Temporal trends of patients with acute coronary syndrome and multi-vessel coronary artery disease - from the ACSIS registry

Predictive value of serum TBA for 2-year MACEs in ACS patients undergoing PCI: a prospective cohort study

Bile acids play important roles in lipid metabolism and glucose homeostasis. Limited research exist on the association between serum total bile acid (TBA) levels and major adverse cardiovascular events (MACEs) in patients with acute coronary syndrome (ACS), particularly those with comorbid type 2 diabetes mellitus (T2DM). This study was conducted to examine the relationship between baseline serum TBA level and T2DM status in patients with ACS after percutaneous coronary intervention (PCI) and to identify the predictive value of TBA levels for a 2-year risk of MACEs. 425 ACS patients underwent PCI were recruited and divided into three groups based on baseline serum TBA concentration. An analysis of the association between the T2DM status and baseline serum TBA levels was conducted using univariate linear regression and multivariate linear regression. The predictive relevance of serum TBA levels was evaluated using the receiver operating characteristic (ROC) curve and Cox regression. Kaplan-Meier curves were employed to analyze the differences among groups in predicting MACEs over a 2-year follow-up period. Baseline serum TBA levels were higher in ACS patients who were diagnosed with T2DM (the median 3.6 µmol/L) than those without T2DM (the median 3.0 µmol/L). T2DM status in ACS patients was positively correlated with baseline serum TBA concentrations (β: 1.7, 95% confidence interval [CI] 0.3-3.0), particularly in the male (β: 2.0, 95% CI 0.3-3.6) and 50-69-year-old (β: 2.5, 95% CI 0.6-4.4) populations. The areas under the ROC curve of baseline serum TBA levels predicted MACEs in ACS and ACS-T2DM patients following PCI were 0.649 (95% CI 0.595-0.703) and 0.783 (95% CI 0.685-0.881), respectively. Furthermore, Cox regression analysis showed that baseline serum TBA level was associated with the occurrence of MACEs in patients with ACS after PCI over a 2-year follow-up period, especially in those diagnosed with T2DM, whose baseline TBA concentration was lower than 10.0 µmol/L. ACS Patients with T2DM had higher serum TBA levels. TBA level at baseline was an independent predictor of MACEs in ACS patients who underwent PCI, especially with comorbid T2DM.

Association between triglyceride glucose index, coronary artery calcification and multivessel coronary disease in Chinese patients with acute coronary syndrome

Background

Multivessel coronary disease (MVCD) is the common type of coronary artery disease in acute coronary syndrome (ACS). Coronary artery calcification (CAC) has been confirmed the strong predictor of major adverse cardiovascular events (MACEs). Several studies have validated that triglyceride glucose (TyG) index can reflect the degree of coronary calcification or predict MACEs. However, no evidence to date has elucidated and compared the predictive intensity of TyG index or/and coronary artery calcification score (CACS) on multi-vascular disease and MACEs in ACS patients.

Methods

A total of 935 patients, diagnosed with ACS and experienced coronary computed tomography angiography (CCTA) from August 2015 to March 2022 in the Second Hospital of Shandong University, were selected for retrospective analysis. The subjects were divided into TyG index quartile 1–4 groups (Q1-Q4 groups), non-multivessel coronary disease (non-MVCD) and multivessel coronary disease (MVCD) groups, respectively. The general data, past medical or medication history, laboratory indicators, cardiac color Doppler ultrasound, CACS, and TyG indexes were respectively compared among these groups. The ROC curve preliminarily calculated and analyzed the diagnostic value of TyG index, CACS, and the combination of the two indicators for MVCD. Univariate and multivariate logistic regression analysis discriminated the independent hazard factors for forecasting MVCD.

Results

Compared with the lower TyG index and non-MVCD groups, the higher TyG index and MVCD groups had higher values of age, smoking history, waist circumference, systolic blood pressure, low-density lipoprotein cholesterol(LDL-C), fasting blood glucose and glycosylated hemoglobin, and CACS, but lower values of high-density lipoprotein cholesterol(HDL-C) (all P < 0.01). Coronary artery calcification is more common in the left anterior descending artery. Compared with non-MVCD, each unit increase in TyG index was associated with a 1.213-fold increased risk of MVCD. Logistic regression analysis adjusted for potential confounders indicated that TyG index is an independent risk factor for MVCD. With the increase of TyG index, the incidence of MACEs, apart from all-cause death, cardiac death, unexpected re-hospitalization of heart failure, recurrent ACS or unplanned revascularization, and non-fatal stroke in coronary artery increased (P log-rank < 0.001).

Conclusion

TyG index could completely substitute for CACS as a reliable, practical, and independent indicator for predicting the severity and prognosis of MVCD in patients with ACS.

When More Means Less: The Prognosis of Recurrent Acute Myocardial Infarctions

Recurrent acute myocardial infarctions (AMI) are common and associated with dismal outcomes. We evaluated the clinical characteristics and the prognosis of AMI survivors according to the number of recurrent AMIs (ReAMI) and the time interval of events (TI). A retrospective analysis of patients who survived following hospitalization with an AMI throughout 2002–2017 was conducted. The number of ReAMIs for each patient during the study period was recorded and classified based on following: 0 (no ReAMIs), 1, 2, ≥3. Primary outcome: all-cause mortality up to 10 years post-discharge from the last AMI. A total of 12,297 patients (15,697 AMI admissions) were analyzed (age: 66.1 ± 14.1 years, 68% males). The mean number of AMIs per patient was 1.28 ± 0.7; the rates of 0, 1, 2, ≥3 ReAMIs were 81%, 13.4%, 3.6% and 1.9%, respectively. The risk of mortality increased in patients with greater number of AMIs, HR = 1.666 (95% CI: 1.603–1.720, p < 0.001) for each additional event (study group), attenuated following adjustment for potential confounders, AdjHR = 1.135 (95% CI: 1.091–1.181, p < 0.001). Increased risk of mortality was found with short TI (<6-months), AdjHR = 2.205 (95% CI: 1.418–3.429, p < 0.001). The risk of mortality following AMI increased as the number of ReAMIs increased, and the TI between the events shortened. These findings should guide improved surveillance and management of this high-risk group of patients (i.e., ReAMI).

Clinical Characteristics and Short-Term Outcomes of Patients Presenting with Acute Myocardial Infarction having Multi-vessel disease - A Single Middle- eastern Tertiary-Care Center Experience

Objective

Patients with multi-vessel coronary artery disease (MVD) compared to single-vessel coronary artery disease (CAD) have more comorbidities and poor in-hospital outcomes. We aim to analyze MVD-AMI patients regarding clinical data and short-term outcomes.

Methods

This is a retrospective analysis of the prospectively collected data registry, a single-center study reviewing the clinical details and hospital outcome measures of AMI patients referred to our center for early revascularization from 2016 to 2019.

Result

Out of 3041 patients presented with AMI, 491 (16%) had MVD on coronary angiogram. MVD-AMI patients were older, had a higher prevalence of DM, HTN, and prior history of ischemic heart disease compared to the non- MVD -AMI group (p < 0.001 for all). However, they presented more with non-anterior myocardial infarction, showed higher rates of post-myocardial infarction LV dysfunction, and mortality (p < 0.001). Older MVD-AMI patients showed higher rates of in-hospital morbidities and mortality compared to younger ones (p < 0.001). MVD- AMI women and Middle Eastern patients were older and showed a higher prevalence of cardiovascular risk factors compared to MVD-AMI men and South Asian patient population respectively. There were no significant differences recorded among the different subgroups of MVD-AMI patients regarding the hospital outcome measures.

Conclusion

Our study highlighted the clinical characters and poor outcomes of a high-risk group of MVD-AMI with different demographic backgrounds. Although age was a strong predictor for in-hospital poor outcomes, neither gender nor ethnicity affected the outcomes in them.

Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

INTRODUCTION

Up to 20% of patients presenting with acute coronary syndrome (ACS) have no traditional cardiovascular risk-factors (RFs). Data regarding the determinants, management, and outcomes of these patients are scarce.

OBJECTIVES

To evaluate the management, outcomes, and time-dependent changes of ACS patients without RFs.

METHODS

Evaluation of clinical characteristics, management strategies, and outcomes as well as time-dependent changes [by 3 time periods: early (2000-2006), mid (2008-2013), and late (2016-2018)] of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of ischemic heart disease, and smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (no-RF group) to those with ≥1 RFs (RF group).

RESULTS

Overall, 554/9,683 (5.7%) eligible ACS patients did not have any RFs [median age 63 (IQR 52-76) years, 25% females]. The no-RF group were older, with lower body mass index and prevalence of other cardiovascular comorbidity and chronic kidney disease compared with the RF group. The in-hospital percutaneous coronary intervention rates were lower among the no-RF vs. the RF group (55% vs. 66%, respectively p<0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge was prescribed in the no-RF group. The rate of in-hospital complications was greater in the no-RF vs. RF group (31.6% vs. 26.1%, respectively p=0.005). The rates of 30-day major adverse cardiovascular events (MACE; 17.6% vs.12.8%, respectively, p=0.002) and of 30-day and 1-year all-cause mortality (8.4% vs. 4.2%, p<0.001 and 11.4% vs. 7.7%, p=0.003 respectively) were higher among patients with no-RF vs. RF. Following propensity score matching 30-day MACE, 30-day and 1-year mortality risk remained higher in the no-RF group. The rate of 30-day MACE decreased between the early and the late study period in the no-RF group (21.5% vs. 10.5%, p=0.003, respectively).

CONCLUSIONS

ACS patients without traditional cardiovascular risk-factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse outcomes. Additional research to identify unique risk-factors and targets for interventions to improve outcomes of this group of patients is warranted.

Acute Kidney Injury Following Admission with Acute Coronary Syndrome: The Role of Diabetes Mellitus

Purpose: To evaluate the role of diabetes mellitus in the incidence, risk factors, and outcomes of AKI (acute kidney injury) in patients admitted with ACS (acute coronary syndrome). Methods: We performed a comparative evaluation of ACS patients with vs. without DM who developed AKI enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. AKI was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or above 1.5 mg/dL or new renal replacement therapy upon admission with ACS. Outcomes included 30-day major adverse cardiovascular events (MACE) and 1-year all-cause mortality. Results: The current study included a total of 16,879 patients, median age 64 (IQR 54–74), 77% males, 36% with DM. The incidence of AKI was significantly higher among patients with vs. without DM (8.4% vs. 4.7%, p < 0.001). The rates of 30-day MACE (40.8% vs. 13.4%, p < 0.001) and 1-year mortality (43.7% vs. 10%, p < 0.001) were significantly greater among diabetic patients who developed vs. those who did not develop AKI respectively, yet very similar among patients that developed AKI with vs. without DM (30-day MACE 40.8% vs. 40.3%, p = 0.9 1-year mortality 43.7 vs. 44.8%, p = 0.8, respectively). Multivariate analyses adjusted to potential confounders, showed similar independent predictors of AKI among patients with and without DM, comprising; older age, chronic kidney disease, congestive heart failure, and peripheral arterial disease. Conclusions: Although patients with DM are at much greater risk for AKI when admitted with ACS, the independent predictors of AKI and the worse patient outcomes when AKI occurs, are similar irrespective to DM status.

Re-evaluating the Role of CABG in Acute Coronary Syndromes

PURPOSE OF REVIEW

The use of coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) has markedly declined during the past decade, with an increase in the use of percutaneous coronary intervention (PCI). However, long-term data continues to show survival advantages for patients undergoing CABG over PCI. We describe the current indications for and outcomes of CABG in patients who present with ACS.

RECENT FINDINGS

Real-world studies demonstrate better long-term outcomes with CABG than with PCI after NSTE-ACS. Staged CABG after culprit-vessel PCI for STEMI is also a feasible option in certain patients. In patients presenting with ACS and cardiogenic shock who are treated with CABG, the use of mechanical circulatory support has produced a limited but significant reduction in mortality. The optimal revascularization strategy after ACS depends on many variables. The pre-eminent factor in selecting the best mode of revascularization and improving outcomes is careful patient selection based on deliberation by an interdisciplinary heart team.