Third universal definition of myocardial infarction

An update on the role and mechanisms of periodontitis in cardiovascular diseases

Cardiovascular diseases (CVDs) are the leading cause of death worldwide. Despite extensive studies into the causes and therapies for CVDs, their incidence and prevalence continue to increase. Periodontitis is a multifactorial, chronic inflammatory disease related to systemic health. Current research suggests that periodontitis may be an unconventional risk factor for CVDs and it may increase the risk of CVDs such as atherosclerosis, coronary heart disease, myocardial infarction, hypertension, heart failure as well as cardiomyopathy. For all these reasons, it is quite plausible that prevention of periodontitis has an impact on the onset or progression of CVDs. Therefore, in this review, we investigated the association between periodontitis caused by oral microorganisms and different CVDs. In addition, we discuss the various mechanisms by which periodontitis contributes to the onset and progression of CVDs. Our review aims to raise global awareness of periodontitis, particularly its role in CVDs, provide a basis for the prevention and treatment of CVDs and offer potential therapeutic targets.

Characterizing high-risk enrollment criteria and impact on clinical outcomes in a large randomized clinical trial: Insights from the TWILIGHT trial

BACKGROUND

The TWILIGHT trial showed that, among high-risk patients who underwent percutaneous coronary intervention (PCI) and were event-free at 3 months, ticagrelor monotherapy versus ticagrelor plus aspirin reduced bleeding without increasing ischemic events.

METHODS

This posthoc analysis describes the risk profiles and outcomes of patients enrolled in the TWILIGHT trial. The primary outcome was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding, and the key secondary outcome was a composite of death, myocardial infarction, or stroke within 1 year after randomization.

RESULTS

The proportion of patients (n = 7,119) fulfilling ≤ 3, 4, 5, or ≥ 6 risk factors was 21.5%, 32.7%, 27.4%, and 18.4%, respectively. Troponin-positive acute coronary syndrome (ACS) was the most prevalent clinical criterion (64.9%), and multivessel disease (MVD) was the most prevalent angiographic criterion (66.5%). The most frequent intersection of criteria was the combination of troponin-positive ACS, atherosclerotic vascular disease, MVD, left main or proximal anterior descending lesion, and stent length > 30 mm. A stepwise increase in ischemic but not in bleeding risk was noted with an increasing number of high-risk criteria. Compared with ticagrelor plus aspirin, ticagrelor monotherapy reduced bleeding regardless of the number of risk factors (≤ 3-RF: 3.5% vs 5.8%, HR 0.59, 95% CI [0.38-0.93]; 4-RF: 3.7% vs 6.4%, HR 0.57, 95% CI [0.37-0.86]; 5-RF: 3.8% vs 8.6%, HR 0.44, 95% CI [0.29-0.66]; ≥ 6-RF: 5.3% vs 7.9%, HR 0.65, 95% CI [0.44-0.96]; p-interaction = .56) without significantly increasing the ischemic risk (≤ 3-RF: 1.6% vs 2.1%, HR 0.75, 95% CI [0.38-1.50]; 4-RF: 3.5% vs 2.2%, HR 1.58, 95% CI [0.91-2.75]; 5-RF: 4.1% vs 5.0%, HR 0.80, 95% CI [0.51-1.24]; ≥ 6-RF: 6.7% vs 6.9%, HR 0.98, 95% CI [0.67-1.43]; p-interaction = .22).

CONCLUSIONS

In the TWILIGHT trial, the high-risk features correlated more strongly with ischemic than with bleeding risk. Nonetheless, the benefits of ticagrelor compared with ticagrelor plus aspirin were consistent, irrespective of the number of high-risk features. These findings are only applicable to patients who are event-free at 3 months after PCI.

CLINICAL TRIAL REGISTRATION

The trial was registered with ClinicalTrials.gov, NCT02270242.

Hyperuricemia is a prognostic marker for antiphospholipid syndrome patients: a retrospective cohort study in China

OBJECTIVE

Hyperuricemia (HUA) is implicated in inflammation and a prothrombotic state, but its prognostic role in antiphospholipid syndrome (APS) remains uncertain. This study aims to evaluate the prognostic value of HUA in APS and identify optimal serum uric acid (SUA) thresholds for predicting adverse outcomes.

METHODS

All patients fulfilled the 2006 Sydney criteria for APS were followed up at Peking University People's Hospital (2009-2022). Patients with persistent HUA were included in the HUA group. Comparative analyses were conducted between APS patients with and without HUA. Subgroup and ROC analyses were performed to evaluate prognostic value and identify optimal SUA thresholds.

RESULTS

Among 240 primary APS patients, 45 (18.8%) had HUA. APS patients with HUA had a significantly higher 10-year cumulative all-cause mortality (60.8% vs. 6.6%, P = 0.002), APS-related mortality (45.2% vs. 2.0%, P = 0.004), and thrombosis recurrence rates (40.3% vs. 17.2%, P = 0.005). Multivariate Cox mortality analysis showed that HUA was significantly associated with 10-year cumulative all-cause mortality (HR = 6.408, P = 0.010), APS-related mortality (HR = 15.409, P = 0.031), and thrombosis recurrence rates (HR = 3.227, P = 0.014). SUA thresholds predicting all-cause mortality (8.7 mg/dL, OR = 44.121, P < 0.001) and thrombosis recurrence (5.6 mg/dL, OR = 4.145, P = 0.004) were identified.

CONCLUSIONS

HUA is associated with a higher risk of adverse outcomes in APS patients. SUA thresholds of 8.7 mg/dL and 5.6 mg/dL may serve as predictors of mortality and thrombotic recurrence, providing potential insights for risk stratification and management in APS. Key Points • APS patients with HUA have higher 10-year cumulative mortality and thrombotic recurrence rates. • HUA may serve as a prognostic marker for APS patients. • SUA thresholds of 8.7 mg/dL and 5.6 mg/dL may serve as predictors of mortality and thrombotic recurrence. • Our observations remind clinicians to focus on APS patients with HUA, and adopt appropriate strategies to reduce the recurrence of thrombosis and mortality.

Right ventricular strain and tricuspid annular plane systolic excursion are associated with mortality in inferior ST-elevation myocardial infarction

BACKGROUND

Patients with inferior ST-segment elevation myocardial infarction face a substantial risk for cardiovascular death. While left ventricular function is known to be associated with clinical outcomes in these patients, we evaluated the prognostic impact of tricuspid annular plane systolic excursion (TAPSE) and advanced measures of right ventricular function (free wall strain [FWS] and global longitudinal strain [RVGLS]).

METHODS

Consecutive patients presenting with acute inferior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention between 01/2012 and 08/2015 were retrospectively analysed. Associations between RV strain measurements and all-cause mortality were evaluated using Cox regression analysis.

RESULTS

207 patients (69.6% male, median 59.0 [IQR: 52.1-70.7] years) were followed for 8.3 (IQR: 7.4-9.3) years, during which 49 patients (23.7%) deceased. Median right ventricular function parameters were significantly better in surviving patients (RVGLS: -17.5% vs. -13.3%, p < .001; FWS: -20.5% vs. -14.8%, p < .001; TAPSE 1.8 cm vs. 1.3 cm, p < .001). All 3 parameters were associated with mortality in univariate and multivariable analysis adjusted for age, sex and the number of comorbidities (chronic kidney disease, hypercholesterinaemia, diabetes mellitus) (adj. hazard ratio [HR] per 1 standard deviation: RVGLS: 1.68 [95% CI: 1.27-2.23, p < .001], FWS: 1.56 [95% CI: 1.56-2.00, p < .001], TAPSE: 1.55 [95% CI: 1.17-2.05, p = .002]). Additionally, right ventricular function was inversely associated with peak troponin T and creatine kinase levels.

CONCLUSIONS

Among patients with inferior ST-segment myocardial infarction, RVGLS, FWS and TAPSE convey crucial prognostic information and might help to identify patients at increased risk requiring intensified monitoring and therapy.

Percutaneous coronary interventions in Sudan: insights from severely influenced conflict zone

Background

Sudan is among the few countries in sub-Saharan Africa that offers free thrombolytic therapy and complimentary access to catheterization laboratories for its patients. This study examines the patterns of percutaneous coronary interventions (PCIs) conducted within 1 year during the Sudan war of 2023-2024 in low-resource regions within the conflict zone.

Methods

We conducted a retrospective descriptive analysis at El-Obeid International Hospital in North Kordofan State, Sudan, from April 2023 to 2024. We have systematically collected data pertaining to patients who underwent the procedure during the specified period.

Results

We investigated 100 patients who underwent PCIs. We performed PCIs in 80% of cases for patients with acute coronary syndrome and 20% for those with chronic coronary syndrome. All patients involved in the procedures used drug-eluting stents. Males constituted 64% of the total, while females accounted for the remaining 36%. The most common age groups are 60-69 and 50-59, with incidence rates of 31 and 30%, respectively. Approximately 51% of the participants resided in rural areas, while the remaining 49% were from urban locations. About 32% of the patients held employment, while 24% were unemployed. In 92% of cases, the vascular access was femoral, while the remaining 8% utilized radial access.

Conclusion

It is feasible to establish and maintain catheterization laboratory services despite the challenges posed by war and the associated risks to personal safety. We must enhance healthcare policies, regional networks, and training to improve access to thrombolytic therapy within the necessary timeframe. Certain centers in Sudan can safely conduct primary PCI.

Employment status as a predictor of adverse outcomes in patients with coronary artery disease

Background

Lack of employment is associated with a poorer prognosis when compared to employment in the general population. Whether this association is present in patients with coronary artery disease (CAD) and similarly extends to adverse cardiovascular outcomes in those with CAD remains unknown. Herein, we analyzed the association of employment status and adverse outcomes in patients with CAD.

Methods

Non-retired participants enrolled in the Emory Cardiovascular Biobank during the years 2003-2023 were divided into employed and non-employed cohorts and analyzed for the primary composite outcome of cardiovascular death or non-fatal myocardial infarction (MI) by competing-risk regression, while accounting for non-cardiovascular death. The secondary outcome of all-cause death was assessed by Cox regression. Sensitivity analyses were performed to explore for heterogeneity of effect.

Results

The study sample consisted of 2809 participants with a mean age of 57 years, 35 % women, and 27 % Black. During a median follow-up of 5.1 years, 406 (14 %) cardiovascular death or non-fatal MI events and 537 (19 %) all-cause death events occurred. After adjustment for demographics, educational attainment level (EAL), and traditional cardiovascular risk factors, non-employment was found to be a significant predictor of cardiovascular death or non-fatal MI (sHR 1.78, 95 % CI 1.41-2.19, P < 0.001) and all-cause death (HR 2.46, 95 % CI 2.02-2.99, P < 0.001), when compared to employed participants.

Conclusions

Non-employment is associated with adverse outcomes in non-retired individuals with CAD, independent of demographics, EAL, and traditional cardiovascular risk factors. Non-employment due to disability was associated with the highest risk of adverse cardiovascular outcomes, highlighting a particularly vulnerable subgroup.

Diagnostic performance of Mindray CL1200i high sensitivity cardiac troponin I assay compared to Abbott Alinity cardiac troponin I assay for the diagnosis of type 1 and 2 acute myocardial infarction in females and males: MERITnI study

OBJECTIVES

We examined the 0- and 2-h diagnostic performance of the Mindray high-sensitivity cardiac troponin I (hs-cTnI) assay using two predefined sex-specific 99th percentile upper reference limits (URL) in patients with normal electrocardiograms to aid in the diagnosis of myocardial infarction (MI).

METHODS

Consecutive emergency department patients undergoing serial high-sensitivity cardiac troponin I (hs-cTnI) testing on clinical indication were studied in the 'Mindray hs-cTnI Assay Analytical and Clinical Evaluation for the Diagnosis and RIsk Assessment of Myocardial InfarctIon' (MERITnI) trial (NCT05853042). Plasma hs-cTnI testing was performed using Mindray CL1200i (investigational) and Abbott Alinity (clinical) assays.

RESULTS

In 1,556 patients (60.7 % male, 43.3 % White, 45.8 % Black, 34.8 % chest pain), 2.7 % had type 1 MI, 2.7 % type 2 MI, and 21.5 % non-MI myocardial injury. At 0 h for all MIs (n=86), using package insert URLs and Universal Sample Bank (USB) URLs, sensitivities were 83.7 and 93.0 %. At 0/2 h for all MIs with package insert and USB URLs, sensitivities were higher with serial testing, at 95.3 and 97.7 %. Negative predictive value (NPVs) were excellent and similar for both URLs, ranging from 98 to 100 %. Substantial hs-cTnI concentration differences were observed between sex and injury types. Alinity hs-cTnI diagnostic observations were similar for both package insert and USB URLs.

CONCLUSIONS

The Mindray CL1200i hs-cTnI assay provides the relevant clinical diagnostic information to enable clinicians to deliver cost-effective care for patients to aid in the diagnosis of MI predicated on 0- and 2-h serial testing based on sex-specific 99th percentiles. Novel observations were observed for findings based on different URLs and for females and MI types.

Relationship between abdominal visceral adipose tissue and cardiovascular events in patients with acute coronary syndrome

Abdominal visceral adipose tissue (AVAT) is associated with the incidence of cardiovascular events (CVEs). We retrospectively evaluated the association between AVAT and the incidence of CVEs in 602 patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Patients were divided into four groups according to the quartiles of AVAT areas using computed tomography. The incidence of CVEs (cardiovascular death, ACS recurrence and stroke) during the follow-up period (median 49.5 months) was evaluated. Cox analysis adjusting for cardiovascular risk factors revealed that the AVAT quartile classification exhibited a significant association with the incidence of CVEs. The risk in quartile 3 (moderate AVAT areas, ≥ 106.0 to < 142.6 cm2) was significantly lower than in quartiles 1 (low AVAT areas, < 71.0cm2; P < 0.01; hazard ratio [HR], 5.06), 2 (mild AVAT areas, ≥ 71.0 to < 106.0 cm2; P < 0.01; HR, 4.25) and 4 (severe AVAT areas, ≥ 142.6 cm2; P < 0.01; HR, 4.52). Polynomial analyses revealed that quadratic model was the most appropriate to illustrate the relationship between AVAT area and the hazard ratios for CVEs (corrected Akaike's information criterion, 49.2; R2, 0.47). The AVAT area and the incidence of CVEs exhibited a U-shaped relationship in patients with ACS undergoing PCI independent of conventional cardiovascular risk factors. The risk of CVEs was the lowest in patients with moderate AVAT areas. Evaluating AVAT may provide additional information for the assessment of long-term prognosis in patients with ACS.

Using higher cut-off values to diagnose acute myocardial infarction in patients with elevated hs-cTnT

It is often challenging to diagnose acute myocardial infarction (AMI) in patients with elevated high-sensitivity cardiac troponin T (hs-cTnT) before a significant rise and/or fall of hs-cTnT can be observed. This study aimed to find an optimal cut-off to rule in AMI. A total of 76411 patients with elevated hs-cTnT were included. The predictive cut-off values for diagnosing ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) were assessed by the area under the receiver operating characteristic curves (AUC). Among the patients, 50466 (66.0%) had non-cardiac diseases, 25945 (34.0%) had cardiac diseases, and 15502 (20.3%) had AMI, including 816 (1.1%) with STEMI and 14686 (19.2%) with NSTEMI. The median hs-cTnT level was 3788.0 ng/L in STEMI patients and 67.2 ng/L in NSTEMI patients. The optimal cut-off for diagnosing STEMI was 251.9 ng/L, with a sensitivity of 90.7%, specificity of 86.5%, and an AUC of 0.942; the optimal cut-off for diagnosing NSTEMI was 130.5 ng/L, with a sensitivity of 40.9%, specificity of 83.8%, and an AUC of 0.638. In patients with elevated hs-cTnT, optimizing the cut-off values for diagnosing STEMI and NSTEMI to 251.9 ng/L and 130.5 ng/L, respectively, demonstrated high accuracy in a large cohort of Chinese patients.

Optimized deep residual networks for early detection of myocardial infarction from ECG signals

Globally, the high number of deaths are happening due to Myocardial infarction (MI). MI is considered as a life-threatening disease, which leads to an increase number of deaths or damage to the heart, and hence, prompt detection of MI is critical to decrease the mortality rate. Though, numerous works have addressed MI identification, an increased number suffer from over fitting and high computational burden in real-time scenarios. The proposed system introduces a novel MI detection technique using a Deep Residual Network (DRN), where the solution is optimized by the proposed Social Ski-Spider (SSS) Optimization algorithm is the novel combination of both Social Ski-driver (SSD) Optimization and the Spider Monkey Optimization (SMO). This model highly prevents the overfitting and computational burden, which increases the MI detection accuracy. Here, the proposed SSS-DRN performs detection by filtering the electrocardiography (ECG) signals. Later, the signal feature, transform feature, medical feature and statistical feature are extracted by the feature extraction phase followed by data augmentation that consists of permutation, random generation and re-sampling processes and finally, detection is accomplished by the SSS-DRN. Moreover, the developed SSS-DRN is researched for its efficiency considering metrics like accuracy, sensitivity, and specificity and observed 0.916, 0.921, and 0.926. Here, when considering the accuracy metrics, the performance gain observed by the devised model is 13.96%, 12.61%, 10.37%, 7.95%, 5%, 2.21%, and 2% higher than the traditional schemes. This indicates the devised model has high detection accuracy, which could be embedded in real-time clinical settings like hospital ECG machines, wearable ECG monitors, and mobile health applications. This improves the clinical decision-making process with increased patient outcomes.

The working mechanism of biomarkers related to sumoylation modification in coronary artery disease

Coronary artery disease (CAD) remains a leading global cause of mortality. The expression of small ubiquitin-like modifier 1 (SUMO-1) is reduced in heart failure. However, the mechanisms underlying its modification in CAD remain underexplored. This study sought to identify SUMOylation-related biomarkers and elucidate the potential mechanisms in CAD pathogenesis. This study analyzed three CAD datasets (GSE42148, GSE23561, and GSE121893) alongside 187 SUMOylation-related genes (SRGs). The overlap between differentially expressed genes (DEGs) and SRGs was used to identify differentially expressed SUMOylation-related genes (DE-SRGs). Biomarkers were validated through expression profiling and receiver operating characteristic (ROC) curve analysis. Enrichment and immune infiltration analyses were performed to explore the molecular mechanisms by which these biomarkers influence CAD. A drug-gene interaction network was constructed using the Drug-Gene Interaction database (DGIdb). Single-cell analysis was conducted to identify key cellular players and validate the differential expression of biomarkers across cell types. A total of 12 DE-SRGs were identified in CAD. Among them, SUMO1 and PPARG were validated as biomarkers, with their expression significantly elevated in the CAD group compared to the control group. Single-sample gene set enrichment analysis (ssGSEA) revealed distinct immune cell distributions in CAD, with central memory CD4+ T cells and memory B cells positively correlated with the biomarkers. Gene set enrichment analysis (GSEA) linked these biomarkers to ribosomal activity, olfactory transduction, and other pathways. Single-cell analysis confirmed the expression of SUMO1 and PPARG in endothelial cells, particularly in the CAD group. Additionally, SUMO1 was differentially expressed in cardiomyocytes, exhibiting higher expression in controls. SUMO1 and PPARG were identified as novel SUMOylation-related biomarkers in CAD, suggesting new therapeutic avenues for CAD management.

Human proteome distribution atlas for tissue-specific plasma proteome dynamics

The plasma proteome is maintained by the influx and efflux of proteins from surrounding organs and cells. To quantify the extent to which different organs and cells impact the plasma proteome in healthy and diseased conditions, we developed a mass-spectrometry-based proteomics strategy to infer the tissue origin of proteins detected in human plasma. We first constructed an extensive human proteome atlas from 18 vascularized organs and the 8 most abundant cell types in blood. The atlas was interfaced with previous RNA and protein atlases to objectively define proteome-wide protein-organ associations to infer the origin and enable the reproducible quantification of organ-specific proteins in plasma. We demonstrate that the resource can determine disease-specific quantitative changes of organ-enriched protein panels in six separate patient cohorts, including sepsis, pancreatitis, and myocardial injury. The strategy can be extended to other diseases to advance our understanding of the processes contributing to plasma proteome dynamics.

Endothelial Activation and Stress Index-A Novel and Simple Prognostic Tool in Coronary Artery Bypass Grafting

Objectives: Risk stratification in coronary artery bypass grafting (CABG) remains challenging despite existing models. The Endothelial Activation and Stress Index (EASIX), originally developed for hematological conditions, has shown promise in various medical fields as a predictor of adverse outcomes. EASIX, calculated from lactate dehydrogenase, creatinine, and platelet count, reflects endothelial dysfunction and systemic inflammation. This study investigates EASIX's potential in predicting mortality and morbidity in patients undergoing CABG. Methods: A total of 475 patients undergoing isolated CABG between January 2017 and June 2020 were retrospectively analyzed. EASIX scores were calculated from pre-operative blood samples. Patients were stratified based on an EASIX cut-off value of 1.16. Results: Patients with EASIX ≥ 1.16 were older and had more comorbidities. They experienced higher 30-day mortality (5.0% vs. 0.8%, p = 0.004), increased wound infections (6.7% vs. 2.5%, p = 0.035), and more frequent prolonged ventilation (9.2% vs. 4.2%, p = 0.040). The long-term survival analysis showed significant differences at 3 years (p = 0.030) and 5 years (p < 0.001). EASIX demonstrated moderate discriminatory power for long-term survival (AUROC 0.669, 95% CI: 0.598-0.740, p < 0.001). Importantly, the multivariable analysis revealed EASIX as an independent risk factor for long-term mortality, even after adjusting for traditional risk factors and comorbidities (HR: 2.65, 95% CI: 1.59-4.42, p < 0.001). Conclusions: EASIX ≥ 1.16 was associated with postoperative morbidity and poorer long-term survival in patients undergoing CABG. This easily calculable score could enhance risk stratification and guide personalized postoperative management.

Outcomes After CABG Compared With FFR-Guided PCI in Patients Presenting With Acute Coronary Syndrome

BACKGROUND

There are limited data comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

OBJECTIVES

The aim of this study was to evaluate differences in outcomes in patients presenting with or without NSTE-ACS after CABG compared with fractional flow reserve (FFR)-guided PCI using current generation drug-eluting stents.

METHODS

The FAME 3 trial (Fractional flow reserve versus Angiography for Multivessel Evaluation; NCT02100722) was an investigator-initiated, randomized controlled trial to attest noninferiority of FFR-guided PCI using the current-generation drug-eluting stents to CABG with respect to the primary endpoint, defined as a composite of death, myocardial infarction (MI), stroke, or repeat revascularization at 1 year, in 1,500 patients with 3-vessel coronary artery disease. The prespecified key secondary endpoint was a composite of death, MI, or stroke at 3 years.

RESULTS

Of 1,500 patients enrolled, 587 (39.2%) presented with NSTE-ACS. Patients were followed up for a median of 1,080 days (Q1-Q3: 1,080-1,080 days). At 3 years, the risk of the composite of death, MI, or stroke was similar between patients presenting with NSTE-ACS and with chronic coronary syndrome (CCS) (11.8% vs 10.0%; adjusted HR [aHR]: 1.20; 95% CI: 0.81-1.77; P = 0.37). Patients presenting with NSTE-ACS had a similar risk of death, MI, or stroke at 3 years after CABG as compared with PCI (aHR: 0.98; 95% CI: 0.60-1.60; P = 0.94), whereas patients presenting with CCS had a significantly reduced risk after CABG compared with PCI (aHR: 0.58; 95% CI: 0.38-0.90; P = 0.02; Pinteraction = 0.11), which was driven by a lower risk of MI (aHR: 0.32; 95% CI: 0.15-0.64; P = 0.002; Pinteraction = 0.01).

CONCLUSIONS

The risk of death, MI, or stroke at 3 years was similar after CABG compared with FFR-guided PCI in patients presenting with NSTE-ACS, but reduced by CABG in patients presenting with CCS. (Fractional flow reserve versus Angiography for Multivessel Evaluation [FAME 3]; NCT02100722).

Prediction of myocardial ischemia-reperfusion injury post-PCI: role of sST2 levels in STEMI patients

BACKGROUND

Myocardial ischemia-reperfusion injury (MIRI) after ST-segment elevation myocardial infarction (STEMI) significantly impacts clinical outcomes. However, only a few studies have examined its clinical predictors and prognostic biomarkers.

METHODS

Patients with STEMI who received percutaneous coronary intervention (PCI) at Liaoning Provincial People's Hospital between 2020 and 2021 were enrolled in the study. Based on a thorough evaluation of clinical features, which included data obtained from intraoperative angiography and inpatient monitoring, patients were divided into the MIRI group and the non-MIRI group. Upon admission, serum solube growth stimulation expressed gene 2 protein (sST2) levels were assessed, and follow-up examinations were conducted for the patients.

RESULTS

Patients with MIRI who were admitted to the hospital present elevated serum sST2 levels (P < 0.001). Serum sST2 was recognized as a standalone risk factor contributing to the occurrence of MIRI in STEMI patients who are undergoing PCI (P < 0.001). Throughout the follow-up duration, 37 (17.0%) patients encountered major adverse cardiovascular and cerebrovascular incidents (MACCEs), which included eight (3.6%) deaths from all causes. The Kaplan-Meier assessment revealed that individuals in the MIRI group had an unfavorable prognosis (all log-rank P < 0.05). Both univariable and multivariable Cox regression models were established using MIRI patients as the study cohort. The findings indicated that sST2 levels exceeding 68.98 ng/mL served as one of independent risk factors for predicting MACCEs (all P < 0.001). The model was evaluated using the C-index, AUC, calibration plot, and Decision Curve Analysis (DCA) curve.

CONCLUSION

Elevated levels of serum sST2 may accurately predict the onset of MIRI following PCI in STEMI patients. Specifically, a serum sST2 concentration > 68.98 ng/mL is a prominent independent risk predictor for overall mortality and MACCE in individuals experiencing MIRI.

Residual cholesterol and inflammatory risk in statin-treated patients undergoing percutaneous coronary intervention†

BACKGROUND AND AIMS

Elevated LDL-cholesterol levels and inflammation, as assessed by high-sensitivity C-reactive protein, correlate with cardiovascular risk. However, data on the relative impact of residual LDL-cholesterol and inflammatory risk among statin-treated patients undergoing percutaneous coronary intervention (PCI) is lacking. Hence, this study aimed to investigate the impact of residual cholesterol/inflammatory risk in patients on statin therapy undergoing PCI.

METHODS

From 2012 to 2022, patients at a tertiary centre undergoing PCI were analysed. Patients were stratified according to LDL-cholesterol (≥70 vs <70 mg/dL) and high-sensitivity C-reactive protein (≥2 vs <2 mg/L) levels: no residual cholesterol or inflammatory risk, residual cholesterol risk, residual inflammatory risk, and combined residual cholesterol and inflammatory risk. Patients presenting with acute myocardial infarction, cancer, no statin treatment at admission, or high-sensitivity C-reactive protein levels >10 mg/L were excluded. The primary endpoint was major adverse cardiovascular events (MACEs), defined as the composite of all-cause mortality, spontaneous myocardial infarction, and stroke 1 year after the index PCI.

RESULTS

A total of 15 494 patients were included. After 1-year follow-up, individuals with isolated residual inflammatory risk had the highest MACE rate (5.1%), followed by patients with combined cholesterol and inflammatory risk, no residual risk, and isolated residual cholesterol risk. After multivariable Cox regression analysis, patients with residual inflammatory risk had a 1.8-fold higher risk for MACE (adjusted hazard ratio: 1.78, 95% confidence interval 1.36-2.33, P < .001) compared with those with no residual cholesterol or inflammatory risk. This was similar in patients with combined residual cholesterol and inflammatory risk (adjusted hazard ratio: 1.56, 95% confidence interval 1.19-2.04, P = 0.001). Of note, no independent association of isolated residual cholesterol risk (adjusted hazard ratio: 1.01, 95% confidence interval .76-1.35, P-value = .920) with MACE was noted (P-trend across all groups <.001).

CONCLUSIONS

Among statin-treated patients undergoing PCI, residual inflammation but not cholesterol risk was associated with an increased risk of MACE during follow-up.

Novel insights into myocardial fibrosis in patients with new onset ST-elevation myocardial infarction following percutaneous coronary intervention through enhanced cardiac magnetic resonance imaging: a prospective cohort study

BACKGROUND

Myocardial fibrosis is a prevalent pathological hallmark of a diverse range of chronic and acute cardiovascular disorders. However, the relevant literature currently provides limited evidence regarding the determinants of myocardial fibrosis severity in patients with new-onset ST-elevation myocardial infarction (STEMI) following successful emergent percutaneous coronary intervention (PCI) utilizing contrast-enhanced cardiac magnetic resonance imaging (CE-CMR).

METHODS

We prospectively enrolled a cohort of 78 patients who presented with new-onset ST-segment elevation myocardial infarction and who underwent successful emergent PCI within 12 h from the onset of symptoms. Late gadolinium-enhanced LGE (LGE) was quantified via CE-CMR, and patients were categorized into two groups on the basis of the median LGE value.

RESULTS

The median LGE was 16% (IQR 12 to 24). Compared with patients with LGE below the median (n = 37), those with LGE above the median (n = 41) presented significantly reduced left ventricular global radial strain(GRS), global circumferential strain(GCS), and global longitudinal strain(GLS) (all p < 0.05). The infarcted radial segment (IRS), infarcted circumferential segment (ICS) and infarcted longitudinal segment (ILS) were significantly reduced in patients with greater LGE (all p < 0.05). The occurrence rates of microvascular obstruction (MVO) (p < 0.001) and wall motion abnormality (WMA) (p < 0.01) were significantly greater in patients with a greater extent of LGE, despite successful reperfusion therapy. LGE exhibited a moderate negative correlation with the global circumferential segment (r=-0.547, p < 0.001) and a weak negative correlation with both the global radial segment and the global longitudinal segment (r=-0.434, p < 0.001; r=-0.437, p < 0.001). In the multivariable linear regression analysis model, the Gensini score (β = 0.258; p < 0.01), LVEF% (β=-0.269; p < 0.05), MVO (β = 0.343; p < 0.001) and GRS (β = 0.227; p < 0.05) emerged as robust predictors of myocardial fibrosis.

CONCLUSION

The present study revealed a correlation of cardiac pathological structure, microcirculation, and myocardial fibrosis in the context of acute myocardial infarction. Therefore, this study provides theoretical evidence from a pathological perspective regarding the progression of myocardial fibrosis in patients with new-onset STEMI following successful PCI.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2400080282; January 25th, 2024).

Wnt signaling pathways in biology and disease: mechanisms and therapeutic advances

The Wnt signaling pathway is critically involved in orchestrating cellular functions such as proliferation, migration, survival, and cell fate determination during development. Given its pivotal role in cellular communication, aberrant Wnt signaling has been extensively linked to the pathogenesis of various diseases. This review offers an in-depth analysis of the Wnt pathway, detailing its signal transduction mechanisms and principal components. Furthermore, the complex network of interactions between Wnt cascades and other key signaling pathways, such as Notch, Hedgehog, TGF-β, FGF, and NF-κB, is explored. Genetic mutations affecting the Wnt pathway play a pivotal role in disease progression, with particular emphasis on Wnt signaling's involvement in cancer stem cell biology and the tumor microenvironment. Additionally, this review underscores the diverse mechanisms through which Wnt signaling contributes to diseases such as cardiovascular conditions, neurodegenerative disorders, metabolic syndromes, autoimmune diseases, and cancer. Finally, a comprehensive overview of the therapeutic progress targeting Wnt signaling was given, and the latest progress in disease treatment targeting key components of the Wnt signaling pathway was summarized in detail, including Wnt ligands/receptors, β-catenin destruction complexes, and β-catenin/TCF transcription complexes. The development of small molecule inhibitors, monoclonal antibodies, and combination therapy strategies was emphasized, while the current potential therapeutic challenges were summarized. This aims to enhance the current understanding of this key pathway.

Lipoprotein(a) Levels and Adverse Outcomes in Heart Failure

BACKGROUND

Although lipoprotein(a) [Lp(a)] level elevation is associated with new-onset heart failure (HF), it is unclear if elevated Lp(a) levels predict cardiovascular events in patients with chronic HF. Thus, we examined the association between Lp(a) levels and adverse cardiovascular outcomes in patients with HF.

METHODS AND RESULTS

A total of 1088 patients with HF undergoing cardiac catheterization at Emory-affiliated hospitals from 2004 to 2022 were divided into low (<30 mg/dL), intermediate (30-49 mg/dL), and high (≥50 mg/dL) Lp(a) groups. The primary outcome was the composite of cardiovascular death and HF hospitalization. Outcomes were assessed by Lp(a) group with competing risk modeling accounting for noncardiovascular death after adjustment for demographics, traditional cardiovascular risk factors, ejection fraction, ischemic HF etiology, and N-terminal prohormone of brain natriuretic peptide. Sensitivity analyses were performed to explore for heterogeneity of effect. The median age was 67 years, 34% were women, 18% were Black, 74% had ischemic HF, and 60% had an ejection fraction of ≤40%. During a median follow-up time of 4.3 years, 474 composite events (44%) occurred. When compared with participants with Lp(a) <30 mg/dL after multivariable adjustment, those with Lp(a) 30-49 mg/dL (subdistribution hazard ratio [sHR] 1.35, 95% confidence interval 1.04-1.76, P = .025) and Lp(a) ≥50 mg/dL (sHR 1.38, 95% confidence interval 1.11-1.72, P = .004) had a significantly higher risk of cardiovascular death or HF hospitalization. This relationship seemed to diminish over time and was nominally stronger in those with ischemic versus nonischemic HF (Pinteraction = .06), but did not meet significance after adjustment for multiple hypothesis testing.

CONCLUSIONS

In patients with HF, Lp(a) ≥30 mg/dL independently predicts the risk of cardiovascular death or HF hospitalization.

Prognostic utility of high-sensitivity troponins according to atherosclerotic vascular disease severity

BACKGROUND AND AIMS

Patients with atherosclerotic vascular disease (ASVD) affecting two or more different vascular beds, so called Polyvascular disease (PolyVD), are at an increased risk for adverse outcomes. In those patients, the prognostic utility of high-sensitivity troponin T and I (hsTnT/I) is under-investigated. We therefore aimed to explore the association between hsTnT/I with the extent of ASVD and outcomes in a contemporary cohort.

METHODS

Patients undergoing coronary angiography with available hsTnT/I concentrations from the cohort study INTERCATH were included. Subgroups of patients without ASVD, monovascular disease (MVD), and PolyVD were created. Cox regression analyses were computed to investigate the associations of hsTnT/I with the extent of ASVD and clinical outcomes (all-cause mortality and major adverse cardiovascular events; MACE).

RESULTS

In 2273 included patients, a stepwise increase of both hsTnT and hsTnI was observed according to the extent of ASVD. However, this association was statistically not significant after adjustment. hsTnT and hsTnI were independently associated with all-cause mortality for PolyVD (adjusted hazard ratio per standard deviation for hsTnT: 1.42 [95 %-CI: 1.16, 1.73]; p < 0.001 and hsTnI: 1.38 [1.14, 1.68]; p = 0.0013) and MVD (hsTnT: 1.32 [1.15, 1.51]; p < 0.001 and hsTnI: 1.35 [1.17, 1.56]; p < 0.001), whereas no association of hsTn with MACE was seen across the burden of ASVD.

CONCLUSIONS

Patients with a greater extent of ASVD had higher concentrations of hsTnT/I and an increased incidence of all-cause mortality as well as MACE. hsTnT/I concentrations were reliably linked to all-cause mortality in patients with ASVD, underscoring the role of biomarkers in risk prediction.

Proteomics of urinary exosomes for discovering novel non-invasive biomarkers of acute myocardial infarction patients

BACKGROUND

Patients with acute myocardial infarction (AMI) can be identified by myocardial enzymes in peripheral blood, but no protein markers have been found in urinary exosomes derived from AMI patients.

METHODS

In the present study, a comprehensive proteomics analysis of urinary exosomes derived from patients with AMI was performed. Firstly, we employed the outstanding separation method known as EXODUS to isolate urinary exosomes from AMI patients and healthy controls. Then, we characterized urinary exosomes by nanoparticle tracking analysis (NTA), western blotting and transmission electron microscopy (TEM). After that, we identified the protein components of exosomes through label-free proteomics and conducted bioinformatics analysis.

RESULT

High-quality exosomes were obtained through separation using EXODUS, which could be demonstrated by NTA, Western blotting and TEM. NTA analysis showed that partilce amount in AMI patients was significantly higher than healthy controls. The equal-volume Western blotting experiment indicated that the expression level of classic exosomal markers Alix, heat shock protein90 (HSP90), CD63 and TSG101 (Tumor susceptibility gene101) in AMI patents was obviously stronger than healthy subjects. We first described the protein profiles of urinary exosomes in AMI patients through proteomics. In this study, We have identified 3194 proteins, among which a total of 30 differential proteins were detected between the urinary exosomes of AMI patients and healthy controls. We investigated F2 and OLR1 among identified exosomal proteins significantly elevated in AMI group, whereas F3 and APCS dysregulated in AMI development.

CONCLUSIONS

F2, F3, OLR1 and APCS are able to distinguish individuals between the AMI group and the healthy controls, and the protein panel represent a novel prospective non-invasive biomarkers for the diagnostic process of acute myocardial infarction.

Blood Transfusion in Patients With Acute Myocardial Infarction, Anemia, and Heart Failure: Lessons From MINT

BACKGROUND

Blood transfusion may precipitate adverse outcomes, including heart failure (HF), among patients with acute myocardial infarction (MI). This study characterizes the effects of a restrictive or liberal transfusion strategy on outcomes in patients with MI and anemia with and without baseline HF.

METHODS

In the MINT trial (Myocardial Ischemia and Transfusion), 3504 patients with MI and anemia (hemoglobin <10 g/dL) were randomized to a restrictive (hemoglobin <8 g/dL) or liberal (hemoglobin <10 g/dL) transfusion strategy. We compared the effects of transfusion strategy on outcomes among patients with and without baseline HF. The primary outcome was death or HF at 30 days.

RESULTS

Compared with patients without baseline HF (n=1633), those with baseline HF (n=1871) had higher rates of death or HF (18.0% versus 10.0%) at 30 days. Restrictive transfusion resulted in numerically higher rates of death or HF (rate ratio, 1.20 [95% CI, 0.99-1.45] versus 0.94 [95% CI, 0.70-1.26]; Pinteraction=0.18) in patients with than in those without baseline HF. Among secondary outcomes, death or recurrent MI and death were more frequent among those with baseline HF. Restrictive transfusion resulted in numerically higher rates of death or MI and death in patients with than in those without baseline HF. Rates of HF were similar between restrictive and liberal transfusion in patients with baseline HF but lower with restrictive transfusion (rate ratio, 0.51 [95% CI, 0.29-0.92]; Pinteraction=0.02) in patients without baseline HF.

CONCLUSIONS

A liberal transfusion strategy is safe for patients with MI and anemia, including those with baseline HF. Restrictive transfusion tended to result in worse outcomes, particularly in patients with baseline HF.

REGISTRATION

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

ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing

This appropriate use criteria (AUC) document is developed by the American College of Cardiology along with key specialty and subspecialty societies. It provides a comprehensive review of common clinical scenarios where implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), cardiac contractility modulation, leadless pacing, and conduction system pacing therapies are frequently considered. The 335 clinical scenarios covered in this document address ICD indications including those related to secondary prevention, primary prevention, comorbidities, generator replacement at elective replacement indicator, dual-chamber, and totally subcutaneous ICDs, as well as device indications related to CRT, conduction system pacing, leadless pacing, cardiac contractility modulation, and ICD therapy in the setting of left ventricular assist devices (LVADs).

The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining device implantation. The indications in this document were developed by a multidisciplinary writing group and scored by a separate independent rating panel on a scale of 1 to 9 to designate care that is considered “Appropriate” (median 7 to 9), “May Be Appropriate” (median 4 to 6), and “Rarely Appropriate” (median 1 to 3). The final ratings reflect the median score of the 17 rating panel members.

In general, Appropriate designations were assigned to scenarios for which clinical trial evidence and/or clinical experience was available that supported device implantation. In contrast, scenarios for which clinical trial evidence was limited or device implantation seemed reasonable for extenuating or practical reasons were categorized as May Be Appropriate. Scenarios for which there were data showing harm, or no data were available, and medical judgment deemed device therapy was illadvised were categorized as Rarely Appropriate. For example, comorbidities including reduced life expectancy related to noncardiac conditions or severe cognitive dysfunction would negatively impact appropriateness ratings.

The appropriate use criteria for ICD, CRT, and pacing have the potential to enhance clinician decision making, healthcare delivery, and payment policy. Furthermore, recognition of clinical scenarios rated as May Be Appropriate facilitates the identification of areas where there may be gaps in evidence that would benefit from future research.

The American College of Cardiology (ACC) has a long history of developing documents (eg, expert consensus decision pathways, health policy statements, AUC documents) to provide members with guidance on both clinical and nonclinical topics relevant to cardiovascular care. In most circumstances, these documents have been created to complement clinical practice guidelines and to inform clinicians about areas where evidence is new and evolving or where sufficient data are more limited. Despite this, numerous gaps persist, highlighting the need for more streamlined and efficient processes to implement best practices in patient care.

Central to the ACC’s strategic plan is the generation of actionable knowledge —a concept that places emphasis on making clinical information easier to consume, share, integrate, and update. To this end, the ACC has shifted from developing isolated documents to creating integrated “solution sets.” These are groups of closely related activities, policy, mobile applications, decision-support tools, and other resources necessary to transform care and/or improve heart health. Solution sets address key questions facing care teams and attempt to provide practical guidance to be applied at the point of care. They use both established and emerging methods to disseminate information for cardiovascular conditions and their related management. The success of solution sets rests firmly on their ability to have a measurable impact on the delivery of care. Because solution sets reflect current evidence and ongoing gaps in care, the associated tools will be refined across time to match changing evidence and member needs.

AUC represent a key component of solution sets. They consist of common clinical scenarios associated with given disease states and ratings that define when it is reasonable to perform testing or provide therapies and, importantly, when it is not. AUC methodology relies on content development work groups, which create patient scenarios, and independent rating panels that employ a modified Delphi process to rate the relevant options for testing and intervention as Appropriate, May Be Appropriate, or Rarely Appropriate. AUC should not replace clinician judgment and practice experience but should function as tools to improve patient care and health outcomes in a cost-effective manner.

I extend sincere gratitude to the writing group for their invaluable contributions to the development of this document’s structure and clinical scenarios; to the rating panelists—a distinguished group of professionals with diverse expertise—for their thoughtful deliberation of the merits of device implantation across various clinical contexts; and to the reviewers for their thoughtful evaluation of the clinical scenarios and evidence mapping. Additionally, I am grateful to the members of the Solution Set Oversight Committee, which provided insight and guidance, and to ACC staff members María Velásquez and Lara Gold, for their support in bringing this document to fruition.

Development of a Novel BifurcAID Risk Score to Predict MACE Following Coronary True Bifurcation Intervention

BACKGROUND

Percutaneous coronary intervention (PCI) for true bifurcation lesions is associated with a higher risk of adverse clinical events.

OBJECTIVES

This study sought to establish a point-based score using clinical and angiographic characteristics in true bifurcation lesions before PCI to predict the risk of major adverse cardiovascular events (MACE).

METHODS

A total of 1,896 consecutive patients undergoing PCI for true bifurcation lesions between 2012 and 2019 in our institution were included. All angiograms were reviewed by an independent core laboratory for classification of the bifurcation lesions. A multivariate model identified factors associated with 1-year MACE, comprising all-cause death, myocardial infarction, and target vessel revascularization. Points were assigned to each risk factor proportional to their regression coefficients to create a cumulative risk score. The score was used to stratify patients into low-, intermediate-, and high-risk cohorts.

RESULTS

At 1-year post-PCI, MACE occurred in 185 patients (9.8%). Eleven predictors of MACE were identified: 5 clinical (insulin-dependent diabetes mellitus, left ventricular ejection fraction ≤30%, non-ST-segment elevation myocardial infarction presentation, age >80 years, and non-white race/ethnicity), and 6 angiographic (left main or left circumflex-obtuse marginal coronary artery lesion, multivessel disease, side branch [SB] thrombus, SB moderate/severe calcium, and SB lesion length >10 mm). The rate of MACE was 4.9% in low-risk patients with a risk score 0 to 6 (reference group), 12.9% in intermediate-risk patients with a score 7 to 9 (OR: 2.63; 95% CI: 1.74-3.98; P < 0.001), and 25.4% in high-risk group with a score ≥10 (OR: 5.18; 95% CI: 3.56-7.53; P < 0.001).

CONCLUSIONS

The BifurcAID risk score may facilitate risk stratification among patients undergoing true bifurcation PCI and guide patient-tailored treatment strategies.

Complete Revascularisation Following Acute MI: A Contemporary Review

Acute MI (AMI) is a leading cause of mortality globally. Swift diagnosis is imperative, with timely reperfusion crucial to minimise adverse outcomes. Revascularisation strategies include culprit-vessel-only therapy, staged complete revascularisation or immediate complete revascularisation. Evidence from randomised trials strongly favours complete revascularisation in ST-elevation MI (STEMI). Data regarding immediate complete revascularisation compared to a staged approach are limited, with uncertainties regarding the advantages of physiology-guided treatment compared to angiographic assessment alone. Non-STEMI (NSTEMI) patients with multivessel disease are often complex and current guidelines offer limited recommendations for this patient group, emphasising the need for individualised treatment. Observational studies have sought to find the optimal approach, yet conflicting data prevails. Dedicated trials for this issue in NSTEMI patients are currently unavailable. To enhance the decision-making processes for patients with AMI, future trials should consider the inclusion of functional health status and health-related quality of life outcomes. The existing gaps in knowledge underscore the intricacies of managing AMI and the ongoing necessity for comprehensive research to refine treatment strategies.

Prognostic impact of residual inflammatory and triglyceride risk in statin-treated patients with well-controlled LDL cholesterol and atherosclerotic cardiovascular disease

AIMS

Identifying alternative contributors to the residual risk of atherosclerotic cardiovascular disease (ASCVD) beyond LDL cholesterol (LDL-C) levels is crucial. We investigated the relative impact of triglycerides (TGs) and high-sensitivity C-reactive protein (hs-CRP) on outcomes in statin-treated patients with well-controlled LDL-C undergoing percutaneous coronary intervention (PCI) for established ASCVD.

METHODS AND RESULTS

We included 9446 statin-treated patients with LDL-C < 70 mg/dL undergoing PCI between 2012 and 2022, stratified into four groups: (i) no residual risk (TG <150 mg/dL + hs-CRP <2 mg/L); (ii) residual TG risk (TG ≥150 mg/dL + hs-CRP <2 mg/L); (iii) residual inflammatory risk (TG <150 mg/dL + hs-CRP ≥2 mg/L); and (iv) residual TG and inflammatory risk (TG ≥150 mg/dL + hs-CRP ≥2 mg/L). The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, consisting of all-cause mortality, myocardial infarction, or stroke. Cox regression analysis was performed, using the no residual risk group as a reference. Of the total population, 5339 (56.5%) had no residual risk, 555 (5.9%) presented residual TG risk, 3009 (31.9%) had residual inflammatory risk, and 543 (5.7%) exhibited residual combined risk. After multivariable adjustment, patients with residual inflammatory or combined risk showed a significantly higher hazard of MACE, mainly driven by all-cause mortality. No significant difference was observed between patients with residual TG risk and those with no residual risk.

CONCLUSION

In statin-treated patients with well-controlled LDL-C undergoing PCI, residual inflammatory risk-alone or in combination with residual TG risk-was associated with a higher incidence of MACE, highlighting the need for targeted preventive strategies beyond LDL-C lowering.

The effects of tranexamic acid in patients treated with extracorporeal membrane oxygenation after cardiac surgery

BACKGROUND

The lysine analog tranexamic acid (TXA) is used as a blood protective drug in cardiac surgery, but efficacy and safety outcomes in patients treated with extracorporeal membrane oxygenation (ECMO) after surgery remain poorly understood.

METHODS

From January 1, 2017 to December 31, 2022, we retrospectively analyzed patients assisted by ECMO after cardiac surgery and divided them into TXA and control groups depending on whether TXA was used or not. The primary study outcome was red blood cell (RBC) transfusion during ECMO.

RESULTS

In total, 321 patients treated with ECMO after cardiac surgery were assessed; 185 patients were eligible for inclusion into to the TXA-intervention group and 136 into to the control group. RBC transfusion during ECMO was 8.0 IU (4.0 IU-14.0 IU) in the TXA group versus 10.0 IU (6.0 IU-16.0 IU) in the control group (p = .034). Median total chest drainage volume after surgery was 1460.0 mL (650.0-2910.0 mL) and 1680.0 mL (900.0-3340.0 mL) in TXA and control groups, respectively (p = .021). Postoperative serum D-dimer levels were significantly lower in the TXA group when compared with the control group; 1.125 µg/mL (0.515-2.176 µg/mL) versus 3.000 µg/mL (1.269-5.862 µg/mL), p < .001. Serious adverse events, including vascular occlusive events, did not differ meaningfully between groups.

CONCLUSIONS

In patients treated with ECMO after cardiac surgery, TXA infusion modestly but significantly reduced RBC transfusions and chest tube output when compared with the control group.

Machine learning-based predictive models for perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery

BACKGROUND AND OBJECTIVE

Accurate prediction of perioperative major adverse cardiovascular events (MACEs) is crucial, as it not only aids clinicians in comprehensively assessing patients' surgical risks and tailoring personalized surgical and perioperative management plans, but also for information-based shared decision-making with patients and efficient allocation of medical resources. This study developed and validated a machine learning (ML) model using accessible preoperative clinical data to predict perioperative MACEs in stable coronary artery disease (SCAD) patients undergoing noncardiac surgery (NCS).

METHODS

We collected data from 9171 adult SCAD patients who underwent NCS and extracted 64 preoperative variables. First, the optimal data imputation, resampling, and feature selection methods were compared and selected to deal with missing data values and imbalances. Then, nine independent machine learning models (logistic regression (LR), support vector machine, Gaussian Naive Bayes (GNB), random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), light gradient boosting machine, categorical boosting (CatBoost), and deep neural network) and a stacking ensemble model were constructed and compared with the validated Revised Cardiac Risk Index's (RCRI) model for predictive performance, which was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), calibration curve, and decision curve analysis (DCA). To reduce overfitting and enhance robustness, we performed hyperparameter tuning and 5-fold cross-validation. Finally, the Shapley additive interpretation (SHAP) method and a partial dependence plot (PDP) were used to determine the optimal ML model.

RESULTS

Of the 9,171 patients, 514 (5.6 %) developed MACEs. 24 significant preoperative features were selected for model development and evaluation. All ML models performed well, with AUROC above 0.88 and AUPRC above 0.39, outperforming the AUROC (0.716) and AUPRC (0.185) of RCRI (P < 0.001). The best independent model was XGBoost (AUROC = 0.898, AUPRC = 0.479). The calibration curve accurately predicted the risk of MACEs (Brier score = 0.040), and the DCA results showed that XGBoost had a high net benefit for predicting MACEs. The top-ranked stacking ensemble model, consisting of CatBoost, GBDT, GNB, and LR, proved to be the best (AUROC 0.894, AUPRC 0.485). We identified the top 20 most important features using the mean absolute SHAP values and depicted their effects on model predictions using PDP.

CONCLUSIONS

This study combined missing-value imputation, feature screening, unbalanced data processing, and advanced machine learning methods to successfully develop and verify the first ML-based perioperative MACEs prediction model for patients with SCAD, which is more accurate than RCRI and enables effective identification of high-risk patients and implementation of targeted interventions to reduce the incidence of MACEs.

Rotational Atherectomy Followed by Modified (Cutting or Scoring) Balloon Versus Plain Balloon Before Drug‑Eluting Stent Implantation for Calcified Coronary Lesions: A Meta-Analysis

Coronary calcification is a major factor leading to stent under-expansion, and subsequent adverse events. This meta-analysis aimed to evaluate the short and long‑term outcomes of rotational atherectomy (RA), followed by modified balloon (cutting or scoring) (MB) versus plain balloon before drug‑eluting stent implantation for calcified coronary lesions. We searched PubMed, Web of Science (WOS), Scopus, and the Cochrane Library Central Register of Controlled Trials (CENTRAL), from inception until 30 January 2024. The risk ratio (RR) with a 95% confidence interval (CI) was used to compare dichotomous outcomes, while continuous outcomes were reported in form of mean difference (MD). Our study included seven studies with 309 patients undergoing RA followed by MB angioplasty, and 414 patients had RA followed by conventional plain balloon angioplasty, before stent implantation. Our analysis revealed no significant difference in-hospital mortality (RR = 0.64, 95% CI [0.18, 2.23], p = 0.49), or long-term mortality (RR = 0.65, 95% CI [0.18, 2.36], p = 0.51). MACE were significantly lower in the cutting balloon group (RR = 0.58, 95% CI [0.37, 0.92], p = 0.02). Angiographic minimum lumen diameter, and change in percent diameter stenosis were significantly higher in the MB group (MD = 0.19, 95% CI [0.08, 0.31], p = < 0.01), and (MD = 3.75, 95% CI [0.76, 6.74], p = 0.01) respectively. No difference was found regarding target lesion revascularization (RR: 0.50, 95% CI [0.24, 1.04], p = 0.06), or target vessel revascularization (RR: 0.71, 95% CI [0.38, 1.33], p = 0.28). RA followed by MB is as safe plain balloon angioplasty before stent implantation in moderate to severely calcified coronary lesions. Moreover, it is associated with significantly better immediate angiographic outcomes, and significantly lower MACE.

Clinical outcomes after complex and high-risk percutaneous coronary intervention according to baseline chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with unfavorable outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). However, its prognostic role in patients undergoing complex high-risk PCI (CHIP) remains unexplored, prompting our investigation.

METHODS

Consecutive CHIP patients treated at a tertiary care center from 2012 to 2022 were included in the current analysis. CHIP was identified by the presence of at least one patient and one procedural criterion from a validated score. Patients were stratified by CKD status, with CKD defined as eGFR < 60 ml/min/1.73m2. The primary endpoint was one-year incidence of major adverse cardiovascular events (MACE), including all-cause mortality, spontaneous myocardial infarction (MI), and stroke. A multivariable Cox regression model was computed adjusted for relevant baseline risk factors and comorbidities.

RESULTS

Among 4855 CHIP patients, 39.6% (n = 1925) had CKD at baseline. CKD patients were older, with more comorbidities, and complex CAD. After multivariable adjustment, CKD was associated with increased 1-year risks of MACE (primarily driven by all-cause mortality and MI rates), and bleeding. In-hospital adjusted hazards for ischemic and bleeding events were similar between the two cohorts, while CA-AKI occurred twice as often in CKD patients compared to non-CKD ones.

CONCLUSIONS

In CHIP patients, CKD is a strong predictor of ischemic and bleeding events at one-year follow-up and doubles the risk of post-procedural CA-AKI, underscoring the need for tailored risk assessment and management of this vulnerable population.

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

BACKGROUND

Acute chest pain has a high hospital referral rate due to the limited ability to exclude acute myocardial infarction (MI) in primary care. We aimed to evaluate the effectiveness of implementing the European Society of Cardiology (ESC) 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) testing in emergency primary care.

METHODS

In a prospective study (April-October 2023), the ESC 0/1-hour algorithm for hs-cTnT was implemented at the main emergency primary care clinic in Oslo, Norway. All consecutive patients ≥ 18 years with acute non-traumatic chest pain having hs-cTnT measurements done were registered. The patients were assigned to MI rule-out, rule-in, or further observation using the algorithm. Patients in the observation group had a 4-hour hs-cTnT measurement done. The outcome measures were the proportion of patients conclusively assessed by the protocol, personnel adherence, reduction in length of stay (LOS) compared to the previous 0/4-hour protocol (historical cohort), and disposition.

RESULTS

During six months, hs-cTnT measurements were conducted in 32.6% (995/3053) of chest pain patients (median age 58 years (IQR 45-68); 50.6% female). A single hs-cTnT measurement assigned 24.1% (n = 240/995) towards MI rule-out, suitable for early discharge, increasing to 63.8% after adding a 1-hour measurement. The observation group (319/995, 32.1%) was reduced to 23.0% (229/995) after a 4-hour measurement. A total of 77.0% of the patients were conclusively assigned to either rule-out or rule-in group. The personnel adhered well to the new protocol, with a median 1-hour sampling interval of 63 min (IQR 60-66) and 4.6 h (IQR 4.1-5.5) for the 4-hour sample. The protocol was misinterpreted or overruled in 8.6% of the cases. Compared to the previous 0/4-hour protocol, LOS was reduced by -2.2 h (95% confidence intervals - 2.6 to -1.7). After completed assessment at the clinic, 14.8% were transferred to hospital, where 20 patients were diagnosed with an MI. The remaining patients were sent home or managed in the outpatient setting; any occurrence of MIs in this group is unknown.

CONCLUSIONS

The ESC 0/1-hour algorithm effectively assesses low-risk acute chest pain in emergency primary care, reinforcing its gatekeeper role by managing these patients at a lower level of care.

Impact of ticagrelor with or without aspirin on total and recurrent bleeding and ischaemic events after percutaneous coronary intervention: a sub-study of the TWILIGHT trial

AIMS

In standard time-to-first event analysis, early aspirin discontinuation followed by ticagrelor monotherapy has been shown to reduce bleeding without increasing ischaemic complications compared with ticagrelor plus aspirin after percutaneous coronary intervention (PCI). We evaluated whether these treatment effects are preserved when recurrent events are considered.

METHODS AND RESULTS

In this TWILIGHT trial post-hoc analysis, we assessed the effects of ticagrelor monotherapy on the total number of events that occurred over the 12-month follow-up among 7119 high-risk patients randomized to aspirin or placebo in addition to ticagrelor at 3 months post-PCI if event-free and adherent to treatment. There were 391 patients with at least one Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding (primary endpoint). Of those, 28 (7.2%) had a recurrent event. The total number of BARC 2, 3, or 5 bleeding events was 148 in the ticagrelor monotherapy arm compared with 278 with ticagrelor plus aspirin arm (P < 0.001). Among 272 patients with at least one key secondary ischaemic endpoint (all-cause death, myocardial infarction, or stroke), 37 (13.6%) sustained a recurrent event. Total ischaemic events were similar (155 vs. 159) in the two groups.

CONCLUSION

Among selected high-risk patients who underwent PCI and completed 3 months of dual antiplatelet therapy followed by ticagrelor with or without aspirin, recurrent bleeding was less common than recurrent ischaemic events over 12 months. Analysis of total events indicates that ticagrelor monotherapy continues to be more effective than ticagrelor plus aspirin in reducing bleeding without a signal of ischaemic harm.

Derivation and Validation of Risk Score Including Nutritional Status Among Patients With Chronic Limb-threatening Ischemia: Insight From I-PAD NAGANO Registry

PURPOSE

Geriatric nutritional related index (GNRI) is a simple and well-established screening method of nutritional status. We aimed to develop and validate a scoring system including GNRI to predict long-term outcomes in patients with chronic limb-threatening ischemia (CLTI) undergoing endovascular treatment (EVT).

MATERIALS AND METHODS

Patients undergoing EVT for symptomatic LEAD from August 2015 to August 2016 were enrolled into the I-PAD NAGANO registry, a prospective, multicenter, observational registry. We identified predictors of amputation-free survival (AFS) at 5 years using Cox proportional hazards regression and developed a risk scoring system. The predictive performance of the risk score was assessed.

RESULTS

A total of 126 patients with CLTI were analyzed. Cox multivariate analysis revealed GNRI score <92 points, ≥72 years of age, hemodialysis, heart failure, and anemia to be significant predictors. We developed a 5-item risk score (I-PAD CLTI score) assigning points to each factor based on the magnitude of association with AFS at 5 years. The I-PAD CLTI score showed a c-index of 0.80 for 5-year AFS. Patients with high score (≥7 points, n=50) had an increased risk of AFS at 5 years compared with those with low score (<7 points, n=68) (26.5% vs 72.1%, p<0.001).

CONCLUSION

A simple 5-item risk score including nutritional status showed reasonable discriminative and prognostic ability for long-term AFS among patients with CLTI.

CLINICAL IMPACT

The I-PAD CLTI score, a simple five-item risk score including nutritional status determined by geriatric nutritional related index, showed reasonable discriminative and prognostic ability for long-term amputation free survival among patients with chronic limb-threatening ischemia. This risk score may be useful for clinicians to accurately predict patient's prognosis and thus identify high-risk patients who may derive the greater clinical benefit from more intensive risk modification. Further research is required to test the clinical utility of risk-score-based treatment approach to improve the prognosis of patients with chronic limb-threatening ischemia.

Outcomes of intravascular imaging-guided percutaneous coronary intervention according to lesion complexity

BACKGROUND

Recent trials have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) improves clinical outcome, as compared to angiography-guided PCI, in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall lesion complexity in each patient.

AIMS

The present study sought to investigate the impact of overall lesion complexity on the benefit of IVI-guided PCI.

METHODS

A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of the Samsung Medical Center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation.

RESULTS

The cutoff value for the number of complex lesion features to predict TVF, determined using the maximally selected log-rank test, was 3. Patients with ≥3 complex lesion features had a higher risk of TVF than those with <3 complex lesion features (11.0% vs 7.2%, hazard ratio [HR] 1.59, 95% confidence interval [CI]: 1.28-1.96; p<0.001). IVI-guided PCI significantly reduced the risk of TVF compared with angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs 14.4%, HR 0.49, 95% CI: 0.35-0.69; p<0.001; <3 complex lesion features: 5.7% vs 8.1%, HR 0.72, 95% CI: 0.53-0.98; p=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs -0.027 vs -0.055 vs -0.077, respectively, for 1 vs 2 vs 3 vs ≥4 complex lesion features; interaction p=0.048).

CONCLUSIONS

In patients with complex coronary artery lesions, IVI-guided PCI showed a lower risk of TVF across all degrees of lesion complexity. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features. (RENOVATE-COMPLEX-PCI [ClinicalTrials.gov: NCT03381872]; Institutional cardiovascular catheterisation database of the Samsung Medical Center [ClinicalTrials.gov: NCT03870815]).

Cardiac adverse events associated with statins in myocardial infarction patients: a pharmacovigilance analysis of the FDA Adverse Event Reporting System

BACKGROUND

Despite the advent of new pharmacotherapies, statins remain a cornerstone in the secondary prevention of myocardial infarction (MI). However, the cardiac adverse events (AEs) linked to statins are not well-documented.

AIM

This pharmacovigilance study used data from the FDA Adverse Event Reporting System (FAERS) to investigate the association between statin use and cardiac AEs in MI patients.

METHOD

Reports from the FAERS database (2004-2023) identifying statins as the primary suspect in MI patients were analyzed. The study evaluated seven types of statins: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin. Disproportionality analysis using four major indices, Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-Item Gamma-Poisson Shrinker (MGPS), was conducted to detect signals of statin-related cardiac AEs.

RESULTS

Of the 20,346,289 reports reviewed, 150 identified statins as the primary suspect drug in MI patients. The most common cardiac AEs were recurrent MI (50 reports), acute MI (14 reports), followed by tachycardia (10), angina pectoris (8), coronary artery occlusion (6), cardiac failure (6), and arrhythmia (6). The analysis revealed no significant signals of statin-induced cardiac AEs.

CONCLUSION

The findings confirm that statin use in MI patients does not significantly increase the risk of cardiac adverse effects, supporting their safety profile in this context.

A review of machine learning methods for non-invasive blood pressure estimation

Blood pressure is a very important clinical measurement, offering valuable insights into the hemodynamic status of patients. Regular monitoring is crucial for early detection, prevention, and treatment of conditions like hypotension and hypertension, both of which increasing morbidity for a wide variety of reasons. This monitoring can be done either invasively or non-invasively and intermittently vs. continuously. An invasive method is considered the gold standard and provides continuous measurement, but it carries higher risks of complications such as infection, bleeding, and thrombosis. Non-invasive techniques, in contrast, reduce these risks and can provide intermittent or continuous blood pressure readings. This review explores modern machine learning-based non-invasive methods for blood pressure estimation, discussing their advantages, limitations, and clinical relevance.

Minimally invasive coronary artery bypass grafting via left anterior minithoracotomy: Setup, results, and evolution of a new surgical procedure

Objective

Minimally invasive total arterial coronary artery bypass grafting offers the advantages of total arterial revascularization through an anterolateral minithoracotomy. However, the procedure is technically challenging and associated with a learning curve. The purpose of our study was to evaluate the progress and development of our program over an 8-year period.

Methods

We collected prospective data on all patients who underwent procedure at our institution from January 2015 to December 2023. Our program underwent several modifications during this study period, including optimization of surgical exposure using various available instruments, efficient intraoperative time management, utilization of a standard technique for all off-pump coronary artery bypass procedures, and close team member mentoring. Changes in quality control consisted of transitioning from routine postoperative coronary imaging to clinically indicated imaging. The influence of these interventions was assessed by focusing on in-hospital mortality as the primary end point, and operative time and perioperative myocardial infarction as secondary end points, over 2 time periods consisting of patients operated on during the first and second 4-year study period (Group 1, n = 137 and Group 2, n = 142).

Results

A total of 279 consecutive patients underwent elective, total arterial minimally invasive total arterial coronary artery bypass grafting at our institution over the study period. The mean age of patients was 66 ± 7 years, with 86% being men (n = 241) and 33.1% having diabetes (n = 77). Triple vessel disease was present in 53% of the cohort (n = 123) and left main disease was prevalent in 43% of patients (n = 101). The overall 30-day mortality was 0.4% (n = 1). Compared with the initial 4-year period, the rate of perioperative myocardial infarction decreased 3-fold (4.3% vs 1.4%; P = .1) and there was a statistically significant reduction in operating time (275 ± 59.5 and 246 ± 72.6 minutes; P < .001) in the most recent group of patients.

Conclusions

Total arterial minimally invasive total arterial coronary artery bypass grafting is a feasible surgical approach that can be performed with very good results, even during the initial learning curve phase. An evolving educational program can provide a smooth transition from off-pump coronary artery bypass grafting to minimally invasive total arterial coronary artery bypass grafting, when performed in selected patients in high-volume cardiac centers.

Predictive Ability of the Academic Research Consortium High Bleeding Risk Criteria in Patients Undergoing Percutaneous Coronary Intervention According to Body Mass Index

BACKGROUND

Whether the high bleeding risk (HBR) criteria of the Academic Research Consortium (ARC) have a consistent predictive ability across different categories of body mass index (BMI) remains unclear.

METHODS

Consecutive patients undergoing percutaneous coronary intervention (PCI) between 2012 and 2019 at Mount Sinai Hospital (New York, USA) were stratified into five BMI categories (18.5-24.9 kg/m2 [normoweight], 25-29.9 kg/m2 [overweight], 30-34.9 kg/m2 [Class I obesity], 35-39.9 kg/m2 [Class II obesity], and BMI ≥ 40 kg/m2 [Class III obesity]) and by HBR status. The primary outcome was major bleeding at 1 year after PCI.

RESULTS

Among 16,123 patients, normoweight, overweight, class I, class II, and class III obesity were found in 23.7%, 41%, 24.5%, 9.3%, 4.8% of patients, respectively. Fulfillment of the ARC-HBR criteria ranged between 34.4% and 48.5% across these BMI categories. One-year rates of major bleeding was 6% in normoweight patients (reference), 4.1% in overweight (adj.HR 0.73, 95% CI 0.60-0.88), 3.5% in class I (adj.HR 0.62, 95% CI 0.49-0.77), 4.2% in class II (adj.HR 0.72, 95% CI 0.54-0.96), and 4.9% in class III (adj.HR 0.83, 95% CI 0.58-1.18) obesity. Consistently across the 5 BMI categories, the fulfillment of ARC-HBR criteria was related with > 4% rates of major bleeding at 1-year and with ≥ 2 times risk increase of major bleeding (pint = 0.177).

CONCLUSIONS

The presence of the ARC-HBR criteria predicted a significantly increased risk of major bleeding consistently in each BMI category.

Microfluidic platforms for monitoring cardiomyocyte electromechanical activity

Cardiovascular diseases account for ~40% of global deaths annually. This situation has revealed the urgent need for the investigation and development of corresponding drugs for pathogenesis due to the complexity of research methods and detection techniques. An in vitro cardiomyocyte model is commonly used for cardiac drug screening and disease modeling since it can respond to microphysiological environmental variations through mechanoelectric feedback. Microfluidic platforms are capable of accurate fluid control and integration with analysis and detection techniques. Therefore, various microfluidic platforms (i.e., heart-on-a-chip) have been applied for the reconstruction of the physiological environment and detection of signals from cardiomyocytes. They have demonstrated advantages in mimicking the cardiovascular structure and function in vitro and in monitoring electromechanical signals. This review presents a summary of the methods and technologies used to monitor the contractility and electrophysiological signals of cardiomyocytes within microfluidic platforms. Then, applications in common cardiac drug screening and cardiovascular disease modeling are presented, followed by design strategies for enhancing physiology studies. Finally, we discuss prospects in the tissue engineering and sensing techniques of microfluidic platforms.

Optimal Definition and Risk Stratification in Prediabetes With Stable Coronary Heart Disease: A Prospective Cohort Study

BACKGROUND

The optimal definition and risk stratification approach to identify high-risk patients with prediabetes and stable coronary heart disease has not been well studied to date. The objective of the current study is to compare the prognostic value of different definitions of prediabetes, and to explore the role of "very-high-risk" (VHR) criteria according to the 2018 American Heart Association/American College of Cardiology cholesterol guideline in the risk stratification of patients with prediabetes and stable coronary heart disease.

METHODS AND RESULTS

This prospective large-cohort study enrolled a total of 7930 patients with stable coronary heart disease. Prediabetes was defined according to various guidelines and further classified on the basis of the VHR criteria according to the 2018 American Heart Association/American College of Cardiology guideline. The primary end point was major adverse cardiovascular events (MACEs), which was defined as the composite end point of cardiac death, nonfatal acute myocardial infarction, and stroke. During a median of 3 years' follow-up, a total of 256 MACEs occurred. Prediabetes defined according to the World Health Organization/International Expert Committee criteria was associated with significant increased MACE risk compared with normoglycemia (adjusted hazard ratio [HR], 1.484 [95% CI, 1.139-1.935]; P=0.0035). The VHR group was associated with increased MACE risk compared with the non-VHR group (adjusted HR, 1.783 [95% CI, 1.344-2.366], P<0.0001). The VHR criteria played an important role in risk stratification, and prediabetes combined with VHR criteria was associated with higher MACE risk regardless of the prediabetes definition.

CONCLUSIONS

Our findings suggested the potential use of the World Health Organization/International Expert Committee definition and VHR criteria in risk stratification of patients with prediabetes and stable coronary heart disease.

The Role of Exercise-Based Cardiac Rehabilitation After Myocardial Infarction on Cholesterol Transfer to HDL

High-density lipoprotein (HDL) is associated with decreased incidence of cardiovascular events, and its functionality also influences prognosis. Exercise is an important tool to improve prognosis in the post-infarction (MI) population, but the role of exercise on HDL functionality is poorly understood. Sixty-two patients with acute MI were randomized in a supervised exercise program for 12-14 weeks (exercise group-EG) or a control group (CG). The main objective of the study was to analyze the role of exercise on esterified cholesterol (EC) and unesterified cholesterol (UC) transfer to HDL. For the total population, the baseline mean rate of EC transfer to HDL was 2.53 ± 0.83 and at the end of follow-up, it was 2.74 ± 0.64 (p = 0.03). The figures for UC were, respectively, 4.08 ± 1.2 and 4.4 ± 1.06 (p = 0.02). The difference (follow-up minus baseline) for EC was 0.15 ± 0.84 for the control group and 0.27 ± 0.69 for the exercise group (p = 0.53); for UC, the figures were 0.28 ± 1.14 and 0.35 ± 0.96 (p = 0.80), respectively, for the control and exercise groups. In post-MI patients, 12-14 weeks of supervised exercise did not improve HDL functionality.

Evaluation of novel ultrathin, biodegradable polymer tetriflex (sirolimus-eluting stent) optimization using intravascular ultrasound (IVUS) in short coronary lesion (≤ 20mm) vs. long coronary lesion (≥ 20mm): Tetriflex IVUS study

BACKGROUND

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) is useful for stent optimization. Outcomes of the ultrathin Supralimus Tetriflex stent (Sahajanand Medical Technologies Pvt. Ltd., India) using IVUS were evaluated among patients with short (≤ 20 mm) versus long lesions (≥ 20 mm).

METHODS

A total of 207 patients underwent PCI, and IVUS was performed post-deployment. The primary outcome was optimal stent deployment, defined as (a) mean surface area (MSA) >5.0 mm²; (b) plaque burden <50%; (c) complete apposition; and (d) no edge dissection. Secondary outcomes were target lesion failure (TLF)-a composite of cardiac death, target vessel myocardial infarction (TVMI), and target lesion revascularization (TLR)-stent thrombosis, and major adverse cardiovascular events (MACE; a composite of death, MI, stent thrombosis, and repeat revascularization).

RESULTS

Suboptimal deployment was significantly more frequent among patients with longer lesions (30.1% vs. 23.3%; p=0.03) due to higher rates of malapposition (17.3% vs. 10.6%) and MSA <5 mm² (9.6% vs. 7.7%). Following post-dilatation, suboptimal deployment was observed in 7.6% and 5.8% of patients, respectively. Residual plaque burden was 4.5% and 5.7%, respectively. The MSA in both groups was 6.3 mm² and 6.5 mm². Minimum and mean stent expansions were 82.1% versus 81.7% and 106.3% versus 109.8%, respectively, with no significant differences. TLF and stent thrombosis were observed in 0.9% versus 0.9% and 2.9% versus 3.8% of patients, respectively, with no significant differences. However, MACE was significantly higher (10.5% vs. 8.7%; p=0.05) among patients with longer lesions.

CONCLUSION

Supralimus Tetriflex stent has very good optimal deployment based on angiogram and becomes better with IVUS imaging, making it safe among long lesions (≥ 20mm).

Bioinformatics-based Analysis and Verification of Chromatin Regulators and the Mechanism of Immune Infiltration Associated with Myocardial Infarction

BACKGROUND

Recent studies have shown that dysfunction in chromatin regulators (CRs) may be an important mechanism of myocardial infarction (MI). They are thus expected to become a new target in the diagnosis and treatment of MI. However, the diagnostic value of CRs in MI and the mechanisms are not clear.

METHODS

CRs-related differentially expressed genes (DEGs) were screened between healthy controls and patients with MI via GSE48060, GSE60993, and GSE66360 datasets. DEGs were further analyzed for enrichment analysis. Hub genes were screened by least absolute shrinkage and selection operator (LASSO) regression and weighted gene co-expression network analysis (WGCNA). GSE61144 datasets were further used to validate hub genes. RT-qPCR examined peripheral blood mononuclear cells (PBMCs) to verify expressions of hub genes. In addition, a correlation between hub genes and immune cell infiltration was identified by CIBERSORT and single-sample gene set enrichment analysis (ssGSEA). Finally, we constructed a diagnostic nomogram and ceRNA network and found possible therapeutic medicines which were based on hub genes.

RESULTS

Firstly, 16 CR-related DEGs were identified. Next, Dual-specificity phosphatase 1 (DUSP1), growth arrest and DNA damage-inducible 45 (GADD45A), and transcriptional regulator Jun dimerization protein 2 (JDP2) were selected as hub genes by LASSO and WGCNA. Receiver operating characteristic curves in the training and test data sets verified the reliability of hub genes. Results of RT-qPCR confirmed the upregulation of hub genes in MI. Subsequently, the immune infiltration analysis indicated that DUSP1, GADD45A, and JDP2 were correlated with plasmacytoid dendritic cells, natural killer cells, eosinophils, effector memory CD4 T cells, central memory CD4 T cells, activated dendritic cells, and activated CD8 T cells. Furthermore, a nomogram that included DUSP1, GADD45A, and JDP2 was created. The calibration curve, decision curve analysis, and the clinical impact curve indicated that the nomogram could predict the occurrence of MI with high efficacy. The results of the ceRNA network suggest that hub genes may be cross-regulated by various lncRNAs and miRNAs. In addition, 10 drugs, including 2H-1-benzopyran, Nifuroxazide, and Bepridil, were predicted to be potential therapeutic agents for MI.

CONCLUSION

Our study identifies three promising genes associated with the progression of chromatin regulators (CRs)-related myocardial infarction (MI) and immune cell infiltration, including Dual-specificity phosphatase 1 (DUSP1), growth arrest and DNA damage-inducible 45 (GADD45A), and Jun dimerization protein 2 (JDP2), which might be worthy of further study.

Toward High-Quality Real-World Laboratory Data in the Era of Healthcare Big Data

With Industry 4.0, big data and artificial intelligence have become paramount in the field of medicine. Electronic health records, the primary source of medical data, are not collected for research purposes but represent real-world data; therefore, they have various constraints. Although structured, laboratory data often contain unstandardized terminology or missing information. The major challenge lies in the lack of standardization of test results in terms of metrology, which complicates comparisons across laboratories. In this review, we delve into the essential components necessary for integrating real-world laboratory data into high-quality big data, including the standardization of terminology, data formats, equations, and the harmonization and standardization of results. Moreover, we address the transference and adjustment of laboratory results, along with the certification for quality of laboratory data. By discussing these critical aspects, we seek to shed light on the challenges and opportunities inherent to utilizing real-world laboratory data within the framework of healthcare big data and artificial intelligence.

Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy

BACKGROUND

Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival.

METHODS

The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization.

RESULTS

Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]).

CONCLUSIONS

One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Nomogram for Predicting in-Hospital Severe Complications in Patients with Acute Myocardial Infarction Admitted in Emergency Department

Background

There is lack of predictive models for the risk of severe complications during hospitalization in patients with acute myocardial infarction (AMI). In this study, we aimed to create a nomogram to forecast the likelihood of in-hospital severe complications in AMI.

Methods

From August 2020 to January 2023, 1024 patients with AMI including the modeling group (n=717) and the validation group (n=307) admitted in Changsha Central Hospital's emergency department. Conduct logistic regression analysis, both univariate and multivariate, on the pertinent patient data from the modeling cohort at admission, identify independent risk factors, create a nomogram to forecast the likelihood of severe complications in patients with AMI, and assess the accuracy of the graph's predictions in the validation cohort.

Results

Age, heart rate, mean arterial pressure, diabetes, hypertension, triglycerides and white blood cells were seven independent risk factors for serious complications in AMI patients. Based on these seven variables, the nomogram model was constructed. The nomogram has high predictive accuracy (AUC=0.793 for the modeling group and AUC=0.732 for the validation group). The calibration curve demonstrates strong consistency between the anticipated and observed values of the nomogram in the modeling and validation cohorts. Moreover, the DCA curve results show that the model has a wide threshold range (0.01-0.73) and has good practicality in clinical practice.

Conclusion

This study developed and validated an intuitive nomogram to assist clinicians in evaluating the probability of severe complications in AMI patients using readily available clinical data and laboratory parameters.

Taohong siwu decoction suppresses oxidative stress-induced myocardial apoptosis post-myocardial infarction by inhibiting PTEN pathway

BACKGROUND

Myocardial infarction (MI) is an important factor inducing mortality globally. Apoptosis and oxidative stress have been identified as major drivers for MI development. Anti-apoptosis therapies exhibit promising effects in protecting against MI. Typically, Taohong Siwu Decoction (THSWD) exerts cardioprotective properties. However, whether THSWD suppresses oxidative stress-induced myocardial apoptosis after MI and the associated mechanisms remain unclear.

PURPOSE

The present work focused on examining the protective effects of THSWD on oxidative stress-induced myocardial apoptosis after MI and its possible mechanisms.

METHODS

The MI mouse model was established via left anterior descending coronary artery (LAD) ligation. Thereafter, echocardiography and histopathology were performed to examine the cardioprotective effects of THSWD. Meanwhile, the protective potential of THSWD against myocardial apoptosis and oxidative stress, as well as modulation of phosphatase and tensin homolog (PTEN) pathway in MI were investigated through TUNEL staining, ROS analysis, immunohistochemistry (IHC), Western blot (WB) and oxidative stress-related biochemical enzyme assay, respectively. Further, the apoptosis of neonatal cardiomyocytes (NCMs) and H9C2 cells was induced by TBHP in vitro. Thereafter, the impacts of THSWD on the TBHP-induced H9C2 and NCMs were detected by Hoechst33342/PI fluorescent staining, WB, ROS analysis, and oxidative stress-related biochemical enzyme assay. In addition, PTEN was overexpressed using transfection viruses in vivo and in vitro for further investigation.

RESULTS

THSWD might inhibit PTEN and promote the PI3K/AKT pathway in MI mice to prevent myocardial apoptosis. In vitro, THSWD prevented the TBHP-induced apoptosis of NCMs and H9C2 cells. This was achieved by blocking PTEN activity and regulating PI3K/AKT pathway. Moreover, PTEN overexpression significantly enhanced the TBHP-induced H9C2 apoptosis and oxidative stress-induced myocardial apoptosis after MI, and partially blocked the protection of THSWD against myocardial apoptosis and modulating PI3K/AKT pathway in vitro and in vivo.

CONCLUSION

THSWD suppressed oxidative stress-induced myocardial apoptosis in vitro and in vivo by inhibiting PTEN pathway.

Rotational, orbital atherectomy and intravascular lithotripsy for coronary calcified nodules: insights from optical coherence tomography

BACKGROUND

The optimal treatment strategy for coronary calcified nodules (CN) remains uncertain. We aimed to evaluate the efficacy and safety of different calcium modification strategies, including rotational atherectomy (RA), orbital atherectomy (OA), and intravascular lithotripsy (IVL) for managing CN with optical coherence tomography (OCT) guidance.

METHODS

Consecutive patients undergoing OCT-guided percutaneous coronary intervention (PCI) for severely calcified lesions using RA, OA, or IVL between January 2017 and December 2022 were included. Primary endpoint was minimum stent area (MSA) post-PCI. Secondary endpoints included MSA at CN site and 1-year target vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target vessel revascularization.

RESULTS

Among 154 patients and 158 lesions, CN was identified in 54 lesions (34.2%) and managed with RA (39%, n = 21), OA (33%, n = 18), or IVL (28%, n = 15). The IVL group exhibited a larger minimal lumen diameter, maximum calcium arc, and maximum calcium thickness. Post-PCI OCT demonstrated comparable MSA (RA: 6.23 ± 0.34 mm², OA: 5.75 ± 0.39 mm², IVL: 6.24 ± 0.46 mm²; p = 0.62) and MSA at CN site (7.17 ± 0.43 mm², 6.46 ± 0.49 mm², 7.86 ± 0.56 mm², respectively; p = 0.55) after adjusting for morphologic factors. The incidence of TVF at 1 year was similar among the group (RA: 19.0%, OA: 22.2%, IVL: 13.3%, p = 0.81).

CONCLUSIONS

In patients undergoing PCI for CN, similar procedural and clinical outcomes can be achieved using RA, OA, or IVL. These findings warrant further investigation in larger, prospective trials.

Peak Procedural ACT Is Associated With All-Cause Mortality After Femoral Access PCI

Background

A minimum threshold activated clotting time (ACT) to guide heparin dosing during percutaneous coronary intervention (PCI) is associated with lower ischemic complications. However, data are variable regarding the risk of high ACT levels. The aim of this study was to assess the impact of peak procedural ACT on complications and mortality for transfemoral and transradial access PCI.

Methods

The UC San Diego Health National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent native vessel PCI from January 2007 to September 2022. Coronary artery bypass graft patients and those who received bivalirudin were excluded. Complications and all-cause mortality at 30 days and 1-year post-PCI were assessed by ACT tertile.

Results

A total of 2473 patients (age 65 ± 12 years; 74% male) undergoing PCI with 53% femoral and 47% radial access were included. The majority (82%) had 1-vessel coronary artery disease with heterogeneous clinical presentations (21.8% ST-elevation myocardial infarction, 25.4% non-ST-elevation myocardial infarction, 4.9% unstable angina, 33.8% stable angina, 3.4% atypical chest pain, 10.7% other indication for PCI). With femoral access, patients in the third tertile (ACT ≥ 275) had significantly higher all-cause mortality at 30 days (5.3% vs 2.7% vs 0.9%; P < .001), 6 months (6.3% vs 4.0% vs 2.0%; P = .007), and 1 year (9.0% vs 6.0% vs 2.7%; P < .001) compared to the second (ACT 228-275) and first tertile (ACT ≤ 228), respectively. A 30-day landmark analysis revealed that there was no difference in all-cause mortality beyond 30 days (3.9% vs 3.4% vs 1.8%; P = .176). There were increased bleeding complications in the highest tertile (12.8% vs 9.8% vs 7.5%; P = .034) and a higher need for blood products (10.4% vs 6.7% vs 5.4%; P = .014). There was no difference in ischemic major adverse cardiovascular events specifically periprocedural myocardial infarction or stroke between tertiles. There was no difference in clinical outcomes by peak ACT for patients who had radial access.

Conclusions

Higher ACT with transfemoral access PCI was associated with increased 30-day mortality, bleeding complications, and need for blood products post-PCI.