml/min showed a 2-fold increase, though this last difference did not reach statistical significance.

CONCLUSIONS

In elective cardiac surgery, isolated preoperative eCrCl seemed to be an accurate indicator of risk for postoperative de novo dialysis. More complex models did not provide additional information to stratify that risk.

A simple risk score in acute ST-elevation myocardial infarction: Modified ACEF(age, creatinine, and ejection fraction) score

BACKGROUND/AIM

The aim of this study was to evaluate if the modified ACEF (age, creatinine, and ejection fraction) score is a predictor of major adverse cardiac and cerebrovascular events during 1 year of follow-up in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

We retrospectively enrolled 1632 consecutive patients who were admitted to our emergency department diagnosed with STEMI within 12 h of chest pain and treated with primary PCI. The modified ACEF score, determined with a simplified scoring system, was calculated. The patients were grouped into tertiles according to this score (group I mACEF < 1.03, group II mACEF 1.03-1.37, group III > 1.37) . The clinical and angiographic data were compared among the tertiles.

RESULTS

In patients with the highest mACEF tertile, out-of-hospital cardiac arrest (1.3%, 1.8%, and 4.1% consecutively; P = 0.003), Killip class &ge; II (P < 0.001), and cardiogenic shock were more common and ejection fraction was lower (P < 0.001). Moreover, in the 1-year follow-up, there was a statistically significant difference between cardiac mortality, target vessel revascularization, stroke, reinfarction, and major adverse cardiac and cerebrovascular events of the groups, while the rates of stent thrombosis were similar.

CONCLUSION

The modified ACEF score is a predictor of cardiac mortality and morbidity during 1-year follow-up.

Non-hemodynamically significant renal artery stenosis predicts cardiovascular events in persons with ischemic heart disease

BACKGROUND/AIMS

Recently, we reported that small renal arteries, defined by a low reference diameter (RD) or minimal luminal diameter (MD), are independently associated with a low GFR, resistant hypertension, and onset of contrast-induced nephropathy and suggested a post-hoc analysis of CORAL trial based on RD categories. Here we hypothesized that RD and MD are markers of nontraditional cardiovascular risk factors and tested whether low RD and MD could impact the prognosis of patients with ischemic heart disease.

METHODS

Prospective cohort study. We used proportional hazards models to analyze the first onset of cardiovascular events in relation with RD, MD, or percentage of renal artery stenosis (RAS) in those with low-to-moderate RAS (10-70%) (n = 181).

RESULTS

During the median follow-up of 4.5 (range, 0.1-5) years, 27.8% participants (n = 623; mean age, 64 years; 29% women) experienced a cardiovascular event (35.4% in those with RAS 10-70%). The presence of low-to-moderate RAS was associated with cardiovascular events. In these subjects, those with low MD were associated with a higher risk of cardiovascular events (MD >4.2 mm, HR: 1; MD 3.2-4.2 mm, HR: 1.66, 95% CI: 0.74-3.72, p = 0.22; MD <3.2 mm, HR: 3.72, 95% CI: 1.65-8.40, p = 0.002). When MD was added to a standard risk-factor model, risk prediction improvement was by 4.1%. Results were qualitatively similar if MD was replaced by RD or percentage of stenosis, but with smaller improvement of risk prediction and model fit.

CONCLUSIONS

In patients with ischemic heart disease and low-to-moderate RAS, MD is a significant predictor of cardiovascular events, improves risk prediction, and may represent a valuable biomarker of cardiovascular disease risk.