Fourth Universal Definition of Myocardial Infarction (2018)

Frequency of ischemic cardiac events in patients receiving long-term multikinase inhibitor: A report of three cases

Objective

To investigate the incidence and characteristics of ischemic cardiac events, specifically major adverse cardiac events (MACE), in patients undergoing long-term treatment with multikinase inhibitors (MKIs) such as lenvatinib and sorafenib.

Methods

A single-center retrospective analysis was conducted on 41 patients treated with lenvatinib or sorafenib for more than one year at our institution from 2015 to 2022. Patient records were reviewed to collect data on demographics, cancer type, cardiovascular risk factors, MKI treatment duration, and MACE incidence. MACE events, defined as acute heart failure, fatal arrhythmia, acute myocardial infarction, and coronary revascularization, were analyzed to determine potential correlations with MKI therapy.

Results

Among the 41 patients, three (7.3%) developed MACE, presenting as acute heart failure, fatal arrhythmia, and acute myocardial infarction, all associated with significant coronary artery stenosis. Notably, none of these patients had a prior history of cardiovascular disease. Despite variations in clinical presentation, all cases suggested a link between long-term MKI administration and accelerated coronary atherosclerosis. Factors involved in atherosclerosis were significantly older and tended to be more hypertensive in the non-MACE group.

Conclusions

Long-term MKI therapy may increase the risk of severe ischemic cardiac events, likely due to accelerated atherosclerosis. Clinicians and oncology nurses should monitor patients closely for early signs of angina, especially in an outpatient setting, to prevent acute cardiac events. Further large-scale studies are warranted to establish a clearer causal relationship between MKI therapy and cardiovascular risks.

Prognostic value of remnant-like particle cholesterol in ischemic heart failure patients following percutaneous coronary intervention

BACKGROUND

The relationship between remnant-like particle cholesterol (RLP-C) and cardiovascular disease risk and prognosis has been established, but its effect on the prognosis of ischemic heart failure (IHF) patients undergoing percutaneous coronary intervention (PCI) remains uncertain.

METHOD

In this study, 2036 patients with IHF who underwent PCI were included. Patients were categorized into tertiles based on their RLP-C levels. The primary outcome was major adverse cardiovascular events (MACE). Kaplan-Meier survival analysis was used to assess the incidence of MACE and other outcomes. Multivariate Cox regression models were employed to investigate the correlation between RLP-C and the studied outcomes. The nonlinear relationship between RLP-C and MACE was examined through the restricted cubic spline (RCS). Subgroup analyses were performed and interactions were assessed.

RESULT

The study results showed a clear association between higher RLP-C levels and an increased incidence of MACE in the participants. This association was validated by Kaplan-Meier analyses. The multivariate Cox regression demonstrated RLP-C was an independent risk factor for MACE, whether assessed as a continuous variable[hazard ratio (HR), 95% confidence interval (CI): 1.50, 1.15-1.98, p = 0.003] or categorized into tertiles[HR, 95% CI: 2.57, 2.03-3.26, p < 0.001, tertile 3 vs tertile 1]. A nonlinear relationship between RLP-C and MACE was observed, indicating that the risk of MACE increased with higher RLP-C levels(Nonlinear p < 0.001). This association remained consistent across various subgroups, as no significant interactions were found.

CONCLUSION

There was an independent and positive correlation between RLP-C and MACE in patients with IHF who underwent PCI.

Association between early heart rate trajectories in post-PCI STEMI patients and prognosis after hospital discharge

BACKGROUND

Timely percutaneous coronary intervention (PCI) is crucial for restoring myocardial blood supply in ST-segment elevation myocardial infarction (STEMI) patients, with the first 72 h being a critical period for early ventricular remodelling. The association between heart rate trajectories within this period and after hospital discharge outcomes in STEMI patients post-PCI remains unclear.

METHODS

We conducted a retrospective study involving STEMI patients who underwent successful PCI at three tertiary hospitals in Zhejiang Province, China. Heart rate data were collected every 8 h post-PCI through nursing records, along with intraoperative findings and biochemical markers. Using trajectory modelling, we identified heart rate patterns at 24, 48 and 72 h post-PCI, determined the optimal number of trajectory groups using Akaike information criterion (AIC) and Bayesian information criterion (BIC) criteria, and performed a minimum 3-month follow-up. Cox regression analysed the association between early heart rate trajectories and major adverse cardiovascular events (MACEs) post-discharge. The prognostic value of trajectory models was assessed using the area under the curve (AUC).

RESULTS

A total of 1257 patients were included, with an average follow-up duration of 28.72 ± 21.14 months and a mean age of 60.42 ± 14.19 years; 1013 (80.59%) were male. Growth mixture modelling identified four distinct heart rate trajectory groups at 24, 48 and 72 h post-PCI. Higher heart rate trajectories with rates greater than 80 bpm were strongly associated with MACEs, and the 72-hour heart rate trajectory showed a predictive value for MACEs (AUC = 0.745, 95% CI: 0.709-0.781).

CONCLUSIONS

Elevated heart rate trajectories exceeding 80 bpm within 72 h after PCI are associated with an increased risk of MACEs post-discharge. Heart rate management should be further emphasized in post-PCI STEMI patients.

CMR-based T2 RV/LV blood pool ratio: Help for risk stratification in heart failure

OBJECTIVES

Blood pool signals on T2 map can reflect intracardiac blood oxygenation. This study aimed to evaluate the T2 RV/LV blood pool ratio (T2 ratio) as a potential parameter for risk stratification in heart failure (HF) patients.

METHODS

217 HF patients undergoing cardiac MRI were categorized into major adverse cardiovascular events (MACE) and No MACE groups. Regions of interest were delineated in the bi-ventricular blood pools on T2 maps to calculate T2 ratios. Clinical and imaging parameters were compared between groups, and independent predictors of MACE were identified using Cox regression analysis. Associations between T2 ratios and other parameters were explored. Survival analyses were conducted across low, moderate, and high-risk groups. Finally, predictive performance for MACE was compared among different models.

RESULTS

The T2 ratio was lower in MACE group (0.65 ± 0.12 vs 0.75 ± 0.12, P < 0.001) and was identified as an independent prognostic predictor of adverse outcomes in HF (HR: 0.966, P = 0.044). The association between T2 ratio and left ventricular ejection fraction (LVEF) followed distinct patterns in different ranges, with a transition around LVEF ≈ 50 %. Survival analysis demonstrated a stepwise decline in event-free survival from low- to high-risk groups (P < 0.05). Finally, the predictive model G incorporating myocardial T1 and T2 ratio demonstrated superior predictive efficacy (C-statistic: 0.806, IBS: 0.087).

CONCLUSIONS

A lower T2 ratio was associated with a higher risk of MACE in HF patients. This parameter may serve as a valuable tool for risk stratification in clinical practice.

Association between the long-term dialysis due to diabetic nephropathy and clinical outcomes in patients with coronary artery disease and chronic renal failure

The clinical outcomes of percutaneous coronary intervention (PCI) in patients with dialysis are still worse compared with those without dialysis. Among patients with dialysis, those who started dialysis due to diabetic nephropathy (DMN) may have a worse prognosis than those who started dialysis due to non-DMN. This retrospective study aimed to compare the clinical outcomes in dialysis patients who underwent PCI between with and without long-term dialysis due to DMN. We included 303 dialysis patients with PCI. The length of dialysis at the time of PCI was used to stratify the study patients. Patients with DMN and the length of dialysis ≥ 3 years were defined as the long-DMN group (n = 117), and the others were defined as the other group (n = 186). The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal myocardial infarction, re-admission for heart failure, and ischemia-driven target vessel revascularization. A total of 165 MACE were observed with the median follow-up of 568 days. The Kaplan-Meier curves showed that MACE was more frequently observed in the long-DMN group than in the other group (p = 0.005). In the multivariate Cox hazard model, long-DMN was significantly associated with MACE (hazard ratio 1.483, 95% confidence interval 1.075-2.046, p = 0.016) after controlling for multiple confounding factors. Among patients with dialysis, the combination of DMN and a long history of dialysis is closely associated with poor clinical outcomes. These patients should be carefully followed up by both cardiologists and nephrologists.

Association between myocardial bridge and upstream plaque morphology in patients with acute coronary syndrome

Myocardial bridging (MB), characterized by systolic coronary artery compression, alters coronary flow and may influence upstream atherosclerotic plaque morphology. We aimed to investigate the relationship between MB and morphological features of upstream culprit plaques in patients with acute coronary syndrome (ACS). We retrospectively analyzed 370 ACS patients who underwent optical coherence tomography (OCT)-guided PCI for a de novo culprit lesion in the proximal left anterior descending artery (LAD). OCT images identified plaque rupture (PR), classifying lesions into PR and intact fibrous cap (IFC) groups. The IFC group was further divided based on the presence of lipid-rich plaque (LRP), defined as a plaque with a maximum lipid angle > 90°. This study included 370 ACS patients (mean age 65.2 ± 12.3 years, 82.4% male). Angiographic evidence of MB was present in 8.6% (32/370) of patients prior to PCI and increased to 17.0% (63/370) post-PCI; all MBs identified pre-PCI were also observed post-PCI. OCT identified 213 lesions with plaque rupture and 157 lesions with IFC (of which 83 exhibited underlying LRP and 74 did not). The prevalence of post-PCI angiographically detected MB differed significantly among the OCT-defined morphological groups: 11.3% (24/213) in the PR group, 18.1% (15/83) in the IFC-LRP group, and 32.4% (24/74) in the IFC-non-LRP group (P < 0.01). No periprocedural myocardial injury occurred in the IFC-non-LRP group. In patients with ACS, the presence of MB was significantly associated with a lower likelihood of plaque rupture and LRP in the upstream culprit lesion as assessed by OCT.

Evaluation of sex-specific 0-h high-sensitivity cardiac troponin T thresholds for the risk stratification of non-ST-segment elevation myocardial infarction

OBJECTIVES

We aimed to evaluate sex-specific 0-h high-sensitivity cardiac troponin T (hs-cTnT) thresholds for risk stratification in patients with suspected non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS

This retrospective study investigated a derivation cohort of 6,691 (44.4 % female and aged 65 (57-72) years) and a validation cohort of 6,589 (48.4 % female and aged 63 (50-71) years) patients with suspected NSTEMI who visited the emergency department. Uniform and sex-specific thresholds were derived and validated, and their performances were compared.

RESULTS

In the derivation cohort, 11.3 % of males and 5.4 % of females were diagnosed with adjudicated NSTEMI. As male-specific thresholds, 0-h hs-cTnT <10 ng/L ruled out 30.1 % of patients with an NPV of 99.6 % [95 % CI (99.0-99.9 %)], and 0-h hs-cTnT ≥65 ng/L ruled in 12.3 % of patients with a PPV of 70.5 % [95 % CI (66.0-74.6 %)]. As female-specific thresholds, 0-h hs-cTnT <9 ng/L ruled out 39.2 % of patients with an NPV of 99.9 % [95 % CI (99.4-100.0 %)], and 0-h hs-cTnT ≥45 ng/L ruled in 6.7 % of patients with a PPV of 71.7 % [95 % CI (64.8-77.8 %)]. The validation cohort showed similar results. Sex-specific and uniform thresholds did not significantly affect rule-in performance, whereas sex-specific thresholds increased female sensitivity by 1 % (99.7 vs. 98.7 %). Patient follow-up did not change when sex-specific thresholds were applied.

CONCLUSIONS

Sex-specific 0-h hs-cTnT thresholds could slightly improve the safety in ruling out NSTEMI in females, but their role in terms of efficiency, rule-in performance and prognosis was similar to that of uniform thresholds.

Long cardiac troponin T forms in a healthy reference population

BACKGROUND

Cardiac troponin T (cTnT) is an established biomarker in the diagnosis of myocardial infarction (MI). Recent studies show better discrimination between MI and other conditions when measuring only intact or minimally fragmented cTnT forms (long cTnT), compared to current cTnT assays that measure both intact and highly fragmented cTnT forms (total cTnT). This study investigated the long cTnT concentrations in a healthy population.

METHODS

Lithium-heparin plasma samples were collected from 314 healthy volunteers aged 21-85 years (59 % female). The samples were analyzed for total cTnT with Roche Elecsys high sensitivity cTnT assay and with a novel upconversion luminescence-based long cTnT assay.

RESULTS

The median (25th-75th percentile) long cTnT concentration of the reference population was 2.0 (1.3-3.0) ng/l. The 99th percentile URL for the long cTnT assay was 7.3 (95 % confidence interval, 5.6-8.4) ng/l. Of the healthy population 98 % had long cTnT levels above the detection limit of the assay (0.4 ng/l). The imprecision (coefficient of variation) of the long cTnT assay at the 99th percentile URL was 5.1 %. While total cTnT was heavily associated with age, especially in the older population, long cTnT remained low regardless of age. Common comorbidities and medications were also associated with the total cTnT concentration but not with the long cTnT concentration.

CONCLUSIONS

The long cTnT assay fulfills the requirements for a high sensitivity cTnT assay. Healthy individuals have low long cTnT concentrations regardless of age and common comorbidities.

Design and early progress of the Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA) trial

BACKGROUND

The usual antithrombotic treatment for symptomatic intracranial atherosclerotic stenosis (ICAS) consists of dual treatment with clopidogrel and aspirin for 90 days followed by aspirin alone but the risk of recurrent stroke remains high up to 12 months. The Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA) trial was designed to determine whether other combinations of dual antithrombotic therapy are superior to clopidogrel and aspirin.

METHODS

CAPTIVA is an ongoing, prospective, double-blinded, three-arm clinical trial at over 100 sites in the United States and Canada that will randomize 1683 high-risk subjects with a symptomatic infarct attributed to 70-99% stenosis of a major intracranial artery to 12 months of treatment with (1) ticagrelor (180 mg loading dose, then 90 mg twice daily), (2) low-dose rivaroxaban (2.5 mg twice daily), or (3) clopidogrel (600 mg loading dose, then 75 mg daily). All subjects receive aspirin (81 mg daily), intensive risk factor management, and will undergo blinded CYP2C19 genotype analysis. The primary goal of the trial is to determine whether rivaroxaban or ticagrelor or both are superior to clopidogrel for lowering the primary endpoint (ischemic stroke, intracerebral hemorrhage (ICH), or vascular death) within 12 months. A prespecified interim safety analysis will be conducted when the first 450 randomized subjects have been followed for 12 months to evaluate the risk of major hemorrhage in the rivaroxaban and ticagrelor arms.

RESULTS

Enrollment began in August 2022 and, as of 26 June 2024, the 450th subject was randomized into the study.

CONCLUSION

CAPTIVA is evaluating two alternative dual antithrombotic therapies to clopidogrel and aspirin to maximize the chance of establishing more effective antithrombotic therapy for symptomatic ICAS, one of the most common and high-risk cerebrovascular diseases worldwide.

The role of resting-state perfusion CMR in the evaluation of microvascular obstruction in patients with acute myocardial infarction: A clinical perspective

Objectives

To investigate the clinical application value of cardiac resting-state perfusion weight imaging (rs-PWI)-derived parameters in patients with acute myocardial infarction (AMI) complicated by microvascular obstruction (MVO).

Methods

Overall, 300 patients with AMI were prospectively enrolled, and divided into the MVO and non-MVO groups, based on the presence of MVO in the infarcted myocardium. Differences in rs-PWI imaging parameters, and the diagnostic value of rs-PWI in reperfusion myocardial ischemia at segment level and MVO were quantitatively evaluated.

Results

The average age was 58.60 ± 13.03 years, and 246/300 (82 %) were males. The MVO group had 176 patients (mean age: 57.90 ± 12.47), including 140 (80 %) males. The left ventricular (LV) volumes occupied by the infarcted myocardium were 19.60 ± 2.70 %LV and 15.20 ± 3.40 %LV in the MVO and non-MVO groups, respectively (P < 0.05). There were 679 LGE positive segments in the MVO group (679/2816, 24.1 %). The area under curve (AUC), sensitivity, specificity, and Jordan index of rs-PWI for MVO diagnosis were 0.95(0.89-0.99), 94.3 %, 93.4 %, and 0.88, respectively. At the segmental level, the maximum rising slope was higher in the MVO than non-MVO group (15.09 ± 2.64 vs. 6.21 ± 1.25, P < 0.05). The time to peak 20 %-80 % was shorter in the MVO group (4.07 ± 0.79 vs. 7.75 ± 1.03, P < 0.05). Comparison revealed differences in perfusion indices (MVO: 0.32 ± 0.09 vs. non-MVO: 0.42 ± 0.04, P < 0.05). The highest diagnostic value for MVO among rs-PWI parameters was AUC 0.90(0.84-0.97), sensitivity 94.1 %, specificity 88.7 %, and accuracy 91.1 %.

Conclusion

CMR rs-PWI sequence effectively evaluates reperfusion myocardial ischemia complicated with MVO, while the perfusion index has high diagnostic value in quantifying myocardial blood flow potential.

Treatment Modifications in Acute Coronary Syndrome Patients Treated with Ticagrelor: Insights from the FORCE-ACS Registry

Patients presenting with acute coronary syndrome (ACS) are frequently treated with the P2Y12-inhibitor ticagrelor. Some patients prematurely discontinue ticagrelor, but the incidence of reasons for and clinical implications of treatment modification are relatively unknown.Data from 4,278 ACS patients (mean age: 63.6 years, 26.1% women) who were discharged on ticagrelor and enrolled in the FORCE-ACS registry between 2015 and 2020 were used. Treatment modifications were categorized as physician-recommended discontinuation, alteration, interruption, or disruption and occurred in 26.7, 20.1, 2.8, and 3.1% of patients within 12 months of follow-up (VISUAL SUMMARY: ). Underlying reasons for treatment modification differed per type of modification. Overall, the rate of ischemic events defined as all-cause death, myocardial infarction, or stroke was 6.6% at 12 months of follow-up. Cox regression analysis using time-updated modification variables as independent variables showed that treatment interruption (adjusted hazard ratio [HR]: 2.93, 95% confidence interval [CI]: 1.48-5.79, p < 0.01) and disruption (adjusted HR: 2.33, 95% CI: 1.07-5.07, p = 0.03) were associated with an increased risk of ischemic events even after adjustment for relevant confounders. Discontinuation and alteration were not associated with increased ischemic risk.In clinical practice, treatment modifications in ACS patients discharged on ticagrelor are common, although type and reasons for modification are heterogeneous. Treatment interruption and disruption are associated with excess cardiovascular risk.

Comparison Between Drug-Coated Balloon and Stents in Large De Novo Coronary Artery Disease: A Systematic Review and Meta-Analysis of RCT Data

PURPOSE

Although a number of studies involving small-vessel de novo coronary disease showed clinical benefits of drug-coated balloons (DCB), the role of DCB in large vessel lesions is still unclear.

METHODS

We searched main electronic databases for randomized controlled trials (RCTs) comparing DCB with stents for large vessel de novo coronary artery disease. The primary endpoint was major cardiovascular adverse events (MACE), composite cardiovascular death (CD), myocardial infarction (MI), or target lesion revascularization (TLR).

RESULTS

This study included 7 RCTs with 770 participants. DCB were associated with a marked risk reduction in MACE [Risk Ratio (RR): 0.48; 95% confidence interval [CI]: 0.24 to 0.97; P = 0.04], TLR (RR: 0.53; 95% CI: 0.25 to 1.14; P = 0.10), and late lumen loss [standard mean difference (SMD): -0.57; 95% CI: -1.09 to -0.05; P = 0.03] as compared with stents. There is no significant difference in MI (RR: 0.58; 95% CI: 0.21 to 1.54; P = 0.27), CD (RR: 0.33; 95% CI: 0.06 to 1.78; P = 0.19), and minimal lumen diameter (SMD: -0.34; 95% CI: -0.72 to 0.05; P = 0.08) between groups. In subgroup analyses, the risk reduction of MACE persisted in patients with chronic coronary syndrome (RR: 0.25; 95% CI: 0.07 to 0.89; P = 0.03), and patients receiving DCB vs. bare metal stent (RR: 0.19; 95% CI: 0.05 to 0.73; P = 0.01). In addition, there was no significant difference between the DCB group and the drug eluting stent group for MACE (RR: 0.69; 95% CI: 0.30 to 1.60; P = 0.38).

CONCLUSION

DCB may be an effective therapeutic option in patients with large vessel de novo coronary artery disease.

A Comprehensive Review on Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): One size does not fit all

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined as clinical evidence of myocardial infarction (MI) without significant obstruction (<50% stenosis) in coronary angiography, making it a clinically distinct and heterogeneous disorder. Unlike MI associated with obstructive coronary artery disease (MICAD), MINOCA is more common in younger women and often involves microvascular dysfunction or vasospastic conditions. Despite recent advancements in understanding MINOCA, its prognosis and predictors remain uncertain, necessitating further research into its pathogenesis. The diverse underlying causes of MINOCA mean that traditional treatment of the "one-size-fits-all" approach used for MICAD may not be appropriate, emphasizing the need for individualized treatment strategies based on accurate diagnosis. There is an urgent need to raise awareness among healthcare providers, implement standardized diagnostic protocols, and conduct targeted research to improve patient outcomes. Multi-centered studies and clinical trials are essential to establish evidence-based therapies and optimize management strategies for MINOCA, ensuring better long-term outcomes.

Progress of nanomaterials in the treatment of ischemic heart disease

Medical or surgical interventions are commonly used to alleviate the clinical symptoms of individuals suffering from ischemic heart disease (IHD), but global morbidity and mortality remain high. This is due to the complexity of disease progression and the pathological basis of IHD, which primarily includes myocardial infarction (MI), myocardial ischemia-reperfusion injury (IRI), and heart failure (HF), as well as underlying mechanisms, such as mitochondrial damage, inflammation, oxidative stress, and cardiomyocyte death. However, many drugs have limitations, such as poor stability and low bioavailability, and surgical strategies are often ineffective in preventing disease recurrence. To overcome these problems, it is necessary to develop effective drug delivery systems and technologies. Due to their advantages in enhancing drug utilization, nanomaterials are being used to control drug biodistribution and achieve targeted accumulation, addressing the therapeutic needs of IHD. In this work, we first described the clinical aspects of MI, IRI, and HF in the context of IHD as well as their shared pathological origins. Next, clinical interventional procedures for IHD are summarized. Finally, recent developments in the use of nanomaterials for the treatment of MI, IRI, and HF are highlighted, along with potential directions for future research.

The influence of habitual tooth brushing frequency on individuals diagnosed with coronary artery disease

Coronary artery disease (CAD) is a prevalent and high-mortality condition globally. The awareness regarding adequate oral care in China was insufficient. This study investigates the outcomes of CAD patients in southwest China based on their tooth brushing frequency. A total of 841 CAD patients were selected from a cohort of 32,709 residents. Over a four-year follow-up period, the incidence of three-point major adverse cardiovascular events (3P-MACEs) was evaluated. The results indicated that the hazard ratios (HR) with 95% confidence intervals (CIs) for 3P-MACEs among the three groups of tooth brushing frequency (twice, once, and thrice daily) were: reference, 1.61 (1.09-2.37) (p = 0.017), and 0.49 (0.15-1.62) (p = 0.241). Patients who brushed their teeth only once a day had a 1.71 (1.18-2.46) times higher risk compared to those who brushed twice or more daily (p = 0.004). In conclusion, insufficient tooth brushing frequency appears to be associated with a higher risk of adverse outcomes among CAD patients.

Symphony of crossfire: Aneurysm, dual vessel occlusion, and lymphoma's hypercoagulable crescendo a case report

Occult asymptomatic myocardial infarction in patients with malignancy (lymphoma), advanced age, and multiple comorbidities may present atypically, complicating the diagnosis of presumed recurrent infarction. We present a highly complex case of a 66-year-old male with lymphoma and multiple comorbidities who collapsed with diffuse ST-segment elevation on electrocardiography (ECG). The diagnostic challenge required concurrent percutaneous coronary intervention (PCI) and echocardiography to identify the thrombotic occlusions in two coronary vessels. Empirical placement of stents in the right coronary artery and left circumflex artery resolved the acute occlusions, while retrograde imaging revealed a previously undiagnosed anteroapical left ventricular aneurysm. This case underscores the importance of integrating multimodal imaging in oncological patients with atypical cardiovascular presentations.

Myocardial ischemia in nonobstructive coronary arteries: A review of diagnostic dilemmas, current perspectives, and emerging therapeutic innovations

Myocardial infarction with nonobstructive coronary arteries is a unique presentation of acute coronary syndrome occurring in patients without significant coronary artery disease. Its pathophysiology involves atherosclerotic and nonatherosclerotic mechanisms such as plaque erosion, coronary microvascular dysfunction, vasospasm, spontaneous coronary artery dissection, autoimmune and inflammatory diseases, and myocardial oxygen supply-demand imbalance. A systematic approach to diagnosis is needed due to the diverse range of underlying causes. Cardiac troponins confirm the myocardial injury and coronary angiography rules out significant obstruction. Cardiac magnetic resonance imaging differentiates ischemic from nonischemic causes, and additional investigations, such as intravascular ultrasound, optical coherence tomography, and provocative testing, play a role in identifying the etiology to guide management strategies. Atherosclerotic cases require antiplatelet therapy and statins, vasospastic cases respond to calcium channel blockers, spontaneous coronary artery dissection is typically managed conservatively, and coronary microvascular dysfunction may require vasodilators. Lifestyle modifications and cardiac rehabilitation are essential for improving outcomes. The prognosis of patients experiencing recurrent events despite treatment is uncertain, but long-term outcomes depend on the etiology, highlighting the need for personalized management. Future research should focus on refining diagnostic protocols and identifying optimal therapeutic strategies. Randomized controlled trials are necessary to establish evidence-based treatments for different subtypes of myocardial infarction with nonobstructive coronary arteries.

Comparison of right ventricular function and clinical outcomes in type 2 diabetes patients with and without obstructive coronary artery disease: insights from a CMR study

BACKGROUND

Obstructive coronary artery disease (OCAD) marks a high-risk group within patients with type 2 diabetes mellitus (T2DM), underscoring the need for tailored prevention and management strategies. However, limited data exist on right ventricular (RV) function and clinical outcomes in T2DM patients with versus without OCAD. This study aimed to investigate the differences in RV function and clinical outcomes between these two groups.

METHODS

The study included 246 T2DM patients {141 patients without OCAD [T2DM(OCAD-)] and 105 with [T2DM(OCAD+)]} and 85 control subjects. Cardiovascular magnetic resonance were utilized to assess RV structure, function, and global myocardial strain [including peak strain (PS), peak systolic (PSSR) and diastolic strain rate (PDSR) in longitudinal, circumferential, and radial directions]. The endpoints, which included all-cause mortality, heart failure hospitalization, and overall composite outcome, were evaluated over a median follow-up period of 5.7 (3.1, 6.7) years. We used linear regression to identify determinants of impaired RV myocardial strain and Cox proportional hazards models to evaluate their associations with clinical outcomes.

RESULTS

RV global circumferential PS (GCPS), longitudinal PS (GLPS) and PSSR (PSSR-L) decreased progressively from control subjects to T2DM(OCAD-) patients, and further to T2DM(OCAD+) patients (all P < 0.05). The presence of OCAD was significantly correlated with impaired GRPS (β = - 0.186), GCPS (β = - 0.121), GLPS (β = - 0.153), PSSR-L (β = - 0.165), and PDSR-R (β = - 0.133) in the context of T2DM. Multivariable Cox regression analysis identified OCAD as an independent predictor of future endpoints, with T2DM (OCAD+) patients showing a 1.91-fold increased risk compared to T2DM (OCAD-) patients (hazard ratio: 1.91; 95% confidence interval: 1.06-3.44; P = 0.031).

CONCLUSIONS

T2DM patients with OCAD showed distinct RV functional impairments and worse long-term outcomes compared to those without OCAD, including more severe RV systolic and diastolic dysfunction and a significantly higher risk of adverse clinical outcomes.

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.

Data-independent Acquisition Proteomics Identifies Plasma Prostaglandin-H2D-isomerase as an Early Diagnostic Biomarker for STEMI and NSTEMI

Myocardial infarction (MI) including ST-elevated MI (STEMI) and non-ST-elevated MI (NSTEMI), remains a leading cause of death worldwide. This study aimed to identify the early diagnostic biomarkers for STEMI and NSTEMI. Plasma samples from 386 patients was classified into four groups: control (CON) (n=62), unstable angina (UA) (n=62), STEMI (n=182), and NSTEMI (n=80). The protein profiles were analyzed using data-independent acquisition (DIA)-based proteomics to identify differentially abundant proteins (DAPs) followed by bioinformatics analysis and ELISA validation. In STEMI, 93 DAPs were detected. Among the selected DAPs that were further validated in a new cohort of patients, prostaglandin-H2 D-isomerase (PTGDS) was elevated at the earliest onset time of STEMI (T1, 1.45h (95%CI: 1.16-1.73)) or NSTEMI (T1, 1.48h (95%CI: 0.97-1.98)) while the current biomarkers (hs-TnI, Myo, CKMB, and BNP) remained within normal ranges. The analysis of diagnostic indices for plasma PTGDS demonstrated a sensitivity of 63.95% and specificity of 65.38% in STEMI, 70% and 71.15% in NSTEMI. Moreover, AUC was 0.61 (95%CI: 0.53-0.69) in STEMI and 0.78 (95%CI: 0.70-0.86) in NSTEMI. The present study demonstrates that in MI patients, plasma PTGDS increases at an earlier stage of onset time than the current biomarkers with similar sensitivity and specificity. Therefore, PTGDS has high potential to be developed as an early diagnostic biomarker. In particular, PTGDS might be of greater clinical significance for patients suspected for NSTEMI, for which biomarker could be more effective in identifying high-risk patients suffering from MI at early stage.

Effectiveness of hypotension prediction index software in reducing intraoperative hypotension in prolonged prone-position spine surgery: a single-center clinical trial

Intraoperative hypotension (IOH) is associated with morbidity and mortality. The Hypotension Prediction Index (HPI), a machine learning-based tool, offers the opportunity for a proactive approach by predicting hypotensive events. This single center, single blind randomized clinical trial aimed to evaluate the hypothesis that an HPI software-guided approach to IOH management during prone position spine surgery could reduce its incidence compared to our standard care practices. 85 adult patients undergoing spine fusion surgery in the prone position were enrolled. Patients were randomized with a 1:1 allocation ratio. Participants were blinded to their group allocation. In the intervention group, the HPI software was actively used to guide IOH management. In the control group, HPI software readings were blinded, and standard care was administered. The primary outcome was the comparison of time-weighted average (TWA) of IOH between the two groups. Secondary outcomes included a comparison of the incidence of postoperative in-hospital events related to IOH between groups. 77 patients were included in the final analysis (39 in the intervention group), as 8 patients were excluded due to technical issues. No statistically significant difference was found between the intervention and control groups in the TWA of IOH (0.10 mmHg [0.05, 0.23] vs. 0.15 mmHg [0.09, 0.37], p-value 0.088). However, the total duration of hypotensive events per patient was significantly lower in the intervention group (4 min [0.5, 12.2] vs. 11.2 min [2.6, 20.1]; p-value 0.019). Postoperative complication rates did not differ significantly between the two groups. HPI-guided management did not significantly reduce the TWA of IOH compared to standard care in patients undergoing prone-position spine surgery. Complication rates were similar between the two groups.Clinical Trial Registration: This trial was registered with ClinicalTrials.gov (registration number: NCT05341167).

Prognostic Implications Of High-Sensitivity Cardiac Troponins In Patients With Acute Kidney Injury Without Myocardial Infarction

Elevated and dynamic high-sensitivity cardiac troponin T (hs-cTnT) concentrations are often observed in patients with acute kidney injury (AKI) without myocardial infarction (MI), yet their prognostic implications are unknown. This study investigated associations between hs-cTnT measurements and prognosis in patients with AKI in the emergency department (ED). All first visits to 7 EDs during 2010-2017 by patients without MI fulfilling AKI criteria and ≥1 hs-cTnT measured were included. Logistic and Cox regression analyses were applied to estimate short- and long-term risks of mortality and major adverse cardiovascular events (MACE) according to peak hs-cTnT and relative hs-cTnT change (Δhs-cTnT). A total of 12,136 patients were included. In-hospital- and long-term mortality was 15% and 49% (median follow-up: 3.8 years, IQR: 1.3-6.0). Adjusted in-hospital mortality risk increased with higher peak hs-cTnT, being >8-fold (aOR 8.68, 95% CI: 6.85-11.0) in the highest quintile of hs-cTnT, in whom long-term risk of cardiovascular mortality and MACE was 3-fold (HR: 3.01, 95% CI: 2.74-3.31) and 2-fold (HR: 2.12, 95% CI: 2.00-2.24). Associated risks were elevated already at intermediately elevated hs-cTnT and evident in patients with transient AKI and with normalized eGFR at discharge. Patients with the highest Δhs-cTnT experienced an increased short-term mortality risk, but Δhs-cTnT was not associated with long-term mortality and only weakly associated with the risk of MACE. In conclusion, in patients with AKI but without acute MI, peak hs-cTnT are associated with a worse prognosis in both the short and long term, whereas dynamic hs-cTnT changes may have less prognostic significance.

Effects of SGLT2 Inhibitor in Patients with Diabetes with Newly Diagnosed Acute Myocardial Infarction: A Multicenter Prospective Cohort Study

PURPOSE

The purpose of the current study is to evaluate the role of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in the treatment of patients with diabetes with newly diagnosed acute myocardial infarction (AMI).

METHODS

This multicenter, prospective, cohort study included 1161 patients with diabetes with newly diagnosed AMI. The primary endpoint events included rehospitalization for heart failure (HF) and major adverse cardiovascular events (MACEs). The secondary endpoint events were recurrent MI and cardiac death.

RESULTS

Patients were categorized into the SGLT2i group and the non-SGLT2i group. During a median follow-up of 1.8 (1.5-2.3) years, the risk of hospitalization for HF (HR 0.58; 95% CI 0.36-0.94; P = 0.026) and MACEs (HR 0.59; 95% CI 0.40-0.86; P = 0.006) were lower in the SGLT2i group, with a similar trend observed for cardiac death (HR 0.51; 95% CI 0.27-0.99; P = 0.046). SGLT2i appears to be a better choice for all such patients. However, our research further found the above trends were observed mainly in the LVEF < 50% subgroup. In addition, our study also revealed novel findings that the protective effect of SGLT2i was not altered by baseline levels of HbA1c in these patients, nor by different SGLT2i medications.

CONCLUSION

The outcomes of the current investigation suggest that SGLT2i is preferred as a hypoglycemic and cardiovascular protective drug for patients with diabetes with newly diagnosed AMI. It could improve cardiovascular outcomes, reducing the risk of rehospitalization for HF and MACEs, particularly in patients with reduced LVEF.

TRIAL REGISTRATION

Role of SGLT2I in Patients with Myocardial Infarction, NCT06245980. https://clinicaltrials.gov/ct2/show/NCT06245980 . Retrospectively registered.

Right Ventricular Strain as a Key Feature in Interpretable Machine Learning for Identification of Takotsubo Syndrome: A Multicenter CMR-based Study

RATIONALE AND OBJECTIVES

To develop an interpretable machine learning (ML) model based on cardiac magnetic resonance (CMR) multimodal parameters and clinical data to discriminate Takotsubo syndrome (TTS), acute myocardial infarction (AMI), and acute myocarditis (AM), and to further assess the diagnostic value of right ventricular (RV) strain in TTS.

MATERIALS AND METHODS

This study analyzed CMR and clinical data of 130 patients from three centers. Key features were selected using least absolute shrinkage and selection operator regression and random forest. Data were split into a training cohort and an internal testing cohort (ITC) in the ratio 7:3, with overfitting avoided using leave-one-out cross-validation and bootstrap methods. Nine ML models were evaluated using standard performance metrics, with Shapley additive explanations (SHAP) analysis used for model interpretation.

RESULTS

A total of 11 key features were identified. The extreme gradient boosting model showed the best performance, with an area under the curve (AUC) value of 0.94 (95% CI: 0.85-0.97) in the ITC. Right ventricular basal circumferential strain (RVCS-basal) was the most important feature for identifying TTS. Its absolute value was significantly higher in TTS patients than in AMI and AM patients (-9.93%, -5.21%, and -6.18%, respectively, p < 0.001), with values above -6.55% contributing to a diagnosis of TTS.

CONCLUSION

This study developed an interpretable ternary classification ML model for identifying TTS and used SHAP analysis to elucidate the significant value of RVCS-basal in TTS diagnosis. An online calculator (https://lsszxyy.shinyapps.io/XGboost/) based on this model was developed to provide immediate decision support for clinical use.

Artificial intelligence applied to electrocardiogram to rule out acute myocardial infarction: the ROMIAE multicentre study

BACKGROUND AND AIMS

Emerging evidence supports artificial intelligence-enhanced electrocardiogram (AI-ECG) for detecting acute myocardial infarction (AMI), but real-world validation is needed. The aim of this study was to evaluate the performance of AI-ECG in detecting AMI in the emergency department (ED).

METHODS

The Rule-Out acute Myocardial Infarction using Artificial intelligence Electrocardiogram analysis (ROMIAE) study is a prospective cohort study conducted in the Republic of Korea from March 2022 to October 2023, involving 18 university-level teaching hospitals. Adult patients presenting to the ED within 24 h of symptom onset concerning for AMI were assessed. Exposure included AI-ECG score, HEART score, GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. The primary outcome was diagnosis of AMI during index admission, and the secondary outcome was 30 day major adverse cardiovascular event (MACE).

RESULTS

The study population comprised 8493 adults, of whom 1586 (18.6%) were diagnosed with AMI. The area under the receiver operating characteristic curve for AI-ECG was 0.878 (95% CI, 0.868-0.888), comparable with the HEART score (0.877; 95% CI, 0.869-0.886) and superior to the GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. For predicting 30 day MACE, AI-ECG (area under the receiver operating characteristic, 0.866; 95% CI, 0.856-0.877) performed comparably with the HEART score (0.858; 95% CI, 0.848-0.868). The integration of the AI-ECG improved risk stratification and AMI discrimination, with a net reclassification improvement of 19.6% (95% CI, 17.38-21.89) and a C-index of 0.926 (95% CI, 0.919-0.933), compared with the HEART score alone.

CONCLUSIONS

In this multicentre prospective study, the AI-ECG demonstrated diagnostic accuracy and predictive power for AMI and 30 day MACE, which was similar to or better than that of traditional risk stratification methods and ED physicians.

Performance of the GRACE and the ACTION risk model in the prediction of in-hospital mortality: external validation, model revision and updating in the Thai Percutaneous Coronary Intervention Registry

BACKGROUND

External validation is crucial before implementing a risk score model in clinical practice. This study examined the performance of Global Registry of Acute Coronary Events (GRACE) and Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With The Guidelines (GWTG) (ACTION Registry-GWTG) Risk Score (AR-G RS) using the Thai Percutaneous Coronary Intervention Registry (TPCIR).

METHODS

Included in this study were 11 455 patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) between November 2015 and May 2018. GRACE and AR-G RS models were externally validated, revised and updated using discrimination (C-statistic score) and calibration (Hosmer-Lemeshow (HL) indexes). Clinical predictors were selected stepwise from the multivariate analysis to evaluate the performance of each risk score in the revised and updated model.

RESULTS

In-hospital mortality was 4.4%. GRACE and AR-G RS demonstrated good discrimination for in-hospital mortality (C-statistics 0.8957 and 0.8823, respectively) with optimal calibration (HL, p=0.036 and 0.006, respectively) and penalty rates of 0.005 and 0.006, respectively. The updated model significantly improved the discrimination performance compared with the original GRACE and AR-G RS models, with a C-statistic of 0.9118 and a penalty of 0.006.

CONCLUSION

GRACE and AR-G RS maintained a good performance in TPCIR. Based on routine PCI practice, we demonstrated that the updated model could improve the accuracy of GRACE and AR-G RS in predicting in-hospital mortality among patients with ACS who underwent PCI.

Enhanced prognosis and regional cooperative rescue systems for acute myocardial infarction: insights from chest pain centers in Ningxia, China

Chest Pain Centers (CPC) demonstrated improved outcomes for patients with acute myocardial infarction (AMI) globally. However, the long-term impact of CPC establishment in economically developing areas, such as Ningxia, China, remains unclear. This study aimed to assess the long-term prognosis and efficacy of collaborative regional rescue systems centered on CPC for ST-segment elevation myocardial infarction (STEMI) patients in Ningxia. This retrospective cohort study analyzed 5344 STEMI patients from the Ningxia Myocardial Infarction Registry (2014-2019). Based on CPC establishment, patients were segregated into two groups: pre-CPC (n = 2141) and post-CPC (n = 3203). Kaplan-Meier survival analysis and Cox proportional hazards models were employed to compare the groups and evaluate long-term outcomes, including mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). A total of 5344 acute STEMI patients were included, with 2141 (40.06%) in the pre-CPC group and 3203 (59.94%) in the post-CPC group. In comparison to the pre-CPC group, the post-CPC group exhibited lower all-cause mortality rates at 30 days (4.53% vs. 6.68%, p = 0.001), 1 year (6.24% vs. 9.11%, p = 0.001), and 3 years (8.55% vs. 11.86%, p < 0.001). Additionally, the post-CPC group showed decreased rates of MACCEs at 30 days (7.90% vs. 10.00%, p = 0.008) and 3 years (18.86% vs. 23.12%, p < 0.001). Kaplan-Meier survival analysis yielded similar results. After adjusting for confounding factors using COX multivariable regression, the CPC establishment was found to be a protective factor for all-cause mortality and MACCEs within 30 days (MACCEs: HR = 0.72, 95%CI 0.59-0.88, p = 0.005; all-cause mortality: HR = 0.59, 95%CI 0.46-0.77, p < 0.001), 1 year (MACCEs events: HR = 0.80, 95%CI 0.68-0.94, p = 0.006; all-cause mortality: HR = 0.59, 95%CI 0.44-0.69, p < 0.001), and 3 years (MACCEs: HR = 0.71, 95%CI 0.62-0.81, p < 0.001; all-cause mortality: HR = 0.55, 95%CI 0.46-0.67, p < 0.001). The establishment of Chest Pain Centers and implementation of regional cooperative rescue systems significantly improved the long-term prognosis of STEMI patients in Ningxia. These findings underscore the importance of developing CPC in underdeveloped regions to enhance cardiovascular emergency care and reduce mortality and morbidity associated with acute myocardial infarction.

Targeting Ischemic Myocardium: Nanoparticles Loaded with Long Noncoding RNA AK156373 siRNA Alleviate Myocardial Infarction

Despite advancements in the development of targeted approaches for the treatment of myocardial infarction (MI), there is a continuing need for improvements in treatment approaches due to the high mortality and prevalence of MI. The identification of specific therapeutic targets and the development of efficient delivery systems are essential. In this study, a nanoparticle delivery system targeting necrotic cardiomyocytes was engineered. This system effectively downregulated long noncoding RNA (lncRNA) AK156373 and reduced oxidative stress and inflammation during MI progression. Mechanistically, silencing lncRNA AK156373 enhanced the viability and mitochondrial function of hypoxic cardiomyocytes and lowered intracellular inflammatory cytokine levels and reactive oxygen species (ROS) production. In vivo, cardiac-specific lncRNA AK15673 knockout mice were generated (AK156373flox/flox, Myh6-Cre mice), and lncRNA AK156373 knockout obviously reduced the infarct size, collagen fiber deposition, and ischemia severity in MI mice, leading to improved cardiac function. Additionally, lncRNA AK156373 modulated miR-204-5p to regulate C-X-C motif chemokine receptor 2 (CXCR2) protein expression via the competing endogenous RNA (ceRNA) mechanism, exacerbating myocardial damage and accelerating MI progression. Subsequently, nanoparticles loaded with lncRNA AK156373 siRNA were synthesized. The nanoparticles significantly inhibited MI progression by modulating the miR-204-5p/CXCR2 axis to reduce oxidative stress and inflammation. Overall, these findings establish a key regulatory role for lncRNA AK156373 in MI progression and present a direct preclinical approach for MI therapy.

Real-World Clinical Impact of High-Sensitivity Troponin for Chest Pain Evaluation in the Emergency Department

BACKGROUND

High-sensitivity cardiac troponin (hs-cTnI) assays can quantify troponin concentrations with low limits of detection, potentially expediting and enhancing myocardial infarction diagnoses. This study investigates the real-world impact of hs-cTnI implementation on operational metrics and downstream cardiac services in patients presenting to the emergency department with chest pain.

METHODS AND RESULTS

We conducted a retrospective study of patients who presented to 3 emergency departments for chest pain and in whom ≥1 troponin concentration was measured. We compared outcomes from January 2021 to March 2022 (conventional cardiac troponin I [cTnI]) against outcomes from April 2022 to March 2023 (post-hs-cTnI implementation). The primary outcome was hospital length of stay. The study included 32 076 emergency department patient-visits (17 267 with cTnI, 14 809 with hs-cTnI). Implementation of hs-cTnI was associated with shorter median total length of stay (6.6 versus 6.0 hours, P [lt]0.001), shorter emergency department length of stay (5.5 versus 5.4 hours, P=0.039), and lower admission rates (32.6% versus 38.2%, adjusted odds ratio [aOR], 0.74 [95% CI, 0.69-0.79]; P [lt]0.0001). Hs-cTnI was also associated with lower odds of cardiology consultation (aOR, 0.91 [95% CI, 0.86-0.97]; P=0.004), echocardiography (aOR, 0.86 [95% CI, 0.82-0.91]; P [lt]0.001), stress tests (aOR, 0.74 [95% CI, 0.67-0.81]; P [lt]0.001), and invasive coronary angiography (aOR, 0.77 [95% CI, 0.70-0.83]; P [lt]0.001), but greater odds of computed tomography coronary angiography (aOR, 1.26 [95% CI, 1.01-1.56]; P=0.03) and percutaneous coronary intervention (aOR, 1.40 [95% CI, 1.20-1.63]; P [lt] 0.001) during the index encounter.

CONCLUSION

Implementation of the hs-cTnI assay was associated with reduced hospital admissions, shorter length of stay, and decreases in most downstream cardiac testing.

Sedentary Behavior and Cardiac Events and Mortality After Hospitalization for Acute Coronary Syndrome Symptoms: A Prospective Study

BACKGROUND

Patients hospitalized with symptoms of acute coronary syndrome remain at high risk for adverse events postdischarge, highlighting a need for modifiable therapeutic targets. The role of sedentary behavior in this risk and the potential benefits of replacing sedentary time with other activities remain unclear. This study examined the association between sedentary behavior and 1-year cardiac events/mortality among patients evaluated for acute coronary syndrome and estimated risk reductions from substituting alternative activities for sedentary time.

METHODS

Patients presenting to the emergency department of a New York City hospital with acute coronary syndrome symptoms were enrolled from 2016 to 2020. Sedentary behavior, light-intensity physical activity, moderate-to-vigorous physical activity, and sleep were measured via a wrist-mounted accelerometer worn for 30 days postdischarge. Cardiac events and all-cause mortality were ascertained 1 year postdischarge via participant contact, electronic health records, and the Social Security Death Index. Participants were categorized into tertiles of sedentary time, with tertile 1 representing the lowest sedentary time and tertile 3 the highest. Cox proportional hazards regression models were used to evaluate associations.

RESULTS

Of 609 participants (mean age, 62 years; 52% male, 58% Hispanic), 8.2% experienced a cardiac event or died within 1 year. Mean sedentary time was 13.6 h/d (SD, 1.8). Sedentary time was associated with increased risk of cardiac events/mortality (tertile 2: hazard ratio [HR], 0.95 [95% CI, 0.37-2.40]; tertile 3: HR, 2.58 [95% CI, 1.11-6.03]; Ptrend=0.011). In isotemporal substitution analyses, replacing 30 minutes of sedentary time (referent) with sleep (HR, 0.86 [95% CI, 0.78-0.95]), light-intensity physical activity (HR, 0.49 [95% CI, 0.32-0.75]), or moderate-to-vigorous physical activity (HR, 0.39 [95% CI, 0.16-0.96]) was associated with lower cardiac event/mortality risk.

CONCLUSIONS

Sedentary behavior was associated with increased risk of 1-year cardiac events/mortality among patients evaluated for acute coronary syndrome. Replacing sedentary behavior with sleep, light-intensity physical activity, or moderate-to-vigorous physical activity was associated with lower risk. These findings highlight reducing sedentary behavior as a potential strategy to improve posthospitalization outcomes.

Lack of Change in the Incidence of Unstable Angina after Transition to High-Sensitivity Cardiac Troponin T

OBJECTIVE

This study evaluated the impact of high-sensitivity cardiac troponin T (hs-cTnT) implementation on the incidence and cardiac evaluations of patients with unstable angina.

METHODS

Retrospective US cohort study of emergency department patients evaluated with troponin (cTn) measurements transition from 4th generation cTnT (6 months pre-implementation) to 5th generation hs-cTnT assay (6 months post-implementation).

RESULTS

Only 39 patients were diagnosed with unstable angina; 18 with 4th cTnT and 21 with 5th hs-cTnT. With 4th generation cTnT assay almost all (94.4%) had values < 99th URL whereas 33.3% had at least one value > 99th (mean = 25ng/L and peak = 26 ng/L) with hs-cTnT. The latter had underlying structural heart disease. There were no significant differences in cardiac evaluations with echocardiography, stress testing or invasive coronary angiography (between groups.

CONCLUSIONS

The incidence of unstable angina did not change with transition to 5th generation hs-cTnT assay. However, stable hs-cTnT increases were more common likely due to underlying structural heart disease. There were no changes in frequency of cardiac evaluations.

Evaluation and comparison of inflammatory and insulin resistance indicators on recurrent cardiovascular events in patients undergoing percutaneous coronary intervention: a single center retrospective observational study

BACKGROUND

The aim of this study was to evaluate and compare the usefulness of the C-reactive protein (CRP)-triglyceride glucose (TyG) index (CTI) and other insulin resistance (IR) or inflammatory indexes for predicting recurrent cardiovascular events in percutaneous coronary intervention (PCI)-treated patients. In addition, the mediating effects of systemic inflammation, represented by high-sensitive CRP (hs-CRP), on TyG index-associated adverse cardiovascular events across different subgroups were also evaluated.

METHODS

The formula for calculating the CTI was 0.412 × ln [high-sensitivity CRP (mg/L)] + ln [triglyceride (mg/dl) × fasting glucose (mg/dl)/2]. The primary endpoint was defined as the incidence of major adverse cerebrovascular and cardiovascular events (MACCEs), including cardiovascular death, nonfatal acute myocardial infarction (AMI), nonfatal ischemic stroke and repeat coronary revascularization.

RESULTS

Among the 2383 PCI-treated patients, 413 experienced MACCEs during a median of 34 months follow-up. Correlation analysis showed CTI was significantly associated with cardiometabolic factors. The CTI was the strongest predictor for MACCEs (adjusted HR 1.85, 95% CI 1.44-2.38) among the inflammatory and IR indicators. CTI had an incremental effect on the predictive ability of the prognostic model for MACCEs (NRI: 0.220, p < 0.001; IDI: 0.009, p < 0.001). Subgroup analysis revealed that the prognostic value of the CTI remained significant across all subgroups (all p < 0.05) whereas the predictive abilities of other IR or inflammatory indicators were more or less influenced by the metabolic abnormalities. Finally, mediation analysis revealed that the effects of systemic inflammation on TyG index-associated MACCEs were more prominent in patients with metabolic disorders.

CONCLUSIONS

CTI was a practical indicator for evaluating cardiometabolic diseases. Among the IR and inflammatory indicators, CTI was the most promising index for predicting recurrent cardiovascular risks in PCI-treated patients. TyG index-associated cardiovascular risks were partially mediated by systemic inflammation in patients with metabolic abnormalities.

AARS2 ameliorates myocardial ischemia via fine-tuning PKM2-mediated metabolism

AARS2, an alanyl-tRNA synthase, is essential for protein translation, but its function in mouse hearts is not fully addressed. Here, we found that cardiomyocyte-specific deletion of mouse AARS2 exhibited evident cardiomyopathy with impaired cardiac function, notable cardiac fibrosis, and cardiomyocyte apoptosis. Cardiomyocyte-specific AARS2 overexpression in mice improved cardiac function and reduced cardiac fibrosis after myocardial infarction (MI), without affecting cardiomyocyte proliferation and coronary angiogenesis. Mechanistically, AARS2 overexpression suppressed cardiomyocyte apoptosis and mitochondrial reactive oxide species production, and changed cellular metabolism from oxidative phosphorylation toward glycolysis in cardiomyocytes, thus leading to cardiomyocyte survival from ischemia and hypoxia stress. Ribo-Seq revealed that Aars2 overexpression increased pyruvate kinase M2 (PKM2) protein translation and the ratio of PKM2 dimers to tetramers that promote glycolysis. Additionally, PKM2 activator TEPP-46 reversed cardiomyocyte apoptosis and cardiac fibrosis caused by AARS2 deficiency. Thus, this study demonstrates that AARS2 plays an essential role in protecting cardiomyocytes from ischemic pressure via fine-tuning PKM2-mediated energy metabolism, and presents a novel cardiac protective AARS2-PKM2 signaling during the pathogenesis of MI.

Relationship and prognostic value of the triglyceride-glucose index and optical coherence tomography-derived physiological index in patients with acute coronary syndrome

The optical flow ratio (OFR), derived from optical coherence tomography (OCT) images, serves as a physiological index, while the Triglyceride-Glucose Index (TyG) is an alternative measure of insulin resistance. Both indices are positively correlated with poor prognosis in patients with acute coronary syndrome (ACS), but the relationship between the TyG index, OFR, and their prognostic value remains unclear. We included ACS patients who underwent OCT between January 1, 2021, and March 31, 2023. The TyG index was calculated as Ln[fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2]. Patients were grouped into three categories (T1, T2, and T3) based on TyG tertiles. The primary endpoint was major adverse cardiovascular events (MACE). In our analysis, the T3 group showed a significantly higher incidence of MACE (P < 0.05), with a progressive decrease in vessel-level OFR observed as the TyG index increased, demonstrating a linear correlation (r = - 0.0146, P < 0.001). The restricted cubic splines (RCS) model revealed a nonlinear relationship between the TyG index and the likelihood of MACE (P for nonlinear < 0.021). Additionally, the cumulative incidence of MACE was significantly higher in patients with a higher TyG index (all Log-rank P < 0.001).These findings suggest a nonlinear relationship between the TyG index and MACE, and a linear association between the TyG index and vessel-level OFR. The combination of the TyG index and OFR significantly improved discriminatory ability (c-index: 0.720 vs. 0.757; P < 0.001) and reclassification ability (net reclassification index [NRI]: 0.373; integrated discrimination improvement [IDI]: 0.031; P < 0.0001) for predicting MACE compared to vessel-level OFR alone. This combination effectively identifies high-risk ACS patients.

Bioinformatics analysis of JUP in patients with acute myocardial infarction and its potential application in clinical prognostic evaluation

Background

Junctional Plakoglobin (JUP) is a critical protein involved in intercellular junctions, playing a significant role in maintaining the structure and function of myocardial cells. However, the expression of JUP in acute myocardial infarction (AMI) and its potential applications in prognostic evaluation of patients remain underexplored. This study aims to investigate the expression levels of JUP in AMI patients and its association with clinical prognosis through bioinformatics analysis.

Methods

A total of 164 patients with acute myocardial infarction admitted from January 2022 to January 2024 were selected as the study subjects. They were divided into an MACE group and a non-MACE group based on the occurrence of adverse prognostic events. Clinical data and myocardial tissue samples from patients post-percutaneous coronary intervention (PCI) were collected. The expression levels of JUP in myocardial tissue were assessed using quantitative real-time PCR (qPCR), and the functional role of the JUP gene in the prognosis of acute myocardial infarction was analyzed. The impact of JUP expression levels on the prognosis of AMI patients was evaluated using Kaplan-Meier method and Cox Proportional Hazards Model.

Results

The expression level of JUP in the MACE group was significantly lower than that in the Non-MACE group (P < 0.05). The results of the Cox Proportional Hazards Model further indicated that TnI levels (HR = 12.512, 95% CI: 1.622-96.507, P < 0.05), multi-vessel disease (HR = 0.300, 95% CI: 0.108-0.834, P < 0.05), and myocardial JUP levels (HR = 0.234, 95% CI: 0.065-0.846, P < 0.05) were independent predictive factors for post-PCI outcomes in patients with acute myocardial infarction. Kaplan-Meier method revealed a significant association between low JUP expression and adverse prognosis in AMI patients (P < 0.05). ROC curve showed that multi-vessel disease (AUC = 0.6548, Sensitivity = 64.29%, Specificity = 66.67%), TnI (AUC = 0.8316, Sensitivity = 40.71%, Specificity = 91.67%), and myocardial JUP (AUC = 0.8299, Sensitivity = 75.00%, Specificity = 84.29%) could all predict the risk of major adverse cardiac events (MACE) after PCI in AMI patients.

Conclusion

The expression level of JUP is decreased in patients with acute myocardial infarction and is closely associated with adverse prognostic outcomes. JUP may serve as a potential biomarker for assessing prognosis in AMI patients, providing new insights for the development of personalized treatment strategies.

Comparison of clinical outcomes in patients with ST-segment elevation myocardial infarction among preserved, mid-range, and reduced ejection fraction

The impact of mid-range (mr) ejection fraction (EF) on long-term clinical outcomes has been reported in patients with heart failure but remains unclear in patients with ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to compare the long-term clinical outcomes among STEMI patients with preserved EF (pEF), mrEF, and reduced EF (rEF), and to evaluate the significance of mrEF as a prognostic factor for patients with STEMI. We included 705 patients with STEMI and divided them into rEF group (n = 155), mrEF group (n = 155), and pEF group (n = 395) according to the pre-discharge EF. The primary endpoint was the major adverse cardiovascular events (MACE), which were defined as the composite of all-cause death, re-admission for heart failure, and non-fatal myocardial infarction (MI). The median follow-up duration was 906 days (Q1:349.5-Q3:1479). The Kaplan-Meier curves showed that MACE and re-admission for heart failure were more frequently observed in the rEF group, followed by the mrEF group, and least in the pEF group (p < 0.001). The multivariate Cox hazard analysis revealed that mrEF as well as rEF were significantly associated with MACE after controlling for confounding factors [rEF: hazard ratio (HR) 2.333, 95% confidence interval (CI) 1.350-4.034, p = 0.002, mrEF:HR1.852, 95%CI 1.139-3.010, p = 0.013]. Mid-range EF as well as rEF was significantly associated with MACE and re-admission for heart failure in patients with STEMI. Our results suggest that mrEF is an important prognostic factor in patients with STEMI.

Integrating the Interleukins in the Biomarker Panel for the Diagnosis and Prognosis of Patients with Acute Coronary Syndromes: Unraveling a Multifaceted Conundrum

Background and Objectives: Despite the latest advancements in interventional procedures and pharmacological therapy, the incidence of heart failure and death rate following an acute myocardial remain unacceptably high. This study was designed in response to the limited and conflicting literature data regarding the diagnostic and prognostic role of modern inflammatory biomarkers in patients with coronary artery disease. Materials and Methods: We conducted a case-control, prospective observational study. A total of 145 patients were analyzed, of whom 105 patients had an acute coronary syndrome diagnosis and represented the study group, while 40 patients with a chronic coronary syndrome diagnosis represented the control group. This study investigates the diagnostic and prognostic role of the interleukin 1β (IL-1β), interleukin 6 (IL-6), interleukin 10 (IL-10), Growth differentiation factor 15 (GDF-15), and classic biomarkers in patients with ischemic coronary heart disease. Results: IL-1β exhibited a prognostic role, being significantly correlated with a left ventricular ejection fraction below 30%. GDF-15 plays a dual role, as a cardio-inflammatory biomarker, being significantly correlated with both N-terminal pro-brain natriuretic peptide (NT-proBNP), and IL-1β, IL-6, and CRP. At the same time, GDF-15 represents a surrogate marker for renal dysfunction. According to the ROC analysis, patients at high mortality risk can be identified with adequate accuracy by cardiac troponin, GDF-15, and IL-10, in addition to NT-proBNP. Logistic regression models confirmed NT-proBNP and IL-10 as mortality predictors. Conclusions: IL-1β stands out for its significant prognostic role, while IL-6 did not demonstrate a diagnostic or prognostic role in acute myocardial infarction patients. IL-10 demonstrated superior predictive value in terms of fatal prognosis compared with the other modern biomarkers. GDF-15 is representative of a multivalent biomarker involved in inflammation, heart failure, and renal dysfunction.

Prognostic Value of Angiography-Derived Index of Microcirculatory Resistance in Patients with Diabetes and ST-Segment Elevation Myocardial Infarction

BACKGROUND

The occurrence of coronary microvascular dysfunction (CMD) after primary PCI in patients with diabetes mellitus (DM) and ST-elevation myocardial infarction (STEMI), and its impact on prognosis remains elusive.

METHODS

This single-centre retrospective observational study included 293 patients diagnosed with DM and STEMI. The coronary-angiography-derived index of microvascular resistance (caIMR) was calculated using the measurement software FlashAngio (Suzhou Rainmed Medical Technology Company, Ltd, Suzhou, Jiangsu, China), whereas cardiac magnetic resonance parameters were quantified using the postprocessing software Cvi42. CMD was defined as caIMR ≥ 25 U. The primary endpoint was major adverse cardiac events (MACE), defined as all-cause mortality, nonfatal myocardial infarction, ischemia-driven revascularization, and heart failure.

RESULTS

MACE occurred in 86 patients (29.4%) during a median follow-up of 31 months. A significant correlation was identified between caIMR and both microvascular obstruction (MVO) (R = 0.61, P < 0.001) and infarct size (IS) (R = 0.39, P < 0.001). Furthermore, caIMR ≥ 25 was identified as an independent risk factor for MACE (hazard ratio [HR], 2.99; 95% confidence interval [CI], 1.78-5.03; P < 0.001). In addition, the integration of caIMR into risk modelling significantly improved prediction of MACE (net reclassification improvement 0.264, P < 0.001; integrated discrimination improvement 0.060, P < 0.001). Finally, the Kaplan-Meier survival curves displayed that patients with caIMR ≥ 25 were at a higher risk of MACE (log-rank P < 0.001).

CONCLUSIONS

The caIMR demonstrated a satisfactory correlation with CMR-determined MVO and IS in patients with DM and STEMI. Elevated caIMR was independently linked to a higher risk of MACE in patients with diabetes and STEMI post-PCI, serving as an effective predictor for MACE.

CLINICAL TRIAL REGISTRATION

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Triglyceride-glucose index predicts ventricular aneurysm formation in acute ST-segment elevation myocardial infarction

Background

The triglyceride-glucose (TyG) index has been confirmed to be a predictor of cardiovascular diseases. The present study aimed to assess the predictive value of TyG index for left ventricular aneurysm (LVA) formation and prognosis in patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

Methods

This prospective study included 991 patients with acute STEMI who underwent primary PCI. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were used to assess the predictive value of TyG index for LVA formation. Prognosis analysis was performed with cox proportional hazard regression.

Results

The prevalence of LVA was 14.4%. A higher TyG index was associated with a greater incidence of LVA (23.1% vs. 11.8%, P< 0.001). The TyG index was also higher in the LVA group than in the non-LVA group (9.4 ± 0.9 vs. 9.0 ± 0.8, P<0.001). Multivariable logistic regression analysis revealed that the TyG index was independently associated with the risk of LVA [odds ratio (OR)= 2.4, 95% confidence interval (CI)= 1.51-3.82, P< 0.001]. The predictive value of the TyG index remained significant even after cross-validation by dividing the study population into a training set (OR= 2.32, 95% CI= 1.24-4.35, P= 0.009) and validation set (OR= 3.19, 95% CI= 1.42-7.19, P= 0.005). Higher TyG index was correlated with increased risk of cardiac death (HR= 2.17, P= 0.04). The maximal length and width of LVA were significantly increased in patients with TyG index ≥ 9.68 compared with < 9.68 (P< 0.001). The discriminant power of TyG index for LVA was 0.742, which was superior to both triglyceride (C statistic= 0.666) and fasting blood glucose (C statistic= 0.613). The combination of TyG index, left ventricular ejection fraction, gensini score, and left anterior descending artery as the culprit vessel could significantly improve the predictive ability (C statistic= 0.908).

Conclusions

A higher TyG index was an independent predictor for LVA formation and increased risk of cardiac death in patients with STEMI who underwent primary PCI.

Associations between periodontal disease and hospitalization outcomes in ST-segment elevation myocardial infarction: Insights from the National Inpatient Sample

BACKGROUND

Periodontal disease (PD) is linked to increased cardiovascular morbidity, but its impact on outcomes in ST-segment elevation myocardial infarction (STEMI) remains understudied. The authors investigated the effect of PD on STEMI outcomes.

METHODS

The authors analyzed STEMI hospitalizations from the 2016-2019 National Inpatient Sample data set, comparing outcomes in patients with and without PD. Primary and secondary outcomes included mortality, mechanical circulatory support, mechanical ventilation, vasopressor use, cardiogenic shock, acute kidney injury, hospital length of stay, and total hospital cost. Multivariable regression adjusted for confounding factors.

RESULTS

Of 2,595,584 STEMI hospitalizations, 0.2% involved patients with an InternationalClassification of Diseases, Tenth Revision, Clinical Modification code for PD. A PD code was associated with higher odds of mechanical circulatory support use (adjusted OR [aOR], 1.57; 95% CI, 1.25 to 1.97), mechanical ventilation (aOR, 1.26; 95% CI, 1.01 to 1.58), cardiogenic shock (aOR, 1.48; 95% CI, 1.20 to 1.83), acute kidney injury (aOR, 1.32; 95% CI, 1.13 to 1.55), longer hospital stays (7.18 vs 4.40 days; P < .001), and higher hospital costs ($141,245 vs $98,152; P < .001). Mortality and vasopressor use were unchanged.

CONCLUSIONS

Among STEMI cases, a concomitant PD code was associated with higher odds of nonfatal adverse events and health care resource use.

PRACTICAL IMPLICATIONS

Recognizing PD as a comorbidity in STEMI may help tailor care strategies, reduce adverse outcomes, and improve resource allocation in clinical practice. Further studies could refine risk-stratification approaches.

All-Cause Mortality Risk in Elderly Patients with Femoral Neck and Intertrochanteric Fractures: A Predictive Model Based on Machine Learning

Introduction

The aim of this study was to identify the influencing factors for all-cause mortality in elderly patients with intertrochanteric and femoral neck fractures and to construct predictive models.

Methods

This study retrospectively collected elderly patients with intertrochanteric fractures and femoral neck fractures who underwent hip fractures surgery in the Third Hospital of Hebei Medical University from January 2020 to December 2022. Cox proportional hazards regression is used to explore the association between fractures type and mortality. Boruta algorithm was used to screen the risk factors related to death. Multivariate logistic regression was used to determine the independent risk factors, and a nomogram prediction model was established. The ROC curve, calibration curve and DCA decision curve were drawn by R language, and the prediction model was established by machine learning algorithm.

Results

Among the 1373 patients. There were 6 variables that remained in the model for intertrochanteric fractures: age (HR 1.048, 95% CI 1.014-1.083, p = 0.006), AMI (HR 4.631, 95% CI 2.190-9.795, P < 0.001), COPD (HR 3.818, 95% CI 1.516-9.614, P = 0.004), CHF (HR 2.743, 95% CI 1.510-4.981, P = 0.001), NOAF (HR 1.748, 95% CI 1.033-2.956, P = 0.037), FBG (HR 1.116, 95% CI 1.026-1.215, P = 0.011). There were 3 variables that remained in the model for femoral neck fractures: age (HR 1.145, 95% CI 1.097-1.196, P < 0.001), HbA1c (HR 1.264, 95% CI 1.088-1.468, P = 0.002), BNP (HR 1.001, 95% CI 1.000-1.002, P = 0.019). The experimental results showed that the model has good identification ability, calibration effect and clinical application value.

Conclusion

Intertrochanteric fractures is an independent risk factor for all-cause mortality in elderly patients with hip fractures. By constructing a prognostic model based on machine learning, the risk factors of mortality in patients with intertrochanteric fractures and femoral neck fractures can be effectively identified, and personalized treatment strategies can be developed.

SHAP analysis and comparative performance of the HEART, HET, and SVEAT scores in 30-day MACE prediction

BACKGROUND

This study aimed to compare the predictive performance of the HEART, HET, and SVEAT scores for 30-day major adverse cardiovascular events (MACE) in patients presenting with acute chest pain in the emergency department (ED).

METHODS

The HEART, HET, and SVEAT scores were retrospectively calculated, and their predictive performance for 30-day MACE was assessed using receiver operating characteristic (ROC) curve analysis, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) analysis. Additionally, SHapley Additive exPlanations (SHAP) analysis was performed to quantify the contribution of each score to MACE prediction.

RESULTS

A total of 1330 patients were included, of whom 167 (12.6 %) experienced 30-day MACE. The HEART score exhibited the highest discriminatory performance (AUROC: 0.872, 95 % CI: 0.853-0.890), followed by the HET score (AUROC: 0.859, 95 % CI: 0.840-0.878). The SVEAT score had significantly lower predictive accuracy (AUROC: 0.823, 95 % CI: 0.802-0.844). Pairwise comparisons showed no statistically significant difference between the HEART and HET scores (p = 0.0787), whereas both HEART (p < 0.001) and HET (p < 0.001) significantly outperformed the SVEAT score. SHAP analysis confirmed that the HEART score contributed the most to MACE prediction.

CONCLUSION

Among the three risk stratification scores assessed, the HEART score demonstrated the highest predictive accuracy for 30-day MACE, followed by the HET score, while the SVEAT score showed lower performance. These findings support the HEART score as a preferred tool for risk stratification in acute chest pain evaluation in the ED.

Development and validation of a risk prediction model for adverse outcomes in patients with suspected coronary artery disease and no significant stenosis on angiography: a retrospective cohort study

OBJECTIVES

To develop and validate a risk prediction model for adverse outcomes in patients with angina with non-obstructive coronary arteries (ANOCA) confirmed by invasive coronary angiography.

DESIGN

Retrospective cohort study.

SETTING

A tertiary cardiovascular care centre in China.

PARTICIPANTS

From 17 816 consecutive patients undergoing coronary angiography for suspected coronary artery disease, 5934 met ANOCA criteria after rigorous exclusion: (1) significant stenosis (≥50% luminal narrowing), (2) established coronary artery disease history, (3) incomplete baseline/follow-up data, (4) non-cardiovascular life-limiting conditions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a composite of all-cause death, non-fatal myocardial infarction (MI), stroke and repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The secondary outcome was major adverse cardiovascular events, defined as cardiac-related death, non-fatal MI, non-fatal stroke, repeat PCI and CABG.

RESULTS

The derivation cohort (n=4452) and validation cohort (n=1482) demonstrated comparable baseline characteristics. The nomogram incorporated eight prognosticators: age, haemoglobin, serum urea, serum sodium, alanine aminotransferase/aspartate aminotransferase ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), left atrial diameter and left ventricular ejection fraction. The prediction model showed robust discrimination for primary endpoint, achieving area under the curve (AUC) values of 0.82 (1 year), 0.90 (2 years) and 0.89 (3 years) in the derivation cohort, with corresponding validation cohort AUCs of 0.75, 0.77 and 0.78. Calibration plots revealed close alignment between predicted and actual event-free survival probabilities in both cohorts. Risk stratification identified two distinct prognostic groups with significant survival differences (log-rank p<0.0001).

CONCLUSIONS

This predictive model integrates routinely available clinical parameters to accurately stratify mortality and cardiovascular risk in ANOCA patients, providing a potential valuable decision-support tool for personalised therapeutic strategies.

The Association Between Peripheral Arterial Disease and Long-Term Bleeding Events in Patients with Acute Myocardial Infarction

Background: Peripheral arterial disease (PAD) is associated with cardiovascular events in patients with acute myocardial infarction (AMI). However, there are limited reports regarding the association between PAD and bleeding events. In this study, we aimed to evaluate whether PAD is independently associated with an increased risk of major bleeding events, in addition to major adverse cardiovascular events (MACEs), in patients with AMI undergoing percutaneous coronary intervention (PCI). Methods: We included 1391 patients with AMI who underwent PCI and divided them into the PAD group (n = 210) and the non-PAD group (n = 1181). The primary endpoint was total bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The secondary endpoint was MACE, defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure. Results: The median follow-up duration was 653 days. Total bleeding events were more frequently observed in the PAD group than in the non-PAD group (24.8% vs. 11.3%, p < 0.001). The multivariate Cox hazard analysis confirmed that PAD was significantly associated with total bleeding events (HR 1.509; 95% CI 1.056-2.156, p = 0.024) as well as MACEs (HR 2.152; 95% CI 1.510-3.066, p < 0.001) after controlling for confounding factors. Conclusions: PAD was independently associated with a higher risk of major bleeding and cardiovascular events in patients with AMI undergoing PCI. These findings suggest that PAD should be recognized as a critical factor in risk stratification for AMI and may affect individualized bleeding risk management strategies in patients with AMI.

A nomogram risk prediction model for ischemic mitral regurgitation after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

AIM

This study developed a nomogram to predict the risk of ischemic mitral regurgitation (IMR) after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) patients and evaluate their long-term prognosis.

METHODS

Data from 342 STEMI patients were collected. Logistic regression identified independent risk factors for IMR during hospitalization, while Cox regression assessed risk factors during follow-up. The nomogram was developed based on these factors. ROC evaluated its predictive value, and decision curve analysis/clinical impact curves assessed clinical utility. Kaplan-Meier analysis evaluated the model's prognostic value.

RESULTS

The independent risk factors for hospitalized IMR after PCI in STEMI patients included Gensini score (OR 1.009; P = 0.047), left ventricular ejection fraction (LVEF) (OR 0.941; P = 0.007), albumin (OR 0.941; P = 0.046), and systemic immune-inflammatory index (SII) (OR 1.096; P < 0.001). During follow-up, diabetes mellitus (HR: 1.154; P = 0.019), hemoglobin (HR: 0.991; P = 0.028), Gensini score (HR: 1.007; P = 0.022), LVEF (HR: 0.972; P = 0.015), and SII/100 (HR: 1.034; P < 0.001) were identified as independent predictors of IMR. The nomogram showed strong clinical benefit, good calibration, and predictive value. Patients with lower scores had better long-term outcomes.

CONCLUSION

This nomogram effectively predicts the occurrence of IMR after PCI in STEMI patients, providing valuable prognostic insights.

Long-Term Clinical and Angiographic Outcomes of Off-Pump Versus On-Pump Coronary Artery Bypass Grafting

INTRODUCTION

This study aimed to compare long-term outcomes in patients undergoing off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) in a single-center propensity-matched population.

METHODS

Between January 2010 and June 2022, 2964 patients were analyzed and divided into two groups: 1671 (56.3%) patients receiving OPCAB and 1293 (43.7%) patients receiving ONCAB. Propensity score matching was performed resulting in 842 pairs.

RESULTS

In the matched cohort, OPCAB was associated with a reduced incidence of early stroke (odds ratio: 0.40; 95% confidence interval [0.17-0.90], P = 0.02) as well as a reduced incidence of reoperation for bleeding and blood transfusion. The median follow-up time was 6.69 y (interquartile range: 3.47-9.83-y). OPCAB and ONCAB had comparable long-term mortality, myocardial infarction, repeat revascularization, and major adverse cardiac and cerebral events. However, OPCAB was associated with higher freedom from stroke at follow-up compared to ONCAB (hazard ratios stratified on matched pairs: 0.61; 95% confidence interval [0.39-0.95]; P = 0.015). A landmark analysis in the matched cohort was performed excluding the first 30 ds of follow-up to exclude the effect of early stroke. In the landmark analysis, OPCAB and ONCAB had comparable freedom from stroke at follow-up. Briefly, 821 patients with 2055 grafts were analyzed. The overall median time to angiogram was 3.68 y (interquartile range: 1.76-6.61). No difference was observed between OPCAB and ONCAB in the patency rates (Fitzgibbon A) of arterial grafts. However, the patency rate of saphenous vein graft was higher in the OPCAB group than in the ONCAB group (77.4% versus 71.7%, P = 0.04).

CONCLUSIONS

OPCAB was associated with lower rates of stroke, reoperation for bleeding, and blood product transfusion. Meanwhile, at long-term follow-up, OPCAB and ONCAB were associated with comparable outcomes, including all-cause mortality, myocardial infarction, repeat revascularization, major adverse cardiac and cerebral events, and stroke.

Prognostic Implications of Machine Learning Algorithm-Supported Diagnostic Classification of Myocardial Injury Using the Fourth Universal Definition of Myocardial Infarction

BACKGROUND

With widespread adoption of high-sensitivity troponin assays, more individuals with myocardial injury are now identified, with type 1 myocardial infarction (T1MI) being less common despite having the most well-established evidence base to inform care. This study assesses the temporal time course of cardiovascular events among various forms of myocardial injury.

METHOD

Consecutive hospital encounters were identified. Using the first episode of care during the sampling period, myocardial injury classifications (i.e., T1MI, acute injury/type 2 myocardial infarction [T2MI], chronic injury, and no injury) were established via two machine learning algorithms. The temporal time course of increased hazard for mortality, recurrent myocardial infarction, heart failure, and arrhythmia over 3 years were explored.

RESULTS

There were 176,787 index episodes; 6.9% were classified as T1MI, 6.0% as acute injury/T2MI, and 26.7% as chronic injury. Although each classification was associated with an early increased risk of all-cause mortality compared with no injury (incidence rate ratio [IRR]<30 days: T1MI: 19.97 [95% confidence interval 12.50-32.69]; acute injury/T2MI: 26.51 [16.80-42.97]; chronic injury: 15.37 [10.22-23.95]), the instantaneous relative hazard for recurrent myocardial infarction was highest in those with initial T1MI (IRR<30 days: T1MI: 28.81 [22.75-36.76]; acute injury/T2MI: 10.23 [7.60-13.77]; chronic injury:5.54 [4.34-7.41]). In contrast, the instantaneous hazard for heart failure in those with initial acute injury/T2MI and chronic injury remained increased over long-term follow up unlike in T1MI (IRR1 3 yrs: T1MI: 5.52 [4.99-6.09]; acute injury/T2MI: 10.36 [9.51-11.30]; chronic injury:7.40 [6.90-7.94]).

CONCLUSIONS

The substantial and persistent rate of late cardiac events highlights the need to establish an evidence base for the therapeutic management of "non-T1MI" diagnostic classifications and suggests opportunity to improve late outcomes using existing and emerging therapies.

Clinical Outcomes, Healthcare Utilization, and Cost Following Implementation of a High-Sensitivity Cardiac Troponin Assay

INTRODUCTION

High-sensitivity troponin (Hs-trop) protocols have been developed for the cardiac evaluation of chest pain patients presenting to emergency departments (ED), but uptake has been suboptimal.

METHODS

This retrospective study sought to evaluate the effects of an Hs-trop protocol (Roche Gen-5 troponin assay) implementation on patient outcomes, healthcare utilization, and costs. Patients presenting to EDs with chest pain following implementation of an Hs-trop protocol (POST) were compared to control patients presenting in the year prior (PRE). Study endpoints included troponin elevations, cardiac diagnostic testing, and ED disposition. Among patients discharged directly from the ED, 30- and 90-day death, new myocardial infarction (MI), ED returns, and hospital admissions were compared. In a subset with insurance data, post-discharge healthcare costs and utilization were compared.

RESULTS

Among 15 015 patients meeting study criteria, there were no differences in MI diagnoses POST versus PRE, but myocardial injury without MI was more frequent POST (aOR = 9.03; 95% CI: 7.44, 10.96). Noninvasive cardiac testing at the index ED encounter was less frequent POST (aOR = 0.72; 0.67, 0.78), with no difference for invasive angiography. Among patients directly discharged from the ED, no differences were observed for death, but POST patients had fewer ED returns (aOR = 0.70; 0.59, 0.83) and hospital admissions (aOR = 0.62; 0.45, 0.85) within 30 days. Overall healthcare utilization was 8.4% lower in the POST group (p < 0.001) but costs were not different.

CONCLUSIONS

Following implementation of an Hs-trop protocol, decreases were observed in noninvasive cardiac testing, and ED returns and hospital admissions within 90 days of discharge, without compromising outcomes. Overall healthcare utilization declined.